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THE PHILIPPINE 

JOURNAL OF SCIENCE 

ALVIN J. COX, M. A., Ph. D. 

GENERAL EDITOR 

Section B 

Tropical Medicine 

EDITED WITH THE COOPERATION OF 

JOHN A. JOHNSTON, M. D., Dr. P. H.; STANTON YOUNGBERG, D. V. M. 

Committee on Experimental Medicine 

J. D. LONG, A. M., M. D.; W. E. MUSGRAVE, M. D. - 
B. C. CROWELL, M. D. 
Committee on Clinical Medicine 

R. C. MCGREGOR, A. B. ; H. E. KUPFER, Ph. B. 

Volume X 

1915 

With 15 Plates and 89 Text Figures 





■:■ -J.' 



299659 

[Qr.t] 2? 



MANILA 

BUREAU OF PRINTING 

1915 



186701 



CONTENTS 

No. 1, January, 1915 

Page. 
Munson, E. L. Cholera carriers in relation to cholera control 1 

Schobl, Otto. Observations concerning cholera carriers 11 

Wharton, Lawrence D. The development of the eggs of Ascaris 

lumbricoides 19 

Ruediger, E. H. The occurrence of Bacillus coli communis in the 

peripheral blood of man during life 25 

Three text figures. 

Ruediger, E. H. The preparation of tetanus antitoxin 31 

Eighty-five text figures. 

Calderon, Fernando. Csesarean section in the Philippine Islands.... 65 

Woodward, R. B. Case report of obstructed labor and Csesarean 

section ...; 69 

Thornburgh, Robert M. Adenocarcinoma of the csecum, compli- 
cated by intussusception 71 

DuMez, A. G. Two compounds of emetine which may be of service 

in the treatment of entamcebiasis 73 

Albert, Jose. The treatment of infantile beriberi with the extract 

of tiqui-tiqui 81 

Philippine Islands Medical Association. Minutes of the Eleventh 

Annual Meeting, held at Manila November 4-7, 1914 87 

Editorial. Progress in the investigation of vitamines 95 

Review 97 

No. 2, March, 1915 

Williams, R. R., and Saleeby, N. M. Experimental treatment of 

human beriberi with constituents of rice polishings 99 

Two plates. 

Williams, R. R., and Crowell, B. C. The thymus gland in beriberi.... 121 

Schobl, Otto. Practical experience with some enriching media re- 
commended for bacteriological diagnosis of Asiatic cholera 127 

Barber, Marshall A. I. Experiments on the immunization of 
guinea pigs by the inoculation of avirulent tubercle bacilli in 
agar. II. Observations on animals inoculated with tuberculosis 
from lepers 145 

Barber, Marshall A., and Jones, Charles R. A test of Coccoba- 

cillus acridiorum d'Herelle on locusts in the Philippines 163 

iii 



IV 



Contents 



No. 3, May, 1915 

Page. 

Barber, M. A.; Raquel, Alfonso; Guzman, Ariston; and Rosa, An- 
tonio P. Malaria in the Philippine Islands. II. The distribu- 
tion of the commoner anophelines and the distribution of malaria.. 177 

Two plates and 1 text figure. 

No. 4, July, 1915 

Crowell, B. C. Pathologic anatomy of bubonic plague 249 

Five colored plates. 

No. 5, September, 1915 

Roberg, David N. The role played by the insects of the dipterous 
family Phoridae in relation to the spread of bacterial infections. 
Experiments on Aphiochseta ferruginea Brunetti with the cholera 
vibrio 309 

Williams, Robert R., and Johnston, John A. Miscellaneous notes 

and comments on beriberi 337 

Schuffner, Wilhelm. Pseudotyphoid fever in Deli, Sumatra (a 

variety of Japanese kedani fever) 345 

Three plates. 

Reviews 355 

No. 6, November, 1915 

Denney, Oswald E. The treatment of the retrogressive skin lesions 

of leprosy with basic fuchsin 357 

Three plates. 

Johnston, John A. Leprosy 365 

Calderon, Fernando. Tropical obstetrical problems 371 

Coulter, J. S. A study of the pathology of the gall bladder and 

biliary passages in cholera 385 

Index 391 



iv Contents 

No. 3, May, 1915 

Page. 

Barbee, M. A.; Raquel, Alfonso; Guzman, Aeiston; and Rosa, An- 
tonio P. Malaria in the Philippine Islands. II. The distribu- 
tion of the commoner anophelines and the distribution of malaria.. 177 

Two plates and 1 text figure. 

No. 4, July, 1915 

Crowell, B. C. Pathologic anatomy of bubonic plague 249 

Five colored plates. 

No. 5, September, 1915 

Roberg, David N. The role played by the insects of the dipterous 
family Phoridse in relation to the spread of bacterial infections. 
Experiments on Aphiochasta f erruginea Brunetti with the cholera 
vibrio 309 

Williams, Robert R., and Johnston, John A. Miscellaneous notes 

and comments on beriberi 337 

Schuffner, Wilhelm. Pseudotyphoid fever in Deli, Sumatra (a 

variety of Japanese kedani fever) 345 

Three plates. 

Reviews 355 

No. 6, November, 1915 

Denney, Oswald E. The treatment of the retrogressive skin lesions 

of leprosy with basic fuchsin 357 

Three plates. 

Johnston, John A. Leprosy 365 

Calderon, Fernando. Tropical obstetrical problems 371 

Coulter, J. S. A study of the pathology of the gall bladder and 

biliary passages in cholera 385 

Index 391 



m 



Vol. X, Sec. B, No. 1 



January, 1915 



THE PHILIPPINE 



JOURNAL OF SCIENCE 



ALVIN J. COX, M. A., Ph. D. 

GENERAL EDITOR 

Section B 

Tropical Medicine 

EDITED WITH THE COOPERATION OP 

JOHN A. JOHNSTON, M. D., Dr. P. H. 
STANTON YOUNGBERG, D. V. M. 
Committee on Experimental Medicine 

J. D. LONG, A. M., M. D.; W. E. MUSGRAVE, M. D. 

B. C. CROWELL, M. D. 

Committee on Clinical Medicine 

R. C. MCGREGOR, A. B.; H. E. KUPFER, Ph. B. 









MANILA 
BUREAU OP PRINTING 

1915 



PUBLICATIONS FOR SALE BY THE BUREAU OF SCIENCE, 
MANILA, PHILIPPINE ISLANDS 



ETHNOLOGY 

A VOCABULARY OF THE IGOROT LAN- 

GTJAGE AS SPOKEN BY THE 

BONTOC IGOROTS 

By Walter Clayton Clapp 

Order No. 408. Paper, 89 pages, $0.75, 

postpaid. 
The vocabulary is given in Igorot-Engllsh 
and English-lgorot. 



THE NABALOI DIALECT 

By Otto Schebeeb 

and 

THE BATAKS OF PALAWAN 

By Edward Y. Miller 

Order No. 403. Paper, $0.25; half mo- 

rocco, $0.75; postpaid. 
The Nabaloi Dialect (65 pages, 29 
plates) and the Bataks of Palawan (7 
pages, 6 plates) are bound under one cover. 



THE BATAN DIALECT AS A MEMBER 

OF THE PHILIPPINE GROUP 

OF LANGUAGES 

By Otto Scheerer 

and 

"F" AND "V* IN PHILIPPINE 
LANGUAGES 

By Carlos Everbtt Conant 

Order No. 407. 

These two papers are issued under ont 
oover, 141 pages, paper, $0.80, postpaid. 



ETHNOLOGY— Continued 

STUDIES IN MORO HISTORY, LAW, 
AND RELIGION 

By Najeeb M. Saleeby 

Order No. 405. Paper, 107 pages, 16 

plates, 5 diagrams, $0.25; half mo- 
rocco, $0.75; postpaid. 

This volume deals with the earliest 
written records of the Moros In Mindanao. 
The names of the rulers of Magindanao are 
recorded in five folding diagrams. 



NEGRITOS OF ZAMBALES 

By William Allan Reed 

Order No. 402. Paper, 83 pages, 62 

plates, $0.25; half morocco, $0.75; 
postpaid. 

Plates from photographs, many of which 
were taken for this publication, show orna- 
ments, houses, men making fire with bamboo, 
bows and arrows, danoes, and various types 
of the people themselves. 



INDUSTRIES 

PHILIPPINE HATS 

By C. B. Robinson 

Order No. 415. Paper, 66 Paget, 8 

plates, $0.50 postpaid. 

This paper Is a concise record of the 
history and present condition of hat making 
In the Philippine Islands. 



THE SUBANUNS OF SINDANGAN BAT 

By Emerson B. Christie 

Order No. 410. Paper, 121 pages, 1 

map, 29 plates, $1.25, postpaid. 

Sindangan Bay is situated on the north- 
ern coast of Zamboanga Peninsula. The Su- 
banuns of this region were studied by Mr. 
Christie during two periods of five and six 
weeks, respectively. 

The 29 plates illustrate the Subanuns at 
work and at play; their industries, houses, 
altars, and implements; and the people 
themselves. 



THE SUGAR INDUSTRY IN THE 
ISLAND OF NEGROS 

By Herbert S. Walker 

Order No. 412. Paper, 145 pages, 10 

plates, 1 map, $1.25, postpaid. 

Considered from the viewpoint of prac- 
tical utility, Mr. Walker's Sugar Industry 
in the Island of Negros is one of the most 
important papers published by the Bureau 
of Scienoe. This volume is a real contribu- 
tion to the subject; it is not a mere com- 
pilation, for the author was in the field and 
understands the conditions of which he 
writes. 



THE HISTORY OF SULU 

By Najeeb M. Saleeby 

Order No. 406. Paper, 275 pages, 4 

maps, 2 diagrams, $0.75, postpaid. 
In the preparation ef his manusorlpt for 
The History of Sulu, Doctor Saleeby spent 
muoh time and effort in gaining access 
to doouments In the possession of the Sultan 
of Sulu. This book is a history of the 
Moros In the Philippines from the earliest 
times to the American occupation. 



A MANUAL OF PHILIPPINE SLLK 
CULTURE 

By Charles S. Banks 

Order No. 413. Paper, 53 pages, 20 

plates, $0.75, postpaid. 

In A Manual of Philippine Silk Culture 
are presented the results of several years' 
actual work with silk-producing larva to- 
gether with a description of the new Philip- 
pint raoe. 



THE PHILIPPINE 

Journal of Science 

B. Tropical Medicine 
Vol. X JANUARY, 1915 No. 1 

CHOLERA CARRIERS IN RELATION TO CHOLERA CONTROL 1 

By E. L. Munson 

(Major, Medical Corps, United States Army. Advisor to the 

Bureau of Health) 

In the recent cholera outbreak in Manila and in Bilibid 
Prison a very high percentage of carriers in persons not cholera 
suspects was early discovered. The number of both carriers 
and cases was showing a steady increase, and there were a 
number of recurrent cases developing in groups found to have 
a high carrier index. It was then decided to depart from pre- 
vious ideas, and to regard actual cases merely as symptomatic 
of a wider spread and more dangerous concealed infection. 

The dangerous nature of frank cases of cholera with diar- 
rhoea, vomiting, and collapse is well recognized by the people, 
and such cases would be avoided, reported, isolated, and followed 
by disinfection of their environment. But the carriers were 
unsuspected sources of infection who were scattering it broad- 
cast through the public latrines, handling and preparing food 
and drink for public consumption, and admitted as welcome 
guests into homes and social entertainments. To avoid a dan- 
ger, it must first be known where it exists. 

Special effort, therefore, was made to seek out and isolate 
the carriers, who were presumably the chief factors in spread- 
ing the infection. It was recognized that the task would be 
one of too great magnitude to include all the inhabitants of 
the entire city, nor was this thought necessary in practice; so, 
after a few special surveys to determine the degree of preva- 
lence of infection, the work of carrier detection was limited to 
contacts with cholera cases, to persons living in a vicinity in 
which several cases had occurred, and to persons engaged in 
the handling of food and drink in hotels, restaurants, bottled- 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

•132195 



The Philippine Journal of Science 



1915 



drink factories, clubs, tiendas, and ice-cream factories, by which 
classes infection was particularly liable to be transmitted. Some 
surprising results were obtained with the last class, and numer- 
ous carriers were found and removed from duties in which they 
might have caused — and doubtless did cause — much damage. 

To meet the needs of the work, the Governor-General author- 
ized additional expenditures which doubled the capacity of the 
Bureau of Science with regard to cholera diagnosis by bacte- 
riological methods. However, after funds were authorized, it 
took several weeks to secure and install the necessary additional 
equipment and to obtain and train the additional personnel. 
Finally, bacteriological examinations were being made at the 
rate of nearly 2,000 per day, due to improved organization and 
technical efficiency of the new employees of the Bureau of 
Science. 

With the increased isolation of carriers thus made possible, 
the cases began to fall. The epidemic appeared to be under- 
mined rapidly at its source. At one time there were 195 car- 
riers in detention. The practical importance of having removed 
such a number of concealed foci from the community at one 
time and put them where they could be of no danger in spread- 
ing the infection thus harbored does not need to be emphasized. 
During the outbreak, 529 cholera carriers were found through 
the health stations and 128 more occurred among the convicts 
of Bilibid Prison. A total of 657 such carriers was thus found 
and isolated within the corporate limits of Manila up to the 
middle of November. 

The following is the report of stool specimens taken from 
persons not cholera suspects and forwarded to the Bureau of 
Science for examination during the months of July, August, 
September, and October, 1914, as taken by the several health 
stations in the city of Manila: 

Table I. — Stool specimens examined for cholera at the Bureau of Sc • 

July-October, 191b. 



Source of specimen. 
Health station — 


July. 




August. 




September. 


Total. 


Posi- 
tive. 


Nega- 
tive. 


Total. 


Posi- 
tive. 


Nega- 
tive. 


Total. 


Posi- 
tive. 


Nega- 
tive. 


















•T 


238 


27 


211 




45 




3.539 


69 




A 


830 


31 


799 


4,851 


US 


4,733 


5,467 


;.; 




C 


304 


13 


291 


1147 


27 


620 


1.796 


26 


1.770 


I 


95 


5 


90 


786 


18 


718 


1,414 


21 


1.898 


L 

Total 


77 


1 


76 


SO 




80 


840 


16 


SC4 


1,544 


77 


1.467 


7,611 


208 


7.483 


IS, 056 


205 


12.861 





X, B. 1 



Munson: Cholera Carriers 



Table I. — Stool specimens examined for cholera at the Bureau of Science, 
July-October, 1914 — Continued. 



Source of specimen. 


October. 


For the four months. 


Total. 


Posi- | Nega- 
tive, tive. 


Nega- 
tive. 


Posi- T^j..,, 
tive. TotaI - 


Health station— 

J 


1,-153 
2,800 
1,489 
513 
1,192 


6 1, 147 

22 j 2,778 

4 | 1,485 

4 509 

| 1,192 


6,257 
18, 948 
4,236 
2,758 
2.189 


147 
244 
70 
48 
17 


6,304 
14, 192 
4,166 
2,806 
2,206 


A 


C 


I„__ 


L 


Total 


7,147 


36 | 7. Ill 


29, 448 


526 


29, 974 





It is interesting to note the way in which the cholera carriers 
have fallen off. In October, including Bilibid Prison, whose 
examinations are not included in the above statistical table for 
health stations, a total of 80 carriers was found. Of these 80, 
there were 57 found in the first half of the month and- 23 in 
the last half of the month. Of the 23 carriers found in this 
last half -month, only 8 occurred in the last week of October. In 
the first week of November, only 3 carriers were found. In 
the first twelve days of November, as a result of approximately 
20,000 examinations made during that period, only 3 carriers 
were found. The last carrier was found on November 4, since 
which date up to the present writing some 16,000 examinations 
have been made. 

The foregoing statistical table shows that for the entire out- 
break, up to November 1, when it was practically over, of nearly 
30,000 persons not cholera suspects but systematically examined 
from health stations for purposes of investigation, almost exactly 
1.75 per cent of the population of Manila examined were found 
to be harboring the cholera infection. But such general pro- 
portion was much exceeded in some instances. Station A in 
August showed 118 positives in 4,851 instances taken at ran- 
dom, or 2.4 per cent. One series of 179 dead bodies showed 
3.6 per cent positive; and certain smaller groups among living 
persons showed even higher percentages of infection than the 
foregoing. The Bilibid Prison outbreak, which is not discussed 
in this paper, has had approximately 5 per cent of the prisoners 
found to he cholera carriers. Fortunately for the work of 
eradication, only a part of the infections above mentioned for 
large groups existed at any one time. 

In some instances, cholera infection was found no more prev- 
alent in cholera contacts than in those not known to have had 
any relation to cholera cases. Thus at Station L for the month 



4 The Philippine Journal of Science ms 

of September 149 cholera "contacts" showed 3 positive, or 2 
per cent, while of 691 specimens taken systematically from the 
inhabitants of city blocks, 13, or almost exactly 2 per cent, were 
positive. The same applies to Station J for September, with 
57 positives out of 2,970 systematic examinations of nonsuspects, 
and 12 positives out of 541 contacts. 

The above statistical table also well shows the invasion of Paco 
district by the infection, due to being conveyed by the floods 
of September. Prior to the floods it had been practically free 
from cases — afterwards, both cases and carriers increased in 
almost parallel ratio. 

The vast amount of assistance given the health work by the 
Bureau of Science is shown by Table II. 

Table II. — Number of examinations for cholera made at the Bureau of 
Science and number found positive for four months in 191 U. 



Month. 



July _ 

August 9,994 | 

September 24,402 

October - 32,824 

Total .' 




From November 1 to November 10 approximately 20,000 bac- 
teriological examinations were made. Cases and carriers have 
both now fallen almost to the vanishing point, and the exam- 
ination for cholera of apparently healthy persons will shortly 
be discontinued. However, when so discontinued, well over 
100,000 such examinations will have been made. 

Of the above gross figures, a considerable proportion of the 
positive findings represent subsequent examinations of cases 
previously found positive which were being examined to deter- 
mine the time when they had cleared up as carriers and could 
be discharged from isolation. 

It will be apparent from the above that the work of detect- 
ing cholera carriers presented grave difficulties of administration 
by reason of its magnitude. There were also social and political 
difficulties which had to be overcome before it was possible to 
undertake the purely scientific and administrative work. The 
work meant invasion of the accepted rights of the home and 
of the individual on a scale perhaps unprecedented for any com- 
munity. The collection of the frecal specimens necessary might 
fairly be regarded as repulsive to modesty. Add to this the facts 
that the search was made among persons apparently healthy to 



x, b, i Munson: Cholera Carriers 5 

themselves and others who could scarcely fall even within the 
class of suspects, and that those found positive were subjected to 
all the inconveniences of isolation, separation from family, loss 
of earning capacity, etc., and it is apparent that the work at 
the outset had to be expanded with caution and only as the orig- 
inal opposition could be removed and public opinion created in 
favor of it as an unpleasant but necessary measure. This was 
brought about rapidly in various ways, and by the middle of 
September the full support of every newspaper in Manila had 
been secured, together with that of practically all persons of 
prominence and of the intelligent classes. It is a credit to the 
people that they accepted the work as a necessity, for without 
their cooperation the work could probably not have been car- 
ried out. By the unprecedented floods of September the greater 
part of Manila was put several feet under water for some days, 
sewers were back pressured, most of the public water closets upon 
which the great majority of the population of Manila depend 
were submerged, and the poorer people were forced to drink 
the foul flood water which could be boiled with difficulty from 
lack of fuel. There was also shortage of food, constant wet- 
ting and chilling from unceasing rain and flood, and crowding 
together of people driven from their homes by rising waters 
and carrying their infection into new places. These conditions 
and the existence of a widespread cholera infection in car- 
riers apparently favored the development of one of the most 
destructive epidemics of cholera that ever occurred in Manila. 
That it did not so occur probably can be attributed largely to 
the campaign against carriers which shortly after began 
to be pushed more energetically, through better organization 
and allaying popular opposition. The flood began on September 
3. Within a week, the number of cases and carriers rose rap- 
idly. In the health districts of Manila and in Bilibid Prison 
together there were 226 carriers found and isolated for the 
period September 8 to September 30. On one day, September 
14, there were 41 carriers found, and on September 15 there 
were 52 carriers found. 

It is evident from the above that in effectively combating a 
cholera infection the use of laboratory facilities in the making 
of bacteriological diagnosis on a large scale is absolutely es- 
sential. Without such assistance as the Bureau of Science, has 
given, the results accomplished would not have been possible. 

The outbreak in Manila was unquestionably spread chiefly 
by personal contact. Cases were isolated so promptly as to 
do little harm. Lack of the use of toilet paper, certain habits 



6 The Philippine Journal of Science wis 

in the use of the toilet, infected fingers, and eating with the 
hands food taken from a common dish were the channels through 
which the infection chiefly passed from the carrier to another 
person. Public water supplies and articles of food could be 
eliminated as channels of infection, and flies played an entirely 
insignificant part in its spread. 

A considerable proportion of the positive specimens taken 
from dead bodies were from cases in which the cause of death 
was reported as enteritis, diarrhoea, dysentery, infantile beri- 
beri, and pulmonary tuberculosis. The cooperation given by 
all the physicians of Manila in the detection and isolation of 
cholera was so genuine that it is not believed that there was 
any effort to conceal cases under other diagnoses. Errors in 
diagnosis were made in good faith. Also, it was quite possible 
for persons to die of one disease and still be carriers of an- 
other, or harbor an infection which had not yet time to develop. 
The proportion of cases of pulmonary tuberculosis found pos- 
itive for cholera on examination of the fseces is notable. Here 
the tubercular lesions of the intestines in advanced cases ap- 
parently played a considerable part in rendering the alimentary 
tract a more favorable environment for development of cholera 
germs. So also with the other intestinal diseases mentioned. 
Apparently almost any intestinal disorder or interference with 
intestinal digestive function materially predisposes to develop- 
ment of cholera infection if the latter gain access to the ali- 
mentary tract. 

At the outset of the campaign for the detection of cholera 
carriers, the accuracy of the microscopic diagnosis made by the 
Bureau of Science was called into question by various persons, 
who objected that in their opinion true cholera germs could 
not be present as reported, as no carrier was developing the 
disease. To this objection reply was ordinarily made that the 
fact that the persons harboring the cholera germs were carriers 
rather than cases was because they possessed such temporary 
powers of resistance to the germs as to be able to prevent the 
development of the disease. However, it was believed that cases 
of cholera might very well occur in carriers as a result of either 
decrease in vital resistance of the host or increase in virulence 
of the strain of germ being harbored; and very shortly a con- 
siderable number of cases occurred to prove this to be a fact. 
For example, in the search for carriers in Bilibid Prison, con- 
victs 8617, 12765, and 30351 were reported as positive carriers 
on September 10 and 11. They were isolated and examined 
bacteriologically every other day, being found continuously pos- 



x. b, i Munson: Cholera Carriers 7 

itive for cholera. Convict 8617 developed true cholera on Sep- 
tember 27, after being a carrier for seventeen days; convict 
12765 developed true cholera on September 27, after being a 
carrier for sixteen days; and convict 30351 developed cholera 
on September 29, after being a carrier for eighteen days, and 
the disease was of a type sufficiently severe to cause death in 
eight hours. 

Several instances have occurred where persons who had given 
specimens became suspicious of possible findings and absented 
themselves from their usual abodes, so that when later deter- 
mined by the Bureau of Science to be positive they could not 
be found and segregated — only to be taken up later as true 
cholera cases in some other portions of the city. And many 
cases have occurred in which the disease has developed within 
the usual period of incubation, such as convict 8486, who was 
found to be a carrier on September 16 and developed active 
symptoms of the disease on September 20. 

What may be the cause of development of the symptoms of 
cholera in carriers can only be surmised with our present knowl- 
edge of the disease. But it is worthy of note that in the Bilibid 
cases at least no causes which might operate to produce a general 
lowering of vital resistance were apparent. They were isolated, 
at rest, well fed, and under every hygienic advantage. 

A number of cases of intermittent carriers have been found, 
and it would probably be shown that these are not rare if re- 
examination of all carriers for a considerable period could be 
carried out. Thus, Mamerto Juanico was found to be a carrier 
on September 16, but was released from quarantine on October 
4 after four negative findings, approximately at two-day in- 
tervals. But on October 26 this case was again found positive 
and so continues at the present time. Here is a case which 
has been an intermittent source of danger for over seven weeks. 
If it can be a carrier for seven weeks, why not for fourteen? 
If the germ can be harbored any such length of time, what 
is the limit of its viability in the intestine? Clearly such cases 
tremendously increase the difficulty of cholera control. 

Take the case of Alejo de la Cruz, who was found positive 
on September 27 and 29 and then was negative for 4 findings 
and released from quarantine on October 14 ; but who was again 
found positive on October 17, developed choleraic symptoms 
on the same date, and was sent to San Lazaro where he re- 
mained until October 27. Was this last manifestation a sud- 
denly increased virulence of a previously existing but scanty 
infection, or was it a sudden lowering of vital resistance, or 



8 The Philippine Journal of Science 1915 

did the man acquire a new and more virulent infection which 
caused him to sicken? 

Apparently healthy persons in quarantined barracks in Bilibid 
Prison, from which carriers were being carefully sought out 
and removed by means of bacteriological examinations made 
every other day, have produced cases in from two- to three-day 
up to twelve- and thirteen-day intervals. This is suggestive of 
persons being able to harbor an infection which is undetectable 
by present methods, or else of a much longer incubation period 
than has previously been accepted. 

One instance is reported of a man who was treated as a case of 
cholera at San Lazaro Hospital in 1913 and this year was found 
to be a cholera carrier and sent there for detention. The ques- 
tion at once presents itself as to whether or not he might per- 
haps have been a host for the cholera germ since his previous 
sickness, and thus be representative of a class whose existence 
in these Islands may reasonably be inferred from the practically 
annual recurrences of this disease and by which the gaps be- 
tween one outbreak and another may very possibly be bridged 
over. 

Treatment to free the intestines of cholera carriers of cholera 
vibrios seems to have been of little value. It will be discussed 
in another paper at this meeting. It is worthy of note that 4 
cases of cholera, 1 case fatal, occurred in carriers who had for 
some time been receiving salol in 0.6 gram doses twice daily in 
the effort to hasten the disappearance of cholera germs through 
the use of intestinal antiseptics. 

As to the duration of the period in which the average cholera 
carrier spontaneously cleared up, there seemed to be some 
variation. Average days of detention were reported from San 
Lazaro as follows: 



Table III,- 


—Average time of detention of cholera carriers 


at San Lazaro. 


Month. 


Males. 


Females. 


July 


Days. 

- 

a 


Pny-\ 

s 
6 
11 




September . 







However, very likely some of these cases which were reported 
as cleared up were intermittent carriers and again became tem- 
porary disseminators of disease germs, and thus the average 
period of infectivity as given above is probably too short. 

Experience would seem to indicate that in an outbreak of 



x, b, i Munson: Cholera Carriers 9 

cholera presenting a high case mortality, the proportion of per- 
sons who are carriers without presenting symptoms of the 
disease will be relatively small. Possibly this may be due to 
the fact that in such an epidemic the strain of germ concerned 
is so virulent that if introduced into the system the average 
power of vital resistance is insufficient to check the invader and 
the host promptly sickens and usually dies. Conversely, where 
the case mortality is light, the lack of virulence in the germ 
will probably permit it to be harbored in many cases without 
the production of symptoms, and a considerable percentage of 
carriers may be expected. 

The recent outbreaks in the provinces and Manila have pre- 
sented most clearly these two distinct types of infection: the 
provincial case mortality has been nearly twice that of Manila 
and relatively very few cholera carriers have been found. 

But we must bear in mind the possibility that an apparently 
mild strain of cholera germ, under conditions of environment 
as yet not fully understood by us, may acquire a high degree 
of virulence and change the type of disease from one of a 
relatively benign character to one of a most fatal type. This 
adds to the necessity of seeking out and removing the concealed 
sources of infection found in cholera carriers. 

One of the most apparent lessons to be learned from these 
recent experiences relates to the possible period of latent in- 
fection in cholera and its bearing on the period of incubation 
and quarantine heretofore accepted for health work. It is un- 
doubtedly true that the five-day period usually accepted for in- 
cubation and quarantine ordinarily will suffice for the control 
of infection in the majority of cases; but it is equally true that 
such a period does not hold good in a very considerable number 
of instances, which sheds much light on cholera situations not 
otherwise readily explainable. For example, convict 30351, who 
died of cholera, might have traveled halfway around the world, 
scattering his infection broadcast during his eighteen-day period 
as a carrier, and died of true cholera in a place many thousands 
of miles from any other source of infection. There is a warn- 
ing in such cases that health officers all over the world would 
do well to heed. 

In conclusion, in such outbreaks as that recently in Manila, 
the carriers would seem to be not only the most numerous but 
the most insidious and dangerous sources of infection. The 
prompt eradication of a general cholera infection, therefore, 
includes the detection and isolation of carriers as a scientific 
prerequisite. 



OBSERVATIONS CONCERNING CHOLERA CARRIERS x 

By Otto Schobl 
(From the Biological Laboratory, Bureau of Science, Manila, P. I.) 

The condition frequently existing in persons termed by Eng- 
lish authors "carriers," "distributors," or "porters," being com- 
mon to all intestinal bacterial infections, is found in Asiatic 
cholera, and in the case of chronic carriers is without doubt 
due to the infection of the gall passages by cholera vibrios. 

The portal of entry as well as the principal field of cholera 
infection in man is the intestinal tract, and it is quite natural 
that we look on the intestinal discharge as the main source of 
supply of the infectious material. Nevertheless we are led by 
experience in typhoid fever, a disease which has much in com- 
mon with cholera, to search for other less commonly infected 
excretions by means of which cholera vibrios may be discharged 
from the human body. The urine and the vomit of patients 
may be mentioned as examples. 

The first question of practical interest with regard to cholera 
carriers is : "How long is a cholera convalescent infective?" The 
following quotation from Greig 2 answers the question : "It is 
impossible from an ordinary medical examination to say 
'whether or not a patient is infective.' " The bacteriological 
diagnosis, which consists of isolating and identifying the spe- 
cific vibrio, requires a fairly well-equipped laboratory and an 
experienced personnel. These are not always available; there- 
fore the data on the vitality of cholera vibrios in the human 
body may be of practical value under these circumstances. 

The results of the examinations of about 80 cholera patients 
and carriers gave the following figures: 

Table I. — Outbreak of cholera in Manila, 1913-1914. 

Stools positive: Patients. 

For from 2 to 7 days 43 

For from 7 to 14 days 22 

For from 14 to 21 days 6 

For from 21 to 28 days 5 

For 48 days 1 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

'Indian Journ. Med. Research (1914), 1, 67. 

11 



12 The Philippine Journal of Science wis 

Pfeiffer :i mentions only 2 cases of from forty-eight to forty- 
nine days' duration; Stiihlern-Zeidler, 3 1 case of ninety days; 
Jakowleff * gives 1 case of fifty-six days ; and Creel, 5 1 case of 
fifty-eight days' duration. Our record case was positive for 
forty-eight days with several intermissions. The case was in 
the care of Dr. C. S. Butler, of the United States Navy. 

According to the clinical report, which I obtained through 
the kindness of Doctor Butler, the patient became sick on 
October 5. The fseces were still positive on November 23. 
Three negative examinations three days apart followed. 

It is interesting to note that the chronic carriers of the Rus- 
sian authors showed intermittent diarrhoea after recovering 
from the acute attack of cholera. It also was noticed that 
chronic carriers exhibited clinical signs of cholecystitis; that is, 
icterus and tenderness in the region of the gall bladder. 

In a recent paper Greig 6 tabulated the results of 271 bac- 
teriological examinations of gall bladders taken from deceased 
cholera cases, and emphasized the significance of the already 
known fact that cholera vibrios frequently are found in the 
bile passages of cholera patients and convalescents. His is the 
largest series of examinations on record. Among the 271 ex- 
aminations the cholera vibrio was found eighty times, and 12 
of the 80 gall bladders which harbored cholera vibrios showed 
pathological changes. 

Kulescha 7 studied the pathology of bile passages during the 
outbreak of cholera in St. Petersburg in 1908-1909. He "found 
in the literature the first report of a necrotic cholecystitis in a 
case of cholera by Pirogoff (1848) and an analogous case by 
Netschaeff (1892). Mentioning the numerous authors who con- 
tributed to the knowledge of the subject, he quotes the results 
of examinations made by M. J. Girode as of particular interest. 
Of 28 cases examined, 14 contained vibrios. There was one 
case of marked cholangitis. Savtschenko found cholecystitis 
twice among 30 cholera autopsies. Kulescha found, among 430 
autopsies performed on cholera cadavers, cholecystitis in 10 per 
cent. The majority were in the first or second week of the 
disease. Cholera vibrios were found in 46 per cent of gall 
bladder examinations in 1908 (109 cases examined) and in 76 

3 Cited from Jansen, Klin. Jahrb, (1910). 
'Cited from Kulescha, Klin, Jahrb. (1910). 

• Journ. Am. Med. Assoc. (1912), 187. 

• See footnote 2. 
; See footnote 4. 



x, b, i Schobl: Concerning Cholera Carriers 13 

per cent of cases in 1909 (50 examinations). His is the unique 
case of a patient who took sick with cholera in November, 1908, 
and became a carrier (fasces positive for cholera vibrios for 
fifty-seven days). Death occurred in September, 1909. Cholera 
vibrios were found in the bile passages, but not in the fasces. 

The close relation between the infection of the gall bladder 
and the condition in convalescents known as cholera carriers 
was early recognized. Nevertheless the emphasis of the fact 
and its importance in regard to the dissemination of the disease 
is justified, because assertions to the contrary are to be found 
in the literature as evident from the statement attributed to 
Roger by Greig: s 

The absence of the infection of the gall bladder and bile ducts by the 
comma bacillus places the disease in quite a different position from that 
of typhoid fever in this respect. 

Considering the lengthy period of infectiveness as found in 
certain instances of cholera carriers and the periodical reoccur- 
rence of cholera vibrios in the stools of convalescents, theo- 
retically it would be difficult to believe that the cholera vibrio 
would live for such a length of time free in the intestinal tract 
where the competition with the normal inhabitants of the in- 
testine and other factors render the conditions unfavorable to 
its vitality. 

The tidal occurrence of the cholera vibrio in the stools of con- 
valescents who become carriers seems to indicate a focus con- 
nected with ^the alimentary canal, where the vibrios multiply 
and are being discharged into the digestive tract. At times 
and under certain conditions they appear in the excreted fasces 
in numbers large enough to be detected by the usual methods. 

As to the genesis of the infection of the bladder and the bile 
ducts two ways come under consideration. Does the invasion of 
the bile passages take place directly from the small intestine 
or is the infection of hasmatogenous origin? The facts that 
the bile passages show marked pathological changes while the 
liver tissue proper exhibits, as a rule, only signs of toxic effect, 
the high percentage of infected gall bladders, and the rarely 
encountered evidence of a bacteremic stage of cholera infection 
speak in favor of the first-mentioned mode of infection. 

It was found that bile is not only a fairly good medium for 
the growth of the cholera vibrio, but also that it inhibits the 
growth of many other intestinal bacteria. As a matter of fact, 

8 See footnote 2. 



14 The Philippine Journal of Science wu 

it was recommended as enrichment medium. During the acute 
attack of cholera the proximal part of the small intestine usually 
contains cholera vibrios in pure culture, and frequently cholera 
vibrios are found in the stomach contents if vomiting sets in. 
Two out of three vomits collected from known cholera cases 
examined by me contained numerous cholera vibrios. 

It is evident that once the lively motile cholera vibrios reach 
the gall bladder they grow practically without competition. 

Kolle and Schurmann" state that the numerous examinations 
of cholera cadavers made in India showed that the cholera 
vibrios are restricted to the intestines while the internal organs 
are free from vibrios. Their statement is based on the findings 
which were published in extenso in the official report of Pro- 
fessor Gaffky. 

Greig 10 believes that the infection of the bile passages is 
of hematogenous origin. He found cholera vibrios in a focus 
in the lungs. 

Kulescha ai admits that under certain conditions cholera vi- 
brios invade the gall bladder through the bile passages, but he 
upholds the theory that the vibrios reach the gall bladder 
through the blood stream on the following ground: he found 
necrotic foci (emboli) in the liver of cholera cadavers and suc- 
ceeded in isolating the cholera vibrios therefrom. As a support 
of the theory of the haematogenous origin of the infection of 
the gall passages by cholera vibrios, this author quotes the 
findings of Sewastjaneff, who found 5 cases of vibrionuria, one 
of them being of four days' duration, and also the case of Lief- 
schiitz-Jakowleff who isolated the cholera vibrio from a stillborn 
child whose mother suffered with cholera. Kulescha made 
numerous examinations of urine in cholera patients under strict 
aseptic precautions and failed to find the cholera vibrio. In a 
preliminary note Greig 12 reports 8 positive findings of cholera 
vibrios in the urine (55 examinations). Several cases analogous 
to that of Liefschutz-Jakowleff came under my observation 
during the outbreak. The results of these examinations are 
summarized in Table II. 

9 Cited from Kolle und Wassermann, Handbuch der pathogenen Micro- 
organismen. Gustav Fischer, Jena. 

10 See footnote 2. 

11 See footnote 4. 
" See footnote 2. 



X, B, 1 



Schobl: Concerning Cholera Carriers 



15 



Table II. — Examination of embryos from cholera mothers for the presence 

of cholera vibrios. 

[The cause of death in the mothers was Asiatic cholera,] 



Case. 



Waters. 



1. Full-grown child 

2. Full-grown child 

3. Almost full grown 

4. Foetus 24 centimeters, 

5. Almost full grown ... 



Placental 
blood. 



! 

Heart. Intestine.i Spleen. 







b— ' 



" In case 3 the sac was found perforated, which explains the presence of cholera vibrios in 
the waters, 
b Bile. 

Of the 39 gall bladders examined for the presence of the 
cholera vibrio, 3 showed macroscopic lesions. In 2 instances (1 
and 25) hydrops cystitis fellea was found; that is, distended gall 
bladder containing mucous bile of light-amber color and flaky 
sediment. When stirred, the bile assumed a milky appearance. 

One gall bladder was rather small; the wall was evidently 
thickened, and the contents were of a rather dark color. Upon 
microscopical examination the epithelium was found desqua- 
mated, the blood vessels distended, and the mucous membrane 
showed a high degree of round-cell infiltration. Blood cor- 
puscles were found free in the lumen of the gall bladder. The 
cystic duct showed like changes, but the epithelium was not 
desquamated altogether. Pure cultures of the cholera vibrio 
were obtained from all three specimens. 



16 



The Philippine Journal of Science 



1915 



Table III. — Showing the results of bacteriological examinations of gall 
bladders for the presence of cholera vibrios. 



No. 


Patient. 


Date of 
examina- 
tion. 


Time 
between 
death and 
autopsy. 


Cholera vibrios. 


Gall 
bladder. 


Intestine. 


1 

2 

3- 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 
28 
29 
30 
31 
32 
33 
34 
35 
36 
37 
88 
39 


A. V.- 


1913. 
Sept. 22 
Oct. 4 
Oct. 6 
Oct. 5 
Oct. 9 
...do— . 


Hours. 

16 
15 

6 
16 

4 
14 
17 


II- IIII+ + + + + ■: -j 1 l 1 1 + l | 1 1 + + I 1 + + I + 1 I + I 1 " 


+ 

+ 
+ 

+ 

+ 

+ 
+ 

+ 
+ 
+ 

+ 
+ 

+ 

+ 

+ 

+ 
+ 

+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 

+ 


R. Q 

F. Unku 


T. D 


S. Q ... 


C. E . 


p. Jap .- 


.. do. 


S.Jap- 


Oct. 11 


20 


DeL. R 


... do — 


5 
3 

(?) 
4 

11 




-.do.... 


A- - 


Oct. 13 
Oct. 14 
___do -__- 


A.P . ... 


J.C 


C 


Oct. 15 


R 


N. T 


Oct. 14 16 


J. B 


-_do .... 


3.5 
6 

11 

7 
15 

4 

1 

2 

4 
12 
(?) 

20 














V. H 


Oct. 13 
...do .... 


G. P - 


E. S -._ 

F. B 

N. S - — 


Oct. 16 
Oct. 17 
... do — 


M. L -. 


Oct. 20 
-.do-- 


N. 


R. S. A — 

p. S - 


do— . 
Oct. 23 
Nov. 26 

1914. 
July 31 
July 14 
June 14 
July 16 
July 21 
July 24 
July 2S 
...do .... 


S.G— 

A. J 


E.deG 


M. L 


M. Sta. M 


V. (?) 

J. Z .-- 


A. C 


M. R ..- — 


A. B 


July 29 
July 31 
Aug. 31 
Aug. 7 
. ..do.— 


A. R 


C. A — . 


A. Z - 


1. P 







! [ydropa 



b Cholecystitis. 



It will be seen from Table III that in the 39 gall-bladder 
examinations the cholera vibrio was found seventeen times. 
The period of time between death and autopsy as far as obtain- 
able is indicated in the table. 



X, B, 1 



Schobl: Concerning Cholera Carriers 



17 



Table IV. — Showing the results of examinations of urine of cholera patients 
for the presence of the cholera vibrio. 



Patient. 


Date of 
examina- 


Cholera vibrio in— 








tion. 


Urine. 


Fasces. 




1913. 




D. C 


Sept. 30 









Oct. 1 


- 


-f- 




Oct. 8 


— 


"r 




Oct. 11 


— 


+ 




Oct. 17 


- 


+ 


B 


Sept. 30 


— 


+ 




Oct. 1 


- 


+ 


F 


...do-.. 





+ 
+ 




Oct. 8 


T _• 


Oct. 11 
Oct. 24 


_ 







P 


Oct. 11 
Oct. 17 
_._do.._. 


- 


+ 
+ 


M 


D 




Oct. 23 




Oct. 24 


- 


+ 


L 


Oct. 22 

...do 


- 


+ 
-r 

+ 


B. L 


T. M 


...do .... 




...do .... 


: 


+ 




Oct. 24 


T. Y 


Oct. 22 


_ 






Oct. 24 


— 


+ 




Oct. 23 
Oct. 24 





+ 
4- 






Oct. 25 


— 


+ 


Cast 


Oct. 23 
Oct. 24 










Quin _ 


___do.___ 


_ 


"T 


M. M 


...do 


- 


+ 
+ 


W. L 


...do 


Lap ... 


Nov. 17 




...do 


— 


+ 


Tomago Y 


...do _.__ 


M. S 


...do 




J. 




1914. 


P. B 


July 22 


_ 


_1_ 




July 24 


— 


— 


L. L 


July 22 










July 24 


— 


- 


T. M 


...do 


- 


+ 


V. M 


...do .... 


S. M 


...do 


D. F .... 


Aug. 1 





All of the 41 examinations of 27 patients and convalescents, 
whose stools contained cholera vibrios at the time of examination 
or some time previous, were negative. It tends to show that 
vibrionuria is not a common occurrence in cholera asiatica. 



132195- 



THE DEVELOPMENT OF THE EGGS OF ASCARIS 
LUMBRICOIDES 1 

By Lawrence D. Wharton 

{From the Zoological Laboratory, College of Liberal Arts, 

University of the Philippines) 

The great frequency with which Ascaris lumbricoides is found 
in the Philippine Islands and the unusual number of cases which 
have been reported recently in which the worms have been the 
direct cause of death or important secondary causes, through mi- 
gration into the liver or pancreas, makes the study of their 
development of considerable importance to us, for it is only 
through a knowledge of the development, whereby we may ob- 
tain knowledge of the means of infection, that we may expect 
to decrease or eradicate these worms in the Philippine Islands. 
It was with this idea in mind that the study of this interesting 
form was undertaken ; and, although my work so far has resulted 
in nothing of great moment, I think that some of the facts 
which have been obtained will be of interest. 

In my experiments I have depended almost entirely upon 
eggs laid in the laboratory by living worms which have been 
obtained from the morgue through the kindness of Dr. B. C. 
Crowell. It was found that if ascarids taken from the intes- 
tine are placed in Kronecker's salt solution (normal salt solution 
to which 0.06 gram of sodium hydroxide per liter is added) 
they will remain alive and active for from six to twelve days 
and the females will generally lay a large number of eggs. 

To obtain the eggs for experiment, separate adult females 
were placed in glass dishes of the solution and each worm was 
removed into a fresh dish as soon as any eggs were laid. The 
majority of the worms laid eggs only two or three times, but 
some laid as many as eight times before dying. The female 
worms were always kept in the light during the daytime and 
the eggs were generally, although not always, laid at night. 

The eggs laid in Kronecker's solution differ in no way from 
those which are found in faeces. The commonest form is the 
typical oval egg consisting of a rounded mass of protoplasm 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

19 



20 The Philippine Journal of Science wis 

surrounded by a shell composed of 2 thin tough layers of chitin 
with a thick outer albuminous layer raised into blunt knobs or 
mammillations. In addition to this form, the various atypical 
forms which are sometimes encountered in fasces were also 
found in the laboratory. The smooth eggs without an outer 
albuminous layer of shell, which have sometimes been considered 
to be the eggs of another species of Ascaris, are the commonest 
atypical form. They are always laid in the laboratory after 
the worm has been kept in Kronecker's solution for some days, 
and are undoubtedly due to the failure of the glands of the 
uterus to function on account of lack of nourishment. Among 
the eggs obtained from 56 female ascarids, the first laying 
consisted of typical mammillated eggs in every case except one 
in which eggs were laid. In those cases where the worm con- 
tinued to lay eggs the albuminous layer became thinner and 
in the last layings obtained disappeared entirely. 

THE DEVELOPMENT OF THE EGGS 

The time required for development of the eggs under natural 
conditions is much shorter than in countries farther north. 
Most European and American authors state that the time of 
development is from several weeks to six or eight months. 
During March, April, and May eggs developed in from ten to 
fourteen days when kept in the laboratory at the ordinary 
temperature. 2 The eggs developed more rapidly and more reg- 
ularly on the surface of moist earth or on earth covered with 
a thin layer of water than in any other medium. Development 
was also rapid in tap water, pond water, and Kronecker's solu- 
tion when the eggs were spread out in flat dishes. In distilled 
water the development was very irregular, most of the eggs 
dying before the embryos were formed. In solutions containing 
0.5 per cent of hydrochloric acid, 0.5 per cent of carbolic acid, 
or 3 per cent of acetic acid, the eggs commenced their develop- 
ment very quickly and developed at first very rapidly, but after 
a few days development ceased entirely and the embryos died. 
Since performing these experiments, I have read of some work 
on the development of the eggs of the pig and calf ascarids 
in which solutions of various acids of the strength of 1 part 
in 1,000 were used, with the result that the development was 
very much accelerated and continued until the embryos were 

2 The most rapid development I have found reported is by Leuckart, who 
developed the egjrs in fourteen days by keeping them in an incubator at 
30° C. 



x. b, i Wharton: Eggs of Ascaris himbricoides 21 

completely developed. It will be interesting to determine if 
the eggs of these forms are more resistant to acids or if a dif- 
ference of 3 parts in 1,000, of, say, hydrochloric acid, is suf- 
ficient to stop the development. In weak solutions of formalin 
and of potassium permanganate the embryos also began to 
develop, but died in a few days. The imperviousness of the 
shell is a source of constant surprise. On two occasions the 
uterus of a female containing eggs was left in 3 per cent nitric 
acid over night to fix it for sectioning and later it was found 
that the eggs had divided into 2 cells. 

A small amount of moisture is a necessary requirement for 
the development of the eggs, although drying does not kill them. 
Eggs dry out so quickly on glass plates that they do not begin 
to develop. After fourteen days and again after twenty-one 
days some of them were placed in water; they began to de- 
velop, the first in twenty-four hours and the others in less than 
forty-eight hours. Some eggs were allowed to dry on earth. 
As the earth dried out very slowly most of the eggs began to 
develop. As soon as the eggs became dry the development 
ceased, but began again when the earth was moistened. 

The eggs will not develop without oxygen, although the 
amount needed seems to be very small. If one or two eggs 
in a drop of tap water are sealed in a hanging-drop slide they 
develop as well as when exposed to the air. However, some 
eggs were introduced into water which had been boiled and 
were covered with a layer of oil to prevent the entrance of air; 
none of them had begun to develop after seven days, but they 
did not die as they began to develop as soon as they were placed 
in fresh water. If a large mass of eggs is put into a deep 
narrow dish with a small surface they will not begin to develop. 
I have kept them in this way for a month without results ; they 
began their development as usual as soon as they were put into 
fresh water in shallow dishes. 

Temperature undoubtedly has more influence on the devel- 
opment of the eggs than any one other factor. The most 
favorable temperature for development is about 30° C. At 
37° development will begin, but all of the eggs die either in the 
4- or the 8-cell stage. If eggs which have partially developed 
are placed in an incubator at this temperature development 
immediately ceases and they die. Exposure of the eggs to a 
temperature above 37° rapidly causes death. When eggs are 
spread on glass and dipped into water at a temperature of 70° 
for five seconds none of them develop. Eggs which contained 
well-developed embryos were placed in tap water at 70° and 



22 The Philippine Journal of Science vsas 

allowed to cool. They were all killed. This point undoubtedly 
is of considerable practical importance in preventing the spread 
of infection. Many fruits and vegetables which are commonly 
eaten raw can be dipped into water at this temperature without 
being injured. 

Moderately low temperatures simply retard the development 
without killing the eggs. Eggs kept for twenty-four days at 
a temperature between 5° and 12° showed no traces of devel- 
opment. At the end of that time they were placed in the labo- 
ratory at ordinary temperature and developed into adult embryos 
in fourteen days in the same medium in which they were kept 
throughout the experiment. 

THE HATCHING OF EMBRYOS 

The embryo, when ready for hatching, is a small worm with 
a blunt anterior and a pointed posterior end. It is coiled in 
the shell and moves almost constantly as long as it is alive. 
It is from 0.12 to 0.20 millimeter long and from 0.014 to 0.02 
millimeter in diameter. In tap water and in salt solution the 
embryos remain active for from one to three weeks. On damp 
earth and in water which contains a large number of algae a 
great many of the eggs hatch, but the young worms die very 
soon. 

In a recent paper A. Martin 3 presents some very interesting 
results of work on the eggs of Ascaris from the calf, pig, horse, 
and dog. He conclusively proves that the embryos of these 
ascarids hatch best in alkaline solutions, and that when devel- 
oped eggs are introduced into the alimentary canal of an animal 
they pass through the stomach unaffected and only hatch after 
they have been subjected to the action of the alkaline juices in 
the intestine. He finds also that none of the juices of the ali- 
mentary canal are able to digest the chitinous layers of the 
shell, that the embryos always emerge through a V-shaped 
opening which appears in the end of the shell, and that the 
shell passes out, undigested, with the faeces. He is of the opin- 
ion that the hatching is due to stimulation of the embryos by 
the alkaline substances in the intestine and by the increase in 
temperature, and not to any action of the juices on the structure 
of the shell. 

He found also, in the cases of the embryos of the calf and 
of the pig ascaris, that it was necessary for the embryos to be 
completely developed before being fed to an animal, or placed in 

Mm/, d. Set. natur. (1913), Nos. 1 and 2. 



x, b, i Wharton: Eggs of Ascaris lumbricoides 23 

artificial juices, at 37°, as any embryos which were not com- 
pletely developed were always killed by the rise in temperature. 
The ascarids of the horse and dog were able to undergo their 
complete development and hatch in artificial pancreatic juice 
at a temperature of 37°. 

My experiments in hatching the eggs of Ascaris lumbricoides 
have not been conclusive except on one point, and that is that 
the embryos must be completely developed before they are in- 
troduced into the alimentary canal. Artificial gastric and pan- 
creatic juices have no apparent effect on the structure of the 
shell, but I have not been able to hatch the embryos with any 
degree of regularity. This is probably due to faulty technique, 
as in other respects the action of these eggs closely parallels 
Martin's results on the pig ascaris. 



THE OCCURRENCE OF BACILLUS COLI COMMUNIS IN THE 
PERIPHERAL BLOOD OF MAN DURING LIFE 1 

By E. H. Ruediger 

(From the Section of Sera and Prophylactics, Biological Laboratory, 

Bureau of Science, Manila, P. I.) 

THREE TEXT FIGURES 

While infections of the body tissues by Bacillus coli communis 
are extremely common, and while there is every reason to 
believe that the spread of the infection in a large number of 
the cases takes place by way of the blood stream, it is remark- 
able how few cases of blood infection with Bacillus coli -com- 
munis during life have been reported. Brian 2 reported 6 cases 
and Tidy 3 reported 3 cases. All of the cases reported by 
Brian recovered, while of those reported by Tidy 2 had died 
and the third was still in the hospital practically unimproved 
when the report was written. 

During routine bacteriologic examinations of blood at the 
Philippine General Hospital, 4 cases of blood infection by Bacil- 
lus coli communis came under my observation. Two of the 
cases proved fatal and 2 ended in recovery. 

Case 1. — The patient, an adult Filipino, was moribund when 
the bacteriologic examination of the blood was made on July 
10, 1912, and died within twenty-four hours. Ten cubic centi- 
meters of blood were obtained and put into 200 cubic centi- 
meters of citrated glucose bouillon. A profuse growth appeared, 
and there was gas production in the broth. On studying the 
organism further, the following biological and cultural charac- 
teristics were brought out: a short motile bacillus; in nutrient 
broth it produces uniform clouding, and a pellicle forms within 
a week. It grows readily on nutrient agar and produces gas 
in nutrient agar that contains glucose. Litmus milk is turned 
acid and is coagulated, and on potato it forms a large brownish 
growth. Diagnosis, Bacillus coli communis. 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

2 Deutsch. Arch. f. klin. Med. (1912), 106, 379. 
3 Lancet, London (1912), 2, 1500. 

25 



26 



The Philippine Journal of Science 



1915 



Case 2. — An adult Filipino was admitted to the Philippine 
General Hospital under the care of Dr. P. K. Gilman on 
August 27, 1914. The following diagnosis was made: Vesical 
calculus, chronic cystitis, chronic nephritis, amoebiasis, broncho- 
pneumonia, ulcerative gastroenteritis, trichuriasis. A bacterio- 



I1IH 



B. Coli in Blood 



/VS. 2 



39 
38 
37 
36 
35 



ZT- 



It 



TO 



2E=^2 



is: 



*-* 



: 



H 



a 



m 



* 



E 



fc^ 



* 



Fig. 1. Showintr temperature of case 2. 

logic examination of the blood was made on September 29, 1914, 
and a pure culture of Bacillus coli communis was obtained. The 
patient died within twenty-four hours after the blood was taken 
(see fig. 1, chart for case 2). 

Case 3. — An adult Filipino was admitted to the Philippine 
General Hospital on September 7, 1914, complaining of orchitis. 
On September 11, 1914, he was operated upon for tuberculous 




Fig. 2. Showing temperature of case 8. 

epididymitis. On September 27, 1914, the temperature rose 
to 38° C., and on the following morning the thermometer re- 
gistered 38°.8 C. A blood culture made on September 29, 
1914, yielded a profuse growth of Bacillus coli communis. 
The temperature remained high and irregular and dropped sud- 



x, b, i Ruediger: Bacillus coli communis in Blood of Man 



27 



denly from 39° C. to 36°. 8 C. between the evening of October 4, 
1914, and the morning of October 5, 1914. After that the tem- 
perature remained low and recovery was rapid. 

The serum obtained from patient 3 on October 5, 1914, ag- 
glutinated the organism obtained from his blood at a dilution 
of 1 : 200 ; the organisms from cases 1 and 2 and a stock strain 
of Bacillus coli communis and Bacillus typhosus were not ag- 
glutinated at a dilution of 1 : 50 (see fig. 2, chart for case 3). 

Case I*. — An adult Filipina was admitted to the Philippine 
General Hospital on September 25, 1914, complaining of fever 
and general sick feeling, which began three days after she had 
been confined two weeks previous. Examination showed a 
bloody discharge from the uterus. On October 2, 1914, 10 cubic 
centimeters of blood obtained from a superficial vein in the arm 
were put into 200 cubic centimeters of citrate-glucose bouillon, 




Fig. 3. Showing temperature of case 4. 

and a pure culture of Bacillus coli communis was obtained. The 
temperature of the patient was very irregular and recovery 
was slow. 

Blood serum obtained from patient 4 on November 5, 1914, 
agglutinated the organism obtained from her blood in a dilution 
of 1 : 400 in six hours. The organisms from case 2 also was 
agglutinated in a dilution of 1 : 400 in six hours, while the or- 
ganisms from cases 1 and 3 and a stock strain of Bacillus coli 
communis and of Bacillus typhosus were not agglutinated in a 
dilution of 1 : 25 (see fig. 3, chart for case 4). 

CONCLUSIONS 

1. Microorganisms corresponding in morphological and cul- 
tural characteristics to Bacillus coli communis may in certain 
cases be obtained from the peripheral blood of patients during 
life. 



28 The Philippine Journal of Science 

2. Invasion of the blood stream by such organisms is not nec- 
essarily terminal infection, as is shown by the large percentage 
of recoveries therefrom. 

3. Such infection may be considered primary as is shown in 
case 3 here reported. 

4. As a peripheral infection like that of case 4 the bacillus 
may enter the blood stream through the infected uterus. 

5. The agglutination test shows that these organisms differ 
from one another. 



ILLUSTRATIONS 

TEXT FIGURES 

Fig. 1. Chart showing temperature of case 2. 

2. Chart showing temperature of case 3. 

3. Chart showing temperature of case 4. 

29 



THE PREPARATION OF TETANUS ANTITOXIN i 

By E. H. Ruediger 

(From the Section of Sera and Prophylactics, Biological Laboratory, 
Bureau of Science, Manila, P. I.) 

EIGHTY-FIVE TEXT FIGURES 

Notwithstanding the fact that tetanus antitoxin is extensively 
used in practically all countries of the world, very little has been 
written about its preparation in recent years. 

Eisler and Pribram - advise the injection of tetanus toxin 
and iodine trichloride for the first three months of the time 
that a horse is being immunized against tetanus toxin. This 
is followed by another three months' treatment with tetanus 
toxin alone. Although weakening the tetanus toxin by mixing 
it with iodine trichloride saves the lives of many serum horses 
and is almost indispensable when tetanus antitoxin is not avail- 
able, it is now rarely used; the horses can be, and now usually 
are, fortified with the antitoxin. 

In order to obtain good antitoxin, good toxin is indispensable. 
Good toxin usually can be obtained by growing suitable tetanus 
bacilli in glucose broth under anaerobic conditions. In my ex- 
perience the following procedure has given fairly good results: 

To 500 grams of chopped lean beef add 1,000 cubic centimeters of dis- 
tilled water and boil for one hour. Enough water should be added to 
allow for evaporation. Allow the infusion to cool; strain and add the 
following: Witte's pepton, 20 grams; sodium chloride, 5 grams; glucose, 
10 grams. 

Prepare the broth in the usual way and with sodium hydrate solution 
reduce the acidity to about 0.5 per cent normal acid. Pass the broth 
through a paper filter, sterilize it in the autoclave, cool it rapidly in run- 
ning water, inoculate with tetanus bacilli, and incubate it under hydrogen 
at a temperature of from 36° C. to 37° C. for from seven to ten days 
(rarely fourteen days). After having been incubated sufficiently long, the 
broth is rendered germ-free by passing it through a sterile germ-proof 
filter. Phenol, in the proportion of 0.5 cubic centimeter per 100 cubic centi- 
meters of filtrate, may be added. The reaction of the filtrate will be 
about 2 per cent normal acid. This should be reduced to practically 
neutral by adding sodium hydrate solution. An acid filtrate produces 
severe local reaction on subcutaneous injection, while after the injection 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, November 4-7, 1914. 

2 Kraus und Levaditi, Handbuch der Technik und Methodik der Immuni- 
tatsforschung. Gustav Fischer, Jena (1909), 2, 139. 

31 



32 The Philippine Journal of Science ms 

of neutral or nearly neutral filtrate (not more than 0.5 per cent normal 
acid) the local reaction is comparatively mild. 

The toxin obtained by this method will usually be such that 
0.0001 (1/10,000) cubic centimeter when injected under the 
skin of a 300-gram guinea pig will prove fatal within five days. 
Toxin of which 0.00005 (1/20,000) cubic centimeter killed the 
guinea pig within five days has frequently been obtained, and 
in one instance the filtrate was such that 0.00002 (1/50,000) 
cubic centimeter killed a 300-gram guinea pig within five days. 

Recently good toxin has been obtained by the method de- 
scribed by Ivan Hall. 3 His method is as follows: 

1. Mix distilled water '. 1,000 c.c. 

NaCl (C. P.) 5 gr. 

Pepton (Witte) 10 gr. 

Beef Extract (Armour's soluble beef) 5 gr. 

Dextrose (Commercial) 10 gr. 

MgCOa (finely powdered commercial) 5 gr. 

2. Determine gross weight. 

3. Dissolve by boiling and stirring. 

4. Restore the original weight with distilled water. 

5. Cool overnight to precipitate the phosphates. 

6. Filter through coarse paper. Reaction should now be found 

faintly alkaline to phenolphthalein. 

7. Add 2 gm. MgCOs and mix thoroughly. 

8. Pour into Florence flasks to shoulder. 

9. Cover to a depth of 2 cm. with hydrocarbon oil (Langley & 

Michaels, San Francisco) . 
10. Sterilize in the Arnold 3 successive days, 40 minutes each time. 

On the following pages are reported the methods of immu- 
nization and the results obtained from 8 horses at the Bureau 
of Science, Manila, P. I. 

HORSE l 

Horse 1 in this series was given about 1,000 units of tetanus 
antitoxin 4 on June 4, 1911, and another dose of about 1,000 
units on June 23, 1911. Tetanus toxin was given at short 
intervals, and the quantity was rapidly increased. 

During the first three months 26 injections were given, and 
at the last injection the horse received 600 cubic centimeters of 
toxic filtrate. It became evident that the injections were being 
pushed too rapidly, so the horse was allowed to recuperate. On 

* Univ. Calif. Publ. Path. (1913), 2, 98. 

4 Unit of tetanus antitoxin refers to the standard unit of the United 
States of America. The quantity of antitetanic serum which neutralizes 
the test dose (approximately 100 minimal lethal doses) contains 0.01 of a 
unit of antitoxin, hence a unit may be said to neutralize 1,000 minimal 
lethal doses of toxin tested on guinea pigs weighing 350 grams o:\oh. 



X, B, 1 



Ruediger: Preparation of Tetanus Antitoxin 



33 



September 11, 1911, another injection of 750 cubic centimeters 
was given. The serum was tested for antitoxin and was found 
to contain 150 units per cubic centimeter. On September 20, 

1911, the horse was bled 3 liters and three days later was bled 
2 liters. 

Beginning with October 2, 1911, the injections were given at 
intervals of a week and the doses were increased more gradually. 
A test sample of blood taken in the latter part of October con- 
tained 350 units of antitoxin per cubic centimeter of serum. On 
November 1, 1911, the horse was bled 3 liters. The injec- 
tions were continued at intervals of a week and on November 
30, 1911, 3 liters of blood were withdrawn. The serum con- 
tained 500 units of antitoxin per cubic centimeter. After this, 
the antitoxin content in the serum rose more slowly, testing 
600 units per cubic centimeter on December 31, 1911, and the 
horse had lost much flesh. Still expecting to drive the antitoxin 
content higher, the injections were continued; but instead of 
rising, the antitoxin content began to fall. On January 25, 

1912, the horse was bled 3 liters and the serum tested 500 units 
per cubic centimeter. 

This horse received a total of 8,856 cubic centimeters of toxin, 
was bled 14 liters, and furnished about 5,600 cubic centimeters 
of serum, or 1,920,000 units of antitoxin. Deducting 50 per 
cent as allowance made for deterioration and accidental losses, 
we can count on marketing 960,000 units (see figs. 1 to 9, charts 
1-A to 1-1, for horse 1). 



1111 Tetanus Ji. 1 A 


Ju N E / 2 


3 H 


S (. 


7 


t i 


10 


// 12 


13 


It 11 


it 


n i% 


n 


20 


21 


21 


23 21 


if 2 b 


21 


2$ 


21 


30 














1 












\ 
































































°C. 
























































































•JO _* 




A 


v, 5 




A 




































-,/ J-i 


l\i 


a ^ 


^2 






A 


' A, 


r, , 


, ,n y 






































' 7 


* 


, v 


v 


, ■- 


V* 1 


> K 


1 


1 


1 s/^ 






"■ 


: 


uZ - 








































■I 
















































17 












1 


















1 




1 


















0' 




<V 


)' 


a 












<-> 

o 










Oq 





FIG. 1. Temperature chart of horse 1 for June, 1911. 



/?// Tetanus M.1 b 


July / x 3 y s fc 7 $ 1 10 it n >i n is it, n it it 20 21 21 23 314 is it, n is if eo 31 






°0. x 


+ 1 


on _ __ ____ _£__ __£ 


J9 — " n _t 


_ □ 




« -«■ 5 H 1- T 


oo . 2 S _ _£,_ _ _ _c_* d_L jc 


OO ft " ~ Z*2Z ^S^- «_ w „sl L I 


i c^5 _ ^ 25 ,5 4 >. -j 5_,3 _j v v t t -. ,.-£ 


s *_, ..ai C* c -» j_i._7 . * _ z v ^2 7 ^^i ^„^_ 




__---■--■■ v y 1 


/ ■ 



Fig. 2. Temperature chart of horse 1 for July, 1911. 



132195 3 



34 



The Philippine Journal of Science 



1915 



1111 



Tf T*NU « 



M. I c 



A jt / a 3 v s t i ? i tc u ix 13 ii is it, n it il zo zi xz z* zi is zh zi z? z? 30 M 

1 — 1 — rrn — 1 — 1 — 1 — 1 — m — r.n — 1 1 1 — 1 — 1 — 1 — 1 — 1 — 1 — i -1- * — rl — I > ' i 




Fig. 3. Temperature chart of horse 1 for August, 1911. 



mi 



■I z I 3 i V I S I 6 I 7 I I J 



Tet*uus 



•>Kl J D 



as i .a. .~ ? 3 i j A 7 *Jf |a?" 30 



" 'iJiL ''>' !S l4 > '? l% '? aa A' Xi,:3 




_.r 



4 



38 



37 



^ 



fe 



"/4£ 



i=l^ii 



1 



:; = :;: 



±fflit££ 



■ f:' 






.x. 



Fig. 4. Temperature chart of horse 1 for September, 1911. 



n/i 



J/'o.l f 



Oct. I 1 I a [ 5 | 1 | 5 I t I 7 I t I 7 I /o I ;/ \11\13\11\1s\1b\n \is\ii[iq[zi \2z.\zi\i'i\is\x>.\z-\xi\i<. 




Fig. 5. Temperature chart of horse 1 for October, 1911. 



mi 



Tetat. us 



Jlfo. i f 



No J. !Z3l$l-i?^tO 



1 H /■? 2? 2/ 23 2J J v - > J( 27 ;i if 30 



Eli 



39 



38 



3 7 



t^ 



i= 



L 



=^ 



£m? 



=3 



2*££ 



:±± 



/ 






^p^ 



V- 



, 



W^B* 



1 



Fig. 6. Temperature chart of horse 1 for November, 1911. 



IVl ■ TlTANUS Jfc-l & 


Ore I X i f s t T I 


1 /« // /j M .'. >t n n ;l .f 3 j ii 

::::::::: :r::::::± 


2 1 2 .» XI IS 2 fc - 


7 2 1 If .< 

■ 


a *i 


39 iPitlliB 


: J:::::.::: :.J:fi: :: 


" - IE pE== 


1 .. 




08 =5-ca;s; 

•> 7 J" X - 


tJTntfc 4JJ/H 1 


__ E 








PI u 


0' 




■; 



FlC- 7. Temperature chart of horse 1 for December. 1911. 



X, B, 1 



Ruediger: Preparation of Tetanus Antitoxin 35 



ITU Tetanus M. 1 H 


Jam. / A 3 H s t> 7 J 9 /o // 12 13 /f is .. /: /? /f jo 21 21 13 24 *^ it, i? *? 5? 50 3; 


_ ______ __ __ ^~~ 




°G. 






jy _~_ 6 s 


t, ' i-_L 


-P.-- t-«. ' S5T c- 


' "^ 1 V^ j * £* A ^ / ^ 


_ - ___s, , )_ _____-*, _____.E__i_ :l_i«--_--s 


«JO D W R ki^_*I 3~ x I <v"_;=>.2 ' »^_a 3 22 ---- ^"=>"2-s> = = 


/ Vu^^-J \ /»_■ <> J _ __u - 




. 2 


07 r.l 


--- *•* N eo-> *>£ 



Fig. 8. Temperature chart of horse 1 for January, 1912. 



MONTHS 


/ 


2 


3 


4 


5 


6 


7 


8 


9 


to 


// 


/<? 


600 
500 
400 
300 
200 
100 


















































































1 
























1 








































/ 

























Fig. 9. Chart showing the antitoxin curve for horse 1. Units per cubic centimeter by months. 

HORSE 2 

The immunization of horse 2 was begun on July 2, 1911. It 
was fortified with 2,500 units of tetanus antitoxin, 750 units 
of which were given on July 2, 1911, 750 units on July 15, 1911, 



36 



The Philippine Journal of Science 



1915 



and 1,000 units on August 1, 1911. The injection of toxin was 
begun with 0.01 cubic centimeter nitrate given at intervals of 
three or four days, and the doses were rapidly increased. During 
the first three months 21 injections were given, and at the last 
injection 1,000 cubic centimeters of toxic filtrate were given. 
On September 27, 1911, the serum was tested; it contained less 
than 50 units of antitoxin per cubic centimeter. 

After September the doses were reduced and the injections 
were given at intervals of a week. On November 10, 1911, the 
horse was bled 3 liters, and the serum contained 75 units per 
cubic centimeter. Three liters of blood were withdrawn on 
December 21, 1911; the serum obtained tested 100 units per 
cubic centimeter. The injections were continued at intervals 
of a week; on February 23, 1912, the horse was bled 4 liters, 
and on February 29, 1912, it was bled 5 liters. The serum 
contained 150 units per cubic centimeter. 

Horse 2 received a total of 8,806 cubic centimeters of tetanus 
toxin; it was bled 15 liters and produced about 6 liters of anti- 
toxic serum or 750,000 units of antitoxin. Deducting 50 per 
cent of antitoxin as allowance made for deterioration and other 
losses, we have left 375,000 units for marketing. 

At this time there was very little demand for antitetanic serum 
or the horses would have been bled more, as will be seen later 
(see figs. 10 to 18, charts 2-A to 2-1, for horse 2) . 



IVl Tetanus JVo. 2 ' 


Juur 1 X 3 15 4 7 t 1 10 It IX 


13 11 l£ lb n It 1-1 -O 11 JZ 23 XI XS Xk 


11 It : 


1 J' J. 


















°C. ■"-_ — z ~~ z~~ z\z z : 
















OQ 


......... \ ■ \ M 


-± 




«*" ._,&__ _ fr - 




J* u 




- A v "•,.*>, ^ - A s /- >-,V 


; = =.;5j5p=. ~z_c^s ^z^zs. ~*= 


ZZ3^^ 


,-X-r- 


£ *"7 M * <r * u ? # - 




1 '•" 


-r 






x 


.- - 


17 __ ;__;iz _z_. 




1 






i % - « » 
■ ; s » • o 

k «• k ►; u 


* 


K 



Fig. 10. Temperature chart of horse 2 for July, 1911. 




Fig. 11. Temperature chart of horse 2 for Autrust, 1911. 



x, b, i Rttediger: Preparation of Tetanus Antitoxin 37 



J 111 Tetanus JVo. 2. - 


S i ft. /a 


SVft 7 i 1 10 11 


/_ /8 11 IS It 17 It 19 Xo XI 12 23 21 25 !<• 27 J I 21 JO 












ll 


"C. Z Z _ 


- M _ _ _ _ 


A 




jfi :___ _ ___ 


_ __:_ _:__c" :_; 


f»o :::: 


_HJ___ JL 


. . ~. , , t, . , 1 i *s : 


08 "" 


_ _ __. _ _ _ _ 8 


^ : ::::::::±S ; _ 




:.::±::::_ c 


IN 




"::± :::::: _ _ 


x ::::±::\ 


"___ 


_t__x_* 


_s _ — jt — c - ; _X 


OQ 2 


:___:fc_3 j_ 


__ ______& at 3_ ____**,,__ _ __ x 


•»« -IE* 




•f.s" > e;"i f: k , \.* v *-~. *: 




___-i£__e~2_ ;? ___-_ 






"i.cx::.- 


_Z- : x _ _____ ± 




_____&____ 


___ -_ __ X . . X 


17 -___ 


_____t________z 


....... . _~ X . . . T"^ 




g 
5 S 


_ *a o 

o *_ 



Fig. 12. Temperature chart of horse 2 for September, 1911. 



nu 



Tetan us 



^fS.i o 



Oct. / 2 3 « \£ t 7 _s_ ? /o ii n 13 il is it n it 11 20 21 i_ 23 21 2s -6 27 -s 11 30 31 




ii 



39 



38 



37 



u 



_=_ 



___ = 



s;==* 



Fig. 13. Temperature chart of horse 2 for October, 1911. 



nu 



Tet/h 



J& -I « 



NOV. I 1 3 t S k 7 9 1 10 II 12 13 II If l& 17 18 II 20 21 22 23 21 25 2b 21 2? 21 30 



39 



38 



37 



* 



F 



55 



=53: 



fefe 



= = 5 



__=_ 



: ^ 



*?.' 



;--P--?: 



^ 



Fig. 14. Temperature chart of horse 2 for November, 1911. 



111! Tetanus M. 2 F ^ 


Dec. I 23 v 5 b 7 s 1 io u ix 13 n is it n i? ii 20 21 22 23 21 if it> n 2% 11 30 31 


1 1 




°C 




lOli A 


»jy fc ft ______ _ _ 


\-ZZZ ___ _ L . ft 


E 1- "--■ 


- X -, C_ -» _3 


qo a n / ^ s h f- ■ 1 


»* *_ £ 3 _ _ _ _~_3 _~__5 *„«, »X v _ a~^""j v,* _ _ ~_^ 


v -a V ."v^"*/"./ vi v^ , v"> A, p»_<\ ^vi v ^ V> A ^v <> 


«/ " ' ' V- v 1 ^ V V 




•>7 ______ _ _ _ _ _ X __ 





Fig. 15. Temperature chart of horse 2 for December, 1911. 



38 



The Philipi)ine Journal of Science 



1916 




Fig. 16. Temperature chart of horse 2 for January, 1912. 



n/2 


Titanus J 


.2 H 


F l B ■ 1 23454774/0 


! 12 IS It IS lb 11 /S - M 20 21 22 23 2 •/ 2 f 2 


6 J? ii J" 




_|_ , 
















°c. 
















39 zzzzz zzzzl- --------- - 


FI-: '-=—=:— "±:-=-::n 


- -r 


... 


__ __ts i 


-'^A- ------------ -----i----z-^ 


------zzzzzh 


4 


38 &E!i=i£==!i=i^;= 


g = rr^-^|=-|||:-^- + ^- 


**:^£EE 




37 ±±j±i_j_±±±_i_±. 

o 




r- 
' ; 


— 



Fig. 17. Temperature chart of horse 2 for February, 1912. 



MONTHS 


/ 


2 


3 


4 


5 


6 


7 


8 


9 


/O 


// 


f2 


200 
/OO 











































































Fig. 18. Chart showing the antitoxin curve for horse 2. Units per cubic centimeter by 

months. 



HORSE 3 

Immunization of horse 3 was begun at the same time as that 
of horse 2, and the two received practically the same treatment. 
This horse produced much stronger antitoxin than did horse -1 : 
in February, 1912, when the serum of horse 2 contained 150 
units of antitoxin per cubic centimeter, the serum of horse 3 



X, B, 1 



Ruediger: Preparation of Tetanus Antitoxin 



39 



contained 400 units of antitoxin per cubic centimeter. The anti- 
toxin content reached its highest mark at the end of the eighth 
month. 

Horse 3 received a total of 8,806 cubic centimeters of tetanus 
toxin; it was bled 15 liters and produced about 6 liters of anti- 
toxic serum or 1,400,000 units of antitoxin. Deducting from 
the antitoxin 50 per cent as allowance made for deterioration 
and accidental losses, we can count on marketing 720,000 units 
(see figs. 19 to 27, charts 3-A to 3-1, for horse 3). 



1111 Tetanus M. 3 A 


July 


/ 


z 


I. 


'..' 


j- 


b 


7 


I 


•7 


10 


// 


11 


13 


: | 


:•• 


It 


i 7 


", 


'■? 


-' O 


1 1 


n 


23 


21 


is 


Zb 


1 7 


1 ! 


11 


!-) 


3 1 


°G. 
38 

37 




















1 


























































































































































































































■f 
























- 














" 












































'•■ 






-t- 




- 


* 


s? 






•> 


n 


H 


,= 


W 


? 


7^ 


V 


f 


<J 


-j 


s/ 


*j 






- 


; 


s/ 




V 




- 










~ 






- 




f 














= 








7.? 


ilU- 








T 




















































































































I 


© 






v> 








** 






> 




| 




^ 






* 








> 






N 




- 







Fig. 19. Temperature chart of horse 3 for July, 1911. 



Hi! Tetanus M. 3 B 


Aue ■ 1 i 3 </ 


4. UJLlJU * UzUl 


W iiiil, '• 


- li 17 |/S 11 30 11 It 13 \lt IS It, 17 Z1 11 30 31 




-■- 44 H 


;= :: 


|. I ' -- 


°°- ->-— -t;E 


i±#±H4±= 




EE=ifer:-:E#EF-EE#EEEEEEEEEf 


,fA _ - - -- 


I 1 ill 




In: 


4U r 


— +-4T-4T-P- 


i _, 


:::!::::::::::::::::::: -::::E 


39 FEEE: 


W#tNira^ 


EEB=== = 


=E=|E==i=Ejj==E=^EE=EE=Ss=E=E 


. ,_ 


i i 


r r ' " 


rrrW 


^Pr^rW 


A : A "1 


rfSditttf^ 


88 5*15 


K«i?¥ 


^: .... 


: ^T^mWfflr^rffl™ 




r i > i 




k * j 




i M : 


j 


i 


IT M ! 


l t I 1 ! 1 1 


_LL - J 


III: 






.!. i... 


V," Q ° ^ o 



Fig. 20. Temperature chai-t of horse 3 lor August, 1911. 



/?N Tetanus M. 3 e 


Sept. / i 3 ■< Sr ] 4 7 ? i /o it n 13 i'I is it. n /» r» " 2/ iljs ihzs n, n it 11 30 


" ■- -- ■- ■- : — 1 ■ ; 




C£ - j 1 _ _ ___- 


1 D /I 


-i n ■ - n i 


4U - --ft - H- -jr ~ ---- ---- — ;t" 


M r 1 . . 


! \ J 


" du» -P 


on ., \ A i \ 


' J J \ \ v 1 


\ 1 v \ ■■■ I > 


i il L'v ' N i 


A v . -i \ A ' ! 1 1 A./*..'-., 


oq c_L._2fc,J \ * a A l^ '..,;! \ ^ l - -v • ;:: 


00 _^ \ M ^»! i? S^ 11 L v ::.,, ,; i / r£_i"^*«">^' ._ 




f" - 1 


! 


97 ,1 1 i ......... 


« 1 1 £'2 
** S 1 »2ot 



Fig. 21. Temperature chart of horse 3 for September, 1911. 



40 



The Philippine Journal of Science 



1915 




Fig. 22. Temperature chart of horse 3 for October, 1911. 



nn 



Tetanu s 



M.3 E 



Nov- i _i_ 3 u s b 7 S 1 io ii [iz 13 m is /»!/; n\ii 2o\n\n 23 if Mil ;nl :Z?l3« 



39 



s 



55=; 



ii 



38 



37 



55 



IP 



=5* 



£*: 



t») 



ra 



5=3 



£A 



Flo. 23. Temperature chart of horse 3 for November, 1911. 




FlO. 24. Temperature chart of horse 3 for December, 1911. 




Fig. 25. Temperature chart of horse 3 for January. 191] 



x, b, i Ruediger: Preparation of Tetanus Antitoxin 



41 



111* Tetanus *M>. 3 H 


Fes. / 2 3 '/ 5 fc / i 9 /o // r_ /a /v /J n n it /? zo 21 zz n xi is zh n i-i j.i 












4jj__j_ _ _+ - __ _______ 


1 ' 


:.:::ts::: t 


3 _!_ 


•>Q _ _: _ ___ _ -E-- - -- - - 


«>y — 5 


l _, 


i- - - % 


1 \ V 




»>o J°c rj v v ~ ^ * A *'_%";.n 7 ■ <. ■ „ ;_; n v,^J. 


^_ A ^J_J- ^v^v"/ V_J v S & A A ' -■ y -■" v v» -. 


1 i \JT ^ v j 


_t _ ± _t_ _ 


T7 ■ ' 





Fig. 26. Temperature chart of horse 3 for February, 1912. 



MONTHS 


/ 


_? 


3 


4 


5 


6 


7 


4 


? 


/o 


// 


/_? 


A 00 
300 
200 
/OO 































































































































Fig. 27. Chart showing the antitoxin curve for horse 3. Units per cubic centimeter by months. 

HORSES 4 AND 5 

On June 1, 1913, the immunization of horses 4 and 5 was 
begun. Each horse was fortified with 2,500 units of tetanus 
antitoxin, 1,500 units being given on June 1, 1913, and 1,000 
units on July 7, 1913. Beginning with a dose of 2 cubic centi- 
meters, injections of toxin were made at intervals of one week. 
The doses were increased to 1,000 cubic centimeters in four 
months and one week. The serums contained 75 units of anti- 
toxin per cubic centimeter, and each horse was bled; horse 4 
was bled 8 liters, and horse 5, 10 liters. After this bleeding 
smaller doses of toxin were given. In the latter part of No- 
vember, 1913, the serum of horse 4 contained 300 units per cubic 



42 



The Philippine Journal of Science 



1915 



centimeters and 11 liters of blood were withdrawn, about 40 
per cent of which was serum. Horse 5 was bled 12 liters in 
the first week of December, 1913, which yielded about 40 per 
cent of serum that contained 300 units of antitoxin per cubic 
centimeter.. The injections of toxin were again continued. On 
January 21, 1914, horse 4 was bled 6 liters ; the serum contained 
300 units of antitoxin per cubic centimeter. Horse 5 was bled 
10 liters — 5 liters on January 23, 1914, and 5 liters on January 
27, 1914. The serum obtained contained 250 units per cubic 
centimeter. In the middle of March, 1914, the serum of horse 
4 contained 300 units of antitoxin per cubic centimeter and the 
horse was bled 8 liters. The serum of horse 5 contained 350 
units of antitoxin per cubic centimeter, and 10 liters of blood 
were withdrawn on March 23. Horse 4 received one more in- 
jection of toxin and was bled to death on March 31, 1914. At 
the last bleeding 14 liters of blood were obtained which yielded 
about 40 per cent of serum, testing 225 units per cubic centi- 
meter. The antitoxin content in the serum of horse 4 reached 
its highest recorded mark in the sixth month and was maintained 
until death, ten months after the beginning of immunization. 

Horse 4 received in all 14,633.5 cubic centimeters of tetanus 
toxin and was bled 47 liters. It produced about 18.8 liters of 
antitetanic serum or 4,500,000 units of tetanus antitoxin. De- 
ducting from the antitoxin 50 per cent as allowance made for 
deterioration and for accidental losses, we have left 2,250,000 
units for marketing (see figs. 28 to 38, charts 4-A to 4-K, 
for horse 4). 



/?/; 



Tet/.ni 



Ao. y a 



June I I I z s I i I s I fc 7 t 1 I i" I n n 13 it is lb n n /■? u ■■ 



s 



li 



II 



■_ 



38 =5=3E5^E5^E53? 



S-A 



- 



i~zi*&- 



1 



,-A 



37 



Fig. 28. Temperature chart of horse 4 for June, 1913 












1^13 j (TArtus MA b 


July i 2 3 '/ s b 7 & 9 


to /' :z /:» n , i lb n IS /? io It 


J r 2] is 


.- 


■ * 1 


t a 1 


1 SO 


SI 


_ 


Z ZC.Z ~z 




- 


- 


--T-- 






°c. :::: ::;:: : 


— - :--:-:;:::-:-:;±;-;: 


- ■ ■ : 


... 













"i __i . ::x:;:; 








1 






O Q __ 


:::::::::a:.- ^ __x. __j 














oy ~ 


— _ — __y — __.j____p 


: t 


< 












F 
















;:::-"±t?==" = = i = = q: 




r 


i 








38 3" = S = = = « = S = IEa2 B 5 5 a i 

Iz^AziUz'zzz'zz'z 


\lillYzi±z\\zllilp^ 


ffi 






- 1 






37 ±±±±±£±±± 

s. ^ 
. . ■*, " ... . 


:__ 1 i 


_L±:_L 






t 







Via. 29. Temperature chart of horse t for July, 1913. 



x. b, i Ruediger: Preparation of Tetanus Antitoxin 



43 



1113 



Tetanus 



MA c 



ii 13 ii is it, n it it 10 



ii ii 13 ii is it n it 



°C. 

40 
39 

38 
37 



r 



1 



? 



'-■ 



m 



c; 



'-■ 



5;= 



- S 5F 



S^^v^ 



Fig. 30. Temperature chart of horse 4 for August, 1913. 



1113 



Tetanus 



M. H D 



3 1 S b 7 1 ? 10 II II 13 II IS 



i II 10 II 11 13 11 IS lb n Zt It 30 




"C. 
40 

39 

38 

37 



I 



: 



m 



i 



'-. 



^ 



- 



■rr 



Fig. 31. Temperature chart of horse 4 for September, 1913. 



/<?/3 



Tetanus 



MA E 



Oct. 1 i i 3 v 5 b 7 | r '7 \io ii ii a j m \is | /t |/7 ;» /? jo i/ n\n m is zt n iv it 30 31 



39 



38 



37 



m 






i± 



? 



e; 



- 



■ 



a 



w 



- 



*3 



E*?; 



^7- 



I--;- 



^ 



^i 



Fig. 32. Temperature chart of horse 4 for October, 1913. 



W3 Tetanus ->KL 4 f 


Nov. 


. 


1 




S h 


7 s 


j 





a 


« 


3 


n 


t s 


,. 


,- 


.■? 


<? 


10 


£J 


.:;: 


:.- 


i<J 2 


y at 11 


■ : 


« 


30 


39 
38 
37 




1 


1 > 


X 






1 




















1 








1 










I 1 






1 1 


j_ 












































1 












1 


',', 












































'* 1 








'■'' 














h 
























I 1 






•ft 
























V 
























1 






.■ 






1 








1 












/ 






























;£ 














■• 












1 


\ 




























1 


^ 
























'■ 


■ 
































- -<S 


i 






1 












. 


/ 














1 h 










1 | 






/ 




: ?^ 


/ V 


"> 


N 




























' 1 










1, 1 




■ 


* 






/ ' 






s/l 




- 


' 


■ 










' 








/ 


, 1/ 


C . 


*^ 


« /> 


.-'■ 


> ' ' 












V 












- 




• 










1 








H 


>,' 






r 












1 










1 
















































t 




























































it _ 




































1 


-i 






1 








| 










5 














s 
















■j 


"* 







Fig. 33. Temperature chart of horse 4 for November, 1913. 



44 



The Philippine Journal of Science 



1V3 



M.H 6 



Z i 1 S L 7 1 9 10 It IX 



'U> 



°c 
40 

39 

38 

37 



ft 



s 



> 



i; 



»• 



^4^ 



?ss: 



Fig. 34. Temperature chart of horse 4 for December, 1913. 



IV H 



Tetanus 



JVo.H H 



J AH. | / | 1 | 3 I 1 I S \ & I 7 | ? | 9 I/O [ II |/1. |/3 i<1 | /f | It | /7 J / ? | /«? |j»|-/ |al |j3.U<l |l J U» |l7[2t|H~|j»|j/ 



5 



39 



38 



37 



% 



m 



ii 



s=P 



-?^ 



r*^ 



= 5 



33 



s3 3 : 



Fig. 35. Temperature chart of horse 4 for January, 1914. 




Fig. 36. Temperature chart of horse 4 for February, 1914. 




Fig. 37. Temperature chart of horse 4 for March, 1914. 



X, B, 1 



Ruediger: Preparation of Tetanus Antitoxin 



45 



MONTHS 


/ 


2 


3 


4 


5 


6 


7 


8 


9 


to 


// 


12 


300 
200 

too 












































\ 























































Fig. 38. Chart showing the antitoxin curve for horse 4. Units per cubic centimeter by months. 

The injections of toxin were continued on horse 5. In the 
middle of May, 1914, the serum was tested and was found to 
contain only about 125 units of antitoxin per cubic centimeter. 
On May 19, 1914, the horse was bled 6 liters and after that 
was used for other purposes. 

The antitoxin content of the serum of horse 5 reached the 
highest recorded mark in the seventh month, fell about 50 units 
per cubic centimeter in the eighth month, and rose again to, or 
a little over, the previous height in the tenth month, and after 
that it began to fall. 

Horse 5 received a total of 18,433.5 cubic centimeters of teta- 
nus toxin and was bled 48 liters. During one year this horse 
produced about 19.2 liters of antitetanic serum or 4,430,000 units 
of tetanus antitoxin. After deducting 50 per cent for loss, we 
have left 2,215,000 units of antitoxin (see figs. 39 to 51, charts 
5-A to 5-M, for horse 5). 



1113 



Teta n us 



JVo. S A 



JUMC 



38 



37 



?Ee5 



^ 



53 



Wr- 



iz»: 



z£4 



£ 



U 



IM 



~M 



t 



t 



Fig. 39. Temperature chart of horse 5 for June, 1913. 



46 



The Philippine Journal of Science 



1113 



Tetanus 



j\o. 5 s 



°C. 
40 

39 

38 

37 



~A- 



A+ 



tf 



T 



-'■ 



=3 



s 



:5=2?b=? 



•V 



V 



-J 



^ 



w 



¥£* 



fej 



Fig. 40. Temperature chart of horse 5 for July, 1913. 



1113 



Tetanus 



^io. i" C 



40 

39 
38 
37 



f 



eeS 



q 



t; 



•■,<;- 



1 



-■•=- 



y 



A 



2i 



"*■ 



Fio. 41. Temperature chart of horse 6 for August, 1913. 



/?/3 



Tetan u; 



./»«. 5 D 



40 



ii 



s 



39 



38 



1 



1 









= $ 



w 






- 



:«E 



?: 



B± = 



?fc 



lli 



iwls 



i*=JS. 



._:. 






3 7 



4 









±i±: 



Fig. 42. Temperature chart of horse 5 for September, 1913. 




lit. IS. T> eraturc rlna-i of hovse ' for October, 1918. 



X, B, 1 



Ruediger: Preparation of Tetanus Antitoxin 47 



1113 Teta ? U3 ^ r °: 5 . / ■ 

-1 i 1— ~T 1 i ! ; 1 1 1 I I 1 I Pi PI PPT I P I I I __JL __L 



39 



38 



fr 



% 



CV 



tS = : 



= = 



V- 



sta^ 



--,-r 



Fig. 44. Temperature chart of horse 5 for November, 1913. 



1113 



Tetani 



M. 5 c 



S t> 7 J 1 



| J/ I 12. 13 ii ts ii> ( n ft n xo xi 2i x 



^ 2b 27 IS If 30 J 



"G. 
39 

38 

37 



VA-; 



_"£ 



^ 



33? : 



;.". 



7 3 J 



r-v 



Fig. 45. Temperature chart of horse 5 for December, 1913. 



1111 Tetanus M. 5 h 


J«H. 1 :>■ j V 3" * 7 r ? 


It) II IX 13 /■/ IS It n It 11 10 


11 11 


i: « is it, n i> 11 so 3/ 


















°C. I _ .. 
















ylH 1 








411 


'<* 








1 






- B_ _ 


x 








-- j£l - 






in . it 


. I. 1 . ' 






vjy ±-fr — tz . zz 


^-t - ---- - 






_~j;_*;~ 


\ 






-4J J £ 


- 4 ^ 






15 j v„ 


J t 






<$s ii_a„2_iyi __;c;x__ 








OO C ~ ™ O "* --f*_Ji-_ 






!s,I25_;S^?"S~5„!w_ 


^_ _ ;; ?j 


1 - vf- 7 V 
















1 






"17 __ _ _ .___ _ 


1 




~l *"" 




bo 




,.=5 o- 3 '»: 



Fig. 46. Temperature chart of horse 5 for January, 1914. 



H/4 Tetanus M. 5 I 


Feb. i a 3 // j- t r jr 9 10 ii Iz 13 it is 16 n |/s /? 20 it 22 23 24 is zt> 21 x'i 


■" " " " " |_.-.-. 


°c 






A f\ - -.______-, 


4U _ _ _ _-_ ___, 


A k '■ ft 


jn ft p fi - - 


p c h r 


on h , ^ 1 1 1 , -t- - -t- 


oy t t t 


LI 5 ll t-. 


-i H -J" S JT -it ^ 


. J _V 4 „*> 1 A _4 Us> 


1« . -,^4 Ca,al c ^l,=.,- J La a -* ^_'^I _ ^s £. i. 


JO 'X / \ V v J V N A ^ / V 1-1 v c> J v' v r 








17 ... L . . _ _._• 


>o c> ti 



Fig. 47. Temperature chart of horse 5 for February, 1914. 



48 



The Philippine Journal of Science 



191* 



niH 



Tetanus 



A r o. 5 J 



M< a. 



/ i 3 t s k 



7 s i io ii tz ii it is it n ii 



If 20 XI 22 23 11 IS 26 21 21 



°c. 

40 
39 
38 
37 



S 



w 



E=i 



H 



;5=5 



P* 



EEi 



££*£$ 



c^: 



w 



^ z 



FlG. 48. Temperature chart of horse 5 for March, 1914. 



niH 



Tetanu* 



jfo. 5 h 



Aph< l 



40 
39 
38 
37 



w 



=§ : 



&* 



tz« 



C3 



S B 3 



=il 



= ?- 



Fig. 49. Temperature chart of horse 5 for April, 1914. 



111H 



Tetanus 



M. 5 l 



2 /3 /</ /* /t. /7 /I If 20 It 11 



IS li 27 2t 2* 



40 
39 
38 
37 



: T - 



v- 



5" 



is! 



£ = a 



fiSi: 



:5S jS 



;-? 



5-2 



* C J 



PlO. ilO. Temperature chart of horse 5 for May, t*Mt 



X. B. 1 



Ruediger: Preparation of Tetanus Antitoxin 



49 



MONTHS 


1 


2 


3 J Ai 


5 


6 


71 


9 


JQ 


// 


/s 


300 
200 
100 


















/ 


A 




















s v 


/ 




K 
























1 


\ 



























Fig. 51. Chart showing the antitoxin curve for horse 5. Units per cubic centimeter by months. 



HORSE 6 



Immunization of horse 6 was begun on November 10, 1913. 
It was fortified with 2,000 units of tetanus antitoxin, 1,000 units 
of which were injected on November 10, 1913, and 1,000 units, 
on November 24, 1913. Beginning with a dose of 1 cubic 
centimeter, tetanus toxin was injected at intervals of a week 
and the doses were increased more gradually than had been the 
practice previously. A test bleeding was made on April 6, 1914, 
and the serum was found to contain 250 units of antitoxin per 
cubic centimeter. The horse was bled 6 liters on April 14, 1914, 
and again 6 liters on April 18, 1914, the serum testing a little 
more than 250 units of antitoxin per cubic centimeter each time. 
The injections of toxin were continued. Eight liters of blood 
were withdrawn on May 26, 1914, from which about 3.2 liters 
of serum were obtained, which tested about 300 units per cubic 
centimeter. Four injections of toxin were given during June, 
1914. On June 29, 1914, the horse was bled 5 liters; the 
serum contained 500 units of antitoxin per cubic centimeter. 
On July 3, 1914, the horse was bled to death; 12 liters of blood 
were obtained this time. The serum contained more than 450, 
but less than 500, units of antitoxin per cubic centimeter. 

Horse 6 received in all 9,578.5 cubic centimeters of tetanus 
toxin and furnished 37 liters of blood. It produced about 14.8 
liters of antitetanic serum or 5,320,000 units of tetanus anti- 

182195 4 



50 



The Philippine Journal of Science 



1915 



toxin. Deducting 50 per cent from the antitoxin as loss, we 
have left 2,660,000 units of antitoxin for the market (see figs. 
52 to 61, charts 6-A to 6-J, for horse 6). 



/?/3 


1 ETA NUS 


./W. 6 4 


Nov. l3.iUSk7t1 


10 II 12. 13 11 IS lb 11 It 19 20 21 22 23 


J« WiC7JllI 


50 






"~_ X-" 








nr 




"• - ,1 Ey » 


r ■: . 


, ;:;± , 




„ '^„_3„e? 




5 -t 4a ? 




oft _^Z _2 _w__ 


w , „''>,2j 3-<:i- -sJSr-B, S" 


u3_ :.lsJj. 


-• 




v * v ' J \ J 


* i ? 1 » / » 


■- 






fc * j- 
















i 




•> 7 _ 




1. . 1 








3 6 





Fig. 52. Temperature chart of horse 6 for November, 1913. 



/1 13 



Te t a n u s 



Ao. o s 



Dec . I 23HSh7?t 10 II I2\I3 H IS Ik 17 /! /? JO £/ \2Z xi\xi -^ ^t ^?Uf|;? 30 



^ 



38 



37 



* 



III 



r- 



m 



£ 



fc?^ 



v>** 



^3*^ 



5** 



_: 



Fie. 53. Temperature chart of horse 6 for December, 1913. 



till 



TETANUS 



J/h. t> c 



J A N.\ I l 3.1 3 \ 1 i i & \ 7 I t [1 \l0] II \ll\ll\l4 \lS\lt>\n\/t\ll\lo\2.! \2i\23 \2l\l5\Xb\lT\3.t\Xl\io\il 




- 



^S. 



38 *v 



zh 



itipiEi'i 



37 



Fig. 54. Temperature chart of horse 6 for January, 1914. 



I1IH Tetanus M. 6 D 


Ft s . / i 3 V 


f t 7 » 9 /« // |/?. 13 It ::. 1 


s /7 /J -•? so 1J :- -3 £f 2i ;* £7 Jl 






4- _ _. 4--L 




' 


:: ::: : .i±. 




U 


; :::; 


on _ 






09 












A * 


- "Ets - - — 


— ^ 


0. v-H V 




i — p — ~ T £ - 


OO s | *;fs 


;s35;?s;E: = ^E;s;i:-5;j 


— l.i-L5-,»,!>.f .L,5.,6„(.-. 
















/ 





| 


> s 

1 Q 



Fio. 55. Temperature chart of horse 6 for February, 1914. 



x, b, i Ruediger: Preparation of Tetanus Antitoxin 51 



IVH Tetanus M. b E 


MAS. 1 X 3 4 S h 7 S . 1 10 II IS 13 11 IS It 17 13 11 SO SI SI S3 SI SS St SI SI SI 30 31 






o. lift 


___*. ju p p F 


i o A A ' i 


Jy ' \ - -- 


J- I -, V 4-1 


■-, i- -, i- -t^«- 3 ^ 4-5 


7 r* 1 t a ^5 4 ^ 3C \ 


oc b l ^^jZ _j ^.,&,, A v ^=.^i>J. ^ „ „ ~«.^4 r 4 £,^a _ oL v 


Jo ,"*■ 25, a & a^t J ^v v^' v£ J i.***^ - 1 < v x v v's. ^Ji 






J- -4- 


*l 7 -L ■ ■ ■■■ -jL 


cj 0)' ci ci ^ 
>o q ca q «a 

«i CO ^- ^ -O 



Fig. 56. Temperature chart of horse 6 for March, 1914. 



1111 Tetanus JVh.b F 


4Pfl. / 2 3 V 5" fe 7 2 9 10 II Is 13 11 IS It 11 1% 11 SO SI SS S3 11 SS St SI Si SI 30 




o/i 5 I 


"■ n x ft 


A P 


on __ -_ - ______ ___ h ____ 


jy i 1 


i I ' 


X c, ] r„ 


33 _,_ » a „ , C5 J t-< 


io _a „ i l2 S.!»,s„C5 -j n _*&___ A ____;4 £ i._____„___3 2. _ 










17 __ __ 


t5 °S ' _ J °^ ° Cb 



Fig. 57. Temperature chart of horse 6 for April, 1914. 



mt i 


ETA N US JVo- h & 


M Ay 


i / 


l 3 


/ 5 


£. 


r 


> 


■? 


. 


/:' 


IX 


'.-> 


/•/ 


/ .5" 


/i 


/7 


/? 


It 




SI 


' .': 


23 ~¥ 


SS St XT ■ 


J? 27 30 3/ 


"C. 

4 

39 
38 
87 








































































































































































































































































































ft 






















































" 




































A 


















1 














ft 






















































" 


































































































































































I 




















_, 


















•■■ 




:s 












1 




















,1 






















; ^ 






/\ 






' 




- \ 








Et^^St 


: -5--»t-7' 






- . v -J 


S 














' 








■^ 




. 




































































a * 






























































































































































































































c 
c 








































;> s_ 





Fig. 58. Temperature chart of horse 6 for May, 1914. 



I1IH 



ETANUS 



JVo. b H 



40 
39 
38 
37 



,&. 



-? : 



ff==;^ 



_?_>.; 



;-_.: 



7^?^ 



Fig. 59. Temperature chart of horse 6 for June, 1914. 



52 



The Philippine Journal of Science 



1915 



niH i 


ETANUS *Ao- & 


July 


; 


.'. 




i 


« 


5 


i 


7 


J 


9 


/9 


// 


/i 


:i 


it 


IS 


16 


n 


/F 


1° 


LO 


1/ 


4.2 


->3 


M 


15 


It 


11 


i ? 


U?lj!> 


i: 


°C. 
38 

37 


































































1 






































■ 










































































































dfz 








































































































! 
























































































































































































































































































































































































































































































































































































































































































































































































































2-i 



























































Fig. GO. Temperature chart of horse 6 for July, 191-! 



MONTHS 


m / 


s 


3 


4 


5 


6 


7 


8 


9 


/a 


// 


/2 


500 
bOO 
300 
200 
100 








































[ 


\ 






















1 



















































































Fig. 61. Chart showing the antitoxin curve for horse 6. Units per cubic centimeter by months. 

HORSE 7 

The treatment of horse 7 was begun on November 10, 1913. 
As a prophylactic 2,000 units of tetanus antitoxin were given, 
1,000 units on November 10, 1913, and 1,000 units on November 
24, 1913. 5 

The injection of tetanus toxin was begun with a dose of 1 



5 Although for the want of space antitoxin and toxin are recorded under 
different dates on the charts, these were given simultaneously, 1.000 unita 
of antitoxin and 1 cubic centimeter of toxin on November 10, 1913, and 
1,000 units of antitoxin and 3 cubic centimeters of toxin on November 24, 
1913. 



X, B, 1 



Ruediger: Preparation of Tetanus Antitoxin 



53 



cubic centimeter; the doses were gradually increased and given 
at intervals of a week. In three months the dose was increased 
to 100 cubic centimeters. On March 9, 1914, the serum con- 
tained 250 units of tetanus antitoxin per cubic centimeter. In 
April, 1914, the horse was bled 11 liters — 6 liters on April 6 
and 5 liters on April 10. The serum tested 500 units of anti- 
toxin per cubic centimeter. The injections of toxin were con- 
tinued. Five liters of blood were withdrawn on June 2, 1914, 
the serum of which contained 700 units of antitoxin per cubic 
centimeter. In July, 1914, the horse was bled four times, 5, 
12, 10, and 10 liters being obtained; the serum obtained tested 
700, 700, 600, and 500 units, respectively, per cubic centimeter. 
Three injections of tetanus toxin were given, then 19 liters 
of blood were withdrawn: 10 liters on August 11, 1914, and 
9 liters on August 14, 1914. The serum contained 500 units 
and 400 units, respectively. Nine liters of blood withdrawn 
on September 1, 1914, yielded 3.5 liters of serum which con- 
tained 250 units of antitoxin per cubic centimeter. Nine liters 
of blood obtained on September 4, 1914, produced 4.4 liters 
of serum with 225 units of tetanus antitoxin per cubic centi- 
meter. A third bleeding of 5 liters on September 7, 1914, yielded 
2.5 liters of serum with about 200 units of antitoxin per eubic 
centimeter. On September 9, 1914, the horse was bled to death. 
Nineteen liters of blood were obtained, which yielded 10 liters 
of serum that contained 150 units of tetanus antitoxin per cubic 
centimeter. 

The antitoxin content of the serum of horse 7 reached its 
highest recorded mark in seven months. This horse received a 
total of 14,619.5 cubic centimeters of tetanus toxin and furnished 
114 liters of blood. It produced 51.7 liters of antitetanic serum, 
or 21,315,000 units of tetanus antitoxin. If we consider 50 
per cent of the antitoxin as lost through deterioration and other 
accidental causes, we can still count on marketing 10,657,500 
units of tetanus antitoxin produced by 1 horse in ten months (see 
figs. 62 to 73, charts 7-A to 7-L, for horse 7). 



/ft 3 Tetanus M. 7 A 


Nov. I s. 


3 1 


5 <• 1 


■lit 


O II 13. 


11 11 u 


■ io n n 


11 li 


21 


22 


23 21 XS 2k 27 3? 3A 30 




rfc 






















r 




















"G 










































-A 


Oft 




















s_ „^__ 


oa 




















:r tzz i 










2 : 




- c_;"i~ 


a^,' 4 


- r'\ 




h & c v Ji L 






5 « 




" & ; 




IZZ * 


/ * . 




'■ 


/ w v -< i± t 






l-t * 


=>-, v ^-i 














v J. * 


>>q __d 






2_ _2 
















OO _t 



































































37 ±i 






X => * 


\ 




«i 








«3 u) S 



Fig. 62. Temperature chart of horse 7 /or November, 1913. 



54 



The Philippine Journal of Science 



1915 



1913 



Tetanus 



Jfo. 7 B 



Die. | / [ a | 3 | ■/ | j" I * I 7 | ? j 7 1 /o | // j ;a f /3 1 ;■/ /f \j*> j n \/1 j'/k Izo^n n \\ ?. z-. is 2b \xi \n 



fc+ 



39 



38 



37 



-^ 



i 



^ 



Sfe 



j ijEjgjg«i 



:■: 



5^2-! 



■^w 



Fig. 63. Temperature chart of horse 7 for December, 1913. 



I9IH 


Tetanus ^Ao.1 C 


jAM.-l3.i1SI.Ti 


1 to it ii /3 n is it. n 


rj 


11 10 It 11 


IS 11 IS Ik 


11 


; 1 


: 1 


S3 


9 J 




_P_ - - _p 




1 1 


1 


-;- 






- 






E 




h 


5 














q a 




4flX 


X 












-/ \- -,=3, ^ i- **• 




Li 


X^A 


, ,. / K 










oo Z £=..,2 a 2 S> 


„5 £w*3 Q _____''■, 


1 l 




l/' r J^ifl. 




' w 










V v * " v A v"^ V 




„ i ■.- '. - - 






/ V V 








' 


1 


1 1 ' 




X 










X 


' 




X4: -U 




q 








17 


l_x 


I 


±± — z 


X r J i 




1 




L - 


- 


CO 


d 

* 




i 


Da 













Fig. 64. Temperature chart of horse 7 for January, 1914. 



19 tH Tetanus M. 7 D 


Feb. / 1 


1 St, 7 t 1 10 n 11 is\n is it n it 11 10 %! 11 13 11 is it n jr 




1 






C. 


A 




X H --- ^t 


O Q 


' 1 \ h 


y 


- — -A- r ------5-s ±-?r-- --- = = = - = 


=;; C E^ 


tft ,2i_: 


c s_-2:>/iizi =i_ i«_-,L__ s3.2_.1_.. — 2 . ^=_:i&_,_. 


1)8 T f 


:»" u " " = 3 >/ u »' WTk/ r 




X t it +i 




11 




' 1 . 


17 _ 


X _ ±:_;;±__±±±±± 





0' © 
© w-, _ 
~> ^ ~. 



Fig. 65. Temperature chart of horse 7 for February, 1914. 



I9IH Tetanus 


J'o. 7 £ 


M »«. 1 X 'S H S t 7 


J 1 10 ti 11 13 1 /■/ // /» /t /? /f _* -1 21 z 


1 l- 1 !? It 27 It 11 30 31 




_ -j-- ._. 


_ ^^___ 








°fi - _E 


4* 


+ 4+ 




ZIII _ JH 


E __ _ 4A-_ 




A , .,. . if' 




Jy H 


z □ z xz : 


ui ::::::::i " 




F 1 \ 


S - ±c: 




-Xi-3 3tv^ a 4 


*-- --- -7 v- 


i t'^'V- - . 


'■ v; -;■ ;s : :_t - . ;" t . z_: ; 




ia 5 - V---SZ *„a„ 


oj V''*'^ p">^" :.:., t:«"«.,i 


_ ; E _ 2 _ £ 2 _ a " a It _ _ 












__: ^ 














x 


17 


1 1 


__;; x_ 


/ ■ 

d 

*■" .... 


= ° 2 


» 0" 

> 

1 -a 



Fig. 


66. Temperature chart of horse 


7 for March, 


L914. 




19 IH 


Tetanus 


. U 7 F 


A PH. / 2 3 >t s (. 


T S 1 10 II 11 IS 11 IS It II 


f /•? 2.0 Xt 21 33 


1 -■ - 


IT It • « 5 .1 


I "T~" 


I 1 








e/> --- - 










°C 








t z : t . 






-- A it 




zflzzxz::: 


in __ 




1 -.. .fc. 




, * 










t 






1 j 




. z z 






- '■- s 




.' - X 




-z-*-*z"^~~~'r^ t '~z~ n ~''v 




V I 




00 vl ^ \/'j v | J 






tfTrr^ 






st 


xxi 


37 ±±X±±± 









: • E 





Flo. 67. Temperature chart of horse 7 for April. 1914. 



x, b, i Ruediger: Preparation of Tetanus Antitoxin 55 



iiti 



Tetanu: 



M. 7 & 



■2 I 3 I i I s |t I 7 It I 7 I /t>' // I ^ /3 |/v|/J /(■ n /» ;? a» ai U* ■" *v a^Ut A7 l- ;? ■ z? 30 '" 




Fig. 68. Temperature chart of horse 7 for May, 1914. 



191 H Tetanus 


JS.7H 


June / 1 3 1 5 4 7 5 1 ID 11 IZ 13 IH 


J /t /7 it 11 10 at n n tl if £« nlzt ii !»» 




""T | --rr'--t"i-"- 




1 


°C. ~ : 


1 ! 




1 1 1 


jin _ _ 


! ' 1 1 


4U 1 


ft . 1 <{ 




f\ ft «' 


I 


' n ra 


,'i 


' i i n 


1Q ' 1 


i . ' ' Mi ' 


«>y i 


t-U- 1 . " ■ '■ ■ - 1- v 


\>\ i 


I A ta ' I ' 


A I 1 


\.s. |s 1 


-, * -, . - ^ - _ A-/ _5 &„£>_'">.=»-, <!»<J 




oo ? a j (," v 7' '■'TV ■■ znsr: v - 


















Jr. ± 


17 . J : ! 


i II 


ul "*=•-• ^ °* °-t Q 


Q S> a 

qj ^ s 
5- ^ "i 



Fig. 69. Temperature chart of horse 7 for June, 1914. 



Iim Tetanus 


. '* M. 1 I 


J uir I is i 


; <, 7 1 1 io ii ii n i'i is it 


17 18 19 20 zi IX 3.3 2.H Z $ 2 1, 2.7 21 29 SO SI 








_ 




' 


-(.' 


1 


::- — :— i — i-:-:::— zi:~:"~ 




-j_ - - 


fi _ c _ _ 


o9 




C T L" 






A <\ 




± 


-, Ea " E^ 


A , 




A ^ S3 -, t- -J *-*^A 






■> >*-» ^*4 - ^ £-3 £±.^a4 V w __.t 


oo -p ■* ^v- 1 


* " ^" 3^ * * *1 a 






"■ 






T 5 <y 




1 7 


__ _|_ X_«. 


: __ _ 




;3ll . liil lill 





Fig. 70. Temperature chart of horse 7 for July, 1914. 



1911 Tetanus JVh. 


7 J 


/lue-. / A 3 ' V S b T 8 


? I/O // /A /3 /V /ff ,'S /7 /B 


11 io\ 


1! 21 13 I'I If It, 1 


7 At 29 30 3/ 


---j- . . 




















°C. 




!_ _ 








E 








on __ H - 


- 




E_ __ 




o» n 


C 




t~ Z 




!> 






t 




/\ 


lie; 








/ V ~s 


■ ^ ^ 


^ '- 


-* 4 s 




i« „>ij.* _2_ *: 




C i 






OO /l 1 4 l.i ' *. , r » 


' 6 5 4 ; s ? 4 ;«;» li i 5 a j -■ 






























- T 








Q7 1 1 


II II 








o 

C5_ 


11 If 1511 1 









Fig. 71. Temperature chart of horse 7 for August, 1914. 



56 



The Philippine Journal of Science 



1916 



mi 


Tetanus ^Vo. 7 k 


Sept. i x s q s t 7 I 1 \i» 


// a 1} 11 IS :k ,7 i', ,1 10 11 


IX 1} 1-1 IS I'.- 17 It tf 10 


X ' T 


1 ' 




I 


1 1 1 


1 1 


"0. 


\ I 


1 






1 


OQ A/v^AA. / ■> 


1 


zt_ _ __ ^^±: 


OO , V" V" V' 1 v" V_ ^ , 


1 1 








ii r r ^"z: 




n 


1 : 






i • i 


17 - - 


1 1 1 


II i 




^ 





Fig. 72. Temperature chart of horse 7 for September) 1914. 



MOHTHS 


1 


s 


3 


4 


5 


6 


7 


8 


9 


to 


// 


12 














• 














7uO 
600 
500 
400 
300 

zoo 














/ 


t 




















/ 


/ 






















/ 






















I 






















/ 


J 












\ 








/ 


/ 














1 




/ oo 



























FlC. 73. Chart showing the antitoxin curve for horse 7. Units per cubic centimeter by months. 

HORSE 8 

The immunization of horse 8 against tetanus toxin was begun 
on November 10, 1913. This horse was fortified with 2.000 



x, b, i Ruediger: Preparation of Tetanus Antitoxin 57 

units of tetanus antitoxin, 1,000 units of which were given 
on November 10, 1913, and 1,000 units were given two weeks 
later, on November 24, 1913. The injection of tetanus toxin 
was begun on November 10, 1913; injections were given at 
intervals of a week, and the doses were increased gradually. 
Twelve liters of blood were withdrawn in the latter part of 
April, 1914, from which were obtained 5 liters of serum testing 
250 units of tetanus antitoxin per cubic centimeter. After the 
bleeding the injections of tetanus toxin were continued. On 
June 9, 1914, the horse was bled 5 liters, which yielded 2 liters 
of serum that contained 250 units of tetanus antitoxin per cubic 
centimeter. After this bleeding large doses of toxin — 750, 1,000, 
1,250, 1,500, and 2,000 cubic centimeters — were injected. Ten 
liters of blood withdrawn on July 21, 1914, yielded 3 liters of 
serum with 300 units of tetanus antitoxin per cubic centimeter. 
Four liters of serum, which were obtained from 10 liters of 
blood withdrawn on July 24, 1914, tested 275 units per cubic 
centimeter. The injections of large quantities of toxin did not 
greatly increase the antitoxin content in the serum of the 
horse. Three injections of tetanus toxin were given — one dose 
of 500 cubic centimeters on July 27, 1914, one dose of 750 
cubic centimeters on August 3, 1914, and one dose of 1,000 
cubic centimeters on August 10, 1914. On August 18, 1914, the 
horse was bled 10 liters and 2.5 liters of serum were obtained, 
which tested 150 units per cubic centimeter. A bleeding of 
10 liters on August 21, 1914, yielded 4 liters of serum with 100 
units of antitoxin per cubic centimeter. 

After the bleeding on August 21, 1914, toxin was given in 
4 injections — 500 cubic centimeters on August 24, 1914, 700 cubic 
centimeters on August 31, 1914, 800 cubic centimeters on Sep- 
tember 7, 1914, and 1,000 cubic centimeters on September 14, 
1914. On September 21, 1914, the horse was bled 10 liters and 
3.5 liters of serum were obtained, which contained 75 units of 
tetanus antitoxin per cubic centimeter. 

Ten liters of blood were withdrawn on September 23, 1914, 
which yielded 4 liters of serum with about 75 units of anti- 
toxin per cubic centimeter. On September 25, 1914, horse 8 
was bled to death ; 14 liters of blood were obtained, which yielded 
6 liters of serum that contained a little more than 50 units of 
antitoxin per cubic centimeter. 

Horse 8 received in all 19,323.5 cubic centimeters of tetanus 
toxin. It furnished 91 liters of blood, which yielded 34 liters of 
antitetanic serum or 5,537,000 units of tetanus antitoxin. If 



58 



The Philip2)ine Journal of Science 



1915 



we deduct 50 per cent of the antitoxin as loss, we can count on 
having 2,768,500 units for the market (see figs. 74 to 85, charts 
8-A to 8-L, for horse 8) . 



1113 



M. % A 



NOV. / 2. 3 1 5 t> 7 ? 1 10 II 12 /3 II IS It a It II 20 21 21 21 2H 25 2k 27 2S 21 30 



°C. 

38 
37 



z-s 



SP?$?5 



2-25 



-^T- 



Vt* 



!° S 



Fig. 74. Temperature chart of horse 8 for November, 1913. 



1113 



ETANUS 



M. % 3 



Dec. I 3. 3 m 5 t t 1 1 io ii 



12 | 13 II IS It 17 1% II 20 21 22 23 11 25 it 27 27 11 30 31 



CX3 



38 



37 



m 



$ 



:=;: 



-/- 



£ 



*c^£ 






' r ffiv / T rs K ' 



Fig. 75. Temperature chart of horse 8 for December, 1913. 



I1IH 


Tetanus ^2. o C 


Jan. / 2 3 i s t 7 si io 


// 12 13 ! M W /t /7 It 17 20 21 


>2 


i s -- 




k 17 


31 


- J 


■ 


! 


T~ 


_ _ _ _ 






rT- 






















1 










°C. 























o ,. 5 












C 2 «- P b a, 


















"° " *■ ~~ Z~~Z"^~~Z 


-, £ « -. n -i * ,-»■ 




- 


, L 








3 


± 




,~j v i.~_=*„ 'V 2 ' £' 






^S* j 


| — 












^x * 










:± 


1 






17 


i 






_t 


1 










CT3 


5- •* 






e 


' 











Fig. 76. Temperature chart of horse 8 for January, 1914. 




Flo. 77. Temperature chart of horse S for February, 1914. 



x, b, i Ruediger: Preparation of Tetanus Antitoxin 59 



/<?/</ 



Tetanus 



JVo.% E 



/ _ 3 H s i r ! 1 lo it /_ n ii is it, n tl 11 20 »/ zz 2s iV xr 



°c. 

40 
39 
38 
37 



? 



5 



& 



i-*i 



^ 



=:____ 



^0° 



i*s: 



:= 



s;*: 



Fig. 78. Temperature chart of horse 8 for March, 1914. 



nm 


Tetanus J*o- 


Apf. IX31SI>7B1lo 


11 ix 12 11 is it, n fs m zo xi 


21 _3 „V 2J" 2fc 27 2? _? 30 






-__ ____j__ . 








C. 




: ± ± 






• 


An - -Z 




: _ _ _tt ___ 


4U 


1 


IA 


_ f 


- n_ 


in 




_ c 


i 




_ tfc 


_t _ 


on ____ __ 


1 


., .j 


oM " r 


-+--- ------- 


: __~__~j"l :: 


t 




_j c _ ____ 


_- __::tr 


- jtt 


7 IaT 


z\ i*> 






00 . _ _ _,_. 


/ "V ^ ,^ 'S ^ " , ' 


,^___^_^,_~____i._, 


«>o _;_; s~a i_ _£;: ;_ 


-5 xj ^ » *% y _~_j_ 


/- w v ~ 3 T * ^ 


_-- v< V - ' *"-- = 


















07 _ _ _____ 




i 


_»/ 

ci 
■_ 

>- — 


i J I 1 


f_ i^'SS ' 

'o ol -1 j — 



Fig. 79. Temperature chart of horse 8 for April, 1914. 



11 W Tet.nus M.1 & 


M^r / _ 3. ¥ J ' _ 7 S -9 to \ n IX 13 It IS it n 11 11 10 Zl ZZ 23 Zl Zf Zt, Z1 23 2? 30 ?l 


r> 


o/i _li 


C- zm 


4fi + K 


il n .......... -B I f 


4U nr t j- - - -.- ft ±- -*-i l - 


_JL A A U 


_J_ T M - - 


T n 


on 


U>9 1 , i 


i 1 ' . ■ " 


/ i a , k A a Ma 


a _ ^./ V -^ A a, c V (">s ^ n 1 V 1 ,, ", / 


oq A v ' A / * v , ^ / v ,/ _ - V v / s-*- 1 t /-._■"' / ./ 










17 _ _ 


_ _ o _ 
e» g — «o 



Fig. 80. Temperature chart of horse 8 for May, 1914. 



60 



The Philippine Journal of Science 



191! 



nit 



Tetanus 



JTo. S H 



UHt I X 3 t S t 7 Itf •? /P » /I /3 H /J" /*■ /7 /8 /* J»ilf 22 2.3 l*\lS ** ^ 7 'i» If |3 




m 



a 



B 



^iSS 



Wf-? 



cr 



^^ 



fczfc 



Fig. 81. Temperature chart of horse 8 for June, 1914. 



lilt Tetanus M. 1 I 


Jiur l2.3VSi.721 to II 


ix n ii is it n ii ii io xi xx 2? 14 x> 


2b 27 2T 11 ISO 3< 


















°c. 










_u 








., ft .,__.__. J_ 






41) .ft 








fl 


II 














1 








on , 1 




; 




oy 


ii ■■" '. " 1 






i--\ 


1 1 « A 








4 fc v cz xi: 






i + 


"• » .. ,. , 7A 






Oft * A C -:s3 M^-^y^d. 


5 „ a J ^^ 7^ Af A /- r J3 ; ^ t ; 


■ ii f VI" 




«>o / v v , rj 


v J v v v \/ * V^,^. 






± _fc Xft 


^fc 


im 




i 1 FT 


+--++ 


+ + 


37 ±:±:_!_±±±_t:±±l.it 


:_ _ ±_ ±:_:__ ±± 


H 1 — r 

<0 


P= 



Fig. 82. Temperature chart of horse 8 for July, 1914. 



lilt 



Tetanus 



M. % J 



34547J9/0 



XX 23 i'J i- r 



40 



39 



33 



:>7 



T 



m 



5 y £ = 5 s : 



iiiiillii 



** 



* s ^ 



Fig. 83. Temperature chart of horse 8 for August, 1914. 



lilt 



Tetanus 



\o.S 



SEPT. txstsitizito 



5 /*> 17 It 19 X0 II 21 23 .24 If ,2^ 27 : > 



39 



38 



37 



Eg 



II 



fb*#> 



m 



■^ * 



i 



m 



^ 



«i=5!z 



«^5*"^ 






I'll.. 84. Temperature nbart of horse 8 for September. 1914. 



x, b. i Ruediger: Preparation of Tetanus Antitoxin 



61 



MONTHS 


I 


2 


3 


4 


5 


6 


7 


8 


9 


/O 


it 


/2 


300 
200 
/OO 








































/ 


\ 








/ 























































FIG. 85. Chart showing the antitoxin curve for horse 8. Units per cubic centimeter by months. 



CONCLUSIONS 

From the results obtained and reported above, the following 
conclusions seem justified: 

1. A suitable strain of the bacillus of tetanus will usually 
produce potent toxin when grown in nearly neutral glucose broth 
under hydrogen. The acidity of the broth will rise to more 
than 2 per cent normal acid, and it should be neutralized with 
sodium hydrate before it is injected into the horse. 

2. Potent tetanus toxin was obtained by the method described 
by Ivan Hall. By this method the acid is continuously neutral- 
ized by the magnesium carbonate present. 

3. Horses differ greatly in the power of producing tetanus 
antitoxin. Of 8 horses reported on, one produced 150 units per 
cubic centimeter of serum, two produced 300 units per cubic 
centimeter of serum, one produced 350 units per cubic centi- 
meter, and in the serum of one the antitoxin rose to 400 units 
per cubic centimeter. Three horses produced 500 or more units 
of tetanus antitoxin per cubic centimeter of serum. 

4. The antitoxin curve reached its highest mark in from six 
co nine months after the beginning of immunization. 

5. The injection of large doses of toxin is not indicated. The 
dosage should be such that the horse does not appreciably lose 
in weight. 



■ILLUSTRATIONS 

TEXT FIGURES 

Showing the temperature and treatment of horses during the preparation 

of tetanus antitoxin. 
Figs. 1 to 9. Charts 1-A to 1-1 for horse 1. 

10 to 18. Charts 2-A to 2-1 for horse 2. 

19 to 27. Charts 3-A to 3-1 for horse 3. 

28 to 38. Charts 4-A to 4-K for horse 4. 

39 to 51. Charts 5-A to 5-M for horse 5. 

52 to 61. Charts 6-A to 6-J for horse 6. 

62 to 73. Charts 7-A to 7-L for horse 7. 

74 to 85. Charts 8-A to 8-L for horse 8. 

63 



CESAREAN SECTION IN THE PHILIPPINE ISLANDS 1 

By Fernando Calderon 

(From the College of Medicine and Surgery, University of the Philippines, 

and the Philippine General Hospital) 

At the last meeting of this society held in November, 1912, 
I had the honor to read an article entitled, Preliminary report 
of the first nine cases of abdominal Csesarean section performed 
in the Philippines in the treatment of placenta praevia. Three 
of these 9 cases were performed in my clinics, while the rest 
belonged to other physicians. Besides these there appeared 5 
other cases of Csesarean section which were performed for the 
treatment of contracted pelvis and for eclampsia, so that at that 
time 14 cases of Csesarean section had been performed in the 
Philippines with the following results: Mothers, 12 recovered 
and 2 died; babies, 8 living and 6 died. 

In the preliminary report, the following conclusions were 
given : 

1. Abdominal Csesarean section, although a spectacular operation, is 
simple and should be more frequently resorted to in cases of placenta 
praevia. 

2. Hysterotomy is a treatment which can best guarantee the life of both 
the mother and the child in those cases of placenta praevia in which the 
cervix is not dilated and the amniotic sac cannot be reached. 

3. In infected cases Porro's Caesarean section is to be performed rather 
than hysterotomy. 

4. In cases where the cervix is widely dilated, the rupturing of the bag 
of waters or the perforation of the placenta, followed immediately by the 
extraction of the foetus, is the operation of choice. 

5. In those cases in which the cervical canal is not obliterated, but in 
which the examining finger is able to reach the amniotic sac, the latter 
should be ruptured, followed immediately by a tight vaginal pack, or by the 
introduction of a balloon to complete the dilatation of the cervix. This 
operation will do away with hysterotomy. 

Two years have elapsed since my preliminary report was 
made, and the experience acquired during that time, thanks to 
the vast number of cases furnished by the department of ob- 
stetrics of the Philippine General Hospital, has shown that the 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

132195 5 65 



66 



The Philippine Journal of Science 



conclusions given in my preliminary report are confirmed by 
results ; therefore they are entitled to receive the approval which 
they deserve. 

During that period of time 17 cases of abdominal Caesarean 
section were performed, giving the following results: 

Table I. — Results of Cesarean section in cases in the Philippine Islands. 



Num- 
ber. 



Operated for placenta previa: 

Recovered 

Died 

Operated for eclampsia, recovered 

Operated for premature separation of placenta, died- 

Total Caesarean sections... 

Total maternal deaths 

Babies'. 

Living 

Died several hours after birth 

Stillborn _._ 



Per 

cent. 



23 

29 
41 
29 



The fact should not be forgotten that the majority of the 
patients coming to the hospital with placenta prsevia are already 
exhausted by loss of blood and that they come to the hospital 
only as a last resort. 

Of these 17 Caesarean sections, 15 were performed in the de- 
partment of obstetrics of the Philippine General Hospital, 1 in 
the San Juan de Dios Hospital, and 1 in the Casa de Salud of 
Drs. Quintos, Angeles, and Velarde, In one of these cases the 
operation was performed on a woman at the eighth month of 
pregnancy, who entered the Philippine General Hospital in a 
serious condition, being unconscious and having convulsive at- 
tacks every five minutes. The cervix was not dilated. Caesar- 
ean section was performed, and both the mother and the foetus 
were saved. In this particular instance, we can readily see 
that, besides placenta praevia, Cassarean section also finds a wide 
field of usefulness in cases of eclampsia during pregnancy in 
which the cervical os is closed, as in these cases, instead of 
wasting our time dilating the cervix by means of balloons and 
other cervical dilators, a process which requires at least twelve 
hours to induce labor, we can solve the gravity of the problem 
in from thirty to forty minutes, if we resort to the abdominal 
Caesarean section. 

Another indication for abdominal Cesarean section is given 
by those women who have contracted pelves and who always 



x, b, i Colder on: Cesarean Section in Philippine Islands 67 

deliver a stillborn foetus. I know of some of these cases in 
Manila, and I hope that as the use of Csesarean section is be- 
coming more general it will also become the operation of choice 
for this kind of cases, especially if we take into consideration 
the fact that Csesarean section, if performed at the right time 
and not as a last remedy, is entirely free from any danger and 
insures the safe recovery of the patient. 

One thing which is of great importance in connection with 
Caesarean section is the mode of procedure before and after 
the operation — that is, the preliminary treatment and the after- 
treatment. In the Philippine General Hospital, whenever the 
haemorrhage has been profuse and the patient shows the symp- 
toms of acute anaemia, our attention first is directed to improv- 
ing the condition of the patient by administering stimulants, 
such as strychnin or camphorated oil, and by hypodermoclysis 
of normal salt solution, 500 cubic centimeters or more being 
injected under each breast. This procedure may be repeated 
again during the operation if necessary. After the operation, 
the patient is placed in Trendelenburg position, camphorated 
oil is given hypodermically, 1 cubic centimeter every hour or 
two, and protoclysis of normal salt solution given in drop method. 
This mode of treatment is usually all that is needed, but in more 
serious cases where the loss of blood has been very great hypo- 
dermoclysis may be repeated in addition. Of course, it is need- 
less to say that different cases require different methods of 
treatment. 

•During the last two months of this year, two of the first pa- 
tients operated by me came back for confinement. In both cases, 
delivery was effected normally without the least sign of any 
untoward complication that might be attributed to Csesarean 
section. 



CASE REPORT OF OBSTRUCTED LABOR AND CESAREAN 

SECTION 1 

By R. B. Woodward 
{Surgeon, United States Navy) 

The following history is of interest as emphasizing the danger 
of ventral fixation of the uterus in child-bearing women. 

Mrs. C, multipara, a short, heavy-set woman, 32 years of 
age. She has had 2 previous labors, both instrumental; one 
child, delivered by high forceps in 1911, is living. 

She had conceived in November, 1913, and came for exam- 
ination in March, 1914, stating that she had been told that 
another pregnancy would kill her. Examination revealed a 
large rectocele and an extreme dilation of the hsemorrhoidal 
veins; the cervix, while high and slightly retroflexed, was in 
fair position. A large abdominal scar, due to a ventral fix- 
ation of the uterus in 1912, accounted for the high position of 
the cervix. The dangers of delivery at term were explained to 
the patient, who, however, being a devout Catholic, refused any 
interference at this time. Pregnancy proceeded normally, and 
September 4 wa,s predicted as the date of beginning labor. The 
patient had false pains a week previous to this, and was much 
alarmed and worried over the onset of true labor. On the 
evening of September 8, at 10.45, the patient started on true 
labor; the os was dilated to admit 2 fingers, and pains came at 
eight-minute intervals, lasting from one to two minutes. Pro- 
gress in dilatation was steady but slow, and the presentation 
was an 0. D. P. At 5 o'clock in the morning the os would 
admit 3 fingers, and the fixation of the uterus would not permit 
the cervix to descend or the head properly to engage. Pressure 
on the fundus was maintained, and under primary anaesthesia 
digital dilatation of the cervix was attempted with no result. 
At 7.30 in the morning, under ether ansethesia, high forceps was 
tried and an honest effort lasting fifty-five minutes was made 
to induce progress. None was made, and under the same 
anaesthesia the patient was conveyed to the hospital and a Sanger 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

69 



70 The Philippine Journal of Science 

operation performed; a living male child weighing 9.5 pounds 
was delivered. The wound in the uterus and belly wall was 
repaired. The child lived seventeen hours, dying in convulsions 
as a result of head injury from forceps. The mother made an 
uneventful recovery, leaving the hospital on the twelfth day. 

A plea is here entered to those having in mind operations 
on the female genital organs for conservatism and proper con- 
sideration of the potential mother. 

The ventrofixation method has given the following statistics. 
DeLee 2 says : 

Ventrofixation and ventrosuspension and adhesion of the uterus to the 
abdominal wall following celiotomy not seldom cause serious dystocia. 
Lindfors, in 68 cases of labor found that the cervix was high in 27; 
transverse presentation occurred in 31; and trouble in the third stage in 
10. There were 30 versions, 13 Caesarean sections, 10 high forceps, 5 
embryotomies, 5 tamponades for post-partum haemorrhage, and many other 
operations necessary. There were 3 deaths. 

Andrew's collection of 395 cases adds 36 cases of Cesarean 
section. 

That frequency of abortion, difficult labor, post-partum haem- 
orrhage, and the necessity for capital operations to overcome 
obstruction should forbid the practice of ventral fixation in child- 
bearing women is the opinion of DeLee, Cragin, and Polak. 

The Alexander and allied operations on the ligaments — espe- 
cially the Andrew's (with ligament sewn behind the uterus) — 
give little real trouble, and with a proper repair of the vaginal 
floor will answer every and all purposes. 

" Principles and practice of obstetrics. Philadelphia, W. B. Saunders 
Company (1914), 402. 



ADENOCARCINOMA OF THE C/ECUM, COMPLICATED BY 
INTUSSUSCEPTION 1 

By Robert M. Thornburgh 

(Major, Medical Corps, United States Army, and Chief of Surgical Service, 

Department Hospital, Manila, P. I.) 

On January 29, 1914, Sergeant A. S., aged 35, was admitted 
to the Department Hospital at Manila. He came from Camp 
Stotsenburg, Pampanga Province, with a transfer diagnosis of 
"dysentery, chronic entamoebic, recurrent." He has had three 
years of tropical service. There was no history of cancer in his 
family. 

Previous history. — Malaria in 1906, good recovery; seven ad- 
missions to hospital for "intestinal trouble" during the past 
year; drinks moderately, smokes moderately, and chews tobacco 
occasionally; had gonorrhoea in 1906, good recovery; denies 
syphilis (Wassermann — ). 

Present illness. — Onset in May, 1912 (?). Severe colicky pain 
in lower abdomen; frequent watery stools, rectal tenesmus, and 
cramps in thighs; mucus present, no blood observed. He re- 
covered from this attack, but from that time on was troubled 
with exacerbations of above symptoms and signs whenever he 
was indiscreet in diet. He is always prostrated and has some 
fever; mucus and sometimes blood in stools. This has required 
one hundred fifteen days in hospital since May, 1912. 

On admission. — Intense colicky pain in lower abdomen; tenes- 
mus of colon and rectum; frequent watery stools containing 
mucus in abundance, very fetid; much flatulence; nausea and 
vomiting; cramps in thighs. 

The patient is well developed, fairly well nourished, facies 
anxious, breath fetid. There is tenderness over colon, espe- 
cially in caecal area; colon distended and hypertympanitic ; bor- 
borygmus is marked. Stools contain much mucus, no blood, 
no ova of intestinal parasites, and no protozoa. The heart 
and lungs are negative; arteries, thickened and hardened 
somewhat. 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

71 



72 The Philippine Journal of Science 

The patient was put on diluted milk diet and improved stead- 
ily; on February 13 he was tried on a baked potato. About 
four hours later he was taken with intense colicky pain in the 
lower abdomen, accompanied by much distention and prostration. 
Local measures, stupes, and enemeta gave relief, but the patient 
grew rapidly worse until an exploratory laparotomy was decided 
upon and done on February 17. (I might add here that there 
were 3 complete blood counts made, all of which were normal, 
90 per cent haemoglobin.) 

Upon opening the abdomen through the right rectus, a mass 
of about the size of a coconut was found filling the entire right 
lower quadrant. The head of the caecum was invaginated, car- 
rying the normal appendix with it. The caecum was enormously 
thickened and formed a ball-valve, completely occluding the 
ileocaecal valve. The condition was so manifestly malignant that 
immediate resection was decided upon. The caecum was am- 
putated and with it 10 centimeters of ascending colon and 5 
centimeters of ileum. A lateral anastomosis by the Moynihan 
method was made high up on the ascending colon. The wound 
was closed without drainage. 

The patient made an uninterrupted convalescence and was 
sent to the Letterman General Hospital, San Francisco, on March 
15, 1914. He weighed at that time 114 pounds. I received a 
letter from him a few weeks ago, written six months after the 
operation, in which he stated that he was in the best of health, 
weighed 163 pounds, and had returned to duty. Another letter 
received March 27, 1915, stated he was perfectly well and was 
on duty at Fort Meade, South Dakota. 



TWO COMPOUNDS OF EMETINE WHICH MAY BE OF SERVICE 
IN THE TREATMENT OF ENTAMCEBIASIS 1 

By A. G. DuMez 

(From the School of Pharmacy, College of Medicine and Surgery, 

University of the Philippines) 

INTRODUCTORY 

While emetine, per se, has become recognized as a valuable 
remedy in the treatment of entamoebiasis only within the past 
few years, ipecac root, from which emetine is obtained, has 
long been employed in the treatment of this disease by medical 
practitioners. 

The available literature on the subject conveys the information 
that the drug was first brought to the notice of Europeans in 
1590 under the name of "igpecaya" or "pigaya" by a Portuguese 
friar, who obtained it in Brazil. 2 We are further informed, how- 
ever, that it was not effectively introduced to European medicine 
until a century later, 1686, when Jean Adrien Helvetius 3 at- 
tained fame through its use in the treatment of dysentery. Sev- 
eral times since then it has fallen into disuse in the management 
of this disease, but has as often been revived, and at present 
its efficacy may be said to be firmly established. However, in 
spite of its established value, there is a marked disadvantage in 
its use which tends to diminish its popularity — that is, its em- 
etic action. Through the combined efforts of the chemist and 
pharmacologist, we are now able to state that this action is due 
to two of its constituents : namely, emetine and cephaeline. 

The chemistry and pharmacology of ipecac root have been 
pretty thoroughly worked out with respect to the constituents 
which might be expected to be physiologically active. The ip- 
ecacuanhic acid of Willigk * was shown by Kimura 5 to be neither 
astringent nor antiseptic. The presence of 5 different alkaloids 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

1 Purchas, His Pilgrimes. London (1625), 4, 1311. 

s Wootton, Chronicles of Pharmacy. Macmillan & Co., London (1910), 
2, 114. 

4 Ipeeacuanhic acid was first isolated by Willigk in 1850. Journ. f. prakt. 
Chem. (1850), 51, 424. 

5 Arch, internat. de Pharm. et Tox. (1903), 405. 

73 



74 The Philippine Journal of Science 

has been reported: namely, emetine; cephaeline; psychotrine ; 
ipecamine, isomeric with psychotrine; and hydroipecamine, is- 
omeric with caphaeline. 6 The pharmacology of emetine and cep- 
haeline was worked out by Wild, 7 who showed that the latter 
was the more energetic in its action as an emetic. All of the 
above work, with the exception of the isolation of the two is- 
omeric bases, was published prior to 1896, by which time the 
ipecac treatment had become generally recognized. It appears, 
however, that no attempt was made to use the pure alkaloidal 
constituents of the drug in the treatment of dysentery until 1912, 
when Rogers 8 reported the results obtained in 25 cases of enta- 
moebiasis treated with emetine hydrochloride given subcuta- 
neously. Although the results obtained by Rogers were the first 
direct clinical evidence of the value of emetine as a remedial 
agent in the treatment of entamoebiasis, we are indebted to 
Vedder for pointing out its probable use in this connection. 

In 1911 Vedder 9 published an article on the effect of ipecac, 
deemetinized ipecac, and emetine on the entamoeba? in vitro in 
which he pointed out the toxic action of emetine with respect to 
this organism. Rogers then took up the work and tested the 
effects of emetine on the entamoeba? found in dysenteric stools. 
He noted that entamoeba? in them were killed by a dilution of 1 to 
10,000 of emetine hydrochloride and rendered inactive even by 
so high a dilution as 1 to 100,000. A microscopic examination 
of the dysenteric ulcers of an advanced case which ended fatally 
failed to reveal a single living amoeba after a dosage of 0.22 
gram of emetine hydrochloride in two and a half days. He was 
so impressed with these results that he began the administration 
of emetine hydrochloride in a number of cases of entamcebiasis. 

At first Rogers tried the administration of emetine hydro- 
chloride in the form of a salol-coated pill, but obtained compar- 
atively poor results owing, undoubtedly, to its rapid elimination. 

"Emetine was obtained by Pelletier and Magendie in 1817. Ann. Chim. 
et Phys. (1817), 4, 172-185. Cephaeline and psychotrine were isolated 
by Paul and Cownley, the former in 1895, the latter a few years later. 
Pharm. J own. (1895), 25, 111, and Am. Journ. Pkarm. (1901), 73, 87. 
Just recently Hesser has reported the presence of ipecamine and hydroi- 
pecamine. Drug. Circ. (Oct., 1914), 613. 

'Lancet (1895), 2, 1274. 

'Therap. Gaz. (1912), 36, 837-842. 

' Vedder showed that deemetinized ipecac was without harmful effect 
upon the entamcebse, but that the destructive properties of ipecac were 
greater than its emetine content would indicate. From which we may 
infer that cephaeline is also toxic to the entamoeba. Bull. Manila 
Soc. (1911), 3, 48. 



X, B, 1 



DuMez: Emetine in Treatment of Entamcebiasis 



75 



However, the results which he obtained upon giving it hypo- 
dermically more than repaid him for his trouble. He advocates 
giving it in normal salt solution in doses of 0.03 to 0.04 gram 
(representing from about 2.6 to 4 grams of ipecac) to adults 
and 0.02 gram to children of about 8 years of age. He reports 
that on several occasions as much as 0.06 gram was adminis- 
tered two or three times a day without the development of any 
untoward symptoms, and that, even in the fullest doses, the drug 
never produced sickness and rarely any nausea. The compar- 
ative results obtained by Rogers with the old ipecac treatment 
and the new emetine are shown in Table I. 

Table I. — Shoiving the results obtained in cases of dysentery treated with 
ipecac and ivith emetine hydrochloride. 



Treatment. 

1 


Died. 


Discharged. 


Total 
cases. 


Within 
3 days. 


After 
3 days. 


Of other 
diseases. 


Very 
bad. 


Not 
cured. 


Cured. 




4 
2 


7 




2 


4 


13 
21 


30 
25 


Emetine hydrochloride 


2 









The observation of Rogers have been corroborated in a meas- 
ure by Baermann 10 and others. Baermann found the drug 
most efficacious if the first 1 or 2 doses were given intraven- 
ously in quantities of from 150 to 200 milligrams (the maximum 
dose being 250 milligrams per 60 kilograms of body weight) , 
the intravenous injections being followed by 4 or 5 subcutaneous 
injections of from 100 to 200 milligrams at two- or three-day 
intervals, and the latter treatment again repeated at intervals 
of three or four weeks. 

Notwithstanding the fact that emetine hydrochloride, as a 
general rule, has yielded good results in the treatment of enta- 
mcebiasis in comparison with those obtained through the use of 
ipecac, there still appears to be an opportunity for improvement 
in the present form of treatment. Very often negative results 
are obtained, even with the administration of emetine. Whether 
this is due to an impurity 1] in the alkaloid as obtained on the 
market or whether it is due to our inability to bring the remedy 
in contact with the entamoeba in the proper concentration for a 

10 Munchen. Med. Wochenschr. (1913), 50, 1132. 

u Five different commercial samples of emetine hydrochloride examined 
in this laboratory showed the presence of cephaeline when tested with 
Frcehde's reagent. As cephaeline has been shown to be much more irri- 
tating than emetine, this condition of the commercial salt may be significant. 



76 The Philippine Journal of Science 

sufficient length of time, 12 I am unable to state. Painful inflam- 
mation occasionally results at the point of injection. Further- 
more the present form of treatment is too complicated to permit 
of emetine being used as a household remedy or as a prophy- 
lactic." It is for the purpose of simplifying the treatment, and 
increasing its efficiency, if that be possible, that I bring to your 
notice the compounds emetine mercuric iodide and emetine 
bismuthous iodide. 

EMETINE MERCURIC IODIDE 

Emetine mercuric iodide was prepared by precipitating an 
acidified aqueous solution of emetine hydrochloride 14 with 
Mayer's reagent, 15 collecting and washing the precipitate with 
water, and drying in the air at a temperature below 50° C. The 
samples used for analysis were dried over sulphuric acid. The 
composition of the resulting precipitate was found to vary with 
the concentration of the solution. Table II shows the approxi- 
mate composition of the compound obtained on precipitation in 
the dilution 1 to 300. 16 

12 Wherry found that emetine killed the entamoebas in dilutions of from 
1: 20,000 to 1: 100,000 only after 24 hours at a temperature of from 36° 
to 38° C. Journ. Infect. Dis. (1912), 10, 162-5. 

18 Willets has pointed out the fact that entamcebic dysentery in an in- 
fected individual can be prevented and that prophylaxis against carriers 
of Entamoeba histolytica can be obtained by expelling the pathogenic enta- 
moebas from the intestines of infected persons. He found ipecac more 
efficacious than emetine for this purpose. This Journal, Sec. B (1914), 
9, 94. 

14 The emetine hydrochloride obtained from Merck and Co. and labeled 
"Nach Paul" was found to contain cephaeline. The cephaeline was sep- 
arated according to the method of Paul and Cownley, and the purified 
emetine hydrochloride was used in the above preparation. 

" Mayer's reagent was prepared by dissolving 1.344 grams of mercuric 
chloride and 5 grams of potassium iodide in 100 grams of distilled water. 
U. S. P. 8th rev. (1905), 529. 

1,3 No direct estimation of the alkaloidal content of the precipitate was 
made, the analyses being conducted as follows: A weighed quantity of the 
precipitate dried over sulphuric acid was dissolved in hot alcohol acidulated 
with sulphuric acid. Silver nitrate solution was then added to precipitate 
the iodine; the precipitate was washed on the filter with hot water, dried 
at 100° C, and weighed. The filtrate was treated with a slight excess of 
hydrochloric acid, and the silver chloride was filtered out, after which hy- 
drogen sulphide was passed in and the resulting mercury sulphide colK 
washed, dried at 100 c C, and weighed. After having found the iodine 
and mercury, the fraction of hydrogen for the HI of the assumed formula 
was added, and the difference was taken as alkaloid. 



x, b, i DuMez: Emetine in Treatment of Entamcebiasis 77 

Table II. — The composition of emetine mercuric iodide. 



Constituent. 


Calculated for 

(C30H40N2O6) 

(10HI) (Hgl2)s. 


Found. 


Mean. 


t 







2, 014. 40 

595. 50 

10.00 

2, 018. 24 


Per cent. 
43.43 
12.84 
0.23 
43.50 


Per cent. 
43.13 
12.53 


Per cent. 
43.03 
12.48 


Per cent. 

43.08 

12.50 

0.23 

44.19 


Mercury ._ 


Hof HI 

Emetine 












4,638.14 


100. 00 


100.00 



Emetine mercuric iodide is a light-yellow powder without 
odor or taste; it is practically insoluble in water or water acid- 
ulated with hydrochloric acid. It is apparently quite stable 
with respect to ordinary physical conditions, as a specimen kept 
in a cork-stoppered bottle for more than four months has under- 
gone no noticeable change. 

EMETINE BISMUTHOUS IODIDE 

The procedure in the preparation of emetine bismuthous iodide 
was similar in all respects to that followed in the preparation 
of emetine mercuric iodide, except that Dragendorff s 1T instead 
of Mayer's reagent was employed in forming the precipitate. 
Here, also, the composition of the precipitate was found to 
vary with the concentration of the solution. The following 
analytical results 18 were obtained for the precipitate formed 
in the dilution of 1 to 300. 

Emetine bismuthous iodide is a brick-red powder, insoluble 
in water or water acidulated with hydrochloric acid. It is quite 
stable in the air. 

" Dragendorff's reagent was prepared by saturating a hot concentrated 
solution of potassium iodide with bismuthous iodide (Bil 3 ), and then dilut- 
ing with an equal volume of a saturated solution of potassium iodide. 
Zeitschr. f. anal. Chem. (1866), 5, 407. 

18 The analysis of the bismuth compound was carried out in a manner 
very similiar to that of the mercury precipitate, except that the solution 
was at all times kept rather strongly acid to prevent the formation of basic 
compounds. The nitrate after the removal of the silver as chloride was 
concentrated by evaporation on a water bath and then diluted with water 
containing acetic acid, after which the bismuth was precipitated as sul- 
phide, washed with water containing H 2 S, dried at 100° C, and weighed. 
The lowest pf several weighings taken at intervals of a half-hour was 
the figure used in the computations. 



78 The Philippine Journal of Science 

Table III. — The composition of emetine bismuthous iodide. 



Constituent. 


Calculated for 
(CS0H40N2O6) 
(5HI)(BiIs). 


Found. 


Mean. \ 


1 


i 




1. 01)7. 20 

206. 90 

5.00 

504. 56 


Per cent. Per cent. 
58.43 ', 58.30 
12.00 12.52 


Per cent. 
58.21 
12.20 


Per cent. 

58.26 

12.36 

0.30 

29.08 




Hof HI ___;__ 


0.30 
■ 29. 27 
















1.723.66 j 100.00 






100.00 



PHARMACOLOGICAL AND THERAPEUTIC ACTION OF THE MERCURY 
AND BISMUTH COMPOUNDS 

With the object of obtaining some information concerning the 
value of the mercury and bismuth compounds in the treatment 
of entamcebiasis, samples of the two salts were sent to the Phil- 
ippine General Hospital some time ago. However, owing to the 
rapid change in personnel taking place in the hospital at the 
time, the salts were misplaced and, therefore, I can bring before 
you no clinical evidence with respect to their usefulness. Theo- 
retically the action, in part, should be similar to that of emetine 
hydrochloride, as emetine will undoubtedly be one of the com- 
pounds liberated in the intestines. 

Emetine mercuric iodide should be decomposed in the stomach 
to a slight extent only. Upon coming in contact with the alka- 
line secretions of the intestines, the compound will very likely 
be decomposed with the formation of emetine; finally, as the 
free base and a salt of mercury which will eventually be con- 
verted in part into the albuminate, in which condition, Cushny 19 
states, it enters the circulation. Therefore we should expect 
the combined action of both emetine and the mercury compound 
upon the entamoebas. 

Insoluble salts of bismuth are converted into bismuth sulphide 
after passing the pyloris. 20 In all probabilities the reaction is 
very slow and takes place as the compound is being spread out 
over the walls of the intestines. The value of bismuth in the 
treatment of entamcebiasis has been demonstrated by Deeks. 21 
In addition, in this case, emetine will probably be liberated 

10 Cushny, Pharm. and Therap. Lea and Febiper, Philadelphia (1911), 
641. 

"Bastedo, Mat. Med. and Therap. W. B. Saunders Co., Philadelphia 
(1914), 494. 

"Joum. Am. Med. Assoc. (1913), 61, 385. 



x, b, i DuMez: Emetine in Treatment of Entamoebiasis 



79 



slowly at the very seat of the trouble. The comparatively poor 
results obtained from the administration of emetine by mouth 
is very probably due to its too rapid absorption and elimination, 
as has already been pointed out. 

These two compounds can be given in doses representing 0.03 
gram of emetine hydroiodide without causing vomiting and 
without any apparent nausea; but vomiting does occur when 
either of them is given in very large doses, as is shown in the 
following tabulation of experiments conducted with dogs: 

Table IV. — The effects of emetine mercuric iodide and of emetine 
bismuthous iodide upon dogs. 



Substance. 


Weight 
of dog. 


Dose. 


Time given. 


Vomiting. 


Emetine mercuric iodide -- . 

Do 


Kilos. 
8.7 
8.S 
7.8 
6.3 
9.8 


Gram. 
0.057 
0.092 
0.066 
0.075 
0.012 


10. 25 a. m. 
10. 33 a. m. 
10. 38 a. m. 
3. 22 p. m. 
10. 40 a. m. 


None at 2 p. m. 
At 11.26 a. m. 
None at 2 p. m. 
None at 5.30 p. m. 
At 11.50 a. m. 


Emetine bismuthous iodide 

Do 

Do 



In these two compounds, then, we may possibly find a remedy 
which can be administered frequently, in fairly large doses, and 
with a minimum amount of trouble, and which will bring eme- 
tine in contact with the entamoebse for a comparatively longer 
time than is true with the forms in which it is administered 
at present. 



THE TREATMENT OF INFANTILE BERIBERI WITH THE EXTRACT 

OF TIQUI-TIQUI x 

By Jose Albert 
(From the College of Medicine and Surgery, University of the Philippines) 

Infantile beriberi is without doubt the most interesting prob- 
lem of pediatrics and of general medicine in the Philippine 
Islands. It is responsible for that phenomenon, without parallel 
in the whole civilized world, in which infant mortality among 
breast-fed children is greater than the mortality among the arti- 
ficially fed, thus giving the impression that human milk as a 
food is a scourge among infants, rather than the "magic liquor" 
which guarantees their lives. Because of its ravages among 
children under one year of age, 38 per cent of which are victims 
of this disease, infantile beriberi constitutes the most formidable 
barrier to both economical and political aggrandizement of these 
Islands. 

Since this disease was discovered, all efforts of therapeutics 
have been to suppress the cause, following the well-known maxim 
of healing pathogenically. Believing that this disease was a 
true intoxication, Professor Hirota of Japan has recommended 
the discontinuance of maternal feeding, which according to him 
is the "materia peccans," and the substitution of artificial 
feedings. In the treatment of this disease Hirota has established 
the two following principles: 

First, that infantile beriberi is a true intoxication produced by the ingestion 
of beriberic milk. 

Second, that the treatment of the disease by means of drugs is of little or 
no value at all. That the discontinuance of maternal feeding is the 
only and safe means of cure, provided that the disease is not too far 
advanced in which case it is no longer of any value. 

According to the same author the improvement which follows 
the discontinuance of maternal feeding is a rapid one, occurring 
on the third day. The complete cure with the exception of the 
aphonia, which lasts for several weeks, takes place in the major- 
ity of cases during the first week. 

1 Read at the annual meeting of the Philippine Islands Medical Associa- 
tion, Manila, November 4-7, 1914. 

132195 6 81 



82 The Philippine Journal of Science 1915 

Simple and ideal as this method of treatment looks, when 
put in practice it offers very serious inconveniences inherent 
in the sudden and untimely discontinuance of maternal feeding. 
To put the baby to a wet nurse is a wise procedure, but this 
offers a great expense which cannot be afforded by this kind of 
patients, for the great majority of them belong to the poorer 
class. To substitute artificial feeding for breast feeding is to 
expose the infant to the dangers of gastrointestinal and other 
nutritional disturbances which usually accompany artificial feed- 
ing. In addition, there is the difficulty or the impossibility of ob- 
taining fresh milk or canned milk and other farinaceous food 
preparations because of pecuniary reasons as already mentioned. 

In view of these inconveniences and believing that this disease 
is due to some deficiency in diet, Breaudat of Indo-China in 
1910 and Gabriel and Luis Guerrero of these Islands in 1911 
fed the mothers of beriberic infants with rice polishings (tiqui- 
tiqui) and mongo — two well-known antiberiberic foodstuffs. 
By this method the mother is given daily about 60 grams of 
tiqui-tiqui and about 150 grams of mongo, prepared in different 
palatable ways so that its ingestion is made agreeable. 

Only 18 cases have been treated by this method in the Phil- 
ippine Islands. The method has two inconveniences : First, the 
tiqui-tiqui is very unpalatable and disagreeable to take, and, 
secondly, breast feeding has to be discontinued for a period of 
from fifteen to forty-five days according to the method of Luis 
Guerrero. Because of these inconveniences Breaudat's method 
did not become widespread. 

Following the theory of "avitaminosis" and drawing their 
conclusions from the prophylactic and curative actions of the 
extract of tiqui-tiqui on "polyneuritis gallinarum," Chamberlain 
and Vedder, of the United States Army board for the study of 
tropical diseases, in February, 1912, recommended the use of the 
extract in the treatment of infantile beriberi without the dis- 
continuance of the maternal feeding, thus avoiding the dangers 
of artificial feeding. The method of preparation of this extract 
is fully described in their paper. 2 Five cubic centimeters of 
the extract thus prepared represent about 82 grams of rice 
polishings. The dose prescribed by them was 5 cubic centime- 
ters of the extract a day given in 20-drop doses every two hours 
while the child is awake. 

I have had the opportunity of using this extract in a great 
many cases of infantile beriberi, from the year 1912 to the 

'Bull. Manila Med. Sac. (1912), 4, 26. 



x, b, i Albert: Treatment of Infantile Beriberi 83 

present date, and I believe that this medicine is of immense 
value in the treatment of the disease in question and that it is 
excelled by no other drug known at the present time. My dis- 
tinguished colleagues of this city, Doctors Calderon, Quintos, 
Luis and Manuel Guerrero, Valdes, Gabriel, and others, are of 
the same opinion. 

Because of these astonishing results, both the committee for 
the investigation of infant mortality and the Segunda Asamblea 
Regional de Medicos y Farmaceuticos have requested the Phil- 
ippine Legislature to adopt measures so that this extract may 
be distributed freely to the poorer class. As a result of this 
request the Philippine Legislature in February, 1914, passed 
Bill No. 2376 providing the sum of 6,000 pesos 3 for the prep- 
aration and free distribution of the extract of tiqui-tiqui. The 
bill also provides that the Liga Nacional Filipina para la Pro- 
teccion de la Infancia will superintend the preparation and ex- 
perimentation, will look after the free distribution of the extract 
among the poorer class, and will present a written report of 
the results of their experiments, through the Secretary of Public 
Instruction, at the beginning of each regular session. 

Although the time that has elapsed since the first experiments 
were made is not long enough to permit us to draw definite con- 
clusions, our opinion with regard to this extract is very favor- 
able. The administration of the extract when given in time 
and in convenient doses is followed at once by marked improve- 
ment. At the end of twenty-four hours the vomiting, whining, 
restlessness, insomnia, dysphagia, polypnoea, and oliguria all 
disappear as if by magic. To the great surprise of the young 
physician the clinical syndromes change in aspect in a very short 
time, and at the end of three days one can say that the disease 
has disappeared, at least externally, leaving the aphonia which 
in its turn disappears by the end of the seventh or eighth week. 
(I have attended a case in which the aphonia lasted for about 
eight months.) If no improvement follows after twenty-four 
hours or if the case under treatment is of great severity, I 
obtain the desired effect by doubling the dose. It is better 
to give larger than smaller doses. The extract is inoffensive and 
entirely uninjurious, save for a slight diarrhoea which follows 
its administration. With the method of giving large doses to 
acute cases, we have in practice saved from sure death many 
cases of beriberi of the pernicious larval type, which formerly 
were believed to be hopeless and incurable. 

3 One peso Philippine currency equals 50 cents United States currency. 



84 The Philippine Journal of Science wis 

The administration of the extract must be continued as long 
as the aphonia persists. So long as the voice has not recovered 
its normal pitch, the infant is constantly threatened by an acute 
attack which may terminate in death in a few hours. In cases 
of infantile beriberi without aphonia, it is wise to prolong the 
treatment at least three weeks after apparent cure, to avoid 
relapses which frequently occur. It is necessary to impress 
upon the mother the importance of prolonging the treatment, as 
it is the tendency, in private practice, to discontinue treatment 
as soon as the acute symptoms disappear. 

The failure of the extract to effect a cure may be due to many 
causes : 

1. Extreme severity of the case — a very advanced neuritis. 
Vedder and Clark, in their work on polyneuritis gallinarum, 
have shown that symptoms appear only when the anatomic 
lesions in the nerves are well advanced. It is the same with 
infantile beriberi. It is not infrequent that mothers bring their 
children when the disease is far advanced. Therefore it is 
necessary to give the extract early in the disease in order that 
the treatment be successful. 

2. The extract proves ineffective also in cases associated with 
other infections, commonly pneumococcic in the form of bron- 
chopneumonia, which is a frequent complication of infantile 
beriberi. 

3. Another cause of failure of the extract is its poor quality. 
It has either an insufficient quantity of the active principle or 
an excess of alcohol which makes its ingestion disagreeable and 
injurious. Analyses made by the Bureau of Science of the ex- 
tracts prepared by the local drug stores revealed the fact that 
all the samples with the exception of one from one drug store 
were very deficient in the active principle. This was why treat- 
ment with extracts of tiqui-tiqui obtained from this drug store 
were the most successful. 

The interpretation of the curative action of the extract of 
tiqui-tiqui is not a hai*d task. Hirota's theory of intoxication 
can be discarded. It does not explain why the beriberic child 
treated with tiqui-tiqui extract improves and gets well even 
without discontinuing the maternal nursing. The extract lias 
no antitoxic properties and, therefore, it cannot be said that it 
neutralizes the toxic action of the breast milk. 

Knowing the prophylactic and curative actions of the extract 
in "polyneuritis gallinarum, which is caused by a deficiency in 
the diet, we must admit that this extract supplies the beriberic 



x. b, i Albert: Treatment of Infantile Beriberi 85 

infant with nutritive elements, probably the vitamines, in which 
the beriberic milk is found deficient. 

According to Funk these vitamines play an important role 
in the metabolism as do the hormones, ferments, and internal 
secretions. 

Bearing in mind that infantile beriberi under a clinical as- 
pect is principally a vagotonia — an abnormal irritability of the 
vagus — it is logical to believe that the curative action of the 
extract is due to the fact that it supplies the vagus with the 
necessary vitamines for the normal performance of its functions. 
Using the words of Eppinger and Hess, we can say that the 
extract of tiqui-tiqui is a vagotropic drug, like pilocarpin, which 
has a selective and specific action on the vagus nerve. 

By supplying the vagus with its much-needed vitamines, its 
abnormal irritability, manifested by vomiting, by angina pectoris 
(whining and restlessness), and by polypnoea because of its 
bronchial and pulmonary terminations, entirely disappears. 

The failure of the extract to cure the aphonia can be attrib- 
uted to a very advanced degenerative neuritis of the recurrent 
branches of the vagus nerve, which are the first to be affected 
in all cases of dietetic deficiency as evidenced by the clinical fact 
that the aphonic form constitutes from 80 to 90 per cent of all 
cases of infantile beriberi. 



PHILIPPINE ISLANDS MEDICAL ASSOCIATION 

MINUTES OF THE ELEVENTH ANNUAL MEETING, HELD AT MANILA 
NOVEMBER 4-7, 1914 

OPENING SESSION, NOVEMBER 4, 4.15 P. M. 

The opening session of the eleventh annual meeting of the 
Philippine Islands Medical Association was called to order by- 
President N. M. Saleeby at 4.30 p. m. on Wednesday, November 
4, 1914, in the assembly hall of the University Hall, University 
of the Philippines, Manila, P. I. 

The addresses as abstracted by the secretary-treasurer follow : 

OPENING ADDRESS — BY HIS EXCELLENCY GOVERNOR-GENERAL - 
FRANCIS BURTON HARRISON 

Governor-General Harrison assured the association, on behalf 
of the Government, of the interest in the deliberations of this 
session for the Bureau of Health, for the Secretary of the In- 
terior, and for himself, and complimented the association on the 
work which it had accomplished in the past and on the high 
standard of the present program. It is to the good offices of 
such associations that the community must look in order to 
secure mutual understanding and helpful cooperation between 
agencies and establishments under the Government and those 
which are the result of individual effort or under private control. 

During the past year the general health service of the Islands 
has again proved its efficiency and shown progress in many lines 
of endeavor. No investment pays better dividends to any com- 
monwealth than money expended for the prevention of disease. 
It is believed that the people of these Islands have come to a 
full realization of the fact that the health service is their best 
friend. 

The need of physicians in the Islands is emphasized, and en- 
deavor to cause such distribution of available medical men as 
will bring the greatest good to the greatest number of people 
is mentioned. A similar condition obtains in regard to the prac- 
tice of nursing, and the excellent service of our graduate nurses 
in the Government service and in private practice or employment 
has led to steps to increase the output of nurses in the Training 
School for Nurses of the Philippine General Hospital. The es- 

87 



88 The Philippine Journal of Science me 

tablishment of a one-year school for midwifery in connection 
with the Philippine General Hospital is announced. 

The extension of hospitals and dispensaries in the provinces 
is most necessary, and the accomplishment of this purpose is one 
of the pressing problems now in process of solution. 

The continued improvement in general health conditions has 
received and will receive Governor-General Harrison's most en- 
thusiastic support. Both he and Secretary Denison promise 
their whole-hearted cooperation in progressive measures for the 
amelioration of the public health. 

PRESIDENT'S ADDRESS : THE MOST IMPORTANT MEDICO-ECONOMIC 
PROBLEM OF THE PHILIPPINE ISLANDS 

By Dr. N. M. Saleeby 

Dispensary experience has shown the writer the widespread 
distribution of subacute, chronic, and recurrent beriberi. In 
1907 he examined in one day 64 patients at the dispensary and 
detected 40 cases with cardiac affections. Within the next few 
months new and acute cases of beriberi were definitely diag- 
nosed. This latter finding explains the etiology of the cardiac 
affections noted above. Emphasis is laid on the fact that mild 
or light symptoms of beriberi, particularly when oedema is not 
marked, often pass unnoticed by the general practitioner. Ear- 
lier observations are corroborated for the coincidence of beriberi 
and the puerperium after uneventful delivery; the mother may 
be partially paralyzed. In some cases the paralysis amounted to 
complete paraplegia, but the majority presented partial paral- 
ysis, accompanied by a group of symptoms generally referred 
to as polyneuritis. The new-born child of such mothers is af- 
fected ; even subacute attacks, combined with deficiency of milk, 
suffice to produce the disease in the child. Weaned infants and 
children of all ages are as apt to contract the disease as adults. 
Diagnosis of mild cases in children is difficult, and treatment 
should be encouraged on grounds of suspicion alone. 

From data available and from his own experience Doctor 
Saleeby then reasserts the extensive existence of beriberi in 
mild form, which though benign in itself considerably lowers 
the vitality of the individual, reduces his capacity for labor, 
and puts him at a great disadvantage in combating tuberculosis 
and other diseases. Further, in certain states of reduced vital- 
ity — as in the puerperium and infancy and during famine and 
hard times — this benign beriberi becomes fatal, spreads rapidly, 
and does more harm than tuberculosis or any other affection. 



x. b, i Philippine Islands Medical Association 89 

After summarizing briefly the literature on the etiology of 
beriberi and the other deficiency diseases, the writer briefly 
refers to his success (with Mr. R. R. Williams) in treating 
human beriberi. He urges the Government control of the mill- 
ing of rice and the elaboration of the diet of the Filipino through 
education and by the increased production of potatoes, beans, 
cattle, goats, and swine. 

SCIENTIFIC SESSIONS: NOVEMBER 5, 6, 7 

Many of the papers presented before the association will be 
published in full in the Philippine Journal of Science. Such 
papers as are not published in full will appear in abstracts. 

The following scientific program was presented and carried 
out in the order indicated : 

i 

SECOND SESSION, NOVEMBER 5, 10.30 A. M. 

COLLEGE OF MEDICINE AND SUEGERY, CALLE HERRAN 

Clinicopathological conference. 

Drs. B. C. Crowell and W. E. Musgrave. 
The technique of the bacteriological diagnosis of cholera (dem- 
onstration at the Bureau of Science) Dr. Otto Schobl. 

THIRD SESSION, NOVEMBER 5, 4 P. M. 
COLLEGE OF MEDICINE AND SURGERY, CALLE HERRAN 

Exhibition of specimens from the museum of pathological anat- 
omy, College of Medicine and Surgery, University of the 

Philippines Dr.. B. C. Crowell. 

Bacteriological findings bearing on the epidemiology of cholera. 

Dr. Otto Schobl. 
Cholera carriers in relation to cholera control. 

Maj. E. L. Munson, U. S. Army. 

Cholera at Bilibid .........Dr. J. W. Smith. 

Observations on cholera in Manila, 1914. 

Drs. A. P. Goff and 0. S. Denney. 

Notes on Philippine water supplies..._ Mr. G. W. Heise. 

Monstrosities and abnormalities Dr. Maria Mendoza-Guazon. 

FOURTH SESSION, NOVEMBER 6, 7.3 A. M. 

PHILIPPINE GENERAL HOSPITAL, CALLE TAFT 

Surgical clinic Dr. P. K. Gilman. 



90 The Philippine Journal of Science wis 

FIFTH SESSION, NOVEMBER 6, 4 P. M. 
COLLEGE OF MEDICINE AND SURGERY, CALLE HERRAN 

Medical and sanitary public welfare work in the Philippine 
Islands .....Dr. L. Booth. 

Malaria in the Philippine Islands Dr. M. A. Barber. 

The sperochaetal infection of ulcers in China.. ..Dr. H. E. Eggers. 

The treatment of infantile beriberi Dr. Jose Albert. 

The experimental treatment of beriberi with the constituents 
of rice polishings: 

Chemical preparations Mr. R. R. Williams. 

Case records. Dr. N. M. Saleeby. 

The protective properties of normal and of autoclaved milk 
against beriberi. ...Drs. R. B. Gibson and Isabelo Concepcion. 

Two compounds of emetine which may be of service in the treat- 
ment of entamcebiasis ...Dr. A. G. DuMez. 

SIXTH SESSION, NOVEMBER 7, MORNING 

Exhibition of a field hospital of the Medical Corps of the United 
States Army Col. M. W. Ireland, U. S. Army. 

[NOTE. — A special car will leave the side track at the Philippine General 
Hospital at 7.30 a. m. for Fort William McKinley and will return after the 
exhibition is over so as to arrive at the General Hospital at 10.30 a. m.] 

Clinical conference at the Philippine General Hospital. 

Drs. W. E. Musgrave, A. G. Sison, and Aristpn Bautista. 

SEVENTH SESSION, NOVEMBER 7, 2 P. M. 
COLLEGE OF MEDICINE AND SURGERY, CALLE HERRAN 

Demonstration of electrically heated and regulated apparatus. 

Dr. E. H. Ruediger. 
Demonstration of pathogenic tropical fungi. 

Capt. Ferdinand Schmitter, U. S. Army. 
Some pathogenic tropical fungi. 

Capt. Ferdinand Schmitter, U. S. Army. 
The occurrence of Bacillus coli communis in the peripheral blood 

of man during life Dr. E. H. Ruediger. 

The germicidal power of glycerol Dr. E. H. Ruediger. 

The preparation of antitetanic serum Dr. E. H. Ruediger. 

The bacteriology of leprosy Dr. J. A. Johnston. 

Schistosomiasis in the Philippine Islands Dr. David Roberg. 

The development of the eggs of Ascaris lumbricoides. 

Mr. L. D. Wharton. 



x, b, i Philippine Islands Medical Association 91 

Csesarean section in the Philippine Islands. 

Dr. Fernando Calderon. 

Cseserean section Surgeon Woodward, U. S. Navy. 

Cancer of the coecum with intestinal intussusception. 

Maj. R. M. Thornburgh, U. S. Army. 
Liver abscess.. Drs. P. K. Gilman and J. E. Reed. 

BUSINESS MEETING, NOVEMBER 7, 1914 

The annual business meeting of the Philippine Islands Medical 
Association was called to order at 5.30 p. m., President N. M. 
Saleeby presiding. 

The minutes of the previous meeting were read and approved. 

The secretary-treasurer reported a balance of 28.07 pesos re- 
ceived from the former acting secretary-treasurer, Elbert Clark, 
from which certain incidental expenditures had been incurred 
for announcements made during the year and for the present 
meeting. He announced that the Manila Medical Society had 
appropriated 500 pesos for the expenses of the present meeting. 

The report of the nomination committee, appointed by Pres- 
ident N. M. Saleeby at the opening session, was read and ac- 
cepted. The following slate was proposed: 

For President: Col. W. D. McCaw, U. S. Army. 

[Lieut. Col. S. C. Gurney, P. C. 
For Vice Presidents : j Dr A Q gison> 

For Councillor: Dr. N. M. Saleeby (vice Heiser). 

There being no further nominations, the secretary-treasurer 
was instructed to cast the ballot for the above candidates. 

It was moved and seconded that the next annual meeting be 
held in Manila during the first week of November, 1915, on 
such days as the council may select. The motion was carried. 

It was moved and seconded that the association express its 
thanks to the proper authorities of the University of the Philip- 
pines and of the Philippine General Hospital for the courtesies 
extended to the association for meeting halls, clinics, etc. The 
motion was carried. 

It was moved and seconded that the association express its 
thanks to the department surgeon of the Department of the 
Philippine Islands for .the exhibition of the Field Hospital at 
Fort William McKinley. The motion was carried. 

It was moved and seconded that a vote of thanks be given 
the officers of the association for their work during the year 
and for the present successful meeting. The motion was 
carried. 



92 The Philippine Journal of Science isib 

The chairman of the committee on arrangements of the 
Manila Medical Society moved the following for that com- 
mittee : 

The committee on arrangements for the tenth annual session of the 
Philippine Islands Medical Association recommends that a vote of sincere 
appreciation of the association be taken and forwarded to the Manila Electric 
Railroad and Light Company, through Dr. H. D. Kneedler, for its courtesy to 
the association in furnishing a special car from the association headquarters 
to Fort William McKinley and return on the morning of November 7, 1914. 

The above motion was seconded and carried. 
It was moved and seconded that the following resolution be 
adopted : 

That the thanks of the association are hereby extended to the three 
American daily papers of Manila for the space they have generously given 
in their columns to the announcements and program of the association. 

This resolution was adopted. 

The three following resolutions were read for the committee 
on public policy and legislation, and these were recommended 
by the committee for adoption: 

Resolved, That in the opinion of the Philippine Islands Medical Associa- 
tion, sufficient evidence has been produced to show that extracts of rice 
polishings, or tiqui-tiqui, are of undoubted value in the curing of infantile 
beriberi and of the majority of acute affections of beriberi in adults; 

That the association, therefore, strongly recommends the preparation of 
these extracts on a large scale by the Government of the Philippine Islands 
and the free distribution in a way to facilitate their acquirement by the 
public, especially for the poorer classes of the inhabitants of these Islands; 

That the commercial manufacture of these extracts be so guarded, con- 
trolled, or licensed as to insure their potency, purity, and safety. 

Resolved, That the Philippine Islands Medical Association indorses the 
estimates for appropriation of funds from the Insular Treasury for antitu- 
berculous work by the Bureau of Health; 

That it further recommends that the aid of the Government be extended 
to continue the present activities of the Philippine Islands Antituberculosis 
Society; 

That the association believes that every effort should be made for the 
further extension of antituberculosis work as much as possible. 

Resolved, That in the opinion of the Philippine Islands Medical Associa- 
tion sufficient evidence has been produced to show that beriberi occurs fre- 
quently in the Philippine Islands in women in the puerperal and nursing life, 
and through them in their infants, and that this condition is the chief cause 
of excessive mortality among infants in these Islands; 

That, accordingly, special hospital facilities, under the control of the Bu-. 
reau of Health, should be established to provide the necessary hospital treat- 
ment for this class of patients, and for the further study of the disease and 
its treatment; 



X, B, 1 



Philippine Islands Medical Association 93 



That it is further the opinion of this Association that this measure is 
both serious and necessary, and that it should take precedence of other char- 
ities and accessory measures of health. 

These resolutions were acted upon individually and were 
adopted. 

On motion, which was seconded, the business session and the 
annual meeting adjourned at 6.45 p. m. 

R. B. Gibson, 
Secretary -treasurer, 
Philippine Islands Medical Association. 



EDITORIAL 

PROGRESS IN THE INVESTIGATION OF VITAMINES 

We take this opportunity to pay tribute to the splendid work 
of Dr. Casimir Funk of the Cancer Hospital Research Institute 
in London. His discovery of the vitamines of rice polishings, 
yeast, and other materials during 1911 and 1912 is by far the 
most notable advance in our knowledge of the deficiency diseases 
for which any one man has been responsible. The significance 
of the theory of vitamines is very far-reaching, extending beyond 
the limits of pathology into the wider and more fundamental 
fields of nutrition and growth. Whether or not the theory as 
a whole will stand the test of time, it has already proved its 
value in stimulating interest and suggesting lines for research. 

At the same time we desire to urge upon Doctor Funk the 
duty of publishing the results of his work more fully and 
promptly, thus enlisting the energies of workers throughout 
the world to an early solution of the more practical phases of 
problems. Workers in the Orient who see thousands of people 
dying each year from beriberi feel with especial keenness the 
crying necessity from a humanitarian standpoint of producing 
vitamines as practical therapeutic agents. Therefore we have 
been looking eagerly forward to the publication of "the results 
of their curative power," and "the chemical investigation of all 
the fractions" 1 (isolated from rice polishings) which were 
promised in June, 1913, and "a method which will be described 
later on" 2 (for obtaining the vitamine fraction from yeast) 
which was referred to a year ago. 

R. R. Williams. 

1 Journ. Physiol. (1913), 46, 179. 

2 Ibid. (1914), 48, 229. 

95 



REVIEW 

The Care and Treatment | of European Children | in the Tropics | by | G. Mon- 
tague Harston | M. D. (Lond.), M. R. C. S. (Eng.), L. R. C. P. (Lond.) 
| fellow of the Society of Tropical Medicine and Hygiene; [etc., 5 lines] 
J with introduction by | Sir Patrick Manson, G. C. M. G., M. D., LL. D. | 
[seal] | London | Bailliere, Tindall and Cox | 8, Henrietta Street; 
Covent Garden | 1912 | [All rights reserved] | Cloth, pp. i-xvi + 1 — 
232 and 47 plain and colored plates. Price, 7/6. 

In recent years the problem of the care of white children in 
the tropics has become of great importance as the warm coun- 
tries have been developed and the length of residence in the 
tropics of men with families has increased. 

This book, based upon fifteen years' experience in the treat- 
ment of children in the tropics, should be of great assistance 
to practitioners in a field in which there is comparatively little 
available literature. 

Doctor Harston presents his ideas clearly and convincingly. 
Four chapters are devoted to the incidence of diseases, climatic 
factors, considerations of hygiene, and the general welfare of 
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experiences in the management of the health of white children 
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Mary Polk. 

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THE PHILIPPINE 

Journal of Science 

B. Tropical Medicine 

Vol. X MARCH, 1915 No. 2 

EXPERIMENTAL TREATMENT OF HUMAN BERIBERI WITH 
CONSTITUENTS OF RICE POLISHINGS 1 

By R. R. Williams and N. M. Saleeby 

(From the Laboratory of Organic Chemistry, Bureau of Science, 

Manila, P. I.) 

TWO PLATES 

The work which we wish to present was undertaken primarily 
in the hope that it might lead to some practical suggestions 
for the treatment of beriberi. In addition, it was felt that the 
experimental study of the etiology of the disease has been too 
much limited to polyneuritis gallinarum and that further work 
on human beriberi would produce more convincing evidence 
of the nature and causes of the disease. Considerable use has 
been made of extract of rice polishings in cases of beriberi. 
It has proved distinctly beneficial in infantile beriberi, 2 but in 
adults, with few exceptions, the treatment has failed to be of 
service. Nevertheless the experimental results produced in 
fowls with certain preparations of rice polishings have been 
such as to demand a further effort to produce a more widely 
useful remedy. 

Many of the cases that we have treated and observed have 
been chronic or recurrent, the type of beriberi most obstinate 
to treat. The number of acute cases in Manila this year 
(1914), other than among infants, has not been large. As the 
Liga Nacional para la Proteccion de la Primera Infancia has 
been carrying on extensive work with infants, we have been 
forced to accept some cases perhaps not very desirable from 

1 Chemical preparations by R. R. Williams; case records by N. M. Saleeby. 
Presented at the annual meeting of the Philippine Islands Medical Associa- 
tion, November 6, 1914. 

2 Bull. Manila Med. Soc. (1912), 4, 26; Albert, This Journal, Sec. B 
(1915), 10, No. 1. 

132716 99 



100 The Philippine Journal of Science wis. 

the experimental standpoint. However, it may be remarked 
that the cases we have observed are a fairer average of beriberi 
as it commonly occurs than an equal number of carefully 
selected cases. 

ALLANTOIN 

The extract of rice polishings is a very complex mixture, 
and the constituents which have shown activity in fowls are 
present in comparatively minute quantities. Funk's vitamine 
is generally regarded as the principal active substance. How- 
ever, this substance is present in a free state in the ordinary 
extract in vanishingly small amounts, and such an extract utterly 
fails to cure severely prostrated birds. One of us working 
with Vedder 3 reported a cure of infantile beriberi with an 
extract from which the vitamine both free and combined had 
been completely precipitated and removed with phosphotung- 
stic acid. Allantoin was subsequently found in this extract. 
It had previously been isolated by Funk 4 by another method, 
and its curative powers tested on fowls. He reported that 
allantoin frequently relieved the prostration and prolonged life. 5 
This is in general accord with our own results on fowls. 

Allantoin is easily prepared synthetically by the oxidation 
of uric acid with potassium permanganate. Allantoin occurs 
normally in the urine of many animals. In birds and human 
beings, according to the best evidence, it is only present to any 
great extent when it exists as such in the food. 6 From what 
is known of Funk's vitamine, it seems probable that allantoin 
resembles this vitamine more or less in its chemical constitution. 
Allantoin could be placed upon the market at a nominal price, 
and its purity could be readily and easily controlled. If it 
should prove beneficial in any considerable proportion of cases, 
it would be a useful although probably far from ideal remedy. 
We have treated 5 cases of human beriberi with allantoin, and 
the records are presented below. 

CASE 1 

A girl aged 5 years was admitted to the hospital, having been 
sick for two weeks and was steadily growing worse. The 
child's sister (case 20) was in much the same condition. The 
mother, who was nursing an infant 2 months old, was chronic- 

• This Journal, Sec. B (1913), 8, 192. 

'Journ. Physiol, (1912), 45, 75. 

"Ibid. (1912), 45, 489. 

•Ackroyd, Biochem. Journ. (1911), 5. 400. 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi 101 

ally beriberic. (Edema in the child was marked and general, 
with puffiness of the eyelids and marked pitting on the legs. 
The gait was rather unsteady, the patellar reflexes were absent, 
and the voice was husky. The face and mucous membranes 
were anaemic, and the child was very restless and peevish. She 
suffered from excessive diarrhoea and prolapse of the rectum. 
The heart showed some enlargement. The first sound was short, 
and the second was accentuated. 

The child was treated for the diarrhoea upon admission, and 
on the following day administration of 0.1 gram of allantoin, 
three times daily, was begun. General improvement was noted 
a day later. In the course of four or five days the oedema 
had practically disappeared, the gait became steady, the voice 
clearer, and the color better. The child was also brighter and 
better contented. The area of heart dullness decreased some- 
what, and the sounds improved, although they did not become 
entirely normal. The patellar reflexes changed very little. 

CASE 2 

A girl, aged 9 years, was first seen about September 12. She 
had been sick a month with fever. The gums were spongy 
and bleeding. She was given a mouth wash, and when again 
seen on September 22, her gums were improved, but were still 
dark, swollen, and spongy. The general condition remained 
much the same as before and may be described as follows: 

The face was pale and puffy, especially around the eyelids. 
The patient appeared fleshy and heavy, but anaemic. (Edema 
was general, but most marked in the legs. The patellar re- 
flexes were much diminished, the calves were slightly tender, 
and the gait was wobbly. The lower limbs were numb. The 
heart showed evidence of palpitation and slight enlargement. 
The first sound was rough and prolonged, and the second was ac- 
centuated. The temperature was 39°. The urine contained 
albumin and abundant blood cells. A blood examination showed 
no filaria. 

The patient was admitted to the hospital on September 22 
and given a cathartic. The following day the fever had dis- 
appeared, and treatment with 0.1 gram allantoin four times 
daily was begun. An improvement in the general condition 
and gait and diminution of the oedema were noted the following 
day and continued for a week. The heart condition was also 
improved considerably after five days, and the patient could 
walk and run without stumbling, which she had been unable 
to do at first. The patellar reflexes remained practically un- 



102 The Philippine Journal of Science 1915 

changed, and the allantoin was increased to five doses daily. 
No further improvement was noticeable, and the patient was 
discharged at the end of twenty-five days. The albumin in the 
urine had gradually diminished to a trace. The patient seemed 
practically normal as to the condition of the mouth, the gait, 
and general comfort, and the oedema had disappeared. 

CASE 3 

A woman, aged 26 years, was admitted to the hospital with 
a sick child 2 months old that she was nursing. She dated 
her illness from about the sixth month of pregnancy and suf- 
fered from that time with swollen legs, pains in the calves, 
and a feeling of weakness. The child was her first. Three days 
after the birth of the child she felt numbness of the legs and 
formication, which still continued at the time of her admission 
to the hospital. She looked weak and anaemic and complained 
of headache, sleeplessness, sense of heat in the chest, pain in 
the back, and inability to walk with comfort. The calves of 
the legs were tender, and the reflexes very slightly sluggish. 
(Edema of the legs was slight. 

The area of heart dullness was very little increased. An 
indistinct systolic murmur was heard only at the apex, and 
the second sound was strongly accentuated. Respirations were 
rapid, deep, and full. A dry musical rale was audible over the 
apex of the right lung. The patient had suffered from a cough 
for some months, which appeared to be largely laryngeal. The 
urine showed no abnormal character. 

The patient was given 0.4 gram of allantoin three times 
daily. She showed no marked improvement in any respect 
during several days. Later the distress in the chest became 
more severe, and the heart murmur was more distinct. The 
allantoin in larger doses seemed to have a depressing effect. It 
was, therefore, stopped, and digitalin was administered with the 
usual effects. She was discharged after twenty days without 
having been materially benefited by the treatment. 

CASE 4 

A woman, aged 25 years, mother of 2 children, the youngest 
being a nursing infant of 3 months, was admitted to the hos- 
pital. She complained of having felt numbness in the limbs 
for two months with formication at times. She was pale and 
anaemic, had little appetite, and felt dizziness and painful op- 
pression in the chest. There was some oedema in the legs, no 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi 103 

09dema in the feet, and the patellar reflexes were exceedingly 
sluggish. The area of heart dullness was slightly increased ; the 
beat was intermittent and arythmic, the first sound being short 
and the second rather valvular and accentuated. There was 
some resonance in the upper lobe of the right lung, but respira- 
tions were deep and full. 

The patient was given 0.4 gram of allantoin three times daily 
for three days. There was no apparent improvement other than 
a more restful appearance. On the fourth day the heart beat be- 
came more intermittent and arythmic. Therefore the allantoin 
was stopped, and strychnine and digitalin were administered. 
The heart became temporarily regular, and the patient was more 
comfortable. 

CASE 5 

A woman, aged 50 years, was admitted to the hospital on 
August 21 with typical symptoms of mild chronic beriberi, \n- 
cluding numbness and heaviness of the legs, tenderness of 
muscles, sense of heat, and formication, with reflexes diminished 
in the left knee and exaggerated in the right. Dyspnoea was 
marked, and the patient tired out very quickly. The second 
heart sound was valvular and accentuated. The lungs and urine 
were negative. 

The patient was given 0.1 gram of allantoin six times daily 
for one week without receiving any benefit; on the contrary, 
if there was any change, the heart condition was slightly worse, 
and the patient seemed rather better after the allantoin was 
stopped. 

These cases treated and observed by us jointly do not afford 
definite evidence of any beneficial result of the treatment with 
allantoin. In those which were distinctly chronic it may be said 
with certainty that the treatment did not produce any improve- 
ment. Rather, there is indication that in large doses allantoin 
produces a depressing effect upon the heart. In the acute cases 
there was marked improvement during the period of observation. 
However, such improvements are not uncommon as a result of 
a good diet, rest, and care alone. 

We are able to present the clinical records of 5 other cases 
treated with allantoin and observed by other physicians. These 
cases were treated in their homes without enforcing any change 
of diet or habits. They indicate that allantoin may frequently 
relieve the severity of the symptoms in acute cases much as it 
does in fowls. Further investigation will be necessary to decide 



104 The Philippine Journal of Science isis 

whether or not treatment with allantoin furnishes any substantial 
advantages as a temporary measure over the symptomatic treat- 
ment of acute beriberi commonly in use. 

The following two cases were treated and observed by Dr. 
Jose Bantug, of Malolos : 

CASE 6 

Symptoms before the treatment. — The patient was ansemic, with frequent 
attacks of palpitation and pain in the precardial region; oppression of the 
chest at times, slight atrophy of the body musculature, formication with 
slight oedema of the legs; pulse strong and rapid, but regular in rhythm, 
second pulmonic sound accentuated and the heart slightly enlarged. 

After using the allantoin preparation for about a week, the patient was 
relieved of most of her complaints so much so that further treatment 
was discontinued. 

She is at present attending to her household duties without experiencing 
the least inconvenience, and all the symptoms have disappeared. She is 
still slightly thin, but beginning to pick up now. 

CASE 7 

A man, 21 years old; family and personal history, negative. 

Present illness. — About four months ago the patient felt pain and un- 
easiness in the stomach whenever empty. The pain was relieved on taking 
food. This pain and distress in the stomach continued daily for the first 
two and one-half months. One and a half months ago the patient noticed 
that his abdomen was getting large and his lower extremities were getting 
swollen. The feet were heavy, and when at home the patient preferred 
to have them elevated. The lower limbs, sometimes benumbed, are easily 
fatigued on slight exertion, with profuse clammy sweats. Palpitation is 
frequent, and without external cause. 

June 16. — First examination: Head and neck, negative; chest, coughs 
a little; lungs, negative; heart, slightly enlarged toward the left; abdomen, 
large; upper extremities, negative; lower extremities, legs slightly pit on 
pressure; knee jerks present, but lessened. 

Five doses of 0.1 gram allantoin were administered. 

June 17. — Stomach feels lighter after meals; pain in the chest; allantoin, 
6 doses. 

June 22. — No change, except that stomach is better; allantoin, 6 doses. 

June 23. — Allantoin, 3 doses. Palpitation less frequent and with less 
force. 

June 29. — Feels well; sweating profuse as formerly. 

July 13. — Still with slight palpitation and profuse sweating. 

Result of treatment: markedly improved. 

Case 8 was treated and observed by Dr. Canuto Reyes. 

CASE S 

A woman, aged 33 years, who had given birth to a child nine days 
previously, was attacked on July 21 with severe pain and numbness in the 
extremities, and pain and oppression in the chest. When seen the following 
day, there was marked general oedema, which was especially apparent in 
the face. The pulse was rapid, and the heart presented palpitations and 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi 105 

an accentuation of the second sound. The knee reflexes were somewhat 
diminished, and the patient could stand and walk only with considerable 
pain and difficulty. 

Allantoin was administered in doses of 0.1 gram six times daily. The 
next day toward evening a fever came on, the temperature reaching 40°. 
All the symptoms were considerably intensified, and the patient was 
unable to rise from her bed. The allantoin was continued. The fever dis- 
appeared during the night, and the following day the patient's condition 
seemed much better than when first seen. After four days she no longer 
complained of pains or numbness and was able to walk without difficulty. 
■She continued to nurse her child throughout the treatment. 

Ten days later her child fell sick with the usual symptoms of infantile 
beriberi and was successfully treated with tiqui-tiqui extract. The symp- 
toms, with the exception of cedema, later reappeared in the mother, although 
much less severely than on the previous occasion. 

Case 9 was treated and observed by Doctor Castaneda. 

CASE 9 

An infant, 2 months of age, had a sudden convulsion on July 16. Slight 
cyanosis was apparent about the mouth; the pulse was 130; the temperature 
was normal. The child was uneasy and vomited frequently and was treated 
with caffein citrate. Four days later the child was paler and more cyanotic, 
had no appetite, vomited frequently, and the urine was scanty. Attacks 
of dypsncea were frequent, and the child cried often. The second heart 
sound was weak. 

The mother was pale and complained of numbness in the legs and pain 
in the chest. The heart palpitated occasionally; the pulse was 95. There 
was no cedema nor loss of reflexes. The child was given 0.05 gram of 
allantoin three times daily, and the mother received 0.1 gram six times 
daily. 

There was a marked improvement in the condition of the child after 
two days. After eight days the cyanosis and dypsncea had disappeared, 
the urine became normal in quantity, and the child's general condition as 
indicated by the color, activity, and contentment was greatly improved. Im- 
provement in the mother was slight. She continued to nurse the child 
throughout the treatment. 

The record of the following case was furnished by Doctor 
Elizalde : 

CASE 10 

Japanese, male, 31 years old, married, a laborer by occupation, residing 
in Calamba, was admitted to the Philippine General Hospital on July 9, 1914, 
complaining of numbness in lower limbs and difficulty in walking. Family 
and past history not reliable, as patient was unable to talk or understand 
English or Spanish. The present illness began twenty days before ad- 
mission with vomiting after meals accompanied by numbness and weakness 
in the lower extremity. 

On physical examination the patient was found to be well developed 
and well nourished; able to walk a few steps with support, but with difficulty. 
He could not flex the legs nor the feet; heart beats were rapid; cardiac 
dullness not increased. A soft systolic murmur was heard best in the 



106 The Philippine Journal of Science wis 

mitral area. Knee jerks were absent. There was tenderness in the 
muscles of the calves when pressed, and the muscles of the hand were 
very weak. 

The day after admission he was given elixir of iron, quinine, and 
strychnine, 4 cubic centimeters three times a day, without noticeable im- 
provement. This treatment was discontinued July 13, and instead he was 
given 0.5 gram allantoin powder twice a day. 

On July 14 the heart beats were still rapid, but no abnormal murmur 
was heard, and the patient could walk better than on admission. One 
centigram of allantoin was given every two hours instead of twice a day. 

On July 17 the patient was able to walk without support. Tenderness 
in the muscles of both calves on pressure still persisted. 

HYDROLYZED EXTRACT 

Heretofore the only extract of rice polishings used upon 
human cases has been that prepared with neutral alcohol. Such 
an extract will produce no prompt effects upon beriberic fowls 
until it is hydrolyzed. The hydrolysis may reasonably be pre- 
sumed to break down the complex nitrogenous substances, thus 
setting free the vitamine together with other cleavage products. 
Attention has been called before to the alteration so produced 
in the character of the extract so that it becomes promptly 
curative, but highly poisonous in excessive doses. The poison- 
ous effect is doubtless due in large part to free choline. We 
desired to try this extract upon human subjects and adopted 
the following method with the idea of reducing the amount of 
free choline as much as possible: 

The polishings were extracted with liberal quantities of 20 
per cent alcohol, instead of 90 per cent, in order to avoid the 
solution of much lecithin from which the choline is derived. 
This extract was concentrated in vacuo and precipitated with 
strong alcohol. The filtrate was evaporated in vacuo until all 
the alcohol was removed. The residue was then hydrolyzed 
by heating five hours on the steam bath with 10 per cent sul- 
phuric acid. The sulphuric acid was removed with calcium 
carbonate, and the extract was made up to such a volume that 1 
cubic centimeter of extract was equivalent to 10 grams of the 
original polishings. We have found that such an extract can 
be used safely in proper doses and have treated 8 human cases 
with it. 

CASE 4. FURTHER TREATMENT 

Very little permanent improvement having been obtained 
during several days' treatment with allantoin, the patient was 
given 15 cubic centimeters of the hydrolyzed extract three times 
daily. She felt considerably more comfortable and was brighter 
after two days. On the fourth day of this treatment the patellar 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi 107 

reflexes were found to be more active; the heart sounds them- 
selves were nearly normal in quality, but the arhythmia seemed 
somewhat increased. This symptom has persisted more or less 
throughout the treatment with hydrolyzed extract, although the 
general comfort of the patient has increased, the pain in the 
legs disappeared, and the sense of heaviness diminished. She 
nursed her sick child (case 18) throughout these treatments. 

CASE 11 

A boy of 17 years was admitted on October 16, complaining of 
numbness, heaviness, and pain in the legs. This condition began 
six days previously and was becoming worse. He reported 
having had a slight swelling and numbness of the feet about a 
year before. The patellar reflexes were diminished, the calves 
of the legs were tender to pressure, and formication was felt 
frequently. (Edema was general, but not excessive. He could 
walk only with much pain and difficulty. The heart was moder- 
ately enlarged to the right, the first sound presenting a faint 
murmur, and the second being accentuated. There was no 
dyspnoea, and the lungs appeared normal. The urine showed 
no albumin nor casts. 

Treatment was begun with 12 cubic centimeters of hydrolyzed 
extract three times daily. The dose was increased from time 
to time to 40 cubic centimeters. The oedema disappeared rather 
rapidly, and the patient felt much more comfortable. After 
a week he could walk with comparative ease, could run a little, 
and stoop and touch the floor with his hands. He stated that the 
pains in the legs had disappeared, the numbness remaining, 
however, over a less extended area. The reflexes were more 
active. After that time improvement was very slow, and when 
last seen the patient still complained that his knees ached on 
walking more than a few meters. 

CASE 12 

A woman, aged 30 years, was admitted to the hospital with 
a child (case 18) 2 months old that had partially recovered 
from an attack of infantile beriberi after treatment with tiqui- 
tique extract by Doctor Castaiieda. The patient dated her ill- 
ness from the birth of the child, and although she had borne 
7 children previously, said she had had no similar illness. She 
complained of pain and oppression of the chest, numbness and 
heaviness of the legs, dizziness, and formication. She was pale 
and anaemic. The knee reflexes were active, and oedema of the 
legs was slight. The heart was slightly enlarged, the first 



108 The Philippine Journal of Science wis 

sound prolonged and presenting a murmur, the second short, 
sharp, accentuated, and split. Venous pulsation in the neck 
was very marked. The urine showed considerable albumin and 
a few blood casts. 

She was given 6 cubic centimeters of hydrolyzed extract three 
times daily. This was later increased to 10 cubic centimeters. 
Within a few days the heart condition improved markedly, the 
splitting of the second sound disappeared, and the murmur 
became fainter. Otherwise, the patient remained much the 
same. As there were evident complications, the case was dis- 
charged without further treatment. 

CASE 13 

A woman, aged 16 years, was admitted with an infant 2 
months old that had been previously treated with tiqui-tiqui 
extract and had nearly recovered except for hoarseness of the 
voice. The child was treated further with tiqui-tiqui extract 
and gained rapidly in weight and vivacity. 

The mother's illness dated from eight days after the birth of 
the child. She complained of numbness and weakness and pain 
in the legs, dyspnoea, difficulty in swallowing, and headaches. 
The patellar reflexes were greatly diminished, and a slight oedema 
of the legs was apparent. She had had more pronounced swell- 
ing previously. The heart was very slightly enlarged; the 
sounds were forceful and arhythmic, the second being accen- 
tuated. The urine showed nothing abnormal. 

She was given 15 cubic centimeters of hydrolyzed extract 
three times daily. Improvement was noticeable in two days 
and continued for a week. The patient became brighter and 
was comfortable, and the heart condition became nearly normal. 
The knee reflexes remained unaffected. The patient continued 
to nurse her child throughout the treatment. 

CASE 14 

A woman, aged 22 years, was admitted on October 15 with 
an infant of 6 weeks (case 20) that had been treated for 
beriberi and partially recovered. The patient complained of 
pains in chest and limbs "like rheumatism," and difficulty in 
walking dating from two weeks before the birth of the child. 
Formication and numbness were marked and general, but oedema 
was slight and limited to pitting over the tibia. The knee re- 
flexes were sluggish. The heart was not enlarged, and the sounds 
were very slightly abnormal. The voice was hoarse. The urine 
showed no albumin nor casts. 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi 109 

She was given 15 cubic centimeters of hyclrolyzed extract 
three times daily for two weeks. She soon felt and looked much 
better. The pains disappeared first, and the numbness de- 
creased in area until only the toes remained anaesthetic. The 
patient could walk much more steadily and comfortably. The 
heart condition and the patellar reflexes remained unchanged. 
The patient nursed her infant throughout the treatment. 

CASE 15 

A woman, aged 30 years, was admitted to the hospital with 
an infant that showed some evidence of beriberi. The mother 
complained of numbness of all the extremities and of the body 
up to the shoulder and of pain in chest and between the shoulder 
blades. The illness dated from the birth of the child three 
months previously, although numbness of the legs was expe- 
rienced after the birth of each of 8 previous children. Of 9 
children she had borne, 5 died before reaching an age of 3 months. 
In each case death was sudden, but the cause was unknown. 
When first seen the mother felt weak and dizzy. Formication 
and dyspnoea were marked. The area of heart dullness was in- 
creased to right and left. The first sound was short and pre- 
sented a slight murmur; the second was accentuated and some- 
what dull. The knee jerks were diminished. No oedema was 
apparent. The urine showed no albumin nor casts. 

Twenty cubic centimeters of hydrolyzed extract were given 
three times daily ; later the dose was increased to 30 cubic centi- 
meters. The patient felt much more comfortable after treatment 
for several days, and all the symptoms diminished in severity. 
She continued to nurse her child during treatment. 

CASE 16 

An infant of 5 months was admitted with the mother (case 
15), who said the child was well. It appeared well nourished, 
but showed a general oedema over body and face. Its movements 
were sluggish and rather weak. It was not treated directly, but 
the mother, who continued to nurse it, was given from 20 to 30 
cubic centimeters of hydrolyzed extract three times daily. The 
child soon became noticeably brighter, stronger, and more active 
and gained rapidly in weight. 

CASE 17 

An infant of 2 months was admitted with the mother, who was 
evidently beriberic. The child had been sick four days, had ap- 
parently had colic, and had been cyanotic in the face. The 
parents had lost their first and only other child by a similar 



110 The Philippine Journal of Science 1915 

illness. They had consulted a physician, who prescribed a seda- 
tive without noticeable improvement according to the parents. 
They said the child had had a convulsion the day before. The 
baby was pale, peevish, and weak. The abdomen was distended, 
vomiting was rather frequent, and the child was persistently 
constipated. There was slight oedema, the face being puffy and 
the skin pitting slightly on pressure. The knee jerks were 
normally active. The heart beat was rather rapid, but other- 
wise apparently normal. 

The child was given 1 cubic centimeter of hydrolyzed extract 
three times daily. The dose was later increased to 3 cubic centi- 
meters. It continued to nurse at the breast, the mother not 
being treated at this time. After three days the child was much 
improved, ceased to vomit, and became stronger and more active, 
although there was still more or less colic. Later it became 
strong and well and gained 23 ounces in weight during ten days, 
beginning with the second day of treatment. 

All of the cases treated with hydrolyzed extract, except the 
2 infants, were chronic or recurrent. Our experience shows 
that hydrolyzed extract gives distinct relief in chronic cases 
and better results than any other line of treatment with which 
we are acquainted. We are strongly of the opinion, previously 
expressed and shared by many others, that such cases can be 
completely cured, if at all, only by long periods of good care 
and feeding. It is quite reasonable to suppose that in these cases 
permanent and extensive nerve lesions have been produced, the 
rapid repair of which is out of the question. The most that 
should be expected of the hydrolyzed extract to do is to stop 
the progress of degeneration. 

In the infant cases hydrolyzed extract produced apparently 
complete cures, and may reasonably be expected to be more ef- 
fective than neutral extract. The danger of poisoning must, 
however, always be kept in mind. 

UNHYDROLYZED EXTRACT 

The following 6 cases were treated with the ordinary neutral 
extract of rice polishings. The infantile cases came under our 
care during the treatment of the mothers and were treated on 
general principles, not for the value of the experimental results. 

CASE 18 

An infant of 2 months was admitted with the beriberic mother 
(case 12), who had partially recovered from an illness previously 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi HI 

diagnosed as beriberi and treated with extract of rice polishings 
by Doctor Castaneda. When seen by us, the child was somewhat 
(edematous all over the body, the voice was hoarse and aphonic, 
and the area of heart dullness was increased slightly. It was 
very restless and peevish. 

After treatment with extract of tiqui-tiqui in quantities from 
4 to 24 cubic centimeters daily for a week, the child gradually 
improved in every respect and seemed quite well, except for a 
slight huskiness of the voice. 

CASE 1!) 

An infant of 2.5 months was admitted on October 5 with its 
beriberic mother (case 4). The child had been coughing for a - 
few weeks. The throat was a little sore, and the voice was very 
aphonic. The child was pale. There was general oedema, es- 
pecially in the legs. The urine was somewhat scanty; the ap- 
petite was good, although vomiting after meals was frequent. 
The heart seemed slightly enlarged downward, but otherwise 
normal. The patellar reflexes were rather exaggerated. 

On October 8 treatment was begun with 1 cubic centimeter 
of tiqui-tiqui extract four times daily. Improvement was rather 
slight for about a week, although the vomiting was much di- 
minished. Later a general improvement in the appearance and 
temper of the child was apparent. The oedema disappeared, the 
vomiting ceased, and the child became strong, active, and 
vivacious and gained 11 ounces in weight during the third week. 
The voice improved very markedly. The child continued to nurse 
the beriberic mother, who first received allantoin without im- 
provement, and later received hydrolyzed extract with somewhat 
better results. The later improvement in the child was no doubt 
in part due to the hydrolyzed extract received by the mother. 

CASE 20 

An infant of 6 weeks was admitted to the hospital with the 
mother, who was beriberic (case 14). The infant had had an 
acute attack of infantile beriberi a week previous to admission. 
It had been ©edematous all over the body, and at times, according 
to the mother, its limbs had become rigid. Having been treated 
by Doctor Castaneda with extract of rice polishings before en- 
tering the hospital, it was much improved. Only a slight puffi- 
ness of the face and a general weakness of movement remained. 
It was further treated with extract and rapidly gained in 
strength, weight, and general appearance. 



112 The Philippine Journal of Science ims 

case 21 

A girl, aged 3 years, was admitted to the hospital on September 
22, together with her 5-year-old sister (case 1), who was simi- 
larly affected. The mother and grandmother living in the same 
house were also beriberic. The patient had been sick two weeks 
and was steadily growing worse. (Edema was general and very 
pronounced in legs and vulva. The abdomen was distended, and 
the face was pale and puffy. The patellar reflex was absent in 
the right knee and diminished in the left. The heart was slightly 
enlarged, and the sounds were somewhat accentuated. The child 
also suffered from diarrhoea, and was very peevish. 

She was treated for the diarrhoea and was given 3 cubic centi- 
meters of extract of rice polishings four times daily. Very slow 
but steady improvement was noted from day to day, especially 
in the brightness and temper of the child and in the diminution 
of the oedema. The dilatation of the heart decreased and the 
sounds improved, although the beats became rather rapid and 
equally spaced. The knee jerks changed noticeably and became 
normal on the left and slight on the right. Some oedema re- 
mained after three weeks of treatment, when the patient was 
discharged at the request of the parents. 

CASE 5 CONTINUED 

After having been treated one week with allantoin without 
benefit, the patient, who still showed the symptoms of chronic 
beriberi, was given 30 cubic centimeters of unhydrolyzed extract 
of rice polishings three times daily. This produced marked 
diarrhoea; so the dose was reduced to 15 cubic centimeters and 
continued for five days. The patient received no benefit, and 
the heart condition became markedly worse; we were forced to 
resort to symptomatic treatment with digitalis and strychnine. 

Of the use of neutral extract we have little to remark except 
the confirmation of the general experience that it is very bene- 
ficial in infantile, but not in adult cases, especially those of long 
standing. 

VITAMINE 

The vitamine found by Funk in rice polishings was isolated 
in a moderately pure condition, and this preparation was used 
in treating 6 cases of human beriberi. The method used for the 
isolation of the vitamine was that described by Funk, 7 with 
minor modifications, which experience suggested. The chemical 
methods will be discussed fully in a later paper. 

' Journ. Physiol. (1911), 43, 395; (1912), 45, 75. 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi 113 

CASE 22 

An infant of 3 months was admitted on October 2 with its beri- 
beric mother (case 3). It had been sick since September 16, 
when it had had an apparent convulsion and was treated by a 
physician. The urine had been suppressed for two or three days 
following. When first seen, the child was restless, slept badly, 
and cried incessantly and seemed to have abdominal pains. It 
vomited frequently after nursing and was constipated. The 
voice was hoarse and aphonic, the face anaemic and puffy around 
the eyes. The legs appeared thin, but were slightly cedematous, 
which condition extended more or less markedly all over the 
body. It was rather active and vigorous in its movements. The 
knee jerks were somewhat exaggerated. The area of heart 
dullness seemed slightly increased. It continued to nurse at the 
breast, the mother being treated with allantoin. 

The next day the infant was given by mouth the vitamine 
fraction from about 12 kilograms of rice polishings, although it 
was later discovered that the amount of vitamine present was 
very small. An equal dose required forty-eight hours to relieve 
fairly completely the prostration of a neuritic chicken. 

Nevertheless, on the following day the child was distinctly 
brighter, much better contented, stronger and more active. 
It had 5 bowel movements, but no rise of temperature. It 
slept quietly, the respirations seemed normal, and the voice was 
improved. Slight improvement continued for three days, after 
which treatment was begun with neutral extract. At the end 
of another week the voice was markedly stronger, the reflexes 
were normal, and the general condition of the child indicated 
a complete cure. During the last week the child gained 9 ounces 
in weight. 

CASE 23 

An infant of 2 months was admitted on October 22, when the 
following observations were made. The child seemed weak and 
had little appetite, had some constipation, and vomited frequently. 
The mother was beriberic. The child's knee reflexes were prac- 
tically absent. The extremities were thin, the skin lying in 
folds. The voice was aphonic, and the heart and lungs were 
negative. 

The mother was given hydrolyzed extract and improved in 
general condition. The child was not treated, but continued 
to nurse at the breast. Vomiting ceased after four days, but 
there was no marked improvement otherwise. 

On October 2 at 4 o'clock in the afternoon the child was given 



114 The Philippine Journal of Science ms 

a hypodermic injection of 80 milligrams of crude semicrystallized 
vitamine, to which some brown sirupy mother liquor still adhered. 
The temperature rose rapidly within a few hours and reached 
40°. 3 during the night. After thirty-six hours the temperature 
had again become normal and has since remained so. Some 
redness and induration appeared at the point of injection, which 
has since practically disappeared. Forty-eight hours after the 
injection the baby was bright and active and seemed quite well. 
In spite of the period of high fever the child gained 5 ounces in 
weight in three days after the injection. The gain continued 
and amounted to 15 ounces at the end of one week. 

CASE 24 

A baby, 2 months old, was admitted on November 3 ; it had been 
sick two weeks. It was pale, cried frequently, and appeared to 
have pain in the stomach; it had vomited often for several 
days. There was slight dyspncea, and the movements of the child 
were slow and weak. The heart beats were rather forceful and 
equally spaced. The mother was beriberic. 

At 4 o'clock in the afternoon of November 3 the child was given 
the semicrystallized vitamine obtained from 10 kilograms of 
rice polishings. It vomited copiously immediately, and a little 
later the dose was repeated. The temperature rose after a few 
hours, reaching nearly 39°, and then subsided gradually. The 
next day the child's condition had changed radically. It had 
not vomited since taking the vitamine and appeared well, 
bright, and contented. It gained 29 ounces in weight during a 
week, although it had appeared well nourished from the first. 

CASE 2T) 

A well-built athletic man, aged 20 years, was admitted to the 
hospital after a month's illness, previous to which his personal 
history appeared negative. His illness began with heaviness and 
numbness of the legs. Later, formication, tenderness of the 
muscles, general oedema, paresthesia, and weakness appeared. 
When first seen, the heart showed a readily visible diffuse impulse 
in the fourth and fifth interspaces. The area of heart dullness 
was increased upward and downward, a little to the left but 
most markedly to the right. A faint diffuse systolic murmur 
and accentuation of the second sound were audible. There was 
marked visible pulsation in the veins of the neck, and the pulse 
was of the water-hammer type and easily compressible. The 
lungs were negative. The calves were markedly tender, and the 



x, b, 2 Williams and Saleeby: Treatment of Human Beriberi H5 

knee reflexes were sluggish. The patient walked with difficulty 
on account of pain in the calves. (Edema was scarcely notice- 
able. The patient was very querulous and depressed. 

He was given in the abdomen a subcutaneous injection of the 
semicrystallized vitamine obtained from 20 kilograms of rice 
polishings. Within a few minutes he complained of being unable 
to see well, and later of dullness of all the senses and severe pain 
in the abdomen. As the patient was in a very timid and excit- 
able condition, perhaps no great importance should be attached 
to his statement of symptoms. There was a very slight rise of 
temperature. 

Little change was observable in the patient's condition until 
the second day after treatment. On the third day the change 
was very marked. The visible heart impulse had almost disap- 
peared, and the dilatation had greatly diminished. The murmur 
and accentuation of the second sound were no longer heard. The 
pain in the muscles was very slight, and the patient could walk 
with ease and could stoop, flexing the knees without pain. The 
knee reflexes also became slightly more active, although not quite 
normal. Especially noticeable was the change in the patient's 
spirits. He continued to improve for a week, and when last seen, 
a month after treatment, he said that he felt quite well and 
strong. 

CASE 26 

An infant, 40 days old, was examined and treated at home with 
the cooperation of Dr. Jose Albert. The general appearance of 
the child indicated that it might have been premature. It was 
small, weighing 2,500 grams. The arms and legs were thin, the 
skin lying in folds. The mother showed no very marked symp- 
toms of beriberi, although the knee reflexes were sluggish. She 
had had 9 children previously, 7 of whom had died at less 
than 3 months of age. The eighth was living and well. The 
child had been sick two days. Dyspnoea was very severe at 
times, the respirations reaching 140 and the heart beats 200 or 
more per minute. The pulse was scarcely detectable. Vomiting 
had not been frequent, and oedema was slight. The voice was 
husky, the face cyanotic, and the child was very restless and 
fretful. The symptoms presented were such that death was to 
be expected hourly. 

The child was given by mouth the semicrystallized vitamine 
from 10 kilograms of rice polishings in 2 doses at 6 and 11 p. m. 
About one fourth of this was lost in administration. There was 
no rise of temperature, and improA^ement in the condition of the 

132716 2 



1X6 The Philippine Journal of Science 1915 

patient was noticeable before the administration of the second 
dose, the dyspnoea having become less severe. The child had also 
eaten with improved appetite. The following day the child 
breathed easily and freely, and the heart was vastly improved. 
The appetite was good, and sleep was sound and unbroken. All 
the symptoms of infantile beriberi disappeared in three days. 
The gain in weight during a week after treatment amounted to 
7 ounces. A month later the child was well and had gained 
greatly in general robustness. 

CASE 27 

A boy, aged 9 years, was admitted to the Philippine General 
Hospital under the care of Dr. Jose Albert, who kindly invited 
us to treat the patient and observed the results with us. Earlier 
than one week previous to admission the family and personal 
history appeared negative. At this time oedema began to appear 
in the face and three days later in all extremities. About the 
same time there was numbness and heaviness of the legs and 
difficulty in walking. Marked dyspnoea and pains in the chest 
began the day previous to admission. All of these symptoms 
were increased in severity, so that when the patient was first seen 
he was unable to stand or walk. The heart showed general 
and marked enlargement. The first sound lacked clearness, but 
was without definite murmur, and the pulmonic second was ac- 
centuated. The apex beat was diffused, and pulsation of the 
neck veins was visible. The muscles of the calves were sensitive 
to pressure, and the knee jerks were entirely absent. The 
urine proved negative for albumin and casts. 

He was observed for thirty-six hours, being treated with nitro- 
glycerin several times. On the second day after admission, 
December 8, there was no substantial change in the condition of 
the patient. (Edema was more marked, and the pulse and res- 
pirations were very slightly improved. The heart was still much 
enlarged, as determined by percussion and verified by a skiagram 
(Plate I). 

He was given at this time the semicrystallized vitamine ob- 
tained from 25 kilograms of rice polishings. This was given by 
mouth during the course of the following twelve hours, being 
divided into 4 equal doses. A scarcely appreciable rise of tem- 
perature occurred. Twenty-four hours after administration of 
the first dose marked improvement of the dyspnoea and heart 
condition was apparent. The oedema was also much diminished. 
At the end of forty-eight hours after the first dose the oedema 



x, b, ■> Williams and Saleeby: Treatment of Human Beriberi 117 

had practically disappeared, the heart enlargement had markedly 
diminished, especially on the right (Plate II), and the general 
condition was vastly improved, as indicated by the temper, ap- 
petite, and voice. Improvement continued for a few days, when 
the child's condition appeared normal, except for the continued 
slight accentuation of the pulmonic second and absence of knee 
jerks. At the end of a month the heart had become entirely 
normal, and the knee reflexes were detectable, although still much 
diminished. 

In 5 of the 6 cases treated with vitamine, improvement was so 
prompt and radical as to leave no doubt of the specific curative 
properties of the substance. Even in the sixth (case 25), al- 
though the dose was relatively minute, amounting to about 0.25 
gram of dry substance for a man weighing about 50 kilograms, 
improvement although gradual was marked. 

We are unable to assign a definite cause for the rise of tem- 
perature after the administration of vitamine. No such tem- 
perature rise has been noted in fowls, nor is there any record 
of an observation to the contrary. Therefore this reaction may 
be due to the vitamine itself or to an impurity in our product. 
Funk 8 has noted that the pure substance is without marked 
physiological properties. If, therefore, the temperature reaction 
is due to the vitamine itself, it must constitute a specific reaction 
for beriberi. It will be noted that in the cases in which the 
temperature rise was slight or absent the amount of vitamine 
was either small or administered in small doses at intervals of 
a few hours. This was done to avoid the rise of temperature, 
which had caused considerable anxiety, especially in case 23. 
It should be noted also that case 4, after treatment for three 
weeks with hydrolyzed extract, also experienced a temporary 
rise of temperature very much like that noted in case 23. 

CONCLUSIONS 

Allantoin has a beneficial effect in certain cases of beriberi, 
although probably never amounting to a complete cure. Its 
value should be tested further. 

Hydrolyzed extract of rice polishings has benefited all the types 
of beriberi upon which it has been tried. It can be of practical 
service, but should be used only in cases under the direct super- 
vision of physicians and nurses. 

Unhydrolyzed extract of rice polishings is a safe and valuable 
remedy for infantile beriberi, but is of little use for older cases. 

% Journ. Phys. (1913), 46, 173. 



118 The Philippine Journal of Science 

The vitamine of rice polishings possesses specific and prompt 
curative properties far beyond those of any other known sub- 
stance. Unfortunately its cost at present prohibits its general 
use among the poorer classes, who are the chief sufferers from 
beriberi. 

As a whole, our observations on the 27 cases recorded in 
this paper in their bearing on the etiology of beriberi are in 
accord with the broad proposition that the disease, in a prac- 
tical sense at least, results primarily from a poor diet, defi- 
cient more particularly in specific substances of the nature of 
Funk's vitamine. The fact that so-called beriberi cases of what- 
ever type respond in a greater or less degree to the same treat- 
ment would indicate that they are in reality one and the same 
disease. We believe that practically all the neuritis which is 
very prevalent among Filipinos, except, of course, a compara- 
tively small percentage of cases for which some other well- 
known cause is assignable, may safely be regarded as beriberi. 

In conclusion, we are happy to have this opportunity to thank 
the physicians whose names have been mentioned above, as 
well as officials of the Bureau of Health and the Liga Nacional 
for their very kind cooperation in securing and observing cases. 



ILLUSTRATIONS 

[Skiagrams by Fernandez.] 

Plate I. Case 27. Showing the heart immediately before the administration 

of vitamine. 
Plate II. Case 27. Showing the heart forty-eight hours after Plate I was 
taken. 

119 



Williams and Saleeby: Treatment of Beriberi.] [Phil. Journ. Sci., X, B, No. 2. 




PLATE I. CASE 27. THE HEART IMMEDIATELY BEFORE THE ADMINISTRATION OF VITAMINE. 



Williams and Saleeby: Treatment of Beriberi.] [Phil. Journ. Sci., X, B, No. 2. 




PLATE II. CASE 27. THE HEART FORTY-EIGHT HOURS AFTER PLATE I WAS TAKEN. 



THE THYMUS GLAND IN BERIBERI 1 

By R. R. Williams and B. C. Crowell 

(From the Laboratory of Organic Chemistry and the Biological Laboratory, 

Bureau. of Science, Manila, P. I.) 

Funk and Douglas - have shown that, among the changes 
which take place in pigeons suffering from polyneuritis as a 
result of an exclusive white-rice diet, a marked diminution in 
size occurs in the glands of internal secretion. Microscopically 
there is a marked degenerative change of the cells with higher 
functions. In most cases the marked atrophy is due to a dis- 
appearance of the cells, the framework of the gland alone re- 
maining. The most marked change is in the disappearance ~ 
of the thymus; microscopically no thymus could be seen in 
any of the beriberic pigeons examined. 

Following these observations, a theory that a severe change 
in the glands of internal secretion occurs in beriberi has been 
proposed by Funk on the a priori grounds that the vitamines of 
the food have a close relationship to the glands of internal 
secretion. 

Funk and Douglas omitted to mention the age of the pigeons 
used in their work, and it seems that this is a factor of supreme 
importance. In human beings the thymus gland normally un- 
dergoes involution after puberty and is also subject to so-called 
"accidental" involution in the course of both acute and chronic 
diseases. It is known that normal involution of the thymus 
occurs in the chicken, but we know of no evidence to prove that 
"accidental" involution occurs. To assume the occurrence of 
accidental involution in any individual case without a knowl- 
edge of the age of the animal seems erroneous. 

In man, in so far as infantile beriberi is concerned, it is known 
that accidental involution of the thymus does not always occur, 
and one of us 3 has drawn attention to the occurrence of en- 
larged thymus in some cases of infantile beriberi associated with 
status thymico-lymphaticus. 

In adult beriberic cases at autopsy our records show that the 

1 Received for publication November 16, 1914. 

2 Journ. Physiol. (1914), 47, 475. 

'Crowell, B. C, This Journal, Sec. B (1913), 8, 77. 

121 



122 The Philippine Journal of Science 1915 

thymus gland is usually "small," but one case was found with 
a thymus gland weighing 28 grams in a child 13 years old 
(2584), and one weighing 12 grams in a case 18 years of age 
(2645). 

In view of the extreme importance of the subject and the 
unknown factors involved, it was deemed advisable to record 
some observations made by us in the course of other work, as 
to the atrophy of the thymus in cases of beriberi. 

In addition, it having been reported that the administration 
of thymus nucleic acid produced marked improvement in birds 
suffering from polyneuritis, 4 a further study of thymus tissue 
seems advisable. Extracts of thymus tissue give the blue color 
reaction with phosphotungstic acid and alkali 3 to a marked 
degree, making the existence of vitamines in the tissue most 
probable. It seemed possible that the thymus might constitute 
a store of vitamines in the body to an extent out of proportion 
to the size of the organ. Some color was lent to this view by 
the fact that young fowls, in which the thymus is normally 
large, are slightly more resistant to the onset of acute symptoms 
of polyneuritis than full-grown ones, and that only a much 
modified form of beriberi occurs in human infants. On the 
other hand, any effect the thymus tissue may have upon the 
onset of polyneuritis may be due to purine and pyrimidine 
bodies. The results which we have obtained with thymus 
tissue are preliminary, and more definite decision awaits the 
isolation of vitamines from the tissue. 

AUTOPSY FINDINGS 

Three supposedly normal pigeons were procured alive in the 
market and were killed at once. Their age was unknown. The 
thymus gland of one was relatively very small ; another, small ; 
and another, large. In 4 beriberic pigeons which had been fed 
on white rice the thymus had completely disappeared in every 
case, as reported by Funk and Douglas. 

However, upon examining 16 chickens in which polyneuritis 
had developed as a result of a white rice diet, it was found 
that the thymus had completely disappeared in 7 cases, was 
considerably atrophied in 5 other cases, and apparently was 
slightly, if at all, altered in the remaining 4. The disappear- 
ance of the thymus, therefore, is not a necessary concomitant 
of polyneuritis in chickens, although it may occur frequently. 

4 Funk, Journ. Phys. (1912), 45, 491. 

"Folin et al., Journ. Biol. Chcm. (1912), 11, 265; (1912), 13, 363. 



x, b, 2 Williams and Crow ell: Thymus Gland in Beriberi 123 

That this atrophy is not due simply to the age of the birds 
is shown by the fact that it took place in half-grown as well 
as in full-grown fowls. 

No relationship could be established between the atrophy of 
the thymus and the length of the incubation period or the 
duration, severity, or specific symptoms of the disease. How- 
ever, our study of the symptoms was not sufficiently minute 
to exclude the possibility of the existence of such relationship. 

The thyroid was also examined in the 16 fowls mentioned, 
and results similar to those of Funk and Douglas were noted. 

Four chickens which had been fed on milk and white rice 
for varying periods in the course of another experiment were 
examined after death. These chickens developed evidence of 
neuritis and were killed. Their sciatic nerves showed micro- 
scopic evidences of degeneration in Marchi preparations. The 
thymus of 1 fed with autoclaved milk and white rice was small. 
The thymus glands of the other 3 chickens which were fed oh 
whole fresh milk and white rice were large. 

The results of all of these examinations are given in Table I. 

ADMINISTRATION OF THYMUS TISSUE 

Two fowls were fed on white rice with an addition of 10 milli- 
grams of dried sheep's thymus daily. It was estimated that the 
quantity of thymus tissue ingested during the normal period of 
incubation would be the same as that normally present in young 
fowls. This small amount of tissue noticeably retarded, but 
did not prevent, the onset of the disease. 

Two fowls were fed on white rice with a daily dose of the 
alcoholic extract of 1.5 gram thymus gland. Here again the pro- 
tection was not complete, although the loss in weight and the 
onset of the disease were retarded. 

Two fowls were fed in the same manner, but with a daily dose 
of the extract of 3 grams of thymus with less protective results. 

For comparison 2 fowls were fed on white rice and 2 milligrams 
of uracil daily. One contracted chicken cholera as shown by a 
blood smear. The other was apparently partially protected by 
the uracil. 

Five fowls suffering from polyneuritis were treated with 
hydrolyzed extract of thymus gland in doses of from 5 to 50 grams 
of the gland. No cures were obtained. 

Two human cases of beriberi were treated with small quan- 
tities of thymus, and a slight improvement was shown in each 
case. This improvement did not continue after the first few 



124 



The Philippine Journal of Science 



1915 



-8 



^ 



s 



-S 



a. 
o 



ta 

CO 

< 



Thymus, with microscopic 
control. 


Very small. 

Large. 

Small and of involuting type. 

None. 

Do. 

Do. 

Do. 
Normal (?) amount. 
Small. 

Fairly large. 
Very small. 
None. 
Very small. 
None. 
Moderate. 
Fairly large. 
None. 

Do. 
Small. 
Moderate. 
None. 

Do. 

Do. 
Small. 
Large. 

Do. 

Do. 


Diet and treatment. 


White rice only . ... 

do 

rln 


o o o o c 

fQ n3 *^3 13 X 


c 


e 

T3 -C 


3 

*o 
oj 

C 

'■£ 
c 

c 

V 



■0 

CM 

3 

"a 


OJ c 

.■t! ^ 


White rice plus 2 mg. nicotinic acid daily .. 
do 

White rice plus 10 mg. thymus daily . ... 
do 

White rice plus 3 doses extract of thymus.- 

White rice plus 5 mg. allantoin daily 

White rice plus 5 mg. uracil daily 

Autoclaved milk plus white rice 

100 cc. fresh milk plus 40 gms. white rice .. 

do 

do 


Cause of death. 


Killed 

do 

do 

Polyneuritis., 

Choline poisoning 


111! 
c 

> 73 -o -a -a -c 

■ 1 1 1 


e 


O C 


b 

E 
E 
c 

a 

'c 

C 

a 
.£ 


j 

p 


1 

e 
- 


a 
'Z 
"u 

% 

| 

c 


; 

! 

c 


c 

■a -c 


e 


c 




5 


000 

"3 "O "U 


1 .5 

3 


2 


H 


Ill + + + + + 

: : ! + + _r + + 4- + + 

III + + + + 


+ + : 


+ , + 






:++: 


3.2 


i i >eO(Mcocooo^cor-icoirtO»-'cftcoeo*ocMOiu3eoio»-t*H 
aj i i i « h ■* « com ^ 

1: i i 

Q ; ; ; 


, 1 


i ' i « C- 05 M i i U3 t- M W 
• 1 i ■ M CM CM CO i i rH i-H i-H r-* 

I|| | c | j 




t-o»-f»-<tocot-oo-*o 

MCCWP5'-'MCCCQeO«>0> 




"a 
E 
'£ 

< 


Normal pigeon 

Do 

Do 

Chicken 

Do 

Do 


e 

Q Q O Q C 


c 
C 


c 


j= 
u 

be e 
= C 
3 

>< 


c 
1 

- 


1 


c 

c 


e 

a a 


c 

Q C 


c 

n 


c 

p 


c 

a 


COO 

a Q Q 



x, b, 2 Williams and Crowell: Thymus Gland in Beriberi 125 

days of treatment, and the patients at the close of the treatment 
still showed the characteristic symptoms of the disease, although 
in a less distressing form. Inasmuch as it was not practicable 
to place these cases in a hospital for accurate observation during 
treatment, the results are of more or less doubtful value, but are 
given here for what they may be worth. The dose used was 
0.3 gram of dried sheep's thymus six times daily. No change 
was made in the diet of the patients. 

CONCLUSIONS 

The experimental evidence indicates that (1) there is no 
apparent fundamental connection between beriberi and the atro- 
phy of the thymus; (2) when the latter occurs in birds fed 
on polished rice, as it frequently does, it is due to some other 
cause; (3) the thymus gland contains no extraordinary amount 
of vitamine, and the protective effect of administering the tissue 
is probably largely due to purine and pyrimidine derivatives ", 
(4) the presence of a comparatively large amount of thymus 
gland in young animals does not appear to be responsible for 
their modified susceptibility to beriberi. 

We feel that the experimental evidence presented by Funk 
and Douglas is far too meager to warrant any positive conclu- 
sions, much less forming any useful theory regarding the role 
of the vitamines in the body. 

Table II. — Thymus- feeding experiments. 



Fowl No. 



20. 
21. 
36. 
38. 



Average of 6 controls . 



Addition to daily diet of 50 grams 
of white rice. 



+ 10 mg. thymus 

do 

+ 1.5 gm. thymus gland. 

do 

3 gm. thymus gland 

do 

2 mg. uracil 



Time 

re- 
quired 
to de- 
velop 
neu- 
ritis. 



Days. 
34 
32 
45 
52 
25 
31 
38 
17.5 



Length 
of life. 



Days. 
37 
37 
46 
58 
29 
35 
43 
21 



Loss in weight. 



Total. 



Per ct. 
28.5 
33.7 
20.8 
20 
31.9 
27.5 
36.6 
26.9 



Daily. 



Per ct. 
0.77 
0.91 
0.57 
0.66 
1.57 
1.25 
0.85 
1.41 



PRACTICAL EXPERIENCE WITH SOME ENRICHING MEDIA 

RECOMMENDED FOR BACTERIOLOGICAL DIAGNOSIS 

OF ASIATIC CHOLERA x 

By Otto Schobl 
{From the Biological Laboratory, Bureau of Science, Manila, P. I.) 

It appears from the literature as though the classical Koch- 
Durham peptone solution has not always given satisfactory 
results. Ohno (1), in this laboratory, made a thorough study of 
the relation between the chemical reaction of the culture medium 
and the morphology of cholera vibrio. Led by the experience 
that a sudden change of chemical reaction of the medium in which 
cholera vibrio is growing causes change in morphology, he tested 
the reaction of a series of cholera faeces. As a consequence of 
this study Ohno advises the use of peptone of three different 
reactions which correspond to the reaction of the cholera faeces : 
namely, 0, 3, -0, 5, -1, 3. The significance of this phenomenon in 
relation to our method of examinations is evident, as the presence 
of vibrios in the peptone culture was used as an indicator in the 
search for contact carriers, and only those samples were plated 
which contained vibrios. The objection may be made that owing 
to the difference between the reaction of the fasces and that of the 
peptone medium the cholera vibrios assumed an atypical form and 
remained unrecognized. It is an actual fact that cholera vibrios 
will lose the typical vibrio shape if transferred from acid to alka- 
line medium or vice versa, but such a change is not a permanent 
one, and the new generations, which follow in rapid succession, 
adapt themselves to the new conditions and soon appear in 
typical vibrio shape. This is particularly true of liquid media, 
provided the reaction remains within the limits of maximal 
acidity and maximal alkalinity. 

Numerous stools from patients, convalescents, and suspects 
submitted by the quarantine hospital, which were all examined 
by hanging drop, enrichment process, and Dieudonne's plates, 
showed that in every instance in which cholera vibrios were 
found on the plates motile vibrios were present in the corre- 
sponding peptone culture after an incubation of from twelve to 
eighteen hours. All liquid stools from cholera patients were of 
pronounced alkaline reaction to litmus paper. 

Several suggestions recently have been made to substitute for 

1 Received for publication December 28, 1914. 

127 



128 The Philippine Journal of Science 1915 

the peptone solution a medium which would act not only as an 
enriching medium, but also as a selective one. The bile medium 
of Ottolenghi and the application of the principle of Dieudonne's 
agar to liquid media as suggested by Kraus are particularly of 
note. The literature on this subject is not lacking in criticism 
in regard to those two media. Contradictory results have been 
obtained by various authors, 2 and the impression seems to prevail 
that the advantages attached to either one of these enriching 
media are so slight as not to warrant a substitution for the pep- 
tone solution. From the purely scientific standpoint the ten- 
dency is to cultivate bacteria on media of simple and uniform 
composition, while from the practical standpoint a reliable me- 
dium is desired which can be prepared with the least loss of time 
and with the least trouble. None of the substitutes exceeds the 
peptone solution in either of the requirements ; besides, as will be 
seen later, their reliability under certain conditions is doubtful. 
Owing to the lack of uniformity in their composition, the media 
must be tested before use. 

CULTURAL EXPERIMENTS WITH THE CHOLERA VIBRIO AND BACTERIA 
ASSOCIATED IN CHOLERA STOOLS 

In a series of experiments I have used various enrichment 
media to compare their practical value — peptone solution of 
varying chemical reaction (NaOH, Na 2 C0 3 ), Kraus's medium, 
and the bile medium. Several instances of these comparative 
tests are given in the tables. 

The arrangement of the experiments is evident from the pro- 
tocols. Liquid stools were used. The stool specimens were 
thoroughly shaken before planting. The platinum loop was of 
uniform size (4 millimeters in diameter). 

Terms used in the protocols. 

— No cholera colonies present. 

= No growth at all. 

-j- Cholera colonies present. 

Very few. Less than half a dozen. 

Few. About one dozen. 

More than a few. About 50. 

Numerous. About 200. 

Very numerous. More than 200. 

PROTOCOLS OF EXPERIMENTS 

One loopful of cholera faeces was inoculated into each tube of enrichment 
medium. Streak cultures were made on agar plates. One loopful 
was transferred. 

* See references at the end of this paper. 



x, b, 2 Schobl: Diagnosis of Asiatic Cholera 

Table I. — Enrichment cultures incubated eighteen hours. 



129 



Enrichment. 


Growth 

on plates. 

Lactose 

agar. 


Remarks. 


Medium. 


Reaction. 




+2 
+ 1.5 
+ 1 
+0.5 
—0.5 
—1 
—1.5 
—2 


+ 
+ 

+ 
+ 
+ 


[■Mostly acid producers present besides cholera. 

Their number decreases toward the alkaline end of 
the series of peptone. Plates made from peptone | 
+2, +1.5, and +1 overgrown by acid producers. 


Do !. 


Do ____ „ 


Do 


Do 

Do .___ 

Do 

Do 



Table II. — Same arrangement of experiment as in Table I. 



Enrichment. 


Growth 
on plates. 

Dieu- 
donne's 

agar. 


Remarks. 


Medium. 


Reaction. 




+2 
+ 1.5 


1 1 1 1 1 1 1 + 


Overgrown by a motile bacillus growing fairly well 
on Dieudonne's plates. One single colony found 
on the plate made from +2 peptone. It proved 
to be one of cholera vibrio. 


Do 


Do 

Do 

Do 

Do 

Do 

Do 


+1 

+ 0.5 

-0.5 

-1 

-1.5 

-2 



Table III. — Same arrangement as Table II. Both lactose agar and Dieu- 
donne's plates used. Incubation of peptone culture, eighteen hours. 



Enrichment. 


Growth on plates. 


Remarks. 


Medium. 


Reaction. 


Lactose 
agar. 


Dieudon- 
ne's agar. 




+2 

+ 1.5 

+1 

+0.5 

—1 

—1.5 

—2 

+2 

+1.5 

H 1 

+0.5 

—0.5 

-1 

—1.5 

—2 


+ 

+ 
+ 
+ 
+ 
-f 




l Few acid producers from +2. The num- 
1 ber of red colonies decreases toward the 
alkaline end of series. No blue colonies 
' except cholera. 

1 Cholera colonies most numerous on plates 
}• made from peptone of from — 0.5 to — 1.5 
J reaction. 

1 Only one cholera colony +2 plate. Plates 
1 show pure growth of cholera. 

Cholera colonies most numerous on plates 
made from peptone of from — 0. 5 to — 1. 5 
reaction. 


Do 




Do 




Do 

Do 






Do 




Do 




Do 


+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 


Do 




Do 




Do 




Do 




Do 




Do 




Do 









130 



The Philippine Journal of Science 
Table IV. — Same arrangement as Table III. 



1915 



Enrichment. 


Growth on plates. 


Remarks. 


Medium. 


Reaction. 


Lactose j Dieudon- 
agar. n€'s agar. 




-t-2 

+1.5 

+ 1 

+0.5 

—1 

-1.5 

—2 

+2 

+ 1.5 

+ 1 

+0.5 

—1 

—1.5 

—2 


+ 

+ 




Reaction +2 exclusively red colonies. 
Red colonies decrease toward the alka- 
line end of the series but are still present 
on the plate made from peptone — 1. 5. 

From +2 to — 0. 5 cholera pure; from — 1 to 
— 2 besides cholera colonies also small 
yellowish colonies present. Their num- 
ber increases with increasing alkalinity 
of peptone. 


Do 




Do 




Do 







Do 


+ 
+ 




Do 




Do 


+ 
+ 
+ 
+ 
+ 


Do , 

Do 

Do 






Do ... 




Do 




Do 




Do 








1 





Table V. — Same arrangement as Table IV. 



Enrichment. 


Growth on plates. 


Remarks. 


Medium. 


Reaction. 


Lactose 
agar. 


Dieudon- 
ng'sagar. 


Peptone 

Do .. . 


+2 

+1.5 

+ 1 

+0.5 

—0.5 

—1 

—1.5 

—2 

+2 

+ 1.5 

+1 

+ 0.5 

—0.5 

—1 

—1.5 

— o 




+ 
+ 



-i 




Exclusively red colonies in +2. More red 
colonies than cholera in — 0. 5. On — 2 

■ plate mostly cholera colonies; only very 
few red colonies. No blue colonies ex- 
cept cholera. 

Pure cholera. Cholera colonies most 
numerous from — 0. 5 to 1. 5 reaction. 




Do . 




Do . 




Do ... 




Do ... . 




Do 




Do 





+ 




+ 


Do 


Do 




Do ____ 

Do 

Do 

Do _ 

Do 

Do 

















X, B, 2 



Schobl: Diagnosis of Asiatic Cholera 



131 



Table VI. — Same arrangement as Table V. Plates inoculated after six 

hours' and eighteen hours' incubation. 

SIX HOURS' INCUBATION. 



Enrichment. 


Growth on plates. 


Remarks. 


Medium. 


Reaction. 


Lactose 
agar. 


Dieudon- 
n£'s agar. 




+2 
+ 1.5 
+ 1 
+0.5 
-0.5 

—1 

—1.5" 

—2 


+ 
+ 

+ 




Few red colonies; no cholera. 
Overgrown with red colonies; no choler». 
Do. 
Do. 
More than a few cholera colonies. Red 

colonies predominate. 
Same as previous, only cholera colonies 

more numerous. 
Very numerous cholera colonies; few small 

white and yellow colonies. 
Numerous cholera colonies; few white and 

yellow colonies. 


Do 

Do 






Do 




Do 




Do 




Do 




Do 





EIGHTEEN HOURS' INCUBATION. 



Peptone . 
Do__. 
Do._ 

Do... 

Do... 
Do... 
Do.-. 
Do._. 
Do--. 
Do... 



+1 

+0.5 


- 






—0.5 
—1 


+ 

+ 







-2 


+ 




+ 1 
+0.5 
— 0.5 




+ 

■4- 




., 


—1 




+ 


—2 




+ 





Exclusively red colonies. 

Do. 
Few cholera colonies; red colonies pre- 
dominate. 
Numerous cholera colonies; only few red 
ones. 
Do. 

Very few cholera colonies, pure. 
Numerous cholera colonies, pure. 
Very numerous cholera colonies, pure. 
Same as — 1. 



Table VII.- — Same arrangement as Table VI. Plates inoculated after six 
hours' and eighteen hours' incubation. 

SIX HOURS' INCUBATION. 



Enrichment. 


Growth on plates. 


Remarks. 


Medium. 


Reaction. 


Lactose 
agar. 


Dieudon- 
ne'sagar. 




+2 

+ 1 

+0.5 
—0.5 

—1 
—2 


+ 
+ 




One subtilis-like colony; no cholera. 
Mostly red colonies; few blue spreading 

colonies; no cholera. 
Overgrown by red colonies; more than a 

few blue spreading colonies; few cholera. 
Only few red colonies; numerous blue 

spreading colonies more than a few 

cholera. 
Overgrown by blue spreading colonies; 

more than few cholera colonies. 
Same as — 1. 


Do 




Do 


Do 




Do 


Do 









132716 



132 



The Philippine Journal of Science 



1915 



Table VII. — Same arrangement as Table VI. Plates inoculated after six 
hours' and eighteen hours' incubation — Continued. 



EIGHTEEN HOURS' INCUBATION. 



Enrichment. 


Growth on plates. 


Remarks. 


Medium. 


Reaction. 


Lactose 
agar. 


Dieudon- 
ne^sagar. 




+ 1 

+0.5 

—0.5 

—1 

—2 

+1 

+0.5 

—0.5 

—1 

—2 


+ 

+ 

+ 




Mostly red colonies; few blue spreading 

ones; no cholera. 
Same as + 1. 
Numerous cholera; few red colonies; few 

blue spreading colonies. 
Very numerous cholera colonies; 12 red 

ones; more than a few blue spreading 

colonies. 
No red colonies; more than a few blue 

spreading colonies; more than a few 

cholera. 
No growth. 


Do 




Do— 




Do 




Do 




Do 


+ 


Do- 




Do 






Do 




+ 
+ 


Very numerous cholera colonies, pure. 
More than few cholera colonies, pure. 


Do . 







Table VIII. — Same arrangement as Table VII. Kraus's and Ottolenghi's 
media included. Plates inoculated after six hours' and eighteen hours' 
incubation. 

SIX HOURS' INCUBATION. 



Enrichment. 


Growth on 
plate. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donne"s 

agar. 




+ 1 
+ 0.5 
—0.5 

-1 

—2 


Per ct. 

6 

10 
15 
20 


+ 

+ 

+ 

+ 

+ 
+ 




No growth. 

Red colonies, exclusively. 

Few red colonies; numerous cholera 

colonies. 
Very numerous cholera colonies: about 

a dozen white ones. 
Numerous cholera colonies; about a 

half-dozen white ones. 
More than a few cholera colonies; same 

number of red ones. 
More than a few cholera colonies, pure. 
No growth. 
Do. 
Do. 


Do 


Do 


Do 


Do 




Do __ 




Do .„..*. 




Do 















X, B, 2 



Schobl: Diagnosis of Asiatic Cholera 



133 



Table VIII. — Same arrangement as Table VII. Kraus's and Ottolenghi's 
media included. Plates inoculated after six hours' and eighteen hours' 
incubation — Continued. 

EIGHTEEN HOURS' INCUBATION. 



Enrichment. 


Growth on 
plate. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donn^'s 

agar- 




+ 1 

+0.5 

—0.5 

—1 
-2 


Per ct. 

20 
15 
10 
5 


+ 

+ 
+ 

+ 

+ 


+ 
+ 
+ 
+ 

+ 
+ 
+ 


Very few red colonies; no cholera. 
More than a few red colonies; no cholera. 
Numerous cholera colonies; about a 

dozen red ones. 
Same as — 0. 5. 
More than a few cholera colonies; very 

few red ones. 
Two blue colonies; no cholera. 
Small white colonies; no cholera. 
More than a few cholera colonies, pure. 
Numerous cholera colonies; very few 

red ones. 
Few cholera colonies, pure. 

About a dozen cholera colonies, pure. 
Numerous cholera colonies, pure. 
Same as — 0. 5. 
More than a few white cholera colonies, 

pure. 
No growth. 

Do. 
More than a few cholera colonies, pure. 
Numerous cholera colonies, pure. 
Few cholera colonies, pure. 


Do 


Do _ . 


Do 


Do 


Kraus's 


Do ._. 




Do 




Do 




Ottolenghi's 




Peptone 


+1 

+0.5 

-0.5 

—1 

—2 




Do 






Do 






Do '.. 






Do 






Do 


20 
15 
10 
5 




Do ._- 




Do 




Do 

















Table IX. — Same arrangement as Table VIII. Plates inoculated after six 
hours' and eighteen hours' incubation. 

SIX HOURS' INCUBATION. 



Enrichment. 


Growth on 
plate. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donng's 

agar. 




+1 

+0.5 

—0.5 

—1 

-2 


Per ct. 

20 
15 
10 
5 


+ 
+ 
+ 

+ 
+ 




Two red colonies; no cholera. 
More than a few red colonies; no cholera. 
Numerous cholera colonies, pure. 
Very numerous cholera colonies, pure. 
More than a few cholera colonies, pure. 
No growth. 

Do. 
More than a few cholera colonies, pure. 
Numerous cholera colonies, pure. 
No growth. 


Do 


Do 


Do 


Do 


Do 




Do 




Do 















134 



The Philippine Journal of Science 



1915 



Table IX. — Same arrangement as Table VIII. Plates inoculated after six 

hours' and eighteen hours' incubation — Continued. 

EIGHTEEN HOURS' INCUBATION. 



Enrichment. 


Growth on 
plate. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donng's 

agar. 




+1 
+ 0.5 
-0.5 
— 1 
-2 


Per ct. 

20 
15 

10 

5 


+ 
+ 
+ 

+ 


+ 
+ 

+ 


Red colonies exclusively; no cholera. 
More than a few cholera colonies, pure. 
Same as +0. 5. 

Numerous cholera colonies, pure. 
More than a few cholera colonies; few 

small white colonies. 
No growth. 
Few small white and yellow colonies; 

no cholera. 
Few cholera colonies; same number of 

small white colonies. 
Same as 10 per cent. 
Few yellow colonies; no cholera. 
No growth. 

Do. 
Numerous cholera colonies, pure. 
Very numerous cholera colonies, pure. 
Numerous cholera colonies, pure. 
No growth. 

Do. 
More than a few cholera colonies, pure. 
Same as 10 per cent. 
No growth. 


Do 1. 

Do 


Do 


Do 




Do L 




Do 




Do 










+1 

+0.5 

—0.5 

-1 

—2 




Do 






Do 






Do 






Do 








20 
15 
10 
5 




Do 




Do 




Do - 

















Table X. 



-Same arrangement as Table IX. Plates inoculated six hours 
and eighteen hours after incubation. 



SIX HOURS' INCUBATION. 



Enrichment. 


Growth 




Medium. 


Reaction. 


Concen- 
tration. 


on plates. 
Lactose nemancs. 
agar. . ' 




+ 1 

+0.5 

—0.5 

—1 
— *> 


Per cent. 


= No growth. 

— i Numerous red colonies; no cholera. 


Do 




Do 




Do • 




+ 

+ 

+ 


few red ones. 

Very numerous cholera colonies; more 
than a few red colonies. 

Numerous cholera colonies; few red colo- 
nies. 

No growth. 
Do. 

More than a few cholera colonies, pure. 

Numerous cholera colonies; same num- 
ber of red ones. 

No trrow th. 


Do 








20 
15 
10 
5 


Do -. 




Do . 




Do 

















X, B, 2 



Schobl: Diagnosis of Asiatic Cholera 



135 



Table X. — Same arrangement as Table IX. Plates inoculated six hours 
and eighteen hours after incubation — Continued. 



EIGHTEEN HOURS' INCUBATION. 



Enrichment. 


Growth 

on plates. 

Lactose 

agar. 


Remarks. 


Medium. 


Reaction. 


Concen- 
tration. 




+1 
+0.5 

—0.5 

-1 

-2 


Per cent. 


+ 
+ 
+ 
+ 

+ 


Red colonies exclusively. 

More than a few cholera colonies; red 
colonies predominate. 

More than a few cholera colonies; same 
number of red colonies. 

Numerous cholera colonies; more than a 
few red colonies. 

More than a few cholera colonies; few 
small white colonies; cholera predom- 
inate. 

Few small white colonies; no cholera. 

Same as 20 per cent. 

Numerous cholera colonies, pure. 

No growth. 


Do 

Do 






Do 




Do 




20 
15 
5 


Do 




Do 















Table XI. — Same arrangement as Table X. Soda medium included. Plate 
inoculated after six hours' and twenty-four hours' incubation. 

SIX HOURS' INCUBATION. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lactose 
agar. 


Dieu- 

donne's 

agar. 




+ 1 

+0.5 

—0.5 

—1 
—2 


Per ct. 


+ 

+ 
+ 

+ 
+ 
+ 




Numerous red colonies; no cholera. 
Do. 

Numerous red colonies; cholera, plus 
numerous small blue fluorescent 
colonies, blue ones predominate; no 
cholera. 
Do. 

Few cholera colonies; few red ones; 
numerous small blue fluorescent 
colonies. 

Few small yellow colonies. 

Numerous cholera colonies; numerous 
small blue fluorescent colonies. Lat- 
ter predominate, no red ones. 

Numerous cholera colonies; numerous 
small blue fluorescent colonies. Lat- 
ter predominate. 

Numerous cholera colonies; very few 
white colonies. 

More than a few cholera colonies; one 
white colony. 

Few cholera colonies; more than a few 
small white colonies. 


Do 


Do 

Do 


Do 








10 
5 


Do — 




Soda peptone 

Do 


—1 
-2 
-3 


Do 



136 



The Philippine Journal of Science 



1915 



Table XI. — Same arrangement as Table X. Soda medium included. Plate 

' inoculated after six hours' and twenty-four hours' incubation — Contd. 

TWENTY-FOUR HOURS' INCUBATION. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donn^'s 

agar. 




+1 
+0.5 
—0.5 
—1 

—2 


Perct. 








Red colonies exclusively. 

Numerous cholera colonies; few red 

ones; few small fluorescent colonies. 

More than a few cholera colonies; few 

red ones; few small fluorescent 

colonies. 

Small yellow colonies; few subtilis-\ike 

colonies. 
Few cholera colonies; small blue fluor- 
escent colonies predominate; verj' few 
red ones. 
More than a few small blue fluorescent 

colonies. 
More than a few cholera colonies; few ' 
small white colonies and small blue ! 
fluorescent colonies; cholera predom- 
inate. 
No growth. 
Do. 
Do. 
More than a few cholera colonies. 
Numerous cholera colonies, pure. 
Do. 
Do. 
No growth. 
Numerous cholera colonies, pure. 

Do. 
Very numerous cholera colonies, pure. 
No growth. 
Do. 


Do 


Do 


Do 


Do 








Ottolenghi's ._ 








Kraus's ... . . 




10 
5 






Do_ 








Soda peptone .. 

Do 


—1 

—2 
—3 

+1 
+ 0.5 
—0.5 
—1 
—2 








= 


+ 

+ 
+ 

+ 
+ 


Do 


Peptone 


Do 






Do 






Do ..__ 






Do.... 






Ottolenghi's 






Kraus's 




10 
5 




Do 




Soda peptone 

Do 


—1 
—2 
—3 






Do 













Table XII. — Same arrangement as Table XI. Incubation, six and twenty- 
four hours. 
SIX HOURS' INCUBATION. 



Enrichment. 


Growth on 
plates. 




Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donn^'s 

agar. 


Remarks. 




+ 1 
+0.5 


Peret. 


+ 




Few cholera colonies; numerous blue 
spreading colonies; numerous red col- 
onies. 

The same as above, but colonies more 
numerous. 


Do 





X, B. 2 



Schobl: Diagnosis of Asiatic Cholera 



137 



Table XII. — Same arrangement as Table XI. Incubation, six and twenty- 
four hours — Continued. 



SIX HOURS' INCUBATION— Continued. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donne's 

agar. 


Peptone 


—0.5 

—1 
—2 


Per ct. 


+ 

+ 

+ 

+ 

+ 
+ 




Numerous cholera colonies; numerous 
blue spreading colonies; the latter 
predominate; few red colonies. 

The same as above, but colonies not so 
numerous. 

More than a few cholera colonies; very 
numerous blue spreading colonies; a 
few red colonies. 

Two small white colonies; no cholera. 

More than a few cholera colonies; few " 
red ones; numerous blue spreading 
colonies. 

No cholera; numerous blue spreading 
colonies; few red colonies. 

Numerous blue spreading colonies; nu- 
merous cholera colonies; cholera col- 
onies predominate; few small white 
colonies. 

Very few blue spreading colonies; more 
than a few small white colonies; few 
cholera colonies. 

The same as above, but no cholera col- 
onies. 


Do 


Do 








10 
5 


Do 




Soda peptone 

Do 


-1 

—2 
-3 


Do 









TWENTY-FOUR HOURS' INCUBATION. 



Peptone 


+1 








Few red colonies; few blue ones; one 












cholera. 


Do 


+0.5 









Do. 


Do 


—0.5 




+ 




The same as above, but cholera colonies 
numerous. 




Do.. 


—1 




+ 




Numerous cholera colonies; very few 
small white colonies. 


Do 


—2 




+ 




More than a few cholera colonies; very 
few small white colonies. 




Ottolenghi's 






+ 




More than a few cholera colonies; more 












than a few small blue fluorescent col- 












onies; few small white colonies. 


Kraus's -_ 




10 


+ 




Same as bile. 


Do _._ 




5 


+ 




More than a few cholera colonies; same 
number of small white colonies. 






Soda peptone 


—1 




+ 




More than a few cholera colonies; very 
few small white colonies. 


Do 


—2 




_ 




Few small white colonies; no cholera. 


Do 


-3 











Peptone .__ 


+1 






= 


Do. 



138 



The Philippine Journal of Science 



1915 



Table XII. — Same arrangement as Table XI. Incubation, six and twenty- 
four hours — Continued. 

TWENTY-FOUR HOURS' INCUBATION— Continued. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donng's 

agar. 




+0.5 
—0.5 
—1 
—2 


Per ct. 




+ 
+ 

+ 
+ 

+ 
+ 


No growth. 

Numerous cholera colonies, pure. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 
No growth. 

Do. 


Do_— 

Do 










Do 














10 
5 




Do 




Soda peptone 

Do 

Do 


—1 
—2 
—3 

















Table XIII.- — Same arrangement as Table XII. Plates inoculated after six 
hours' and twenty-four hours' incubation. 

SIX HOURS' INCUBATION. 



Enrichment. 


Growth on 
plates. 


Remarks. 

* 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donnfi's 

agar. 




+1 
+0.5 

-0.5 

-1 
—2 


Per ct. 


+1 + + + II 




No cholera; numerous small blue opal- 
escent colonies; few white onesT 

No cholera; very numerous small blue 
opalescent colonies; a number of white 
ones. 

More than a few cholera colonies; nu- 
merous small blue opalescent colonies; 
very few white ones. 

Few cholera colonies; more than a few 
blue opalescent colonies. 

Numerous cholera colonies; numerous 
small opalescent colonies; cholera col- 
onies predominate. 

No cholera; few white colonies. 

Same as — 2 plus small white colonies. 

Same as — 1. 

Same as — 0. 5. 

Very few cholera colonies; more than 
a few blue spreading colonies; numer- 
ous small yellow colonics. 

Few blue opalescent colonies; no chol- 
era. 


Do 

Do 

Do 


Do . 








10 

5 


Do 




Soda peptone 

Do 

Do 


—1 
—2 

-3 









X, B, 2 



Schobl: Diagnosis of Asiatic Cholera 



139 



Table XIII. — Same arrangement as Table XII. Plates inoculated after six 
hours' and twenty-four hours' incubation — Continued. 

TWENTY-FOUR HOURS' INCUBATION. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donnfi's 

agar. 




+ 1 

+0.5 
—0.5 

—1 

-2 


Per ct. 





+ 

+ 

+ 

+ 

+ 
+ 
+ 


+ 
+ 

+ 
+ 
+ 
+ 


No cholera; more than a few white col- 
onies. 

Very few small white colonies; numer- 
ous cholera colonies. 

More than a few cholera colonies; more 
than a few small blue opalescent col- 
onies. 

Few small white colonies. 

Few cholera colonies; numerous small 
blue opalescent colonies. 

More than a few cholera colonies; nu- 
merous small blue opalescent colonies. 

Same as 10 per cent. 

Same as — 1. 

No cholera; few small white colonies. 

No growth. 
Do. 
Do. 

Numerous cholera colonies, pure. 

More than a few cholera colonies. 

No growth. 

Few cholera colonies, pure. 

Very numerous cholera colonies, pure. 
Do. 
Do. 

No growth. 


' Do - 

Do 

Do .... 


Do 








10 
5 


Do 




Soda peptone . ._ 
Do 


—1 
—2 
—3 

+ 1 
+ 0.5 
—0.5 
-1 
—2 


Do___ 


Peptone .... 


Do 






Do ___ 






Do 






Do 






Ottolenghi's . 










10 
5 




Do . 


—1 
—2 
—3 


Soda peptone 

Do 






Do 













Table XIV. — Same arrangement as Table XIII. Plates inoculated after six 
hours' and twenty-four hours' incubation. 



SIX HOURS' INCUBATION. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donn£'s 

agar. 


Peptone 


+1 

+ 0.5 
—0.5 

—1 


Per ct. 


+ 
+ 




No cholera colonies; numerous red 
colonies. 
Do. 

Numerous cholera colonies; numerous 
blue spreading colonies; cholera 
predominates. 

Same 'as —0. 5, only cholera more nu- 
merous. 


Do 


Do ... 


Do 





140 



The Philippine Journal of Science 



1915 



Table XIV. — Same arrangement as Table XIII. Plates inoculated after six 
hours' and twenty-four hours' incubation — Continued. 



SIX HOURS' INCUBATION— Continued. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donne's 

agar. 




—2 


Per ct. 


+ 

+ 

+ 

+ 

+ 
+ 




Cholera colonies numerous; few blue 1 

spreading- colonies. 
No cholera colonies; few small white 

colonies. 
Same as — 0. 5. 
Very few cholera colonies; numerous 

blue spreading colonies; numerous 

red colonies. 
Numerous cholera colonies; a few blue 

spreading colonies; very few white 

colonies. 
Very numerous cholera colonies; very ! 

few white colonies. 
More than a few cholera colonies, pure. 








10 
5 


Do 




Soda peptone 

Do 


—1 

—2 
—3 


Do 





TWENTY-FOUR HOURS' INCUBATION. 





+1 
+0.5 
—0.5 
—1 

—2 




- 






Do 

Do 












Do 




+ 
+ 

+ 

+ 
+ 

+ 


+ 
+ 
+ 
+ 

-i- 
+ 
+ 
+ 




Do 


few red ones. 




few red colonies. 






10 
5 




Do 




numerous small blue opalescent colo- 
nies; very few red ones. 


Soda peptone 

Do ._ 


—1 

-2 

—3 

+ 1 

+0.5 

—0.5 

—1 

—2 


More than a few cholera colonies; very 
few small white colonies. 
Do. 


Do 




Peptone 


Do. 


Do 








Do 








Do 






Do. 


Do 

Ottolenghi's 






Do. 












10 
5 




Numerous cholera colonies, pure. 
Do. 


Do 




Soda peptone 

Do 


—1 
—2 
-3 








Do. 


Do 

















x, b, 2 Schobl: Diagnosis of Asiatic Cholera 141 

Table XV. — Same arrangement as Table XIV. ' Eighteen hours' incubation. 



Enrichment. 



Medium. 



Peptone. 
Do.. 



Do 



Soda peptone . 



Do 

Do 

Ottolenghi's .. 

Do 

Do 

Do 

Do 

Peptone 

Do 

Do__ 

Soda peptone . 

Do 

Do 

Ottolenghi's .. 

Do 

Do 

Do 

Do 



Reac- 
tion. 



+ 1 
— 1 



-2 
—3 



+ 1 
— 1 
—2 
— 1 
—2 
—3 



Con- 
centra- 
tion. 



Per ct. 



Growth on 
plates. 



Lac- 
tose 
agar. 



Dieu- 

donne's 
agar. 



Remarks. 



Few red colonies; no cholera. 
More than a few cholera colonies; more 
than a few red ones: cholera predomi- 
nates. 
Few cholera colonies; more than a 
few small white colonies; latter 
predominate. 
More than a few cholera colonies; few 
small Whiteones; cholera predominate. 
No growth. 

Do. 
Few small white colonies. 

Do. 

Do. 

Do. 

Do. 
No growth. 

Very numerous cholera colonies, pure. 
Numerous cholera colonies, pure. 
Very numerous cholera colonies, pure. 
No growth. 

Do. 

Do. 

Do. 

Do. 

Do. 

Do. 



Table XVI. — Same arrangement as Table XI. Eighteen hours' incubation. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 

donne's 

agar. 




+1 
+0.5 

-1 

-2 


Per ct. 


+ 
+ 
+ 

+ 




Few red colonies; no cholera. 

Few cholera colonies; few red ones; 
latter predominate. 

More than a few cholera colonies; few 
red ones. 

More than a few cholera colonies; few 
spreading colonies; cholera predom- 
inate. 

Few small white colonies. 

Numerous cholera colonies; few small 
white ones. 


Do 


Do 


Do 








15 







142 



The Philippine Journal of Science 



1915 



Table XVI. — Same arrangement as Table XI. Eighteen hours' incuba- 
tion — Continued. 



Enrichment. 


Growth on 
plates. 


Remarks. 


Medium. 


Reac- 
tion. 


Con- 
centra- 
tion. 


Lac- 
tose 
agar. 


Dieu- 
donne's 
agar. 


Kraus's 




Per ct. 

10 

5 


-j- 
+ 


-r 
+ 
+ 

+ 
+ 
+ 
+ 

= 


More than a few cholera colonies; equal 

number of red ones. 
Few cholera colonies; equal number 

of red ones. 
More than a few cholera colonies; few 

white ones. 
Few small white colonies; no cholera. 

Do. 
No growth. 
More than a few cholera colonies, pure. 

Do. 
Numerous cholera colonies, pure. 
No growth. 
Very numerous cholera colonies, pure. 

Do. 
More than a few cholera colonies, pure. 
Numerous cholera, pure. 
No growth. 
Do. 


Do 




Soda peptone _ .. .. 
Do 


—1 

—2 
—3 
+1 

+ 0.5 

-1 

—2 


Do 


Peptone 


Do ._ 






Do-. 






Do 




Ottolenghi's 






Kraus's. . 




15 

10 
5 





Do 




Do 




Soda peptone 

Do 


—1 
—2 
—3 






Do 













SUMMARY 

It will be seen from the protocols that the bacteria other 
than cholera vibrios, as encountered in cholera stools, can be 
divided into three groups from the practical standpoint, namely : 

1. Bacteria which prefer an acid medium to an alkaline one; 
they are lactose fermenters — that is, representatives of the 
coli group. They were most frequently met with. Fortunately 
this class of bacteria can be successfully eliminated, or at least 
reduced so as not to interfere with the growth of the cholera 
vibrio, by alkaline reaction of the enrichment medium. They 
do not grow on Dieudonne's medium. 

2. Bacteria which prefer strong alkaline reaction. They do 
not acidify lactose and are of little importance. Being cocci, 
they form small colonies, grow slowly, and occur in small 
numbers on the plates. They grow on Dieudonne's medium 
(Tables IV, VI, VIII, X, XI, XII, XIII, XIV. XV. XVI). 

3. Bacteria which exhibit the same tolerance toward alkaline 
reaction of the medium as the cholera vibrio does and which 
have a broad range of growth in regard to the reaction of the 
medium. They were found to form numerous, some of them 



x, b, 2 Schobl: Diagnosis of Asiatic Cholera 143 

spreading, colonies. Although the inhibition of growth by Dieu- 
donne's medium is evident in some cases, they do not grow on 
alkaline ox-blood agar (Tables II, VII, XI, XII, XIII) . Bacteria 
of this class do not acidify lactose and are evidently dangerous 
competitors of the cholera vibrio during the enrichment process 
(Table II). 

The number of examinations in which peptone solution of 
+1, +0.5, —0.5, and —1 reaction was used being about the same, 
the results allow a fair comparison. When +1 peptone was 
used, the cholera vibrio was recovered in 11 per cent; from 
peptone +0.5, reaction in 61 per cent; from —0.5 peptone solu- 
tion, in 88.2 per cent; and peptone of —1 reaction gave 94.2 
per cent positive results. 

As to the bile medium the results were very unsatisfactory. 
It failed three times out of five. In our experiments the bile 
medium was prepared according to Ottolenghi's prescription, 
with the exception that dry bile was used instead of fresh, the 
latter not being available. Whether the low percentage of pos- 
itive results was due to that fact or not I am not in a position 
to say. In this connection it may be of interest to mention 
that of the 20 strains of vibrios planted in human bile 2 strains 
of true cholera and 1 choleralike vibrio refused to grow in 
the bile. 

Much better results were obtained with Kraus's medium. 
It was noticed that this medium eliminated the bacteria of the 
coli group more thoroughly than peptone solution, but the bac- 
teria which prefer alkaline reaction thrive in it. Owing to the 
fact that the surface of the medium is of the least degree of 
alkalinity, they frequently form a pellicle, thus subduing the 
growth of the cholera vibrio. As the degree of alkaline re- 
action decreases with the age of the medium, more concen- 
trated solutions of alkaline ox blood in meat broth are necessary 
in order to achieve the same selective effect. 

All considered, Kraus's medium has a decided advantage 
over the peptone solution. The use of this medium will be 
particularly indicated in searching for carriers. In a laboratory 
like that of the Bureau of Science, where daily examinations 
of stools for cholera are being conducted all the year round, 
it is necessary that a sufficient amount of ox blood always be 
kept on hand, as Dieudonne's plates are indispensable in our 
work. This being the case, Kraus's medium can be easily 
prepared. 

Combinations of peptone solution and selective enriching me- 
dium suggest themselves. The fact that the peptone solution 



144 The Philippine Journal of Science 

is more favorable for the rapid growth of the cholera vibrio, 
while the selective enriching medium inhibits the growth of 
the bacteria other than vibrios more thoroughly than the al- 
kaline peptone solution, can be utilized in the double enrichment 
process with advantage in certain instances. 

REFERENCES 

Ohno, Y. K. The reaction of culture media in relation to the morphology 

of the cholera organism. Phil. Journ. Sci., Sec. B (1909), 4, 341. 
Haendel-Baerthlein. Vergleichende Untersuchungen iiber verschiedene 

Choleraelektivnahrboden. Arb. a. d. kais. Gesiindheitsamte (1912), 

40, 357. 
Pilon, P. Blut-soda-agar als Elektivnahrboden fur Choleravibrionen. 

Centralbl. f. Bakt. etc., Orig. (1911), 60, 330. 
Neufeld-Woithe. Uber elektive Choleranahrboden insbesondere den Dieu- 

donneschen agar. Arb. a. d. kais. Gesiindheitsamte (1910), 33, 605. 
Bocchia, I. Ueber den Wert der neueren Methoden zur bakteriologischen 

Diagnose der Cholera. Centralbl. f. Bakt. etc., Orig. (1911), 60, 434. 
Sgalitzer, M., and L6wy, O. Ueber die Verwendbarkeit der Blutalkali- 

bouillon als Anreicherungsmittel fur Choleravibrionen. Centralbl. f. 

Bakt. etc., Orig. (1913), 69, 556. 
Kkombholz, E., and Kulka, W. Ueber Anreicherung von Choleravibrionen 

insbesondere iiber Ottolenghi's Galleverfahren. Centralbl. f. Bakt. etc., 

Orig. (1912), 62, 521. 
Goldberger, J. Some new cholera selective media. Bull. U. S. Hyg. Lab. 

(1913), No. 91. 
Hofer, G., and Hovorka, J. Versuche zur elektiven Ausgestaltung des 

Dieudonneschen Choleranahrbodens. Centralbl. f. Bakt. etc., Orig. 

(1913), 71, 103. 



1. EXPERIMENTS ON THE IMMUNIZATION OF GUINEA PIGS BY 

THE INOCULATION OF AVIRULENT TUBERCLE BACILLI IN 

AGAR. II. OBSERVATIONS ON ANIMALS INOCULATED 

WITH TUBERCULOSIS FROM LEPERS 1 

By Marshall A. Barber 
(From the Biological Laboratory, Bureau of Science, Manila, P. I.) 

In previous experiments 2 I succeeded in immunizing guinea 
pigs against virulent plague by the inoculation of small doses 
of living avirulent plague bacilli mixed with agar. These ex- 
periments have shown that the agar masses may persist for 
some time (twenty-nine days in one case), and that the plague 
bacilli multiply freely in such masses injected subcutaneously. 
In the following experiments living avirulent bacilli of tuber- 
culosis were mixed with glycerin agar and inoculated. It was 
hoped by this method to obtain in tuberculosis a more effective 
immunization through the relatively slow absorption of a dose, 
comparatively small at the beginning and .gradually increasing 
during absorption. 

The avirulent strain of tuberculosis used was a human strain 
("ki"), kindly furnished me by Dr. E. R. Baldwin of Saranac 
Laboratory, Saranac Lake, N. Y. It has been long cultivated 
in the laboratory, grows rapidly on glycerin agar, and is of 
very low virulence. In addition, a few inoculations were made 
with an avian strain. 

Series 1, Table I. — In this short preliminary series (series 
I) the interval of time — one hundred sixty-eight days — between 
the immunizing and the virulent, or test, doses was relatively 
long. Only one immunizing dose was given, and that was rela- 
tively small. Some of the animals received avirulent human 
bacilli, mixed with agar, some received avian bacilli, and one 
animal received an emulsion of the avian strain without agar. 

The avian dose was prepared by mixing about 30 cubic centi- 
meters of 5 per cent glycerin agar with 3 cubic centimeters 
of a thick emulsion in salt solution of bacilli from glycerin 
agar culture. The dose of human bacilli was made in the same 

1 Received for publication November 24, 1914. 

2 This Journal, Sec. B (1912), 7, 245. 

145 



146 The Philippine Journal of Science 1915 

way, except that a somewhat smaller proportion of bacteria 
was added to the agar. The agar was cooled to about 40° before 
adding the bacteria and was inoculated while still liquid. All 
inoculations were subcutaneous. The needle was introduced 
well into the subcutaneous tissue, since, if the agar is deposited 
just under the skin, necrosis is likely to take place over it. Care- 
ful asepsis in inoculation was observed to avoid the introduction 
of contaminating bacteria with the agar. In addition to the agar 
mixtures of both strains ("Tbag A" and "Tbag H" in the 
tables), one animal was given a thick emulsion of the avian type 
without agar. Three cubic centimeters of the agar mixture 
were given in all except one, which received 2.5 cubic centimeters. 

Avian 6032 developed some diarrhceal disease with par- 
alysis of the hind legs and was sacrificed eight days after in- 
oculation. Transfers from the agar lump in this animal to 
nutrient medium showed a good growth of tuberculosis in pure 
culture. The other animals showed more or less infiltration 
around the agar mass, which in some cases became the site of 
an abscess with creamy pus. Long before the virulent dose 
was given, practically all lesions had disappeared except in 
avian 6035, which had a lump about the size of a filbert at the 
point of inoculation. All animals were healthy, and six of the 
nine had gained in weight. 

The dose of virulent tuberculosis was given one hundred 
sixty-eight days after the avirulent. The dose was prepared 
as follows : The sputum of three patients with pulmonary tuber- 
culosis was mixed, making in all about 140 cubic centimeters. 
The three samples examined microscopically showed in the first 
moderately numerous tubercle bacilli, in the second many, and 
in the third very many bacilli. To the mixed sputum enough 
antiformin was added to make a 25 per cent solution, and the 
mixture was allowed to stand for half an hour to emulsify. 
It was then centrifugalized at high speed. The sediment was 
washed with sterile distilled water and again with sterile salt 
solution. Microscopical examination showed a large number 
of tubercle bacilli in this mixture. All animals, immunized and 
controls, were inoculated subcutaneously in the right inguinal 
region with 0.5 cubic centimeter of this sediment, diluted with 
a small quantity of salt solution. 

The results are given in Table I. The symbols +, -f-K 
H — \--\~ described roughly the size and number of palpable tuber- 
cles formed in the inguinal region. The first class includes 
tubercles of approximately pea or small bean size, the second 
of lima bean or hazelnut size, and the third larger sizes. 



X, B, 2 



Barber: Experiments on Immunization 



147 



The results of all series are fairly uniform, and the discussion 
of this, as of Tables II, III, and IV, will be found after Table IV. 



Table I. — Series 1. 



Comparatively small avirulent dose, part avian, part 
human. 



Guinea 
pig No. 


Virulent dose, Dec. 20, 1911. 


Weight, 
June 5, 
1912. In- 
oculated 

with 
virulent 

Tb. 


Aug. 6, 1912; 16 days 

after virulent 

dose. 


Sept. 23, 1912; 110 

days after virulent 

dose. 


Strain. 


Vol- 
ume. 


Weight. 


Inguinal 
glands. 


Weight. 


Inguinal 

glands. 


Weight. 


6030 
6031 
6032 
6033 
6034 
6035 
6036 
6037 
6038 
6039 


Tbag A». 

do ... 

do ... 

do ... 

Emuls av 
TbagH" 

do ... 




ec. 
3 
3 
3 

2.5 
1 
3 
3 
3 
3 
3 


400 
460 
640 
490 
390 
450 
660 
420 
500 
670 


g. 

460 

610 


+ 
+ 


g. 

590 
640 




g. 


ian only.. ... 


+ + 


640 


500 
560 
650 
630 
410 
410 
670 


+ 
+ 
+ 
+ 
+ 
-t- 
+ 


480 
610 
690 
650 
480 
450 
720 


+ 

+ 

+ 

+ + 
+ + + 

+ 
+ + . 


410 
670 
710 
660 
520 
450 
730 




do 


do 


do 


Ave] 








544.4 


590 


i 
















Guinea 
pig No. 


Nov. 16, 1912; 164 

days after virulent 

dose. 


Dec. 19, 1912; 197 

days after virulent 

dose. 


Died 

after 

virulent 

dose. 


Autopsy. 


Body 
weight. 


Spleen. 


Lesions. 


Ratio of 

spleen 

weight to 

body 

weight. 


Inguinal 
glands. 


Weight. 


Inguinal 
glands. 


Weight. 


6030 
6031 
6032 
6033 
6034 
6035 
6036 
6037 
6038 
6039 




g. 




0- 


Days. 

88 
179 
8 
133 
349 
377 
311 
222 
187 
283 


g. 

360 
510 


g. 

0.6 
4.2 


Tb. 
Tb. 
0>) 
Tb. 
Tb. 
Tb. 
Tb. 
Tb. 
Tb. 
Tb. 


0. 0016 
0. 0082 


+ + 


530 


















320 
480 
580 
470 
370 
340 
620 


2.5 
3.5 
1.6 
2.6 
3.5 
5.4 
2.0 


0. 0078 
0. 0073 
0. 0027 
0. 0055 
0. 0095 
0. 0159 
0. 0032 


+ 
+ + 

+ + + 
+ 
+ + 


680 
690 
650 
470 
410 
740 


+ 

+ + 
+ + 
+ + + 


640 
740 
640 
420 


+ + 


730 






236.6 






0. 0069 

















a Tbag A and Tbag H refer to mixtures of agar with avian and human types of bacilli, 
respectively. 
b Sacrificed. 

Series 2, Table II. — In this series one hundred twenty-seven 
days intervened between the immunizing and the avirulent doses. 
For immunization only the human avirulent strain was used, and 
the animals were divided into four groups. The first group, 
"Tbag a," received an agar mixture prepared as follows : Three 
cubic centimeters of a thick emulsion from a 40-day culture was 

132716 4 



148 The Philippine Journal of Science 

Table II. — Series 2. Animals receiving larger doses. 



1915 



Guinea 
pig No. 


Avirulent dose. 


Jan. 30, 1912. 


Apr. 29, 1912; 
90 days after 
avirulent dose. 


Inocu- 
lation 
of viru- 
lent Tb. 
June 5, 
1912. 


Aug. 6, 1912; 
61 days after 
virulent dose. 


Sept. 23, 1912; 
110 days after | 
virulent dose. 


Strain. 


Vol- 
ume. 


Weight. 


Tumor. 


Weight. 


Weight. 


Ingui- 
nal 
glands. 


Weight. 


Ingui- : 
nal Weight. 

glands. 


6074 
6076 
6076 
6077 
6078 
6079 
6080 
6081 
6082 
5889 
5891 
5892 
6083 
6084 
6085 
6086 
5887 
5888 
6043 
6087 
6088 
6089 
6090 
6091 
6092 
6094 
6095 
6096 
6097 
6098 


TbagA: 

do .... 


cc. 

3 

3 

3 

3 

3 

3 

3 

3 

2.5 

1.5 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

3 

0.5 

1 

0.3 

1' 

0.5 

0.5 

0.5 

1 

1 


g. 

570 
510 
500 
430 
540 
420 
390 
420 
430 
410 
540 
560 
470 
400 
340 
300 
420 
520 
480 
470 
410 
580 
510 
400 
500 
520 
430 
440 
410 
450 








+ + 


g. 

640 
580 
590 
570 
610 


<7. 
650 
560 
620 
600 
620 


+ 
~r 
-f 

+ 


g. 

690 
560 
730 
660 
660 


a. 

+ + ! 700 
+ 590 


... do . ... . 


do 


+ 670 


.. .do 


"T 


670 


do 


do 


+ a 

~~T a 

+ a 



+ + 




+ 






c 



+ + 

+ + 





+ a 



420 
530 
530 
590 
620 
740 
670 
500 
450 

• 370 
570 
640 
660 
610 

■ 540 
610 
580 
510 
560 
580 
540 


440 
550 
560 
600 
640 
740 
620 
500 
490 
390 
580 
640 
680 
630 
550 
610 
590 
510 
550 
560 
560 


+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ + 
+ 

+ 
+ 
+ 

+ 
-f ? 

+ 
+ + 


520 
630 
630 
610 
680 
750 
650 
550 
530 
460 
620 
680 
710 
690 
580 
670 
660 
560 
610 
620 
640 


+ 
+ 


600 

640 


do 


do ._ 

Tbag-B 


+ 630 
+ + 630 


do 


+ 
+ + 


700 
790 


do 


do 


4- + 660 

+ + i 560 
+ + J 550 
+ + 630 

+ + j 620 


do 


do 


do 


TbagA 


— do 


do __• 


+ + 690 


do_ ___. 

do 


+ + 

+ 

+ 
+ + 

+ 
+ + 
+ + 


710 
620 
730 
670 
570 
640 
620 
630 


Tb emuls A. 

do 


do .... 


do 


Tb emuls B 

do 

do 

do... 

do 


+ 


520 
570 


550 
570 


+ 
+ ? 


610 


+ + 


630 













573.2 



















« Slight. 



x, b, 2 Barber: Experiments on Immunization 149 

Table II. — Series 2. Animals receiving larger doses — Continued. 





Nov. 16, 1912; 164 
days after viru- 
lent dose. 


Dec. 19, 1912; 197 
days after viru- 
lent dose. 


Died af- 
ter viru- 
lent dose. 




Autopsy. 




Guinea 

pig No. 


Inguinal 
glands. 


Weight. 


Inguinal 
glands. 


Weight. 


Body 
weight. 


Spleen. 


Lesions. 


Ratio of 
spleen 
weight 
to body 
weight. 






9- 




g. 


Days. 


O. 


a- 






6074 
6075 










160 
354 


700 
400 


7.1 
3.0 


Tb. 
Tb. 


0. 0101 
0.0075 


+ 


590 


+ 


580 


6076 
6077 
















w 

Tb. 




+ 


620 


+ 


700 


456 


550 


2.8 


0. 0051 


6078 


+ 


680 


+ 


720 


812 


500 


1.0 


Tb. 


0. 0020 


6079 
6080 












420 
420 




(b) 

Tb. 




-1- + 


430 


+ 


490 


255 


4.1 


0.0098 


6081 


+ + 


670 


+ 


690 


319 


560 


4.5 


Tb. 


0. 0080 


6082 


+ + + 


600 


+ 


620 


240 


570 


4.3 


Tb. 


0. 0075 


5889 


H- r 


610 


+ 


570 


238 


470 


7.8 


Tb. 


0. 0166 


5891 


+ 


690 


+ 


710 


418 


600 


. 3.0 


Tb. 


0.0050 


' 5892 


+ 


760 


+ + 


770 


228 


720 


2.6 


Tb. 


0. 0022 


6083 


+ + + 


640 


+ + + 


650 


313 


580 


2.4 


Tb. 


0. 0041 


6084 


+ 


580 


T" 


570 


282 


450 


5.1 


Tb. 


0. 0133 


6085 
6086 


+ + 

+ 


490 
540 


1 


203 
300 


430 
390 


3.3 
4.0 


Tb. 
Tb. 


0. 0077 
0. 0103 


+ 


540 


5887 


+ + 


610 


+ 


600 


227 


490 


2.9 


Tb. 


0. 0059 


5888 
















(») 




6043 


+ + + 


690 


+ + 


690 


256 


550 


7.2 


Tb. 


0. 0181 


6087 


+ + 


700 


+ + 


740 


380 


610 


1.5 


Tb. 


0. 0024 


■ 6088 


+ 


600 


+ + 


600 


234 


540 


6.2 


Tb. 


0. 0115 


6089 
6090 


+ + 
+ + 


730 


+ 


750 
620 


345 
246 


400 
530 


3.2 
2.0 


Tb. 
Tb. 


0.0080 
0. 0038 


640 


+ + 


6091 


+ + 


570 


+ 


560 


304 


490 


4.0 


Tb. 


0. 0082 


6092 


+ ? 


690 


+ ? 


700 


270 


650 


4.1 


Tb. 


0. 0075 


6094 


+ + 


630 


+ + 


630 


315 


490 


9.2 


Tb. 


0. 0188 


6095 


+ + 


630 


+ + 


610 


264 


550 


4.8 


Tb. 


0. 0088 


6096 
6097 
















(c) 

Tb. 




+ + 


630 


+ + 


610 


300 


410 


5.0 


0. 0122 


6098 
















w 
























302.8 






0. 0084 

















a Plague. 



b Sacrificed. 



c Intercurrent disease. 



150 The Philippine Journal of Science isis 

thoroughly mixed with 30 cubic centimeters of a 5 per cent 
glycerin agar made somewhat stiffer than usual. The culture 
had grown on 5 per cent glycerin agar to which a few drops 
of sterile unheated human serum had been added, and showed an 
abundant growth. Three cubic centimeters of this mixture were 
given to all animals except one, which received 2.25 cubic centi- 
meters. The second group, "Tbag b," received the same agar 
mixture as the first group, except that the proportion of bacilli 
in the agar was doubled. 

The third and fourth groups include animals which received 
emulsions of bacilli without agar. The third group, "Tb emuls 
a," received the same thick emulsion, undiluted, as that used in 
making "Tbag b." The total number of bacilli received by 
animals of the third group was evidently much larger than that 
given in the agar doses. Avian 6090, for example, received 
twenty-two times as many bacilli as avian 6074. The fourth 
group, "Tb emuls b," received thick emulsion in salt solution of 
a 55-day glycerin agar culture of the avirulent strain. 

All doses were inoculated subcutaneously in the right inguinal 
region. The volume of the dose in all groups is given in the 
tables. 

All agar-inoculated animals of series 2 showed marked in- 
filtration around the agar mass, and seventeen days after in- 
oculation a lump of agar-plus tissue, the size of a hazelnut or 
larger, was present. As shown in Table II, few had any marked 
lesions ninety days after the avirulent inoculation. At the time 
of the inoculation of virulent bacilli all were apparently healthy 
and all had gained in weight. 

The virulent dose was exactly the same as that given in series 
1 and was given in the same way and at the same time. Avian 
6079 was sacrificed, avian 6096 died of some intercurrent in- 
fection before receiving the virulent dose, and Nos. 6076, 5888, 
and 6098 died of accidental plague infection of rat-flea origin 
after receiving the virulent dose. All others survived the vi- 
rulent dose for at least one hundred sixty days and at autopsy 
showed typical lesions of tuberculosis. 

Series 3, Table HI. — In series 3 the animals received two avi- 
rulent doses. The second was given fifty days after the first. 
In preparing the first dose, an emulsion of a 26-day culture and 
one of an 11-day culture of the avirulent human strain were 
mixed and added to a 5 per cent glycerin agar containing 2 
per cent agar, in the proportion of 1 cubic centimeter of emulsion 
to 35 cubic centimeters of agar. One animal received a thin 
emulsion without agar. 



x, b, 2 Barber: Experiments on Immunization 151 

Three animals (Nos. 5990, 5991, and 5992) received this dose 
intraperitoneal^ ; animal 5989, both intraperitoneal^ and sub- 
cutaneously ; and the rest, subcutaneously in the inguinal region. 
The local reactions following the first subcutaneous dose were 
much the same as in the other series — infiltration for a few days 
and a hard lump which persisted for ten days or more. None 
showed more than a scar forty-four days after inoculation. One 
animal, No. 5986, died of sepsis two days after inoculation. 

The character of the second inoculation is the same as in series 
2 and is shown in Table III, where the same symbols are used 
in describing the dose as in Table II. All received the agar 
mixture, all a dose of 3 cubic centimeters, and all were inoculated 
subcutaneously in the right inguinal region. 

The reaction following the second avirulent dose was more 
marked than in animals of series 2 not previously treated, which 
received the same dose. The effects were more permanent also, 
as may be seen by comparing the results in the two series after 
ninety days (Table III). This more marked reaction was prob- 
ably due to a sensitization resulting from the first dose. All 
were well and gaining in weight when the virulent dose was 
given. 

The virulent dose of series 3 was of the same character and 
amount as in the other series and was inoculated on the same 
day, in this series one hundred twenty-seven days after the 
second avirulent dose and one hundred seventy-seven days after 
the first. Animal 5991 died of some intercurrent disease before 
receiving the second avirulent dose. 

Twelve controls received the virulent dose at the same time 
as the animals in series 1, 2, and 3. The same dose of sputum 
bacilli was given to all. The immediate reaction following the 
test dose was small, and on the whole, slightly less than that of 
the treated animals. The control group is given in Table IV. 

In Tables I to IV the entry "Tb" indicates that the animal 
showed lesions of tuberculosis at autopsy. These in general were 
most marked in the inguinal glands, spleen, liver, and lungs. 
Tubercles in the mesentery or kidneys were rarely shown in the 
gross examination. Lung lesions were almost constant, con- 
sisting usually of many consolidated areas, although no cavity 
formation occurred such as has been described by some authors 
for chronic tuberculosis in guinea pigs. 

SUMMARY OF THE RESULTS GIVEN IN TABLES I, II, III, AND IV 

With regard to a possible immunization of the animals as 
judged by the length of time of survival after receiving the 



152 The Philippine Journal of Science 

Table III. — Series 3. Animals receiving 2 immunizing doses. 



1915 



Guinea 
pig No. 


First avirulent dose. 
Dec. 11, 1911. 


Second avirulent dose. 
Jan. 30, 1912. 


Apr. 29, 

1912; 90 

days 

after 

2d 
dose. 
Tumor 
at point 
of inoc- 
ulation. 


1 

Inocu- 
! lation 


Aug. 6. 1912; 61 
days after vir- 
ulent dose. 


Strain. 


££wefeht 


Strain. 


cc. 


Weight 


\ ulent 
! Tb. 
June 5, 

1912. 
Weight 


Ingui- 
nal Weight 

glands. 


6980 

6981 

6982 

5983 

5984 

5985 

5986 

5987 

5988 

5989 

5990« 

5991a 

5992 a 

5994 


Tbag .. 

do. 

do. 

do. 

do. 

do. 

do. 

do. 

do. 

do . 

do. 

do. 

do. 




cc. 
3 
3 
3 
3 
3 
2 
2 
2 
2 
3 
3 
3 
3 
2 


0- 

350 
440 
410 
450 
660 
600 


Tb 

Tb 

Tb 
Th 


B 


3 
3 
3 
3 
3 
3 


0- 

420 
500 
400 
500 
470 
630 


+ + 

+ 

+ + 

+ 




a- 
520 


4- 


a. 

610 
670 
380 
670 
580 
700 




.do 

ag B 


600 

460 + 
650 + 
560 + + 
Ron 4 






do . 






ag B . . . 




630 










410 
350 
600 
430 
360 
570 
630 


Tb 




3 
3 
3 
3 
3 
3 
3 


360 
360 
630 
440 
460 
580 
630 


+ 430 
+ Kan 


+ 

+ 
4- 


530 
680 
690 




.do 






.do 


+ + 

+ + + 


670 
540 




.do 




.do 






do 





680 

710 


+ 
+ ? 


700 
760 






.do 


Average 


















595.0 
















1 




Guinea 
pig No. 


Sept. 23, 1912; 
110 days after 
virulent dose. 


Nov. 16, 1912; ) Dec. 19, 1912; 
164 days after 197 days after 


Died 
after 
vir- 
ulent 
dose. 


Autopsy. 


virulent dose. 


virulent dose. 


Body 
weight. 


Spleen. 


Le- 
sions. 


Ratio 

of 
spleen 
weight 
to body 
weight. 


Ingui- 
nal 
glands. 


Weight 


Ingui- 
nal 
glands. 


Weight 


Ingui- 
nal 
glands. 


Weight 


6980 

6981 

5982 

6983 

5984 

5985 

6986 

5987 

6988 

6989 

6990 a 

5991a 

6992* 

5994 


+ 
+ 


a- 

420 
690 




0- 




0- 


Days. 
110 
239 
97 
842 
183 
212 


420 


a. 

2.7 


Tb. 
Tb. 
Tb. 


0.0064 
0.0069 


+ + 


690 


+ + 


690 


580 ; 4. 
2.1 


+ 
+ + 

+ + 


690 
570 
730 


+ 
+ + 
+ + 


670 
500 
680 


+ 


710 


500 
440 
530 


1.0 
5.2 
7.0 


Tb. 
Tb. 
Tb. 
CO 

Tb. 
Tb. 
Tb. 
Tb. 

w 


0.0020 
0.0119 


+ + 


610 


0. 0182 


+ 

+ 

+ + 

+ 


580 
670 
690 
620 


+ 

+ t 

+ + + 

+ 


580 
670 
600 
590 


+ 

+ + 


580 
700 


291 
380 
189 
271 


640 
620 | 
550 : 
560 


4.2 
2.0 
8.1 
2.0 


0.0078 
0.0038 
0. 0147 


+ 


610 


0.0036 


+ 
+ 


730 
730 


+ 

+ + 


720 
700 


+ 
+ + 


730 
710 


453 
248 


650 
660 ; 


3.2 
2.7 


Tb. 
Tb. 


0.0049 
0.0041 

0.0072 






292. 9 ' 





















■' First dose intraperitoneal: all other doses subcutaneous. 
b Died from sepsis 2 days after first inoculation. 
c Intercurrent disease. 



X, B, 2 



Barber: Experiments on Immunization 



153 









Table IV. — Controls of series 


I, 2 


, and 3. 








6 
Z, 

'5. 
a 
c 
'3 
O 


|» 

+3 Q) 

rt C 


Aug. 6, 

1912; 61 

days after 

virulent 

dose. 


Sept. 23, 

1912; 110 

days after 

virulent 

dose. 


Nov. 16, 

1912; 164 

days after 

virulent 

dose. 


Dec. 19, 

1912; 197 

days after 

virulent 

dose. 


Apr. 14, 
1913; 313 
days af- 
ter viru- 
lent dose. 


6 

EH 

o 

T3 
+J 
G 
0) 

3 
u 

'> 
u 
o 

<H 

■a 

5 


Autopsy. 


A 

to 
'5 
& 
>> 

■s 

M 


c 
"a 


c 
o 
'53 

0) 

►J 


Ratio of spleen 
weight to body 
weight. 


13 . 

3 C 


J5S 
'5 


3 c 


'Sj 


"5 . 
,5-S 

3 C 

Si 


4J 

'5 


H . 

3 C 

5 


to 
'5 


C m 

3 C 

r <s 


to 

'53 




». 




a. 




9. 




ff. 




g. 




9. 


Days. 


ff. 


a. 






6252 


480 


+ 


500 


+ 


580 


+ 


550 


+ 


610 


"T 


630 512 


670 


3.8 


Tb. 


0.0057 


6253 


480 


+ 


540 


+ 


590 


+ 


540 


+ 


590 


+ 


550 361 


470 


1.7 


Tb. 


0. 0036 


6254 
6255 


480 
610 


+ 
+ . 


400 
600 


+ 


440 
650 














159 
460 


400 
440 


2.6 
1.8 


Tb. 
Tb. 


0. 0065 
0. 0041 


+ 


600 


+ 


640 


+ 


630 


6256 


590 


+ 


550 


+ 


610 


+ 


540 


+ 


580 


+ 


465 465 


560 


1.9 


Tb. 


0. 0035 


6257 


500 


+ 


550 


-r 


560 


■ + 


520 


+ 


540 


+ 


600 497 


450 


1.0 


Tb. 


0. 0022 


6258 
6259 
6260 


530 
430 
600 


+ 


470 


+ 


420 














132 


390 

310 
460 


8.7 
3.1 


Tb. 
(») 

Tb. 


0. 0223 
0. 0067 














+ 


600 


++ 


620 


++ 


550 


++ 


480 






202 


6261 


580 


+ + 


570 


+ 


600 


+ 


670 


+ 


600 


+ 


650 


482 


500 


7.5 


Tb. 


0. 0150 


6262 
6263 


540 
440 


+ 


510 


T 


500 














136 
5 


450 


8.2 


Tb. 
« 


0.0182 
0. 0088 










































539 




340.6 




4.03 























Intercurrent disease. 

virulent dose, it is noteworthy that avian 6078, series 2, Table II, 
survived the virulent dose eight hundred twelve days, or over 
two years and two months, and that avian 5983 survived eight 
hundred forty -two days, or over two years and three months. 
However, if we take the series as a whole, we find that the 
average number of days of survival of the controls (Table IV) 
is higher than that of any series of treated animals. 

These averages, compared with the controls, are as follows : 

Table V. — Average survival of treated and of control guinea -pigs. 



Series. 


Table. 


Ani- 
mals. 


Aver- 
age 
sur- 
vival. 


1 

2 


I 

II 
III 

IV 


9 
25 
11 


Days. 
236.6 
308.8 
292.9 


3 


Controls 


10 


340.6 



A few animals died of plague of rat-flea origin. These and the 
animals which died of any other intercurrent disease are re- 



154 



The Philippine Journal of Science 



1915 



corded in the tables, but are not included in the averages. Ani- 
mals 6078 and 5983 are included in the averages of Tables II 
and III, respectively. 

If we compare the several groups of series 2, Table II, we 
have: 

Table VI. — Average survival of guinea pigs inoculated with different strains 

of bacilli. 



Bacillus strain. 


Ani- 
mals. 


Aver- 
age 
sur- 
vival. 


"Tbaga" 


11 
7 
4 
3 


Days. 
335.7 
283.1 
291.3 
293.0 


"Tbagb" 

"Tb emuls a" 

"Tb emuls b" 



If we compare the average weights of controls with those 
of the treated animals, both taken at the same time of inoculat- 
ing the virulent dose, we have, including only animals which 
subsequently died of tuberculosis: 

Table VII. — Average weights of treated and of control guinea pigs. 



Series. 


Ani- 
majs. 


Aver- 
age 

weight. 


1- ...- 

2 


9 

25 
11 

10 


Grams. 
544.4 
573.2 
595.0 
539.0 


3 


Controls 



In view of these averages it is evident that the greater re- 
sistance of the controls was not due to a selection of larger 
animals. 

Considering the averages of all series, it appears that the 
preliminary treatment with avirulent bacilli in agar has afforded 
no protection against a subsequent dose of virulent bacilli. If 
of any effect, it has apparently tended to diminish the resistance 
of the animals. The avirulent bacilli, without agar, has also 
failed to immunize, so far as can be judged by the comparatively 
small number of animals in this series. 

In the case of the two animals which survived the virulent 
dose over two years, however, there is some evidence of partial 
immunization. Their weights taken at the time of the inocula- 



x, b, 2 Barber: Experiments on Immunization 155 

tion of the virulent dose were 620 grams for animal 6078 and 
650 grams for animal 5983 — weights greater than those of any 
control and greater than the average of any series; but that 
of animal 6078 was equalled or exceeded by five animals of 
the same series, and that of 5983 by four animals of its series. 
The change in weight of these animals is shown in the tables 
up to April 14, 1913. Some later weighings are: 



Table VIII.— Animal No. 6078 




Date. 


Weight in grams. 


July 11, 1913 


690 


October 1, 1913 


720 


March 17, 1914 


750 


June 9, 1914 


680 


After death 


500 


Animal No. 5983. 




July 11, 1913 


710 


October 1, 1913 


710 


March 17, 1914 


740 


June 9, 1914 


670 


After death 


500 



Both animals showed enlarged inguinal glands during the 
whole period following the virulent dose. The fact that these 
enlargements appeared on both sides, increased at various 
periods, and persisted so long would make it unlikely that they 
were due to the avirulent inoculation alone and that neither 
guinea pig was infected by the virulent dose. In animal 5983 
inguinal abscesses formed and opened at least two years after 
the virulent dose. In both animals the tumor formed at the 
point of inoculation by the last avirulent dose persisted for at 
least ninety days after that dose. This greater reaction to the 
dose may have increased the amount of immunization. The 
amount of this reaction, however, was equalled or exceeded by 
three other animals in each of the series to which animals 6078 
and 5983 belong. The average length of time of survival of 
the three of series 2 exhibiting the greater reaction was three 
hundred thirty-three days, only about twenty-one days above the 
average of the series, and the three of series 3 gave an average 
of only one hundred ninety days, considerably below that of the 
whole number in the series. It is evident, then, that a greater 
reaction to the last immunizing dose was not necessarily followed 
by a greater resistance. 

It is possible that these two animals exhibit only a greater 
natural resistance to infection. One of the nontreated controls 
survived the virulent dose for five hundred twelve days. How- 
ever, the facts that animal 6078 survived this control by three 



156 The Philippine Journal of Science 1915 

hundred days and that animal 5983 outlived it by three hundred 
thirty days afford an indication that the treated animals were 
in some degree immunized. 

At autopsy animals 6078 and 5983 showed great emaciation 
with enlarged lymphatic glands and consolidated areas in the 
lungs. Sections of the lungs showed that these consolidated 
areas consisted mainly of fibrous tissue with very limited active 
processes. Tubercle bacilli were found in small numbers in 
the lungs of both and in the spleen of animal 6078 as well. 
Evidently a marked healing process was accompanying the 
progress of the tubercular lesions ; but whether this healing was 
any more marked than in those nonimmunized controls which 
also exhibited a very chronic course of the disease is doubtful. 
On the whole, the evidence for immunization must rest largely 
on the longer survival of animals 6078 and 5983. 

In summary, while there is some evidence of the partial im- 
munization of these two animals, the average results of all 
animals give little encouragement for this method of treatment. 
It is possible that the method might be modified to serve a 
practical use in some immunization work — for example, that of 
cattle against bovine tuberculosis. The results obtained with 
the two animals long surviving indicate that the method is, at 
least, worth another trial in the same or a modified form. 

A noteworthy fact in these experiments in both control and 
treated groups is the long life of a considerable number of ani- 
mals after infection with the test dose and the steady gain in 
weight of some animals even for two hundred or three hundred 
days after becoming distinctly tuberculous. During the slow 
progress of the infection, glands often formed abscesses, which 
broke down and later healed, the animal continuing in com- 
paratively good health. 

In the explanation of the long survival of animals in the above 
groups four factors must be considered: namely, the condition 
under which the animals were kept, the size of the dose, the 
virulence of the dose, and the method of inoculation. 

The conditions under which animals can be kept in the tropics 
differ widely, taken the whole season through, from those pre- 
vailing in most experiments on guinea pigs with tuberculosis 
conducted in northern countries. The temperature is fairly uni- 
form, making it possible to maintain a good ventilation at all 
times. The animals were kept in a house closed on the sides 
by wire netting only, and were confined in roomy cages, which 
were open to ventilation on the top and sides. Except in the 



x, b, 2 Barber: Experiments on Immunization 157 

few cases of females having young, only one animal was put 
in a cage. They were given a uniform daily diet of cooked rice 
and grass with no water except that contained in the rice. 
Among the guinea pigs of this laboratory there have been few 
of the epidemics not uncommon in many laboratories. Doubtless 
these favorable conditions contributed to the resistance to tuber- 
culosis of the animals used in these experiments. 

Lack of virulence for guinea pigs in bacilli from the mixed 
sputum of three human pulmonary cases would hardly be ex- 
pected, and the short treatment with 25 per cent antiformin was 
scarcely sufficient to affect the virulence. The size of the dose 
could not be closely estimated since the proportion of dead bacilli 
in the sputum could not be known. Nearly all animals, however, 
showed tubercles within a short time after inoculation. In the 
subcutaneous inoculation a slower progress of the disease would 
be expected than by the intraperitoneal. 

In any case, either the smallness of the dose or a possible 
lack of virulence must have affected the result, since animals 
in other groups (see Tables V and VI), kept under the same 
conditions and inoculated subcutaneously with bacilli from a pure 
culture of another origin, survived a much shorter time. 

OBSERVATION ON ANIMALS INOCULATED WITH TUBERCULOSIS 

FROM LEPERS 

SERIES A 

On October 9, 1911, a monkey was inoculated subcutaneously 
"with spleen pulp taken at post mortem from a case of leprosy 
which showed very numerous leprosy bacilli in the spleen. This 
monkey (No. 5804) died December 6, 1911, with lesions of 
tuberculosis. Spleen emulsion from monkey 5804 was inoculated 
into monkey 5975, which died twenty-nine days later (primarily 
of tuberculosis). From the inguinal glands of this monkey a 
pure culture was made. This culture was inoculated May 31, 
1912, into a series of 20 guinea pigs. An amulsion in salt 
solution was made of a 106-day culture on glycerin agar plus a 
few drops of human serum. A portion of this emulsion was 
further diluted with salt solution, and a portion was mixed in a 
stiff agar containing 5 per cent glycerin. Dilutions were made 
so that the dose employed, 2 cubic centimeters, contained in both 
salt solution and agar approximately the 'same quantity, about 
0.04 of the original culture. By counting, the dose was found 
roughly to approximate 1,000,000 bacilli. All inoculations were 



158 



The Philippine Journal of Science 



1915 



made subcutaneously in the left inguinal region. The results 
are given in Table IX. 

Table IX. — Series A. Animals inoculated with a culture of tuberculosis of 

leper origin. 



Gui- 
nea 
pig 
No. 


Weight 


May 3, 1914. Dose, two 
cubic centimeters. 


95 days after 
inoculation. 


Died 
after 
inocu- 
lation. 

Days. 

29 
173 

91 

60 

74 

2 

170 

73 
106 
132 
196 

78 
122 
184 

27 
190 
114 
154 
104 




Autopsy. 




Tuber- 
cle. 


Weight 
g. 


Body 
weight. 


Spleen. 


Le- 
sions. 


Ratio of 
spleen 
weight 
to body 
weight. 


6204 

6205 

6206 

6207 

6208 

6209 

6210 

6211 

6212 

6213 

6214 

6215a 

6215b 

6216 

6217 

6218 

6219 

6220 

6221 

6222 


a- 

500 
330 
550 
410 
300 
480 
300 
530 
390 
340 
440 
360 
400 
500 
600 
330 
490 
340 
420 
520 






a. 


g. 


Tb. 
Tb. 
Tb. 
Tb. 
Tb. 
(») 
Tb. 
Tb. 
Tb. 
Tb. 
Tb. 
Tb. 
Tb. 
Tb. 
0>) 
Tb. 
Tb. 
Tb. 
Tb. 




.....do 

do. 


+ 


400 


300 
500 


6.3 

8.6 


0.0210 
0. 0172 


... do 






do 






280 






do 








do. 

do 

do 

do 

do 

do 


+ 

+ 

+ + 
_ + + 


370 

410 
420 
430 


300 

370 
350 
132 

300 
350 
838 


4.0 

10.5 
5.1 
5.0 
3.7 
6.9 
0.7 


0.0133 


0.0300 
0.0124 


0.0123 
0. 0197 
0.0021 


do 

do 

do 


+ + 

+ + + 


430 
390 


Emuls 

do ... . 


+ + 


400 


340 
440 
420 
410 


10.1 
2.4 
12.6 

14.7 


0.0297 
0.0055 
0.0300 
0. 0359 


...do 


+ 
+ 



480 
430 
550 


do 














120.6 





6.9 


0. 0191 









Sepsis. 



b Intercurrent disease. 



The average survival of the animals in this group is 120.6 
days for the 17 dying of tuberculosis — a time much shorter than 
that of the animals in series 1, 2, and 3, inoculated with tubercle 
bacilli from sputum. The majority gained weight up to ninety- 
five days after inoculation, but all had died by the one hundred 
ninety-sixth day, and those receiving bacilli in agar died on the 
average sooner than those receiving the emulsion only, although 
the latter group was too small to form a basis for any general 
conclusion. 

In order further to test this strain of tuberculosis, guinea pigs 
were inoculated with' material from the much enlarged spleens of 
different animals of the above group which died of tuberculosis. 
All were inoculated subcutaneously and all with a small portion 
of the spleen pulp. The results are given in Table X. 



X, B, 2 



Barber: Experiments on Immunization 



159 



Table X. — Series A. 



Animals inoculated with material from enlarged 
spleens. 







•a 
a) 

«. 1 




Weight. 


3 


Autopsy. 






3<H 
























o 










c 








c o . 


% 




If 


Date of inoc- 


<M* 


H 


CO 


'" c 

u.° 


4J 

A 








bo 






ulation. 


^H 


Oi 


as 


0) 4J 


bo 






™x g 


a 














=H~ 










a 

c 
'3 


4J 

bt 
'8 


.8- 

o O 




CD 

> 




d 


3 

u 

p. 


■73 




c 

0) 


c 
o 

'5 




O 


£ 


§ 




z 


P 


<H 


p 


pq 


CO 


. P 


M 




g- 




1912. 


g. 


<7. 


ff. 


Days. 


a- 


g. 






5221 


680 


6221 


Aug. 16 

do. 


500 






98 


410 


13.2 


Tb. 


0. 0328 


5216 


460 


6221 


420 






96 


410 


12.5 


Tb 


0. 0305 


6400 


500 


6218 


Sept. 7 

do 


470 


480 




193 


380 




Tb. 




6401 


670 


6218 


570 


590 




201 


510 


2.0 


Tb. 


0. 0039 


6426 


410 


6220 


Oct. 4 


430 


480 


420 


' 201 


360 


5.6 


Tb. 


0. 0156 


6427 


450 


6220 


do 


330 


350 


370 


222 


320 


1.6 


Tb. 


0.0050 


6428 


450 


6220 


do 

Average 


460 


490 


490 


224 


400 


5.0 


Tb. 


0. 0125 

0. 0167 








176.4 




6.6 









A striking result in the autopsy findings in series A is the 
unusual enlargement of the spleen. This was shown in both 
culture-inoculated and spleen-inoculated groups. The weight of 
the spleen at autopsy showed the very high maximum of 14.7 
grams to 410 grams body weight in animal 6221, and the high 
average of 6.9 grams for all of series A of which spleen weights 
were taken. 

As a basis of comparison the ratio of the spleen weight to the 
body weight at autopsy was calculated for a considerable number 
of the guinea pigs dying of tuberculosis of human-sputum origin. 
These animals belong to series 1, 2, and 3, treated animals of 
part I of this paper, and the controls of that series. The aver- 
ages of these ratios compared with those of leper series B are 
given in Table XL 

Table XI. — Average ratios of spleen weights to body weights in all series. 



Series. 


Table 
No. 


Origin of tubercle bacilli inoculated. 


Aver- 
age of 
ratios, 
spleen 
weight 
to body 
weight. 


Aver- 
age 
sur- 
vival 
after 
inocu- 
lation. 


Ani- 
mals 
aver- 
aged. 


1_ _ 


I 

II 
III 
IV 
V 
VI 




0. 0069 
0. 0084 
0. 0072 
0. 0088 
0. 0191 
0. 0167 


Days. 
236.6 
308.8 
310.7 
340.6 
134.6 
173.7 


9 
25 
11 

10 
12 
6 


2 


do 


3_ 


do__* 




do 


A.. 


Leper spleen __ 

do_ 


A 







160 The Philippine Journal of Science 1915 

It will be seen in Table XI that the average ratios of the 
two leper series far exceeds that of any sputum series; in fact, 
that of A, Table X, the lowest of the two leper series, is nearly 
double the highest of the other series. 

The average number of days of survival of the leper series 
is much below that of any sputum series; but by comparing in- 
dividual ratios in all tables with the corresponding number of 
days of survival, it does not appear that there is any constant 
correlation between the time of survival and the enlargement of 
the spleen. The evidence is good that we have to do with a 
strain of tuberculosis which in guinea pigs tends to enlarge the 
spleen to a greater degree than occurred in the other series of 
animals inoculated with the mixed strains from sputum. In 
calculating the average number of days of survival in Table VII, 
only those animals are included of which the spleen weight was 
known. 

SERIES B 

Spleen pulp from a human case of leprosy, taken at post 
mortem, was inoculated August 5, 1912, into four guinea pigs 
subcutaneously. The leprosy case was well advanced and showed 
numerous lepra bacilli in the spleen pulp and glands. Two of 
the four guinea pigs developed tubercles in the inguinal region 
in less than forty days after inoculation, while the other two 
showed no signs of infection after having been kept under ob- 
servation over one and one-half years. One, 6349, died No- 
vember 7, 1913, about one year and three months after inocula- 
tion, with numerous tubercles in the spleen, liver, and lungs, and 
enormous numbers of acid-fast bacilli in the liver. The spleen 
weight was 2.1 grams; its ratio to body weight, 0.0051. A 
portion of the spleen pulp of 6347 was inoculated into a new 
guinea pig, 6816. This guinea pig died two hundred twelve days 
after inoculation, showing tubercles in spleen, liver, and inguinal 
glands. The ratio of spleen to body weight in this case was 
0.0084. On June 8, 1914, a mixture of spleen and liver tissue 
was inoculated subcutaneously into guinea pigs 6970 and 6971. 
These, at present, October 10, 1914, exhibit palpable tubercles 
in the inguinal region. 

SERIES C 

Two guinea pigs were inoculated with the spleen pulp of a 
third human case of leprosy on August 14, 1912; no acid-fast 
bacilli were found in a smear from the spleen. After over two 
years of observation, no signs of tuberculosis has appeared in 
either of these animals. 



x, b, 2 Barber: Experiments on Immunization 161 

SERIES D 

Five guinea pigs were inoculated August 16, 1913, with spleen 
pulp of a case of human leprosy. Acid-fast bacilli were not 
found in the human spleen. One animal died of sepsis soon 
after inoculation. None of the other four developed any signs 
of tuberculosis. 

SERIES E 

Five guinea pigs were inoculated August 18, 1913, with spleen 
pulp of a case of leprosy, tubercular form. Numerous bacilli 
leprae were found in the spleen. Of these, three animals show 
no signs of tuberculosis after over one year's observation. One 
died about one year after inoculation with no signs of tuber- 
culosis, and one died forty-two days after inoculation, with en- 
larged inguinal glands, and apparently tubercles in the lungs 
and spleen, but acid-fact bacilli were not found in smears from 
the inguinal glands. Probably this animal died of some other 
disease. 

SUMMARY " 

1. Five series of guinea pigs or monkeys were inoculated with 
the spleen pulp of lepers taken at post mortem. Lesions of 
tuberculosis or lesions very similar to those of tuberculosis de- 
veloped in two of these series. In one of the two series only 
part of the pigs developed tuberculosis. In one (series E) 
one guinea pig out of five showed lesions, possibly those of 
tuberculosis. 

2. A series of guinea pigs inoculated with a strain of tuber- 
culosis of leper-spleen origin (series A) exhibited at post mortem 
a remarkable enlargement of the spleen. The average ratios of 
the spleen weight to the body weight at post mortem were nearly 
double the average ratios of a series dying of tuberculosis of 
human-sputum origin. 



A TEST OF COCCOBACILLUS ACRIDIORUM D'HERELLE ON 
LOCUSTS IN THE PHILIPPINES 1 

By Marshall A. Barber and Charles R. Jones 

(From the Biological Laboratory, Bureau of Science, and the Entomological 

Division, Bureau of Agriculture, Manila, P. I.) 

In view of the reported success following the use of Cocco- 
bacillus acridiorum d'Herelle in the destruction of locusts in 
Argentina, South America, it was deemed advisable to test the 
method in the Philippine Islands. 

It may be stated at the outset that we are unable to obtain 
any results of practical value, but in view of the number of ex- 
periments made and the thoroughness of the trial, it has seemed 
worth while to record our negative results. 

A sealed agar culture, arriving in perfect condition, was re- 
ceived in May, 1913. It bore the label of the Pasteur Institute, 
and complete directions for its use were sent with it. Following 
the directions, we proceeded to exalt the virulence of the culture 
and to inoculate a series of locusts with a broth culture of the 
bacillus. Subsequent lots were inoculated with material taken 
from dead or dying insects of the preceding series, and so on. 
The locusts chosen were adults, fairly fresh from the field, and 
the inoculated ones and controls were kept in large cages and 
were supplied with food. A layer of white filter paper on the 
bottom of each cage served to reveal the presence of diarrhoeal 
fseces. In inoculation a fine-pointed glass pipette was used in- 
stead of a syringe, since the former appeared more convenient 
to handle and allowed a more accurate dosage. The technique 
followed was a modified form of a technique used by one of us * 
in the inoculation of cockroaches with plague bacilli. Inocula- 
tions were made into the abdomen as directed, and dilutions 
were made with broth in later transfers. Practically every dose 
was examined microscopically, and cultures were made at each 
inoculation. 

Several exaltation series were carried out. In one, carried to 
the thirtieth set of insects, we used for the most part diluted 

1 Received for publication November 13, 1914. 

2 This Journal, Sec. B (1912), 7, 521. 

132716 5 163 



164 The Philippine Journal of Science iais 

faeces for inoculation, pressing it out of the abdomen and diluting 
with broth as the directions recommended. For convenience in 
reference we have designated this series as 30x (Table I). 

We early found that our inoculated insects did not show the 
one characteristic described — the liquid excrement. This may 
have been present in a few cases, but was decidedly rare. Since 
we often failed to find fasces with the abundant actively motile 
bacilli as described in the directions, we did not always dilute so 
highly with broth as the author of the directions recommends. 
It was found that if we gave too light a dose, even after a con- 
siderable number of insect transfers, the death of the insects was 
long delayed. The volume of the dose as given in the directions, 
"two or three drops," is rather indefinite, and we may have 
averaged a somewhat smaller volume of material. But since 
the effective dose depends on the number of viable bacteria, this 
ought not to make a material difference, especially in view of 
the fact that increase of virulence of the bacteria should go 
on as well with small doses as with large, provided only that 
enough is given to cause a fatal infection. 

On account of the inconstancy of the number and character 
of the bacteria in the fasces, we undertook a second exaltation 
series carried out in another way. Here any material from the 
gut was carefully avoided, and the bacilli were taken wholly from 
the body cavity. This was accomplished in most inoculations 
by injecting broth into the body cavity of the dead or moribund 
insect, withdrawing it by means of the pipette, and using this 
liquid for inoculation — always after microscopical examination 
to assure us of the presence of motile organisms. This series, 
carried through 15 insect transfers, we have designated as 15x 
(Table II). 

Later, when field experiments with 30x and 15x had given no 
practical results, a third exaltation series was carried out. In 
this series the inoculation material consisted of fluid pressed with 
aseptic precautions from the leg of a dead or moribund insect. 
When full of actively motile coccoid forms, as was usually the 
case, this liquid was diluted with sterile broth and used for the 
next set. Wingless locusts in the later stage were used for the 
most part, and the series was carried to the twelfth insect 
transfer. This series we have designated 12x. 

In the first two series especially, we often divided the lot of 
insects to be inoculated at any one time into several sets, one 
set receiving material from the gut, another from the body cavity 
of the dead insect used as a source of material, or one lot was 



x, b, 2 Barber and Jones : Coccobacillus acridiorum d'Herelle 165 

given a larger and another set a smaller dose. This gave us 
some criterion of the amount and character of dosage to use. 
In each of the three series of insects inoculated there were lots 
in which some or all of the locusts inoculated with moderate 
doses died within from six to eight hours after inoculation; so 
that we had apparently reached the degree of virulence required 
by the directions. 

In each of the three series the starting culture was that 
received from the original source. In order to make sure that 
the culture which passed through a series was the same as that 
used in starting, a careful comparison was made of the culture 
obtained from insects at the end of the 12x series with that used 
at the beginning. Both were found to have the same appearance 
and motility in hanging drop, and both were Gram-negative and 
exhibited the same morphology in stained specimens. Both 
showed the same rapid growth in plain agar, and agreed in 
showing very slight gas, with little or no acid, in lactose litmus 
agar and in lactose broth fermentation tubes. In glucose broth 
fermentation tubes both formed gas to the extent of about seven 
tenths of the volume. of the closed tube, and both showed gas 
and acid in maltose litmus agar and in mannite litmus agar. 
Neither showed gas nor acid in saccharose litmus agar. It is 
possible that these sugars were not pure in every case, since 
they had been kept for some time in the tropics; but however 
that may have been, it is to the last degree unlikely that a 
contaminating organism would show so many characteristics 
in common with the original culture. In one of the control 
series (see below), Bacillus prodigiosus was used for a series 
in place of Coccobacillus acridiorum. This easily recognized 
organism was recovered from the body of an insect after the 
twelfth insect transfer. 

As controls, material was taken from the body contents of 
10 healthy locusts taken directly from the field and was spread 
on agar in test tubes. Nine of these tests showed no growth, 
while one exhibited 3 colonies, possibly contaminants. The 
method of making these cultures as well as of taking cultures 
from infected insects was as follows: The posterior leg of 
a locust was removed, preferably above the trochantofemoral 
joint. The distal part of the femur was held between the 
thumb and finger, and alcohol was dripped over it in order 
partially to sterilize the surface. After the alcohol became dry, 
the end of the femur was cut off with hot scissors, and some of 
the contents of the leg were pressed upward until they appeared 



166 The Philippine Journal of Science 1915 

at the cut surface. They were then touched with the sterile loop 
and transferred to an agar slope. Abundant growth practically 
never failed in the test tube when microscopical examination 
had previously shown the presence of bacteria in the body cavity. 

CONTROLS 

During the exaltation series, controls of uninoculated insects 
were kept; and besides, some insects were inoculated with broth 
alone. Such controls remained in good condition for days with 
but little diminished numbers. In addition to the above, controls 
were made of insects inoculated with other bacteria. Bacillus 
prodigiosus was carried through 12 insects transfers at the 
same time as 12x of Coccobacillus acridiorum. The death of 
the insects followed the inoculation with about the same regular- 
ity and after as short an interval as in the case of Coccobacillus. 
Cultures were made from the insects after many passages and 
sprayed on the food of locusts in corrals and in the field. Several 
insects found dead in the corrals showed Bacillus prodigiosus 
apparently in pure culture in the body cavity. Precautions 
were taken to avoid surface and gut contamination in making 
cultures. One insect found dead in the field after spraying with 
Bacillus prodigiosus also showed this organism in the body cavity. 

Another control series was started with inoculations of the 
gut contents of an insect which died at a station some distance 
from the laboratory where inoculation experiments were being 
carried on. At this station there was no possibility of accidental 
infection with Coccobacillus acridiorum from the laboratory. 
Insects died just as promptly after similar intraabdominal doses 
of this material as after doses of the Coccobacillus, and ingestion 
experiments in cages gave, if anything, better results (Tables 
III and V "Singalong"). Field experiments were alike negative 
with both strains. 

A special experiment was arranged to compare the effect of 
small doses of the original culture of Coccobacillus acridiorum, 
as received, with those of a culture of the same source which 
had been passed through a series of locusts ("12x" series). 
The exalted culture had been passed through 12 series of locusts, 
with one or two exceptions in the nymph stage. It was kept 
at refrigerator temperature for about three weeks, with the 
exception of about three days at room temperature. This cul- 
ture came directly from the leg of an infected insect. It was 
then planted on agar to get a fresh growth and inoculated into a 
set of mature locusts. From the first one dying, a new set 



x, b, 2 Barber and J ones : Coccobacillus acridioritm d'Herelle 167 



of mature locusts was inoculated, and from the first or second 
dying in this series, an agar culture was made from the leg. 
It had then been passed through 14 series of insects, the last 
two immediately before the experiment. 

The stock culture had been transferred about four times on 
agar and kept at room temperature for about six weeks. A 
broth emulsion was made of a 10-hour agar culture of this 
stock strain and a similar emulsion of the "exalted" strain. 

With a fine, very sharp capillary pipette, approximately 
equal doses of each emulsion were inoculated into the abdominal 
cavity of mature locusts recently taken from the field. The dose 
was gauged by a mark on the pipette, and the same pipette was 
used for all inoculations. It was sterilized in hot water after 
the inoculation" of each lot. The size of the dose was larger, 
if there was any material difference, for the exalted strain 
than for ,the stock culture, and the exalted strain was inoculated 
after the stock, so that any growth taking place in the broth 
would tend to make the exalted strain larger. The aim was 
to have any error in the direction of increasing the exalted 
culture corrected. The dose of the exalted culture, as measured 
in the Thoma Zeiss counting chamber, approximated 2 cubic 
millimeters ; and by measuring the dimensions of the lumen of the 
capillary, approximately the same result was obtained. The 
number of bacteria per dose roughly approximated 1,500,000. 

Fifty locusts were inoculated with each strain, and as con- 
trols, 50 were inoculated with the same dose of sterile broth 
and 50 were placed in a cage with no treatment. 

The four lots were placed in separate cages under similar 
conditions. The results are given in Table I. 

Table I. — Locusts inoculated with Coccobacillus acridiorum. 



Lot 

No. 



Dose, about 2 cubic milli- 
meters of — 



Stock culture 

Exalted strain, 14 insect pas- 
sages 

3—1 Broth alone 

4 ! No inoculation 



1 

Lo- 
custs 
in- 
ocu- 
lated. 




Locusts dead or moribund at the end of — 




Hours. 


Days. 


22. 


25. 


34. 


2. 


3. 


4. 


5. 


7. 


17. 


50 

50 
50 
50 


1 
1 


1 

5 
1 
1 


2 

21 
1 
1 


21 

34 
3 
2 


34 

44 
6 
4 


40 

46 
7 
5 


41 

a 47 

7 
5 


42 


a 47 


7 
5 


12 
9 



a All dead. 



The table shows that the insects died somewhat sooner from 
the dose of the exalted strain than from that of the stock 



168 The Philippine Journal of Science me 

culture. The exalted dose may have been slightly larger, but 
it is not probable that this excess alone could account for the 
difference. The slow response to the inoculation in both series 
was probably due to the small size of the dose. A few locusts 
escaped from the cages, and although the dead insects were 
removed at each examination, some may have been eaten by 
others; so that the total number at the close does not reach 
quite 50. 

The white filter paper covering the bottoms of the cages 
showed few traces of diarrhoea in either, and less in the cage 
containing those inoculated with the exalted strain than in the 
other. 

Ingestion experiments were conducted in relatively small 
cages in the laboratory, in similar cages placed on the grass 
of a lawn, in corrals made of galvanized iron, and in the open 
field on a large scale. The results of the field experiments are 
given in Table II. 

By far the most attention was given to the field experiments. 
The insects here were for the most part wingless and varied 
from nymphs soon after emerging from the egg, in one series, 
to nymphs of the third to fifth instar. The greater number of 
tests were made on insects of the latter size. Automatic 
sprayers of a good type ("Autospray" No. 1, Rochester, N. Y.) 
were used, and the infective material was sprayed as early in the 
day as the insects began to feed well. The material was sprayed 
on the grass or other food in, and just in front of, the advancing 
swarm. 

Shipments were received from the laboratory daily of a num- 
ber of large bottles containing sterile broth. Usually two such 
bottles, each containing from 2.5 to 3 liters of broth, were used 
for a single spraying. Broth cultures started the day before 
were used, and never until they had become well clouded. A 
much larger amount of broth culture was used in proportion 
to the area than that recommended by the directions. 

The experiments extended over a period of more than twenty 
days, and through one period of wet weather, although for the 
most part the weather was hot and dry. The material sprayed 
consisted of cultures of 30x, 15x, 12x, and the control strains, 
Bacillus prodigiosus and Singalong. In the case of the strains 
exalted in the laboratory, 30x, 15x, and Singalong cultures 
were taken directly to the field, about half a day's journey 
from the laboratory, immediately after the last insect transfer, 
and the stock cultures were kept in a refrigerator in the field. 
In the case of 12x, the strain exalted during the field exper- 



x, b, 2 Barber and Jones: Coccobacillus acridiorum d'Herelle 169 



ID 

"3 

DQ 

M 


Negative. 

Do. 

Do. 

Partially negative. 
Negative. 
Do. 

Do. 
Do. 
Do. 
Do. 

Do. 
Do. 
Do. 
Do. 
Do. 
Do. 
Do. 
Do. 

Do. 
Do. 


c 
o 
« <i 

rt --3 


Hot and very dry _ 
Hot and dry 

Relatively cool 
and damp. 

Warm and damp . . 

do 

do 

do 

do 

do 

Rainy and warm.. 

Warm and damp__ 

do-... 

do.. 

do 

do 

do.. 

do ... 

do 

do 

do 


•a 

0) 

>> 

a 

CO. 

e 


Cm 


§ i '! Mi i i 1 i Ml!!!!! M 

U5 


< 


U9 O U9 O U9 O U3 O O OOOOOOOO OO 
y-1 O •-< COr-tO H M ^ O COCOOCOCOOOO OO 

C£> to t-ClcS OS oS w O aicioCTSOr-iOf-H OO 


■a 
<u 
>, 

a 

(0 

eg 
JH 
3 

o 


Twelve hours' broth cultures 30x and XIX of 

Singalong. 
Twelve hours' broth 30x plain and with 10 per 

cent solution molasses and stale beer. 
Twelve hours' broth 30x, Singalong, and 15x 

Twelve hours' broth 30x and crushed hoppers-. 

Twelve hours' broth 30x . 

30x, 15x, and 21 Singalong, crushed hoppers 

and 20 per cent stale beer and molasses. 
Crushed hoppers 30x and 15x and 21 Singalong- 

do 

do 
30x— 

30x and Singalong .. . . ._ 

do 

do 

do 

do 

30x, Singalong, and B. prodigiosus 

30x, 12x 

30x, 12x, and B. prodigiosus, plus molasses and 
tiqui-tiqui. 

do -_-_ 

do 


3 
JD 

*w 
O 
0) 

be 

< 


Nymphs. Third in- 
star. 
Nymphs. First and 

second instar. 
Nymphs. Third in- 
star. 

do 

do 

Nymphs. Fourth in- 
stall. 

do 

do 

do 

Third and fourth in- 
star. 

do.-.. _.. 

do 

do 

do 

do — 

do-_ 

do 

do 

do 

do 


2 

o 

c 
o 
JS 

-5 
c 
o 
O 


Rice paddy, very dry 

High cogon, river bot- 
tom sand, moist. 
Rice paddy, very wet.— 

do ._ 

do 

do 

do 

do _ -.-_ 

do 

River bottom, high co- 
gon, sandy. 

do _-_ _ — 

do 

do 

do 

do 

do 

do •_ 

do 

do 

do 


a! 
Q 


CO ** l£9 (O [- 00 OiOwtM CO-^tOCOt-OOOO H w 

i-ti-lT-l r-*T-lrHrHiHr-*rHCM <M CM 

COD Q> Q> 4) QJ V 1) Q) Q) V QjqjcjQjojajQJQ) flj GJ 

■zt c c c ace ccec cccccccc cc 

S3 3 3 333 3333 33333333 33 
>-3 1-5 >-S >-3 1-9, l-S >"9>-9>-9>-9 >-9>-9>-9l-9'-9>-9>-9 , -9 <-><-> 



170 The Philippine Journal of Science ms 

iments, broth was inoculated from young cultures, and in some 
cases directly from the body cavity of infected insects. In one 
of our field-corral experiments a considerable number of insects 
died after inoculation with one of the exalted strains. These 
insects were collected, crushed in broth, and the broth, after 
two or three hours' growth, was sprayed in the open field. 
Our one partially positive field experiment followed a spraying 
of this material. We gave our personal attention to the 
spraying and examination of the swarms. 

Since the insects usually did not begin to feed freely until the 
day was well advanced, it was thought that our negative results 
might be due to the fact that the insects did not ingest a sufficient 
quantity of culture before it had been killed or attenuated by 
the heat or dryness. So another method of feeding was employed 
in some later experiments. Fresh broth cultures were mixed 
with rice polishings (tiqui-tiqui) and a small amount of sirup im- 
mediately before being set out for the insects in the field. The 
insects fed on this mixture greedily, collecting on it immediately 
after it was exposed. Two such experiments gave results as 
clearly negative as the ordinary spraying. Intermittent spray- 
ing practiced on the same swarm during the course of a morning 
likewise gave negative results. 

The fields were visited on the day following spraying and 
usually on several subsequent days, and careful search was made 
for dead or infected insects. As stated before, only one experi- 
ment gave partially positive results. This experiment was con- 
ducted in an open paddy field during a relatively wet period. 
The material sprayed was broth in which were crushed a large 
number of insects found dead in a corral experiment. A consid- 
erable number of insects, amounting perhaps to several liters, 
were found dead in the field the following day ; although the dead 
were but a small percentage of the total swarm, and apparently 
there was no marked diminution of the swarm. There was ab- 
solutely no indication of a natural spread of the infection in this 
swarm, and cultures from dead insects found in the field and 
emulsions of the body contents of these insects failed to give 
positive results in subsequent sprayings. In no case was there 
any indication of the prevalence of diarrhoea among insects in 
the field. 

We do not believe that our failure to obtain field results of 
practical value was due to any error in technique or any lack of 
thoroughness in the test. Two conditions may have contributed 
to make our results less successful than those reported from 



x, b, 2 Barber and Jones : Coccobacillus acridiorum d'Herelle 171 

Argentine — the species of insects and the prevailing high 
temperature. 

Two species of locusts in mixed swarms were sprayed during 
these experiments; namely (Edaleus nigrofasciatus DeGeer, and 
Locusta vnigratoroides R. and F. 3 The room temperature ranged 
from 28° to 32° C. or over during the time of these experiments, 
and the temperature in the fields exposed to the sun must have 
been much higher. Even during the short rainy period (the time 
when we attained a partial success) the temperature, though 
somewhat lower, remained relatively high. The author of the 
directions especially cautions against cultivating the organism at 
ordinary incubator temperature. If high temperature is an ob- 
stacle to attaining or maintaining an effective virulence of the 
bacterium, the method is much handicapped in the Philippines, 
where the insects often pass through the nymph stage during 
the hot dry season. 

In order to determine whether or not our failure to obtain ~ 
practical results with Coccobacillus acridiorum d'Herelle might 
have been due to some error in technique, the Bureau of Science 
sent to M. d'Herelle, at the Pasteur Institute, a detailed report of 
our 1913 experiments and their results. The following is an 
extract (translated from the French) of the reply kindly trans- 
mitted to the Bureau by M. d'Herelle and received November 
11, 1913: 

Your lack of success doubtless must be attributed to a lack of strength 
of the virulence. Dr. Sergent, director of the Pasteur Institute in Algiers, 
while working with Stauronoutus maroccanus, was obliged to obtain 56 
passages before obtaining a coccobacillus sufficiently strong to propagate 
the epizootic in the field. As the locust in the Philippine Islands also 
belongs to a different genus from that of America, where the virus orig- 
inated, doubtless the passages must be multiplied in order to adapt the 
microbe (for use in the field) . 

The directions accompanying the cultures stated that usually 
12 passages suffice to exalt the virulence to the necessary degree, 
but that the final test of virulence is that the coccobacillus be 
sufficiently virulent to kill the inoculated locusts within from eight 
to ten hours. We carried one of our series to the thirtieth 
passage, another to the fifteenth, and a third to twelfth. In 
a series conducted in May, 1914, in Mindoro by one of us 
a series was carried to the twenty-third passage. Judging 
by the time necessary for the bacterium to kill the inocu- 
lated insect, we had in all of the series a virus of fully sufficient 
exaltation. In reference to the experiments on the grasshopper 

"Identified by A. N. Condil, United States National Museum. 



172 The Philippine Journal of Science 1915 

in Algeria it appears from reports received from the American 
Consul at Algiers (see page 175) that no satisfactory field 
results were obtained even from a virus that had passed through 
from 74 to 87 grasshoppers. In laboratory experiments, how- 
ever, many passages apparently were necessary, in the Algerian 
grasshoppers, to exalt the virus to a sufficient degree. According 
to the report mentioned above, the virus, at first not certainly 
fatal after a period of from twenty-four to thirty-six hours 
following artificial inoculation, was exalted to a degree where it 
was invariably fatal within four hours. 

Experiments on locusts with Coccobacillus acridiorum were 
continued in May, 1914, in Mindoro by one of us (Barber). A 
new culture obtained from Argentina was used and submitted to 
23 locust passages. In the laboratory experiments in this series 
there was more tendency among infected insects to discharge 
liquid excrement than was observed in the experiments of 1913 
in Luzon, but this diarrhoea was by no means a constant symptom. 

Field experiments were conducted with cultures from insects 
where the bacterial dose (diluted ten times) was sufficiently 
strong to kill inoculated insects within six hours. 

In the field experiments infection was attempted on both 
winged locusts and "hoppers." The cultures were applied to the 
grass or cane on which the insects were feeding in several dif- 
ferent ways: namely, spraying or broth cultures alone, broth 
cultures plus meal and molasses, and the extract from dead 
crushed insects. These were taken from a large cage, where 
they had been fed on a presumably exalted virus. Locusts 
confined in cages during this series of experiments fed much 
better than during our experiments of 1913. Grass soaked in 
culture media was devoured immediately, and healthy insects 
readily fed on the dead ones. So, in order to get a further 
method of spreading the infection in the field, locusts were 
caught, fed on culture-soaked grass, and turned loose among 
the field swarms. 

In not a single instance during the whole of the Mindoro 
experiments was there the slightest evidence of the spread of 
infection among insects in the field. During the experiments the 
weather was hot with frequent afternoon showers. 

On the application of the Bureau of Science for information 
regarding the practical success with Coccobacillus acridiorum 
obtained in other countries, the following reports from consuls 
in Argentina, Columbia, and Algeria were transmitted through 
the Government at Washington to the Bureau of Science. These 
are given verbatim. 



x, b, 2 Barber and Jones : Coccobacillus acridiorum d'Herelle 173 

Department of State, 

Washington, May 13, 19 H. 
The Honorable the Secretary of War. 

Sir: Referring to your letter of October 1 and the Department's reply 
of October 10 last, I have the honor to inclose for your information a copy 
of a despatch from the American Charge d'Affaires at Buenos Aires, 
reporting on the experiments made in the Argentine with the Coccobacillus 
d'Herelle. 

I have the honor to be, sir, 

Your obedient servant, 
For the Secretary of State: 

Robert Lansing, Counselor. 

Inclosure: From Argentine Republic, No. 272, April 9, 1914. 

Legation of the United States of America, 

Buenos Aires, April 9, 191U- 
No. 272. 
The Honorable, the Secretary of State, 

Washington. 
Sir: Referring to the Department's instruction No. 91, of October 10, 
1913 (File No. 105 P. I. 14), instructing the Legation to secure further 
information regarding the use in this country of bacteria cultures for 
destroying locusts, I have the honor to report that a commission appointed 
by the Minister of Agriculture has decided that Coccobacillus acridiorum 
d'Herelle, the bacteria sent by the Legation to the Department at the 
request of the Philippine Government, did not produce favorable results in 
this country. 

M. d'Herelle has severed his connections with the Argentine Ministry 
of Agriculture and has gone to Europe. He claims that he was not given 
a fair opportunity to test the result of his bacteria and that he was hampered 
in his work by the hostility of the minor officials of the Agriculture 
Department. It is announced that the Ottoman Government wishes him 
to test his bacteria in Asia Minor. 
I have the honor to be, sir, 

Your obedient servant, George Lorillard, 

Charge d'Affaires ad interim. 

[First indorsement.] 

B. I. A., War Department, 
Washington, D. C, May 18, 191k- 
Copy to the Governor-General of the Philippine Islands, Manila, P. I., 
reference being had to letter from this Bureau of May 9, 1914. 
Copy for The Director of the Bureau of Science, June 24, 1914. 



6478-37 

War Department, 
Bureau of Insular Affairs, 

Washington, May 9, 191 U- 
From: Bureau of Insular Affairs. 
To: Governor-General of the Philippine Islands. 

Subject: Experiments with d'Herelle bacillus for destruction of locusts. 
1. In connection with this bureau's letter to you of May 7, and con- 



174 The Philippine Journal of Science 1915 

firming telegram from this office of even date, I quote below letter received 
from the State Department, dated May 6, 1914: 

"Referring to previous correspondence on the subject of the use of the 
d'Herelle bacillus for the extermination of locusts, I have the honor to 
say that the Department has received a telegram from the American 
Minister at Bogota, dated the 2nd instant, in which he states that ex- 
haustive experiments for the extermination of the locust have recently 
been completed by the Colombian Central Commission, and that they proved 
that the d'Herelle bacillus was effective but the application of it was not 
practical. 

Mr. Thomson added that he was informed that experiments made in 
January in the Argentine Republic, under the supervision of d'Herelle 
himself, gave the same results and that the efforts now being made must 
look to the discovery of a practical method of disseminating the germ. Mr. 
Thomson further stated that he would forward reports just published by 
the Colombian Central Commission." 

(Sgd.) Chas. C. Walcutt, Jr. 

Assistant to Chief of Bureau. 

Copy for The Director of the Bureau of Science, June 24, 1914. 



War Department, Bureau of Insular Affairs, 

Washington, May 7, 191U- 
From: Bureau of Insular Affairs. 
To: the Governor-General of the Philippine Islands. 
Subject: Experiments with d'Herelle bacillus for destruction of locusts. 

1. Reference is had to your telegram of the 7th ultimo and to this 
bureau's reply of even date, relative to the results obtained in the Argentine 
Republic, Colombia, and Algeria, by the use of d'Herelle bacillus for de- 
struction of locusts. 

2. The Bureau is now in receipt of a communication from the State 
Department reading as follows: 

"Referring to previous correspondence with your Department concern- 
ing the inquiry made by the Philippine Government as to the results obtained 
in the Argentine Republic, Colombia, and Algeria, by the use of d'Herelle 
bacillus for destruction of locusts, I have the honor to say that the Depart- 
ment received a telegram, in reply to its telegraphic instruction, from the 
American Charge d'Affaires at Buenos Aires, dated the 25th ultimo, stating 
that the results obtained in the Argentine had not been satisfactory. 

The American Consul at Algiers reported by cable on the 28th ultimo 
that no experiments had been made on locusts by the use of the d'Herelle 
bacillus, but that the results, from its use on grasshoppers, were inconclusive. 

The Department has so far received no reply to its telegraphic in- 
struction to the American Minister at Bogota." 

(Sgd.) Chas. C. Walcutt, Jr. 

Assistant to Chief of Bureau. 

Copy for The Director of the Bureau of Science, June 12, 1914. 



Department of State, 

Washington, May ;?i, 19l£. 
The Secretary of State presents his compliments to The Honorable the 
Secretary of War, and has the honor to transmit, for the information of 
the Philippine Government, a copy of a report received from the American 



x, b, 2 Barber and Jones: Coccobacillus acridiorum d'Herelle 175 

Consul at Algiers, Algeria, giving the result of experiments that have 
been made in Algeria with Coccobacillus acridorium of d'Herelle. . 

Reference is made to a letter on this subject, dated April 18, 1914, 
from the Assistant Secretary of War. 
Inclosure: From Algiers, May 2, 1914, with inclosure. 
105 P. I./92. 

[First indorsement.] 

Bureau of Insular Affairs, 

May 23, 1914. 
To the Governor-General of the Philippine Islands, Manila, P. I. 

CO. 
Inch 6478-41. 

[Second indorsement.] 

The Government of the Philippine Islands, 
Executive Bureau. 
Lc 

Manila, June 29, 1914- 
Through the Director of the Bureau of Science, to the Director of Agri- 
culture. 

EXPERIMENTS IN ALGERIA ON GRASSHOPPERS WITH THE COCCOBACILLUS 
ACRIDORIUM OF D'HERELLE 

In 1913 Professor Sergent of the Pasteur Institute of Algeria com- 
menced investigations to ascertain whether the destruction of the grass- 
hopper indigenous in Algeria, the Stauronotus maroccanus Thunberg, could 
be effected by the bacillus of d'Herelle. 

As the results obtained were considered inconclusive further experiments 
are being made at present the results of which will be duly reported when 
experiments are concluded. 

The following information was obtained through a personal interview 
with Professor Sergent. 

It was found that injections of cultures containing the bacillus d'Herelle 
sometimes caused the death of grasshoppers in from 24 to 36 hours but 
that in other instances injections were not fatal. It was further found 
that the virulence of bacillus was increased in the bodies of grasshoppers 
and that by injections of bacillus from one grasshopper to another the 
virulence of the bacillus was increased to such a degree that death could 
invariably be caused within four hours of infection. After transmission 
of virus through 28 insects the average life of insect after infection was 
seven hours, after transmission through 70 insects 6 hours, and after 
transmission through 100 insects four hours. 

The process of infection from one grasshopper to another had to be 
carried on 20 days to obtain a regular mortality in seven hours after in- 
fection, one month for six hours and seven weeks for four hours. 

Two tests were made by Professor Sergent in the Department of Oran 
in 1913 to determine the practical value of infection of grasshopper with 
the bacillus d'Herelle. 

From the 15th to the 22d of April an area of about 40 acres was sprayed 
with 37 liters of bouillon containing virulent bacilli of d'Herelle, in the 
line of march of a column of grasshoppers. From the first day that spray- 
ing was commenced dead grasshoppers were found infected with bacillus. 
On the 30th of April large numbers of dead grasshoppers were found 
but the great majority of insects constituting the column were not affected. 



176 The Philippine Journal of Science 

A second experiment was made from the 13th to the 21st of May with 
a more vjrulent virus which had been transmitted through from 74 to 
87 grasshoppers. Ninety-three liters of bouillon were sprayed with the 
apparatus of vermorel [Vermeil?] over an area of about 80 acres. On 
the 28th of May very large numbers of dead grasshoppers were observed 
averaging about 5 grasshoppers per square meter of area sprayed along 
the course of a brook which probably arrested the advance of the column 
for some time; the bodies of insects were piled up in heaps. 

On the other side of the ravine through which the brook flowed a field 
of wheat was occupied by the column among which grasshoppers were 
captured whose intestines contained the bacillus d'Herelle but which showed 
no sign of sickness. 

The grasshoppers located in the field of grain were observed during 
three weeks prior to a further flight which could not be followed. Every 
morning considerable numbers of dead grasshoppers were found but no 
noticeable diminution in number of living grasshoppers could be observed. 

It would appear that when part of a column of grasshoppers is infected 
by spraying area over which column passes further infection ensues owing 
to the dejections of diseased insects. The experiments made tend to show 
that infection is not spread by contact or by the eating of dead bodies. 

It was admitted by Professor Sergent that the results so far obtained 
with the bacillus d'Herelle were less satisfactory than the results obtained 
by other methods of destruction currently employed. 

It was ascertained from Professor Trabut, the Director of the Botanical 
Service of Algeria, that the report of Professor Vermeil, the Government 
Professor of Agriculture of the Department of Oran, who observed the 
field tests was decidedly unfavorable and that he himself considered the 
tests so far made to be inconclusive. 

No experiments have been made in Algeria on locusts with the bacillus 
d'Herelle as no locusts have been found in the country since investigations 
were first commenced. 

Dean B. Mason, 
American Consul. 

Algiers, Algeria, May 2d, 19 lb. 

American Consulate, 
Algiers, Algeria, May 2, 191U- 
Subject: Transmission of report on Experiments in Algeria in destroying 
grasshoppers with the Coccobacillus acridorium d'Herrelle. 

The Honorable the Secretary of State, 

Washington. 
Sir: Referring to Department cable of April 28th directing that a brief 
report be made by cable as to the results obtained with the locust bacillus 
d'Herrelle and to the reply of this Consulate stating that experiments 
have not been made on locust and that results with grasshoppers were 
inconclusive I have the honor to submit herewith a more detailed report 
as to the experiments that have been made in Algeria with the Coccobacillus 
acridorium d'Herelle. 

I have the honor to be, sir, 

Your obedient servant, Dean B. Mason, 

American Consul. 
Inclosure: Report in triplicate. 



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CONTENTS 

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THE PHILIPPINE 

Journal of Science 

B. Tropical Medicine 

VOL. X MAY, 1915 No. 3 

MALARIA IN THE PHILIPPINE ISLANDS 

II. THE DISTRIBUTION OF THE COMMONER ANOPHELINES AND THE 
DISTRIBUTION OF MALARIA 1 

By M. A. Barber, Alfonso Raquel, Ariston Guzman, and 

Antonio P. Rosa 

(From the Biological Laboratory, Bureau of Science, Manila, P. I.) 

TWO PLATES AND 1 TEXT FIGURE 

This work logically follows that of Walker and Barber 2 on the 
transmission of malaria in the Philippine Islands. In this work 
the infectivity to malarial parasites of Anopheles (Pseudomy- 
zomyia) rossii, Anopheles (Myzomyia) febrifer, Anopheles (My- 
zorhynchus) barbirostris, Anopheles (Myzorhynchus) sinensis, 
and Anopheles (Nyssorhynchus) maculatus was compared by 
feeding experiments on gamete carriers. Some 184 feeding ex- 
periments and the dissection of some 1,287 mosquitoes were 
carried out with special reference to the relative infectivity of 
different species. It was found that of 162 specimens of Ano- 
pheles febrifer dissected 108, or 66.66 per cent, were infected; 
of 3 A. maculatus, 2, or 66.66 per cent, were infected; of 187 
A. rossii, 35, or 18.71 per cent, were infected; of 100 A. bar- 
birostris, 6, or 6 per cent were infected; and of 12 A. sinensis 
none were infected. These numbers and percentages are based 
on certain strictly comparative experiments in which the different 
species were fed at the same time on the same patient, in which 
only females that were known to have sucked blood were con- 
sidered, and in which it was known that the patient's blood con- 

1 Read before the Philippine Islands Medical Association, November 6, 
1914. 

J This Journal, Sec. B (1914), 9, 381-439. 

133057 177 



178 



The Philippine Journal of Science 



1915 



tained viable gametes at the time of experiment from the fact that 
at least one mosquito at each feeding became infected. Taking 
into consideration all of the experiments, the numbers and per- 
centages are as follows : 



Species. 



Dis- 
sected. 



Infected. 



A nopheles febrifer 

Anopfteles maeulatus. 

Anopheles rossii 

Anopheles barbirostris 
Anopheles sinensis 



373 

49 

642 

205 

18 



Per ct. 
35+ 

6+ 
10— 
3+ 




With regard to sporozoites in the salivary glands the numbers 
are as follows: 



Species. 



Salivary glands. 



Dis- 
sected. 



Infected. 



Number. Per cent. 



Anopheles febrifer 

Anopheles maeulatus . 

Anopheles rossii 

Anopheles barbirostris 



111 

1 

125 

75 



18- 
100 





Taking into consideration these percentages and the numbers 
and distribution of anophelines as far as then known, it was 
concluded that Anopheles febrifer was probably the chief carrier, 
or one of the chief carriers, in the Philippine Islands. 

The object of the present work has been to study more widely 
the distribution of the commoner anophelines of the Archi- 
pelago and the distribution of endemic malaria as determined 
by the parasite and spleen indexes of children, for the most part 
of children ten years and less of age. Special attention was 
given to the relation between the breeding places of anophelines 
and the presence of malaria. The contiguity of the breeding 
places of anophelines to inhabited places, the character of sur- 
roundings, and other factors were also studied with the aim of 
determining why one locality is malarious and another not. 
Data were obtained on the habits of anopheline larva? and 
imagoes, and some experiments in the destruction of the larva 1 
of Anopheles in running streams were carried out. In short, 
our aim has been to establish a scientific basis for combating 
malaria in the Philippine Islands. 



x, b, 3 Barber et al.: Malaria in the Philippines 179 

THE DISTRIBUTION OP ANOPHELINES 
LARViE 

In determining the number and character of the larvse of a 
locality, the following method for the most part was employed : 
Larva? were collected in jars and bred, and the species were de- 
termined from the imagoes. In a large proportion of the local- 
ities for which the malarial index was determined, the character 
of the mosquito fauna and the breeding places of the mosquitoes 
were also surveyed. An anopheles-mosquito survey was made 
of many other localities. For the determination of some species 
we are under obligations to Prof. C. S. Banks, entomologist of 
the College of Agriculture of the Philippine Islands. In general, 
we have found the relative numbers and habitats in various 
provinces much the same as they are in the neighborhood of Can- 
lubang, Laguna Province, Luzon, which was very thoroughly 
surveyed by Walker and Barber. 3 Anopheles rossii is by far 
the most abundant and the most widely spread. Anopheles 
febrifer and A. barbirostris come next in order of abundance; 
of these, A. febrifer, although of more restricted habitat, probably 
exceeds A. barbirostris in abundance, because of the far greater 
numbers of larvae found in the breeding places. Anopheles 
sinensis probably ranks fourth. Its relative abundance is rather 
difficult to determine, since it is preferably a rice-paddy breeder, 
and may occur in considerable numbers under certain circum- 
stances. Anopheles maculatus is probably the least plentiful of 
the five species, since its breeding places are restricted, and rel- 
atively few mosquitoes are found in them. A wider search 
conducted in each locality through all months of the year may 
change the order given for the last two, but probably not for 
the first three. Thus far no other species has been found in 
any considerable abundance.* 

3 Loc. cit. 

* Specimens of anopheles from larvse collected in a brook at Buhisan, 
Cebu, were sent to Dr. C. S. Ludlow, of the Army Medical Museum, Wash- 
ington, D. C, who identified them as Myzomyia parangensis Ludlow. These 
larva were very plentiful in the brook at Buhisan, and have been found 
by one of us (Barber) in Bugsanga River, Mindoro, where they occurred 
in abundance in May. Specimens from this lot of mosquitoec were identified 
by Mr. C. S. Banks, entomologist of the College of Agriculture of the 
Philippine Islands, as Myzomyia rossii. In view of the rather indefinite 
status of this . species, we have in this paper taken the more conservative 
ground and included it and some very similar forms under the name 
Anopheles (Myzomyia) rossii. We believe that breeding experiments with 
this and similar doubtful forms should be carried out in order to determine 



180 The Philippine Journal of Science ms 

Details as to the distribution of the various species in different 
localities will be found in Table I, but in general, Anopheles rossii 
and A. febrifer have been found in nearly all localities where 
careful search has been made for them. Anopheles febrifer has 
been found in various parts of Luzon, Mindoro, Palawan, Cebu, 
and Negros Islands — practically in all localities where fresh 
flowing water has occurred in ditches, brooks, and rivers. 
Anopheles maculatus has been found in Luzon (Canlubang, 
Camp Stotsenberg, Antipolo, and near Taytay), Mindoro (San 
Jose), and Cebu (near the city of Cebu). Anopheles sinensis 
has thus far been found only in Laguna Province, Luzon; but 
it is probable that a search throughout rice paddies at different 
seasons would prove that it is widely distributed in the 
Archipelago. 

As to habitat Anopheles rossii is by far the most adaptive. 
It has been found in the very salt water of evaporating ponds 
used in obtaining salt (Paranaque) and in brooks flowing from 
springs. It occurs in temporary puddles at roadsides and in the 
largest rivers. It is the commonest anopheline of rice paddies. 
While preferring moderately fresh water, it is often found abun- 
dantly in foul pools, carabao wallows, and even in the very foul 
water of tanks containing soaking cane (Canlubang). It has 
been found in small pools among stones practically in the middle 
of a clear flowing brook, where no algas or other vegetation 
occurred except the small amount growing on the stones (Cebu) . 
In general, it is a sun-loving species and is rarely missing where 
masses of alga? in ponds or rivers are well exposed to the sun. 

Anopheles barbirostris, while very widely distributed, has a 
more restricted distribution than A. rossii. It is less often found 
in foul water and is commonest where the water is comparatively 
fresh and aquatic plants are abundant. We have found it in 
a pool of brackish water separated from the sea by a railroad 
embankment (Tayabas), in a succession of pools of different 
grades of saltiness in the bed of a nearly dry stream, and in 

the amount of variation possible in the offspring of a single pair of 
mosquitoes. It may well be that only by such experiments will a sound 
basis for the classification of some species of anopheles be obtained. As 
stated by Walker and Barber [This Journal, Sec. B (1914), 9, 439, note] 
specimens of Anopheles {Myzomyia) febrifer Banks were sent by us to 
Doctor Ludlow, who identified them as Myzomyia christophcrsi Theobald. 
Doctor Ludlow informed us by letter that this is the same species as that 
reported by her from the Philippines as M. funcsta. [See Ludlow, Bulletin 
No. 4, War Department. Office of the Surgeon General (1913), p. 36, 
footnote.] Myzomyia christophersi is a well-known malaria carrier of the 
hill regions of India. 



x, b, 3 • Barber et al.: Malaria in the Philippines 181 

the apparently pure salt water of the inflowing tide at the mouth 
of a river (Tayabas). It is very often associated with A. rossii 
in masses of alga? exposed to the sun, especially in rivers. 

Anopheles febrifer is more restricted in habitat than either 
of the foregoing species. We have never found it in brackish 
water. It shows a decided preference for clear flowing water, 
especially where there is an abundance of overhanging grass, 
roots, or other vegetation at the margin. It is rarely found 
except at the banks of the stream or at the edges of islets of 
grass or the like, and when liberated in the center of the stream 
the larva? usually wriggle rapidly to the shaded margin. It 
prefers brooks and small streams to large rivers, although it 
may sometimes be found at the margins of the latter, especially 
if a steep bank or grass or other vegetation offers shelter. It 
often occurs in small indentations in the shore or along the 
banks of slightly widened parts of a stream where quieter water 
is found. It almost never occurs where a current strikes the 
banks ; small dams, often made in small streams to obtain a pool 
for laundry purposes, afford a favorite shelter. Although pre- 
ferring vegetation at the margin of a stream, Anopheles febrifer 
may sometimes be found on a bare clay bank, especially if it 
is slightly overhanging. We have found it in small numbers 
among stones at the margin of a river (Palawan) and on stones 
at the walled sides of ditches in the streets of a town (Lilio) . 

This species tends to avoid the presence of decaying vegetation 
in water beyond a certain degree. It is usually absent in small 
bayous of half a meter to a few meters in length, extending from 
brooks in which it is abundant. Where a brook broadens to a 
width of a meter or more, offering quiet water at the margins, A. 
febrifer is often found abundantly, but if the stream widens to a 
broad pond, the larva? become rare or absent. Where the same 
brook becomes swiftly flowing again, the larva? reappear. We 
have not found them in pools or ponds without outlet. A certain 
amount of sewage or other animal matter in water is tolerated. 
We have found the species abundantly some rods below the exit 
of a large septic tank (Canlubang), but not immediately below. 
It also occurs, often in considerable numbers, in ditches serving 
as open sewers, these containing clear water with a small amount 
of sewage. We have found it in a brook into which water was 
seeping from pits containing soaking hides (Magdalena). Al- 
though usually found in clear water, it may occur in brooks 
rendered turbid by carabaos (Cebu). Anopheles febrifer has not 
been found in rice paddies, and the flow of water over extensive 
rice paddies seems to unfit it for this species — a very important 



182 The Philippine Journal of Science 1915 

matter in the epidemiology of malaria in regions where rice lands 
are centers of population. 

While brooks or small rivers are preferred as breeding places, 
Anopheles febrifer may occur in streams of very small flow. In 
one stream there was at that season no flow above ground, but 
the larvae were found near the exit of a spring (Mindoro) . They 
have been found in swamps, but only where there was a clear 
stream flowing over the swampy surface. 

While preferring shaded places, the larva? are often found in 
brooks and ditches exposed to the sun, but only where there is 
some vegetation or other protection at the margin. 

The general character of the soil does not seem materially to 
affect the breeding of Anopheles febrifer. It has been found 
in brooks in the red soil of Bataan Province, in sandy streams 
of Pampanga, in streams worn in volcanic rock in Laguna, in 
the limestone region of Cebu, and in the stiff clay region of 
Mindoro. It has been found abundantly at considerable distances 
from any human habitation, and in ditches flowing between and 
under houses in large towns. 

The two localities in which Anopheles febrifer has been found 
most abundantly are two small rivers, one in southern Mindoro 
and one in Negros. In the latter locality, a clear brook with 
steep banks and much vegetation, sometimes between 100 and 
200 larvae could be taken up at one dip of a small collecting pan. 

The number of larvae in a given part of a stream may vary 
from time to time, apparently independently of any change in 
conditions. This we have found to be the case in some streams 
at Canlubang, which we visited many times in the course of 
about five months for the purpose of collecting mosquitoes for 
feeding experiments. We found wide variations in the frequency 
of other species also. 

This species is sometimes found in association with Anopheles 
barbirostris in streams with abundant vegetation. It may often 
be found at the margin of a stream, while A. rossii is plentiful 
in algae at the center. We have sometimes found it in nearly 
"pure culture" at the steep shaded margin of a large brook, 
while A. barbirost?~is and A. rossii occurred at the more exposed 
margin at the other side. In a certain brook (Negros) A. 
febrifer was abundant at the margin, while A. rossii alone 
occurred in carabao tracks containing water and exposed to the 
sun only a few centimeters from the margin of the brook. 

Fig. 1 shows the relative frequency of the larvae of four species 
of Anopheles in habitats arranged according to the amount of 
decaying organic matter in solution in the water. 



X, B, 3 



Barber et at.: Malaria in the Philippines 



183 



Of course, the distribution as given in fig. 1 is true only in 
a very general way and takes into account only one factor: 
namely, the amount of decaying vegetable matter in the water. 
For example, seepage from small springs, or the overflow of 
wells, often fills animal tracks or small depressions in the soil 
with comparatively fresh water. Where exposed to the sun, 
these pools often contain many larvae of A. rossii and of no other 
anopheles. It must be borne in mind, also, that where a species 
is very abundant it may overstep the limits commonly fixed where 
the numbers are only normal. Furthermore, in times of scarcity 
of water eggs may be laid in less preferred places. However, 
in both the dry and wet seasons we have found the distribution 
of A. febrifer comparatively limited, and we have not found it 
except where the water was kept comparatively fresh by a 



Vegetation at 
margins of streams 
of very fresh water. 


Vegetation at 
margins of clear 
brooks and ditches. 


Small bayous from 

clear brooks 

and rivers. 


Ponds and rice paddies 
with much vegetation and 
relatively clear water. 


Foul 

stagnant 

water. 






— ■■ 


s 


N 
\ 









Fig. 1. The relative abundance of four species of Anopheles in habitats arranged according 
to the amount of decaying organic matter in solution in the water. 

spring or some flowing stream. We have frequently found larvae 
of mosquitoes other than anopheles in water contained in the 
axils of leaves, in upright joints of bamboo, or in coconut shells,, 
but never anopheles, although such occurrence of anopheles has 
been reported by others in the Philippines. 

Anopheles maculatus has been found in about the same sort 
of habitat as A. febrifer, but is far less common and apparently 
much more restricted to very fresh water. It has been found 
in localities at elevations of from 100 to 200 meters, such as 
Antipolo and a brook near Taytay, Rizal Province; Camp Stot- 
senberg, Pampanga Province; and Buhisan, Cebu Province; but 
it occurs near sea level at San Jose, Mindoro, and not far above 
sea level at Canlubang, Laguna Province. In Mindoro it was 
found among aquatic plants in a large irrigation ditch exposed 
to the sun. The larvae from these patches of weeds were care- 



184 The Philippine Journal of Science 1915 

fully kept separate and bred in a separate jar, and proved to 
be A. maculatus. 

Anopheles sinensis, while not so carefully studied as the pre- 
ceding species, appears to occur in about the same sort of local- 
ities as A. barbirostris, but is much less frequently found. 

We have found larvae of A. febrifer and A. barbirostris breed- 
ing in mountain brooks the temperature of which was 23° C. 
and in brooks with a temperature of 28° C. Anopheles rossii 
is often found in small shallow pools exposed directly to the 
tropical sun where the temperature is much higher. 

The different seasons in the Philippines affect the breeding of 
anopheles chiefly through diminution of breeding places in the 
dry season and the flushing of streams during the wet season. 
We have found very young larvse of anopheles, apparently of 
A. febrifer, during freshets, in eddies among floating debris. 
Apparently enough eggs or larvse remain in a stream after a 
freshet to restock it, even where no females are at hand to 
deposit new eggs. Anopheles rossii may be found in roadside 
puddles or ditches during the rainy season. The stream breed- 
ers, A. febrifer and A. maculatus, require more permanent 
conditions, and their breeding places are consequently more 
restricted. We have found A. febrifer in considerable quantities 
during every month of the year. The year 1914 was somewhat 
exceptional in the Philippines in the lack of long-continued rains 
during the wet season, and this condition favored the stream 
breeders, since they were less disturbed by freshets. In the arti- 
ficial ditches of running water, with which some towns are 
abundantly supplied, the amount of flow varies less from season 
to season than in brooks, so that the breeding of anopheles is 
less interfered with there. 

IMAGOES 

■ A matter of much importance in the dissemination of malaria 
is the behavior of mature anopheles, especially with reference 
to their habits of visiting houses and biting human beings. The 
avidity for human blood of anopheles in captivity is shown by 
Walker and Barber, 5 who give the following percentages for 
females that took advantage of one opportunity to suck blood: 

Per cent. 

Anopheles rossii 63.6 

Anopheles barbirostris 49.4 

Anopheles febrifer 54.8 

Anopheles maculatus 50.0 

Anopheles sinensis 67.8 

' Loc. cit. 



x, b, 3 Barber et al. : Malaria in the Philippines 185 

With regard to the avidity for human blood and the habit of 
house visiting of anopheles under natural conditions, we have 
data from two localities : namely, the San Jose Estate, Mindoro, 
and the Iwahig penal colony, Palawan. 

The region occupied by the San Jose Sugar Estate is com- 
paratively flat and not much above sea level. It was formerly 
covered with cogon grass. Some three years ago it was noted 
for a very large amount of malaria with a high mortality, but 
at the present time very severe cases are few and the mortality 
from malaria is almost nil. Latent malaria is still present to 
a considerable degree, as shown by the figures in Table I. 
Barber spent the month of May, 1914, on the estate, and during 
this time a squad of assistants made visits almost daily to houses 
belonging to the estate for the purpose of catching mosquitoes, 
especially anopheles. The mosquitoes were caught in test tubes 
or by means of nets of gauze or cobweb and were brought fresh, . 
often living, into the laboratory for identification. Dr. G. W. 
Daywalt, resident physician of the estate, has for many months 
kept mosquito catchers employed on the estate, and he ascribes 
much of the diminution of malaria to this part of the work. He 
kindly put at our disposal his squad of trained mosquito catchers 
to assist our own employees. We take this opportunity of ac- 
knowledging this and other courtesies shown us by Doctor Day- 
wait during our visit to the estate. 

The results of the mosquito catching are given by barrios 
in Table I. The number of days on which mosquitoes were 
caught, 25 in all, are given for each barrio. When morning 
and afternoon visits were made on the same day to a given local- 
ity the two visits are recorded as one. 

It is seen that the ratio of Anopheles febrifer to A. rossii varies 
greatly in different barrios. Two barrios, "J" and Magbando, 
show a relatively large number of A. febrifer. Barrio "J" was 
at that time a small barrio of only seven or eight houses. It 
is comparatively new and is situated about 2 kilometers from the 
center of population of the estate. There was a minor outbreak 
of malaria in this barrio earlier in the season, and the general 
locality has in the past been notably malarious. Larvae of 
A. febrifer were found by us in moderate numbers in a ditch fed 
by the seepage from an irrigation canal near this barrio, and they 
also occurred in small numbers in grass at the edge of the very 
swift water of the canal itself. They were abundant in a brook 
flowing through a wooded swamp less than half a kilometer 
distant. Some oiling of the seepage ditch near the barrio had 
been done, but little or none was done farther up this ditch or 



186 The Philippine Journal of Science 1915 

in the swamp. The inhabitants are all Filipino laborers and 
their families. 

, Magbando barrio consists of only two or three houses at the 
edge of or just outside of the estate. A clear stream containing 
numerous larvae of A. febrifer flows through the woods a few 
meters from the houses. Little oiling has been done in this 
region, since it is far from the center of population of the estate. 
The small population consists of Filipinos and Filipino-Mangyan 
mestizos. 

In the other barrios Anopheles rossii considerably outnumbers 
A. febrifer. Bugsanga barrio includes a long string of from 
15 to 20 buildings including some small dormitories and is 
situated on the bank of a large river, the Bugsanga. Numerous 
larvse of A. rossii and comparatively few of A. febrifer were 
found by us in this river. There is also an irrigation ditch 
entering this river in the upper part of the barrio. The popu- 
lation of the barrio is relatively small and includes both Amer- 
icans and Filipinos. This barrio is at the edge of the cultivated 
part of the estate and is about 1 kilometer from the center of 
population, so comparatively little oiling has been done in the 
river. 

The barrios of Mindoro and Lubang include the largest part 
of the population of the estate. They are situated on the banks 
of a small winding stream, Magbando River, which in places 
has swampy banks. There are numerous irrigation ditches in 
the neighborhood and small streams formed by seepage from 
these ditches. We found larvae of A. febrifer in small numbers 
at the edge of this stream and some of A. rossii in the swampy 
ground. The various streams and ditches have been faithfully 
oiled, and the larvae are remarkably few considering the difficulty 
of destroying them over such a large and abundantly watered 
area. Mindoro barrio has about 140 houses. Lubang has about 
75 houses including some small dormitories. The population of 
both barrios is largely Filipino with a small percentage of Japan- 
ese and a few Americans. 

Dormitory H, situated at one end of Lubang barrio, is here 
considered separately, since the conditions were somewhat dif- 
ferent from those of the other houses of the barrio. The build- 
ing, except the kitchen, is screened. It is comparatively well 
shaded and is near Magbando River on one side and a seepage 
ditch on the other, neither of which showed many larvae. A 
considerable percentage of the anopheles caught in this building 
were found in the screened vestibule. On some nights this ves- 
tibule was purposely made into a mosquito trap by leaving the 



x, b, 3 Barber et al. : Malaria in the Philippines 187 

outer door open and keeping the inner door carefully closed. 
Twenty-two specimens of Anopheles rossii were caught in this 
vestibule at one time. It is worthy of note that nearly all of 
the mosquitoes caught in this vestibule were females containing 
blood, so they must have obtained their blood elsewhere and have 
been later attracted by the lights or people in the dormitory. 

Fewer visits were made to some barrios than to others, and 
the number of houses visited varies, so that Table I shows only 
approximately the frequency of anopheles in each locality, but 
the data for the proportion of the several species are more nearly 
accurate. No reliable data as to the length of flight of anopheles 
could be obtained in this region, since there was no barrio which 
did not have a possible breeding place within a few meters. The 
ground is comparatively open with few trees or underbrush to 
shelter mosquitoes or to retard their flight. 

In Table I are given data showing the amount of latent mala- 
ria found in these barrios. The presence of malaria was deter- 
mined by the percentage of parasites found in blood smears. 
No intentional selection was made of the sick in obtaining 
samples. People of all ages were examined as they could be 
obtained. An examination of all persons in each barrio could 
not well be made, and the inhabitants of the different barrios, 
with the exception of Magbando, tend to shift more or less from 
one locality to another, so no very definite correlation between 
the mosquito fauna and the amount of indigenous malaria in the 
several barrios could be expected. Of the two barrios showing 
a relatively large proportion of Anopheles febrifer, barrios "J" 
and Magbando do not show a larger percentage of indigenous 
malaria than the other localities. However, Magbando contains 
a population that has long resided in a malarious region and may 
have acquired some immunity. Among the nine negatives, the 
blood of three showed indications of anaemia, possibly resulting 
from previous attacks of malaria. Barrio "J" is a compara- 
tively new barrio, and as stated above exhibited a minor epidemic 
of malaria earlier in the season. The percentage of positive 
cases, however, was only 33.3, which is slightly below the aver- 
age of the whole population. Moreover two examinations at 
different dates were made of a part of the people of this barrio 
and all positives included in the percentage. The lower part 
of Mindoro barrio has many more breeding places than the up- 
per, and whether by coincidence or not, the lower streets showed 
a much greater amount of latent malaria than the upper. 

The proportions of sexes of the different species of anopheles 
and the proportion of females containing blood in the stomach 



188 



The Philippine Journal of Science 



1915 



are shown in Table II. All anopheles caught are included in 
this table, so that the total somewhat exceeds that of Table I, 
which includes only those of which the place of origin was known. 
The great preponderance of females and the large proportion 
of these which had taken blood are so apparent in the table 
that no further analysis is necessary. 

Table I. — Anopheles and indigenous malaria in the various barrios of San 
Jose Estate, Mindoro. Mosquitoes were caught in houses during 
May, 191b- 



Barrio. 


Houses 

(ap- 
proxi- 
mate) . 


Days on 
which 
visits 
were 
made. 


Mosquitoes caught. 


Persons exam- 
ined for mala- 
rial parasites. 


A.fe- 
brifer. 


A. ros- 
sii. 


A. bar- 
biros- 
tris. 


A. ma- 
cula- 
tus. 


Total. 


Num- 
ber. 


Posi- 
tive. 


"J" 


6-8 

2-3 
15-20 
125-150 
70-75 


11 
4 
10 
15 
12 

17 


166 
34 
20 
13 
17 

1 


34 
14 
110 
122 
69 

192 







1 






1 






200 
48 
131 
135 

87 

193 


48 
11 
16 
127 
15 


Per ct. 
33.3 
IS. 2 
66.3 

37.0 
46.7 


Magbando 

Bugsanga 




Dormitory H with 
kitchen 


Total 










251 


541 


1 


1 


794 


217 


37.3 









Table II. — Anopheles caught in houses during May, 191b, in San Jose Estate, 

Mindoro. 



Species. 



Anopheles febrifer 

Anopheles rossii 

Anopheles barbirostris 
Anopheles macutatus . 

Total 



Females. 



With 
blood. 



232 
452 

1 

1 



Emp- 
ty. 



686 



33 



Doubt- 
ful. 



Males. 



Total. 



249 
572 

1 
1 



Females 
contain- 
ing 
blood. 



Per ct. 

93.5 

87.1 

100.0 

100.0 



a 823 



9.2 



Total exceeds that of Table I, because some are included here the distribution of which 
was doubtful. 

The Iwahig penal colony, Palawan, was visited by Barber in 
June, 1914. This colony occupies a considerable territory, much 
of it comparatively flat and elevated from a few centimeters to 
7 meters above high tide. Like the San Jose Estate, most of 
the colony land has been cleared of jungle within a few years, 
and some parts of it are still being cleared. The whole region 
has long been known as very malarious. 



x, b, 3 Barber et al.: Malaria in the Philippines 189 

Owing to the proximity of a high range of mountains the 
region is well watered. A large river with numerous bayous 
flows through the colony grounds, and the region is well supplied 
with brooks of clear water. 

A large part of the land is devoted to coconut trees, but 
there are some irrigated rice fields. Larvae of Anopheles rossii, 
A. febrifer, and A. barbirostris were found in the river and in 
various brooks in the colony. 

The time at our disposal at Iwahig was too short to organize 
an effective corps of mosquito catchers, so all imagoes caught 
were obtained inside of sleeping nets. These nets, where used 
by the prisoners, were often badly adjusted, and mosquitoes could 
enter under the edges or from beneath where the sleeping mats 
failed to cover the floor or the bottoms of the bunks. The record 
of mosquitoes caught is given in Table III. Here both the 
anopheles of different species and, under the head of "Culex,"~ 
mosquitoes not anopheles are included. Dates of catches are 
given, different buildings are noted, and in one column only the 
mosquitoes caught in a certain bed are included. On certain 
mornings the bed nets were left down so as to facilitate the 
capture of mosquitoes. Each bed was occupied by only one 
person. 

The houses on the river bank are from 5 to 7 meters above 
the large river noted above in which larvae of A. febrifer, A. 
rossii, and A. barbirost?'is were found. The brigade dormitory 
is a large building separated from the houses on the river bank 
by a nearly open parade ground approximately 160 paces broad. 
A careful search, continued through several days, showed that 
there was at that time no mosquito breeding place nearer the 
brigade dormitory than the river. So the distance of flight to 
this dormitory must have been at least 170 paces. In accounting 
for the fewness of mosquitoes in the brigade dormitory, there 
must be taken into account not only the distance of flight, but 
also the fact that mosquitoes in coming from the river are 
naturally first attracted to the houses along the river bank. 
Again, the brigade dormitory is partially inclosed, and the beds 
occupy three stories. On the third floor of this building 39 nets 
at one collection yielded only 7 specimens of culex and none of 
anopheles. The beds in the houses on the river bank, on the 
other hand, were on the veranda, a little above the ground level. 

Balsahan and Esperanza are small barrios of the colony. The 
beds are in small dormitories but little above the ground level 
and only a few rods from brooks where larvae of A. febrifer 
were found. 



190 



The Philippine Journal of Science 



1916 









I 
1 



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8 
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•S> 
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13 



-si 

1 



s 



H 
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X, B, 3 



Barber et al. : Malaria in the Philippines 



191 



In proportion to the population a larger number of acute cases 
of malaria in Iwahig come from the outlying barrios than from 
the central or better improved part of the colony. This is prob- 
ably due in part to the more exposed situation of the newer 
barrios, and possibly in part to the fact that the quinine prophy- 
laxis practiced in the colony (5 grains per day to each person) 
could not be so rigorously carried out in the barrios. In order 
to give some idea of the amount and origin of acute cases of 
malaria, a record is given in Table IV of the admission of fever 
cases to the colony hospital during three days. The micro- 
scopical examinations were made by Barber. 

Table IV. — Cases of acute malaria admitted to Iwahig hospital during 
three days of June, 19 H. 



Date. 


Pa- 
tient. 


Resi- 
dence in 

the 
colony. 


Residence when taken ill. 


Microscopical findings in blood. 


1914. 
June 22— 
Do— 
Do— 
Do— 
Do— 
Do— 
Do— 
Do— 
Do- 
June 23- 
Do— 
Do— 
Do— 
Do- 
June 24— 
Do— 
Do— 

Do— 

Do— 
Do— 
Do— 
Do— 
Do— 
Do— 
Do- 


7303 
5627 
8123 
9080 
8184 
7734 
2976 
6851 
8845 
8398 
8811 
7077 
8701 
5455 
8597 
8657 
8611 

8784 

9016 
8150 
5906 
6840 
6184 
8891 
8567 


Yrs. mos. 
9 
7 
6 
4 
1 
4 
5 
1 
1 
1 
1 
1 
2 
1 
1 
4 
6 

1 

2 

3 

S 

6 
5 

4 
1 




Tertian +. 
Tertian, rare. 

Anasmia, parasites doubtful. 
Negative. 

iEstivo-autumnal ++. 
Tertian, few. 
^stivo-autumnal +. 
iEstivo-autumnal, few. 

Do. 
^stivo-autumnal, rare. 
Tertian +. 
Tertian, rare. 
iEstivo-autumnal, rare. 
Negative. 

jEstivo-autumnal +. 
Tertian +. 
^3stivo-autumnal with crescents, 

rare. 
^Estivo-autumnal rings, rare, cres- 
cents +. 

Do. 
i^Estivo-autumnal, rare. 
Negative hemoglobinuria. 
iEstivo-autumnal, rare. 
iEstivo-autumnal +. 
Tertian, rare. 
.SDstivo-autumnal +. 


do 


do 


Central — 

do 


do 


do 




do 
















do 




do- — 




do 




do 


do 


do— — 





Examined 
Parasites found 
Cases from barrios 
Cases from Central 
Average admissions per day 



SUMMARY OF TABLE IV. 



25 

21 = 84 per cent. 
15 = 60 per cent. 
10 = 40 per cent. 
8.3 



192 The Philippine Journal of Science 1915 

According to the resident physician, Dr. Jose Marfori, the 
admissions during this period somewhat exceeded the average. 
It is impossible to state what portion of these 25 cases are re- 
currences. But all prisoners had spent at least two years in 
Bilibid Prison at Manila before coming to Iwahig. We have 
received the following information from the Bureau of Health: 

Malaria is infrequent among prisoners who have been in Bilibid for 
two years or more. Occasionally malaria develops, apparently from latent 
infection, after operation. During the month of December, 9 tubercular 
patients were returned from Iwahig, among whom 4 were found with the 
enlarged spleens and blood positive for malarial organisms. 

So it is likely that malaria in a large proportion of the cases 
mentioned in Table IV was contracted in Iwahig. 

With regard to the amount of latent malaria at Iwahig we 
have data of 62 men of the central brigade dormitory, the 
occupants of which are probably somewhat less exposed to in- 
fection than the average population. Only men apparently 
healthy were examined. Of the 62, 8, or 12.9 per cent, harbored 
malaria parasites. Of the 8 positives the length of residence in 
the colony was as follows : Three months, 1 person ; eight months, 
1 ; nine months, 1 ; eleven months, 2 ; one year, 1 ; three years, 2. 

A noteworthy deduction from the data obtained at Iwahig is 
the large proportion of A. febrifer as compared with other species 
of anopheles, and the large number of A. febrifer found in houses 
in proportion to the number of larvae found in the neighboring 
breeding places. Further, it seems to be demonstrated that the 
flight of this species is at least 170 paces, although comparatively 
few got so far. 

The data from both Iwahig and San Jose, Mindoro, demonstrate 
that Anopheles febrifer, like A. rossii, is a house-seeking species 
and readily takes blood from human beings. In both San Jose 
and Iwahig A. barbirostris was found in dwellings, and the fact 
that specimens of A. barbirostris containing blood were found 
in sleeping nets at Iwahig proves that this species will enter 
houses and bite human beings. In India A. barbirostris has 
been generally considered a "wild" species, little disposed to visit 
houses. 8 When we compare the small number of this species 
found in nets in Iwahig with the number of larvae found breeding 
in the vicinity, it seems probable that in the Philippines, also, this 
species has a less tendency to visit houses than either A. febrifer 
or A. rossii. Only one specimen of A. maculatus was found in 

' Stephens and Christophers, The practical study of malaria, etc. The 
University Press of Liverpool (1908), 169, 181. 



x, b, 3 Barber et al. : Malaria in the Philippines 193 

houses (Bugsanga barrio, San Jose) , but the larvae of this species 
were so few in that locality that no trustworthy deductions can 
be made. 

Some definite data regarding the lurking places of anopheles, 
other than houses, were obtained at San Jose, Mindoro, by a 
study of A. febrifer. A clear brook flowing through woods near 
Magbando barrio contained numerous larvae of A. febrifer, but 
comparatively few of any other species of mosquito. A search 
was made for hiding imagoes in the numerous crab holes and 
in the matted tree roots along this brook. Smoke was blown 
through a tube into these holes and roots, and the mosquitoes, 
on being driven out, were caught in a large glass funnel having 
the neck plugged with cotton. The bottom of the funnel was 
quickly covered with a large piece of pasteboard, and the mos- 
quitoes, stupefied by means of tobacco smoke, were blown into the 
neck of the funnel. They could then readily be removed to vials.- 
Numerous specimens of culex were found in these lurking places, 
but only 2 of A. febrifer, although the larvae of the former were 
few and of the latter many. Both specimens of A. febrifer were 
females. One was caught in a crab hole but half a meter from 
a much frequented spring. The other, caught in matted roots, 
contained about 70 nearly mature ova. No malarial parasites 
were found in either on dissection. Magbando barrio (see 
Table I), where 34 specimens of A. febrifer were caught in 
houses, is located only a few rods from the bank where the 2 speci- 
mens of A. febrifer were caught in the crab hole and in roots. 

A careful search for mosquito imagoes was made in Bioos, 
Negros Island, along the banks of a jungly brook, which con- 
tained very numerous larvae of A. febrifer. Banks deeply cov- 
ered by overhanging vegetation, crab holes, hollow logs, and 
vegetation of various sorts were "smoked," but very few mos- 
quitoes of any kind were found and none that could be identified 
as anopheles. Other species of anopheles, A. rossii and A. barbi- 
rostris, were breeding in this brook. Dwellings and the shelters 
of sheep, horses, and pigs located near the brook were searched 
at daylight and at various times during the day with negative 
results. No signs were observed of anopheles flying at daylight 
to or from the brook or buildings. At that time only a moderate 
amount of malaria existed among the people living on the coconut 
plantation bordering this brook, but it is said to have been much 
more prevalent there before the jungle was cleared away. 

Enemies of mosquitoes — myriads of ants and many spider 
webs — were abundant along the banks of this brook. However, 
in view of the multitudinous lurking places which a jungle offers, 

133057 2 



194 The Philippine Journal of Science ms 

it is very easy to overlook mosquitoes when they are concealed 
in the daytime, and it is possible that a large proportion of the 
stronger larvae emerged and reached safety. 

Similar negative results were obtained in a comparatively 
short search for mature anopheles in Magdalena, Laguna Prov- 
ince, where A. febrifer larvse were plentiful and malaria very 
prevalent. 

It is possible that certain meteorological conditions favor 
the dispersal of this species of anopheles as well as that of other 
species. In Mindoro, where many anopheles imagoes were found, 
the weather was hot with frequent afternoon showers. At 
Iwahig, where many mature A. febrifer were caught, the tem- 
perature was comparatively low for the tropics and the humidity 
great. At Negros, where negative results were obtained, the 
weather was hot with occasional showers, not unlike that of 
Mindoro at the time of our visit there. At Magdalena it was 
hot and dry. However, the facilities for obtaining mature 
anopheles were much better at Mindoro and Iwahig than at the 
other localities examined, and it is probable that a search con- 
tinued over some time and during a variety of meteorological 
conditions would reveal the lurking places of any anopheles in a 
locality where their larvse are found in any number. 

In the Philippines, as well as in other places where observa- 
tions have been made, anopheles usually remain hidden during 
the daytime. During many days of work in shady woods and 
canons we have observed anopheles flying by day on only one 
occasion, when a specimen of A. barbirostris settled on the hand 
at noontime on a cloudy day in a narrow canon. The mosquito 
filled its stomach with blood and expelled a drop from the anus. 
The specimen was caught and taken to the laboratory for dis- 
section and identification. 

Owing to a lack of time a comparatively small proportion of 
the mature anopheles caught at Mindoro and Iwahig were dis- 
sected and examined for malarial parasites. Moreover the 
relative' infectivity for malarial parasites had already been de- 
termined for all the species obtained in these places. All 
dissections that were made were negative. In Mindoro, where 
mosquitoes were caught in houses almost daily, the chances of 
finding an infected one were probably small. In some Panama 
barracks, where a daily routine of catching anopheles was prac- 
ticed, Darling' reports that only one naturally infected mosquito 
was found in about 500 dissected. 

' Proc. Canal Zone Med. Assoc. (April, 1909. to March, 1910). 



x, b, 3 Barber et al. : Malaria in the Philippines 195 

DISTRIBUTION OF MALARIA IN VARIOUS PROVINCES, 
TOWNS, AND BARRIOS 

In determining the malarial index of a locality, both the para- 
site and the spleen indexes were taken, in a large proportion of 
cases by the examination of school children, the majority of 
whom were from 5 to 10 years of age. No intentional selection 
of well or sick children was made. The examinations were made 
during school hours of children in attendance on that day. The 
examination of school children entails two disadvantages. First, 
the children who are seriously ill are less likely to be in at- 
tendance, so there was some selection of those less likely to be 
malarious. However, as numerous cases showed, children often 
return to school very soon after their illness, and since com- 
paratively little systematic quinine treatment is practiced in 
Filipino towns, children recently recovered from malaria are 
likely to show parasites. Therefore the error through selection" 
of the well is not great. Secondly, the parasite rate is usually 
higher in children from 1 to 5 years of age than in older children 
(see Magdalena, Table VI), and since few children below 5 
years of age attend school, our percentage would be somewhat 
lower than for all young children. Neither source of error, how- 
ever, affects the value of our statistics in the comparison of 
different localities. Moreover it is improbable that any con- 
siderable amount of indigenous malaria can exist in a locality 
without some cases appearing among children from 6 to 10 
years of age. Since our aim was primarily to ascertain the 
distribution of malaria, the advantage of quickly obtaining 
specimens from a large number of children in schools would out- 
weigh the disadvantages of this method. 

In some cases examinations were made of children, taken in 
part at least, out of school or of older persons. These cases are 
indicated in the tables. 

Blood for examination for parasites was taken from the ear, 
and as a rule, but one slide was taken of each person at a 
visit. A thick smear and a thin smear were made on the same 
slide. The blood was dried in the air, then the slide was care- 
fully wrapped in a piece of paper on which were recorded the 
data of the case: namely, name of person, age, sex, result of 
spleen examination, and history of recent illness. The wrapped 
slides were closely fitted into pasteboard boxes, and the boxes 
were inclosed in paper and sent as quickly as possible to the 
laboratory. These precautions were taken in order to minimize 
dangers from moisture or overdrying, according to the season, 



196 The Philippine Journal of Science 1915 

and to protect the preparations against cockroaches or ants, 
which will eat the blood on exposed slides. As a rule, the 
slides reached the laboratory in time to be stained within three 
days after collection. 

At the laboratory the slides were labeled and stained, the 
data on the slips and the results of the examination were entered 
in a book, so that it was possible to compare the results obtained 
from a given individual with those made at a later examination. 
The names of children positive for malarial parasites were re- 
ported to the principal of schools in order that treatment might 
be given these cases. In staining, the thin portion of the slide 
was fixed in methyl alcohol and dried. Then, with no fixing 
or other treatment of the thick smear, the slide was immersed 
for about one hour in staining jars containing Giemsa-Ro- 
manowski stain 1 part to 40 parts of water. The stained pre- 
parations were rinsed in distilled water, dried, and examined 
under the oil immersion without a cover glass. 

In determining the presence of parasites, we depended largely 
on the thick film, although the thin was used where comparison 
or confirmatory evidence was needed. The examinations were 
nearly all made by Barber and Guzman, both of whom had had 
a long previous training in examining thin smears for malaria 
in the tropics and in comparing the appearance of parasites in 
the thick smears with that in the thin smears. 

In most of our preparations the haemoglobin was well laked 
out by the watery stain and the parasites stood out clearly against 
the bluish or purplish background between the leucocytes. As 
a rule, both the cytoplasm and the chromatin of the parasites 
stained fully as well in the thick as in the corresponding thin 
smear, or even better. We found that much depends on the char- 
acter of the water used in diluting the stain. Spring or tap 
water laked out the blood well, but the parasites sometimes failed 
to take a good stain. Distilled water without the addition of 
some alkali often stained the background too red. We got our 
best results with rain water or a mixture of rain water with 
distilled water. Bacteria in water, especially from the bottom 
of a container, sometimes occur in numbers sufficient to obscure 
the background, and sometimes animalcules breed in water which 
might possibly be confused with some blood parasites. To avoid 
these we usually autoclaved the fresh or comparatively bacteria- 
free rain or distilled water and kept it in bottles ready for use. 
Chromatin granules, or red chromatinlike granules, not associated 
with the blue cytoplasm were never counted as parasites. 

The thick-film method in the examination of blood for parasites, 



x, b, 3 Barber et al.: Malaria in the Philippines 197 

which was introduced by Ross 8 and employed by Koch 9 in the 
examination for trypanosomes, has found favor with many in- 
vestigators of malaria. It was modified by Ruge 10 and employed 
by Dempwolf. 11 

Dempwolf reports on malaria examinations in Daressalam, in 
which examinations by the thick and the thin smears are com- 
pared. Summarizing all cases, which include children and 
adults, quinine treated and untreated, and various nationalities, 
9,758 examinations by the thin-smear method gave 8.5 per 
cent positive, while 5,770 examinations by the thick-film 
method gave 25.7 per cent positive. In this method the unfixed 
thick film was dried for from two to twenty-four hours, then 
a mixture of 2 drops of Giemsa stain to 2 cubic centimeters of 
water was poured on the slide and allowed to remain for from 
fifteen to twenty minutes. The slide was then rinsed and dried. 
The author recommends the thick-film method for the exam- 
ination for blood parasites where large numbers of persons must 
be examined. 

James 12 made use of the thick-film method. He first laked 
out the hsemoglobin in ethyl alcohol plus a small percentage of 
hydrochloric acid (10 drops of commercial hydrochloric acid 
to 50 cubic centimeters of alcohol) fixed to the slide, washed 
the slide for from ten to fifteen minutes in running tap water, 
dried it in the air, and then stained with any good modification 
of the Romanowski method, such as Hastings's, Wright's, or 
Leishman's. The stain in liberal quantity was put on the slide, 
allowed to remain two or three minutes to fix, then diluted with 
all the distilled water that the slide would hold. After a few 
minutes he diluted again and after five minutes often made a 
further dilution. The stained slide was washed in tap water. In 
100 cases of malaria in the Canal Zone he obtained 94 per cent 
positive by the thick-film method where the thin-film method of 
the same cases gave only 60 per cent positive. The time of 
examination was limited to five minutes for the thick films from 
each* patient. By the thick-film method he was able to demon- 
strate parasites in quinine-treated cases, on the average, three 
days after the beginning of the treatment, even in latent or 
scanty infections. 

8 Rept. Thompson Yates Lab. (1903), 5, part I. 
"Deutsch. Med. Wochenschr. (1907), 1889. 
" Malariakrankheiten, 2 Aufl. (1906), 290. 

11 Arch. f. Schiffs- u. Tropenhyg. (1908), 12, 435. 

12 Proc. Canal Zone Med. Assoc. (April to September, 1911), 4, pt. I, 49. 



198 The Philippine Journal of Science mo 

Muehlens, 13 in an investigation of malaria in Emden, Germany, 
used the thick-film dried and stained unfixed in Giemsa's stain in 
the usual dilution. He compared the thick- and thin-film method 
by examining for the same period of time (at first ten then five 
minutes) thick and thin preparations from each person. He 
found both thick and thin positive one hundred thirty-one times ; 
and the thick positive, but the corresponding thin negative, one 
hundred two times. 

Masterman 14 successfully used the thick-film method in the 
investigation of latent malaria in Palestine. He used the method 
of Muehlens. 

In our own work, dealing largely with latent malaria in which 
the parasites are often very few, we have found the thick-film 
method invaluable. In many preparations a parasite will be 
found only after many fields of the thick film have been searched, 
and in a comparatively small percentage of our cases only a 
single ring, Plasmodium, or crescent could be found in the entire 
preparation. When a parasite was found in these scanty in- 
fections, we made it a rule to search for other parasites for 
confirmation unless the character of the first one found also 
was beyond doubt. Doubtful parasites are sometimes found in 
thin preparations as well as thick, and the thick offers the 
advantage of giving a better chance of finding a second parasite 
for confirmation. 

In some preparations a part of the red corpuscles containing 
malarial parasites failed to lake out and stood out conspicuously 
against the background, so that they could readily be found and 
their species determined. This behavior of the parasitized cor- 
puscle, by no means constant, was noted in both tertian and 
sestivo-autumnal infections. 

A matter of much importance in the examination of blood 
smears for malarial parasites is the time necessary to give to 
the examination of a preparation before declaring it negative. 
In our work, where thousands of preparations had to be ex- 
amined by only two persons, a saving of time and eye strain was 
of vital importance. 

In all the preparations from three towns, and in the greater 
part of those from a fourth, we carefully noted the time given 
to examination before a preparation was declared negative, and 
we also noted the time required to find the first parasite in the 



"Beih. z. Arch. f. Schiffs- u. Tropenhyg. (1912), 16, 46. 
"Jouni. Hyg. (1913), 13, 49. 



X, B, 3 



Barber et ah: Malaria in the Philippines 



199 



positives. A large proportion of positives from these towns 
were latent cases, and the number of parasites found per slide 
was small. Of the total 75 positives only 4 preparations showed 
as many as 1 parasite per leucocyte. The time given to exam- 
inations in these towns is shown in Table V. 

Table V. — Time devoted to examination of preparations from Mabitac, 
Santa Maria, Lucena, Tayabas, and the greater part of those of Sini- 
loan. Thick films. 



Negative. 


Positive. 


Time examined before the preparation 
was declared negative. 


Slides 

exam- 
ined 
of 

which 
time 
was 

taken. 


Time required to find the first parasite. 


Slides 

exam- 
ined 
of 

which 
time 
was 

taken. 




9 

23 

236 

48 

73 

24 

19 

8 

9 

1 

4 

1 

4 

1 

1 

2 




13 . 

4 

8 
13 

6 
10 

3 

6 

2 

3 

3 

1 

1 

1 

1 






















7 minutes _ 




7.25 to 7.75 minutes 




8 minutes. 




8.25 to 8.75 minutes ... .. 












10 minutes 




10.5 minutes 




13 minutes _ . 








Total 


Total 




463 


75 





Summary of Table V. 



Time required for 463 negative slides 
Average time per negative slide 
Total number of negatives and positives 
Percentage of positives 



2,588 minutes. 
5.6 minutes. 



13.9 



There were 588 preparations of which the time was taken. 
Seventy-five, or 13.9 per cent, were positive, and the average 
time of examination of negatives was 5.6 minutes. This may 
be slightly in excess of the average time in all our examinations, 
but had the time of examination for the series in Table V been 
limited to four minutes, we would still have had 13.1 per cent 
positive. If it had been limited to even three minutes, we would 
have had 11.7 per cent positive. So it is evident that the per- 
centage of error is small for the time we actually devoted to 
examination in our series. It must, also, be taken into consid- 



200 The Philippine Journal of Science i9i« 

eration that positives often show something suspicious (baso- 
philic erythrocytes, granules of chromatin, or the like), so that 
the search for parasites in such slides is prolonged beyond the 
average time. In the course of antimalarial work it might be 
necessary to make a malarial survey in the shortest possible 
time. In such a case an experienced worker might limit the 
time devoted to each thick film to three minutes or less and 
obtain results sufficiently accurate for practical purposes. The 
thick films were so spread as to present thicker and thinner 
areas, and both sorts were included in the search. 

Nearly all of the spleen examinations were made by Raquel 
and Guzman, but those of the third examination of Magdalena, 
those of Cagayan Province, and a few others were made by Rosa. 
While as a routine the blood specimens were taken at the same 
time that the spleen examination was made, our records for 
some localities show more spleen examinations than blood ex- 
aminations. In most cases this is due to the fact that the slides 
were unfit for examination, usually because we were unable to 
get at them before the haemoglobin had become too dry to lake 
out well. Many of the cases occurred during our absence in 
Mindoro and when the weather was hot and dry. 

The general result of the malarial survey is given by provinces 
in Table VI, together with some notes on the anopheles survey 
of each locality. Nearly all of the mosquito surveys were done 
by Barber. A large proportion of the localities were visited, 
but it was impracticable to visit all of them in the time at our 
disposal. Some of them, as those in Cagayan Province, would 
require a journey of about three weeks. 

In choosing localities for survey we aimed, first, to include 
localities of various topographical types as far as possible rep- 
resentative of the main centers of population of the Archi- 
pelago ; secondly, to survey some localities known to be malarious 
in order to determine why and to what extent the disease is 
prevalent in them. In the Philippines nearly all the population 
is found in towns or villages ; few people live in scattered houses ; 
so the indexes of towns fairly represent that of the whole popu- 
lation. Where the word "town" is used in this paper it has 
reference to the center of population, and does not include the 
surrounding country. In the case of school children the sur- 
rounding country is in a measure represented by children 
temporarily residing in the town. All dates are 1914 unless 
otherwise stated. 



X, B,3 



Barber et al.: Malaria in the Philippines 



201 



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Barber et al.: Malaria in the Philippines 



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218 



The Philippine Journal of Science 
Summary of Table VI. 



1915 





Age. 


Exami- 
nations. 


Parasites posi- 
tive. 

Num- Per 
ber. cent. 


Spleen positive. | 

Num- Per 
ber. cent. 


All ages: 

Both spleen and parasites 




4,360 








Spleen only . 




1,844 

795 








Parasites only. _ _ 




1 






Total 








6,999 
5,155 






Total examinations for para- 
sites. 

Persons examined, all ages (deduct- 
ing for localities surveyed twice 
or three times), estimated: 












3,928 


1 






1,598 
725 








1 


Total 









6,251 
4,653 


• 


Total persons examined for 
parasites. 

Children only, parasites 

Total 










i 


4.051 466 11.fi 


1 


I under. 

Ill to 15 years 695 


115 j 16.6 










4,746 


681 i 14.3 








1 




5.046 




755 | 15.0 ' 


Children only, spleen _. J un( j er 

111 to 15 years 855 


1 


125 14.6 


Total 








5,901 




880 14.9 






1 --- 






3. 545 


366 


10.3 
15.0 




locality included, thus eliminating \ under. 










Total ' 


4,113 ' 451 ! 11.0 




| 




Children only, one survey of each [10 years and 
locality included, thus eliminating s under, 
all duplicate examinations. Ill to 15 vears 


4,646 1 613 13.2 

780 ' 113 14.5 


Total ! 


5,426 




726 1 13.3 








1 







In summarizing the data given in Table VI, we find a parasite 
index of 11 where only one survey of each locality is included 
and a spleen index of 13.3. These rates are very probably higher 
than for children generally in the Philippines, since so many 
malarious localities were included in our survey. If we omit 
only one town, Magdalena, from the list, the parasite index drops 
to 6.8. The spleen index in a general way runs parallel to the 
parasite index, both in the aggregate and in the separate local- 



x, b, 3 Barber et al. : Malaria in the Philippines 219 

ities, although in most cases the spleen index is higher. If we 
make a list which includes only children of whom both blood 
and spleen were examined, and which includes only one exam- 
ination of each locality, we have: Examined, 3,686; positive for 
parasites, 278 or 7.5 per cent; spleen enlarged, 458 or 12.4 per 
cent. These figures best represent the ratios between the two 
indexes. In nearly all towns where some positives for parasites 
were found the spleen index was higher than the parasite index, 
and many towns show a positive spleen index where the parasite 
index is 0. 

In 314 cases positive for malarial parasites and of whom spleen 
examinations were also made, 164, or 51.4 per cent, showed an 
enlarged spleen. Of approximately 569 cases presenting enlarged 
spleens of whom the blood was examined, 164, or 28.8 per cent, 
were positive for parasites. It is well known that cases ex- 
hibiting splenomegaly, known to be the result of malaria, often 
fail to show parasites in the blood. 

The percentage of parasite-positive cases among spleen-neg- 
atives is of comparatively little significance in our series of 
examinations taken as a whole, since our list includes so large 
a number of nonmalarious localities. If we include only com- 
munities in which at least one parasite-positive was found, we 
have what is probably a fairer estimate. In these communities 
approximately 1,883 spleen-negative cases were found of which 
144, or 7.7 per cent, were parasite-positive. Only children are 
included and only those of whom both spleen and blood exam- 
inations were made. 

The important question comes up as to whether a spleen index 
of considerable magnitude indicates a present or recent preva- 
lence of malaria in a locality. 

Ross, Christophers, and Perry 15 have recently expressed the 
belief that the spleen rate is the "most readily and extensively 
applicable, and at the same time the most reliable measure of the 
amount of malaria in a community" with a serious qualification 
in the fact "that other diseases than malaria, very notably kala- 
azar, produce splenic enlargement and may, to an unknown 
extent, modify or even seriously interfere with the value of the 
figures obtained." These authors examined 469 children of 
London and found only about 1 per cent with enlarged spleens. 
Only about 1 per cent of cases were found in which the question 
of enlargement was doubtful. They conclude that with the 

ls Proc. Third All-India Sanitary Conf. Lucknow. Jan. 19-27, 1914: 
Supplement to Ind. Journ. Med. Res. (1914), 4, 15. 



220 The Philippine Journal of Science 1915 

ordinary palpation as practiced in the field there is small likeli- 
hood of serious error. 

Gill 16 believes that the parasite rate is of less value than the 
spleen rate in the measurement of the malaria rate in a com- 
munity. The number of parasites in the blood may be so small 
as to be overlooked, they may be reduced by the use of quinine, 
and the parasite rate varies greatly at different seasons of the 
year. In northern India he found that benign infections reach 
their maximum in June, and the subtertian in the autumn. 
However, while believing that in northern India no definite 
relationship can be expected to exist between spleen and parasite 
rates, he found that where the spleen rate is high the parasite 
rate also tends to be high. 

In the Philippines, where there is much less seasonal change 
than in northern India, we would expect less seasonal variation 
in the parasite rate. We have found some variation in the para- 
site rate of towns examined at different times in the same year 
(Table VI, Nos. 2, 7, 8, 9, 10, 12, 14, 15, 16, and 51), but only 
one town, Lilio (Table VI, No. 9), showed a negative parasite 
rate at one examination and a very considerable rate, 14, at 
another, and in this town the slides were not in perfect condition 
at the first examination. Many of the towns we examined 
showed a spleen index of 0, although these towns, while not 
in a malarious region, were in no way protected from other 
diseases which might cause enlargement of the spleen. Some 
towns which show a parasite index very low, even 0, with a 
high spleen index are in localities where malaria would be 
expected, as Suliaw and Bolhoon. 

While a larger series than ours may be needed to solve this 
question, we believe that a spleen rate over 10 indicates present 
or past malaria in the most, if not all, the communities of the 
Philippines. However, we would not recommend that the ma- 
larial survey of a locality should rest on the spleen examination 
alone. 

The amount of enlargement of the spleen was measured in 
most towns studied. Of 639 examinations where the degree of 
enlargement of the spleen was reckoned, 336, or 52.6 per cent, 
were classed as simple palpable; 8, or 1.3 per cent, as 1 centi- 
meter below the costal border ; 105, or 16.4 per cent, as 2 centi- 
meters below; 125, or 19.6 per cent, as 3 centimeters below; 22. 
or 3.4 per cent, as 4 centimeters below, and 43, or 6.7 per cent, 
as at or below the umbilicus. 

'"Ibid., 18. 



x, b, 3 Barber et al.: Malaria in the Philippines 221 

Both parasite and spleen indexes of children from 11 to 15 
years of age are higher than those of children from 5 to 10 years 
of age. Possibly if a larger proportion of older children had 
been included, we would have obtained a different ratio. Again, 
a very small proportion of children 5 years of age or younger are 
included. If all children from 1 to 10 years of age had been 
included, the parasite rate for the younger group probably would 
have been higher. In the third examination of Magdalena (see 
Table VI, No. 10) several groups of ages were considered sepa- 
rately. Here we find the highest rate, 69.9 per cent, among 
children from 1 to 5 years of age. 

As a rule, the number of parasites found in positive cases was 
small, as might be expected in latent malaria. The percentage 
of positives in which the parasites were approximately as numer- 
ous as or exceeded the number of leucocytes is given in Table 
VI. This gives a rough index of the proportion of more acute 
cases occurring in a locality. An approximate estimate of the 
number of parasites was recorded for nearly all positives. For 
children of 15 years of age and under they are as follows : Only 
one parasite found after considerable search, 36 cases, or 6.3 
per cent; those marked "rare" (about 1 parasite to 10 or 15 
fields) , 244, or 42.9 per cent; "few" (about 1 parasite to 5 fields) , 
109, or 19.2 per cent; "+" (1 or more per field), 122, or 21.4 
per cent; "++" (1 or more per leucocyte), 58, or 10.2 per cent. 
All estimates, of course, are only approximate. 

As to the type of parasite, quartan occurred more frequently 
in these latent cases of children than has been our experience 
in acute cases of adults examined in the tropics. In 272 positives 
obtained by Walker and Barber in the examination of thin 
smears from acute cases at Canlubang, 54.4 per cent were sub- 
tertian, 41.5 per cent tertian, and only 4.1 per cent quartan. 

A frequent finding in the latent cases among children was a 
very few sporulating quartan. It is sometimes difficult to de- 
termine the species of parasite when only a very few can be found 
in the thick smear. Where plentiful enough they may be found 
in the thin smear and the identification confirmed. The error is 
probable in the direction of increase of subtertian at the expense 
of the other types, where only very scanty numbers of young 
rings can be found. 

Including only persons of 15 years of age and under, results 
were as follows : Subtertian, 291, or 49.6 per cent ; tertian, 185, 
or 31.6 per cent; quartan, 108, or 18.4 per cent; mixed, 4, or 
0.3 per cent. Long search through all preparations would un- 
doubtedly increase the percentage of mixed infections. 



222 The Philippine Journal of Science 1915 

As a rule, where considerable numbers of parasites were 
found, more than one stage of development occurred. This is 
what would be expected in latent cases, the majority of whom 
had undoubtedly been infected a long time. 

Of 641 positives of 15 years of age or under, 376, or 58.7 
per cent, were males and 265, or 41.3 per cent, were females. 
The town of Magdalena, third examination, gave of 194 males 
104, or 53.7 per cent, positive and of 177 females 92, or 52.0 
per cent, positive. Examinations of 23 localities including Mag- 
dalena gave: Males, 1,360 ; positive 194, or 14.3 per cent; females, 
991 ; positive, 173, or 17.5 per cent. 

While a single survey can give approximately the percentage 
of persons harboring parasites at any one time, repeated exam- 
inations would be necessary to show the number parasitized at 
some time during childhood, or even during a single year. In 
the town of Magdalena three surveys were made; the first, 
March 28; the second, July 22; and the third in late October 
and early November. About four months intervened between 
the first and the second and about three months between the 
second and the third. A record was kept of the name of each 
person examined. Fifty-eight children came for all three exam- 
inations. An analysis of the results of these 58 cases may be 
of interest (Table VII). 

Table VII. — Children of Magdalena examined on three separate occasions. 



Number. Per cent 



Positive at all 3 examinations ..! 4 6.9 

Positive at 2 examinations, negative atl IT 29.3 

Positive at 1 examination, neeative at 2 j 21 ; 36.2 

Negative at all 3 examinations _' 16 27.6 



Total ! 58 100.0 



Positive at first examination 9 15.5 

Positive at second examination 35 60.3 

Positive at third examination 24 41.4 

Positive at at least 1 examination 1 12 72.4 



The highest percentage, 60.3, obtained at the second examina- 
tion was brought up to 72.4 by the additional positives obtained 
at the other examinations. It is probable that repeated exam- 
inations of the children of this town during two years would 
give nearly 100 per cent of positives, and that few of the children 
of this town escape malaria at some time during childhood. 
None of the 58 of this group were under 6 years of age. A 



X, B, 3 



Barber et al. : Malaria in the Philippines 



223 



similar test of children of 5 years of age or under would prob- 
ably give higher percentages of positives (Table VI, No. 10, 
Magdalena) . 

The "ditch" or "canal" towns have a peculiar interest on 
account of their topography and may well be considered apart. 
Water, which is usually obtained from a neighboring brook or 
river, is brought into one of these towns by a large ditch or canal. 
In the town many laterals carry the water to various streets, 
where it is available for laundry or culinary purposes, and 
smaller laterals carry it between and under houses for the pur- 
pose of carrying away sewage. The water is usually clear, and 
may flow swiftly or quietly through the ditches, depending on 
the nature of the town site. Small dams are frequently made 
in order to obtain a convenient source of water for laundry or 
other purposes. The ditches are sometimes walled, usually with 
loose stones, but often have only the natural clay sides. Grass 
frequently grows at the margin, and various refuse finds its way 
into the water. As numerous examinations have shown, these 
ditches are excellent breeding places for Anopheles febrifer. We 
have found this species abundantly at the grassy margins of 
the ditches and occasionally in crannies of the walled sides. 
Few other mosquitoes have been found in these ditches. Fre- 
quently where the water is very swift in the street ditches small 
laterals, often immediately under the houses, furnish favorable 
breeding places. 

For convenience the "ditch" towns are taken from Table VI 
and given in a separate table with additional data (Table VIII). 

Table VIII. — "Ditch" or "canal" towns. 



No. 

in 

Table 

VI. 


Name. 


General surroundings. 


Ditches. 


Other breeding 
places. 


2 


Calamba 


Level plain; irrigated 


One main; several laterals; 


River, side of 






rice country. 


flow comparatively slug- 
gish. Water from rice 
paddies. 


town. 


9 














mountains. 


mostly swift, but some 
quiet places. 


town. 


10 


Magdalena 


Plain; coconut-palm 


Very many laterals; clear 


Brooks, one on 






region. 


water; flow compara- 
tively slow. Much veg- 
etation. 


either side of 
town. Pools 
near market. 


15 














tains; elevation, 275 


flow swift ' with some 


near town. 






meters. 


quiet places. Some 
vegetation. 





224 The Philippine Journal of Science 

Table VIII. — "Ditch" or "canal" towns — Continued. 



1915 



No. 



Table 
VI. 



Name. 



General surroundings. 



Ditches. 



Other breeding 
places. 



49 



50 



Nagcarlan 

Lucban . . . 
Tayabas _ . 

Sariaya ... 



Hilly 



Mountain; elevation, 

425 meters. 
Hilly 



Hilly; elevation, 
meters. 



195 



Many laterals; clear water; 
flow swift with quieter 
places. Some vegetation. 

Many laterals; clear water; 
swift. Little vegetation. 

Many laterals; clear water; 
mostly swift, but with 
quiet places. Some 
vegetation. 

Not many laterals; mostly 
swift. Some refuse veg- 
etation. 



Brook 
town. 



Brook in town. 



Brook 
town. 



No. 



Table 
VI. 



Anopheles survey. 



Malarial survey. 



Date. 



Exam- 
ined. 



Percentage posi- 
tive. 



Parasite. Spleen. 



A. rossii in ditch. A. rossii and A. bar- 
birostris numerous in river. 

A. febrifer in crevices of walls of ditches, 
also elsewhere in ditches and in brook. 

A. febrifer numerous in ditches, also in 
brooks. A. sinensis (?) in ditch. A. ros- 
sii in pools. 

A. febrifer in ditches and numerous in 
brook. 

A. febrifer in ditches and in brook 

A. febrifer in brook. None found in 
ditches. January 7, 1915. 

A. febrifer in ditches 

A. febrifer in ditch in alley 



| Mar. 18,1914 
[Aug. 6, 1914 
[Apr. 30,1914 
Aug. 19, 1914 

[ do 

Mar. 28, 1914 
July 22, 1914 
Oct.-Nov., 1914 

1 do 

Mar. 31.1914 
Aug. 18, 1914 

do 

Apr. 29, 1914 
Aug. 20, 1914 

do 

Dec. 11, 1914 



Dec. 
Jan. 



10, 1914 
8, 1915 



52 
116 

54 j 

50 j 
120 
137 | 
128 j 
371 ! 
292 [ 

49 

51 
118 

53 

52 I 
112 I 
112 

110 
29 



0.0 

0.0 

"0.0 

14.0 



0.0 
0.0 
7.4 





1.7 


19.0 


57.8 
52.6 


39.1 




70.9 


8.2 


35.3 






40.7 
9.4 


11.5 
28.9 




S.9 



3.6 



29.1 
4.4 



14.4 



32.7 
51.7 



* Slides not in best condition for examination. 

The parasite index of all these towns is relatively high with 
the exception of Calamba, Lucban, and Sariaya. Calamba af- 
fords a case of especial interest. One long ditch runs through 
the main street of the town, and a few laterals extend from it. 
Quiet places suitable for the breeding of Anopheles febrifer are 
plentiful, but the water in the ditch comes from rice paddies 
and is comparatively warm and foul. A long search for larva? 



x, b, 3 Barber et al. : Malaria in the Philippines 225 

of anopheles in this ditch yielded only a few specimens of A. 
rossii. The parasite and spleen indexes of Calamba were 0. 

Lucban and Sariaya show rather low parasite indexes and 
somewhat higher spleen rates. Each town has many ditches 
containing clear flowing water, which in the case of Lucban, 
especially, are plentiful throughout the streets. Both towns 
are hilly, and the water runs swiftly in most parts of the 
ditches, but there are many possible breeding places for ano- 
pheles. In the survey made of these towns January 7 and 8, 
1915, a few larvae of A. febrifer were found in a ditch in a 
street of Sariaya, but considerable search failed to disclose any 
in the ditches of Lucban, although a few were found in a brook 
flowing through the town. Possibly the season of the year may 
in part account for the fewness of anopheles and the low para- 
site rate of these towns. Both towns are in a mountain region 
and rather high (Sariaya, 195 meters above the sea and Lucban, - 
425 meters), and the climate is comparatively cool. We were 
informed at Lucban that the worst fever months there are May, 
June, and July. We do not have sufficient data to indicate 
whether mountain towns of moderate elevations have malarial 
rates much different from towns of lower elevations. Antipolo 
(Table VI, No. 25), with an elevation of from 180 to 190 me- 
ters above the sea, shows a lower rate than would be expected 
taking into consideration the number of brooks flowing through 
the town and the number of A. febrifer and of A. maculatus 
breeding in them. On the other hand, Majayjay, Laguna, with 
an altitude of 275 meters shows high parasite and spleen rates. 

Repeated examinations at different seasons of the year would 
probably throw some light on these apparent exceptions. How- 
ever, taken as a group, the high parasite and spleen indexes of 
these towns, situated in immediate contact with A. febrifer 
breeding places, points to a decided relationship of this species 
to the transmission of malaria. 

The number and distribution of malaria cases and the number 
and location of the ditches in the town of Magdalena are given 
on the map (Plate II). The data of a single survey appear on 
the map, the examination of late October and early Novem- 
ber, 1914 (Table VI, No. 10). The blood specimens were col- 
lected and the cases located on the map by Rosa, and the slides 
were examined by Barber. Children of all ages were taken, 
many of them in a house-to-house canvass. It is evident that 
both breeding places and cases are uniformly and abundantly 
distributed. 

133057—4 



226 The Philippine Journal of Science 1915 

Before proceeding to a summary of our data regarding the 
relation of malaria to topography, it may be well to examine 
the data on certain severe epidemics which have followed the 
introduction of large bodies of laborers into malarious regions 
in the Philippines. Three cases occurring in recent years are 
given in Table IX. 

All of these localities are in breeding places of Anopheles 
febrifer, and the epidemics occurred at seasons when the breed- 
ing of any stream species of anopheles was not materially inter- 
fered with by freshets or drought. In every case there were 
species of anopheles other than A. febrifer and A. maculatus 
present, but of these only A. rossii and A. barbirostris occurred 
in any numbers. 

The epidemic of malaria which occurred on the Manila-Baguio 
turnpike in Nueva Ecija during the construction of a bridge 
over Baliuag River merits a more detailed description. Mr. A. 
W. Austin, district engineer, who had charge of the work kindly 
gave us the following information. The epidemic occurred 
during the months of November and December, 1912, and of 
January, February, and March, 1913. Some thousands of ap- 
parently healthy men, many of them from nonmalarious regions, 
were brought into a camp on the banks of the river. Some 
lived in temporary grass huts on an area of dry gravel in the 
bed of the stream itself. Malaria was so severe that it was 
necessary to keep 2,400 men on the payroll in order to keep 
800 men at work. In one instance, of 300 men who turned out 
to work in the morning, only 18 were able to work until noon. 
The number of deaths is difficult to estimate, since many died 
after returning to their homes, but probably the number of fatal 
cases went into the hundreds. 

This locality was surveyed by Barber on December 31, 1914. 
The river at this point flows through a plain mostly covered 
with grass, but with low trees especially near the river. There 
are no swamps of any kind near. The stream is small, being 
more like a brook than a river. The water is clear, and flows 
with alternate swifter and slower stretches. The bed of the 
stream is gravelly, and there is much flow in the gravel below the 
surface. There is some vegetation at the margin of the stream, 
but the banks are cleaner than in the case of many streams 
examined by us in the Philippines. In a number of places, how- 
ever, coarse grass extends from the margin into the water. At 
one such place at the former site of the camp A. febrifer was 
found in abundance, sometimes 8 or more larvae would be brought 
up at one dip of the collecting pan. Anopheles febrifer was 



X,B, 3 



Barbei- et al.: Malaria in the Philippines 



227 













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228 The Philippine Journal of Science 1915 

also found at other points near the camp. Anopheles rossii 
occurred in algse and in pools in the bed of the stream. A few 
larvse of A. barbirostris were also found (Plate I, fig. 2). 

Mr. Austin informed us that a camp 6 kilometers beyond the 
river, away from any stream, remained malaria free. 

This epidemic shows clearly the relation between clear streams 
and malaria in the Philippine Islands. It is said that the people 
of this region refuse to settle on this river because of the severe 
type of malaria which prevails there. The stream is reputed by 
them to be haunted and is known as "Devil River." 

In reviewing the data given in Table VI, little can be deduced 
with regard to distribution by provinces because no complete 
survey was made of any province, and because the great variety 
of topography in each province makes a partial survey incon- 
clusive. However, in the two provinces of Cebu and Laguna the 
number and variety of localities visited were considerable, and 
some comparison is possible. Cebu, a long narrow island of 
coral formation, is comparatively poorly watered. The interior 
is mountainous, and the large proportion of the population is 
found along the coast. The towns for the most part are but 
little above high tide. Permanent brooks and rivers are com- 
paratively few, and there seems to be less tendency here than 
in other parts of the Archipelago to locate towns immediately 
on the streams, possibly on account of floods. 

In September, 1914, Barber made a malarial survey of the 
province in company with Dr. A. Villalon, an assistant of Dr. 
Arlington Pond, district health officer of Cebu. On the east 
coast various localities from Oslob to Sogod, and on the west 
coast from Tuburan to Aloguinsan, were visited. Mosquito sur- 
veys were made and fever cases examined wherever they could 
be found. In locating fever cases we had the assistance of the 
local health officers. In addition, the parasite and spleen indexes 
were taken of school children in the towns of Bolhoon, Carcar, 
and Argao. The amount of malaria found was small. But few 
cases of malaria were found, and nearly all of these could be 
traced to recent residence in a construction camp in Tayabas 
Province, Luzon, where malaria is very prevalent and where 
many laborers recruited from Cebu are employed. Only three 
cases could be found (these in Pardo barrio near Bolhoon) which 
could not be traced to this source. 

Doctor Pond informed us that in ten years of experience 
in Cebu he has observed comparatively few cases of malaria 
indigenous in the province and that he has not seen one case of 



x, b, 3 Barber et al. : Malaria in the Philippines 229 

malarial fever that could be traced to the city of Cebu. Maj. 
Roger Brook, 17 of the United States Army, reports on the prac- 
tical absence of cases of malaria contracted in Cebu by soldiers 
at Warwick Barracks in Cebu city. On the whole, it may be 
concluded that the amount of indigenous malaria in the province 
is comparatively small. In some localities we were informed 
that fever formerly prevailed in places where the jungle was 
being cleared. The province as a whole is densely populated 
and relatively free from jungle. 

In our mosquito survey of the province all the common species 
of anopheles were found; Anopheles rossii was plentiful, A. febri- 
fer occurred in moderate numbers, and A. barbirostris and A. 
maculatus were few. With the exception of localities occupied 
by A. rossii there were few breeding places and the number of 
anopheles was comparatively small. Anopheles rossii was found 
abundantly in some brackish pools in the city of Cebu. Major 
Brook reports the finding of A. rossii and A. ludlowii in Cebu. 

Laguna Province is in a volcanic region and is well watered 
by numerous brooks and rivers which flow the year around. 
There is a great variety of topography, and large areas, espe- 
cially in the mountains, are covered with jungle. As shown 
in the tables, the rice-field regions, some of them irrigated the 
year around, are comparatively free from malaria, while there 
is a much larger amount of malaria in the hill towns. The 
province as a whole contains much more malaria than Cebu. 

In general in the Archipelago, regions long cultivated are 
freer from malaria than newer localities. The sparsely settled 
Islands of Mindoro and Palawan are notoriously malarious, and 
much malaria is reported from Mindanao. However, the "ditch" 
towns, which show such a high degree of endemic malaria, are 
old towns, and what is at present probably the most highly in- 
fected place in the Philippines, the line of construction of the 
Manila Railroad Company in Tayabas, is in part in an old 
settled region. However, in this place there has been a large 
importation of laborers, and the railroad line penetrates some 
areas either original jungle or once cultivated and now reclaimed 
by the jungle. A region planted with coconut trees, especially, 
is likely to be allowed to relapse into jungle along the streams 
and in areas not occupied by the coconut trees. Often the edges 
and sometimes other parts of towns are practically jungle (Mag- 
dalena, Majayjay, and Bongabon). A considerable proportion 

"Milit. Surgeon (1914), 34, 201. 



230 The Philippine Journal of Science ms 

of the towns which show a high parasite index are situated in 
coconut regions. Such regions are by no means always ma- 
larious. Much of the coast of Cebu, where the bulk of the pop- 
ulation is found, is lined by coconut trees. Few of these towns 
have allowed the coconut groves to relapse into jungle. Factors 
which favor the dispersal and shelter of mature anopheles must 
be considered as well as the presence of breeding places; and 
given sufficient numbers of the proper mosquito carriers, jungle 
and other overgrowth favor the development of malaria in a 
community. 

In summarizing the results by type of locality, we find that 
as a rule low-lying coast towns in which the high tide extends 
into the streams well among or back of the houses show little 
or no malaria. Paranaque, Orion, and the swampier portions 
of Manila are good types of towns of this class. In or near 
these three localities A. rossii was found breeding in abundance, 
but no case of malaria was found in over 700 children examined. 
Cases of malaria contracted in Manila are few, if, indeed, they 
ever occur. We have questioned many physicians of the city, 
and have examined suspicious fever cases obtained in houses 
or in clinics and have found but few cases positive for malaria, 
and those almost always gave a history of residence in some 
other locality, usually a malarious one. The positive cases found 
in routine examination at the laboratory of the Philippine Gen- 
eral Hospital at Manila nearly always show a history of origin 
of the disease outside of the city. Large cities usually show 
a lower rate than rural communities. 

Bentley 18 states that even small towns of Bengal, India, al- 
though intensely malarious, may present areas in their centers 
nearly malaria free. With a fixed number of anopheles carriers 
the rate tends to fall as the population increases. However, the 
portions of Manila examined are for the most part immediately 
contiguous to swamps or ponds, and if A. rossii were a carrier we 
would expect at least a small positive spleen or parasite index. 

Mangarin in Mindoro and Limay in Bataan Province are ex- 
ceptions to the rule that low coast towns are malaria free. Man- 
garin, which shows a parasite index of 39.3, is situated on a flat 
swampy coast. In the dry season there is no fresh flowing 
water within a kilometer. From the nature of the country it 
is probable that fresh streams are found much nearer to the 
town in the wet season. Palangeran River flows into the sea 

18 Ind. Journ. Med. Res. (1914), 4, suppl. 78. 



x, b, 3 Barber et al. : Malaria in the Philippines 231 

at from 1 to 1.5 kilometers from the town. At the time of our 
survey the larvae of A. febrifer were more numerous in this river 
than in any other stream, except one, surveyed in the Philippines. 
Doctor Daywalt informs us that in the wet season there is a 
spring in the town itself at the margin of which larvae of A. 
febrifer were found. He sent us some specimens of mature ano- 
pheles caught in houses in the town during the rainy season and 
among these was one A. febrifer. So it is evident that this 
species either breeds in or near the town or is able to reach it 
by flight from a distance. Mangarin is situated in a highly 
malarious region, and there is more or less intercommunication 
with the inhabitants of the San Jose Estate and other places 
where malaria is, or has been, very prevalent. 

Limay, Bataan Province, shows a parasite index of only 6.8. 
It is situated on the coast near the foot of the mountains, and 
a lumber mill is situated in it and connected by a railway with 
the mountains at the foot of which the town lies. Shortly be- 
fore this region was surveyed for mosquitoes, there had been a 
freshet, so that few larvae of any kind were found, but a few 
larvae, apparently A. febrifer, were found in a brook at the 
edge of the town. 

Of the coast towns situated well above high tide, Puerto Prin- 
cesa, Palawan Island, shows a parasite rate of 28.6. Numerous 
larvae of A. febrifer and A. rossii were found in a small stream 
at the edge of this town. Like Mangarin, Puerto Princesa is 
in more or less communication with a highly malarious region. 

The results of this work tend to confirm the preliminary 
conclusion of Walker and Barber that the chief carrier of the 
Philippine Islands is Anopheles febrifer. The mosquito survey 
has shown the wide distribution of this species, the abundance 
of its breeding places, and the large numbers of larvae often 
found in them. Further it has been shown that this species is 
house-seeking and readily bites human beings. Its distance of 
flight is at least 170 paces, and the number found in houses 
in some localities was large in comparison with the number of 
larvae found in the neighboring breeding places. 

The distribution of malaria agrees, in general, with the dis- 
tribution of A. febrifer. In every malarious town in which 
it was possible to make an adequate anopheles survey, either 
larvae of A. febrifer were found in or near the locality or adults 
were caught in the houses. The high rate of malaria occurring 
in "ditch" towns where A. febrifer breeds in close proximity to 
houses tends to strengthen the evidence against this species. 



232 The Philippine Journal of Science 1915 

It is true that A. febrifer was found breeding near towns 
with little or no indigenous malaria, but the breeding places 
were in most cases more or less remote from the majority of 
the houses or comparatively few larvae were found in them. 
The lack of gamete carriers might in some cases account for 
the lack of malaria in these localities. However, none of the 
localities surveyed were found nonmalarious where A. febrifer 
bred abundantly near houses and had unobstructed flight to 
them. Possible exceptions are Bolhoon, Cebu, and some more 
or less recently established barrios on large plantations. Many 
factors are concerned in the transmission of malaria, and as 
investigations in many localities of other countries have shown, 
the juxtaposition of mosquito malaria carriers and of population 
is not necessarily accompanied by malaria. 

The results of our study of Anopheles rossii as a whole tend 
to confirm the conclusions of investigators in India that this 
species is responsible for little if any transmission of malaria. 
There is probably no locality in the Philippines where this species 
does not breed at some time during the year and in most places 
very plentifully. If it were a carrier, we would expect a cor- 
respondingly wide distribution of malaria, yet our survey shows 
that there are many localities where A. rossii breeds at almost 
all times of the year in large numbers and close to houses, yet 
these localities show an index of 0. This is true of towns like 
Manila, Parafiaque, and Cebu city and other coast towns of 
Cebu where A. rossii breeds abundantly in salt or brackish 
water, and in towns like Calamba in Laguna Province and Orion 
in Bataan Province, surrounded by rice paddies, which afford 
fresh-water breeding places the year around. 

There also seems to be little correlation between the breeding 
places of A. barbirostris and A. sinensis and the presence of 
indigenous malaria. The occurrence of both in irrigated rice 
paddies where the malarial index has been found to be low 
indicates that they are not important carriers. Anopheles barbi- 
rostris and A. sinensis do not seem to be by preference house- 
seeking species. 

Anopheles maculatus probably transmits malaria in certain 
localities and at certain seasons in the Philippines. In Decem- 
ber, 1913, this species occurred in considerable numbers in a 
brook at Canlubang. On the banks of this brook a barrio is 
located in which considerable malaria occurred at that time and 
earlier in the season, and it is possible that A. maculatus was a 
carrier. At Camp Stotsenberg. Pampanga Province, this species 



x, b, 3 Barber et al. : Malaria in the Philippines 233 

occurred in the immediate neighborhood of a malarious barrio. 
In both localities A. febrifer was also found. However, A. macu- 
latas is relatively scarce, and probably plays a far less part in 
the transmission of malaria than A. febrifer. 

Watson 19 believes that A. maculatus (= A. wilmori) is the 
chief carrier in certain hill regions of the Federated Malay 
States. He reports this species from a Dutch island off Singa- 
pore, where malaria is intense, and from Hongkong. In any 
case, antimalarial measures directed against A. febrifer would 
be equally efficacious against A. maculatus, which has similar 
habits. 

In general, the highest indexes of malaria have been found 
in well- watered, but not necessarily swampy regions; and small 
clear streams, especially where in close proximity to houses, 
offer more danger than swamps, lakes, or wholly stagnant 
water. 

SEASONAL INDEX OF MALARIA 

From information obtained locally in malarious towns re- 
garding the worst "fever" months, it would appear that March, 
April, and May, in the hot dry season, are most free from mala- 
ria, but the evidence is not without contradictions. For the rest 
of the year the information obtained varied widely in different 
localities, but the rainy season and the cooler dry months were 
more often mentioned as malarious. Where the number of latent 
cases is large, we would expect a proportion of these cases 
to become acute at times when there is the most exposure to 
weather — the rainy season and the cool season, when the nights 
are often decidedly chilly and thinly clad people suffer from cold. 
As shown in Table VI, towns examined twice give a percentage 
of positives obtained during the hot dry season lower in nearly 
every case than that obtained between July and December 1. 
In some cases the slides obtained in the hot months were in 
poorer condition for examination, but making allowance for this 
there is still a lower percentage for the hot dry season. 

A very important matter in the epidemiology of malaria is 
the time of the year when most infections occur. This is a 
matter difficult to determine from statistics obtained from the 
indigenous population of a malarious district where a large 
percentage of the people harbor parasites the year around. 
Some information may be obtained from isolated epidemics 

19 Trans. Soc. Trop. Med. & Hyg. (1913), 59. 



234 The Philippine Journal of Science ms 

where a comparatively malaria-free population has been intro- 
duced into a malarious district. Dr. G. W. Daywalt informed 
us that a group of about 400 laborers came to the San Jose 
Estate in February and March, 1911. Within two weeks 90 
per cent of them were attacked by malaria of a pernicious type, 
and many of them died. This was in the dry season. Gen- 
erally, according to Doctor Daywalt, the severest epidemics 
on the San Jose Estate have begun in May, a hot month with 
frequent afternoon showers. 

On the line of construction of the Manila railroad where 
malaria was very prevalent at least up to November, 1914, the 
fewest cases appeared in the hot dry season, according to Dr. 
S. R. Cox, who until recently was resident physician there. 
Barber surveyed this region during the dry season and again 
in November. Evidently there is much more flow of water in 
the brooks, which are plentiful there, after the rainy season, 
and some brooks go dry, or nearly so, in the dry season. La- 
borers were continually being introduced into this region from 
Cebu and other relatively nonmalarious regions. 

The severe epidemic at the bridge-construction camp at Ba- 
liuag River, in Nueva Ecija Province, occurred in the dry sea- 
son — that is, November, December, January, February, and 
March. The epidemic on the line of construction of the Manila 
water works in 1906 occurred in February. 

The severe outbreaks mentioned above have occurred near the 
habitat of stream-breeding mosquitoes and at times when their 
breeding was not interfered with by freshets or drought. In 
the "ditch" towns (Table VIII) the supply of water is often so 
regulated that breeding is less interfered with by heavy rains. 
We found a very high rate of infection in Magdalena, Laguna 
Province, in July, and the people in this town state that the 
fever is worse during the rainy season. 

We believe that the results of our work give a more opti- 
mistic outlook for successful antimalarial work in the Philip- 
pines. Large parts of the more populous portions of the Is- 
lands contain little or no indigenous malaria, and the people 
residing in them are little exposed to infection. It is probable 
that the amount of morbidity and mortality from malaria in 
the Philippines has been overestimated. The following data 
were kindly furnished us by Dr. Victor G. Heiser, Director of 
the Bureau of Health of the Philippine Islands: 



X, B,3 



Barber et ah: Malaria in the Philippines 



235 



Annual death rates and morbidity rates from malaria in the Philippine 
Islands, 1909 to 1913, inclusive. 



Year. 


Deaths 

from 
malaria. 


Total 
deaths. 


Average. 


Cases 
reported. 


Popula- 
tion. 


Average. 


1909 


a25,751 
26, 359 
28, 181 
27, 229 
17,619 


179, 355 
191, 576 
188, 412 
184, 639 
147, 544 


14.35 
13.75 
14.95 

14.74 
11.94 


a 16, 516 
10, 225 
19,363 
11, 555 
20, 378 


6,331,695 
6, 956, 979 
7, 007, 081 
6, 857, 892 
6, 770, 736 


0.26 
0.14 

0.27 
0.16 
0.30 


1910 _- 


1911 . 


1912 


1913 





* In the first four years the deaths from malaria exceeded the cases reported because of 
incomplete returns from the provinces. 

Dr. Arlington Pond, district health officer for Cebu Province, 
gave us the following information by letter: 

In this year (1912) there were over 4,000 deaths reported from malarial 
fever (Province of Cebu). The following year I employed eight doctors 
and divided the province up into districts. As the result of this the number 
of cases of so-called malaria dropped to 400 instead of the 4,000 of the 
previous year. 

From results obtained during our survey of the province in 
1914, it would seem that even this figure is far above the actual 
rate. It is probable that if facilities were available for more 
accurate diagnosis in all provinces a far lower morbidity and 
mortality rate for malaria would be reported. 

If, as our results indicate, the greater part of the transmission 
of malaria is due to a species of mosquito of rather limited 
habitat, the outlook is encouraging for eradicating or greatly 
reducing the mosquito carriers of malaria in many malarious 
localities. An anopheles-mosquito survey, and wherever prac- 
ticable a malarial survey, should be made of every locality where 
antimalarial work is contemplated. Wherever children in 
schools are available for blood and spleen examination, the ex- 
amination of 50 persons can be completed by a trained worker 
within three days at the most. The data thus obtained are of 
the greatest importance as a basis for antimalarial work. Cli- 
nical evidence alone is much less satisfactory unless obtained by 
a trained diagnostician who has resided some time in a locality. 

With the scientific data at hand the next step is to choose the 
point of attack best suited to the locality and the resources 
available. In the "ditch" towns, for example (Table VIII), the 
attack can be most advantageously made against the larvae in the 
ditches. The most radical measure would be simply to abolish 
the ditches by cutting off the main canal and to rely on water 



236 The Philippine Journal of Science ms 

supply from other sources. Water equally good, even if a little 
less conveniently at hand, is found in most of these towns within 
a hundred meters or less. Again, the open sewers and other 
ditches under the houses could be cut off and only two or three 
ditches in the main streets retained. These might be cemented 
at little cost, or, if this much expense is impossible, they could 
be kept clean and their channels so arranged that the water could 
have swift and unobstructed passage and the larvae could be kept 
down by the use of larvicides. Near many towns not of the 
ditched type the breeding places of Anopheles febrifer are very 
limited. In Puerto Princesa, for example, we could find but 
one such breeding place anywhere near the town. One or 
two hours' work by one person would suffice to destroy practically 
every anopheles larva in that place. 

In localities where one or more streams flow through or near 
the houses, the destruction of the larvae is more difficult, but still 
quite practicable. As a rule, the breeding places of anopheles 
do not occupy the whole margin of the brooks, but occur here and 
there where vegetation offers some protection. Cleaning out 
these breeding places would accomplish much and in many 
streams we have surveyed would require comparatively little 
time and expense. 

Permanent good may be accomplished by clearing the stream 
bed so as to make it narrower and swifter and to do away with 
some of the pools and quieter water where the larvae breed. 
Work of this sort has been done successfully at the Calamba 
Sugar Estate. 

Watson 20 brought about a great diminution of the malaria 
rate in certain estates in the Federated Malay States by subsoil 
drainage of the clear streams where Anopheles macalatus breeds. 
This was done only for certain sanitary areas, and on account 
of the expense such permanent improvements would be difficult 
to carry out in most localities in the Philippines. Larvicides are 
cheaper and at the present offer a more practical method for 
mosquito destruction in these Islands. 

Since the larvae of Anopheles febrifer and of other stream 
breeders have the habit of hiding in crevices in the bank and 
under vegetation, it is difficult to apply a larvicide adequately. 
However, this characteristic renders it unnecessary to treat any 
part of the stream other than the bank. Barber has made some 
experiments in the destruction of the larvae of A. febrifer, the 
results of which are given in Table X. 

"Loc. cit. 



x, b, 3 Barber et al.: Malaria in the Philippines 

Table X. — Experiments with vwsquito larvicides. 



237 



Ex- 




peri- 
ment 


Date. 


No. » 






1914 


1 


Apr. 14 


2 


Apr. 15 


3 


May 16 


4 


July 31 



Locality. 



Nature of breeding place. 



Ap- 
proxi- 
mate 
width 

of 
stream. 



Preliminary survey. 



Station 
No. 



Ap- 
proxi- 
mate 
dips. 



Larva? 



Canlubang, Laguna. 
Santa Rosa, Laguna. 

San Jose, Mindoro.. 
Magdalena, Laguna. 



Rocky brook with much 
vegetation and jungle. 

Swift clear brook; com- 
paratively little vegeta- 
tion. 

Small brook; moderate 
amount of vegetation. 

Narrow ditch; much 
grass. Water cut off 
half an hour before oil- 
ing. 



Meters. 
0.5-5 

2 -6 

0. 5-3 
0.3 



128 
113 

65 
113 



Larvicide. 



Kind. 



Amount. 



Ap- 
proxi- 
mate 

dis- 
tance 
worked. 



Ap- 
proxi- 
mate 
time. 



Inter- 
val be- 
tween 
spray- 
ing and 
reex- 
amina- 
tion. 



Survey after 
use of larvicide. 


Average per 
dip. 


Dips. 


Larva? . 


Before. 


After. 


200+ 


7 


9.1 


0.035 


137 


38 


10.0 


0.280 




8 


6.5 


w 


81 


1 


4.3 


0.012 


55 





4.3 


0.00 


many 





4.3 


0.00 



Ratio per 
dip before 
and after. 



Crude petroleum. 
Larvicide, Dar- 
ling. 
Crude oil 



Kerosene 



Liters. 
2 

7 



4.5 



Meters, 
1,000 

400 

60 
370 



h. m. 

3 
30 



Hrs. 

20 
24 



15 | 



48 
16 



100:0. 4- 
100:2. 8 

d 100:1 
100:0. 3 
100:0. 
100:0. 



a The depth of Nos. 3 and 4 was only from 3 to 5 centimeters except where very narrow. 
No. 1 averaged from 10 to 20 centimeters where the water was swift, and No. 2 had two or 
three times the flow of No. 1. In Nos. 1, 2, and 3 brooms were used to work the larvicide 
into the bank. In No. 4 kerosene was put on the water and simply splashed on the sides of 
the narrow ditch. Nos. 1 and 4, larvicide applied by one person. Nos. 2 and 3, larvicide 
applied by two persons, each taking one side of the bank. 

b 19 days. 

c After treatment larvse found only two or three times along the whole distance and in 
very small numbers. Exact data not recorded. 

* Estimated. 

Preliminary experiments showed that the larvicide when 
merely poured on a stream and allowed to float down was in- 
effective, especially where the current was swift. So the lar- 
vicide was distributed along the margins and worked in 
mechanically. We found one of the best methods of distributing 
the oil was by means of a can provided with a long spout, and 
for working it into the breeding places we used, in most ex- 
periments, Filipino brooms made of stiff twigs. This method 



238 The Philippine Journal of Science 1915 

is not so time-consuming as it appears, since, in experiment 
1, one of us "cleaned" both sides of a very much obstructed brook 
for a distance of nearly 1 kilometer in three hours with no 
help except that of assistants to carry a supply of crude oil. 
The brook was much obstructed by trees and jungle and was 
one of the worst in this respect of any we have visited in the 
Philippines. 

In order to control the results of the larvicide in our experi- 
ments, the whole distance to be treated was first surveyed. At 
certain stations dips were made at the margins with the collect- 
ing dish, the larvae obtained were counted and replaced in the 
water, and the results were entered in a note book. The stations 
were marked, usually with numbered stakes made conspicuous 
with strips of red cloth. At a known interval of time after the 
application of the larvicide, dips were again made at the stations 
and at points between them, and the larvae counted. The dips 
were made in places where by long experience in collecting we 
knew that larvae were likely to be found. The streams in all 
experiments contained clear flowing water, and there were few 
larvae other than of Anopheles febrifer present. There had been 
no preliminary clearing away of breeding places. In experi- 
ment 4 the water had been shut off from the ditch half an 
hour before the application of the kerosene, and was not turned 
on again for some hours. As a result, the quantity and the 
movement of the water were diminished, and the larvicide was 
made more effective. After the application of the larvicide the 
stream was searched for larvae before the water was turned on, 
and was searched a second time some hours after the water had 
been allowed to flow into it. 

The percentage of larvae destroyed can be estimated only 
approximately, but it is apparent from the data given in the 
table that from 95 to 100 per cent of the larvae of Anopheles 
febrifer may be destroyed by one application of any good lar- 
vicide where it is well worked into the breeding places. Where 
the breeding places are limited to one or two small streams in 
or near a town; as is frequently the case in the Philippines, one 
trained person could keep down the larvae for a distance of 
at least several hundred meters above and below the town. 

Our data also show that the time and expense required are 
not great. In our experiments we "scrubbed" the entire margins 
of both banks, except at certain points which were left as 
controls. If we had confined the treatment to known breeding 
places, much time and larvicide might have been saved. How- 
ever, where the larvicide is applied by a person unfamiliar with 



x, b, 3 Barber et al. : Malaria in the Philippines 239 

the breeding places, it would be inadvisable to skip any part 
of the bank. 

A practical application of our method of larva destruction 
has been made by Dr. I. S. Diller, of the Calamba Sugar Estate. 
The brook treated by us in experiment 1 flows near a large barrio 
of the estate. This brook has been systematically treated op- 
posite and some distance below the barrio by an assistant whom 
we trained. Doctor Diller reports a diminution both in the 
number of mosquitoes and in the cases of malaria in the barrio. 

We have not observed much tendency in these larva? to follow 
the current down the stream, except when there is abundant 
floating debris for them to cling to. In experiment 4 the treated 
ditch was found practically free of larvae nineteen days after 
the ditch had been opened to the main ditch above, where larvae 
were plentiful. It is probable that if a portion of a stream is 
thoroughly cleared it will remain so until a fresh supply of 
larvae have had time to develop. 

As stated above, we found that larvicide merely poured on 
the brook was comparatively ineffective. One experiment con- 
ducted on the same brook as that described in experiment 1, 
Table X, may be described in detail. Twelve dips at 12 stations 
gave, before treatment, 150 larvae. The distance was approx- 
imately 100 meters. Then about 3 liters of crude oil were 
poured on the stream at the upper station. Twenty-four hours 
later the brook was again examined. Twelve dips at the sta- 
tions gave 36 larvae, and 78 additional dips above and below 
the stations gave 95 larvae, a total of 131 larvae. The average 
numbers obtained per dip were 12.5 larvae before treatment, 
1.5 larvae after treatment. The destruction of the larvae was very 
marked where the current was comparatively slow and the 
margin of the bank little protected by vegetation, but it was 
very little where the current was swift and the bank protected 
by overhanging roots and ferns. In experiment 1, Table X, 
certain stations were left untreated as controls. These stations 
showed decidedly less diminution of the larvae than did the 
places where the larvicide was worked in. 

In Magdalena, at the same time that experiment 4 was made, 
a ditch on another street was partially dammed, and a quantity 
of petroleum was placed immediately below the dam and at other 
points below. Then the water was liberated so that the larvi- 
cide could be carried down by the rush of the stream. There 
was some destruction of larvae, but the results were not wholly 
satisfactory. A second experiment of the same sort also gave 
indifferent results. It seems that it is necessary to work the 



240 The Philippine Journal of Science 1916 

larvicide in mechanically in order to destroy the larvae of these 
stream-breeding species, especially where much vegetation is 
present. In the walled ditches passing under houses or into 
other inaccessible places a simpler treatment might be devised. 

As stated above, Anopheles febrifer and other stream breeders 
avoid rice paddies and water in ditches which has previously 
stood on large paddies. Moreover towns in rice-paddy regions 
where there are few brooks or other streams are comparatively 
malaria free. In Calamba, Laguna Province, a ditch from a rice 
paddy flows through the main street of the town, and laterals 
extend to other streets. We could find no anopheles other than 
A. rossii in this ditch, and the malarial index of the children of 
the town is 0. 

Watson 21 remarks on the fewness of stream breeders and 
the comparative absence of malaria in certain rice-paddy areas 
in the Federated Malay States while malaria is plentiful in the 
neighboring hill regions. He believes that irrigation as well as 
drainage may in some localities be an efficient antimalarial 
measure. 

Kendrick 22 finds that in the irrigated rice regions of central 
India two factors must coexist in order to bring about a high 
rate of endemic malaria: namely, breeding places of anopheles- 
mosquito carriers and shade in the form of trees, shrubs, long 
grass, or other jungle. 

Not all the species of malaria-bearing anopheles of central 
India are found in the Philippines. Climate and other con- 
ditions differ so that we do not expect the distribution of malaria 
here to correspond closely with that of India, but it is worthy 
of note that in the Philippines as well as in central India open 
irrigated rice regions may be nearly malaria free. Generally 
malarious localities in the Philippines are on streams which come 
more or less directly from wild land or land uncultivated for 
many years. In some parts of the Philippines the further 
development of rice culture may result in the diminution of 
malaria. However, water in irrigation ditches, if it has not 
previously stood on extensive rice paddies, affords good breeding 
places for Anopheles febrifer. 

While drainage has undoubtedly played a large part in the 
diminution of malaria in various regions — for instance, the 
middle west of the United States — it seems that extensive cul- 
tivation of the soil might also have been an important factor. 

"Loc. cit. 

"Ind. Journ. Med. Res. (1914), 4, suppl. 64. 



x, b, 3 Barber et al. : Malaria in the Philippines 241 

Not only the diminution of water but the rendering of it unfit 
for malaria-carrying mosquitoes is to be considered. Whether 
a change in water may affect the susceptibility of the mosquito 
to malaria without impairing its breeding is a question which 
cannot be solved with the data now at hand. 

Among the natural enemies of stream-breeding mosquito 
larvae we have most often encountered a species of Ranatra. 23 
We have observed the insects and larvae of a species of the 
family Dytiscidae 23 feeding on mosquito larvae in streams. In 
a shallow pool containing Anopheles rossii we have observed 
flies catching larvae. The flies rested on twigs and on the 
surface-tension layer of the water and seized the larvae from 
above when the latter came to the surface to breathe. In a 
brackish pool in Palawan Province tadpoles were observed 
catching the larvae of a species of Culex. These tadpoles had 
developed legs, but were still gill-breathing. A specimen was 
put into formalin and later dissected in the laboratory where 
mosquito larvae were found in the upper part of its digestive 
tract. 

Where larvae are protected by algae, grass roots, stones, or 
floating debris, we have observed that they breed in large num- 
bers in spite of the immediate presence of their enemies. This 
has been the observation of most workers in various countries. 
The rapid destruction of larvae in breeding jars by natural ene- 
mies is not a reliable index to the behavior of these enemies in 
the natural state. It is apparent that natural enemies cannot 
alone be depended on effectively to keep down anopheles. The 
introduction of larvae-destroying fishes or other mosquito enemies 
should be practiced wherever possible. They are most effective 
in ponds, tanks, basins, or other still waters, but we would not 
hope for much success from them in streams where larvae are 
well protected. 

The destruction of adult mosquitoes in and about houses, es- 
pecially those which have taken blood, has been one of the means 
successfully used in antimalarial work in Panama. As stated 
in the description of our work in Mindoro, Doctor Daywalt, 
resident physician of the San Jose Estate, keeps a squad of 
mosquito catchers employed, and he attributes to this work no 
small part of the reduction of malaria on that estate. The suc- 
cess of this measure must depend to a great degree on assistants 
who will carry on the work persistently and throughout the year. 

23 Identified by C. S. Banks. 

133057 5 



242 The Philippine Journal of Science 1915 

In the Philippines it is doubtful if enough of such assistants 
could.be trained and kept at work in the various malarial towns. 
The hiding places of adult mosquitoes are not necessarily con- 
fined to buildings. We found 2 adult females of Anopheles 
febrifer among roots and in a crab hole in Mindoro. The aver- 
age Filipino room in the Philippines is open to the high thatched 
roof, and the space under the house also offers lurking places 
not easily accessible. The houses on the San Jose Estate are 
for the most part provided with ceiling, and the under part of 
the houses are so ventilated that they are not favorable as hiding 
places for mosquitoes. As a result, mosquito catching on this 
estate is probably easier than would be the case in the average 
Philippine barrio. This kind of antimalarial work will probably 
be most likely to succeed on plantations or other localities where 
the work can be kept under close supervision. 

Educational work is certainly worth while, if only to make 
the people more receptive to antimalarial measures conducted 
by the authorities. We have several times talked to pupils or 
teachers in malarial towns on malaria transmission, and shown 
them specimens of anopheles breeding in the vicinity. 

The clearing of the jungle, whether woods or high cogon grass, 
has undoubtedly been a factor in the reduction of malaria in 
some parts of the Archipelago. But, as stated above, the jungle, 
especially in some coconut regions, has been imperfectly cleared 
or allowed to grow again, and some of the most malarial towns 
in the Islands have been settled for a century or more (Magda- 
lena and Majayjay, Laguna Province, and Bongabon, Nueva 
Ecija Province). 

The penetration of new territory in the Philippines by troops 
or by men employed in construction works or in the development 
of mines, plantations, or lumber industries has frequently been 
followed by severe outbreaks of malaria. We believe that much 
of this malaria could be prevented by comparatively inexpensive 
antimalarial measures undertaken early and based on an adequate 
preliminary anopheles survey and where practicable a malaria 
survey of the indigenous population. In the case of an estab- 
lishment in a hilly region where breeding places are compara- 
tively limited the destruction of larvse in the neighborhood of 
camps would be especially feasible. Very little expenditure of 
time and money would have sufficed to prevent the outbreak on 
Baliuag River in Nueva Ecija (Table IX). A small construc- 
tion camp in Cebu is located immediately over a small brook 
offering excellent breeding places for anopheles, but we were 



x, b, 3 Barber et al. : Malaria in the Philippines 243 

unable to find more than one or two larvae after considerable 
search. We found that the foreman of the camp had been using 
moderate amounts of crude carbolic acid in this stream. We 
could find no malaria in the camp, and there were few mos- 
quitoes about. 

A large proportion of laborers recruited from the large centers 
of population in the Philippines are undoubtedly little infected 
at the start, and as experience has shown they offer little or no 
resistance to the disease. When brought into construction camps 
they have suffered severely with malaria. Once well infected 
it is difficult to eradicate the epidemic in the camp, and as such 
populations are rarely permanent, gamete carriers are spread 
throughout the country. The supervision of such camps and 
the prevention of malaria in them becomes a matter of general 
as well as of local importance. 

We have had no opportunity of judging the success of quinine 
prophylaxis in any locality in the Philippines except at the Iwahig 
penal colony in Palawan, where 5 grains of quinine per day are 
given to each colonist. The amount of acute and latent malaria 
in this colony and the results of the mosquito survey there are 
given in Table IV and the accompanying text. Since anopheles 
mosquitoes are abundant there and the region is very malarious, 
it is probable that the prevalence of malaria in the colony is 
materially reduced by the prophylaxis, but as the data show it 
is by no means wholly prevented. Quinine prophylaxis is gen- 
erally considered advisable only as a temporary measure or in 
an intensely malarious region where more permanent antimala- 
rial means are impracticable. 

Measures have already been taken by the Bureau of Health 
by which quinine is made available to people in many localities 
at comparatively little cost. Such measures are not only of the 
greatest value in curing the sick, but the number of gamete 
carriers is undoubtedly reduced. It is difficult, however, to get 
people to follow a quinine treatment persistently enough to get 
rid of latent malaria and consequently of the gametes of the 
parasite, and many probably do not take quinine at all. There- 
fore, in order to get permanent results, the distribution of quinine 
should be supplemented by measures for the prevention of the 
transmission of the disease. 

Bed nets, efficacious where intelligently used, are not to be 
relied on for an ignorant population, as shown by the results of 
the mosquito survey at Iwahig where many anopheles were 
found inside of badly adjusted nets. Many people in the Islands 



244 The Philippine Journal of Science 1915' 

are averse to the use of bed nets. In a temporary hospital in 
a very malarious region in Luzon, which we visited before day- 
light in order to observe the behavior of mosquitoes, we found 
but few of the nets in use, although nearly all beds were provided 
with them. 

In summary, we believe that the destruction of larva? by larvi- 
cides and where practicable by the abolition of breeding and 
lurking places offers more encouragement than any other anti- 
malarial measures in the Philippines. These measures should 
be supplemented by others as conditions advise. Where re- 
sources are adequate, all breeding places of all mosquitoes should 
receive attention, but in case means are limited, the stream 
breeders, Anopheles febrifer and A. maculatus, should be erad- 
icated or much reduced, and the streams should be freed from 
them for as great a distance as possible from towns or camps. 
The destruction of these species is made easier by the restricted 
nature of their breeding places, and the cleaning of a very 
jungly stream has been shown to be a practical possibility. 

Filarise were found only once during this work. No special 
search was made for them, but species occurring in the blood 
during the day must be very uncommon among Filipino children, 
else they would have been oftener observed in the course of 
examination of thousands of thick smears. In the one positive 
case, an adult Japanese at Canlubang, filarise were found in blood 
specimens taken at midday on several successive days, but were 
fewer than in specimens taken early in the morning. 

GENERAL SUMMARY 

1. The commonest species of Anopheles in the portion of the 
Philippines covered by our survey are A. rossii, A, febrifer, A. 
barbirostris, A. maculatus, and A. sinensis. It is probable that 
these are the commonest species of anopheles over the whole 
Archipelago. 

2. The results of this work and that of the work of Walker 
and Barber indicate that Anopheles febrifer and, to a less ex- 
tent, A. maculatus are the chief transmitters of malaria in the 
Philippines. 

3. Anopheles febrifer is a stream breeder widely distributed 
and often occurring abundantly in the breeding places. It seeks 
houses and readily bites human beings. 

4. The distribution of malaria in the Philippines, as indicated 
by nearly 7,000 examinations of spleen or blood of school 
children, is by no means universal but is most abundant in 



x, b, s Barber et al. : Malaria in the Philippines 245 

such regions as afford breeding places for A. febrifer and 
A. maculatus. 

5. Antimalarial measures should be based upon a thorough 
anopheles and malaria survey, and those measures should be 
employed which will best meet the conditions. The best single 
measure is the destruction of larvae of malaria carriers, and in 
this work the breeding places of the stream breeders should 
receive first attention. 

6. Our own experience and that of others in the destruction 
of stream breeders by means of larvicides leads us to believe 
that this measure is a practical one in the Philippines and that 
it is within the means of many malarious communities in the 
Archipelago to reduce the amount of malaria by this measure. 



ILLUSTRATIONS 

Plate I 

Fig. 1. A stream flowing through Bongabon, Nueva Ecija Province, Luzon, 
a town with a high malarial index. Anopheles febrifer is abun- 
dant along both margins of this stream, wherever vegetation or 
indentations in the bank afford shelter. 
2. Baliuag River, Nueva Ecija Province, Luzon. A bridge-construction 
camp, where there was a severe outbreak of malaria in 1912-1913, 
was located on the bank at the right of the picture. Larvae of 
Anopheles febrifer were found in the grass at the margin of the 
stream at the right. 

Plate II 

Map of Magdalena, Laguna Province, Luzon, showing the results of a mala- 
rial survey of the town. 

TEXT FIGURE 

Fig. 1. Diagram, showing the relative abundance of the larva? of four species 
of Anopheles in habitats arranged according to the amount of 
decaying organic matter in solution in the water. 

247 



Barber et al. : Malaria in the Philippines.] 



[Phil. Journ. Sci., X, B, No. 3. 




Fig. 1. A stream flowing through Bongabon, Nueva Ecija, a town with high malarial index. 




Fig. 2. Baliuag River, Nueva Ecija. Larvae of Anopheles febrifer were found in the grass at 
the margin of the stream at the right. 



PLATE I. 



[Phil. Joukn. Sci., X, B, No. 3. 



rtAGDALENA.LAGUNA PROVINCE, P. 

FROM A MALARIAL SURVEY MADE IN LATE 
OCTOBER AND EARLY NOVEMBER, 1914 

The symbols represent cases of malaria in children 
lb years of age or less found in the houses 



Subtertian 
Tertian 
Quartan 
Negative 

Child not examined 
Ditches containing 
clear flowing water 



□ 



to Maj o yj n ij 



HDD DDBD DLTDDBHlTB: 



ber p,, AL , : Malaria in the Philippines.] 



[Phil. Joukn. Sci., X, B, No. : 




PLATE II. MAGDALENA, LAGUNA PROVINCE, LUZON, SHOWING THE RESULTS OF A MALARIAL SURVEY OF THE TOWN. 



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By B. C. Crowell 

(From the Department of Pathology and Bacteriology, University of 

the Philippines, and the Biological Laboratory, Bureau 

of Science, Manila, P. I.) 

FIVE COLORED PLATES 

TABLE OF CONTENTS 



Introduction. 

Source and Character of Material. 

Mortality. 

Race. 

Sex. 

Age. 

Duration of illness. 
Classification of Plague Cases. 

Bubonic and pneumonic plague. 

Septicsemic plague. 

Intestinal plague. 

Cutaneous plague. 

Pestis minor. 

Author's classification. 
General Description of the Path- 
ology of Bubonic Plague. 
Portal of Entrance of the In- 
fective Agent. 
Skin. 
Lymphatic Glands. 

Bubonic plague with early sep- 
ticaemia. 

Femoral buboes. 



Lymphatic Glands — Contd. 

Primary (?) iliac buboes. 

Popliteal buboes. 

Axillary buboes. 

Cervical buboes. 
Pharynx and Tonsils. 
Respiratory System. 

Lungs. 

Pleura. 

Bronchi and trachea. 

Larynx. 
Spleen. 
Liver. 

Gastrointestinal Tract. 
Peritoneum. 

Cardiovascular System. 
Nervous System. 
Urinary System. 
Generative Organs. 
Pancreas. 
Adrenals. 
Associated Lesions. 



NOV 1 1915 



4s 



^!°nal Muse^ 



INTRODUCTION 



The present study is based on 75 cases of bubonic plague 
that have been autopsied in Manila during the period between 
June, 1912, and June, 1914. Other extensive studies on the 



1 Received for publication May 7, 1915. 



133736 



249 



250 The Philippine Journal of Science wis 

same subject have appeared from time to time, and these will 
be referred to in detail in this study, but confusion still reigns 
concerning some phases of the pathologic anatomy of bubonic 
plague. 

This study was undertaken primarily for the purpose of 
correlating the plague material on hand. Especial attention 
has been given to accuracy of observation of isolated facts, 
to the correlation of these facts with allied facts as exemplified 
in other acute infections, and with the principles that have 
been deduced therefrom to form the laws of general pathology. 
A perusal of the literature of the pathologic anatomy of bubonic 
plague and a study of our own cases seemed to make a study 
from this general standpoint especially desirable in this disease. 

The abundant material has naturally furnished some valuable 
data relative to the frequency of the occurrence of various 
lesions in the disease. In the course of the work it has been 
possible also to draw some definite conclusions concerning the 
association of some of the lesions in bubonic plague. 

An attempt has been made to simplify the classification of 
cases of plague by recognizing only the primary bubonic and 
primary pneumonic forms and placing all other previously rec- 
ognized types under these two forms. This is very simple, 
save in that ill-defined class of cases spoken of as "septicaemic 
plague." From a review of the literature on the subject and 
from a study of our own cases reasons have been deduced 
for calling these cases "bubonic plague with early septicaemia," 
in the belief that this phrase more accurately describes them. 
The further classification of plague cases that is suggested ap- 
pears to satisfy both anatomic and clinical requirements, and 
is based on the prominent lesions other than the bubo. 

A previous study of a series of primary pneumonic-plague 
cases excited interest in the relation between the incidence of 
cervical buboes, tonsillar and pharyngeal lesions, and pulmonary 
lesions. This relation has particularly engaged the attention 
in the present study of bubonic cases, and interesting facts have 
been elicited. In brief, it has been found that there is no con- 
stant relation between the lesions of the tonsils, cervical lym- 
phatic glands, and the lungs. Specific pulmonary and tonsillar 
lesions may occur together or separately in cases with primary 
buboes in distant parts. On the other hand, primary tonsillar 
lesions or primary cervical buboes sometimes are and sometimes 
are not followed by specific pulmonary lesions. The classifica- 
tion of pulmonary lesions adopted follows very closely that 
suggested by the Austrian Commission. The term "primary 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 251 

tonsillar bubo" has been introduced to designate the lesion oc- 
curring in the tonsil when that organ forms the portal of 
entrance of the bacillus to the organism, and it appears that 
such "tonsillar buboes" are associated with primary buboes of 
the second order in the prevertebral glands, whereas primary 
buboes of the parotid or submaxillary lymphatic glands are not 
associated with tonsillar lesions. 

It appears of importance to emphasize the occurrence of pha- 
ryngeal lesions in cases without pulmonary involvement, since 
these, as well as the pulmonary cases, may have infective sputum. 
The more thorough the study of bubonic plague, the greater 
appears the number of methods of possible direct and indirect 
transmission of the disease. In regard to the other viscera the 
particular features brought out in the present work are the 
relative infrequency of specific focal plague lesions except in the 
skin and the relative frequency of that lesion of the kidneys to 
which Herzog especially directed attention : namely, fibrin throm- 
bosis of the glomerular capillaries, which was present in at 
least 41 per cent of my cases. Two notable cases of plague 
meningitis have also been encountered in this series. 

SOURCE AND CHARACTER OF MATERIAL 

Bubonic plague appeared in Manila in June, 1912, 89 cases 
occurring up to June 13, 1914. In rats the disease is known 
to have been present since August 31, 1912, and 49 plague- 
infected rats were found up to June 13, 1914. Seventy-five of 
the human cases proved fatal, and post-mortem examination of. 
all of these cases was made. 

All fatal cases were autopsied at periods varying from a 
short time to two or three days after death ; two of them were 
performed after extensive putrefactive changes had taken place, 
the bodies having been previously buried. In all except these 
two cases the bodies were in a good state of preservation. The 
anatomic diagnosis was always confirmed by smears, cultures, 
agglutination of cultures, or by guinea-pig inoculations of por- 
tions of tissue removed from various parts of the body. In 
all of the earlier cases the bacteriological investigation included 
all four of the above procedures, as was also true in the later 
cases in which there was any possibility of doubt as to diagnosis. 
The tissues selected for routine bacteriological examination were 
from the buboes and spleen. 

Mortality. — Up to June 13, 1914, 89 cases occurred in Manila, 
75 of which were fatal. The mortality was, therefore, 84.27 
per cent. 



252 



The Philippine Journal of Science 



1915 



Race. — Fifty-eight of the cases were Filipinos, 16 were Chi- 
nese, and 1 was an American. 

Sex. — Sixty-two of the fatal cases were in males and 13 in 
females. 

Age. — The age of the patients ranged from 5 months to 56 
years. Table I shows the age incidence. 

Table I. — Age incidence of fatal plague cases. 



Age. 


Cases. • 

1 1 

9 
15 


Age. Cases. 


Under 1 year . 

I to 5 years 

6 to 10 years 

II to 15 years _ 

16 to 20 years 


21 to 25 years i 10 

26 to 30 years J 12 

31to40years 14 

41 to 50 years ._ ... .1 7 

51 years and over i 2 



Duration of illness. — The average duration of illness was five 
days. The occurrence of 6 cases with illness lasting from ten 
to fifteen days makes the general average higher than it other- 
wise would have been. In more than half the cases the duration 
of illness was five days or less. Table II shows the duration of 
illness. 

Table II. — Duration of illness in fatal plague cases. 



Duration 
of illness. 


Cases. 


Duration 
of illness. 


Cases. 


Days. 




Days. 




1 


5 


9 


1 


2 


6 


10 


3 


3 


15 


11 





4 


12 


12 





5 


9 


13 





6 


6 


14 


1 1 


7 


9 


15 


2 


8 


2 


unknown 


4 1 



The epidemic which furnished the material for this study was 
entirely of cases of the bubonic type, and it is with that type 
alone that this paper will deal. The epidemiologic and bac- 
teriologic aspects of this same epidemic have been the subjects 
of papers by Heiser 2 and by Schobl ". They have shown a 
direct relation between the incidence of the disease in rats and 
human beings in this epidemic. The origin of the epidemic is 
unexplained, the first recognized case occurring in a native who 
had not been out of Manila. Heiser ascribes it to the importa- 

' This Journal, Sec. B (1913), 8, 109. 
•Ibid. (1913), 8, 409. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 253 

tion of rats in cargo from China, since China at the time had 
infected ports from which vessels were constantly arriving. 

CLASSIFICATION OF PLAGUE CASES 
BUBONIC AND PNEUMONIC PLAGUE 

It is known that Bacillus pestis may produce two types of 
disease which differ in their epidemiologic, symptomatologic, 
and pathologic aspects. This difference in the type of disease 
caused by the same microorganism is dependent on the portal 
of entry into the host and on the condition of the atmosphere 
in regard to temperature and humidity. 4 When infection occurs 
through the skin or exposed mucous membranes, the bubonic 
type of the disease occurs and is manifested usually by enlarge- 
ment of the superficial lymphatic glands draining the area in- 
oculated, by fever and prostration, sometimes by extensive 
cutaneous symptoms, sometimes by marked pulmonary symp- 
toms, and frequently by marked cerebral symptoms. When the 
infection takes place through the respiratory tract, the primary 
pneumonic type of the disease occurs with symptoms chiefly 
referable to the lungs. The bubonic type is said to be trans- 
mitted chiefly from infected rats to the human being through 
the agency of the rat flea (Loemopsylla cheopis). Attention 
has been drawn to the possibility of its transmission by the 
cat, 5 as well as by direct contact with either plague patients 
having open cutaneous lesions, or with material infected by 
such patients, or by those with pulmonary or pharyngeal lesions 
from which the sputum may be infective. 

In the primary pneumonic form infection occurs by the inhala- 
tion of droplets of infective material produced in the acts of 
coughing or sneezing by patients with the pneumonic type of the 
disease. It is known that this method of transmission is com- 
mon during an epidemic of primary pneumonic plague, and it 
is a possibility that, under suitable conditions of temperature 
and humidity, the primary pneumonic type may be similarly 
contracted from a patient with bubonic plague who has a sec- 
ondary plague pneumonia. In these cases the infection is said 
by some to occur in the upper respiratory tract and extend 
secondarily to the lungs through the blood stream. Others main- 
tain that a primary infection of the lung occurs by direct inhala- 
tion of the infective material into the finer bronchioles and 
air sacs. 

'Teague and Barber, Ibid. (1912), 7, 172. 
'Schobl, Ibid. (1913), 8, 426. 



254 The Philippine Journal of Science ms 

SEPTICEMIC PLAGUE 

While these two types of plague (primary bubonic and primary 
pneumonic) are universally recognized, other types of the disease 
have been described by various authors. The Anglo-Indian 
Plague Commission G recognizes four types of the disease : 
namely, (1) bubonic, (2) septicemic, (3) pneumonic, and (4) 
pestis minor or ambulans. In this classification they refer to 
a primary plague septicaemia, and present the following descrip- 
tion of the type : 

Distinguishable clinically though, from the point of view of the path- 
ologist, not sharply marked off from the secondary plague septicaemias just 
described, are the cases of plague commonly spoken of as septicaemic, in 
contradistinction to bubonic cases. These are the cases where, owing to 
the more rapid passage of bacteria through the lymphatic filter, and 
possibly to a greater production of bacterial poisons, the constitutional 
symptoms precede and overshadow the local symptoms, the disease being in 
most cases rapidly fatal. 

In another part of the same report we find the following : 

Intense or septicemic type of plague. — In those cases in which the plague 
virus or toxin is in the patient widespread from the beginning of the illness, 
so as early to produce a general poisoning, whether septicaemic or toxaemic, 
the pathological changes, as might be expected, are much the same as in 
the more severe cases of Pestis major. Some observers, however, believe 
that pathological differences occur to distinguish this form of plague, and 
to serve, along with the symptoms, as a justification for the establishment 
of a so-called septicaemic type of the disease. They consist of the absence 
of buboes having the characters above described, and of a widespread in- 
volvement of glands, with distinctive changes in several of them. Although 
the lymphatic glands are always affected, in place of the affection consisting 
of one or, more rarely, of several groups of glands being enlarged and 
surrounded with sero-sanguineous extravasation, while the other glands 
are either normal or merely enlarged or congested, in this, the so-called 
septicasmic form, the affection of the glands shows itself as a general 
involvement of all, or nearly all, of the lymphatic glands of the body, 
although in many instances the affected glands were chiefly those of the 
mesentery. In no case, however, did the involvement proceed to the forma- 
tion of the characteristic plague buboes, but only to a moderate degree of 
change, practically restricted to the glands themselves, but still displaying 
in several of them certain distinctive features. These were moderate 
enlargement and oedema without much congestion, the glands being pink 
in color, firm and rounded, and with a soft interior, often possessing here 
and there small areas of softening surrounded by firm substance. Several 
of the affected glands may be thus modified, while others of them are merely 
enlarged and engorged with blood, thus resembling the less affected glands 
of ordinary Pestis major. Excepting the lymphatic glands, the parts that 
were affected showed essentially the same pathological changes as in the 

'Report of the Indian Plague Commission (1898-99), 5, 54. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 255 

bubonic variety of Pestis major, but usually the number of parts affected 
was smaller and the degree of change in them was less. 

From the pathologic standpoint the most detailed description 
of the so-called septicsemic type of plague is furnished by Childe. 7 

In the bubonic form of plague, one set of glands with extravasated blood 
around them forms the bubo, and there is practically no alteration in the 
remaining glands of the body; but in the septicaemic form there is no such 
bubo, yet there is general involvement of nearly all the lymphatic glands. 
Yet though so many glands show evidence of disease, one gland or several 
glands of one set show characteristic changes which are pathognomonic of 
this type of plague. These appearances are: — The gland is enlarged to the 
size of an almond or less, is rounded, firm and pink in colour; on section 
it shows some but not much engorgement and some oedema, its substance 
is rather soft and can be easily scraped off with a knife, and sometimes 
small softening areas were present. There was no haemorrhage in the 
areolar tissue around this gland and at most only a little oedema and 
trifling engorgement of the vessels. Commonly there were one or several 
such glands in one inguinal region, and usually the lowest gland of the 
chain was most markedly affected; whilst those higher up varied in size 
from a bean to an almond, and had the same firm pink appearance though 
there were at times some which looked nearly normal in size and shape. 
The iliac glands of the same side were similarly affected, as large as 
almonds and either pink and firm or softer and of a dark red colour. The 
inguinal glands of the opposite side showed similar changes, but sometimes 
to a less extent, and the iliac sometimes showed slighter changes or some 
of them looked normal. The lumbar usually showed slight enlargement 
and were either pale and soft or somewhat pink and firm. The cervical 
and axillary varied in size from hazel-nuts to peas and usually showed 
merely engorgement, being full of dark blood; but sometimes some of them 
showed the pink firm appearance described above. The mesenteric were 
enlarged to the size of peas and beans and were either slightly or con- 
siderably engorged. The supra-trochlear and popliteal were normal or 
engorged. There was no haemorrhage or oedema around any of the above- 
mentioned glands, and no enlargement of the lymphatic vessels was observed. 
The condition of the remaining organs was such as has already been 
described under the bubonic form. 

Note. — In several cases of Plague-septicaemia where death had occurred 
shortly after attack, the glands were found slightly enlarged, of a dark red 
colour and contained much blood and oedema fluid. This appeared to be an 
earlier form of the characteristic pink plague glands described above. The 
difference between the bubonic and septicaemic form of plague appears to 
be this : — In the bubonic form the plague bacillus after entering the body is 
arrested at the nearest group of glands, grows here vigorously, and as a 
result of its growth the bubo is formed. Here the bacillus forms the toxins 
which are discharged into the system and cause the symptoms of plague, 
but the glands of the bubo form a barrier which prevents the bacilli from 
passing on and growing generally throughout the body; and it is. only 
shortly before death, in fatal cases, that this resistance is overcome and 

'Report of the Indian Plague Commission (1898-99), 1, 368. 



256 The Philippine Journal of Science imb 

the bacilli are able to pass on into the system generally. But in the 
septicemic form the bacillus, after entering the body, meets with feeble 
resistance at the nearest glands; it speedily overcomes all opposition and 
passes on to infect other glands and organs where it grows abundantly. 

The Austrian Commission also recognizes this type of the 
disease, which it calls septicopyemic. 

Concerning primary plague septicemia, the German Commis- 
sion s reports : 

Primary plague septicaemia probably does not exist. At least our own 
Commission as well as the Austrian one, and other investigators, have 
found on post-mortem examination, in such cases in which the portal of 
entrance of the virus could not be ascertained, small haemorrhagic glandular 
foci, or a focus in the lung. These had in consequence of the indifference 
of the patients, or in consequence of their occult location, escaped notice 
during life. Hence plague septicaemia is not a special type of the disease, 
but the generalization of a primarily local process. That it may then again 
lead to other secondary internal foci we have demonstrated in a case of 
plague meningitis. 

Strong and Teague, 9 who had the opportunity of studying the 
epidemic of primary pneumonic plague, reached the following 
conclusion in regard to primary plague septicaemia : 

From our studies made upon human beings, during the Manchurian 
epidemic, as well as from the animal experiments quoted above, we must 
conclude that primary plague septicaemia does sometimes take place and 
that death may occur, though rarely, before visible lesions have taken place 
either in the lungs or lymphatic glands. 

Herzog 10 opposed the classification of plague in man as a 
general haemorrhagic septicaemia. This conclusion he bases on 
"the fact that all observations made on man show that the plague 
bacillus is not present at all early in the course of the disease in 
the general blood circulation," and further on the fact that 
"histologic examinations have further demonstrated that as a 
rule plague bacilli are either found not at all in the vascular 
system or are present in such very small numbers that an agonal 
or post-mortem invasion suggests itself." 

Herzog's classification of plague is as follows : 

(1) Primary uncomplicated bubonic plague; (2) primary bubonic plague 
with secondary septico-pyemia ; (3) primary bubonic plague with secondary 
plague pneumonia; (4) primary plague pneumonia; (5) primary plague 
pneumonia with secondary septico-pyemia ; (6) primary plague septicaemia. 

In regard to the presence of B. pestis in the circulating blood 

* Arb. a. d. kais. Gesundheitsamte (1899), 16, 75. 

1 This Journal, Sec. B (1912), 7, 180. 

'"Pub. Bur. Govt. Labs., Manila (1904), No. 23, 20. 



x, b, 4 Croivell: Pathologic Anatomy of Bubonic Plague 257 

Schobl u made blood cultures from patients with bubonic plague 
at periods of from three and one-half to seventy-five and one- 
half hours before death. He concludes that: 

(1) A severe septicaemia may be present at a comparatively early stage 
of the disease and for a considerable number of hours before death, and 
(2) the septicaemia may be of an irregular and fluctuating type. 

Further he states : 

(1) * * * that positive blood culture was obtained in practically 
every case that was examined in the febrile stage of the disease, even 
when buboes or signs of pulmonary involvement had not been detected 
clinically. (2) It is evident that Bacillus pestis may be found in the circu- 
lating blood of the patients even in cases which subsequently recover. 

In the evidence concerning the occurrence of septicsemic plague 
above quoted, there appears much that is indefinite and some 
that is conflicting. Hence it is not surprising that there is some 
confusion as to exactly what constitutes a case of "septicsemic 
plague," if, indeed, such a category is necessary in the nomen- 
clature of plague. Strictly speaking, any case of plague in 
which the organisms multiply in the circulating blood is a case 
of septicemic plague, but the adoption of this standard would 
place all fatal cases of both primary bubonic and primary 
pneumonic plague in this category. Therefore it would seem 
more rational to include in this class only those cases (1) in 
which septicaemia is evidently an early event (2), those in which 
gross focal visceral plague lesions occur, and (3) those in which 
the primary buboes are not prominent. These cases are the ones 
which give rise to the greatest difficulty from the clinical stand- 
point, which fall naturally into a class by themselves in the 
mind of the clinician, and which present both clinically and 
anatomically the most unmistakable evidences of septicaemia or 
septicopyaemia. 

All three of these features may not be present in the same 
case, and therefore all cases in this class may not be of exactly 
the same type anatomically. 

In this class should also be placed those cases in which there 
is mixed infection ; that is to say, those in which more than one 
variety of organism can be isolated from the spleen after death. 

INTESTINAL PLAGUE 

Some writers have considered that the gastrointestinal tract 
may be the portal of entry of the plague bacillus and have dis- 

11 This Journal, Sec. B (1913), 8, 413, 415. 



258 The Philippine Journal of Science wis 

tinguished another type of plague of this class. Wilm, 12 Hos- 
sack, 13 and Zuppita " have reported such cases, but no case of 
primary intestinal plague has been unequivocally proved. 
Childe 15 says : 

* * * That no bubo of the mesenteric glands was ever found; these 
glands were always examined, and though changes might be found in them, 
they were always less marked and less distinct than plague glands found 
in other parts of the body. In short, there was no autopsy which went 
to show that the plague bacillus had reached the stomach or intestine, e. g., 
in food, and then infected the mesenteric glands. 

However, this does not exclude the occurrence of secondary 
intestinal lesions in plague, which will be described in my cases. 

CUTANEOUS PLAGUE 

Cutaneous plague does not present any characteristics entitling 
it to recognition as a separate entity, and the lesions encountered 
on the skin will be later described. 

PESTIS MINOR 

The Anglo-Indian Commission 16 reports on pestis minor or 
ambulans as follows: 

In addition to the three main types of plague which have been described 
above (bubonic, septicaemic, and pneumonic) , an abortive form of bubonic 
plague comes under observation. This is technically known as pestis minor 
or pestis ambulans. It cannot be doubted that in these abortive bubonic 
cases the bacteria are, as in the case of ordinary bubonic plague, carried 
to the lymphatic glands, but they are held back there, the disease stopping 
short of the septicaemic stage. In correspondence with this the constitu- 
tional symptoms are very light. Indeed in certain cases not only the 
constitutional, but also the local symptoms may be so slight as to be, except 
for their pathological interest, almost undeserving of attention. Such 
cases appear to be extremely common among persons who have been much 
exposed to the infection of plague and are characterized by sensations of 
numbness and tingling, or by neuralgic pains, which in many cases are 
associated with the development of shotty glands in the armpit and the 
groins. We may, however, remark here that the whole question of pestis 
minor urgently requires to be more fully elucidated. 

Since my experience has been gained in the morgue and 
laboratory, and cases of pestis minor are not fatal, I am not 
in a position further to refer to these cases. 

12 Hyg. Rundschau (1897), Nos. 5 and 6 (quoted by Herzog). 
"Brit. Med. Journ. (1900), 2, 1486. 
u Zeitschr. f. Hyg. u. Infectionskrankh. (1899), 32, 268. 
"Report of the Indian Plague Commission (1898-99), 1, 368. 
"Ibid. (1898-99), 5, 54. 



x, b, 4 Crow ell: Pathologic Anatomy of Bubonic Plague 259 

author's classification 

From a study of my cases and those in the literature it seems 
sufficient from the pathologic standpoint to recognize only the 
two main types of plague: namely, the primary bubonic and 
the primary pneumonic types. These two types appear to me to 
include all cases of the disease. If it be desirable to subdivide 
the types in order to emphasize the fact that the alterations and 
symptoms do not always follow the same course, they may be 
so subdivided as to give prominence to the features most com- 
monly encountered. This subdivision will be more of value to 
enable one unfamiliar with the disease to recognize an atypical 
first case in a community, rather than as serving to indicate 
any essential difference in the pathologic processes occurring. 
Such a classification is here suggested. 

I. Primary bubonic plague. 

1. Uncomplicated bubonic plague. 

2. Bubonic plague (with early septicaemia or without superficial bu- 

boes). 

3. Bubonic plague (secondary pneumonic type). 

4. Bubonic plague (secondary meningeal type). 

5. Bubonic plague (secondary cutaneous type). 

II. Primary pneumonic plague. 

To follow this classification to its logical conclusion, those 
types in which focal hepatic or renal lesions are present should 
also be separated, but this would serve only unduly to complicate 
the classification, especially as these types do not present prom- 
inent clinical differentiating characteristics. 

GENERAL DESCRIPTION OF THE PATHOLOGY OF BUBONIC PLAGUE 

The lesions of bubonic plague are due to Bacillus pestis and 
its endotoxins. The bacilli are introduced by the bite of an 
infected rat flea. A small papule may appear at the point of 
inoculation. The bacilli multiply and pass along the lymphatic 
vessels to the lymphatic glands into which they drain. The 
glands act more or less perfectly as bacterial filters and are at 
the same time usually profoundly altered by the action of the 
bacilli. These primarily affected glands are spoken of as the 
primary bubo of the first order, and from these the bacilli pass 
along the lymphatics to the next proximal glands, producing 
alterations in these glands which are, as a rule, of a lower grade 
of severity than in the primarily affected glands. The glands 
which are infected from the primary bubo of the first order by 
direct lymphatic continuity are spoken of as primary buboes 
of the second order. The bacilli, at some time in the disease, 



260 The Philippine Journal of Science ma 

usually, if not always, enter the circulating blood, and other 
lymphatic glands throughout the body become infected. These 
glands, infected through the circulating blood, are known as 
secondary buboes. 

The other parts of the body suffer degenerative changes as 
the result of the action of the bacteria, of their endotoxins, and 
of the resultant fever. 

The action of the bacilli is particularly severe on the walls of 
the blood vessels, which accounts for the widespread haemor- 
rhages which take place. 

Focal lesions in different portions of the body occur as the 
result of bacillary emboli; in this way are produced areas of 
necrosis, focal or larger, in the spleen, liver, and kidneys, and 
pneumonic foci in the lungs. Extensive cutaneous lesions may 
also be thus produced. Meningitis occurs in a small percentage 
of the cases. 

A septicaemia probably occurs at some stage of the disease in 
the majority of the cases and certainly before death in all fatal 
cases. 

In bubonic plague, as well as in other acute bacterial infections, 
the infective agent may produce its most injurious effects some- 
times in one part of the body and sometimes in another; and 
according to the parts most seriously affected, there may be 
distinguished several subtypes of the disease. These have al- 
ready been referred to under the head of Classification. 

PORTAL OF ENTRANCE OF THE INFECTIVE AGENT 

Entrance occurs most frequently on the skin and less fre- 
quently on the mucous membranes. 
Dieudonne and Otto 17 say : 

In bubonic plague the portal of entry for the plague bacillus is chiefly 
the skin. In practice it is usually very difficult to find this portal of 
entry. In the majority of cases small abrasions of the skin, flea-bites, 
and insignificant scratch wounds evidently suffice to furnish the bacteria 
an entrance; indeed even intensive rubbing the skin with fingers or clothes 
to which pest bacilli are adherent is sufficient to produce an infection. Since 
the flea while sucking regularly deposits faeces, it is very possible that by 
scratching the place the pest bacilli present in the faeces of the flea may 
be rubbed into the small wounds in the skin. 

Dieudonne and Otto's statement that in practice it is usually 
very difficult to find the portal of entry has been corroborated 
by my experience. In the majority of the cases at autopsy no 

17 Kolle und Wassermann, Handbuch der pathogenen Mikroorganismen. 
Gustav Fischer, Jena (1912), 4, 207. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 261 

lesion was visible in the area drained by the glands forming the 
primary bubo which could be designated as the portal of entry. 
In a few cases small papules looking like insect bites were found, 
which in sections showed some necrosis of the skin and masses 
of bacilli, but it cannot be denied that these might have been 
noninfective bites which formed a locus minor resistentiss, which 
favored infection through the blood stream. 
Castellani and Chalmers state : 1S 

The site of inoculation is sometimes marked by a vesicle, the contents 
of which contain the Bacilhis pestis in considerable numbers. 

Albrecht and Ghon state: 19 

In no single case could we demonstrate with absolute certainty and 
incontestably the immediate portal of entry of the pest virus. 

The skin is a frequent seat of secondary plague lesions, and 
plague bacilli may also contaminate wounds and abrasions of 
the skin. Therefore the presence of pest bacilli in a cutaneous 
lesion, even though the infection occur in the area of skin drained 
by the glands constituting the primary bubo, is not sufficient 
evidence to class that lesion as indubitably the primary portal 
of entry. 

The mucous membranes that form portals of entry are those 
lining the nose, mouth, pharynx, conjunctiva, and the genitalia. 
The tonsils are a frequent portal of entry in cases of cervical 
buboes. (See discussion under cervical buboes.) 

In 2 of our cases (1969, 2084) there were found lesions on the 
foot which, judging especially from the histologic appearance, 
were in all probability primary lesions. The lesion appears to 
extend, in these cases, from the skin into the subcutaneous 
tissues, and is characterized by congestion, oedema, necrosis, 
haemorrhage, masses of bacteria, leucocytes, and swelling of the 
endothelial cells. One of these cases will be described in greater 
detail. 

Case 2084. — Over the middle of the fifth left metatarsal bone is a small, 
pale papule, or blister, of the skin. Section of this shows it to contain 
a small amount of turbid fluid. This case has a left femoral bubo and 
cutaneous petechia?. Microscopic section of the papule shows some cedema 
of the epithelium and corium. In the corium and subjacent tissue the 
fibers of connective tissue are separated (cedema) . The vessels are dis- 
tended with blood. There are large zoogleal masses of bacteria between 
the tissue fibers, about the sweat glands, and in the lymphatic vessels. 

"Manual of Tropical Medicine. Wm. "Wood & Co., New York (1910), 
783. 

10 Uber die Beulenpest in Bombay im Jahre 1897. Wien (1898), II B, 
484. 



262 The Philippine Journal of Science i»is 

A few polymorphonuclear leucocytes are present. There is a small hami- 
orrhagic extravasation in the outer portion of the corium and some 
necrosis of tissue about this. Nuclear fragments are seen scattered through- 
out the area. The area of involvement is greater in the subcutaneous 
tissue than in the epidermis; the bacteria are very numerous and are 
present throughout the entire lesion. The endothelial cells lining the lym- 
phatics are large and prominent. While this picture does not furnish 
absolute evidence of primary cutaneous infection, neither does it exclude 
it, and taken with the other findings in the case, it is considered that this 
is in all probability the portal of entry. 

SKIN 

The Austrian Commission 20 states that the most frequent 
alteration in the skin is the occurrence of multiple haemorrhages, 
varying in size from 2 millimeters to several centimeters in 
diameter. These are embolic in nature, the vessel lumen being 
occluded by a bacterial embolus, and they are most frequent in 
cases with abundant bacteria in the blood and spleen. That 
they are not purely toxic in origin is shown by the fact that 
when only a few or no bacilli are in the circulation these haem- 
orrhages are scant or absent. 

In my cases haemorrhages in the skin were not noted as of 
unusually frequent occurrence, and they were often so small 
as to escape notice after death, unless attention was drawn to 
them by the physician who had seen the case during life. Small 
vesiculopapular lesions were present in at least 8 of my cases, 
in some being numerous and widespread over the body and in 
others being localized. The most frequent type is one in which 
there are small pinhead-sized, conical, pearly nodules surrounded 
by a hyperaemic zone. Incision into these discloses a turbid fluid 
which contains plague bacilli in greater or lesser numbers. 

Plague carbuncles occasionally occur. These are described by 
the Austrian Commission as circular, prominent areas, up to 8 
centimeters in diameter, with elevated, firmly infiltrated mar- 
gins. In the center the epithelium is raised as in a blister, 
which is filled with thick, reddish exudate. If the blister bursts, 
the contents, with many bacilli, flow out and the dried-up epithe- 
lium collapses and lays bare a moist, damp, bright red and yellow- 
spotted and speckled corium forming the base of the ulcer. 
These may develop from direct extension over a bubo, by in- 
fection through the lymph stream, or through the blood stream. 

In 5 cases there were lesions of the skin which corresponded 
more or less closely to the description of the plague carbuncle 
furnished by the Austrian Commission. In 3 cases these were 

"tJber die Beulenpest in Bombay (1898), II B, 4S1. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 263 

single, and in 2 cases, double. In 1 case the lesion was situated 
in immediate relation to a primary bubo, while in the other cases 
the infection was presumably through the blood. 

Case 2628. — The upper arms and back present numerous small, circular, 
red, slightly elevated foci without suppuration, which measure up to 0.5 
centimeter in diameter. In the left axilla is a large dark area measuring 
1.5 centimeter in diameter, on section into which there is necrosis of the 
skin and immediately underlying tissues, with very dark discoloration as 
though due to haemorrhage. A similar, slightly smaller area is present 
over the manubrium sterni. 

Case 2993. — On the left shoulder over the supraspinous fossa is a rup- 
tured pustule, 0.5 centimeter in diameter. Surrounding this is a circle of 
elevated vesicles, one or two of which have been ruptured. These contain 
reddish serous fluid. Surrounding this is a zone of deep red skin, the 
entire area measuring 4 centimeters in diameter. The underlying tissue 
is firm. Just behind the clavicle to the inner side of the skin lesion are 
two adjacent, softened, hemorrhagic lymphatic glands about 1 centimeter 
in diameter. The tissue surrounding these is cedematous and red with 
numerous haemorrhages. This forms the primary bubo. 

Case 2888. — Over the left buttock just to the left of the lumbosacral 
articulation there is a slight excoriation of the skin with a broad zone of 
reddish discoloration about it. On section into this, reddish creamy fluid 
exudes, and there is found extensive softening and reddish discoloration 
of the subcutaneous tissue, extending for a depth of 0.5 centimeter. Over 
the right buttock near the gluteal fold is a smaller and more superficial 
reddish area, section into which shows slight reddish discoloration of the 
tissue only; there is no pus at this point. At other portions of the body 
are seen a few minute, red punctaa, these being most numerous over the 
arms. 

HISTOPATHOLOGY OF THE SKIN 

The lesions occurring at the points which were supposed to be 
the portals of entry have been already described. There remain 
the haemorrhages, papules, and carbuncles. The hemorrhagic 
lesions consist of simple haemorrhages in the corium and sub- 
cutaneous tissue. This haemorrhage is small and does not often 
extend into the epithelial layer. In my cases there were no 
large diffuse cutaneous haemorrhages such as have been described 
in some epidemics. It was these large cutaneous haemorrhages 
that caused the disease to be described as the "black death." 
The papules present a very characteristic picture of necrosis of 
the skin with leucocytes and bacterial invasion. A detailed des- 
cription of one of the papules from case 2335 is here given. 

Case 2335. — At the point of the lesion the skin is slightly elevated on 
account of the infiltration to be described. The epidermis at the apex is 
reduced to about one quarter of its normal thickness, and all traces of epi- 
dermal layers have been destroyed. Here the papillae are lacking, and 
the epidermis is represented by an almost homogeneous eosinophilic mass 
with very few nuclei visible. Clefts in this epidermis show masses of 



264 The Philippine Journal of Science wis 

bacilli. The corium and a superficial part of the subjacent tissue have 
undergone necrosis and are replaced by a mixture of polymorphonuclear 
leucocytes, bacilli, and nuclear fragments. The bacilli form dark blue 
masses in strands and globules. It cannot be recognized whether these 
strands are in lymphatics or blood capillaries. This infiltration extends 
slightly laterally in the corium, but not deeply. The vessels in the corium 
just surrounding this zone of infiltration are much engorged. 

The histological changes in the carbuncles differ only in degree 
from those in the papules. The necrosis and loss of tissue is 
much greater, and the zone of infiltration with leucocytes and 
bacilli extends more deeply, forming a virtual phlegmon. 

LYMPHATIC GLANDS 

Lymphangitis between the point of entry of the infective 
agent and the primary bubo does not occur. The primary bubo 
occurs in the lymphatic glands draining the area of the skin 
which forms the portal of entry of the plague bacillus. 

The Anglo-Indian Commission 21 points out that the skin sur- 
faces which drain respectively into the glands of the neck, the 
axilla, and the groin stand to each other approximately as the 
figures 1:1.8:5 and that there is a striking coincidence between 
these figures and those which express the relative frequency of 
the buboes in these situations, which they found to be 1:1.3:5.8. 
When the portal of entry of the bacillus is situated in the distal 
parts of the extremities, the popliteal and cubital glands are 
seldom the seat of the primary bubo. In this disease, as in 
other similar infections, the infection passes to the groin and 
axillary glands, although no satisfactory anatomical explanation 
of this phenomenon has been offered. 

The changes occurring in the primary bubo may be very 
striking. In a well-marked case there is a visible rounded prom- 
inence over the site of the glands, which to the palpating hand 
feels boggy, elastic, and firmer than normal. Individual glands 
cannot be palpated, and it may be impossible to move the skin 
over the subjacent structures. The whole mass is indefinitely 
outlined, merging gradually into the surrounding tissue. Punc- 
tate haemorrhages may be present in the skin overlying the bubo, 
and in a very small number of cases definite pustules may have 
formed. The entire extremity, in the case of femoral or axillary 
buboes, may be osdematous as the result of pressure of the en- 
larged glands upon the vessels and as the result of lymph 
obstruction. 

-'Report of the Indian Plague Commission (1898-99), 5, TO. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 265 

On section into a primary bubo there will be found a dense 
subcutaneous tissue which typically exudes a large amount of 
clear yellowish fluid. A mass of glands will be found which 
are enlarged sometimes to as much as 5 centimeters in diameter. 
These glands are conglomerate and hsemorrhagic, as is also the 
periglandular areolar tissue, thus making the outlines of the 
glands indistinct. In the early stages the glands are firm and 
red, while in the later stages they become softened and show 
yellowish areas. One or several glands may be involved in this 
mass, and the amount and extent of the oedema and haemorrhage 
varies in different cases. Most frequently there are several 
glands involved, and the tissues surrounding the glands are also 
very hsemorrhagic and oedematous, this condition involving 
muscles, vessel walls, and fascia? (Plate V). Extension along 
fascial planes may also be a marked feature, as in groin cases, 
down Hunter's canal, and, in axillary cases, up into the neck. 
The infiltration of the subcutaneous areolar tissue between the 
bubo and the skin may be so dense as to make this tissue almost 
of cartilaginous consistence. 

While this description applies to a well-marked case, the 
changes may be of a much slighter grade, the primarily affected 
glands being small and showing very little intra- or extra- 
glandular haemorrhage, oedema, or necrosis. In some cases the 
primary bubo consists only of a single gland with relatively 
slight changes. It is maintained by the Anglo-Indian Commis- 
sion that this is the type of disease in which an early septicaemia 
occurs, the bacteria not being held back by the lymphatic glands. 
The Austrian Commission demonstrated that true suppuration 
may occur in the primary bubo from the action of the plague 
bacillus. In my series are instances of suppuration in the 
primary bubo and in the meninges, in which the plague bacillus 
was the only infective agent demonstrable. 

Schobl 22 says : 

It can be seen from the table that the plague bacilli may not be detected 
in the enlarged gland at first and that their presence may be revealed only 
after repeated examination of the bubo. It is also evident from the results 
of repeated examinations that the plague bacilli disappear from the infected 
gland in a comparatively short time, as a rule at the time when pus starts 
to form. Contrary to the findings in patients who died, distinct phagocytosis 
was noticed in the smears made from the aspirated liquid in those patients 
who recovered and who had been treated with serum soon after the onset 
of the disease. It is undoubtedly this process that clears the gland of the 
infectious agents. 

22 Loc. cit., p. 412. 

133736 2 



266 



The Philippine Journal of Science 



1915 



These primarily affected glands just described constitute the 
primary bubo of the first order. 

The infection passes from these glands along the lymphatic 
channels to the next proximal glands, which in turn form the 
primary buboes of the second order. Retrograde metastases may 
occur along the lymph channels to the glands of the opposite side, 
and these glands show changes similar to the primary bubo of 
the second order. The possibility of a double primary bubo must 
be borne in mind. That this may occur cannot be doubted, and 
such cases have been recorded. In only one case (2131) of my 
series did this seem probable among the groin cases, but seven of 
the cervical buboes were bilateral, and the lesions on the two sides 
were so similar that it could not be denied that both might have 
been primary, although it seems improbable that this was so in all 
of these cases. The glands of the opposite side of the body may 
also become infected through the blood, in the same manner as 
the glands in other parts of the body, thus constituting secondary 
buboes. The changes in the primary buboes of the second order 
are similar in character to those in the primary buboes of the 
first order, but less in degree. The involvement of the glands 
and periglandular tissue in oedema, haemorrhage, and necrosis is 
less, and the glands are not as a rule matted together nor so 
much enlarged. The oedema, especially, is usually much less 
marked than about the primary bubo of the first order. 

The secondary buboes show lesions similar in character to 
those usually exhibited in an acute infection by the blood stream. 
They are slightly enlarged and much congested, but seldom show 
haemorrhage, surrounding oedema, or much necrosis. We have, 
however, encountered one case in which suppuration occurred 
in a secondary bubo. 

Table III shows the location of the primary buboes in our 
series. 

Table III. — Location of buboes in 75 fatal cases. 



Gland. 


Right. 


Left. 


Double. 


Total. 

55 

10 

6 

3 

1 




31 
2 
2 
2 
1 


24 

1 
4 


1(?) 
7(?) 

1 








Popliteal -- 











From this table it will be seen that cervical, axillary, and 
femoral buboes in our series occurred in the proportion of 
1:0.6:5.5, as compared with the Anglo-Indian Commission's pro- 
portion of 1 : 1.3: 5.8. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 267 

HISTOPATHOLOGY OF THE LYMPHATIC GLANDS 

To trace the morphological changes in the glands from the 
beginning of the disease to its advanced stage requires a study 
of many glands in different stages of the disease. As the 
primary buboes of the second order are infected through the 
lymphatics and show lesions slighter in degree than those in 
the primary buboes of the first order, but similar in character, 
they form the best material for the study of the earlier changes. 

The lesion in the glands is essentially a hemorrhagic inflam- 
mation with coagulation necrosis. In the early stages the plague 
bacilli are present in large numbers and are situated in masses, 
chiefly in the peripheral perifollicular lymph sinuses. Early 
there occurs what is practically a "catarrh" of the lymph sinuses. 
The endothelial cells lining them enlarge and multiply, and 
many are found lying free in the sinuses intermingled with red 
blood cells and a granular material. The sinuses are dilated, 
apparently from cedema. At the same time oedema of the gland 
causes it to assume a much looser and more open arrangement of 
its constituent parts, losing its follicular arrangement. 

Extreme congestion of the blood vessels is an early event, 
and changes in the vessel walls appear. They become swollen 
and lose their normal appearance, becoming more homogeneous 
and fibrillar in appearance, Small clefts appear in the vessel 
walls, and the nuclei fail to stain with hsemotoxylin. This ap- 
pearance is very similar to an cedematous hyaline change. The 
lining endothelial cells of the vessels become swollen and are 
often separated from the basement membrane by small spaces. 
Fibrin appears at the periphery of the lumen and may be seen 
in some of the spaces in the vessel wall and, later, in the tissues 
immediately about the vessels. In some cases this fibrin net- 
work completely occludes the lumen of the vessel, but its peri- 
pheral arrangement is much more frequently seen. In the later 
stages the vessels may be very much dilated; their walls are 
thin, and the lumen may be filled up with polymorphonuclear 
and mononuclear leucocytes, erythrocytes, and fibrin. Bacilli 
are also frequently found in these thrombi in the late stages. 

The blood passes from the vessels into the surrounding tissue, 
and the gland is so much enlarged and so hemorrhagic that the 
scattered remains of the original adenoid structure are difficult 
of recognition. They appear as small masses of lymphocytes 
amid the masses of blood cells and bacteria. Necrosis of the 
adenoid elements occurs and is represented by masses of granular 
material containing chromatin fragments. The trabecule of the 
gland undergo a change similar to that of the vessel walls ; they 



268 The Philippine Journal of Science ims 

become hyaline and loose in structure and finally become unrecog- 
nizable. Polymorphonuclear leucocytes may appear in relatively 
large numbers, and these may contain bacteria. This seems 
to be particularly true in cases that have lived for several days. 
In those cases that have shown macroscopic evidence of sup- 
puration the polymorphonuclear leucocytes are especially abun- 
dant. The capsule of the gland becomes infiltrated with red 
blood cells, leucocytes, and bacteria and undergoes a hyaline 
degeneration Math eventual necrosis. The entire process thus 
extends to the periglandular tissue, where the adipose tissue 
may be seen to be infiltrated, haemorrhagic, and necrotic, in the 
same manner as is the gland itself. Traces of the capsule of the 
gland can usually be found microscopically. The vessels in the 
periglandular tissue may show the same changes as those within 
the gland, and it is not infrequent to find these occluded by leu- 
cocytic and bacillary thrombi. In the gland and periglandular 
tissue large mononuclear cells, probably derived from the endo- 
thelial cells, may be numerous. These engulf the bacteria and 
fragments of other cells. Groups of plasma cells are not in- 
frequent. The nerves in the neighborhood of the bubo, and 
the walls of the large vessels, may show morphologic changes 
similar to those described in the gland. 

The blood cells which compose the haemorrhagic mass in the 
late stages lose their contour and become a more or less solid 
mass of eosinophilic structureless material. There may be 
visible shadows of individual cells. This process is one of 
haemolysis. 

The number of bacilli appearing in large masses in the glands 
and periglandular structures is frequently enormous. In the 
earlier stages these appear to be largely confined to the lymph 
sinuses ; but with the breaking up of the structure of the glands, 
the bacterial masses are scattered throughout — within the gland, 
in the surrounding tissue, and in the vessels. In autopsy ma- 
terial, post-mortem proliferation of the bacilli has probably 
occurred. 

In the examination of a bubo in the late stages it may be 
impossible to recognize it as of glandular structure. One may 
see only haemorrhage, cedema, bacterial masses, and necrotic 
material. From such an examination one could not determine 
whether the necrosis or haemorrhage is primary, but it would 
seem in many instances, at least, that the necrosis of the vessel 
walls appears before the massive haemorrhages take place. 

It is not possible to state accurately the chronological order 
in which the various changes in the glands occur, but the changes 



x, b, 4 Crow ell: Pathologic Anatomy of Bubonic Plague 269 

may be summarized somewhat as follows: First, there is mul- 
tiplication of bacilli; then follow congestion, oedema, "catarrh" 
of the lymph sinuses, hyaline degeneration and necrosis of the 
walls, migration of erythrocytes and leucocytes, necrosis of 
glandular tissue, haemorrhage, formation of fibrin in and about 
the vessels, vascular thrombosis, and similar involvement in 
the capsule of the gland and the periglandular structures. These 
changes are essentially those of hemorrhagic (occasionally sup- 
purative) inflammation, with coagulation necrosis. The chief 
peculiarity of the plague bubo is the very abundant oedema of 
the periglandular structures. The lesions that have been de- 
scribed occur in varying grades of intensity and in varying 
combinations in all plague-infected glands. In some the haemor- 
rhage and oedema may be the most-marked feature, while in 
others suppuration may occur. In slightly affected glands the 
changes may consist only of bacterial multiplication, oedema, 
congestion, and catarrh of the sinuses. These form the most 
prominent features in the average secondary bubo, although 
in some of these there may be slight haemorrhage and slight 
necrosis. The involvement of the capsule and the periglandular 
tissue is usually minimal or absent in secondary buboes. 

BUBONIC PLAGUE WITH EARLY SEPTICAEMIA ( SO-CALLED SEPTICEMIC PLAGUE) 

The literature on septicaemic plague has been quoted rather 
fully in the introduction. The evidence as to what exactly 
constitutes a case of septicaemic plague is rather confusing. 
Strictly speaking, any case of plague in which the organisms 
multiply in the circulating blood is a case of septicaemic plague, 
but the adoption of this standard would place all fatal cases 
of both primary bubonic and primary pneumonic plague in this 
category. It would, therefore, seem more rational to include 
in this class only those cases in which septicaemia is evidently 
an early event, those in which gross focal visceral plague lesions 
occur, and those in which the primary buboes are not prominent. 
These cases are the ones which give rise to the greatest difficulty 
from the clinical standpoint, which fall naturally into a class 
by themselves in the mind of the clinician, and which present 
both clinically and anatomically the most unmistakable evidences 
of septicaemia or septicopyaemia. All three of these features 
may not be present in the same case, and therefore all cases 
in this class may not be of exactly the same type anatomically. 

In this class should also be placed those cases in which there 
is mixed infection — that is to say, those in which more than one 
variety of organism can be isolated from the spleen after death. 



270 The Philippine Journal of Science wis 

In three of my cases (2092, 2148, 2150) the pneumococcus and 
the plague bacillus were isolated from the spleen, in another 
(2125) a streptococcus and the plague bacillus, and in a third 
(2267) a streptococcus, Bacillus mucosus capsulatus, and the 
plague bacillus. These cases will be referred to again in the 
description of the lesions in the spleen. 

Excerpts from the autopsy reports of three cases in which 
the primary bubonic lesion was slight will be presented, and 
one typical case showing the widespread, gross, focal plague 
lesions will be reported in full. The following cases illustrate 
the lesions found in cases of early septicaemia. 

Case 2125. — Filipino, male, 20 years old. The duration of illness was 
four days. The inguinal glands are somewhat enlarged, firm, dark, but 
no haemorrhages are present in the surrounding tissues. The glands of 
the left side are slightly more prominent than those on the right. Slight 
oedema is present on both sides. On section these glands are dark red 
and present small haemorrhages. The axillary glands are smaller, discrete, 
and red, and show no haemorrhages in or about them. The popliteal glands 
are small and red. Internal glands show no change. Bacillus pestis was 
found in the inguinal glands and spleen. Streptococcus pyogenes was also 
isolated in culture from the spleen. No other focal plague lesions were 
found. 

Case 2295. — Filipino, male, 15 years old. Duration of illness was stated 
as one day. Section over the femoral regions reveals pale, firm, discrete, 
slightly enlarged lymphatic glands. There is no surrounding cedema nor 
haemorrhage. The mesenteric and lumbar glands are small, firm, and pale. 
Section over the axillary lymphatic glands shows them to be slightly 
enlarged, discrete, firm, and somewhat reddened. They, however, present 
no haemorrhages, nor is there surrounding cedema or haemorrhage. The 
faucial tonsils are pale, firm, and not enlarged. The superficial and 
deep cervical glands are not enlarged, but all are deep red; they show 
no surrounding haemorrhage nor cedema. At the bifurcation of the trachea 
is one large haemorrhagic and much softened lymphatic gland. This case 
had numerous cutaneous vesicles and extensive, secondary plague nodules 
in the lungs. 

Case 2378. — Filipino, male, 16 years old. The duration of illness was 
three days. The superficial lymphatic glands are not palpably enlarged. 
On section over the right groin the tissues are found very slightly cedem- 
atouS; the glands are not enlarged, but are somewhat red. The glands 
in the left groin appear unchanged. The glands in both axillae are red, 
but there is no oedema surrounding them and they are not softened. The 
peribronchial, mesenteric, lumbar, and cervical glands are not enlarged. 
There were no focal plague lesions. Bacillus pestis was isolated from the 
spleen. 

Case 1909. — Chinese, male, 32 years old. The duration of illness exceeded 
three days. Autopsy was performed one hour after death. The body is 
that of a well-nourished, male Chinese. On the inner surface of the right 
foot there is a very small incised wound, which represents the place from 
which cultures were made of a papule suspected of being the point of 
inoculation. On the left arm, just below the elbow, is a superficial ulcera- 



x. b, 4 Crow ell: Pathologic Anatomy of Bubonic Plague 271 

tion of the skin, which looks like a large ruptured vesicle. This was 
excised for histological examination. There is marked rigor mortis and 
no external oedema. Slight post-mortem hypostasis is present. 

In both femoral regions are marked rounded prominences. Other su- 
perficial nodes are not enlarged. On section into the femoral regions the 
lymph nodes are found somewhat enlarged but discrete. There is little 
or no oedema of the tissues surrounding these lymph nodes, and neither 
the nodes nor surrounding tissue are hsemorrhagic. On the right side 
one lymph node measures 2 centimeters in diameter and the others are 
somewhat smaller. On section into these nodes they are somewhat softened, 
rather pale, and show yellowish white centers which appear softer than 
the peripheries. 

On body section there is a moderate amount of subcutaneous fat. The 
abdominal cavity is free from adhesions and contains but a small amount 
of fluid. The liver reaches 4 centimeters below the right costal margin. 
The diaphragm is at the lower border of the fourth rib on the right and 
the fifth rib on the left. 

The thorax. Tissues of the superior and anterior mediastinum are dry 
and pale. The left lung is adherent at its extreme apex by rather firm, 
fibrous adhesions. The precordial area is rather small and is covered 
with fat. The organs of the neck and thorax were removed en masse. 
The lingual tonsils are rather prominent. Faucial tonsils are small and 
pale, but show no lesions. The pharynx and oesophagus are normal. The 
larynx and trachea are pale. The trachea appears rather broad, and in 
its upper portion near the bifurcation is a gelatinous strand of mucus, 
which can be pulled out from the large bronchi, forming practically a cast. 
There is no congestion of the larynx or trachea. The cervical lymph nodes 
are not enlarged and are pale. The thyroid is small, rather firm, and of 
a deep brown color. 

The lungs are voluminous, and the pleura over them is thin. Both lungs 
show practically identically the same picture. They are completely filled 
with nodules, which are firm on palpation through the uncut lung. The 
nodules average about 1 centimeter in diameter and are uniformly dis- 
tributed throughout the whole lung, being separated from one another by 
spaces never more than 1 centimeter in width. Through the pleura, in 
numerous places, superficially placed nodules appear in the form of discrete 
and conglomerate yellowish white masses. On section the lung cuts with 
considerable resistance. There is one old pleural scar at the left apex. 
The cut surface of the lung is red and moist and presents very numerous 
nodules varying in size from a few millimeters to 1.5 centimeters. 
These are rather firm on palpation, grayish white, not distinctly cir- 
cumscribed, and their centers are somewhat softened, so that purulent or 
necrotic material can be scraped from their centers by the knife. The 
intervening lung tissue is deep red and shows some of the smaller nodules. 
Some of the larger nodules have immediately adjacent to them smaller 
nodules, giving them an irregular outline. There is no definite cavity 
formation anywhere, and no fibrosis of the lung and no calcification. One 
large lymph node at the bifurcation of the trachea is anthracotic, somewhat 
soft, and rather hemorrhagic. The other peribronchial lymph nodes appear 
normal. 

The heart. The pericardium is free and contains a normal amount of 
clear fluid. There are no ecchymoses. The heart is rather large, the right 
side being dilated but flabby. The blood is dark and but slightly coagulated. 



272 The Philippine Journal of Science wis 

Aside from the dilatation of the right heart there is no change except in 
the musculature, which is pale, rather dry, fairly firm, and somewhat 
glistening on a smooth cut surface. The endocardium shows no change. 
The base of the aorta is free. 

The spleen is enlarged to about one and a half times its normal size. 
The capsule is rather loose and is steel-blue. On the superior surface, 
through the capsule near the left extremity, a pale, yellowish white area 
about 7 millimeters in diameter is visible. Two or three similar, pinhead- 
sized areas are also visible through the capsule. On section the organ is 
rather soft and the cut surface is of a pale brown color, the lymphoid and 
interstitial elements being obscured. Section through the pale areas men- 
tioned shows definite abscess formation, the contents being soft and 
grumous. 

The adrenals are small and rather thin, the adrenal medulla being 
scarcely visible. 

The kidneys are of about normal size. The capsule strips with slight 
difficulty; the exposed surface is slightly roughened and pale red. A few 
pinhead-sized, white foci are visible on the surface. On section the con- 
sistence is somewhat diminished. The cortices are rather broad, and the 
glomeruli are fairly prominent. The vascular striae are indistinct. The 
parenchyma is pale, soft, and bulging. The pyramids are bluish at their 
peripheries and paler at their apices. The ureters and urinary bladder 
are intact. 

The mesenteric lymph nodes are not enlarged. The mesentery contains 
a moderate amount of fat. 

The gall bladder and bile ducts are normal. 

The liver is considerably enlarged, and the capsule is smooth, thin, and 
transparent. Through the capsule are visible numerous pinhead-sized, pale, 
yellowish white areas. On section into the liver the consistence is about 
normal. The cut surface presents numerous small, circumscribed, rather 
soft, pinhead-sized areas and a few larger areas about 1 centimeter in 
diameter, yellowish white, rather definitely circumscribed, with softened 
centers and pale peripheries, surrounded by a red zone. The remaining 
liver is of a brownish red appearance, the central parts of the lobules being 
darker than the peripheries. 

The stomach and pancreas are normal in appearance. 

The lumbar, retroperitoneal, cervical, axillary, epitrochlear, and popliteal 
lymph nodes are not enlarged. 

It is impossible to say from the anatomical findings where the primary 
bubo was situated, but from the clinical history the right inguinal would 
seem to be the glands first affected. The corresponding lumbar glands, 
however, showed no macroscopic lesions such as would be expected in buboes 
of the second order. 

Anatomic diagnosis. — Plague septicemia; acute inguinal lymphadenitis, 
bilateral; multiple abscesses of lungs, liver, spleen, and kidneys; acute 
parenchymatous degeneration of heart, liver, and kidneys; dilatation of 
right heart; chronic adhesive pleurisy, localized; cutaneous vesicles. 

Report on bacteriological examination of specimen taken from this case 
two days before death. Furnished by Doctor Schobl, of the Bureau of 
Science. 

The right femoral bubo is aspirated. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 273 

(1) Smears made from the aspirated liquid showed a number of plague- 
like bacilli. 

(2) Cultures made from the said liquid showed pure culture of B. pestis 
bubonicx. They were Gram-negative, nonmotile bacilli. Agglutination 
with antiplague serum was positive. 

(3) Two guinea pigs were inoculated with the liquid. They showed 
considerable swelling at the place of inoculation on the third day; also, 
the enlarged inguinal glands were palpable. One animal died on the third 
day; the other, on the sixth day after inoculation. 

(4) A maculopapulous efflorescence located on the inner part of the 
right planta pedis was incised, and the edges of the wound were scraped; 
the material so obtained was used to inoculate agar tubes. 

(5) Culture obtained therefrom proved to be B. pestis, having all the 
characteristics of B. pestis including agglutination. 

(6) One guinea pig was inoculated with the material subcutaneously. 
In three days considerable swelling was noticeable at the place of inocula- 
tion. The inguinal glands were swollen and tender. The animal died of 
plague on the fifth day after inoculation. 

History of case 1969. — Ting Nu, 32 years, male, barber by occupation. 
This case was admitted to the Philippine General Hospital on August 10, 
1912. Had fever, femoral bubo, evidence of congestion or some pneumonia, 
and bloody sputum. He was transferred to San Lazaro Hospital as highly 
suspicious of plague. While in San Lazaro Hospital he had distinct buboes 
in both femoral regions, some cough, no bloody sputum, but evidence of some 
pulmonary complication, delirium, restlessness, and high fever. The glands 
aspirated on the right side, and organisms morphologically like the plague 
bacillus were found; also, pure culture was obtained. Animals were 
inoculated. 

This patient had, on the left forearm, a vesicle which he claimed came 
from a burn, and on the right foot on the inner surface a small papule 
apparently containing a minute quantity of serum or pus, which it was 
thought might have been a flea bite and possibly the seat of the primary 
infection. This did not look, however, like a so-called plague pustule. 
Some material was taken from this by the bacteriologist. 

The case died the morning of August 13, having been sick, according 
to the history obtained, about seven or eight days. 

This case received about 30 cubic centimeters of plague serum, and his 
condition after receiving it seemed to be improved. 

This case exemplifies well that class of cases which should be designated 
"bubonic plague with early septicaemia." The primary bubo was not a 
prominent feature, whereas the evidences of septicaemia were predominant 
from both the clinical and anatomic aspects. The secondary focal visceral 
lesions are well shown in this case (Plates I and II). 

FEMORAL BUBOES 

Femoral buboes occur more frequently than buboes in any 
other situation, this being explained by the Anglo-Indian Com- 
mission by the fact that a much larger area of skin surface is 
drained by these glands than by any others. 

Fifty-five femoral buboes were encountered in my series, con- 



274 The Philippine Journal of Science wis 

stituting 73.3 per cent of the total. Twenty-four of the buboes 
were on the left side and 31 on the right. In 1 case (2131) there 
was apparently a primary bilateral bubo, and in 4 cases (2072, 
2080, 2085, 2131) the inguinal rather than the femoral glands 
were the seat of the greatest changes. However, as a rule, the 
femoral and inguinal glands were coextensively involved, and 
they have been classed, in general, as femoral buboes. In a 
typical case of femoral bubo there is a visible, rounded promi- 
nence over the site of the glands, which in this case is most 
frequently just below the middle of Poupart's ligament. This 
swelling may, in some cases, be so slight as not to be readily 
appreciable to the eye, but in these cases palpation of the two 
groins will usually reveal a difference manifested bs^ a greater 
firmness, greater fullness, and greater elasticity over the affected 
glands. It is usually impossible to differentiate the individual 
glands by inspection or palpation or to move the skin over the 
subjacent structures. Punctate haemorrhages may be present in 
the skin overlying the bubo, and in a very few cases definite 
pustules may have formed. (The application of vesicants or 
caustics over the bubo is a frequent practice among the Filipinos 
and Chinese.) The entire extremity of the affected side may 
present an oedematous condition. On section over the glands 
there is encountered the appearance described on page 265 in 
the general description of the lymphatic glands. A single gland 
or all of the femoral and inguinal glands may be involved in 
the change, and the femoral glands are usually more extensively 
involved than the inguinal. The oedema about the glands fre- 
quently extends along the fascial planes well down into Hun- 
ter's canal. The amount and extent of the periglandular oedema 
and haemorrhage varies from scarcely perceptible amounts about 
a single gland to a diffuse, widespread involvement of all the 
neighboring structures. Typically, a mass of enlarged glands 
will be found, usually lying along the femoral vein. These glands 
are enlarged sometimes to as much as 5 centimeters in diameter. 
They are hemorrhagic, as is also the periglandular areolar tissue, 
thus making the outlines of the glands indistinct. In the early 
stages the glands are firm and red; later, they become softened 
and show yellowish areas. 

Posteriorly to the middle portion of Poupart's ligament is 
usually found a gland, enlarged to 3 or more centimeters in 
diameter, which is well encapsulated but very hemorrhagic and 
sometimes softened. Extending upward from this, the lymphatic 
glands along the iliac vessels are usually enlarged, hemorrhagic. 



X, B, 4 



Croivell: Pathologic Anatomy of Bubonic Plague 275 



and sometimes softened. The haemorrhage and oedema about 
these glands are generally not so marked as about the glands 
forming the primary bubo of the first order ; but the haemorrhage 
and oedema about the ureter and lower pole of the kidney of the 
affected side may be very extensive. The involvement of the 
glands may extend upward along the vertebral column, affecting 
all the lumbar glands as far up as the coeliac axis, and may extend 
across the vertebrae, involving the glands of the opposite side. 
The peritoneum overlying these glands may show punctate, or 
larger, more diffuse haemorrhages. Frequently the serous sur- 
face of the sigmoid flexure of the colon lies in apposition with the 
peritoneum covering the iliac glands and becomes the seat of 
an extensive haemorrhagic condition. Retrograde metastases 
may occur along the lymph channels to the groin opposite the 
original bubo, and the glands here may show changes similar 
to those of primary buboes of the second order. The glands 
of the opposite side may also be infected secondarily through the 
blood stream. 

The Anglo-Indian Commission maintains that the type leading 
to early septicaemia is that in which the glands forming the 
primary bubo of the first order show very little enlargement 
and but little intra- or extraglandular haemorrhage or oedema. 
In this instance the bacilli are said not to be held back by the 
lymphatic glands. Cases have been encountered in my series 
in which the femoral and inguinal glands showed slight or no 
changes, while the iliac glands showed the changes usual in 
primary buboes of the second order. Those cases in which no 
changes were recognizable in the femoral or inguinal glands will 
be referred to under the heading of "iliac buboes." 

The Austrian Commission demonstrates that true suppuration 
may occur in the primary bubo from the action of the plague 
bacillus. In my series are instances of suppuration in the pri- 
mary bubo and in the meninges in which the plague bacillus only 
was demonstrable. Abstracts of the records' of these- cases 
follow. 

CASES OF SUPPURATION OF BUBOES 

Case 2086. — Filipino, male, 37 years old. The duration of illness was 
seven days. This was anatomically a typical uncomplicated case of bubonic 
plague with a right femoral primary bubo. The description of the bubo is 
as follows : The right femoral region shows slight bulging. On section over 
this region a large cedematous mass is disclosed, which includes one large 
and several small lymphatic glands. The largest is about 3.5 centimeters 
in diameter, reddish gray, and very soft and necrotic. The smaller glands 
are red and haemorrhagic, but not much softened. There is very little 



276 The Philippine Journal of Science ms 

haemorrhage in the tissue surrounding the glands. Just beneath the middle 
of Poupart's ligament are two lymphatic glands which are about 2 centi- 
meters in diameter. These are pale and on section are seen to contain 
a considerable amount of greenish pus. Smears from the primary bubo 
show many pest bacilli; smears from the pus show very, very few pest 
bacilli and no other organisms. 

Case 2134. — Filipino, male, 5 months old. The duration of illness was 
fifteen days. This was anatomically a typical uncomplicated case of bu- 
bonic plague with primary cervical bubo. The description of the bubo is 
as follows: The right side of the neck, just back of the sternocleidomastoid 
muscle, shows a slight enlargement over an area measuring 2.5 by 2 
centimeters. The apex of this is soft but not fluctuating. On cutting 
through the skin, the knife encounters in the subcutaneous tissue a small 
amount of purulent reddish gray fluid, which seems to be the substance 
of broken-down lymphatic glands. The glands in this region are all 
enlarged, extending upward behind the angle of the jaw and downward and 
outward behind the clavicle. The glands are for the most part discrete, 
but swollen and congested. Smears from the purulent fluid show no 
organism other than B. pestis. 

Case 2431. — Filipino, female, 19 years old. The duration of illness was 
two weeks. This was a case with suppuration in the left axilla and an 
intense suppurative ependymitis. In the right axilla are several glands 
which are slightly enlarged and moderately hyperaamic but not haemorrhagic. 
In the anterior part of the axilla two or three small cavities containing 
thin grayish pus are opened. It is difficult to say that these abscesses 
have arisen in the lymphatic glands, though one or two have that appear- 
ance. There is slight oedema of the fatty tissue in the anterior part 
of the axilla, but there are no haemorrhages. No other glands appearing 
like primary buboes were found. The cerebral leptomeninges contain a 
slight excess of fluid, which appears slightly turbid. On opening the right 
lateral ventricle, it is found to contain a considerable amount of yellowish 
gray pus. The choroid plexus is gray and soft. The left choroid is 
smaller, but is also surrounded by grayish exudate. The fourth ventricle 
is apparently free. The brain substance is pale and shows nothing ab- 
normal. In smears from the spleen, glands, and pus from the axilla 
no bacteria were found. Smears from the pus of the ventricle were 
loaded with plump bacilli, which varied greatly in size. These were shown 
by culture and animal inoculation to be plague bacilli. 

Case 3129. — Filipino, male, 6 years old. ,The duration of illness was 
one week. This case was one with extensive pharyngeal and laryngeal 
involvement and pulmonary infarcts, with suppuration in the mesenteric 
and cervical lymphatic glands. There was a mass of suppurative glands 
at the head of the pancreas, and some of the cervical prevertebral glands 
were suppurative. The portal of entry of the bacilli in this case was 
apparently either the tonsils or pharynx. A few plague bacilli were found 
in smears from the suppurative glands, and a pure culture was obtained 
from the spleen. 

Case 3215. — Chinese, male, 16 years old. The duration of illness was 
four days. This was a case with primary left femoral bubo, which de- 
veloped a large secondary cervical bubo and lobular pneumonia while under 
observation. The extensive primary bubo had undergone marked necrosis 
and suppuration in its central portion, and in smears from this pus many 
plague bacilli were found, a number of which were intracellular. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 277 

Case of primary bilateral buboes. — The following case (2131) has been 
interpreted as one of probable bilateral primary inguinal buboes, as glands 
on both sides showed the lesions of primary buboes of the first order, and 
the iliac and lumbar glands on each side showed the lesions characteristic 
of primary buboes of the second order. Filipino, male, 35 years old. 
The duration of illness was seven days (?). A single hyperemic but not 
enlarged lymphatic gland is found in the right popliteal space. In opening 
up the right inguinal region, the subcutaneous tissues are found to be 
very moist, while just below Poupart's ligament is the greatest swelling. 
On dissecting away the cedematous fat, a chain of enlarged lymphatic 
glands is found parallel to the ligament. These are surrounded by hemor- 
rhagic fatty tissue. On section about four or five glands are found to be 
involved, the largest being 2 centimeters in diameter. They are hemor- 
rhagic and spotted with numerous small, bright red areas and a few 
yellowish softened areas. The femoral glands are very slightly, if at all, 
enlarged and are rather pale. In the left inguinal region the fatty tissues 
over Poupart's ligament are also slightly cedematous, and one enlarged 
hemorrhagic inguinal gland surrounded by hemorrhagic fatty tissue is 
found ; the other inguinal and the femoral glands on the left side are- 
slightly hyperemic, but not hemorrhagic or softened. The iliac and lumbar 
glands on both sides are much enlarged and are hemorrhagic, while about 
the glands and iliac vessels there is much diffuse hemorrhage in the tissues. 

PRIMARY (?) ILIAC BUBOES 

Extensive hsemorrhagic lymphadenitis was present in the iliac 
glands in three cases (2024, 2989, 3194) in which no popliteal, 
femoral, nor inguinal bubo was recognizable at the time of 
autopsy. 

In the first case (2024) 23 there were also extensive changes 
in the lumbar, mesocolic, and mesenteric glands and extensive 
gastrointestinal haemorrhages. Cultures of B. pestis were ob- 
tained from the iliac glands, spleen, and lungs. The duration 
of illness in this case was not recorded. 

In the second case (2989) there was found a slightly enlarged, 
right femoral gland which was firm and red, but was without 
apparent haemorrhage. The right iliac glands were much en- 
larged, hsemorrhagic, and friable, with extensive haemorrhages 
about them, extending along the lumbar region as far as the 
cceliac axis. This case had also extensive secondary pulmonary 
involvement, and the duration of illness was stated to be ten 
days. 

In the third case (3194) there was no visible change in any 
of the superficial lymphatic glands, but there was found a mass 
or chain of enlarged, very haemorrhagic glands, situated along 
the right iliac crest and in the right lumbar region to about 5 
centimeters above the bifurcation of the aorta. There was no 

28 This case is reported in full on page 296. 



278 The Philippine Journal of Science 1915 

oedema nor infiltration of the tissues surrounding these glands, 
and they were more or less conglomerate and of firm consistence, 
showing numerous yellow foci on the red background. Bacillus 
pestis was found in the iliac glands and spleen in large numbers. 
No other primary focus was found. The duration of illness in 
this case was said to be one day. 

According to Piersol 2 * the iliac nodes receive afferent vessels 
from the bladder and prostate gland, from the lower part of 
the uterus and the upper part of the vagina, and from the 
glans penis and clitoris. If the portal of entry of the bacillus 
be in any of these parts, the iliac glands may form the primary 
bubo, thus accounting for some of the reported cases in which 
no bubo was recognizable clinically. The possibilities are that 
the femoral or inguinal glands, from which the infection spreads 
to the iliac glands, may never have undergone extensive struc- 
tural changes; or, on the other hand, they may have recovered 
from their more severe changes before death occurred. 

POPLITEAL BUBOES 

In the reports of the German, Austrian, and Anglo-Indian 
Plague Commissions I have been able to find no report of an 
autopsy of a case with popliteal buboes, although it is recognized 
that these occur clinically. The popliteal and cubital glands are 
seldom the seat of the primary bubo, the organisms in this 
disease, as in other acute infections, originating in the extremi- 
ties, passing to the glands in the groin or axilla. 

One case of this series had a primary popliteal bubo, and an 
excerpt from the autopsy record is here presented. These glands 
may be the seat of secondary buboes, which become infected 
through the blood stream, and it is said that they may constitute 
primary buboes of the second order, infected by a retrograde 
passage of the organisms through the lymph stream. 

Case 2081. — There is a considerable bulging in the right popliteal and in 
the right femoral regions, and in the popliteal region there is found con- 
siderable oedema of the tissues. About the deep vessels between the two 
layers of the gastrocnemii are some much enlarged, deep red, softened, 
hsemorrhagic glands. The tissues about these are slightly hemorrhagic, 
and the cedema extends up through Hunter's canal. On section over the 
right femoral region the oedema is very great, and there is a large mass 
of cedematous fat inclosing enlarged lymphatic glands, one of which meas- 
ures 3.5 centimeters in diameter. This is reddish yellow and soft, and 
there is considerable haemorrhage in the tissues about this gland. The 

24 Human Anatomy. J. B. Lippincott Company, Philadelphia and London 
(1907), 984. 



x, b, 4 Croivell: Pathologic Anatomy of Bubonic Plague 279 

other superficial lymphatic glands are somewhat enlarged, but not haemor- 
rhagic nor oedematous. 

In this case both popliteal and femoral glands appear in the gross like 
primary buboes of the first order." 

AXILLARY BUBOES 

. When the primary bubo affects the axillary glands, the swell- 
ing may be high up in the concavity of the axilla or lower on the 
thoracic wall at the margin of the pectoral muscles. In the 
former condition the axillary space may be completely filled up 
by a large, elastic swelling through which individual glands can- 
not be palpated. If the swelling be lower, it will be seen along 
the anterior border of the axilla as a diffuse swelling, some 
cedema extending in all directions about it. On section the glands 
and periglandular tissue will be found in the same condition as 
has been described in the groin. The cedema not infrequently 
extends upward along the muscle fascia beneath the clavicle, as 
far as the postpharyngeal wall, and this cedema may be very 
evident in the pharynx. The cervical prevertebral glands may 
show the lesions of a primary bubo of the second order. These 
will be further discussed along with the primary cervical buboes. 

The enlargement of the axillary glands may lead to a diffuse 
cedema of the upper extremity of the affected side, as the result 
of pressure upon the vessels. 

Among my cases 6 presented axillary buboes — 2 on the right 
and 4 on the left. The liability of the deep cervical glands to 
involvement as primary buboes of the second order, with infection 
spreading from them more readily to the lung, would seem to 
render the lungs more liable to specific plague infection in the 
case of primary axillary buboes than is the case with primary 
buboes in the groin. This a priori hypothesis is shown to be 
true in our cases, as 50 per cent of the cases with primary axillary 
buboes had specific pulmonary involvement as compared with 
about 7 per cent of the cases with primary buboes in the groin. 
These figures must not, however, be accepted without due 
allowance for the disparity in incidence of buboes in the axilla 
and groin. 

CERVICAL BUBOES 

Fiexner 26 says : 

The buccal mucous membrane forms one of the portals of entry into 
the body of the plague bacilli. It is probable that the cervical buboes arise 

" 5 This case is almost exactly analogous to case 18/XLVIII of the Austrian 
Commission [liber die Beulenpest in Bombay (1898), II B, 315], in which 
cubital and axillary glands were similarly involved. 

26 Am. Journ. Med. Sci. (1901), n. s. 122, 405. 



280 The Philippine Journal of Science ms 

from that source of infection. Of all the buccal structures the tonsils 
seem to be most frequently the primary one attacked. In this fact we have 
only another illustration of the importance of incomplete epithelial invest- 
ment and perhaps of previous disease in promoting infection. Other parts 
of the buccal cavity may become secondary points of development of the 
bacilli. 

The Anglo-Indian Commission 2T reports : 

The question as to whether there are channels other than the skin 
through which the plague bacillus effects an entrance into the system 
may unhesitatingly be answered in the affirmative. In favour of the view 
that the infective material may in some cases obtain access to the system 
through the mucous membranes of the nose, mouth, or pharynx, are: first, 
the fact that the infection in plague can, in animals, be experimentally 
produced by the inoculation of the plague bacillus on the mucous membrane 
of the nose; secondly, the fact that in man buboes under the chin and 
about the angle of the jaw are not uncommon; thirdly, the fact that the 
plague bacillus has been found in the human patient in association with 
primary inflammatory lesions of the tonsils and of the mucous membrane 
of the nose and the pharynx; lastly, certain epidemiological facts appear 
to speak in favour of the possibility of the bacillus entering the system 
by means of the mucous membrane of the nose, such as the fact that, in 
certain places, epidemics which have been diagnosed as epidemics of mumps 
preceded and may possibly have stood in casual [?] relation to epidemics 
of plague. Again, in one instance at least, there is, as we shall see here- 
after, reason to suspect that an epidemic of severe coryza may have stood 
in causal association with a subsequent epidemic of plague. 

Strong and Teague 28 have shown that in guinea pigs cervical 
buboes sometimes may result from the inhalation of a suspension 
of virulent pest bacilli, and that local application of the bacilli 
to the tongue or pharynx of monkeys may produce cervical 
buboes. 

In human beings primary cervical buboes may also result 
from infection of the cutaneous areas drained by the cervical 
glands. 

In this series primary cervical buboes occurred 10 times. In 
2 of these cases the bubo was on the right and in one case on 
the left. In the other 7 cases it appeared to be double, or, at 
any rate, both sides were involved, and it was impossible to tell 
on which side the bubo was primary. The glands involved were 
sometimes superficial at the angle of the jaw and sometimes 
were deep prevertebral or perilaryngeal glands. The involve- 
ment of the prevertebral glands as primary buboes of the second 
order with primary axillary buboes has already been mentioned. 
There is usually much oedema associated with primary cervical 

• T Report of the Indian Plague Commission (189S-991, 5. 71. 
: " This Journal, Sec. B (1912), 7, 17:!. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 281 



buboes, this extending into the loose tissues about the pharynx. 
As a result 8 of the 10 cases with primary cervical buboes showed 
lesions of the pharynx, varying from a simple oedema up to a 
very marked pseudomembranous pharyngitis and tonsillitis. 
There seemed to be no method of determining after death, in an 
individual case, whether or not the glandular involvement was 
consequent upon primary pharyngeal infection. Careful inves- 
tigation of the course of events in clinical and experimental cases 
alone will determine the sequence, and such experience by Strong 
and Teague has been referred to above. 

Our observation that severe pharyngeal lesions, amounting 
even to a severe grade of tonsillitis, may be secondary to primary 
axillary buboes suggests that the pharyngeal lesions may also 
be secondary to cervical buboes when the portal of entry of the 
infection is on the cutaneous surface. Similar observations were 
made by the Austrian Commission. 

Table IV shows the relation, in this series, of the cervical bu- 
boes, pharyngeal lesions, and focal pulmonary plague lesions. 

Table IV. — Association of cervical glandular, -pharyngeal, and pulmonary 

lesions. 



Cases with — 



Cervical buboes 

Pharyngeal lesion3 

Focal pulmonary lesions 



Num- 
ber. 



Associated lesions. 



Cervical 
buboes. 



Pharyn- 
geal 

lesions. 



Focal 
pulmo- 
nary 
lesions. 



None of 
preced- 
ing. 



The relation shown in the table between the cervical buboes 
and the pharyngeal lesions has already been discussed. The table 
shows that, of our 10 cases with cervical buboes, 6 had focal 
plague pulmonary lesions, and that 5 of the 13 cases with focal 
plague pulmonary lesions had neither cervical buboes nor pha- 
ryngeal lesions. An explanation of these will be offered in the 
part of this article dealing with pulmonary lesions. 

PHARYNX AND TONSILS 

The lesions of the pharynx should receive consideration in 
close association with the cervical buboes. 

Pathologic conditions of the pharynx are of frequent occur- 
rence in plague. There may be a simple cedema of one part of 
the pharyngeal wall, or the entire wall may be very much swollen 
and show various grades of necrosis, haemorrhage, and ulceration. 

133736 3 



282 The Philippine Journal of Science ws 

The entire pharyngeal ring may be thus involved, or the lesions 
may be largely confined to the faucial tonsils. In the latter case 
enlargement, with congestion and the formation of a pseudo- 
membrane or deep ulceration, may be present. 

These tonsillar and pharyngeal lesions may represent the re- 
action of the tissues at the portal of entrance of the bacilli to 
the body, or they may occur as the result of infection of the 
parts through the blood stream when the primary portal of 
entrance of the bacilli is in a distant part of the body. Refer- 
ence has also already been made to the possibility of the exudate 
about an axillary bubo extending by direct continuity of tissue 
to the pharynx. It has also been suggested that these pharyn- 
geal lesions may be secondary to primary cervical buboes when 
the portal of entrance occurs on the skin surface. 

In my series necrotic and ulcerative lesions of the tonsils were 
present in 3 cases (1894, 2171, 2259) with primary femoral 
buboes and in 2 cases (2148, 3012) with primary axillary buboes. 
In the cases of primary buboes of the parotid or submaxillary 
lymphatic glands (2134, 2150, 2267) the tonsils have not been 
markedly affected. On the contrary, when the deep preverte- 
bral cervical glands are the ones chiefly involved, severe changes 
in the tonsils (and sometimes other parts of the pharynx) have 
been found (2074, 2160, 2335, 2389, 2993, 3129). 

These facts would seem to indicate that the tonsils in these 
latter cases have formed the portal of entrance for the bacilli, 
and that the involvement of the prevertebral cervical glands 
occurs secondarily, through the lymph stream. 

Plague bacilli are known to multiply rapidly in lymphadenoid 
tissue, and such tissue forms the major portion of the tonsils. 
Since, when infected by the plague bacilli, the tonsils undergo 
changes which are exactly analogous to the changes occurring 
in the ordinary plague bubo in a lymphatic gland, it is a question 
whether such primarily affected tonsils may not properly be 
spoken of as "primary tonsillar buboes." There seems no valid 
reason why such a term should not be applied to them. There 
occur in the tonsils congestion, oedema, exudation, haemorrhage, 
necrosis, enormous bacterial multiplication, and destruction of 
the capsule, with involvement of the surrounding structures, and 
these are the changes that occur in an ordinary plague bubo in 
a lymphatic gland. On such a basis the prevertebral cervical 
glands would be called primary buboes of the second order. 

From the figures quoted above it will be seen that tonsillar 
lesions are a not infrequent occurrence in bubonic plague (about 
15 per cent in this series). 









x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 283 

HISTOPATHOLOGY OF THE PHARYNX AND TONSILS 

The changes that occur in the pharynx generally are of a 
character similar to those in the tonsil, and our description will 
be confined to the lesions of the latter. The conclusions that 
were arrived at as the result of the macroscopic examinations are 
completely confirmed by microscopic examination. In the cases 
in which the parotid or submaxillary lymphatic glands form the 
primary bubo, the tonsillar changes are much less severe than 
in those cases of primary femoral or axillary buboes with ton- 
sillar involvement or in the cases of so-called primary tonsillar 
buboes. In fact, a moderate grade of congestion, causing some 
swelling and reddening of the tonsils, is the only change that 
could be detected in the examination of the tonsils from the 3 
cases with parotid or submaxillary buboes. 

In the 12 other cases with tonsillar involvement, as noted 
above, irrespectively of whether the primary bubo was femoral, 
axillary, or tonsillar, the changes in the tonsil are so extensive 
that it is practically impossible to follow the changes in their 
order of sequence. The most that can be done is to state the 
changes that are found, and their order of sequence will suggest 
itself by analogy. Congestion of the tonsils in these cases is 
a constant feature. In the cases which do not show severe 
changes there also appears to be some active proliferation of 
the cells in the central parts of the tonsillar follicles. In the 
later stages all of the internal architecture of the tonsils may 
be destroyed, so that the follicular arrangement, the sinuses, and 
the crypts can no longer be oriented. Smaller or larger areas 
of necrosis occur, containing nuclear fragments, a granular cell 
detritus, often many bacilli, and usually many polymorphonuclear 
leucocytes. The bacilli may be present in large masses, and just 
as abundant as in any primary bubo in a lymphatic gland. Large 
cells with large centrally placed nuclei, containing in their cyto- 
plasm bacilli and nuclear fragments, may be seen, but these are 
not frequently numerous. Polymorphonuclear leucocytes may 
be very numerous and scattered widely throughout the tonsils 
or may be localized to form abscesses. Not infrequently these 
cells and lymphocytes may be seen passing through the epithelial 
layer lining the crypts. Small haemorrhages may also occur 
throughout the tonsil. In some cases the cellular elements appear 
to be separated by spaces in which is a granular material, thus 
giving the appearance of a loose arrangement to the whole tonsil. 
This is probably a manifestation of oedema. 

Some cases have been seen in which the capsule covering the 



284 The Philippine Journal of Science ms 

lateral and posterior portions of the tonsil has been infiltrated 
in the same way as the tonsil itself, the oedema, haemorrhage, 
and cellular exudate passing for a short distance into the sur- 
rounding tissue. 

In regard to the epithelium covering the tonsil, sections in 
some cases may show little, if any, change, even when the tonsil 
beneath is the seat of severe changes. On the other hand, there 
may be all grades of infiltration of the epithelium leading to 
complete necrosis and the formation of a pseudomembrane. This 
pseudomembrane is made up of necrotic epithelial cells, mucus, 
leucocytes, red blood cells, fibrin, cellular detritus, and bacteria. 
Similar masses of granular detritus, bacteria, and leucocytes 
may be found with the crypts. In cases of less severity the 
epithelium covering the tonsil may show a simple vacuolation 
with small collections of bacteria and leucocytes contained within 
small clefts in the epithelial layer. A not unusual finding is the 
presence of large masses of bacilli filling a zone immediately be- 
low the epithelium covering the tonsil and surrounding pharynx. 

It will thus be seen that these changes in the tonsil are remark- 
ably similar to those occurring in a primary lymphatic bubo. 
The tonsil seldom, if ever, reaches the size of the average lym- 
phatic bubo, but this may be accounted for by the fact of its 
superficial position and the ease with which the exudate may pass 
on to the surface. 

Attention is here again drawn to the fact that such pharyngeal 
or tonsillar lesions may occur without specific pulmonary in- 
volvement. Therefore the sputum may be infective not only in 
primary bubonic cases with secondary pulmonary involvement, 
but also in cases with specific pharyngeal lesions. 

RESPIRATORY SYSTEM 
LUNGS 

Secondary plague lesions occur in the lungs in bubonic plague, 
and such cases should be distinguished from primary pneumonic 
plague cases. In the latter class of cases the infection is primary 
in the respiratory tract, and the pulmonary lesions produced 
differ very essentially from those that may occur in the course 
of bubonic plague. 

According to earlier studies by Strong, Crowell, and Teague -": 

* * * it would appear that epidemic plague pneumonia results from 
inhalation, the primary point of infection being the bronchi. * * [In 

the lungs] The bacilli rapidly multiply and produce at first pneumonic 

"This Journal, Sec P (1912). 7, 220. 






x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 285 

changes of the lobular type, and shortly afterwards from the fusion of 
several rapidly spreading areas more general lobar involvement of the 
lung tissue * * *. The tonsils may become secondarily infected in 
pneumonic plague, just as other lymphatic glands — -for example, the bron- 
chial ones — become so infected. However, in pneumonic plague death occurs 
before any very marked macroscopic changes occur in the tonsils. There is 
no doubt also that the tonsils may become primarily infected in epidemics 
of pneumonic plague, just as has occurred in sporadic cases during epidemics 
of bubonic plague. 

In many epidemics of primary bubonic plague sporadic cases 
of such primary respiratory infections occur and are probably 
to be explained by the same method of transmission as occurs 
in epidemics of primary pneumonic plague, the contagium in 
this case arising from the sputum of cases of primary bubonic 
plague with secondary pulmonary or pharyngeal lesions of the 
type about to be described. Teague and Barber 3n have offered 
an explanation, on the basis of temperature and humidity, of 
the failure of pneumonic plague to become epidemic once a case 
has occurred during the course of an epidemic of bubonic plague. 
Their explanation is as follows : 

We believe we are justified in concluding from these experiments that 
were the plague organisms sprayed under similar conditions they would 
persist longer than cholera vibrios, but a shorter time than prodigiosus 
bacilli. Hence, it seems probable that the plague bacilli contained in fine 
droplets of pneumonic-plague sputum would suffer death from drying in a 
few minutes unless they were suspended in an atmosphere with an extremely 
small water deficit. Infection in pneumonic plague follows the inhalation of 
droplets of pneumonic sputum and obviously the longer these droplets 
remain suspended in the air, the greater is the danger of infection. As 
has just been stated, these fine droplets disappear very quickly except when 
they are suspended in an atmosphere with a very small water deficit. Such 
an atmosphere is under ordinary circumstances of common occurrence in 
very cold climates, whereas it is extremely rare in warm ones. Hence, 
since the droplets of sputum persist longer, the plague bacilli remain alive 
longer in the air, and there is a greater tendency for the disease to spread 
in cold climates than in warm ones. 

The pulmonary lesions in bubonic plague are of three types: 
the ordinary bronchopneumonic form of the aspiration or hypos- 
tatic type, the type of true peripheral infarcts, and a type mani- 
fested by few or many nodules widespread throughout the lung 
which are of metastatic origin. Aside from these focal lesions, 
varying grades of congestion and oedema of the lungs form a. 
constant feature of bubonic plague. In the first or ordinary 
bronchopneumonic type of lesion the changes are not macros- 
copically different from a bronchopneumonia due to other 

"This Journal, Sec. B (1912), 7, 172. 



286 The Philippine Journal of Science ms 

organisms. The description of the lungs in the following case 
exemplifies the type of lesion encountered in this class of cases. 

Case 2073. — Filipino, 31 years old. This case had a typical right femoral 
primary bubo. 

The lungs. The pleurae are deep bluish red throught, and the lungs 
are slightly nodular on palpation. On section, especially in the posterior 
part of the lower lobes, are diffuse, slightly elevated, airless areas which are 
deep red and slightly granular but not redder than the surrounding tissue, 
which is everywhere deep red and somewhat oedematous. The larger bronchi 
contain some mucopus, and the mucosa is much reddened. The pulmonary 
arteries are intact. The peribronchial lymph nodes are red and somewhat 
softened. At the bifurcation of the trachea are one large and two or three 
small, very deep red and slightly softened lymphatic glands. The trachea 
itself has a very much reddened mucosa. The other structures of the neck 
show no change. 

In the infarcted type of pulmonary lesion, also, the changes 
do not essentially differ from the usual pulmonary infarcts. The 
infarcts may be single or multiple. In one of our cases (2073) 
the single infarct was in the upper left lobe; in another (2150) 
there was an infarct in each lower lobe; and in still another 
(3129) there were multiple infarcts in the lower lobes. 

This type of lesion is exemplified in the lungs of the following 
case. 

Case 3129. — Filipino, male, 6 years old. This case had a cervical bubo 
probably originating through tonsillar infection, with a severe pseudo- 
membranous pharyngitis, tonsillitis, and laryngitis. 

The lungs. The pleurae are smooth. On the surface of the left lung 
are found a few small slightly reddened areas, and the tissue beneath 
these is firm. On section these firm areas have a smooth or slightly 
granular, grayish red surface, darker in color than the surrounding lung 
tissue. All are found at the surface and for the most part are more or 
less wedge-shaped with the bases at the surface. They vary from 0.5 to 
3 centimeters in diameter, about 6 being found. The remainder of the 
lung substance is gray, soft, and moist. The bronchi contain a small 
amount of mucus. The right lung is similar to the left. The largest 
nodule is found in the lower lateral edge of the lower lobe. The peribron- 
chial lymph nodes are slightly enlarged and are hyperaemic. No haemor- 
rhages are seen in the pleura. 

In the third or metastatic type of pulmonary lesion the char- 
acteristics are exemplified in case 1969 (page 270). The lesions 
vary in size and number from multiple miliary nodules to single 
or multiple larger nodules up to 2 centimeters in diameter. 
These may be very widespread throughout the lungs and occur 
also on the pleural surface where they cause some elevation of 
the pleura. The pleura over them shows injection of the smaller 
vessels, and there may be a delicate layer of fibrin on the pleura 
over the nodule. The color varies from a pale red to gray or 



x, b, 4 Croivell: Pathologic Anatomy of Bubonic Plague 287 

yellowish gray, and the areas are surrounded by a narrow red 
hypersemic zone. The consistence of the nodules is firm in the 
earlier lesions, and softening occurs in the central part of the 
older nodules. In the same lung there may be nodules of vary- 
ing size, color, and consistence. In some cases it is possible to 
recognize a definite arrangement of these about the bronchi, 
while in other cases no such arrangement is discernible. The 
nodules are circular in outline and discrete, and no evidence of 
any attempt at fusion of the nodules to form a more general 
lobar involvement has been seen. The sharp delimitation of 
these areas contrasts with the indefinite outline of the early 
pulmonary lesions in primary pneumonic plague. The lung 
substance between these nodules is crepitant, but as a rule con- 
gested and cedematous. 

It will thus be seen that the lesions in this type of plague 
correspond to those described in other infections as metastatic 
or septic embolic pneumonia. However, these lesions never pro- 
gress to the stage of cavity formation, probably because of the 
short duration of the disease. These nodules can best be ex- 
plained on the basis of a metastatic or embolic origin. While 
the type of true peripheral infarct and the metastatic embolic 
type of pneumonia are similar from the etiologic and microscopic 
standpoints, it seems desirable to separate them on account of 
their macroscopic variations. The term "infarct" suggests at 
once the idea of a peripherally situated, cone-shaped area of 
necrosis with possible suppuration, such as is encountered in my 
second class. When, on the other hand, cases occur with globular 
nodules found widespread throughout the lung, having no pre- 
dilection for a peripheral situation, the cases may well be segre- 
gated in a class by themselves. From their situation in relation 
to the bronchi, and from the existence of a true bronchitis in 
these cases, it may well be that some of them are of bronchogenic 
rather than hsematogenic origin. 

An attempt has been made to correlate these pulmonary lesions 
with the existence of laryngeal, pharyngeal, or tonsillar lesions, 
but all three types occur irrespectively of whether such lesions 
exist and independently of the site of the primary bubo. My 
series shows that 5 of the 13 cases with pulmonary lesions had 
neither cervical buboes nor pharyngeal lesions; that of 10 cases 
of cervical buboes 6 had pulmonary lesions; and that of 11 
cases of pharyngeal lesions 7 had pulmonary lesions. These 
figures do not give proportions sufficient to justify one in drawing 
any positive conclusions as to the necessity for a causal relation 
between these lesions. This doubt as to the causal relation is 



288 The Philippine Journal of Science mi 

enhanced when it is learned that the pulmonary changes spoken 
of are of both origins — as infarcts and as metastases. 

HISTOPATHOLOGY OF THE LUNGS 

. In the first or purely bronchopneumonic type of lesion the 
microscopic changes do not differ essentially from the same 
lesions caused by other organisms. Surrounding the bronchi 
there occur localized areas in which the alveoli contain some 
serum, many red blood cells, a few leucocytes, and some large 
pigment cells. The capillaries in the alveolar walls are engorged, 
and small haemorrhages may occur. The tissue immediately 
surrounding the consolidated area is congested and may show 
some collapsed alveoli. The bronchi show evidence of a simple 
catarrhal inflammation. Bacilli are, as a rule, not a prominent 
feature in sections of lungs of this type. Fibrin in the exudate 
is very scant or completely lacking. 

In lesions of the second and third types (peripheral infarcts 
and metastatic embolic pneumonia) the leucocytes and bacteria 
are present in greater abundance, and the destruction of tissue 
is greater than in the first type. Here one finds foci of very 
dense infiltration with polymorphonuclear leucocytes and a few 
erythrocytes. These are enmeshed in a fine fibrillar network. 
Weigert's stain for fibrin shows some fine strands and networks 
of fibrin, but this is not nearly so abundant as in a frank lobar 
pneumonia. In the alveoli are also seen many large pigmented 
cells, obviously desquamated epithelial cells from the alveolar 
wall. These cells are found very constantly in the pulmonary 
alveoli in plague, irrespectively of whether or not there is con- 
solidation present. Bacilli may be present in some of the alveoli 
in rather large numbers, but in this series they are not nearly 
so abundant nor so conspicuous a feature as they were in a 
previous series of primary pneumonic-plague cases. Nuclear 
fragments may also be abundant in the alveoli. 

In the central parts of the nodules the interalveolar septa are 
represented by diffuse eosin-staining masses, which show no 
organized structure. In the places of some of these are dense 
masses of bacilli, which masses have such shapes as to suggest 
that they lie in vessels, although all traces of the vessels have 
disappeared. The peripheral parts of these foci show better 
preserved septa, with engorged capillaries; the septa, however, 
show the same type of changes as described in the smaller splenic 
vessels. They are thickened and more or less homogeneous, 
take the acid stains, and show a fibrillation of their structure. 

Over the peripherally placed infarcts there is a delicate layer 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 289 

of fibrin on the pleura, and this contains a few leucocytes and 
some bacteria. The endothelial cells beneath the fibrin are 
seldom recognizable. Just beneath the pleura at these points 
there is usually a very dense mass of bacilli. 

Surrounding the nodules just described there is seen a zone of 
compressed alveoli with engorged vessels. 

Sections of the bronchioles and bronchi show regularly some 
desquamation of the lining epithelial cells and a mass of cell 
detritus containing leucocytes and bacteria in the lumen. In 
the walls of the bronchi there is marked engorgement of the 
vessels. 

PLEURA 

The most frequent lesion of the pleura is the presence of 
punctate haemorrhages, which may be very few in number or may 
be numerous and scattered over both the parietal and the visceral 
layers. Such haemorrhages were noted in 33 of our cases, these 
standing, in this series, next in frequency only to those on the 
epicardium. Localized areas of an acute fibrinous pleuritis may 
also be present over the peripherally placed infarcts and metas- 
tatic foci in the lungs. 

BRONCHI AND TRACHEA 

Congestion and an acute inflammation may be present in the 
trachea and bronchi, occurring most often in those cases in which 
there was specific pulmonary involvement. The inflammation 
may be of the simple catarrhal or of the croupous type. One case 
occurred in which a large plug of fibrin and mucus was pulled out 
of the trachea and bronchi, of which it formed an imperfect cast. 

LARYNX 

The larynx is most liable to involvement in the case of axillary 
or cervical buboes in which there is a widespread involvement 
of the pharyngeal region. Haemorrhages on both sides of the 
epiglottis, and oedema, which may involve the aryteno-epiglottid- 
ean folds, the epiglottis, and the vocal cords, constitute the 
chief laryngeal changes encountered. A pseudomembranous 
laryngitis and pharyngitis was found in two cases (2389, 3129) , 
in one of which (3129) the clinical diagnosis of diphtheria had 
been considered. 

SPLEEN 

The spleen in bubonic plague presents a very characteristic 
appearance, the most characteristic features being its color and 
its consistence. The spleen is usually enlarged, but not in all 
cases. The size varies from those which are smaller than normal 



290 The Philippine Journal of Science wis 

up to those nearly three times larger than normal, the average 
being somewhat above normal. The enlargement takes place in 
all directions. In an average of 14 spleens of my series that 
were measured the measurements were 13 by 9 by 4.5 centi- 
meters. The spleens that were measured do not include those 
of the greatest size, so that these measurements are probably 
minimal rather than maximal. The average measurements of 
the spleen given by the Austrian Commission are 12 to 22 by 6 
to 17 by 3 to 6 centimeters. These sizes are stated without ref- 
erence to cases in which the enlargement of the spleen was 
obviously due to chronic preexisting disease. 

The capsule of the spleen is tense, opaque, and varies in color 
from a reddish brown to a steel gray. Frequently the capsule 
presents numerous, small, discrete or confluent haemorrhages 
scattered over its surface. The consistence of the organ is firm, 
and this is as marked after as before transverse section. When 
placed on the table after removal, the spleen retains its shape, 
and after section the organ does not collapse nor does the pulp 
flow out. In this respect the spleen differs remarkably from the 
acutely enlarged spleen seen in typhoid fever and other septi- 
cemic conditions. 

The cut surface of the spleen is a dull grayish red color and is 
not glistening. Both the consistence and color are remarkably 
like those encountered in cases of diffuse amyloid disease of the 
spleen. The cut surface, however, lacks the glistening appear- 
ance and is not smooth. It is rather rough and has a shagreen 
appearance, the pulp bulging out in the form of small, rounded, 
closely packed masses. As a rule, the trabecule, smaller vessels, 
and lymphoid follicles are not recognizable. Small haemorrhages, 
which are darker in color than the surrounding pulp, may be 
recognizable on the cut surface. 

Small infarcts and necrotic nodules are visible to the naked 
eye in a small proportion of cases, and in these cases there are 
usually similar lesions in other viscera. In other words, these 
occur in cases of septicopyemia. Three cases with splenic 
infarcts occurred in the series, and their description follows. 

Small areas of focal necrosis were also recognizable in a few- 
cases. The color and consistence of the spleen are considered 
among the most characteristic features occurring in plague. 
After having become familiar with them, we have ventured the 
diagnosis of plague even before inspection of the buboes, and 
even in some cases when the bubo was atypical. Furthermore, 
after having become familiar with the color and consistence 
of the spleen in plague, on finding a soft, pulpy, diffluent spleen 



x, b, 4 Croivell: Pathologic Anatomy of Bubonic Plague 291 

of dark color in a case of known plague, the diagnosis of mixed 
or secondary infection was ventured before bacteriological 
examination and was later confirmed. That it is possible to do 
this is shown by the fact that this was an independent observation 
of mine, and it is only recently that I have found that this 
observation was also made by the Austrian Commission. 

CASES OF SPLENIC INFARCTS 

Cases 2079. — Filipino, male, 34 years old. The duration of illness was 
five days. The anatomic diagnosis was as follows: Bubonic plague; acute 
femoral lymphadenitis, right (primary bubo) ; acute iliac and lumbar 
lymphadenitis (primary bubo of the second order) ; acute lymphadenitis, 
left femoral and axillary (secondary buboes) ; double hydrothorax; con- 
gestion, oedema, and atelectasis of lungs; epicardial, endocardial, pleural, 
gastric, renal, peritoneal, and splenic ecchymoses; congestion and degen- 
eration of kidneys and liver; acute splenitis; infarcts of spleen; tri- 
churiasis. Very numerous plague bacilli were found in the buboes and 
spleen. The description of the spleen is as follows: The spleen is con- 
siderably enlarged, measuring 15 by 11.5 by 6 centimeters. The capsule 
is steel-blue and tense. On section the organ is firm and deep red, the 
cut surface being smooth and showing numerous minute haemorrhages 
scattered throughout the pulp. The lymphoid tissue is not visible. There 
is a small wedge-shaped, peripherally placed, yellow, somewhat softened 
area. 

Case 2993. — Chinese, male, 35 years old. The duration of illness was 
three days. The anatomic diagnosis was as follows: Bubonic plague; acute 
hasmorrhagic lymphadenitis (left lower cervical) ; acute pustular and 
vesicular dermatitis (plague carbuncle) ; acute hasmorrhagic lymphadenitis 
(right upper cervical) ; acute pseudomembranous tonsillitis; acute splenitis; 
infarcts of spleen and liver; petechial haemorrhages in epicardium; con- 
gestion and oedema of lungs. The description of the spleen is as follows: 
The spleen is enlarged to about twice or three times its normal size and 
is very friable. The cut surface is moist, uneven, and deep red but not 
dark. The Malpighian bodies and the trabeculse are obscured by the soft 
swollen pulp. On the surface are seen a few small grayish areas from 
2 to 8 millimeters in diameter. They consist of opaque friable tissue. 

See also the report of the spleen in case 1969 (page 270). 

HISTOPATHOLOGY OF THE SPLEEN 

Extreme engorgement of the spleen with red blood cells is 
the most striking feature. On account of the structure of the 
splenic sinuses it is difficult to recognize small haemorrhages 
histologically, but in bubonic plague the presence of large areas 
in which nothing but erythrocytes are visible, even in very thin 
sections, leaves no doubt in the mind that actual haemorrhage 
has occurred. Such haemorrhages, either at the periphery of the 
spleen or in its central part, are an almost constant feature of 
this disease. The erythrocytes are found in all stages of dis- 
solution. The endothelial cells lining the sinuses become en- 



292 The Philippine Journal of Science wis 

larged and vacuolated and frequently desquamated. Large cells, 
which are apparently derived from these, are found lying free 
in the sinuses. Their nuclei are single or they may be double. 
Cells no larger than these are also seen with as many as 10 or 
12 closely packed nuclei and with very indefinite cytoplasmic 
structure. The origin of these latter cells was not determined; 
they may be derived from the endothelium lining the sinuses, 
or they may be marrow cells. It is not unusual to find consid- 
erable numbers of polymorphonuclear leucocytes lying among the 
cells of the splenic pulp. 

The condition of the lymphoid follicles varies. In a fair 
percentage of the cases they are normal in size, and in no case 
of this series were they noticeably enlarged. Diminution in 
size and relative scarcity of the follicles is frequently seen. 
The central vessel in the follicles is usually engorged, and its 
walls appear thickened and poor in nuclei with a fibrillated 
structure which is eosinophilic. The adventitia is loose, and 
there is frequently a clear space immediately about the vessel. 
The entire structure of the follicles is loose and open, the lym- 
phocytes being separated from one another. Evidence of hy- 
perplasia of the follicles, as manifested by enlargement and 
mitotic figures of the cells in the germinal centers, is not fre- 
quently seen in plague. Bacilli within the follicles are never 
numerous. Haemorrhages from the surrounding pulp may ex- 
tend into and break up the follicles. In some cases the con- 
gestion of the spleen is most marked about the follicles, as has 
been noted previously in pneumonic plague, but this feature is 
not so noticeable and not nearly so constant in the spleens of 
this series. 

The trabecules show the same evidences of hyaline degenera- 
tion and frequently necrosis, as has been described in the walls 
of the blood vessels and the trabecular in the buboes. Small 
localized areas of haemorrhagic necrosis occur throughout the 
spleen in a large proportion of the cases. In these one sees 
large numbers of erythrocytes with very few other formed 
cellular elements, but large masses of chromatin particles. 
Larger infarcted areas were visible to the naked eye in three 
of our cases, as noted previously. These infarcted areas are 
rich in bacilli. Plague bacilli are almost always present in the 
spleen in rather large numbers, but they do not occur in the 
large zoogleal masses such as are seen in the buboes. They 
are more widely scattered through the splenic pulp, in the sin- 
uses, and in the endothelial cells. They are sometimes seen 



x, b, 4 Croivell: Pathologic Anatomy of Bubonic Plague 293 

in the polymorphonuclear leucocytes. In one of our cases no 
bacilli were found in smears, cultures, or sections of the spleen. 
As a rule, at autopsy smear preparations from the spleen show 
large numbers of plague bacilli, whereas in appropriately stained 
sections they frequently appear to be relatively few. 

Fibrin formation is not prominent in the spleen in bubonic 
plague. In a few cases only were fine threads of fibrin found 
in and about the vessels and sinuses. 

The essential lesions in the spleen in bubonic plague then 
are congestion and haemorrhage, necrosis, endothelial prolif- 
eration, and bacillary infiltration, with degenerative changes in 
the walls of the blood vessels and trabeculse. 

LIVER 

The liver regularly presents the condition of acute parenchy- 
matous degeneration, which does not essentially differ from the 
same condition encountered in other acute infections. 

Haemorrhages in the capsule of the liver and about the gall 
bladder are a frequent finding. Small haemorrhages and areas of 
focal necrosis are recognizable in some of the livers by the naked 
eye. Extreme congestion may be present in some cases, and 
some few present a fairly advanced fatty degeneration. In gen- 
eral, the macroscopic appearances of the liver are not especially 
characteristic of the disease and do not differ from those found 
in other acute infections. 

Infarcts and nodules similar to those found in the spleen were 
present in the livers of two of my cases (1969, 2993). An acute 
cholecystitis was also present in one instance (2074). 

HISTOPATHOLOGY OF THE LIVER 

The histological changes in the liver are chiefly acute paren- 
chymatous degeneration, congestion, and focal and larger areas 
of necrosis. Acute parenchymatous degeneration of a moderate 
grade is a practically constant finding in our cases. Congestion 
is also of frequent occurrence. This is especially marked in the 
central parts of the lobules, and the columns of liver cells may 
be widely separated by the engorged vessels, giving the ap- 
pearance of a chronic passive congestion. Pigment in the cells, 
such as is seen in such a condition, is, however, not frequently 
found. The liver cells show not only the evidences of acute 
parenchymatous degeneration, but are frequently vacuolated, and 
the nuclei often lie in a clear space. Foci are seen which seem 
to be especially in the peripheral parts of the lobules, in which 
the protoplasm has undergone solution, leaving a spongelike 



294 The Philippine Journal of Science wis 

reticular structure. As a rule, only a few cells are involved in 
such a focus. The nuclei may remain apparently intact, or they 
may become fragmented and disappear. These areas of focal 
necrosis are similar to those seen in typhoid and other acute 
infections. Haemorrhages into these necrotic foci sometimes 
take place. The endothelial cells of the vessels appear swollen, 
and small fibrin threads are sometimes seen. The areas of focal 
necrosis can be found in almost every case, if several slides are 
searched for them. Lymphocytes, and occasionally polymor- 
phonuclear cells, are frequently found in the portal spaces sur- 
rounding the portal vessels. Desquamation of the epithelium in 
the bile ducts in the portal spaces is often seen. The vessels 
seldom show thrombosis. Bacilli are found, but not in as large 
numbers as in the spleen or buboes. In a few of the cases 
nodules like infarcts were found. These show large masses of 
bacilli amid necrotic liver cells with some polymorphonuclear 
leucocytes. Vascular thrombosis probably accounts for these 
changes, but we were unable definitely to associate them with 
the lesions in our cases. 

GASTROINTESTINAL TRACT 

Here also the chief lesions encountered are obviously due to the 
haemorrhages. 

In 30 cases haemorrhages were noted in the mucosa of the 
stomach, and in 27 cases in the intestine. Of all haemorrhages 
on mucous membranes these are the most frequent. In some 
cases they are small and widely scattered, while in others they 
are larger and more closely packed. In the stomach they occur 
mostly on the crests of the rugae and here frequently give rise to 
superficial erosions of the mucosa. These erosions or small 
ulcers are either circular or linear in outline, following the direc- 
tion of the rugae on which they are placed. They are frequently 
multiple and may be very numerous. The circular ones vary in 
diameter from 1 to 3 or 4 millimeters, while the linear ones are 
from 0.5 to 1 centimeter in length. The larger ones frequently 
have a yellowish base and margins and are placed in the central 
part of the haemorrhagic area. Twenty of the cases showed 
these erosions of the mucosa in the stomach (Plate IV). 

A general hyperaemia of the gastric mucosa without haemor- 
rhages was not infrequent, and in many cases there was an excess 
of mucus on the surface. 

In the intestine any part may be affected, and the haemorrhages 
occur with about equal frequency in the small and large intestine. 
In some cases the entire mucosa of the large intestine may be 



x, b, 4 Croivell: Pathologic Anatomy of Bubonic Plague 295 

very thickly beset with punctate haemorrhages, so that no square 
centimeter of the entire surface is free from them. A type of 
plague has been described by some authors in which the intestine 
was said to form the portal of entrance for the bacilli to the body. 
In such cases primary buboes were described as occurring in the 
mesenteric glands. 

Attempts by various workers to reproduce this type of plague 
in animals by feeding cultures of the bacilli have resulted in 
primary infection through the mouth or pharynx rather than 
through the intestine. Similarly, in animals naturally infected 
by ingestion, cervical rather than mesenteric buboes occur. The 
Anglo-Indian Commission u and the Austrian Commission 32 
agree in stating that no case was seen in which alimentary 
infection was considered probable. In my series three cases 
occurred in which plague lesions other than haemorrhages were 
present in the intestine, but in each of these there were portals 
of entry in other parts, and both the intestinal lesions and the 
slight changes in the mesenteric glands were interpreted as 
secondary infections with the plague bacilli through the blood 
stream. 

In the first case (2125) the infection apparently entered 
through the tonsil, which showed ulceration and the lesions 
described elsewhere in this paper as those characteristic of a 
primary tonsillar bubo. All of the superficial glands showed 
lesions characteristic of secondary buboes. 

In the intestine beginning with the descending portion of the 
colon, extending through the sigmoid, and most prominent in 
the rectum, were numerous small ulcers, pin-point to pinhead in 
size. These were surrounded by a narrow hyperaemic zone. In 
the descending colon there were many grayish white, pinhead- 
sized, soft nodules. In the rectum the ulcers were so numerous 
as to give a hyperaemic appearance to the entire mucosa. The 
mesenteric glands were red and moist, like secondary buboes. 
No other focal plague lesions were found in this body. Strepto- 
coccus pyogenes and Bacillus pestis were isolated from the 
spleen. 

The second case (2148) was one with left axillary bubo and a 
pseudomembranous pharyngitis and laryngitis. The mucosa of 
the intestine showed no lesions except in the rectum, where there 
were fairly numerous pinhead-sized, slightly raised, pale, soft 
foci. Some of these were surrounded by a narrow red zone. 

n Report of the Indian Plague Commission (1898-99), 1, 368. 
"Uber die Beulenpest in Bombay (1898), II B, 543. 



296 The Philippine Journal of Science ms 

The mesenteric and mesocolic nodes were slightly enlarged, firm, 
and pink. Pneumococcus and B. pestis were isolated from the 
spleen. 

The third case (2024) will be reported in full. 

These cases form no basis for assuming a primary intestinal 
infection, but on the other hand prove that these intestinal lesions 
may occur secondarily. 

The intestinal lesions contain large numbers of bacilli, which 
would make the faeces of these cases a source of contamination. 

Intestinal parasites (Ascaris lumbricoides , Trichuris tri- 
chiuris, and hookworms) were found in 46 of the 75 cases. In 
8 of the cases all 3 species were found, in 18 cases 2 species were 
found, and in 20 cases only 1 species was found. 

CASE WITH EXTENSIVE GASTROINTESTINAL HAEMORRHAGES 

Case 202^. — Filipino, male, 30 years old. Anatomic diagnosis: Bubonic 
plague; acute haemorrhagic lymphadenitis, iliac (primary bubo), mesocolic, 
mesenteric, and lumbar; retroperitoneal ecchymoses; haemorrhages, epicar- 
dial, pleural, peritoneal, intestinal, and gastric; acute gastritis with 
haemorrhagic erosions; congestion of lungs, kidneys, and liver; parenchym- 
atous degeneration of kidneys and liver; acute hyperplasia of spleen. 

The body is that of an adult, male Filipino which is well-nourished and 
exhibits marked rigor mortis and some post-mortem suggillation. The body 
is still warm. There are no scars or cutaneous abrasions. The super- 
ficial lymphatic glands are not markedly enlarged. The pupils are equal, 
moderately dilated, circular. The conjunctivae and corneae are clear. The 
nose, ears, and mouth are normal. On section there is a moderate amount 
of subcutaneous fat. The muscles are well-developed, brown, and moist. 
The abdominal cavity is free from fluid and adhesions. The initial body 
section was continued into both inguinal regions, where no oedema was found; 
the lymphatic glands were not enlarged. The intestines are moderately 
distended, and the peritoneum along the brim of the pelvis shows diffuse 
bluish discoloration with minute petechia;. The liver reaches the right 
costal margin. The diaphragm is at the fourth interspace on the right and 
fifth interspace on the left. 

The thorax. The pleural sacs are free from fluid and adhesions. There 
is a small amount of thymic tissue which is pink and glandular, the thymic 
tissue probably not exceeding 5 grams in weight. The tissues of the 
anterior mediastinum are not oedematous. The lungs are somewhat re- 
tracted, exposing a large praecordial area. On opening the pericardium, 
there is a slight excess of clear fluid. The parietal pericardium is smooth 
and pale. 

The heart is large; the apex is formed by the left ventricle. The right 
ventricle presents anteriorly. There are numerous petechiae over the epicar- 
dium, especially on the right side of the heart. The right heart contains a 
considerable amount of red fluid and clotted blood. The tricuspid ring admits 
three fingers. The endocardium is smooth and pale throughout the right 
heart. The tricuspid and pulmonary leaflets are thin and pliable. The 
muscle of the left ventricle is considerably thickened, dark, and moist. The 



x, b, 4 Crotvell: Pathologic Anatomy of Bubonic Plague 297 

left heart is empty. The mitral ring admits two fingers. The endocardium 
throughout is smooth. The mitral and aortic leaflets are thin and pliable. 
The base of the aorta is free. The muscle of the left ventricle is dark, 
moist, and firm and not hypertrophied. The coronary arteries are intact. 

The lungs are somewhat diminished in volume, the pleura over them 
being smooth but showing numerous petechia? over both lungs. The lungs 
are crepitant, and their elasticity seems diminished. On section of the lungs 
the cut surface shows the same appearance anteriorly and posteriorly in both 
superior and inferior lobes. This consists of a moist, dark red, smooth 
surface which exudes some bloody, frothy fluid on pressure, but this is not 
large in amount. The bronchi have a bluish purple mucosa and are empty. 
The pulmonary vessels are free. The peribronchial lymph nodes are small, 
deeply pigmented, and firm. 

The neck organs. The faucial tonsils are very slightly enlarged, but 
show no gross changes. The lingual follicles are very prominent and 
pale. The tissues of the pharynx have a normal appearance, being perhaps 
slightly congested. The larynx and trachea have a normal appearance. 
The oesophagus is normal. The cervical lymphatic glands are not enlarged. 
The thyroid is normal in appearance. 

The spleen is very considerably enlarged (to about twice the normal 
size). The capsule is rather tense. On section the organ is of good 
consistence, and the cut surface is of an opaque, grayish red appearance, 
the pulp being rather prominent. The lymphoid and interstitial elements 
are obscured. There are no visible hemorrhages. The cut surface, while 
firm, is not absolutely smooth. 

The adrenals are of normal appearance. 

The kidneys are somewhat enlarged. The capsule strips readily and 
shows no hemorrhages. The surfaces of the kidneys are smooth and very 
deep red. The consistence of the organ is somewhat increased, and it is 
rather resilient. The cut surface shows deep congestion of both cortex 
and pyramids with few rather diffuse, paler areas in the cortex. These 
are rather large and not well circumscribed. The vascular markings are 
rather prominent, but the glomeruli are not readily seen. The pelves and 
ureters are intact. 

The urinary bladder is distended with a clear urine. Its mucosa is pale. 
The prostate is normal. 

The intestines. The small intestine, from the duodenum to the ileocecal 
ring, contains some dark flecks of coagulated blood and a small amount of 
dark, semiformed faecal material. The mucosa throughout shows numerous 
minute petechias, but there is no suggestion of any membrane and no 
ulceration. The large, intestine from the caecum to the rectum is the seat 
of still more numerous petechial hemorrhages, these all being isolated 
and minute but very closely packed throughout the entire intestine. Here, 
also, there is no evidence of any inflammatory reaction. The mesenteric 
and mesocolic lymphatic glands are prominent on account of their color, 
these being deep red, but they are not enlarged and show no evidence of 
necrosis nor surrounding oedema. 

The gall bladder and bile ducts are normal. 

The liver is slightly enlarged; its capsule is thin and smooth and is 
without hemorrhages. On section the cut surface is smooth, brownish red, 
and slightly opaque with fairly distinct lobular markings. 

The pancreas is normal in appearance. 

The stomach contains some blackish flecks of coagulated blood over the 

133736 4 



298 The Philippine Journal of Science 1915 

mucosa. On removal of this there are found very numerous petechia? in 
the mucosa. In addition, there are numerous excavations mostly circular 
in outline which are not deep and do not extend beneath the submucosa; 
their bases are flat and very deep red in color, and the mucosa immediately 
surrounding them is also very deep red in addition to presenting the 
petechial haemorrhages. The cardiac end of the oesophagus is absolutely 
normal in appearance, and the sharp demarcation of the congestion and 
haemorrhages which begins at the cardiac orifice is very striking. 

The retroperitoneal tissues. On dissecting up the peritoneum from the 
course of the iliac vessels and the aorta, there is found a diffuse haemorrhagic 
condition which extends up as high as the cceliac axis and outward over 
the poles of both kidneys. On dissection into this haemorrhagic tissue there 
are found numerous, enlarged, softened, and haemorrhagic lymphatic glands, 
some of which show small yellowish areas. The tissues between these 
lymphatic glands are so haemorrhagic as to make the differentiation between 
the lymphatic tissue and intervening tissue rather difficult. This com- 
pletely surrounds the abdominal aorta, which is of a very small caliber; 
its endothelium, however, is smooth. 

The head. The structures of the scalp and calvarium are normal. The 
dura mater is nonadherent and is rather bluish externally and pale and 
smooth internally. There is no excess of fluid in the meninges over the 
hemispheres or at the base. The meningeal vessels are filled with blood. 
The ventricles are not distended. The ependyma is smooth. Section of the 
brain substance reveals no gross lesions. 

Section into the axillae shows normal lymphatic structures. 

The report on bacteriological examination of material obtained by autopsy 
was made by Doctor Schobl, of the Bureau of Science. Specimens subjected 
to examination consisted of: 

(1) Smears from the retroperitoneal haemorrhagic glands, from the 
spleen, and from the lungs. 

(2) Cultures on agar slants made at the autopsy. 

All smears revealed numerous typical plague bacilli (Gram-negative). 

Cultures from the spleen: Scanty growth was noticed on the surface 
of the culture medium at the end of twenty-four hours' incubation. Smears 
were made from the water of condensation. They showed typical bipolar- 
staining bacilli arranged in chains. In forty-eight hours small colonies de- 
veloped on the surface, showing typical shape and elevated, granular center, 
with thin wavy margin. The culture was agglutinated by antiplague serum. 

Cultures from the glands: Cultures were slightly contaminated. Sub- 
cultures were pure and typical for plague. 

Animal experiment: Owing to the purity of the spleen cultures one 
guinea pig was infected by subcutaneous, another one by intraperitoneal 
infection. They both died on the fourth day after inoculation and exhibited 
typical lesions in the inguinal glands at the place of infection and in the 
spleen. Upon microscopical examination of the smears made from the 
bubo, spleen, and blood of the diseased animals typical B. pestis were found. 

HISTOPATHOLOGY OF THE STOMACH AND INTESTINE 

A catarrhal condition of the mucosa of the stomach and in- 
testine is almost constant in bubonic plague. The haemorrhages 
which have been spoken of as of such frequent occurrence in the 
gastric and intestinal mucosa are, as a rule, very superficial. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 299 

Near the tips of the papillae or villi in the areolar tissue between 
the glands in both the stomach and intestine small haemorrhages 
occur from the capillaries. These haemorrhages may involve only 
the area between two glands or may include several papillae. The 
vessels in the lower stratum of the mucosa and submucosa show 
engorgement. In simple haemorrhages no other change is seen. 

In those areas in the stomach that have been referred to as 
haemorrhagic erosions there is seen a severer change. Here the 
haemorrhage involves a larger area and extends more deeply into 
the mucosa. However, this lesion is usually entirely restricted 
to the mucosa, only one of our preparations showing haemorrhage 
below this, and there is always a zone of haemorrhagic glandular 
tissue recognizable above the muscularis mucosae. Necrosis and 
sloughing of a cup-shaped area of the mucosa occurs, and the 
margins of the small ulcer are formed by mucosa which appears 
normal with the exception that haemorrhage has occurred into 
it. A large number of polymorphonuclear leucocytes has been 
noted in the haemorrhagic tissue. Necrosis of the cells of the 
upper layer of the mucosa of the stomach and intestine has been 
stated by many authors to be very common in plague. In my 
work the changes in these cells have been interpreted as a 
simple post-mortem digestion. 

Pest bacilli are demonstrable in the haemorrhagic areas, but 
I have never encountered them in very large numbers. Al- 
though these haemorrhages have been interpreted by many, with 
whom I do not disagree, as due to bacillary emboli, we have failed 
to demonstrate such emboli in our sections. In the cases cited 
above as showing abscesses of the intestinal mucosa, the lesions 
show sharply circumscribed areas of necrosis in the mucosa and 
submucosa, with the presence of polymorphonuclear leucocytes, 
and engorgement of the vessels in the neighborhood. Numerous 
bacilli are seen in the necrotic areas. 

Many authors on the subject of plague refer to the occurrence 
of swelling and hyperaemia of the intestinal lymphoid tissue, 
which may be readily visible to the naked eye. No such case 
has been seen in my series, although microscopic sections from 
the intestines which pass through the follicles often show marked 
engorgement of these structures. 

PERITONEUM 

The most frequent change found in the peritoneum is the 
presence of haemorrhages. They occur either in the peritoneum 
itself or in the subperitoneal tissues. They are most abundant 
in those cases of femoral buboes which have marked primary 



300 The Philippine Journal of Science isis 

buboes of the second order in the iliac and lumbar glands, in 
which cases massive retroperitoneal haemorrhages may be found 
about the iliac and lumbar glands, ureters, and kidneys, on one 
or both sides. Discrete punctate haemorrhages may also be 
found scattered over the parietal and visceral surfaces. These 
haemorrhages are in some cases especially abundant in the mes- 
entery and on the inferior surface of the diaphragm. 

Reference has already been made to the extensive haemor- 
rhages which may be found in the serosa of the sigmoid flexure 
of the colon when it lies in apposition to the peritoneum cover- 
ing primary buboes of the second order in the iliac glands. 

An acute fibrinous peritonitis may also occur in the form 
of a delicate fibrinous membrane on the peritoneum overlying 
severely affected glands, or on the serosa of the sigmoid flexure 
in those cases which present the conglomerate haemorrhages, 
to which reference has just been made. 

CARDIOVASCULAR SYSTEM 

PERICARDIUM 

Practically the only lesion found in the pericardium consists 
of haemorrhages, and these are more frequent in the peri- 
cardium than in any other serous membrane. They were noted 
in 44 of our cases. They occur much more frequently over 
the visceral (epicardial) than over the parietal surface, and 
more often over the right side of the heart than over the left. 
They seem to be most frequent and most numerous about the 
auriculo-ventricular groove on the right side posteriorly. These 
may be very few in number and small in size, or they may be 
very numerous and widely scattered over the entire heart. A 
slight excess of fluid in the pericardium was noted in 2 cases, 
but the fluid is always clear, never being turbid nor sanguineous 
(Plate III). 

HEART 

The myocardium is almost always the seat of a parenchyma- 
tous or fatty degeneration, and in some cases a Zenker's degen- 
eration was seen, similar to that which was frequently noted 
in the skeletal muscles. Small haemorrhages in the myocardium 
were noted in a few cases. Dilatation of the right side of the 
heart is a not infrequent finding, and probably is an agonal 
event such as occurs in other acute infections. 

The endocardium in a few cases shows small haemorrhages, 
but in no case has any acute inflammatory manifestation been 
seen, nor has any reference to such an event been found in the 
literature of plague. 



x, b, 4 Crowell: Pathologic Anatomy of Bubonic Plague 301 

Chronic inflammatory lesions of the endocardium and myo- 
cardium have been found in a few cases, but these were indu- 
bitably due to preexisting disease. 

The vessels show no macroscopic lesions attributable to the 
plague infection other than the presence of haemorrhages from 
them which are due to microscopic lesions, which will be de- 
scribed with the histology. The presence of haemorrhagic in- 
filtration of the walls of the larger vessels in the immediate 
vicinity of the primary bubo is very frequent and has been 
especially noted by the Austrian Commission, who conclude that 
this may form a portal for the direct passage of the bacilli 
from the primary bubo to the blood stream in the veins. 

HISTOPATHOLOGY OF THE HEART 

The myocardium constantly shows evidence of acute paren- 
chymatous degeneration, with a marked swelling of the fibers. 
Small haemorrhages beneath the epicardium have been noted as 
of very frequent occurrence. Congestion of the smaller vessels 
between the muscle bundles is frequently a prominent feature, 
and it is not unusual to see small haemorrhages separating the 
muscle fibers. Cellular exudate from the vessels does not occur. 
(Edema may be marked and widespread, causing wide separation 
of the muscle fibers. 

The muscle fibers often show marked vacuolation, but seldom 
fatty change. Some of the muscle fibers become opaque, and 
the striation, especially the cross striation, becomes very in- 
distinct. Transverse clefts and even complete fragmentation of 
the fibers is often seen. This homogeneity of the fibers, with 
the breaking up into small fragments, is apparently a Zenker's 
hyaline degeneration of the muscle fibers. Such a degeneration 
was frequently noted in the macroscopic examination. Bacilli 
may be found within the vessels and are particularly numerous 
in the vicinity of the haemorrhages. 

NERVOUS SYSTEM 

Meningitis in plague has been reported by the Austrian 33 and 
German 34 plague commissions and by Calmette and Selembini 35 . 
Two noteworthy cases have occurred in my series. 

The first case (2431) was a 19-year-old female Filipino, who had been 
ill for two weeks. The anatomic diagnosis was bubonic plague; acute 
suppurative lymphadenitis (primary bubo), right axillary; acute suppu- 

33 Tiber die Beulenpest in Bombay (1898), II B, 287. 

34 Arb. a. d. feat's. Gesundheitsamte (1899), 16, 101. 
85 Arm. Inst. Pasteur (1899), 13, 865. 



302 The Philippine Journal of Science 1915 

rative ependymitis ; acute leptomeningitis; acute parenchymatous degenera- 
tion of kidneys, liver, and myocardium; chronic fibrous pleurisy, left; 
pregnancy, sixth month. The description of the brain is as follows: The 
cerebral leptomeninges contain a slight excess of fluid which appears 
slightly turbid. On opening the right lateral ventricle, it is found to 
contain a considerable amount of yellowish gray pus. The choroid plexus 
is large and soft. The left choroid is smaller, but also surrounded by 
grayish exudate. The fourth ventricle is apparently free. The brain 
substance is pale and shows nothing abnormal. 

In smears from the spleen, glands, and pus from the axilla no bacteria 
were found. Smears from the pus of the ventricle were loaded with 
plump bacilli, which varied greatly in size but did not show altogether 
typical bipolar staining. Agar cultures from the spleen showed a few 
colonies which proved to be plague. Agar cultures from the ventricles 
showed an abundant growth of plague bacilli; a guinea pig inoculated 
cutaneously with this culture died in five days with typical lesions of plague. 

The second case (3247) was an 18-year-old male Filipino, who was 
said to have been ill for one month. This case had cervical retropharyngeal 
buboes, bronchopneumonia, acute suppurative meningitis, acute parenchy- 
matous degeneration of the viscera, acute splenitis, and trichuriasis. 

The meninges over the hemispheres are dry, and the convolutions are 
flattened. At the base of the brain, about the circle of Willis and ventral 
to the pons, is found considerable greenish yellow pus. The lateral ventricles 
contain a turbid, slightly greenish fluid, mixed with a thick, stringy, green- 
ish yellow pus, which is adherent to the floor of the ventricles, especially 
at the region of the choroid plexus, which is completely enveloped in the 
exudate. The floors of the ventricles are thickly covered by this shaggy 
mass. The third and fourth ventricles contain a slightly turbid fluid. 

Bacillus pestis was recovered in cultures from the exudate from the 
ventricles, and a guinea pig vaccinated with the culture died with typical 
plague lesions. 

Aside from these cases of frank meningitis, the meningeal 
vessels in almost all cases examined showed a congestion, and 
in some cases the brain substance showed some oedema. No 
other lesions were found. 

URINARY SYSTEM 

The kidneys in plague invariably show evidence of an acute 
parenchymatous degeneration, the renal parenchyma being swol- 
len and opaque, with relatively broad and bulging cortex. The 
pyramids are sometimes paler, with bluish red peripheries, and 
sometimes they are intensely red. In some cases the swelling, 
opacity, grayness, and friability of the cortex is so marked as 
to justify the macroscopic diagnosis of necrosis of the kidney. 
Haemorrhages in the capsule, in the mucosa of the calices and 
pyramids, and in the renal parenchyma are frequent. The renal 
capsule may be studded with punctate haemorrhages. In the 
pelvic mucosa the haemorrhages may be punctate or massive so 



x, b, 4 Crow ell: Pathologic Anatomy of Bubonic Plague 303 

as to fill the pelvis with blood. The fat and areolar tissue about 
the pelvis of the kidney may also be the seat of extensive haem- 
orrhage, especially on the side on which extensive retroperi- 
toneal haemorrhage occurs about primary buboes of the second 
order in the lumbar glands. The haemorrhages occurring in 
the renal parenchyma may be numerous and punctate on the 
outer surface and in the cortex. These for the most part occur 
in the glomeruli, constituting, along with the degeneration, a 
true haemorrhagic glomerulonephritis. However, such a condi- 
tion occurs in a relatively small proportion of the cases. 

The glomeruli in some cases appear pale, lusterless, and 
elevated. Focal areas of necrosis, not larger than 2 millime- 
ters in diameter, were seen twice (1969, 2989). In both cases 
there were other metastatic plague foci in the viscera. 

The ureters show no marked lesion other than the presence 
of haemorrhages in and about them. Punctate haemorrhages 
on the mucosa occur. Frequently the ureter on the side on 
which the femoral bubo occurs is completely surrounded by, and 
embedded in, haemorrhagic retroperitoneal tissue, and this haem- 
orrhagic condition may not only be about the ureter, but may 
extend through its walls so as to be visible on the mucous surface 
at localized portions. 

The urinary bladder may similarly show punctate haemor- 
rhages on its mucous surface; no other change has been en- 
countered. 

HISTOPATHOLOGY OF THE KIDNEYS 

The morphologic changes occurring in the kidney are im- 
portant and frequently characteristic. They consist essentially 
of a degeneration of the tubular epithelium and an intracapillary 
glomerulonephritis. Changes in the vessels also occur as well 
as some oedema and haemorrhages, but cellular reaction in the 
form of evidence of regeneration or exudation is minimal or 
lacking. 

The epithelium of the primary convoluted tubules undergoes 
a marked granular degeneration with swelling of the cells. Fre- 
quently hyaline masses appear in the cells and the latter become 
broken up. Necrosis of these cells with their desquamation into 
the lumen frequently occurs. Very seldom are other cellular 
elements found in the tubules, except occasionally red blood 
cells. A granular material is practically always present in the 
distended tubules. 

Congestion of the vessels is frequently marked between the 
tubules, both in the cortex and in the pyramids. Small haem- 



304 The Philippine Journal of Science wis 

orrhages also occur in all parts of the kidney, beneath the 
capsule, beneath the pelvic mucosa, and in the cortex and pyra- 
mids. (Edema may widely separate the tubules, and it is not 
infrequent to find fine threads of fibrin in the intertubular vessels. 
This fibrin is attached to the walls of the vessels, and the endo- 
thelium to which it is attached may show no change; in other 
cases the endothelial cells are decidedly enlarged. 

Glomerular changes may also be marked, and these form the 
most characteristic change in the kidneys in plague. However, 
marked glomerular changes are not present in all cases, as in 
some the changes in the tubular epithelium, as above described, 
may be predominant. Degeneration and vacuolation of the 
epithelium covering the tufts may be present. As a rule the 
changes in the epithelium lining Bowman's capsule are slight. 
The capsular space frequently contains a granular retic- 
ulated material, similar to that found in the tubules. Occasion- 
ally red blood cells are also found here as well as desquamated 
epithelial cells. Much more rarely are leucocytes found in the 
capsular space. Congestion of the tuft capillaries is very fre- 
quent. In 41 per cent of my cases fibrin thrombi were found 
in the tuft capillaries. This fibrin may be in the form of fine 
threads, which are adherent to the walls of some of the tuft 
capillaries, or may completely fill some or all of the capillaries 
of some or all of the tufts in a section. The larger thrombi 
can be readily recognized with the haemotoxylin and eosin stain, 
but the smaller threads may require a selective stain, such as 
Weigert's fibrin stain, for their detection. The endothelium 
lining the capillaries does not show evidence of marked change 
in those cases with thrombosis. 

The bacilli occur in relatively small numbers in the kidney 
as compared with the bubo or spleen. They may be found in 
the vessels of the kidney, as in all parts of the body. They 
are, at least, not always demonstrable in association with the 
vascular thrombi. 

GENERATIVE ORGANS 

These organs are not frequently the seat of marked change. 
Haemorrhages have been encountered in the mucosa of the uterus, 
in the peritoneum covering it, in the ovaries, in the testes and 
epididymes, and along the course of the vas deferens. 

In the uterus of one of our cases was a 6-month foetus, and 
another uterus was enlarged, with adherent placenta and dilated 
cervix, the patient having aborted a foetus of about the eighth 
month the dav before death. 



x, b, 4 Croivell: Pathologic Anatomy of Bubonic Plague 305 

Scheube 36 cites a case of intrauterine infection with plague 
that was reported, by Leumann. 

In my case (2431) of which the uterus contained a 6-month 
foetus no pest bacilli were demonstrable in sections of the pla- 
centa or umbilical cord. 

HISTOPATHOLOGY OP THE TESTES 

In two cases haemorrhages in the testes were noted micro- 
scopically. These appear histologically as diffuse intertubular 
haemorrhages, which widely separate the tubules from one 
another. Much of the blood has undergone haemolysis. The 
cells of the tubules themselves show no recognizable alteration. 

PANCREAS 

No recognizable macroscopic lesion has been seen in the pan- 
creas aside from the occurrence of occasional small haemorrhages 
in its capsule and in the interstitial tissue and some congestion 
of the organ. 

HISTOPATHOLOGY OF THE PANCREAS 

No marked morphologic change has been found in the pancreas 
in any of the cases. In two cases large vessels within the pan- 
creas showed thrombosis, the vessels being filled with leucocytes 
and a small amount of fibrin with numerous bacilli. No asso- 
ciated change in the surrounding pancreatic tissue was recog- 
nizable. 

ADRENALS 

The adrenals in plague are as a rule swollen and moist and 
often red. Haemorrhages occur about the capsule of the organs, 
in the cortex, and in the medulla. These are as a rule small and 
punctate, but more diffuse haemorrhages have been seen within 
the medulla. 

HISTOPATHOLOGY OF THE ADRENALS 

The lesions in the adrenals are not a prominent feature in 
bubonic plague, but there are a variety of lesions which not in- 
frequently occur. 

A degeneration of the cells especially in the zona fasciculata 
may be present, in which the cytoplasm of the cells appears to 
dissolve away, leaving only a spongelike cytoplasmic reticulum 
surrounding the nucleus". This may involve nearly all of the 
cortex, or may be restricted to a few cells. In a few cases small 
areas were found in which the nuclei also disappeared, constitut- 
ing areas of focal necrosis. There was never seen any evidence 
of exudation of cells into these areas. 

38 Krankheiten der warmen Lander. Gustav Fischer, Jena (1910), 267. 



306 The Philippine Journal of Science 

(Edema of the gland is also a very common feature, and this 
is most noticeable between the vessels and columns of cells in the 
zona fasciculata. This may cause a considerable widening of 
the spaces between these columns of cells. Congestion of the 
cortical vessels is exceedingly common, and in a few cases the 
medullary vessels were engorged. No cellular exudate, however, 
appears to take place, although fine fibrin threads were found in 
the cortical vessels in 23 per cent of 26 adrenals examined with 
this point in view. 

Small haemorrhages may occur in the gland — more frequently 
in the cortex than in the medulla. These were found in 32 per 
cent of 26 adrenals that were carefully examined. Small haem- 
orrhages in the medulla occurred in 2 cases only. 

The changes then that were found in the adrenals consisted 
of degeneration, oedema, congestion, haemorrhage, focal necrosis, 
and fibrin thrombosis. 

ASSOCIATED LESIONS 

Osier's seemingly paradoxical statement that persons rarely 
die of the disease with which they suffer does not apply to plague. 
Neither is plague a disease which has any predilection for those 
who have had their resistance to infection lowered by chronic 
disease. These statements probably apply with a greater degree 
of truth to plague than to any other known acute epidemic dis- 
ease. The virulence of the plague toxin and the rapidity of mul- 
tiplication of the plague bacillus are such that they do not require 
a ground already prepared in order that they may exert their 
harmful effects to the fullest extent. Scheube 3T places the high- 
est age incidence of plague between the ages of 25 and 30 years. 
Reference to Table I shows that the highest age incidence in my 
series was between the ages of 15 and 40 years ; in other words, 
individuals in the prime of life are most frequently attacked. 
This undoubtedly accounts for the relatively small number of 
cases of plague that show at autopsy evidence of associated lesions. 

In my series associated lesions were minimal in number. 
Chronic adhesive pleurisy heads the list with 20 cases. Evidence 
of tuberculosis (or other evidence of tuberculosis) was found 
in 5 cases. Chronic cardiac or renal disease, or both, was found 
in 5 cases only. Of uterine conditions 1 case had a myoma, 1 
was pregnant, and 1 had recently aborted. Status lymphaticus 
was found to be present in 5 cases (1894, 2084, 2086, 2124, 
2378), aged respectively 19, 14, 37, 15, and 16 years. No other 
associated lesions were found. 

37 Krankheiten der warmen Lander. Gustav Fischer, Jena (1910). 267. 



ILLUSTRATIONS 

Plate I 

Metastatic pulmonary lesions in bubonic plague seen through the pleura. 
Case 1969. See page 270. (Drawing by T. S. Espinosa after Kaiser- 
ling preservation.) 

Plate II 

Metastatic pulmonary lesions in bubonic plague. Cut surface of same lung 
as in Plate I. (Drawing by T. S. Espinosa after Kaiserling preserva- 
tion.) 

Plate III 

Heart, showing epicardial haemorrhages in bubonic plague. (Drawing by 
T. S. Espinosa after Kaiserling preservation.) 

Plate IV 

Stomach, showing haemorrhages and hemorrhagic erosions in bubonic 
plague. (Drawing by J. Castro after Kaiserling fixation.) 

Plate V 

(Drawn by T. S. Espinosa after Kaiserling preservation. Natural size.) 

Fig. 1. Femoral bubo, showing involvement of several glands with haemor- 
rhage and necrosis of interglandular tissue. Case 1952. 
2. Axillary bubo. Case 2048. 

307 



Cbowell: Bubonic Plague.] 



[Phil. Journ. Sci., X, B, No. 4. 






PLATE I. METASTATIC PULMONARY LESIONS IN BUBONIC PLAGUE SEEN THROUGH 

THE PLEURA. 



Crowell: Bubonic Plague.] 



[Phil. Journ. Sci., X, B, No. 4. 




PLATE II. METASTATIC PULMONARY LESIONS IN BUBONIC PLAGUE. 



Crowell: Bubonic Plague.] 



[Phil. Journ. Sci., X, B, No. 4. 






'-': . 



PLATE III. HEART, SHOWING EPICARDIAl. H/EMORRHAGES IN BUBONIC PLAGUE. 



Crowell: Bubonic Plague.] 



[Phil. Journ. Sci.. X. B, No. 4. 




PLATE IV. STOMACH, SHOWING H/EMORRHAGES AND H/EMORRHAGIC EROSIONS IN 

BUBONIC PLAGUE. 



Crovvell: Bubonic Plague.] 



[Phil. Joup.n. Sci., X, B, No. 4. 




Fig. 1. Femoral bubo, showing involvement of several glands with haemorrhage and necrosis of 

interglandular tissue. 




Fig. 2. Axillary bubo. 
PLATE V. 



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THE PHILIPPINE 

Journal of Science 

B. Tropical Medicine 

Vol. X SEPTEMBER, 1915 No. 5 

I. THE R6LE PLAYED BY THE INSECTS OF THE DIPTEROUS 

FAMILY PHORIDvE IN RELATION TO THE SPREAD OF 

BACTERIAL INFECTIONS. II. EXPERIMENTS ON 

APHIOCHyETA FERRUGINEA BRUNETTI 

WITH THE CHOLERA VIBRIO T 

By David N. Roberg 

(From the Laboratory of Medical Entomology, College of Medicine and 

Surgery, University of the Philippines) 

It is interesting to note that so many years elapsed after the 
discovery of bacteriology before flies as agents in the transmis- 
sion of disease were given serious attention. As early as 1886 
Spillmann and Haushalter(l) isolated the tubercle bacillus, and 
Tizzoni and Cattani(2) isolated the cholera vibrio from flies 
caught in the vicinity where human cases occurred. Earlier 
still, in 1862, before the days of bacteriology, Budd(3) observed 
that flies were instrumental in the spread of malignant pustule. 
World-wide attention was first attracted to flies as agents in the 
transmission of disease when the extensive outbreak of typhoid 
fever occurred in the concentration camps of the American Army 
during the Spanish-American War, when Reed, Vaughan, and 
Shakespeare (4) reported the origin of the outbreak as due to 
flies. 

There is a long list of contributors on the subject of flies, most 
notable of whom are those who wrote first on the development 
and life history of flies [Lowne,(5) Griffith, (6) Newstead,(7) 
Graham-Smith, (8) and Howard (9)]. 

Numerous contributions have been made on the carriage of 
infection in the alimentary tract of flies. Chief of these are 

1 Thesis presented for the degree of D. T. M., University of the Phil- 
ippines, 1915. Received for publication June 24, 1915. 

135264 309 



310 The Philippine Journal of Science 1915 

the articles by Grassi,(i0) Maddox,(n) Alessi,(12) Celli,(i3) 
Uffelmann,(i4) Sawtchenke, (15) Yersin,(i6) Firth and Hor- 
rocks,(i7) Manning, (18) Hayward,U9) Lord, (20) Chante- 
messe, (21) and Buchanan. (22) 

Instances are recorded in which flies have been caught in the 
neighborhood of human cases infected with virulent organisms, 
and the interior of the flies or their dejecta have shown the 
presence of pathogenic bacteria. In this manner wild flies have 
been found to harbor cholera vibrios by Tizzoni and Cattani, (2) 
Simmonds, (23) and Tsuzuki;(24) typhoid bacilli by Hamilton, (25) 
Faichnie,(26) Bertarelli,(27) and Cochrane; (28) tubercle bacilli 
by Spillmann and Haushalter, (l) Hofmann,(29) Lord, (20) Hay- 
ward, (19) Cobb, (30) and Buchanan; (22) anthrax by Cao;(3l) 
and plague bacilli by Yersin(i6) and Hunter. (32) 

Articles too numerous to mention here have been written on 
the transmission by flies of typhoid fever, tuberculosis, cholera, 
dysentery, infantile diarrhoea, anthrax, smallpox, ophthalmia, 
oriental sores, yaws, and parasitic diseases. 

Of the numerous articles on the transmission of disease by 
flies the Diptera usually referred to are of the larger species. 
Heading the list is Musca domestica, then Calliphora vomitoria, 
Lucilia cxsar, Sarcophaga carnaria, and others. 

In determining the species of most importance in relation to 
the spread of disease, Howard (33) examined a great number of 
flies in regard to their breeding places and found 36 species 
which bred in human fasces. Of these, especially 6 were found 
in dining rooms and kitchens, and thus constitute particularly 
a menace in the spread of disease. These species were repre- 
sented by Musca domestica, Drosophila ampelophila, Homalomyia 
canicularis, H. brevis, Stomoxys calcitrans, Phora femorata, 
and Sarcophaga tibialis. 

In subsequent bulletins issued by Howard no other mention 
is made of Phoridse as a menace in the carriage of bacteria and 
spread of infection. The Phoridae, then, are only casually men- 
tioned in the literature, and no experimental work has been done 
on the family in relation to the carriage of disease. 

As so much of the Avork done on flies is of recent date, and 
as it is only within a few years that their life history, habits, 
and their relation to disease are becoming understood, not much 
attention has been given this important family of Diptera. 

It is the object of this paper to ascertain, by a series of experi- 
ments on Aphiochssta ferruginea Brunetti, whether the results 
obtained would indicate this fly to be instrumental in the carriage 



x, b, 5 Roberg: Bacterial Infections 311 

of disease, and whether it can be considered as important as the 
more commonly noted Musca domestica, Stomoxys calcitrans, 
Lucilia, Sarcophaga, Calliphora, and other of the larger species 
which have received so much attention in the literature. 

DESCRIPTION OF THE FAMILY PHORIO-E 

The family Phoridee contains, according to Kertesz, (34) 27 
genera and 221 species. Malloch, (35) in reviewing the Phoridae 
in the United States National Museum, enumerates 79 species 
under the genus Aphiochseta. 

According to Malloch's description the insects of this family 
are for the most part very small, black or yellow flies, which on 
account of their minuteness are easily overlooked. Of the life 
history of this group there is very little known. Strange to say 
it is over a century since the first species was described, and even 
now but little is known of its habits. Complete life history- 
records of this family are rare, and the list of those so recorded 
is very meager. 

Those species that have been reared have, for the most part, 
been bred upon fungi and dead or decaying vegetable or animal 
matter. Some have been reared from snails, and a few from the 
bodies of bees, ants, or beetles. Whether or not some of these 
are true parasites is a matter of conjecture. They may be found 
throughout the year, especially within houses. 

Malloch lists 57 species of the Phoridse whose habits are par- 
tially known. As some of these species named may be instru- 
mental in the carriage of disease, because of their breeding 
places, and as they are few in number, the names are here given. 

Recovered from exhumed human bodies are: Trupheoneura 
opaca Meigen and Conicera atra Meigen. From a buried human 
corpse, Phora aterrima Fabricius. The following 5 species 
were recovered from carrion : Trupheoneura trinervis Becker, 
T. perennis Meigen, Dohmiphora abdominalis Fallen, Chsetoneu- 
rophora calignosa Meigen, and C. ora curvinervis Becker. 

The remainder of the 57 species occur on dead snails, bees, 
caterpillars, and other insects, rotting vegetable matter, leaves, 
or plants, or as commensals with other insects. 

Brues,(36) who revised and monographed the North American 
Phoridas, gives the following description of the family and of the 
genus Aphiochxta. 

Although a considerable number of Phoridse have been de- 
scribed during the past few years, our knowledge concerning the 
extent of the family is still very meager. The forms occurring in 



312 The Philippine Journal of Science ms 

Europe and North America are comparatively well known, but 
those of less accessible regions have not been so thoroughly 
collected as most other families of Diptera. The generic rela- 
tions of the family seem to be very similar in the most widely 
separated geographical regions. 

FAMILY CHARACTERS 

Phoridae are probably the most readily recognized family 
among all the Diptera. Apart from the wingless forms they 
possess such a peculiar and constant type of wing venation that 
they may be readily recognized at a glance. The important 
family characters are : Small or minute species with a hunched- 
back appearance. Head small, hemispherical or rather flattened ; 
front broad in both sexes, usually bearing 3 or 4 transverse rows 
of bristles; face very short, concave. Oral opening large, the 
palpi well developed and projecting, usually with strong bristles. 
Eyes never very large, often much reduced in wingless forms; 
ocelli always present in the winged forms. Antennae of peculiar 
form; the third joint large and concealing the others, spheroid 
or pointed, with a long, nearly bare subdorsal or apical arista. 
Thorax usually large and arched above, the scutellum rarely 
absent. Abdomen short, more or less slender and narrowed be- 
hind in the male; in the female more oval in shape and pointed 
at the tip. Genitalia of the male usually prominent, often large. 
Those of the female small and projecting. In a few genera 
the ovipositor is hard, chitinized, and projecting. Legs well 
developed; coxae stout, the anterior ones very long and free at 
the base ; femora stout ; the posterior pair often swollen or flat- 
tened ; tibia generally with a few strong bristles, sometimes bare. 
Wings usually large, but sometimes very small or entirely ab- 
sent in the female. When present, they have a series of two 
heavy veins anteriorly which reach only halfway to the apex of 
the wing, and three or four much lighter ones which run 
obliquely across the disc of the wing. 

GENERIC CHARACTERS 

The most important characters for the definition of genera 
are to be found in the presence or absence of strong macro- 
chaetae on the tibia, the position of the frontal bristles, and the 
venation of the wings, especially with regard to the branching 
of the third vein. The reduction of the wings and the remark- 
able elongation of the ovipositor are important for the recogni- 
tion of some genera. 



x, b, 5 Roberg: Bacterial Infections 313 

GENUS APHIOCH^ETA BRUES (37) 

Characters. — Head usually rather small, the front usually 
about quadrate, with 4 rows of bristles; anterior row consist- 
ing of 2 or 4 closely placed, proclinate ; three upper rows of 4 
each normally, although the median pair of the lower row is 
sometimes absent. Eyes moderately large, ocelli on a tubercle. 
Frontal impressed groove generally present. Antennae oval, 
with a dorsal arista. Palpi scarcely ever strongly enlarged, 
usually with strong bristles. Proboscis usually small, but some- 
times enlarged or heavily chitinized. Cheeks each with a pair 
of macrochaetae. Thorax with a single pair of dorsocentral 
bristles. Abdomen oval or long and tapering in the female, 
much slenderer in the male, with projecting hypopygium. Ovi- 
positor retractile, soft, and fleshy. Legs without preapical 
bristles on the tibia, although the four posterior ones are, 
sometimes finely setulose. Spurs present on four hind legs. 
Wings ample, the third vein forked at the apex, mediastinal 
vein present. 

APHIOCH^TA FERRUGINEA BRUNETTI 

Aphiochseta ferruginea was described by Brunetti.(38) Al- 
though the flies were accidentally reared from a dead lizard in 
1907, the description was not published until 1912. Brunetti 
describes this species at length as he found it to correspond with 
some specimens of flies at the Indian Museum sent there by 
Doctor Crombie, obtained from the fasces of a European in 
Rangoon suffering with myiasis. In the faeces were passed 
eggs and maggots as well as adult flies. 

According to Brunetti A. ferruginea has a wide distribution 
throughout the tropical regions and some adjacent parts of the 
temperate zone, also. 

Brunetti's description is as follows: 

c? ?. India, Ceylon. Long. 24-3 mm. 

Head. — Brownish yellow, yellowish, often more or less tinged with grey, 
sometimes entirely greyish. Eyes black, microscopically pubescent, poste- 
rior orbit with a row of short black bristles; two strong macrochaetae 
below the lower angle of each eye, and a vertical row of short bristles 
on the cheeks. Antennae pale yellowish, varying to brownish yellow, 
arista long and microscopically pubescent. Palpi brownish yellow or 
yellowish, with several shorter bristles on outer side, a few hairs on inner 
side and five or six separated strong spines towards the tip. Frons 
generally concolorous but sometimes with brownish irregular marks in 
the middle on a yellowish ground colour, the vertical impressed line 
sometimes very distinct. The frons is furnished with four rows of four 
macrochaetae each. The upper or vertical row are reclinate, equidistant, 



314 The Philippine Journal of Science 1915 

the outer ones at the upper angles of the eyes, the median pair on the 
inner side of the two upper ocelli, and slightly below the vertical margin. 
Behind the vertical margin is a bristle on each side, almost immediately 
contiguous to the outer bristle of the vertical row. These post-vertical 
bristles are convergent. The second row is just below the lower ocellus, 
and consists of four equidistant bristles, the median pair fractionally but 
perceptibly higher on the frons than the outer ones. The bristles in 
this row are generally reclinate but sometimes are almost at right angles 
to the frons. The 3rd and 4th rows are so composed as to almost make 
a single semicircular row of eight. They probably, however, represent 
two rows of four each, those forming the 3rd row placed thus: the 
outer pair near the eyes as usual (and immediately under the outer 
ones of the 2nd row but rather more distant vertically from them 
than these latter are from the vertical or 1st row) ; the inner bristles 
rather closer than usual to the outer ones, leaving a wide space of 
the frons between the inner pair, which latter are much lower on the 
frons than the outer pair. Of this row, the outer ones are always 
reclinate, but the median ones are often more nearly horizontal. 

The 4th row is placed wholly on the middle of the frons in a short 
semicircle, the two median ones the lowest, and the outer ones still proxi- 
mad of the median pair of the 3rd row. Of this 4th row, the outer ones 
are more or less horizontal, the median pair always very distinctly 
proclinate. 

In some specimens the outer pair of the 3rd row are rather further 
removed from the median pair, and in this case these latter alone may be 
considered as forming the 3rd row, and the median pair, with the outer 
two of my fourth row, as forming a row of four representing the 4th 
row. There would then be a pair of additional proclinate median bristles 
below this fourth row. The previous interpretation of their arrangement 
is apparently the truer one. 

Thorax. — Generally bright ferruginous or brownish yellow, varying in 
shades and with or without an admixture of grey; occasionally with two 
faint greyish dorsal lines. Some strong bristles of unequal length and 
number laterally from the shoulders (where there is always one strong 
humeral bristle) to the posterior corners, there being generally four towards 
the hinder border of the dorsum. Some stronger ones in front of the 
wings; three small ones close together near the fore coxas, a fan-shaped 
row of six or more small but distinct ones at the extreme base of the 
costa, and a similar row behind the base of the wing. Sides of the thorax 
rather lighter; scutellum concolorous, with four strong bristles, the outer 
pair usually the larger. 

The whole surface of the thoracic and scutellar dorsum is covered with 
minute stiff bristles. 

Abdomen. — Dark ferruginous or brownish yellow, practically bare and 
very variable. Normally brownish yellow, the posterior half (or there- 
abouts) of each segment black or blackish, but this colour sometimes 
occupies the greater part or whole of one or more segments; in some 
specimens a clearer space, more or less oval in shape, remains in the 
centre of the segments; or the abdomen may be wholly black or blackish, 
with or without pale edges to the segments, this character itself being 
present or absent irrespective of other coloration. 



x, b, 5 Roberg: Bacterial Infections 315 

Sometimes the abdomen is black or dark reddish ferruginous with the 
centre part generally pale, forming a light wide irregular dorsal stripe. 
Belly generally brownish yellow or some kindred shade. 

Genitalia in S dark, not prominent, bluntly conical, with a few hairs; 
in $ the ovipositor is subcylindrical, pale yellowish, with two stiff hairs 
at tip. 

Legs. — Pale dirty yellow, minutely pubescent. Coxae with some strong 
black bristles at tip. Femora without distinct bristles, the hind pair 
are often paler in colour, and are generally blackish towards the tips, 
often only very slightly so. Tibiae with a distinct row of short bristles 
on outer side, the four posterior tibiae with two terminal spurs, the hind 
pair having a close row of very minute hairs on the outer side, adjacent 
to the row of bristles. Tarsi slightly blackish. 

Wings. — Pale yellowish, a little iridescent, costal border shortly bristly 
with two divaricating rows as far as the tip of the 3rd longitudinal vein, 
which, shortly forked, reaches about the middle of the wing, the 1st 
longitudinal ending just beyond the middle of the costal cell. Of the light 
veins, all of which attain the wing-margin, the 1st takes a single, distinct 
curve upward, the 2nd and 3rd are moderately bisinuate (sometimes much 
less so), the 4th is nearly straight. Halteres pale yellow. * * * 

Note. — This species is very variable in colour, ranging from bright 
ferruginous to grey, the proportion of black on the abdomen totally altering 
the general appearance of the insect. The species, however, once well 
understood, is tolerably easy to recognize. 

Concerning the life history of Aphiochseta ferruginea, Bru- 
netti's (39) notes showed that it required a period of from twelve 
to fifteen days for the first generation to emerge. Pupation 
occurred from five to eight days after the eggs were laid. Emer- 
gence of the imagines took place seven days after pupation. 
As the eggs were not noted at the time they were laid, there 
is a variance of three days in the process. 

The first generation laid eggs when they were five or 
six days old. Three days after pupation a few imagines 
emerged. Due to the scarcity of food the majority of the second 
generation emerged from sixteen to twenty days after the eggs 
were laid. 

The specimens of flies which were secured and employed in 
the experiments outlined in this paper were compared with the 
identified specimens in the Bureau of Science collection at Ma- 
nila by Prof. Charles S. Banks, and were found to correspond 
with Aphiochseta, ferruginea collected by him. There is, also, 
a correspondence with the description given by Brunetti. 

Before going into detail concerning the object of the experi- 
ments in this paper, a review of the literature will be gone 
into concerning the phenomenon of the larvae of dipterous insects 
transferring pathogenic bacteria from the medium upon which 



316 The Philippine Journal of Science 1915 

they feed into the emerging imagines. The question of flies 
becoming infected by means of the pathogenic bacteria taken up 
by the larvae from which they develop is of importance from a 
public hygienic standpoint. 

Concerning this question there have been but five investigators 
who have reported their results. The first of these, Cao,(3i) 
in 1906, made observations upon the larvae of the following 
diptera: Musca domestica, Calliphora vomitoria, Lucilia csesar, 
and Sarcophaga carnaria, they being feeders on putrefied meat 
or carrion. 

Feeding these larvae on putrefied carrion, and then securing 
cultures from their intestinal flora, he demonstrated that death 
resulted in guinea pigs in from three to five days after being 
injected by these cultures. From the guinea pigs could be 
isolated a virulent strain of Bacillus coli, two or three varieties 
of typhoidlike organisms, and less frequently a pseudomalignant 
oedema bacillus, Staphylococcus aureus, an anthraxlike bacil- 
lus, and a very virulent Proteus fluorescens. 

The intestinal flora of the larvae were like those which are 
present during putrefaction, being Proteus vulgaris, P. mira- 
bilis, P. zenkeri, Bacillus subtilis, B. radiciformis, an anthrax- 
like bacillus, B. fluorescens liquefaciens, B. fluorescens non- 
liquefaciens, cocci, typhoidlike and colilike bacilli, and less 
frequently the sarcinae, Bacillus prodigiosus, the o'idia, and 
blastomycetes. 

As a result of his investigations Cao came to the following 
conclusions : 

The bacterial intestinal flora of larvae is like the bacteria 
which occur in the putrefying meat upon which they feed. 

The intestinal flora consists of the Proteus group, the subtilis 
group, the fluorescent group, coli and typhoidlike organisms, 
and cocci. 

The bacterial flora is alike in the flesh of cold- or warm-blooded 
animals and alike in the different species of flies. 

The intestinal flora of larvae acquired during feeding upon 
putrefied meat shows a greater virulence than those existing 
in the meat. 

The germs in putrefying dead animals are derived from the 
air, from their intestinal contents, from the blood of those 
dying of septicaemia, and from flies as they deposit their eggs. 

The interior of the eggs of flies is sterile, but the shell contains 
many bacteria. 



x, b, 5 Roberg: Bacterial Infections 317 

Bacteria introduced into the intestinal tract of flies are passed 
in the faeces, living and virulent, and contaminate the surface of 
the eggs as they are laid. 

The pathogenic bacteria occurring in meat also occur in the 
intestine of larvae feeding thereon. 

Pathogenic bacteria occurring in the pupa are transmitted 
to the imago which in turn disseminates infection in its faeces. 

In 1909 Faichnie, (26) following Cao's suggestions, used Bacil- 
lus typhosus. His procedure was as follows: 

Into a box of earth containing three ounces of faeces, infected 
with typhoid bacilli, 30 flies were let loose and covered with a 
wire gauze. In a day or two all these flies died, but fourteen 
days later 1 fly emerged. On the fifteenth day 12 more emerged. 
On this day the box was replaced by an earthenware dish washed 
in bichloride of mercury, and water and sugar were intro- 
duced as food and covered. 

The 1-day-old fly was transfixed with a red-hot needle, flamed 
and washed in 1 cubic centimeter of sterile salt solution, part 
of which was inoculated into McConkey's broth, which remained 
unchanged for forty-eight hours. This same fly, when crushed 
in sterile salt solution and a drop plated, showed the presence 
of typhoid bacilli. Four other 1-day-old flies gave identical 
results. 

Two flies 6 days old and two 9 days old gave the same results. 

Two flies 13 days old showed faeces infected with B. typhosus. 

One fly 16 days old showed typhoid-contaminated faeces ; when 
crushed it showed the same contamination. 

Faichnie concludes that of 13 flies bred from a typhoid stool 
at least 6 contained the bacillus in the intestines and that a 
16-day-old fly contained bacilli both in the intestines and faeces. 

The results described by Faichnie are to be questioned, be- 
cause there is no evidence in his paper that the larvae fed on 
the infective material were separated from the pupae or newly 
emerged adult flies. There is no evidence to exclude the pos- 
sibility that the emerging adults were not reinfected by feeding 
on the typhoid faeces. (The species of flies used are not men- 
tioned.) 

In considering later the work done by Ledingham, it will 
appear remarkable that the typhoid bacilli in the faeces remained 
capable of infecting the flies for a period of twenty days. In 
Ledingham's paper it will be further pointed out that typhoid 



318 ^ e Philippine Journal of Science ms 

bacilli are weak in competing with the intestinal bacterial flora 
of larvae and that they are soon outgrown by the more vigorous 
organisms mentioned by Cao. 

A. W. Bacot, (40) in 1911, employed B. pyocyaneus in order 
to determine its persistence from the pupa? to the imagines of 
Musca domestica. His technique and results are as follows: 

A vessel containing sterile sand, mixed with baked milk, cooked 
rice, gristle of meat, and other food, had added to it the eggs 
of M. domestica. Several cultures of B. pyocyaneus were added 
to this, and the growing larva? were fed thereon. 

Some of the larvae were secured; their surfaces were disin- 
fected by washing them in 5 per cent lysol for five minutes. 
These surface-sterilized larvae when crushed and inoculated into 
broth showed a growth of B. pyocyaneus. 

Flies just as they emerged were secured, and their surfaces, 
likewise, were sterilized in lysol. These flies had no opportunity 
to infect themselves by feeding upon B. pyocyaneus. When 
crushed and inoculated into broth, they showed a growth of 
B. pyocyaneus. 

Ledingham confirmed these results by securing the pupae of 
flies, and in place of sterilizing the surface with lysol, held them 
between the fingers, searing the anal extremity with a red-hot 
knife-point, passing a blunt pipette into the intestines and with- 
drawing the contents which were then mixed with salt solution 
and sprayed on plates. This modified technique was more satis- 
factory, because pupal disinfection by lysol is difficult, owing to 
the fact that, when the pupae are shaken in broth or sterile 
salt solution, bacteria escape from their interiors. 

Ledingham, (41) in 1911, having confirmed Bacot's work, per- 
formed a series of experiments to ascertain whether or not an 
organism like B. typhosus could adapt itself to conditions pre- 
vailing in the larval and pupal interior in competition with 
organisms of a more hardy nature. His work includes the 
following : 

In the first series eggs of M. domestica were placed in a 
sterile dish, containing sterile sand mixed with sterilized food in 
the form of mashed potatoes, meat, and turnips. This mash was 
repeatedly drenched with broth cultures of typhoid bacilli. 

While the larvae were growing and feeding, the mash devel- 
oped a strong ammoniacal odor. 

As this mash was so liberally drenched with cultures of ty- 
phoid bacilli, plates of McConkey's medium were inoculated with 
the mash to ascertain whether or not B. typhosus would be the 



x, b, 5 Roberg: Bacterial Infections 319 

predominating organism. On examination none of the plates 
showed the presence of B. typhosus. Constantly found was a 
typhoidlike organism, provisionally called Bacillus "A." Bacil- 
lus prodigiosus was also found. The strong ammoniacal odor 
was liberated by Bacillus "A." 

Pupae were taken from the mash; their exterior was steri- 
lized, and then crushed and inoculated on plates of McConkey's 
medium. These plates showed profuse growths of Bacillus "A" 
and B. prodigiosus, but B. typhosus could not be recovered. 

Similar examination of the larvae before pupation resulted, 
also, in the isolation of Bacillus "A," but not of B. typhosus. 

A newly emerged fly was chloroformed, and its exterior was 
sterilized. The intestines were removed aseptically, mashed, 
and inoculated on to plates. There was an absence of B. typho- 
sus. Bacillus "A" was recovered. 

In the second series cultures were made from the shells of- 
eggs from which the larvae had just hatched. These cultures 
showed growths of the following organisms: Bacillus "A," B. 
proteus vulgaris, B. prodigiosus, and a streptococcus. 

Larvae which had fed upon a sterile mash were secured, and 
their surfaces were sterilized. When mashed and inoculated 
upon plates, they showed growths of Bacillus "A," B. prodigio- 
sus, and a lactose-fermenting organism provisionally called 
Bacillus "B" No. 3. 

In the third series the eggs were first sterilized in lysol and 
then placed upon sterile agar and fed with sterile human blood 
to which were added typhoid cultures. The larvae secured from 
this mixture, when their surfaces were sterilized, gave pure 
cultures of B. typhosus when crushed and inoculated upon plates. 

Other larvae were removed from this agar-human blood and 
typhoid mixture, placed upon sterile sand, and allowed to pupate. 
These pupae showed upon examination that they contained pure 
cultures of B. typhosus when crushed. 

Ledingham's conclusions are summarized as follows: 

Although typhoid bacilli were liberally supplied to the larvae, 
B. typhosus could not be isolated from the pupae or imagines, 
until recourse was had first to the disinfection of the eggs. 

When unsterilized eggs were used there appeared constantly 
a typhoidlike bacillus. This typhoidlike bacillus, called Bacil- 
lus "B," thoroughly adapts itself to the conditions in the interior 
of the larvae, pupae, and imagines. 

There was, also, evidence that B. typhosus, when isolated 
from the interior of larvae fed upon typhoid bacilli under ideal 



320 The Philippine Journal of Science 1915 

conditions, was not in a state of proliferation but that of 
dying out. 

The presence of other bacteria in the mash made it difficult 
for B. typhosus to exist in competition with them. 

Graham-Smith, (42) in 1911, made observations on the ways 
in which artificially infected blowflies (Sarcophagidae) carry 
and distribute pathogenic and other bacteria. 

Larvae of the blowfly were fed on meat artificially infected 
with the spores of anthrax bacilli. Flies emerging from these 
larvae were infected with anthrax bacilli and remained infective 
for fifteen days. 

Larvae were fed on meat infected with the respective nonspore- 
bearing organisms, B. typhosus, B. enteritidis, B. prodigiosus, 
Vibrio cholerse, and a pink-colonied coccus. Examination of the 
emerging flies did not reveal the presence of any of these 
organisms. 

This indicates that nonspore-bearing organisms do not sur- 
vive sufficiently long to be found in the emerging blowflies. 

Later, in 1911, Graham-Smith (43) made more extensive ob- 
servations along these lines and employed the larvae of Calli- 
phora erythrocephala, Lucilia csesar, and Musca domestica. 

series 1 

Graham-Smith, failing to infect the emerging flies from larvae 
fed on artificially infected food, secured larvae of C. erythroce- 
phala and L. csesar and fed them upon the flesh of guinea pigs 
which had died from infection with B. enteritidis and B. an- 
thracis. Several emerging flies when examined did not show the 
presence of spore-free anthrax bacilli or of B. enteritidis. 

series 2 

Here the females of M. domestica were allowed to lay their 
eggs upon a mixture of boiled meat, potatoes, and rice. Indi- 
vidual groups of larvae were secured and placed in separate 
sterile sand boxes, and each was fed respectively on B. prodi- 
giosus, Morgan's bacillus, B. enteritidis, B. anthracis, and a pink- 
colonied coccus. The intestinal contents of the emerging flies 
when examined showed negative results in the following: B. 
prodigiosus, B. enteritidis, and the coccus. Examination of the 
flies emerging from larvae fed on Morgan's bacillus gave a 
positive result. Of those emerging from larvae fed on anthrax 
bacilli, positive results occurred in 78 per cent of the cases. 

These results indicate that nonspore-bearing organisms, such 
as B. prodigiosus, B. enteritidis, and certain cocci, cannot sur- 



x, b, 5 Roberg: Bacterial Infections 321 

vive long enough in the larval intestine to appear in the imagines. 
Morgan's bacillus, which is often a commensal in the intestine 
of larvae, constantly persists in the intestine of the imagines, 
along with other nonlactose-fermenting organisms. The spores 
of B. anthracis, also, persist. 

SERIES 3 

To ascertain whether different substances on which larva 
were fed in any way favor the persistence of different bacteria, 
separate boxes were prepared and the following sterilized sub- 
stances were placed therein: namely, in the first cooked meat 
and rice, in the second human faeces, and in the third box un- 
sterilized human faeces. Eggs and larvae grown on sterilized 
food were placed in these boxes and infected separately with B. 
typhosus, B. enteritidis, Morgan's bacillus, and B. prodigiosus ; 
one box was uninfected as a control. 

When the flies emerged the intestinal bacteria were exam- 
ined. Growths on plates of McConkey's medium showed sev- 
eral nonlactose-fermenting colonies, none of which proved to 
be B. typhosus. Morgan's bacillus could be isolated from flies 
from the different foods. 

Different foodstuffs, then, apparently exercise no influence 
on the persistence of bacteria in. the intestines of newly emerged 
flies. 

As previously stated, observations and attention have been 
particularly centered upon the larger and easily visible species 
of flies. This is especially true in Manila, where it is stated 
that a scarcity exists in flies. The scarcity of flies in Manila 
applies only to the larger species and not to the minute mem- 
bers of the family Phoridae, which are abundant. No doubt 
as a result of their minuteness they have been overlooked. 

These minute Phoridae, then, having biological features simi- 
lar to the common large species of Diptera, should be regarded 
as a menace in the spread of bacterial infections. 

The members of this group lay their eggs and breed in putre- 
fying material, and if human faeces are available, they are the 
more preferable. 

Even though sanitary regulations be severe in regard to the 
disposal of human faeces, and suitable so-called fly-proof sanitary 
pails be recommended or furnished by the Bureau of Health, 
these minute flies nevertheless gain ready access to the faeces. 
Should the faeces be contaminated with pathogenic bacteria, as 
they so frequently are from cholera carriers or active cholera 
cases, and from infections where pathogenic organisms are dis- 



322 The Philippine Journal of Science ms 

charged with the faeces, it is easy to conceive how these small 
flies, when feeding thereon, can disseminate infections by the 
carriage of bacteria either upon the surface of their bodies or 
contained within their intestinal tracts. As they are omnivorous 
feeders when they enter homes, they may either contaminate 
food upon which they feed or become a source of danger by being 
ingested with the food. 

Special emphasis is laid upon their minute size, as they can 
pass through the ordinary so-called fly-proof screen with great 
ease. Entrance may be gained through very small apertures 
or cracks into food-containing vessels, and the fly imprisoned and 
killed therein. Pails or chambers which are used for the deposit 
of human faeces, although safe against the common house fly, are 
by no means safe against the ingress of these very minute insects. 

Aphiochseta ferruginea Brunetti is a very common species in 
the Philippines. As this species has been reported as producing 
intestinal myiasis in man, a field of speculation is opened of grave 
importance, should this prove to be of commoner occurrence than 
has been reported. Cases of intestinal myiasis may readily be 
overlooked, by regarding the larvae or eggs as being deposited in 
the faeces after they have been passed. Adult flies may be passed 
per rectum and fly away and not be seen. 

Should myiasis occur in a case of cholera, and adult flies be 
discharged, dissemination would occur by means of these cholera- 
drenched flies. 

Before too much significance is attached to the Phoridae as 
porters or carriers of bacterial infection, certain facts must be 
established by experimentation regarding them. 

In the experiments outlined in this paper Aphiochseta ferru- 
ginea was chosen for the following reasons: (1) Its great fre- 
quency as a breeder in human faeces. (2) When once determined 
it can readily be recognized. (3) It is a trifle larger than the 
other members of the family and can be handled with less dif- 
ficulty. (4) No experimental work has been performed on this 
species since it was discovered. (5) Facts ascertained concern- 
ing this species will open a field of investigation appertaining 
to the entire family, of which very little is known. 

The object in view is to establish the following facts: 

1. Whether or not cholera vibrios are harbored during the 
chrysalis stage. 

2. Is infection transmitted from the chrysalis stage to the 
imago ? 

3. Do adult flies, when fed on cholera vibrios, harbor these 



x, b, 5 Roberg: Bacterial Infections 323 

organisms on their surfaces or in their intestinal tracts; and 
for what length of time do they remain infective? 

4. Which media are preferably chosen by these flies for 
breeding ? 

5. Biological features concerning the development of the fly. 

6. Ability of the flies to pass through small apertures. 

TECHNIQUE EMPLOYED IN EXPERIMENTS AND A CONSIDERATION OF 
THE FINDINGS ELICITED 

In the four series of experiments outlined here are recorded 
the results of positive findings. For the purpose of brevity and 
clearness the positive findings are described separately from the 
negative. 

The obstacles encountered and the technique developed in the 
course of the experiments are best described before outlining the 
series of experiments. 

In series I, concerning the biological features of Aphiochseta, 
little difficulty was met with. The minute Phoridse were readily 
trapped, as the vessels used as traps were placed in a screened 
room which excluded the larger species of flies. As traps were 
covered with cloth gauze, only minute flies could gain entrance 
therein. When a considerable number of flies had been caught, 
they were kept imprisoned until they had laid their eggs. 

These imprisoned flies, when seen through the glass wall of 
the vessel containing them, for the most part presented abdomens 
of a brownish yellow ground color, with transverse blackish 
stripes. The thorax was characteristically hunched. These 
characteristically colored and hunched-back flies were uniform 
in size and averaged 2.5 millimeters in length. A number of 
these flies were removed from the traps by covering the traps 
with a glass funnel, and as the flies passed up the stem of the 
funnel they were caught in a glass Erlenmeyer flask inverted 
over the upright funnel stem. When killed and mounted on 
needles, they were found to be Aphiochseta ferruginea, as 
previously stated and described. 

These flies, having a characteristic appearance and color, could 
be readily recognized in the vessels containing them; therefore, 
as they could be seen as the predominating flies contained in the 
traps, the eggs when laid and hatched out would give origin to 
a new generation of flies, of which Aphiochseta ferruginea would 
predominate greatly over others which might be present and 
not recognized on account of their similarity to Aphiochseta. 

Among these brownish yellow flies could be seen a few which 



324 The Philippine Journal of Science ms 

were entirely black and smaller in size. These were regarded 
by Banks as males of Aphiochseta. Brunetti also states in his 
description of Aphiochseta ferruginea that there is a variance in 
color. 

When a medium of sand was employed, containing food in the 
form of sugar, bread, human fasces, and bouillon, the eggs de- 
veloped into a great number of flies, the great majority of 
which were the brownish yellow Aphiochseta. There were, also, 
present fewer numbers of those having a blackish appearance. 

To identify the flies, a considerable number were secured im- 
mediately upon emergence and studied with a magnifying glass. 
Most of those examined were found to be female Aphio- 
chseta; others, the small and darker males. As it was impos- 
sible to examine all the flies which emerged by this method, it 
was possible that other allied species were present whose simi- 
larity might cause them to be confused with Aphiochseta. 

The period of development could be definitely ascertained, 
because when the flies emerged they were secured and identified 
as Aphiochseta. 

In series II and III considerable difficulty was encountered 
where experiments were performed to ascertain whether larvae 
when growing in a medium infected with cholera vibrios contain 
these organisms in their intestines, and whether a transference 
of vibrios occurs from the larvae, through the pupae and into the 
emerging imagines. - 

Repeated attempts were made to keep larvae alive on a medium 
containing a pure growth of cholera vibrios. Larvae could exist 
for only a day or two on growths of cholera vibrios on agar-agar 
and Dieudonne's medium. On agar-slant growths of vibrios to 
which sand was added larvae could subsist for four or five days. 

Larvae could be kept alive for nine days on an agar-slant 
growth of cholera vibrios containing sterile sand liberally soaked 
with bouillon. In this case flies were allowed to enter the test 
tube containing the vibrio growth and sand by inserting a bent 
glass tube into the test tube and connecting it with a flask con- 
taining flies. The flies traveled from the flask into the tube, 
where they were imprisoned sufficiently long to allow them to lay 
their eggs, after which they were allowed to pass along a bent 
glass tube into another flask. The larvae, although living for 
nine days, did not attain their full size nor did they pupate. 

From this tube 6-day-old larvae were removed with a sterile 
platinum needle and examined to see whether their intestines 
contained cholera vibrios. To remove the surface vibrios, the 



x, b, 5 Roberg: Bacterial Infections 325 

larvae were washed for five minutes in a 5 per cent solution of 
lysol. The larva? were then washed three times in sterile salt 
solution and placed in Dunham's peptone solution, after which 
they were crushed with a sterile glass rod. This material was 
incubated for twenty-four hours and streaked on Dieudonne's 
medium. Growths of cholera vibrios were looked for. 

Three attempts to find vibrios in the intestines of 6-day-old 
larvae failed by this method. It was believed that in killing the 
surface vibrios with 5 per cent lysol sufficient liquid was ingested 
by the larvae to kill the vibrios contained in the gut. To pre- 
clude any possibility of lysol entering the larval interior, the 
larvae were sealed by applying a red-hot platinum point to the 
anal extremities, thus searing and closing the openings. Larvae 
treated in this manner and washed in lysol also did not reveal 
the presence of any cholera vibrios. Failing to find vibrios 
within the larvae, the agar-slant growth was examined for vibrios 
and found to contain none, but did possess other contaminating 
organisms. 

To keep larvae alive on a medium containing cholera vibrios 
until emergence of the adults occurred, it was found necessary 
to obtain a medium as free as possible from putrefying material ; 
to use larvae of an age which would soon pupate ; and repeatedly 
to drench the sterile sand with 24-hour-old cholera broth cultures. 
This method is outlined in series III. In this series the cholera 
vibrios were identified by smears stained with Sterling's gentian 
violet, by the characteristic growth on Dieudonne's medium, by 
typical motility in hanging-drop preparations, and by agglutina- 
tion of the vibrios in hanging drops by the addition of cholera- 
immune serum. 

In series IV experiments were performed to determine 
whether cholera vibrios are harbored in the intestinal tract of 
flies which have been fed upon media containing vibrios, and 
the length of time they remain infective; if vibrios adhere to 
the surface of the body; and how long they remain infective. 

In performing these experiments it was necessary to use 
extreme care in handling the minute flies which were infected 
with cholera vibrios to prevent their escape. Under ordinary 
circumstances they can be caught with a forceps as they attempt 
to escape when the lid is raised from the vessel containing them. 

Before cholera-infected flies were handled, various methods 
were tried in order to find a means whereby it would be im- 
possible for them to escape. The most satisfactory means was 
the employment of a bent glass tube which served as a passage- 

135264 2 



326 The Philippine Journal of Science ms 

way for the flies from one flask to another, or from test tube 
to test tube. 

The procedure in this series of experiments consisted of the 
following: The bent glass tube was inserted between the cotton 
stopper and the neck of the flask containing a number of unin- 
fected flies, and the other end of the bent tube was inserted in 
a like manner into a test tube containing an agar-slant growth 
of cholera vibrios. When a number of flies had passed from the 
flask into the test tube, the bent connecting tube was removed. 
The flies were allowed to remain in the test tube until they had 
fed upon the cholera growth and were then passed into a clean 
flask by means of the bent connecting glass tube. On some oc- 
casions it required about two hours for the flies to pass from one 
vessel to another. Attempts were made to hurry the flies by 
darkening or heating one of the vessels ; this, however, seemed to 
have little effect. 

Infected flies were removed from time to time from the flask 
and passed into a tube of Dunham's peptone solution by means of 
the bent tube. The flies were washed in Dunham's peptone 
solution to ascertain whether or not any vibrios were present 
on the surface of the fly. This washing was incubated for 
twenty-four hours and streaked on Dieudonne's medium. A 
second Dunham's peptone solution was employed for the same 
fly which was crushed with a sterile glass rod. This was in- 
cubated for twenty-four hours and then streaked on Dieudonne's 
medium. The growth on the Dieudonne plate was studied mor- 
phologically by means of smears stained with Sterling's gentian 
violet. Hanging-drop preparations were observed for the char- 
acteristic vibrio motility, and the final identification was made 
by securing an agglutination by the addition of cholera-immune 
serum to the hanging drop. 

In determining the presence of vibrios on the fly surface or 
within its gut, after various intervals of time had elapsed since 
the feeding of the flies on vibrios, it was necessary to examine a 
great number of flies bacteriologically. In series IV are recorded 
only the positive findings. 

In a considerable number of instances the infected flies were 
killed in handling them or they died in the flask containing them, 
as they were given no food nor drink. Furthermore, in many 
of the flies examined negative findings occurred. This may have 
been due to insufficient enrichment of the vibrios by not making 
enough subinoculations into Dunham's peptone solution. It was 
found that when only one fly was employed four or five transfers 
into Dunham's peptone were necessary to enrich the vibrios 



x, b, 5 Roberg: Bacterial Infections 327 

present, in order to isolate them on Dieudonne's medium. When 
four or five flies were employed, it was necessary to enrich the 
vibrios present in only one or two changes of Dunham's peptone 
solution. 

OUTLINE OF EXPERIMENTS 

SERIES I. BIOLOGICAL FEATURES 

On the evening of March 29 four traps were set to catch flies, 
with the object of securing Apiochseta ferruginea and to breed 
them after their eggs had been deposited upon the substances 
contained in the traps. 

Three of these traps consisted of wide-necked 8-ounce bottles, 
containing a perforated stopper in which was placed the stem of 
a glass funnel. Over the orifice of the funnel was stretched a 
single layer of cloth gauze, having 20 squares to the linear inch. 
The fourth trap consisted of a 6-inch beaker, over which was 
stretched a layer of the same gauze. 

Into each of the three bottles were placed, respectively, the 
following food substances for breeding the flies: agar-agar, a 
mixture of human fasces and melted agar, and a dead snail. In 
the beaker was placed a mixture of human faeces and melted 
agar. 

On the following morning (March 30) these traps were set 
at 5-foot intervals in a room, carefully screened with wire netting 
(having 16 squares to the linear inch), which prevented larger 
flies from entering the room. 

In the vicinity of the beaker, which smelt strongly of fasces, 
there began soon to appear a few small flies which could scarcely 
be seen at a distance of 3.5 meters. During the course of the 
day great numbers of these hovered about the beaker ; some were 
seen to alight upon the surface of the gauze, readily pass through 
into the beaker, and settle upon the fseces-agar mixture, which 
they greedily devoured. 

The bottle trap which, also, contained a fasces-agar mixture, 
smelt less strongly, and fewer flies were seen hovering about it. 
Some of them passed through the gauze and into the bottle. 

The bottle containing the dead snail smelt of putrefaction, but 
fewer flies were seen there than in the two previous traps. 

The bottle containing plain agar attracted no flies. 

On the morning of March 31 a considerable number of flies 
were still in the bottle and beaker which contained the faeces- 
agar mixture. These were covered to prevent further ingress 
or egress of flies and kept for observation. 

The bottle containing the dead snail contained only a few 
flies. This was covered. 



328 The Philippine Journal of Science ms 

The bottle containing the agar-agar had but two flies. This 
was covered. 

The flies from these four traps were removed and placed in 
separate flasks for identification. For the most part these flies 
averaged 2.5 millimeters ; some were smaller. Specimens of the 
larger type were compared with members of the Phoridae in 
the Bureau of Science collection, identified by Professor Banks. 
These flies corresponded with Aphiochseta ferruginea of that 
collection and coincided with Brunetti's description. 

Before the present series of experiments was undertaken, I 
had exposed, on March 4, a large gauze-covered specimen jar 
containing faeces. In this jar hundreds of small flies had 
emerged. These proved to be Aphiochseta ferruginea, and were 
saved as a stock supply for future experiments. 

On April 1 great numbers of small larvae were seen crawling 
about the faeces-agar mixture in the bottle and beaker. Fewer 
were seen on the dead snail. On the plain agar they were not 
yet visible. 

On April 6, the bottle containing the faeces-agar mixture being 
small and having a great number of larvae measuring from 2 to 
3 millimeters, the entire contents were placed into a large speci- 
men jar containing sand, lumps of sugar, bread, faeces, and bouil- 
lon. Eight layers of cloth gauze (having 20 squares to the 
linear inch) were stretched over the orifice to prevent new flies 
from entering. 

Upon transferring the contents it was seen that a number of 
the larvae were pupating. Examination of larvae which had 
not yet pupated showed on their blunt extremities, on the in- 
ferior portion thereof, two small hooks not unlike those described 
by Brunetti as appearing like two small walrus tusks. The body 
is whitish yellow, and the dark intestinal contents are visible 
through the body wall. 

On April 8 a newly emerged fly made its appearance. On the 
following day (April 9) flies appeared in great numbers. On 
examination the great majority were found to be Aphiochssta 
ferruginea. 

It is interesting to note that some of the flies escaped from 
the jar, passing through eight layers of gauze tightly stretched 
over the surface. 

The emerged flies were allowed to remain in the jar. On 
April 14 deposits of small eggs were seen on the sides of the jar. 
These are whitish with a tinge of yellow, and measure 0.2 by 0.5 
millimeter. The extremities are rather blunt, and there is a 
slight curve in the long axis. 



x, b, 5 Rob erg: Bacterial Infections 329 

Summary of results. — Specimens of Aphiochasta ferruginea 
readily pass through a wire screen having 16 squares to the 
linear inch. It is possible for them to pass through 8 layers 
of tightly stretched gauze having 20 squares to the linear inch. 

The time elapsed from the laying of the eggs to the emergence 
of the adult is from nine to ten days. Eggs are laid by the 
flies five days after emergence. Pupation of the larvae takes 
place five or six days after they are hatched. 

By indoor-breeding experiments Aphiochseta ferruginea are 
indicated as the commonest of the small flies which breed in 
faeces. 

SERIES II 

To ascertain whether larvae when growing in a medium in- 
fected with cholera vibrios contain these organisms in their 
intestinal tracts, the following experiments were performed: 

a. On April 1 eggs were removed from the beaker trap 
(series I) and placed on a cholera culture growing on a Petri 
plate of Dieudonne's medium. This plate was placed in a large 
glass-covered stender dish to await the hatching of the larvae. 

5. On the same day a similar plate culture of cholera was 
placed in a large gauze-covered stender dish containing faeces 
to attract flies, which in turn would deposit their eggs upon the 
medium. As soon as the dish was exposed, a small fly was seen 
to enter through the gauze and immediately leave the dish again. 
As it was possible for the flies to leave the dish after entering 
it and disseminate infection, this method of securing eggs was 
abolished. 

The eggs placed on Dieudonne's medium in a hatched out 
in twenty-four hours. The larvae lived for twenty-four hours 
and then died from a lack of nourishment. 

c. On April 2 three larvae were secured from the bottle of 
faeces-agar mixture (series I) and placed on the surface of a 
cholera growth in a test tube of slanted agar. These larvae 
when removed from the bottle showed their intestines to contain 
a dark substance which could be seen through the larval wall. 
After feeding for twenty-four hours the intestinal contents 
became colorless. Two days later the larvae died. 

SERIES III 

In a, b, and c, of series II it was impossible to keep larvae 
alive longer than two days on a pure culture of cholera vibrios, 
as there was a scarcity of nutriment in the agar and Dieudonne's 
medium. 



330 The Philippine Journal of Science ms 

The following steps were undertaken to keep larvae alive in a 
medium containing cholera until emergence of the imagines 
should take place. 

As was noted in series I, a fly emerged on April 8 in the 
large jar. On April 10 there were, in addition to the emerging 
flies, a considerable number of large and well-advanced larvse. 
As these larvse were due soon to emerge as imagines, they were 
selected because they would have only a short time to be culti- 
vated. They measured from 3 to 4 millimeters in length. 

a. Thirty of these larvae were removed from the large jar and 
placed in a sterile glass-covered stender dish containing sterile 
sand. The sand and the larvae were drenched with a broth 
culture of cholera vibrios. A fresh hen's egg was opened asepti- 
cally and the albumen transferred with a sterile pipette into the 
stender dish as food for the larvae. 

b. On the following day (April 11) no active larvae could 
be seen, as several of them had pupated. 

One of these pupae was removed with a sterile platinum loop 
and placed in 5 per cent lysol for five minutes, in order to kill 
the cholera vibrios adhering to its surface. After three wash- 
ings in sterile salt solution to remove the lysol, a final washing 
was made in a tube containing Dunham's peptone solution. 
This tube was incubated for twenty-four hours and then 
streaked on Dieudonne's medium. Examination of the plate 
showed the absence of cholera vibrios. There was present, how- 
ever, a growth consisting of a coccus and a spore-bearing 
bacillus. 

The lysol-sterilized and washed pupa was placed in a tube 
containing Dunham's peptone solution and macerated. A por- 
tion of the contents of this tube after being incubated for 
twenty-four hours was streaked on Dieudonne's medium. Plate 
examination revealed the presence of cholera vibrios. There 
was, also, a growth containing a coccus and a spore-bearing 
bacillus. 

c. Three new pupae were secured and subjected to the same 
steps as in b. The results proved identical. 

d. A portion of the sand was inoculated into Dunham's pep- 
tone and later streaked upon Dieudonne's medium. Examina- 
tion showed typical colonies of cholera vibrios. There were, 
also, present colonies consisting of cocci and variously formed 
bacilli, many of which contained spores. 

e. On April 14 some actively moving larvse were noted. 
These had not yet pupated. 

One of these larvae was removed, and the extremities were 



x, b, 5 Roberg: Bacterial Infections 331 

seared with a red-hot platinum point. It was then placed in 
5 per cent lysol for five minutes, washed three times in sterile 
salt solution, and the final washing in Dunham's peptone was 
placed in a tube and incubated for twenty-four hours. This 
tube was perfectly clear and did not show any bacterial growth. 

The lysol-disinfected larva, when crushed in Dunham's pep- 
tone, incubated for . twenty-four hours, and plated on Dieudon- 
ne's medium, did not reveal the presence of cholera vibrios. 

/. Sand inoculated into Dunham's peptone, incubated and 
plated on Dieudonne's medium, did not reveal the presence of 
cholera vibrios. Several variously formed bacilli and cocci 
were present. 

g. As the results of e and / indicate that the vibrios had 
been outgrown, not only in the sand but also in the intestinal 
tract of the larvae, it was necessary again to replenish the cholera 
vibrios by the addition of 24-hour-old broth cultures to the 
medium in which the larvae were developing. 

The larvae and pupae were removed and placed in a new 
sterile stender dish containing sterile sand. This was again 
drenched with broth cultures of cholera vibrios. 

h. On April 16, as no flies had emerged, another transfer was 
made to a new sterile dish and again drenched with vibrios. 

i. On April 18, as no flies had emerged, they were again 
transferred and redrenched with vibrios. 

;'. On April 20 one fly emerged. As I was not present at the 
time of emergence, it was not tested for vibrios contained in 
its intestines. Another transfer was made into a sterile dish 
and again drenched with vibrios. 

k. On the morning of April 21 six or seven flies had emerged. 
Four of the pupae which were soon to emerge into flies were 
removed and placed on a sterile moist filter paper and covered 
with a beaker. During the day these pupae were constantly 
watched and late in the afternoon one fly emerged. Immediately 
upon emergence the fly was chloroformed to prevent its escape 
or possible reinfection from cholera vibrios on the filter paper. 

This fly was placed in 5 per cent lysol for five minutes and 
washed three times in sterile salt solution. The final washing 
was in Dunham's peptone, which was incubated for twenty-four 
hours and then plated on Dieudonne's medium. Examination 
of the plate showed no cholera vibrios. 

The lysol-disinfected and washed fly was crushed in Dunham's 
peptone solution, incubated for twenty-four hours, and streaked 
on Dieudonne's medium. Examination of this plate revealed 
the presence of cholera vibrios. 



332 The Philippine Journal of Science ms 

SUMMARY OF RESULTS 

Larvae when fed on a medium containing cholera vibrios 
harbor these organisms in their intestinal tracts only as long 
as cholera vibrios are present in the medium and sufficiently 
plentiful in numbers not to be outgrown by other organisms. 

There is a transference of vibrios from the larvae to the pupae 
and from the pupae to the imagines. This, however, is only 
possible when the larvae and the pupae are constantly changed 
to a sterile medium and drenched with 24-hour-old broth cul- 
tures of cholera vibrios. If this is not done, the vibrios are 
outgrown by the bacteria which are commensals in the intestines 
of the larvae and by the bacteria which are associated with putre- 
faction of the medium. 

In b and c the failure of complete disinfection of the pupal 
surface was probably due to bacteria derived from the pupal 
intestine as it was shaken in Dunham's peptone solution. 

The delay in the emergence of the flies is accounted for by the 
scarcity of nutriment present. 

SERIES IV 

Series 4 was undertaken to determine whether cholera 
vibrios are harbored in the intestinal tract of adult flies which 
have been fed upon media containing the vibrios, and the length 
of time they remain infective; and to determine if vibrios 
adhere to the surface of the body, and how long they remain 
infective. The following experiments were performed : 

a. On April 1 a Petri dish of Dieudonne's medium, on which 
there was a good growth of cholera vibrios, was placed in a 
large stender dish containing human faeces and covered with 
a layer of gauze. Three flies were seen to alight upon the gauze 
and enter the dish, after which it was securely covered and the 
flies allowed to remain therein for sixteen hours. The flies 
had a choice of both faeces and vibrios upon which to feed. At 
the expiration of sixteen hours the flies were removed and placed 
in separate flasks. 

b. When ten hours had elapsed since the feeding on vibrios, 
one fly was secured and placed in Dunham's peptone and washed 
for five minutes. This tube, containing the bacteria washed 
from the fly's surface, was incubated for twenty-four hours. As 
the growth was slight it was successively inoculated into three 
changes of Dunham's peptone to enrich the vibrios which might 
be present. It was then inoculated on Dieudonne's medium and 
examined. The plate contained pure cultures of cholera vibrios. 



x, b, 5 Rob erg: Bacterial Infections 333 

The washed fly was placed in Dunham's peptone and crushed. 
This was incubated for twenty-four hours and reinoculated into 
three successive changes of Dunham's peptone for enrichment 
and plated on Dieudonne's medium. The plate did not reveal 
the presence of cholera vibrios. 

c. When twenty-six hours had elapsed after the vibrio feeding, 
the second fly was secured and washed in Dunham's peptone. 
This was incubated twenty-four hours, enriched in peptone three 
times, and inoculated on Dieudonne's medium. The plate when 
examined did not reveal the presence of cholera vibrios. 

The washed fly was placed in Dunham's peptone, crushed, 
incubated, enriched three times in peptone, and inoculated on 
Dieudonne's medium. The plate showed pure cultures of cholera 
vibrios. 

d. When thirty-four hours had elapsed since the vibrio feed- 
ing, the third fly was taken and subjected to the processes rer 
corded in b and c. Cholera vibrios could neither be found in 
the surface washing nor in the crushed fly. 

e. A number of flies were taken from the stock jar and 
allowed to feed upon an agar-slant culture of cholera vibrios. 
After being fed, they were placed in a flask. When twenty-two 
hours had elapsed since they were fed on vibrios, three of them 
were secured and placed in Dunham's peptone to wash off the 
surface bacteria. This was incubated for twenty-four hours 
and then enriched three times in peptone and plated on Dieu- 
donne's medium. The examined plate showed no cholera vibrios. 

The washed flies were crushed in Dunham's peptone, incubated 
for twenty-four hours, enriched three times in peptone, and 
plated on Dieudonne's medium. Examination of the plate 
showed pure cultures of cholera vibrios. 

CONCLUSIONS PROM RESULTS 

Aphiochseta ferruginea, when fed on media infected with 
cholera vibrios, harbors the organisms on its body for ten hours 
and in its intestinal tract for twenty-six hours. 

Failure to isolate cholera vibrios from the crushed fly in b, 
in which ten hours had elapsed since it was fed on cholera 
vibrios, was no doubt due to a killing of the organisms by using 
a too hot platinum needle in making inoculation transfers. 

SUMMARY AND CONCLUSIONS 

Aphiochseta ferruginea is a species of fly which breeds in 
human fseces, and as indicated by indoor laboratory experi- 



334 The Philippine Journal of Science ms 

ments, is the commonest of the small flies which breed therein. 
Its period of development is from nine to ten days, and eggs are 
laid when the fly is 5 days old. The promptness with which 
faecal or putrefying material attracts these flies when kept in- 
doors suggests that they are not scarce. 

Their minute size enables them to pass through the ordinary 
fly-proof screens used as prophylactic means against the invasion 
by the common house fly and other large species of Diptera. 

In these series of experiments sufficient evidence is furnished 
to indicate this species of Diptera as a possible porter or carrier 
of Asiatic cholera. 

These flies may serve as agents in the dissemination of Asiatic 
cholera and, by analogy, other alimentary infections, such as 
typhoid fever, bacillary dysentery, and infantile diarrhoea; by 
ingested food which has been contaminated by organisms from 
the fly's body surface and fasces; or by ingestion of the entire 
fly which may have become incarcerated within the food. 

Fly-proof wire-screen bell jars employed in restaurants, 
kitchens, and tiendas to protect food against the common house 
fly do not exclude the Phoridae. 

Fly-proof sanitary pails which are ordinarily used for the 
deposit of human excrement, although proof against the common 
house fly, may not be secure against invasion by the Phoridae. 

The fact that cholera vibrios may be transmitted from larvae, 
through pupae, into emerging imagines is of importance from a 
public hygienic standpoint only under exceptional circumstances. 
This is possible only if faeces heavily infected with cholera vib- 
rios should be deposited among larvae which are due to emerge 
as adults in a day or two. 

Chantemesse,(2i) in studying the spread of cholera in Europe, 
lays special emphasis upon the common house fly as a carrier of 
cholera vibrios by contaminating food with vibrios contained 
on their feet and in their faeces. He demonstrated that flies 
harbor vibrios in the tubes of their feet and in their faeces for 
seventeen hours. 

Cholera vibrios have been isolated by Ganon(44) from flies 
twenty-four hours after they had been fed on infective material. 
Graham-Smith recovered them in the faeces and on the legs 
after thirty hours, and in the crop and gut after two days. 

In the Philippine Islands, where there are many questions un- 
solved in the epidemiology of Asiatic cholera, the insects of the 
dipterous family Phoridae are worthy of serious consideration. 



x. b. 5 Roberg: Bacterial Infections 335 

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fasc. i, 1. 
Uffelmann. Beitrag zur Biologie des Cholerabacillus. Berl. klin. 

Wochenschr. (1892), 1213. 
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cholerique. Vratch (St. Petersburg) ; review in Ann. Inst. 

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Manning. A preliminary report on transmission of pathogenic 

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336 The Philippine Journal of Science 

(24) Tsuzuki. Ber. ueber meine epidem. Beobachtungen, etc., im Jahre 

1902. Arch. f. Schiffs- u. Tropenhyg. (1904), 8, 71. 

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Div. Ent. (1901), n. s. No. 30. 

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described species of Phoridae that causes myiasis in man. Rec. 
Ind. Mus. (1912), 7, pt. I, 83. 

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mihi. Rec. Ind. Mus. (1912), 7, pt. V, 515. 

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(42) Graham-Smith. Further observations on the ways in which artifi- 

cially infected flies carry and distribute pathogenic and other 
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(43) Graham-Smith. An investigation into the possibility of pathogenic 

micro-organisms being taken up by the larva and subsequently 
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1911-12 London (1912), 330. 

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2. Quoted in Journ. Trop. Med. & Hyg. (May 15, 1909). 



MISCELLANEOUS NOTES » AND COMMENTS ON BERIBERI 2 

By Robert R. Williams and John A. Johnston 

(From the Laboratory of Organic Chemistry and the Biological Laboratory, 

Bureau of Science, Manila, P. I.) 

It is a matter of common belief among physicians who have 
had practical experience with beriberi that the incidence of the 
disease is highest, other things being equal, among those upon 
whose metabolic processes the greatest demands are made. 
Thus it has been generally observed that women during the 
period of the puerperium are very subject to beriberi even 
though the other members of the same household, other than 
the children of the beriberic mother, do not betray the slightest 
symptoms of the disease. At various times mention has been 
made of a high incidence of beriberi among those performing 
unusually hard manual labor, such as firemen on board ship. 

The effect of heat and physical exercise upon the onset of 
polyneuritis in fowls was tested in the following experiments : 

Four fowls were fed on polished rice under ordinary condi- 
tions; 4 were fed on unhusked rice (palay) under the same con- 
ditions; 4 were fed on white rice and given from ten to twenty 
minutes exercise twice daily in a treadmill moving at a rate of 
about 25 meters per minute; 4 were fed on palay and given 
the same exercise ; 4 were fed on white rice in cages in which the 
air temperature was maintained at from 37° to 38° C. ; 2 were 
fed on palay in cages kept at the same temperature; and 2 
were fed on white rice and kept in cages in which the air tem- 
perature was maintained at 15°. 

The results indicate that high temperatures and physical work 
slightly hasten the onset of the disease. They are more inter- 
esting as illustrations of the general inadequacy of a white rice 
diet, since birds fed on white rice succumbed under these con- 
ditions even before definite symptoms of polyneuritis had time 
to develop. 

1 These notes have been collected at the close of an extended period of 
investigation of beriberi, although much of the experimentation is incom- 
plete. The results and comments are, therefore, offered only as sug- 
gestions. 

' Received for publication April 23, 1915. 

337 



338 



The Philippine Journal of Science 
Table I. — Record of experiments with fowls. 



No. of 
fowl. 


Condition. 


Duration 
of exper- 
iment. 


Weight 
change. 


Day of death. 


Symptoms and 
remarks. 


1 

2 
3 
4 
5 

6 
7 
8 
9 

10 
11 

12 
13 

14 
15 

16 

17 

18 

(70) 19 
(73) 20 

(71) 21 

(72) 22 
23 
24 


White rice control.. _ 


Days. 


Per cent. 
—26.5 

—29.9 
—21.7 
—40.8 
+ 3.0 

— 1.2 

+ 4.8 
+ 1.2 
—27.0 

—14.5 
—15.3 

—20.2 

— 6.0 

— 8.2 

— 5.6 

— 5.0 
—24.1 

—35.2 
—64.2 
—34.0 

—18.0 

— 8.8 
—51.9 
—21.5 


Thirty-first 


Typical neuritis. 

Do. 

Do. 

Do. 
Alive and well at 
end of 60 days. 

Do. 

Do. 

Do. 
Apparent exhaus- 
tion after exer- 
cise. 
No neuritis. 

Do. 
Typical neuritis. 

Do. 
Alive and well at 
end of experi- 
ment. 

Do. 

Do. 

Do. 
Prostration with- 
out neuritis. 
Typical neuritis. 

Do. 
Prostration and 

slight neuritis. 
Alive and well at 
end of 60 days. 
Do. 
Typical neuritis. 
Do. 


do 




Twenty-ninth 

Twenty-second . 
Twenty-eighth . 


do 




do 

Palay control 

do 

do 

do 

White rice and 40 
minutes exercise. 

do 




60 

60 
60 
60 








Seventh . . 
Fourth 


White . rice and 20 

minutes exercise. 
do 






Twenty -fourth 


Palay and 40 minutes 
exercise. 

do 


60 

60 
60 

60 




Palay and 20 minutes 

exercise. 
do 

White rice at 37° 


Fourth 


do 






do 




Thirty-third 


do 




Tenth 


Palay at 37° 


60 
60 


do 


White rice at 15°__- - 


Thirtieth. 

Forty-fourth . _. ._ 


do ' 





That beriberi is due to an intoxication of some sort has been 
the basis of several theories of the etiology of the disease. Such 
a hypothesis has much support in the symptom complex, espe- 
cially of acute beriberi. Very similar forms of neuritis are 
produced by alcohol, arsenic, and some other poisons and a few 
toxins. Since the discovery of the vitamines there has been a 
general tendency to ignore this evidence and accept the idea that 
beriberi is due to a deficiency of vitamines per se. A theory 
that regards the vitamines simply as constituents necessary for 
tissue building fails to account rationally for a number of re- 
corded facts regarding beriberi in men and animals. 



x, b, 5 Williams and Johnston: Notes on Beriberi 339 

Perhaps the most cogent argument against such a supposi- 
tion is that beriberi in its severest form almost invariably de- 
velops very rapidly. Often within the space of a few days an 
apparently healthy and normal person reaches a condition of 
severe prostration. Recoveries are likewise prompt upon the 
administration of vitamines in some form. A process of star- 
vation with respect to some essential food would be expected to 
produce a very gradual development of the symptoms. It is 
true, of course, that chronic human beriberi does often develop 
in this way. In fowls fed exclusively on polished rice gradual 
appearance of the symptoms is not observable in most cases, 
but nevertheless frequently occurs. In a series of 150 fowls fed 
exclusively on polished rice 10 have survived at the end of 
periods of from four to eight months. Of the 10, four showed 
marked lameness and spasticity of gait at the end of from 
thirty to forty days, which condition continued from three to' 
ten days, after which they recovered except for a very slight 
stiffness of gait and an apparent dullness of sensation. The lat- 
ter condition was evidenced by a retarded response when prod- 
ded or otherwise disturbed. It amounted to nothing more than 
a slight torpidity. The remaining 6 fowls gradually developed 
the mild, chronic condition without passing through an acute 
stage. It may be noted here that among the 150 fowls at least 
3 showed an unmistakable oedema in the feet. 

The development of beriberi in breast-fed infants is particu- 
larly rapid. When completely weaned from the breast and fed 
artificially on fresh milk rapid improvement frequently begins. 
In a number of cases we have noted that a single nursing at 
the breast causes a prompt and more or less severe exacerbation. 
Such a result would not appear to be accounted for by a simple 
deficiency, the less so since Gibson 3 has shown that fresh milk 
does not possess antineuritic properties in any extraordinary 
degree. 

In addition, Sawazaki 4 has recently reported the production 
of a paralytic condition in fowls by injection of the milk of beri- 
beric women. 

The existence of various very dissimilar forms of beriberi 
have led to a classification as wet and dry, acute and chronic. 
This classification, however, is very indefinite and its value 
may be questioned. The only distinction that need be drawn 

3 This Journal, Sec. B (1913), 8, 469. 

* Mitt. Med. Gesell. Tokio (1913), 27, No. 3, Abstract in Zeniralbl. f. 
Biochem. u. Biophys. (1913), 15, 314. 



340 The Philippine Journal of Science 1915 

for practical purposes is that between beriberi of short and 
long duration. Nevertheless the more detailed classification has 
been made the basis of considerable argument and speculation 
regarding the identity as to etiology of the various forms of 
the disease. Of the essential identity we feel less and less 
doubt in the light of further experience. Chronic beriberi in 
mothers and the acute form in nursing infants are almost in- 
variably associated with each other and all types are benefited 
by the same treatment. 5 

These facts, namely, (1) the symptom complex, (2) the rapid 
development of, and recovery from, acute beriberi, (3) the prop- 
erties of the milk of beriberic mothers, and (4) the apparent 
close association of all types of the disease, have led us to for- 
mulate a working hypothesis somewhat as follows : That in beri- 
beri there exists a toxic substance which produces the symptoms 
of the disease. If produced rapidly or in great quantities this 
toxic substance brings about a condition similar to anaphylactic 
shock, resulting in acute beriberi. If gradually developed there 
results chronic beriberi with progressive nerve lesions. This 
toxic substance may be produced by a hypothetical organism or, 
as may perhaps seem more probable, may be the product of 
normal or slightly disturbed metabolism. The vitamines are 
then necessary antidotes for the poison and are, therefore, to 
be regarded as therapeutic agents rather than foods. Incident- 
ally it may be mentioned here that the results of the chemical 
investigation of the vitamine, which are to be published shortly, 
bear out this view rather than otherwise. 

Our efforts to demonstrate the presence of such a toxic sub- 
stance in beriberic fowls have for the most part been unsuc- 
cessful. Nevertheless the occasional positive results obtained 
warrant further effort along this line as the possibilities have not 
been exhausted by any means. The problem is doubtless some- 
what complicated by the apparent presence of some vitamines in 
the carcasses of pigeons." The fact that alcoholic extracts of 
such carcasses are curative rather than poisonous is no argu- 
ment against the existence of a toxic substance, as the latter 
would probably be destroyed or eliminated by extraction with 
alcohol. 

Our first experiments consisted in the injection of the defi- 
brinated or citrated blood of neuritic fowls into the veins of 
healthy birds. Quantities of from 5 cubic centimeters to 20 

"Williams and Saleeby, This Journal Sec. />' (1915), 10, 99. 
' Funk, Zeitschr. f. physiol. Chem. (1914), 89, 378. 



x, b, 5 Williams and Johnston: Notes on Beriberi 341 

cubic centimeters of blood were used in injections into 7 fowls 
without obtaining any certain positive indications of transmis- 
sion of the disease. In two fowls the wings drooped noticeably 
for two or three days following the injections. Four fowls 
into which blood was injected had previously been fed for ten 
days on polished rice in the hope of increasing their suscepti- 
bility to the disease. Even these birds, on a continued white 
rice diet, failed to develop polyneuritis any earlier than controls. 

A number of attempts were made to transfuse the blood 
of neuritic fowls into healthy ones. These were unsuccessful 
on account of the mechanical difficulties encountered. 

The entire fresh carcasses of three birds which had died from 
polyneuritis were ground in a meat grinder and the fluids ex- 
pressed from the flesh. In each case the entire fluid expressible 
from a carcass was introduced into the crop of a healthy bird. 
No neuritic symptoms appeared in these fowls within thirty 
days, during which time they were fed on unpolished rice. 

The kidneys, liver, spleen, and heart of a bird which died of 
polyneuritis were removed and minced up together. About 5 
grams of the minced tissues were fed to each of three healthy 
fowls, which were thereafter fed on unhusked rice. This ex- 
periment was repeated with the organs of three neuritic birds. 
Of the total of 9 fowls receiving the mixed minced tissues of 
the internal organs only one showed unmistakable signs of 
neuritis. This bird, nine days after ingestion of the diseased 
organs, developed all the typical symptoms of polyneuritis pre- 
cisely as do fowls fed on white rice. The second day thereafter 
the bird became completely prostrated, displayed increasingly 
severe neck retraction and labored breathing, and died. This is 
the first case we have observed of the development of apparently 
typical polyneuritis in an animal fed exclusively on a diet sup- 
posedly rich in vitamines and known to be highly antineuritic. 
Several of the remaining fowls displayed more or less severe 
wing drop and torpidity during the second and third day, but 
later recovered completely. 

A further series of fowls was submitted to repeated dosage 
with the organs of diseased fowls. Data on this series is given 
in Table II. 

McCarrison 7 has reported the isolation of an organism in 
cultures from the liver, spleen, kidney, and heart of birds in 
which polyneuritis had been developed by feeding on white rice. 

''Indian Journ. Med. Research (1914), 2, 369. 

135264 3 



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x, b, 5 Williams and Johnston: Notes on Beriberi 343 

By injection of these cultures he was able to reproduce in fowls 
a disease which appeared to be typical polyneuritis. He reported 
the transmission of the disease by this means in a large per- 
centage of cases. 

We have repeated McCarrison's experiments without being 
able to verify any of his essential findings. 

Ten fowls with polyneuritis gallinarum were examined by us, 
and cultures from the heart blood, spleen, liver, and kidneys 
remained sterile in each case except one, and in this case we 
obtained a small Gram-negative bacillus with a tendency toward 
bipolar staining. There was no tendency to gas production 
in mannite, glucose, or galactose, and but slight acidity. Rabbits 
inoculated intravenously with 1 cubic centimenter of a suspen- 
sion of a 24-hour growth on agar died in from fourteen to 
twenty hours. Five tenths of a cubic centimeter of a similar 
suspension produced no results. Eight fowls inoculated intra- 
muscularly with 0.5 cubic centimeter of a similar suspension 
showed no effects, except that a slight wing drop ensued in one, 
probably the result of manipulation, as it was noticeable only 
on one side. 

Cultures of the milk of 4 beriberic women were examined 
with negative results. 



PSEUDOTYPHOID FEVER IN DELI, SUMATRA (A VARIETY OF 
JAPANESE KEDANI FEVER) 1 

By WlLHELM SCHUFFNER 

(Chief Medical Officer, Senembah Maatschappij, Deli, Sumatra) 

THREE PLATES 

INTRODUCTORY 

In the course of my practice in Sumatra I have, since 1902, 
met with a number of cases which, though resembling enteric 
fever in their general clinical characters, appear from the re- 
sults of bacteriological investigation to constitute a distinct 
disease. At the Bombay Medical Congress in 1909 I referred to 
these cases under the name pseudotyphoid and in collaboration 
with Dr. Margarethe Wachsmuth published an account of them 
in the same year. 

Further observation during the past five years has shown 
that the disease is preceded by an initial lesion in the form of 
a small area of dermal necrosis in some part of the body; this 
necrosis is followed by the formation of a small ulcer and more 
or less pronounced enlargement of neighboring lymphatic glands. 
These facts, together with the occurrence of a rash, show that 
the disease possesses many of the features which characterize 
kedani or tsutsugamushi fever of Japan. Until recently this 
disease has been known only in Japan, but in 1908 Ashburn and 
Craig described an analogous disease in the Philippine Islands, 
and it is probable that it occurs in other countries, also. 

As I have had no opportunity of observing personally the 
Japanese disease, it is impossible for me to compare it in detail 
with the disease which occurs in Sumatra. I must, therefore, 
content myself with an enumeration of the more outstanding 
points of resemblance and difference. 

COMPARISON OF PSEUDOTYPHOID WITH KEDANI FEVER 

SEASONAL INCIDENCE 

Kedani fever appears in Japan only at certain times of the 
year, which are determined by the periodical floods. In Sumatra 
there is no such regularity; the disease is observed throughout 
the year. The 158 cases during 1908 were distributed as 
follows : 

1 Received for publication May 7, 1915. 

345 



346 The Philippine Journal of Science 

Table I. — Incidence of kedani fever in Sumatra. 



1915 



Month. 



January . 
February 
March ... 

April 

May 

June 



Number. 



Month. 



July 

August 

September 
October __- 
November 
December. 



Number, 



19 
19 

7 

5 

25 

19 



From this distribution one can say that the disease occurs 
most frequently during the months of June to August (54 cases) 
and during the months of November to January (59 cases). 
These two periods are not at all alike so far as meteorological 
conditions are concerned; the period June to August is dry, 
while the period November to January is the time of greatest 
rainfall. 

MORTALITY 

The second important difference is in regard to mortality. In 
Japan it is accepted that an average mortality of about 30 per 
cent occurs; according to older writers it was as high as 70 
per cent. In advanced age the disease is especially dangerous. 
In Sumatra the mortality is only about 3 per cent, and though the 
estate laborers are for the most part young, this low mortality 
shows that despite the grave symptoms observed in its course 
the disease must be classed among the less dangerous maladies. 
Enteric fever in Deli is accompanied by a mortality of about 
15 per cent; it is much more dangerous than pseudotyphoid. 

TRANSMITTING AGENTS 

There is, also, a difference in the transmitting agents of the 
disease in the two countries. In Japan a small, red mite, 
the larval form of an unknown Trombidium, is known to be the 
infecting agent; the true host of this mite is the field mouse, 
which harbors the parasite often in large numbers about the 
ears. It has been shown experimentally by the Japanese in- 
vestigators Miyajima and Asakawa that the mite is the transmit- 
ting agent of the virus from mouse to man ; they were able 
to infect monkeys by allowing mites to feed on these animals. 
Up to the present I have been unable to determine the transmit- 
ting agent of pseudotyphoid in Deli, but here, also, judging 
from the histories given by patients, it is a question of ticks 
or mites. On the estates where the disease occurs the laborers 
suffer greatly from the attacks of minute acarines, red in color 



x, b, 5 Schiiffner: Pseudotyphoid Fever in Deli 347 

and so small as to be scarcely visible to the naked eye. These 
acarines have been examined by Professor Nuttall, who found 
them to be of two kinds. One is the larval form of a Trombidium 
and resembles, therefore, the kedani mite. The other one, with 
the long legs, is the larval form of a Cheyletus. It has not 
been possible to determine the species in either case, as the 
adults are unknown. 

The larval Trombidium of Deli differs from the Japanese form 
as figured by Tanaka in the structure of the body and of the 
mouth parts ; the measurements correspond to those of the small 
form of the kedani mite (0.15 millimeter broad and 0.25 milli- 
meter long). The Deli mite is thick-skinned, not easy to crush, 
and its bite causes a violent itching after about fifteen minutes, 
while the bite of the Japanese variety may remain unnoticed 
until several days have elapsed. 

In Deli we consider these acarines as suspect only, lacking 
direct proof of their association with the disease; their exist- 
ence in large numbers in the dangerous areas and the analo- 
gies which the disease presents with kedani fever would appear 
to justify this suspicion. Some of my patients had been bitten 
by a larger acarine, which I believe may be the nymph of a 
species of Hyalomma and which I have often observed to 
attack man. 

It can be affirmed with certainty that the Deli disease is 
transmitted to man by the bite of an arthropod and that it is 
not directly contagious. Moreover it is probable that there is 
a reservoir of the virus in another host as in the case of the 
field mouse of Japan. The development of the disease among 
recent immigrants in areas previously uninhabited proves this 
to be the case, unless one accepts the possibility that the virus 
may remain alive for a long time in man. 

SYMPTOMATOLOGY OF PSEUDOTYPHOID FEVER OF DELI 

THE DERMAL, NECROSIS 

In 39 per cent of cases the original point of infection is dis- 
coverable; in Europeans, in all cases. It is much easier to rec- 
ognize the ulcer, often very small and after a time not very 
characteristic, on the healthy skin of a European than it is on 
that of the native, who is frequently a sufferer from other skin 
affections. It is for this reason that for a long time I overlooked 
the connection between the disease and the ulcer. 

In the earliest stage that I was able to observe, the lesion 
showed itself as a flat vesicle, 3 to 4 millimeters in diameter. 



348 The Philippine Journal of Science 1915 

surrounded by a dull red areola. The papule soon bursts, and 
beneath it there appears a small, dark area of blackish necrosed 
skin some 4 millimeters in diameter ; five to eight days later the 
slough is cast off, leaving a small, round, or oval ulcer with 
steep edges and the floor covered with mucopus. In most cases 
there is slight evidence of local reaction. The ulcer is of indo- 
lent character, shows small tendency to healing, and may persist 
throughout the illness. The typical initial ulcer is distinguished 
from other forms of skin ulcerations by its clean-cut borders and 
from furuncles by the fact that the lesion is only superficial. 
Lymphangitis has not been observed, but the lymphatic glands 
in the neighborhood of the ulcer are enlarged and tender, some- 
times markedly so; in some cases I have noted glands as large 
as a pigeon's egg. Such glands remain freely movable, how- 
ever, as there ■ is no inflammation of the periglandular tissue. 
The general lymphatic system shares in the infection, but remote 
from the lesion the glands are only slightly affected. 

The site of the initial lesion varies, but is commonest in the 
regions of the groins, the armpits, and the neck. As the lesion 
is minute, it is frequently recognized with difficulty. In some 
such cases enlarged glands have been sought for and thus the 
bite has been located. 

That the dermal affection is an essential part of the disease 
has been shown in a small epidemic among the Europeans on one 
of the estates. In May, 1909, three Europeans became ill, each 
showing similar symptoms which varied only in severity and 
duration. In all of them I found the characteristic initial lesion 
with its accompanying lymphadenitis. This feature I hold to 
be constant in the pseudotyphoid of Deli; where no such lesion 
has been observed, either it has already healed or has been over- 
looked — this I believe occurred in regard to the former series 
of cases which I reported. Until we learn more of the etiology 
of the malady, it is unwise to admit the existence of two diseases, 
differing as they do only in unimportant clinical details. 

THE RASH 

The second characteristic symptom is an eruption which 
appears on the second or third day of the disease and attains its 
full development on the sixth to eight day ; it then presents itself 
as roseola, the raised spots varying in size from that of a hemp 
seed to a threepence. It closely resembles the roseola of second- 
ary syphilis. The rash covers most of the body, being thickly 
placed on the flanks and less marked on the face and extremities ; 
it persists from eight to ten days longer, then changes to a 






x, b, 5 Schiiffner: Pseudotyphoid Fever in Deli 349 

brownish color, and slowly disappears. In some cases the erup- 
tion may be very slight, consisting only of a few reddish spots. 
In this rudimentary form, while it is distinctive in the European, 
it can very easily be missed on the dark skin of the native. To 
this I attribute the fact that with natives I found the rash only 
in 70 per cent of my cases, while with Europeans it was present 
in all. On the other hand, the rash may be so pronounced as to 
resemble the eruption of measles — in one of my cases some spots 
on the abdomen became hemorrhagic, and in this case only was 
there desquamation. 

THE TEMPERATURE CURVE 

The course of the fever can best be described by saying that it 
corresponds in all respects to that seen in enteric fever. In 
severe cases the temperature attains its maximum in four or 
five days and so remains for some time, then gradually falls by 
lysis. This course sharply distinguishes the disease from typhus/ 
with its brusque onset and termination by crisis. Cases are 
met with in which the fever is of a remittent type, as in mild 
cases of enteric fever, or, again, after ten days or thereabouts of 
high fever, there may be transient remission, to be again followed 
by another period of high fever of about the same duration. 

As in the case in enteric fever the nervous system suffers 
greatly. In mild cases there may be violent headache, and in 
severe cases drowsiness, the "typhoid state" or continuous 
delirium. Restlessness is a notable feature of the disease, espe- 
cially during the night; patients attempt to rise from the bed, 
there are involuntary evacuations, and constant watchfulness 
is necessary. It is characteristic that this serious nervous dis- 
turbance appears relatively late in the course of the disease, when 
the fever has been at its maximum for several days, and that 
these disturbances continue even when the temperature is fall- 
ing. In many cases it is only in the afebrile period that the 
mental state returns to normal. 

I do not know whether these symptoms have been noted in 
kedani fever in Japan, but they are eminently characteristic of 
the disease as it appears in Deli. 

CHANGES IN THE BLOOD 

A moderate leucocytosis from 10,000 up to 12,000 per cubic 
millimeter is the rule, but cases in which the leucocytes number 
as many as 26,000 per cubic millimeter or as few as from 4,000 
to 5,000 per cubic millimeter have been noted. 

More significant, however, than the total leucocyte count is 
the relative proportion of the different varieties. Where there 



350 



The Philippine Journal of Science 



1915 



is no bronchitis or pneumonia, a diminution of polymorpho- 
nuclear forms and an increase in lymphocytes are almost con- 
stantly found. This change is more marked toward the end of 
the disease when the polymorphonuclear forms may number less 
than 8 per cent and the lymphocytes as much as 86 per cent of 
the total. One finds a large number of immature lymphocytes 
recognizable by their large size and their nucleus. These forms 
resemble the myeloblasts of Nageli or the "Lymphoiden Mast- 
zellen" of Tiirck. The remarkable lymphocytosis is, perhaps, 
due to the general involvement of the lymphatic glands met with 
in the disease. 

The polymorphonuclear leucocytes show the degenerative 
changes described by Schilling and Torgau. Their number 
rises immediately when lung complications arise. Eosinophiles 
may be as few as 0.25 per cent, but they do not disappear 
altogether as is the case in enteric fever. 

Tables II and III show the blood counts in typical cases. 

Table II. — Shoiving blood counts in a typical case. 



Case No. 2071. 


Total leu- 
cocytes. 


Poly- 
morpho- 
nuclear. 


Lympho- 
cytes. 


Eosino- Mast- Large 
Philes. zellen. j „»«£_ 




6,200 
10, 000 

5,250 

4,400 


Per cent. 

14 
8 

25 
34 


Per cent. 
76 
86 

68 
58 


Per cent. 


Per cent, i Per cent. 
6 1 






6 


Seventeenth (temperature has 
fallen) 




1 
7 


Twenty-second (convalescent) 


S 


1 4 



Table III. — Showing blood count in a typical case. 




OTHER SYMPTOMS 



There are no characteristic symptoms associated with the in- 
ternal organs. Diarrhoea is uncommon. The lungs and bronchi 
may be involved, and in fatal cases extensive bronchopneumonia 
has been found. Albuminuria may be present and in severe 



x, b, 5 Schiiffner: Pseudotyphoid Fever in Deli 351 

cases may last until the fever has subsided or until the rash 
disappears. 

Finally I would mention the occurrence of rheumatoid pains 
in the smaller joints. This symptom appears sometimes soon 
after the fever has subsided, but does not last more than two 
or three days. 

Convalescence follows a normal course, but it is usually some 
time before the patient is completely well. 

In regard to special methods of inquiry, in all cases agglutina- 
tion tests were applied with the patients serum for B. typhosus, 
B. paratyphosus A, and B. paratyphosus B; attempts were, also, 
made to cultivate organisms from the blood on suitable media. 
These inquiries, as well as microscopic and bacteriological 
examination of exudate from the initial lesion and of excised 
glands, were entirely without result and gave no hint as to the 
etiological factors concerned in the malady. As it was not pos- 
sible to infect monkeys by injection of blood from cases of the 
disease, I could not ascertain whether or not a filterable virus 
played any part in its causation. 

In the post-mortem examination of seven fatal cases, I found 
only such lesions as may be present after pyrexia. 

SUMMARY 

1. There exists in Sumatra a disease which resembles enteric 
fever in its general clinical characters, but is clearly distinct 
from that disease in causation. 

2. There is evidence that this disease is transmitted in a man- 
ner similar to that which has been demonstrated for kedani fever 
in Japan. 

3. Though the pseudotyphoid of Deli would appear to be a 
much less fatal disease than kedani fever of Japan, there are 
yet many points of resemblance between the two diseases. 

REFERENCES 

Miyajima, M. Centralbl. f. Bakt. — Ref. (1911), 50, 34. 

ScHUFFNER, W., and Wachsmuth M. Trans. Bombay Med. Cong. (1909), 

55. 
Idem. Zeitschr f. klin. Med. (1910), 71, 133. 
Tanaka, K. Centralbl. f. Bakt. (1899), 26, 432. 






^ 






Schuffner: Pseudotyphoid Fever.] 



[Phil. Journ. Sci., X, B, No. 5. 




Fig. 1. Larva (Trombidium sp.). 




Fig. 2. Larva (Cheyletus sp.). 
PLATE I. 



Schuffner: Pseudotyphoid Fever.] 



[Phil. Journ. Sci., X, B, No. 5. 




Fig. 1. Primary lesion in the axillary region. 




Fig. 2. Primary lesion in the supraclavicular region. Lymphadenitis. 
PLATE II. 



SCHUFFNER : PSEUDOTYPHOID FEVER.] 



[Phil. Journ. Sci., X, B, No. 5. 




Fig. 1. Primary lesion, front of leg, showing inflammatory halo. 




Fig. 2. The same twelve days later. Healing has begun. 
PLATE III. 



ILLUSTRATIONS 

Plate I 



Fig. 1. Larva (Trombidium sp.). 
2. Larva (Cheyletus sp.). 

Plate II 

Fig. 1. Primary lesion in the axillary region. 

2. Primary lesion in the supraclavicular region. Lymphadenitis. 

Plate III 

Fig. 1. Primary lesion, front of leg, showing inflammatory halo. In this 
case there was involvement of the femoral glands but no 
lymphangitis. 
2. The same twelve days later. Healing has begun. 

353 



REVIEWS 

An International System | of | Ophthalmic Practice | edited by | Walter 
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355 



356 The Philippine Journal of Science 

to be very instructive to the student, who, after a few dissections, 
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B. Tropical Medicine 

Vol. X NOVEMBER, 1915 



No. 6 



THE TREATMENT OF THE RETROGRESSIVE SKIN LESIONS OF 
LEPROSY WITH BASIC FUCHSIN 1 

By Oswald E. Denney 
(Culion Leper Colony, Culion, P. I.) 

THREE PLATES 

To one familiar with the clinical aspects of leprosy the curative 
treatment of the secondary skin lesions is one of the most difficult 
and discouraging problems. 

The frequency with which ulcerations occur, either in the 
course of the disease or from trauma to poorly innervated tissue, 
and the almost hopeless task of curing these sluggish lesions 
tax to the utmost therapeutic resources. 

A recent inspection of the 3,500 lepers comprising the Culion 
Leper Colony showed 42 per cent of them to have ulcers of 
either the hands or feet. Considering that at some time in his 
life nearly every leper has ulcers, the magnitude of the work 
required to care for a large number of lepers can be appreciated. 

Among the patients presenting themselves daily for treatment 
at the surgical clinic of the colony, there is a variety of lesions, 
many of which have remained unchanged for months or years. 
Most of the lesions, with proper medication, remain clean ; those 
receiving indifferent attention present an entirely different 
picture. The slovenly habits of the average leper, the scanty 
clothing accommodated to the hot climate, the unfortunate anaes- 
thesias, and the lowered body resistance cooperate in producing 
infection which, untreated, frequently results in gangrene. 
With the loss of pain sense, and frequently the loss of smell, also, 
the unfortunate leper fails to recognize the seriousness of his 
condition until the gangrene has invaded better innervated tissue. 



1 Received for publication September 28, 1915. 



186701 



357 




358 The Philippine Journal of Science ms 

This final condition fortunately is unusual, for while an average 
of one new case of gangrene is treated daily in the surgical 
clinic of the colony, the gangrenous process is usually an early 
and superficial one. 

The Filipino leper differs in no way from other lepers in his 
regard for medicine. A "new medicine" is welcomed for a 
period, and treatment is regularly received; then interest lags, 
and it becomes extremely difficult to continue treatment even in 
the face of encouraging results. Partly for this reason the 
treatment of skin lesions in individual lepers in Culion has been 
changed from time to time, but mainly because of lack of im- 
provement with a given prescription. 

In the treatment of the chronic ulcerations at Culion the 
greatest difficulty has been experienced in causing epithelial 
proliferation. The wounds can be kept clean with a variety of 
antiseptics, but the epithelial margins of the lesions remain 
unchanged, giving them sometimes the "punched out" appear- 
ance of luetic ulcers. 

E. S. May, 2 in an article on the germicidal action of basic 
fuchsin, presents the following conclusions: 

1. From the results of my investigations with basic fuchsin, I conclude 
that I have a germicidal agent which is more powerful than phenol 
(carbolic acid) and one which has a greater diffusibility and is less toxic. 

2. From my clinical observations I conclude that I have found a ger- 
micidal agent which has a marked stimulative action on epithelial and 
granulation tissue growth. 

In a subsequent paper 3 on basic fuchsin in chronic leg ulcers 
May and Heidingsfeld give a preliminary report on treatment 
which, while showing satisfactory results, was incomplete 
because the unauthorized substitution of commercial fuchsin for 
the more refined fuchsin interrupted their work. 

Basic fuchsin as exhibited by May and Heidingsfeld in the 
treatment of chronic ulcers was either in 1 per cent ointment 
after the following formula: 

Fuchsin (Griibler's Fuchsin fur Bakt.) 1 part 

Petrolatum 5 parts 

Anhydrous wool fat 100 parts 

or in gauze bandages saturated with 1 to 1,000 aqueous solution. 
Upon theoretical grounds, then, basic fuchsin — a germicide 
and epithelial and granulation tissue stimulant — should be a 
desirable preparation in the treatment of leprous lesions. 

'Journ. Am. Med. Assoc. (1912), 58, 1174-1176. 
'Ibid. (1913), 60, 1680-1682. 



x, b, 6 Denney: Skin Lesions of Leprosy 359 

Accordingly, without regard to the character of the lesions, 
132 patients were selected from the members of the colony for 
experimental treatment. 

Since a majority of the ulcers are continuously bathed 
in serum, it was at the outset considered inadvisable to use 
ointments, experience having shown this form of medication to 
be unsatisfactory. Cotton pledgets, soaked in 1 to 500 aqueous 
solution of basic fuchsin, were packed into the lesions and kept 
in place by gauze bandages. After a few days the patients com- 
plained of a burning sensation in the lesions, and thereafter a 
solution of 1 to 1,000 was adopted for routine use with little or 
no discomfort. 

The lesions treated may be classified as follows : 

a. Ulcerated tubercles. 

b. Neurotrophic ulcers; 

c. Infected neurotrophic ulcers. 

d. Simple burns. 

e. Infected burns. 

/. Ulcers with sinuses leading to necrotic bone. 
g. Early gangrene (superficial) . 
h. Late gangrene (deep). 

a. Ulcerated tubercles (Plate I, fig. 1) responded rather slowly 
to basic fuchsin treatment. Within a few weeks, however, the 
lesion assumes a pink, healthy appearance, which may con- 
tinue until the epithelium finally covers the wounds, leaving 
raised, flat, smooth cicatrices. Of the four cases treated, one 
eventually repaired, one showed considerable improvement, 
and two were unimproved after five months of treatment. 

b. Neurotrophic ulcers (Plate III, figs. 1, 2, and 3), many of 
which had resisted treatment for long periods of time, quickly 
showed improvement. The epithelial margins approximated, 
leaving smooth, pink cicatrices. The repair, however, not being 
permanent, subsequent trauma resulted in new ulcers. Thirty- 
three cases were treated, fifteen of which continued to complete 
repair, fourteen improved considerably, three did not improve, 
and one died (from leprous cachexia). 

c. Infected neurotrophic ulcers (Plate II, figs. 4 and 5) 
responded to treatment in a manner similar to simple neuro- 
trophic ulcers, the infection being checked readily and repair 
continuing. Of the six cases treated, four continued to complete 
repair, while one died of meningitis and one from septicaemia 
(each of these two patients was extremely ill when treatment 
was started). 

d-e. Simple and infected burns are very frequent lesions in 



360 The Philippine Journal of science 1915 

the anaesthetic form of leprosy, and of the four cases selected 
for treatment all quickly repaired. 

/. Perforating ulcers (Plate I, figs. 2 and 3), more particularly 
those of the hands and feet, are usually the openings for sinuses 
leading to necrotic bone, it being almost impossible to close the 
ulcers as long as the necrotic bone exists. In a few cases simple 
curettage of the bone led to speedy repair, but in cases in which 
all the bones of the foot or the hand were affected, no surgical 
interference was made, the condition usually being painless and 
the member being serviceable even in its maimed condition. Of 
the fifty-three cases treated, twelve were completely repaired, 
thirty-one improved, nine did not improve, and one died (from 
leprous cachexia). 

g. Superficial gangrene results frequently from extensive 
burns or from ulcers which are not regularly dressed. In such 
cases basic fuchsin acted promptly and efficiently. After 
twenty-four hours no odor could be detected in the wounds, and 
the progress became checked; after forty-eight hours much of 
the necrotic tissue could be curetted away ; and after seventy-two 
hours evidence of repair could almost always be seen. Of the 
8 cases treated, all repaired promptly. 

h. Late gangrene (Plate II, figs. 1, 2, and 3), which sometimes 
exists several days before the patients call for assistance, 
responded satisfactorily to fuchsin treatment. Prompt curet- 
tage of the superficial necrotic tissue and the packing of the 
wound with 1 to 500 aqueous solution of basic fuchsin in most 
cases checked the progress of the disease. The treatment, 
however, was useless when the patient had already become delir- 
ious, or when hyperpyrexia existed. Of the fourteen cases 
treated, thirteen repaired and one died from septicaemia. 

In this series of cases basic fuchsin as antiseptic has proved 
most satisfactory; as an epithelial and granulation tissue 
stimulant it has brought about repair in many cases which have 
resisted a host of medications. Aside from the slight burning 
sensation from the stronger solutions neither discomfort nor 
toxic effect was noted. 

As basic fuchsin proved to be of great value in the treatment 
of leprous lesions, it had been adopted as a routine medication 
even before the completion of the observations on the 132 cases 
treated experimentally. Several hundred lepers are now re- 
ceiving this treatment daily, with results approximating those 
reported in this series of cases. 



X, B, 6 



Denney: Skin Lesions of Leprosy 



361 



Table I. — Resume of cases treated with basic fuchsin at the Culion Leper 

Colony. 



Lesions. 


Re- 
paired. 


Im- 
proved. 


Not im- 
proved. 


Died. 


Total. 




1 
15 

4 
10 

4 
12 

8 
13 


1 

14 




31 




2 
3 




9 





1 
2 



1 



1 


4 
33 

6 
10 

4 
53 

8 
14 






Simple burns 










Total 


67 


46 


14 


5 


132 



ILLUSTRATIONS 

Plate I 

FlG. 1. Large, raised, rough, ulcerated tubercles covering the arms and legs. 

2. Case 118. T. I. Large perforating ulcer of the sole with the 

metacarpal bones exposed. Phalanges of four of the toes com- 
pletely absorbed, the nail of the little toe being attached to the 
dorsum of the foot. Fuchsin treatment was begun on April 6, 
1915. Photograph was taken on April 25, 1915. 

3. Case 118. T. I. Photograph four months later, showing marked 

improvement. Large rough cicatrix with small sinus below the 
little toe. 

Plate II 

Fig. 1. Case 70. J. D. Gangrene of the dorsum of the hand, showing 
the invasion of the deep tissues. Treatment was begun on 
March 25, 1915. Photograph taken on the same day. 

2. Case 70. J. D. Photograph taken one month later, showing par- 

tial repair. The infection having invaded the extensor sheaths, 
partial excision was necessitated. 

3. Case 70. J. D. Photograph taken May 25, 1915, showing com- 

plete repair with a slightly rugged T-shaped cicatrix. 

4. Case 7. P. J. Large confluent ulcers of one year's duration, be- 

came infected and speedily worse. Treatment with basic fuchsin 
was begun on March 1, 1915. Wound became clean, but showed 
no evidence of repair when photograph was taken, April 15, 1915. 

5. Case 7. P. J. After four months of continuous treatment with 

basic fuchsin the epithelial margins of the lesion began to grow. 
Photograph was taken on August 1, 1915. Considerable im- 
provement is evident. 

Plate III 

Fig. 1. Case 8. T. M. Large ulcers of both legs following trauma; lesions 
of two months' duration. Fuchsin treatment was begun on 
March 3, 1915. Photograph was taken on March 18, 1915. 

2. Case 3. T. M. Photograph taken five weeks later, showing great 

improvement, the ulcer of the right leg being almost healed. 

3. Case 3. T. M. Photograph taken one month later, showing com- 

plete repair. 

363 









~ UJ 

"S i- 

= 3 

Q. 




Dennby: Treatment of Skin Lesions of Leprosy.] 



[Phil. Journ. Sci., B, No. 6. 




Fig. 1. Gangrene of hand. 





Fig. 2. Same as fig. 1. 



Fig. 3. Same as fig. 1. 





Fig. 4. Large confluent ulcers of foot. 



Fig. 5. Same as fig. 4. 



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LEPROSY l 

By John A. Johnston 
(From the Bacteriological Laboratory, Bureau of Science, Manila, P. I.) 

Leprosy may be defined as an extremely chronic, practically 
incurable disease, with a long incubation period of from two to 
ten years, according to various authorities. Prodromal symp- 
toms are stated to exist, but they can hardly be definitely stated 
to be peculiar to leprosy, as they are usually so indefinite, con- 
sisting of malaise, attacks of fever, sweating, and somnolence. 

Two well-defined types of the disease exist: namely, the 
nodular or tubercular and the anaesthetic. A combination of 
these two may give rise to a third division — the tuberculo or 
maculoansesthetic or mixed. 

Leprosy existed throughout the world several thousand years 
before Christ. A disease is mentioned in the Hindu sacred 
writings and also in the Ebers papyrus which is similar to what 
we now call leprosy. Ancient writers undoubtedly confused 
other skin diseases with leprosy, but it has been well established 
that leprosy was introduced into Europe from Egypt in the 
first century before Christ by the returning troops of Pompey. 
The returning crusaders in the fourteenth century spread the 
disease generally over Europe. It is stated that in France alone 
there were over 2,000 leprosaria. Very drastic segregation 
seems to have been established, so that by the end of the fifteenth 
century the disease had practically disappeared. At the present 
day in Europe there are a few isolated cases in Norway, Sweden, 
Turkey, the Balkans, France, Germany, Spain, and the British 
Isles. Outside Europe leprosy is found in Africa, which is 
heavily infected, China, Japan, India, the Philippines, the 
United States, Hawaii, and in many of the islands of the Pacific 
Ocean. 

In the Philippine Islands the records show that the disease 
was introduced from Japan. The early missionaries from the 
Philippines had made strenuous endeavors to obtain a foothold 
in that country. The Emperor finally advised the church 

1 Read before the Manila Medical Society, July 12, 1915. Received for 
publication October 2, 1915. 

365 



366 The Philippine Journal of Science ms 

authorities in Manila that he would send a shipload of Japanese 
for them to experiment upon and endeavor to convert. The 
good padres were highly delighted, but their pleasure was turned 
to distress when it was found upon the arrival of the ship in 
1633 that the new recruits consisted of 150 lepers. They were 
permitted to land, but no attempt at segregation was made, and 
so these people scattered throughout the Islands, spreading in- 
fection wherever they located. According to estimates made 
by the Franciscan fathers, there were at one time 30,000 lepers 
in the Archipelago. This number was probably greatly exag- 
gerated, as in 1902 the Bureau of Health began making a sys- 
tematic census of known lepers and reported an estimate of 
10,000, probably much less. 

During the Spanish regime all leper hospitals were conducted 
by the church. No very definite policy seems to have been 
followed. The first leper hospital in Manila was established 
in 1633 by the Franciscan order as a separate department of 
their general hospital and was located across the street from the 
present United States Army Department Hospital. Lepers were 
here cared for except, for an indefinite period, between 1662 
and 1681. At this time Chinese pirates threatened an invasion 
of Manila, and the patients were moved to Quiapo for safety. 
In 1784 the church authorities deemed it best to move from 
Calle Concepcion, and the Government gave them the present 
San Lazaro estate with the proviso that a portion was to be 
used for the location of a hospital and the bulk of the estate 
rented and the money so obtained devoted to maintenance. 
Portions of the original structure are still standing and are, I 
believe, in use as the leper department of the present San Lazaro 
Hospital. 

In 1859 Pedro Felix Huertas took charge of the hospital; he 
seems to have been a very excellent executive and to have made 
many improvements. The stone walls, which exist to-day, were 
built by him at a cost of 30,000 pesos. 2 

At the time of the American occupation there were three 
hospitals devoted to the care of lepers : namely, the San Lazaro 
in Manila, one in Cebu, and another in Ambos Camarines, the 
total capacity of the three being estimated at 400. 

In the report of the former Board of Health (now Bureau of 
Health) for 1902 mention is made of the necessity for establish- 
ing a leper colony. A committee appointed by the military 

2 One peso Philippine currency equals 100 centavos, equals 50 cents 
United States currency. 



x, b, 6 Johnston: Leprosy 367 

authorities had reported favorably upon Cagayan Sulu Island, 
but had overlooked the question of a proper water supply. 
The Philippine Commission appointed a committee to make a 
new survey, and Culion Island was decided upon as a good 
site. It was not until 1906 that lepers were sent to the colony. 
The first colonists numbered 500, and at the present time some 
3,000 persons are living there. 

ETIOLOGY 

Leprosy is caused by an acid-fast bacillus— the so-called 
bacillus of Hansen, or Bacillus lepras — which resembles the 
tubercle bacillus both as to morphology and staining peculiarities. 
It is a slender rod, 2.5 to 3.5 microns in length by 0.3 micron in 
thickness. It is usually straight, but sometimes slightly curved, 
and occasionally clubbed forms are seen. It is nonmotile, and 
is not definitely known to produce spores. I have often seen, 
however, in smears from leprous nodules, small rounded bodies 
0.5 to 2 microns in diameter, which are distinctly acid-fast, and 
have noted that where these exist the typical leprosy bacilli will, 
also be found after careful search. Leprosy bacilli are found in 
the tissue cells in the lymph spaces, and while isolated organisms 
are frequently noted, a characteristic grouping of from two to 
three to many individuals in a bunch or bundle may occur. This 
has not been inaptly likened to a package of cigars. 

A word as to the differentiation between the bacillus of 
tuberculosis and that of leprosy. The leprosy bacilli are usually 
present in large numbers, often packed in groups, or bundles, 
in the juice squeezed from a leproma or in scrapings from the 
nasal mucosa, provided an ulcer of the septum exists. In 
tubercular skin lesions it is the exception to find a single bacillus 
in juice obtained after such a procedure. The leprosy bacilli 
are said to be less acid-resisting than the tubercle bacillus. This 
fact is in a measure true, but I have often found typical leprosy 
bacilli that were as acid-fast as the tubercle bacillus. 

It has been stated by several authors that the leprosy bacillus 
stains more solidly and when granules are present they are 
coarser and more widely separated than the fine granulations 
of the tubercle bacillus. The bacilli are chiefly spread by the 
lymphatics, but they may be found in the blood stream in the 
nodular type of the disease. The following procedure should 
be used: Puncture a vein and permit the blood to flow into 10 
per cent acetic acid solution in the proportion of 1 to 10, allow it 
to act from one to two hours at 37°C, and then centrifuge. 
Very beautiful specimens may be secured in this way. 



368 The Philippine Journal of Science 1915 

It is a well-known fact that in cases of the nodular type 
recrudescences apparently occur at varying intervals, to be 
followed by feverish attacks with accompanying swelling and 
congestion of the nodules and a new outcropping of lesions. 
This condition is well recognized by the lepers at Culion, and in 
the Tagalog language the condition is termed alabajar. I have 
not had the opportunity to make repeated examinations in these 
cases, but the symptoms suggest a true bacteremia. 

It is generally believed that each case of leprosy takes origin 
from contact with another case for a varying period of time. We 
have no definite knowledge at the present time as to the exact 
method of transmission, but one well-established fact seems to 
be that intimate contact is necessary. In adults such contact 
can easily be accounted for by the sexual relation, and in 
children by familiar relations which are more or less intimate. 
Even with such close contact, infection is rare, as is shown by 
the following figures taken from a report on the health conditions 
at Hawaii. Of 225 healthy natives living in the same house as 
lepers only 4.5 per cent acquired leprosy. Among the married 
only 9 out of 181 contracted the disease from their leprous wives, 
or husbands, as the case might be. 

Many writers have endeavored to involve the insect world as 
bearing an epidemiologic relation to the disease. Thus flies, 
bedbugs, cockroaches, head lice, mites, and ticks have all been 
hailed as carriers and conveyers of leprosy bacilli, but there is 
still no proof of actual guilt. When we stop to consider the 
ubiquity of acid-fast bacilli in nature, and the habits of feeding 
of these insects, one wonders if almost all of the reported positive 
findings of leprosy organisms in different insects are not errors. 
My own experience in this line consists in one series of observa- 
tions. Three hundred fifteen bedbugs were collected at Culion 
from the beds in hospital, from houses, and from clothing. 
Fifteen of these bugs were examined individually by dissecting 
out the mouth parts and the intestinal tract, crushing between 
slides, and making a smear. Acid-fast bacilli were found in the 
intestine in one instance. The remaining bugs (300) were 
ground up in lots of 50 in sterile salt solution and centrifuged, 
and smears were made. An average of 100 smears was examined 
from each lot. Acid-fast bacilli were found four times, making 
a total of five times for the entire number of bugs. 

Much stress has been laid by various writers on the importance 
of examining the nasal mucus, but unless there is a leprous ulcer 
of the septum, this is of little significance. The mere presence 



x. b, 6 Johnston: Leprosy 369 

of acid-fast bacilli in nasal mucus should not be regarded as 
diagnostic of leprosy in the absence of clinical signs. 

The diagnosis of leprosy may be considered under clinical and 
microscopical heads. 

CLINICAL 

The patient should be in a good light, and at first the examiner 
should stand some distance away, as by so doing he will often be 
able to distinguish certain areas which in the dark-skinned races 
show up only at a distance, such as dusky reddish patches, 
which on a near view one cannot differentiate at all from the 
surrounding skin. Fixing these patches in mind, they should 
next be palpated ; usually a certain degree of inelasticity will be 
felt. Such a patch is less than an induration and is apparently 
not due to any subcutaneous oedema or effusion, but rather to an 
atrophy of muscular tissue. In old cases the skin will remain 
after being pinched up. In early cases these areas are excep- 
tionally greasy, but later on dry, and frequently they do not 
sweat. Tests for anaesthesia should always be made in these 
spots. The center of the area is usually more anaesthetic than 
the borders. One should also look for loss of eyebrows, nodules 
in the ears — or, in old people, for elongation of the pinna — and 
nodules in the nasal alae. In leprous skin lesions there does not 
seem to be a true pigmentation, as what is often called pigmenta- 
tion is really a loss of natural color as compared with the 
surrounding area. The most confusing diseases which are fre- 
quently mistaken for leprosy are syphilis, lupus, yaws, mycosis 
fungoides and psoriasis, elephantiasis, and madura foot. Some 
authors have cited syringomyelia as being especially difficult of 
differentiation. In a personal experience covering several thou- 
sand cases I have never seen a case of this disease. 

MICROSCOPICAL 

Success in detecting the leprosy bacillus depends largely on 
the method of taking the specimen. Selecting a nodule or the 
edge of an indurated area previously circumscribed with a 
sharp scalpel, one or more slight incisions should be made just 
through the true skin. If the incision is properly made, only 
a small amount of blood will appear. This is wiped off, and the 
serum which exudes is taken up by the blade of the scalpel; 
it is well to scrape the edges of the incision. The whole 
should be smeared as evenly and thinly as possible on a slide. 
Dry in air and fix by direct heating over the flame or by dropping 
one or two drops of alcohol on the slide and setting fire to it. 



370 The Philippine Journal of Science 

Stain with carbol fuchsin and heat until boiling. Allow to cool, 
wash in distilled water, decolorize either with Gabbet's methylene 
blue and sulphuric acid or with 20 per cent aqueous nitric or 
sulphuric acid, and counterstain with Lceffler's blue. Personally 
I do not like a counterstain, but this is a matter of little 
importance. 

BIBLIOGRAPHY 

Stitt. Diagnostics and treatment of tropical diseases (1914). 
Encyclopedia Britanica, 11th ed. (1910-11). 
Annual Rep. P. I. Bur. Hlth. (1913). 



TROPICAL OBSTETRICAL PROBLEMS l 

By Fernando Calderon 

(From the Department of Obstetrics, College of Medicine and Surgery, 

University of the Philippines) 

There is not the slightest doubt that since the American occu- 
pation of these Islands in 1899 much progress has been made in 
this country in the different branches of medicine. 

If we confine our consideration to obstetrics, the advance in 
this branch of medical science is still more remarkable. In 
the past, obstetrical teaching in this country consisted merely 
in didactic lectures, sometimes demonstrations on the manikin, 
and of two or three cases of labor during the school year, and 
it frequently happened that the students were graduated without 
having seen a single obstetrical case. Owing to these circum- 
stances many physicians, when called upon to attend an obstet- 
rical case, were very much afraid to meet any complication 
that might arise during labor, and when a physician whose 
inclinations were for obstetrics wanted to develop his knowledge 
in order to be a specialist in this line, he had to go abroad, as 
there were no facilities here for special work. 

In July, 1907, the College of Medicine and Surgery was es- 
tablished with its obstetrical department in the city of Manila. 
At first the obstetrical clinics were held provisionally in a small 
room in Saint Paul's Hospital with only four beds, and two 
municipal physicians were appointed to attend outside obstetrical 
cases. At that time we had very few patients, the majority 
of whom were outside cases, because, in general, the Filipino 
women were opposed to entering the hospital, their habits and 
customs being to deliver in their own houses, and also, because 
they were imbued with many superstitions and were accustomed 
to their own practices. I think it will not be out of place in this 
connection to present a list of superstitions relating to obstetrics, 
which I have carefully collected from the ignorant classes of our 
people. 

BEFORE THE BIRTH OF THE CHILD 

DURING PREGNANCY 

During pregnancy it is believed that the asuang has a great 
influence upon the pregnant woman. The asuang is supposed 

1 Read before the Manila Medical Society, March 1, 1915. Received for 
publication March 5, 1915. 

371 



372 The Philippine Journal of Science ins 

to be a very active evil spirit, troublesome alike to men and 
women, especially to women who are pregnant or in labor, and 
also, to new-born children. The asuang resembles the vampire 
of Europe, and is believed to suck the blood of human beings 
while they are sleeping. This belief causes pregnant women to 
be careful, for fear they become its prey. 

The asuang is believed to be more troublesome at night than 
in the daytime, and for this reason pregnant women endeavor 
to remain in the house at night. Should occasion require them 
to leave the protection of the house, it is customary for them 
to let down the hair, as in so doing the asuang is frightened 
and dares not approach the woman for the purpose of transform- 
ing the prospective child into another asuang. It is, also, cus- 
tomary to keep a light or fire burning at night beneath the 
house, as these evil spirits are believed to be frightened away 
by this means. 

The asuang is supposed to be a very clever spirit, but it is 
unable to see any person who is covered by a cloth, and pregnant 
women are always advised to sleep under a black blanket during 
the last months of pregnancy. 

In the presence of a pregnant woman it is considered unlucky 
to cross a halter, or rope, attached to a horse or any other animal, 
as a difficult labor will be caused. 

Pregnant women are not allowed to eat tutong, or rice crust, 
because by so doing the expulsion of the placenta will be delayed. 

When a pregnant woman voids urine on the ground, it is 
necessary for her to pour water over the place where she urinated, 
otherwise the asuang might smell the urine, and the woman 
will have haemorrhage at the time of labor. 

Pregnant women should not carry coins under the folded 
waistband of their skirts, because if they do so the child will have 
tumors. 

When engaged in cooking, they must be careful to place the 
wood in the stove large end first, otherwise the baby will be 
born in the opposite direction — that is, a breech presentation 
will result. 

During the last three months of pregnancy what is termed 
pagbubungkal is performed, which consists in turning the baby 
in order to place it along the median line of the mother. This 
is a very dangerous practice. 

DURING LABOR 

On arrival the midwife rubs the body of the parturient with 
her hands. 



x, b, 6 Colder on: Tropical Obstetrical Problems 373 

The yolk of eggs is then administered in order to give strength. 
Sometimes uncooked cocoa, pure chocolate, or human milk is 
given, in order, it is said, to facilitate labor. The midwife never 
allows any one to stand in the doorway; otherwise the child 
will stop at the pelvic outlet. 

During labor the asuang may, also, do harm to the parturient 
woman, and in order to keep it away, a light is kept burning 
under the house all the time. Sometimes this precaution 
is considered insufficient, and in this case, the doors and win- 
dows are smeared with a mixture of garlic and salt, in order 
to prevent the entrance of the asuang. 

To facilitate the birth of the child, the midwives and medi- 
quillos resort to the following procedure: 

The salag. — This method consists in locating the foetus by 
palpation, and by pressing and pushing, causing it to slide down 
against the abdominal wall, thus making labor easier. These 
manipulations are usually performed by a strong man or woman, 
preferably a man, who makes compression and expression of the 
uterus with his hands or with a piece of wood in such a manner 
that the abdomen as well as foetus is often bruised or wounded, 
and there is a too rapid expulsion of the foetus and resulting 
lacerations. Rupture of the uterus itself has occurred under 
such treatment. 

The use of a decoction made from roots of cogon and other 
plants is believed to facilitate labor. 

To stop strong labor pains, the leaves of bagabaga are burned 
near the woman in labor, or twelve buyo leaves are bruised in 
milk, and the mixture is rubbed over the lower part of the ab- 
domen and the thighs. At the same time the woman is made 
to take one raw egg and to apply another egg over her abdomen 
as a poultice. 

WHEN THE CHILD IS BORN 

After the birth of the child the cord is not cut until the placenta 
is expelled. The child is, therefore, exposed for several hours 
sometimes, while waiting for the placenta to be delivered. 

When the expulsion of the placenta is delayed, the midwives 
pull on the cord, while at the same time they push the uterus 
downward. This method is dangerous, because the cord might 
be torn off the placenta, or else the placenta might be forcibly 
detached from the uterine wall, leaving behind some cotyledons, 
or inversion of the uterus may be produced. 

When the placenta is delivered, the cord is cut and it is buried 
in the ground. It is believed to be a bad practice to throw 

136701 2 



374 The Philippine Journal of Science 191B 

it away. A hole is made for it, and care is taken to make it 
just large enough to fit the placenta, because, if the hole is too 
big, the baby will become a glutton, and if it is too small, 
the baby will have a poor appetite and small intestines. Some 
think it better to throw the placenta in the river, so that 
the baby will become healthy and strong. Others believe that 
if the placenta is buried wrapped in paper with a pen or a book 
the baby will become an active and wise man. 

The placenta is, also, used as a medicine. It is cut in pieces 
and then boiled and given to a primipara to eat, for the purpose 
of preventing many kinds of diseases during the puerperium. 

The child is separated from the placenta by cutting the cord 
with a knife made of a piece of bamboo, preferably boho, but 
sometimes with a dirty bolo or a pair of scissors. The cord is 
then coiled, dressed with ashes, and finally wrapped in a piece 
of linen or paper, which is usually dirty. 

If the cord is cut in pieces and hung on the eaves of the house, 
it is believed to prevent the diseases of childhood. 

In some portions of Luzon, as in Nueva Ecija, for example, 
before dressing a male child a barbarous maneuver is performed, 
which consists in fracturing the penis by folding it over at its 
middle. The reason for this is to prevent the child becoming 
effeminate. There is a commoner but less dangerous practice. 
It is what is called minamainitan, which consists in heating pieces 
of flannel or other cloth and then applying them hot over the 
abdomen, umbilicus, and sexual organs of the child. If the child 
is a male, they rub the cloths upward over the sexual organs to 
prevent hernia. Leaves of vomer o may, also, be used for this 
purpose. 

After cleaning and dressing the baby, the midwife administers 
a purgative, or a bitter juice, as the juice from alpalea, which 
is sometimes mixed with a few drops of the mother's milk. The 
juice is produced from the leaves, the number of which must 
always be uneven in order to be effective. 

The baby is wrapped in such a way that both hands and 
feet may not move, and it is not allowed to nurse for two days. 

After the birth of the child the mother is transferred to a 
clean mat and then the operation called pagkaban is performed 
by the midwife and her assistant, or salag. 

The operation of pagkaban is performed as follows : The mid- 
wife, squatting on one side of the parturient, holds the hands 
of her assistant (salag), who is in the same position on the 
other side. Then they compress the woman's pelvis with their 
feet, pulling each other's hands as they do so in order to return 



x, b, 6 Calderon: Tropical Obstetrical Problems 375 

the bones to their normal position. Finally, massage and irri- 
gation are given and repeated every afternoon. 

AFTER LABOR 

As soon as the placenta is delivered, a binder is tied very 
tightly around the waist of the patient. The object is to prevent 
the entrance of air into the abdomen, in case the woman takes 
a deep breath, and also, to prevent the blood from going up 
into the head. 

If there is postpartum haemorrhage, the hair of the patient 
is tied very tightly on the top of the head in order to stop the 
bleeding. This remedy is, also, used as a prophylactic treatment 
for haemorrhage. 

Another remedy for haemorrhage is heat, produced by burning 
bamboo in the form of sulo, or a torch, under the house. There 
is still another remedy by filling the vagina with kayas, or cut- 
tings of bamboo. 

The day after labor the woman begins to suffer from a se- 
ries of maneuvers performed on her by the hilot, or midwife. 

There is what they call sara, which consists in compressing 
the bones of the pelvis, a process which I have already de- 
scribed. When the woman complains of pain, weakness, paraly- 
sis of the legs, or prolapse of the uterus after labor, it is 
because the sara has not been made or because it has not been 
well done. 

The massage of the abdomen, which the hilot performs with 
caution, continues every day for eight days. After each massage 
the tight binder is put back in place. 

In some places, as in the Ilocano and the Tagalog provinces, 
the people perform the saklap, or salap, which consists in giving 
the woman a steam bath to produce a profuse perspiration. 
Many women become anaemic from this treatment, and if the 
condition of the woman after the treatment is bad, the hilot 
says that she has not been properly "cooked." 

Bathing. — After ten days a bath is given. On the preceding 
afternoon leaves of certain plants, such as talbak, tanlad, la- 
gundi, suha, galamayamo, and sambong, are collected and boiled 
together in a kettle. The next morning a bath is given with 
this infusion, while the leaves are all taken from the kettle and 
placed upon the mat where the woman sits in a squatting 
position. 

The leaves are again boiled and then covered with banana 
leaves to prevent evaporation. This is used for the operation 
called pagkukidob as follows: After lunch and a little rest the 



376 The Philippine Journal of Science ms 

woman is wrapped from the neck down with a buri mat, and 
then she is asked to stand with feet wide apart over a kettle 
of hot water covered with banana leaves. While the woman is 
in this position, a hole is made little by little in the banana 
leaf cover in order to allow the steam from the kettle to heat 
the external organs and the whole body. 

The bath after labor is taken in various ways. In some places 
it is taken only when there is no more lochial discharge. In 
others, as in the Ilocano provinces, immediately after labor the 
woman takes a bath and she does so every day for six days. 
After each bath she goes near a kalan, or a stove, and she re- 
mains there all day to warm up her hips. In San Fernando, 
Union, the woman just delivered takes as many baths as the 
number of days that have passed since the time of labor. For 
example, one bath on the first day, two baths on the second day, 
etc., until the ninth day when she takes nine baths. 

Every afternoon the abdomen is massaged with a heart-shaped 
stone or a piece of iron about 10 centimeters long, prepared for 
this purpose, which is heated and then wrapped with leaves 
of pandakaki. 

Any puerperal disturbance, such as puerperal insanity, for 
example, is attributed to the mangkukulam, or witch. 

DURING LACTATION 

The woman must not nurse her baby if she has been cooking 
or ironing, because her milk has been altered by the heat 
(panis). If she has not nursed her child for several hours, her 
milk becomes bad, also, and so she must remove the supposed 
bad milk first before giving her breast to the child. 

Anything that is sour is bad for a nursing woman, because 
it coagulates the milk and the baby will have colic. 

She must, also, see that no lizard drinks her milk, otherwise 
the secretion of milk will be stopped. 

Hyperlactation is prevented by the use of a key as an amulet 
or a few papaya flowers suspended from the neck. 

OBSTETRICAL PROBLEMS 

As I have already said, we had, at the beginning of the ob- 
stetrical department, only a few cases, not more than 10 a month, 
consisting of the worst cases in the city — those suffering from the 
misguided attentions of ignorant midwives and friends. The 
large majority of the patients refused to be confined in the hos- 
pital ; consequently the work had to be done in the homes of the 
poor, which were usually in a most unsanitary condition and 



X, B, 6 



Colder on: Tropical Obstet?-ical Problems 



377 



where it was sometimes even impossible for us to obtain clean 
water to use for the patient and her baby. The patients were, 
in the majority of cases, so poor that they could not afford to 
furnish even basin, soap, or towel. 

In spite of all these difficulties students were taught to con- 
duct labor, make application of the forceps, and perform podalic 
version and other operations. 

The death rate was high, due to the ignorance of the Filipino 
women in matters of hygiene and to the fact that they were 
opposed to calling in a physician, except when they were already 
in a very serious condition, and when it was impossible or al- 
most impossible to do anything for them. With the object of 
enlightening the people, several movements were begun in the 
department to improve the service and to educate the people, 
such as the organization of the out-patient service with resident 
physicians and internes at the hospital, the distribution of 
pamphlets and letters among the poor Filipino women in Manila, 
and lectures and conferences in the different health districts 
of the city. 

These lectures and conferences dealt chiefly with those sub- 
jects pertaining to the pregnant woman, care of children, and 
midwives, and we always tried, in so far as possible, to gather 
at our meetings the pregnant women and midwives of the 
district. Our work was satisfactory, as it resulted in the grad- 
ual increase of our cases and decreases of our death rate, 
especially in the out-patient department, as shown in Table I. 



Table I. — Obstetrical cases from 1907 to 191U, showing increase of 
hospital and decrease of outside service. 



Year. 


Deliveries and 
puerperium. 


Abortions. 


Hospital. 


Outside. 


Hospital. 


Outside. 


1907 to 1910 


110 
241 
336 
513 

567 


454 
282 
515 
373 
316 


10 
21 
46 
3 
45 


24 
6 
8 
1 

7 


1911 


1912 


1913 _ 


1914 


Total _ 


1,767 


1,940 


125 


46 





It is only just, however, to state that the success in educating 
the people in the advantages of hospital care was not entirely, 
although it was mainly, due to the activities of our department, 
because we have, also, to consider the influence of other insti- 



378 



The Philippine Journal of Science 



1915 



tutions, as an example the Mary J. Johnston Hospital, where 
Filipino women learned that hospitalization was a good thing 
for them, be they in normal or abnormal labor. In January, 
1911, or a little over four years ago, the obstetrical department 
was transferred from the small room in Saint Paul's Hospital 
to floor 11 of the Philippine General Hospital, where we had 
better facilities for obstetrical work of all kinds. This transfer 
of the maternity department to a modern and well-equipped 
institution contributed very considerably toward attracting 
women to be subjected to hospital treatment, not only because 
they saw that the new maternity ward was excellent in the 
matters of hygiene and afforded an ample space for a large 
number of patients, but also, because they saw that we had 
all the facilities that were necessary, especially in cases needing 
intervention. As a result of all these influences that contrib- 
uted to the education of the Filipino women, we have been 
able to increase the number of confinement cases with medical 
assistance in the city of Manila from 5 per cent to 70 per cent. 
The department of obstetrics was organized in July, 1907, 
in Saint Paul's Hospital, and from that time to December, 1914 — 
that is, a period of seven years and a half — we have had 3,707 
cases of deliveries and puerperium and 171 abortions, with the 
complications, deaths, and operations shown in Table II. 

Table II. — Classification of 3,707 delivery and puerperal cases from 
July, 1907, to December, 191U- 



Cases. 



Hospital. 



Outside. 



Total. 



Per cent. 



Complications: 

Placenta praevia . 

Eclampsia 

Puerperal infection 

Operations: 

Forceps - 

Podalic version... 

Embryotomy 

Csesarean section 

Laparotomies for abdominal pregnancy- 
Maternal deaths: 

Placenta praevia 

Eclampsia _ 

Puerperal infection 

Other causes 



125 
125 
115 

158 
121 
15 
16 



15 



140 
39 
119 

227 
188 

16 

»16 

2 

36 
18 
19 
84 



Total 



157 



* Two post mortem. 



x, b, 6 Colder on: Tropical Obstetrical Problems 379 

We have had 4 per cent of placenta prsevia, as against 1 per 
cent of eclampsia, which shows that placenta prsevia is more 
frequent in this country than eclampsia, a fact which is just 
the opposite to what I have observed in several clinics of France 
and America, where eclampsia seems to be more frequent than 
placenta prsevia. Placenta prsevia occurs in the majority of 
cases in multiparas, and the reason why it is common in this 
country is, to my mind, due to the defective management of 
previous labors which almost always give rise to many kinds 
of uterine diseases and displacements which favor defective 
implantation of the placenta during the development of the 
foetus. 

In regard to puerperal infection we have 3 per cent, which 
is not high, due to the fact that we had practically no cases 
with puerperal infection except those brought from outside, 
who came after they had already been infected, either during 
a prolonged labor attended by midwives and friends, or during 
the puerperium. In the hospital parturient women who come 
before or at the onset of labor do not develop puerperal infection, 
as a rule, and those who become infected develop only a mild 
type of infection. 

The great majority of forceps applications has been for inertia 
of the uterus and in a few cases of contracted pelvis. Podalic 
version is resorted to in all cases of transverse presentation when 
the foetus is alive and, also, when the foetal head is high and not 
engaged in the pelvic inlet. We found from experience, how- 
ever, that podalic version is not always a safe procedure in cases 
of transverse presentation, as when version is made several hours 
after the rupture of the amniotic sac, and the foetus is already 
dead, there is almost always danger of rupturing the lower seg- 
ment of the uterus, leading to postpartum hsemorrhage, perito- 
nitis, or infection. For this reason we have made it a rule in our 
practice in the hospital to resort to embryotomy in all cases of 
neglected transverse presentation — that is, when the uterine 
cavity is already drained of its amniotic fluid and the foetus is 
dead. Also, in prolonged labors due to contracted pelvis, or 
large foetal head, instead of applying forceps and other measures, 
we perform craniotomy as soon as we determine that the foetus 
is dead. We have performed Csesarean section in all cases, 
except one, on women with placenta prsevia, the exception being 
a case of intrapartum eclampsia in a primigravida. In this case 
Csesarean section was the best way to extract the foetus, as the 
cervix was not dilated and rapid delivery was indicated. The 



380 The Philippine Journal of Science 1916 

performance of any other operation, such as the dilatation of 
the cervix by metal dilators and balloons, would require at least 
one or two hours and then there would be the additional risk 
of rupturing the artificially dilated lower segment of the uterus 
if forceps application or podalic version was made in an attempt 
to deliver the child. We found from the result of our observa- 
tions that Csesarean section is the best and safest procedure to 
follow in all cases of placenta prsevia where the cervical canal 
is not widely dilated, because we can prevent in this way the loss 
of much blood which would surely result if the cervix were to 
be forcibly dilated for the extraction of the foetus through the 
parturient canal. In Csesarean section we have always obtained 
good results in cases of placenta prsevia and eclampsia, except in 
cases where the patients come in bad condition; these usually 
die, no matter what kind of intervention is made. 

Some authorities claim that labor subsequent to the per- 
formance of Csesarean section is dangerous, citing several cases 
where the uterus has ruptured in the scar of the uterine incision. 
Three of our patients on whom we performed Csesarean section 
for placenta praevia have returned to us for delivery, and in 
these three cases labor was perfectly normal in every way, thus 
proving the conclusion that Csesarean section does not predispose 
to rupture of the uterus during labor as long as the suturing of 
the uterine wound is properly made to effect good and complete 
healing. 

Among our cases there were two abdominal pregnancies, one 
of which was interstitial ovarian pregnancy, while the other was 
interstitial uterine pregnancy. To extract the foetuses, which 
were alive, laparotomy was performed in both cases. 

A few cases of contracted pelvis necessitated the application 
of forceps, but none of them required the performance of pubiot- 
omy, Csesarean section, or the like. The reason is that a con- 
tracted pelvis seems to be just as rare here as in other countries, 
although it is true that, compared with the pelvis of white women, 
Filipino women have small pelves. The size of the Filipino 
woman's pelvis has attracted our attention since the department 
was organized, and although we made it a routine practice to 
take the external measurements of every parturient both in the 
hospital and outside, we did not begin to make a more systematic 
determination of the average external and internal measurements 
of the female pelvis in this country until last year. Our work 
along this line is still going on, and. therefore I am not in a 
position to offer any final conclusion; but in order to give an 
idea of the difference between our measurements and those given 



X, B, 6 



Colder on: Tropical Obstetrical Problems 



381 



in textbooks, I present some of our findings, which are based 
upon the measurements of 300 pelves. 

Table III. — Comparative measurements of the pelvis in Filipinas and 

Americans. 



Amer- 
ican. 



Filipino. 



Differ- 
ence. 



Diameter between the iliac spines. 
Diameter between the iliac crests . 
Diameter between the trochanters. 

Baudelocque 

Diagonal conjugate 

Anteroposterior diameter of outlet 
Transverse diameter of outlet 



Cm. 
25.47 
27.99 
30.90 
19.71 
12.26 
12.50 
11.00 



Cm. 
23.90 
24.90 
28.10 
17.63 
12.00 
10.05 
11.00 



Cm. 
1.47 
3.08 
2.79 
2.08 
0.26 
2.44 



As can be seen, the pelvis of the Filipina is smaller than that 
of the American or the European in all the diameters except in 
the tranverse diameter of the outlet where they are in the same 
proportion. I cannot go into details, however, in the considera- 
tion of this subject, as our investigation is not as yet complete, 
but one of the principal reasons why the Filipinas have small 
pelves is because the Filipinas are small in stature, and their 
pelves are in proportion to their size. In measuring the heads 
of 260 new-born babies, we found that the cephalic diameters of 
Filipino babies are smaller than those of the American. 

Table IV. — Comparative measurements of heads of new-born babies 
of Filipinas and Americans. 



Diameter. 



Occipitomental 

Occipitofrontal 

Sub-occipitobregmatic 

Biparietal 

Bitemporal 



Amer- 
ican. 



Cm. 
13.33 
11.70 
9.70 
9.25 
8.00 



Filipino. 



Cm. 
12.11 
10.96 
9.28 
8.63 
6.82 



Differ- 
ence. 



Cm. 
1.22 
0.74 
0.42 
0.62 
1.17 



This diminution in the diameters of the foetal heads in this 
country can, of course, be accounted for by the small size of 
the pelvis of the Filipino mothers— that is, it is due to the law of 
pelvic accommodation. It is, therefore, important to bear this 
in mind, else we might be lead to resort to some drastic measures 
when we happen to have on hand a difficult case of labor in a 
Filipino patient and when we find that her pelvic measurements 
are less than those given in the textbooks. 



382 The Philippine Journal of Science 1915 

The general death rate of 4 per cent is based upon the result 
of our work from the beginning of the institution, and therefore 
it is not the present death rate of our cases in the Philippine 
General Hospital, which is, of course, considerably less. 

Obstetrical teaching in this country used to be deficient in the 
extreme, as I have already stated, due to the fact that the instruc- 
tion was entirely didactic and the students could, therefore, 
manage normal labor and perform obstetrical operations in 
theory only; but since the opening of the department of obstet- 
rics of the former Philippine Medical School, which has now 
become the College of Medicine and Surgery of the University of 
the Philippines, modern methods of instruction are in use, and 
the students are now given not only lectures, but also actual, 
practical demonstrations on the pregnant, parturient women. 
Besides demonstrations, the students are permitted to assist in 
all normal and operative cases of labor, and they are allowed 
to deliver normal cases in the presence of one of the residents 
of the department. 

The course in medicine in our university lasts five years. 
Obstetrics is taught beginning in the fourth year and continuing 
through the fifth or senior year. During these two years the 
students are required to be on duty, in rotation, for twenty-four 
hours in the Philippine General Hospital, ready to be called at 
any time to attend, together with the obstetrician on duty, all 
cases of labor both in the maternity ward and in the out-patient 
service of the department. In 1914 we had 883 delivery and 
puerperal cases and 52 abortions. As there were only 21 fourth- 
and fifth-year students, and all our patients have practically 
been attended by them, it is safe to assume that each student 
has seen at least 42 cases of labor, some of which he delivered 
under the supervision of one of the members of the staff. The 
training of our students, therefore, compares favorably with that 
of the medical students in other up-to-date universities, if it 
does not give them advantage over the latter, as in most of the 
other universities the students do not usually have the oppor- 
tunity to see so large a number of normal and abnormal cases, 
the variety of which as well as the number of operations per- 
formed I have already enumerated. As a result of this new 
procedure in obstetrical teaching our students are already 
equipped, before graduation, with a sufficient practical knowledge 
of those matters which they will likely meet in private practice. 

From all that I have explained, we can conclude that the solu- 
tion of the obstetrical problems in the city of Manila is at the 
point of complete realization, as the women have already learned 
the advantages of medical assistance. It is now a common thing 



x, b, 6 Calderon: Tropical Obstetrical Problems 383 

to see them go to the hospitals for confinement or to call physi- 
cians, nurses, or qualified midwives to attend them in their homes. 
However, it is necessary to remember that the strongest attrac- 
tion for them is the free medical assistance given by the Govern- 
ment in the Philippine General Hospital and in the out-patient 
service of the Department of Obstetrics of the College of Medicine 
and Surgery, and in order that a larger number of women may 
be attended in these two maternity services, it is necessary to 
increase our facilities, enlarging the maternity ward of the 
Hospital and increasing the appropriation for maternity work, 
especially in the out-patient department. In this way we shall be 
ready to meet the real needs of the Filipino mothers, having more 
physicians and nurses to go around the entire city and to handle 
our cases in the hospital. 

Obstetrics in the provinces, however, is an entirely different 
matter, as there are no influences, such as exist in Manila, to 
abolish superstitious ideas concerning midwifery. It is evident 
that to accomplish such an object there should be provincial 
maternity institutions with staffs of physicians, nurses, and 
qualified midwives to show them the modern way of living and 
of taking care of themselves and their children. This side of 
the problem has already been taken up by the Legislature, and 
as a beginning a law has been passed creating the School of 
Midwifery in connection with the School of Nursing of the 
Philippine General Hospital, where young women from the 
provinces are given a special course in obstetrics to enable them 
to practice scientific midwifery in the provinces. When the time 
comes when the graduates of the School of Midwifery begin to 
spread throughout the Philippines, and when the provinces are 
divided into sanitary districts having physicians, nurses, and 
qualified midwives to look after the health of the people, we 
shall have accomplished the aspiration of the country, which 
is to wipe epidemics away from these Islands, to save the lives 
of a great many parturient women, to solve the very important 
problem of our high infant mortality, and to make the Filipinos 
a healthier, and stronger people. 



A STUDY OF THE PATHOLOGY OF THE GALL BLADDER AND 
BILIARY PASSAGES IN CHOLERA 1 

By J. S. Coulter 
(Captain, Medical Corps, United States Army) 

In most of the literature dealing with cholera little or no 
mention is made of the pathology of the biliary passages and the 
gall bladder in this disease. Recently several papers have been 
published on this subject, calling special attention to its im- 
portance in relation to chronic and intermittent cholera carriers. 
This study was undertaken to determine the pathological condi- 
tion of the gall bladder and the bile ducts of the cholera autopsies 
in the cholera outbreak in Manila in 1913-14. 

Kulescha(i) first emphasized the importance of this subject 
in relation to the carrier question. In his review of the litera- 
ture he notes that Pirogoff(2) in 1848 observed two cases of 
diphtheritic cholecystitis in cholera autopsies, one of which 
showed perforation of the fundus of the gall bladder and general 
peritonitis. Netschaeff (3) records a similar case in 1892, also 
one with acute cholecystitis without perforation, and two that 
showed catarrhal inflammation in sections of the gall bladder. 

There were a number of early observations on the presence 
of the cholera vibrio in the bile. Nicati and Rietsch, (4) in 1884, 
examined the bile in three cases of cholera and found the vibrio 
in two, and later in two of five cases. Similar observations were 
made by Doyen, (5) Kelsch and Vaillard,(6) Tizzoni and Cat- 
tani, (7) Raptschevsky,(8) Rekovsky,(9) and Defressine and Caze- 
neuve.(iO) Sawtschenko,(H) in 1892, found cholecystitis twice 
among 30 cholera autopsies. In a series of 28 cases recorded by 
Girode,(i2) vibrios were found in 14. ■ One case showed marked 
symptoms of cholangitis and cholecystitis with vibrios present 
on bacteriological examination. Brulloff(i3) found vibrios in 
76 per cent of his cases. 

1 Received for publication September 28, 1915. 

385 



386 The Philippine Journal of Science 1916 

Kulescha,(i) in the cholera epidemic at St. Petersburg in 1908- 
1909, performed 430 autopsies. He found cholecystitis in 42 
cases, or nearly 10 per cent; 21 of these were in the first 
week of the disease, and 19 were in the second week. 

In these cases the gall bladder was brown or yellowish gray, 
distended, and greatly congested. The mucous membrane was 
covered with a thick, turbid mucus often mixed with pus. 
When this was removed, the mucous membrane was seen to be 
swollen and bright red. In one case he found a great number 
of small, scattered areas covered by diphtherialike membranes. 
In eight cases the gall bladder contained a thick, colorless 
fluid. 

Microscopically his cases showed the mucous membrane of 
the gall bladder denuded of its epithelium and infiltrated with 
round cells. The submucosa shows a marked round-cell infil- 
tration, dilatation and congestion of the blood vessels, and some 
blood extravasations. In more severe forms there is a necrosis 
of the mucosa extending to the submucosa. Kulescha charac- 
terizes this as a catarrhal hemorrhagic inflammation, the same 
as is seen in the intestines. 

Bacteriological examination of the bile showed the vibrio in 
40 cases. 

In regard to the bile ducts Kulescha found only four cases in 
the above series in which cholangitis could be recognized 
grossly. Microscopically these cases showed the bile ducts 
denuded of their epithelial layer and the wall infiltrated with 
round cells. The lumen was filled with granular debris, com- 
posed of leucocytes, bile pigment, and cells of cylindrical epithe- 
lium. Some cases showed necrosis extending to Glisson's 
capsule and even to the liver cells. This inflammation was more 
eevere in the larger ducts. 

Of the four cases, Kulescha (l) describes three as purulent 
biliary hepatitis and one as hepatic biliary cirrhosis. Bacterio- 
logically cholera vibrios were found in all four, but in only two 
in pure culture. By appropriate staining methods vibrios were 
demonstrated in sections from one of these cases. The vibrios 
found in the tissues were not identical with the ordinary vibrio, 
but resembled involution forms of the cholera vibrio when grown 
on agar or potato — that is, thick and swollen. 

In this connection Kulescha records an interesting case illus- 
trating the importance of this infection in regard to chronic and 
intermittent carriers. A woman, aged 36, one year before her 



x, b, 6 Coulter: Gall Bladder and Biliary Passages in Cholera 387 

death, was admitted to the hospital with cholera with the usual 
symptoms as well as marked jaundice. Physical examination 
showed an enlarged liver. Vibrios were found in her stools at 
this time and for fifty-seven days thereafter. Seven months 
later she was admitted to another hospital with enlarged and 
painful liver. At autopsy, four months later, cholera vibrios 
were recovered from the bile ducts, but not from the intestines. 
Kulescha quotes this case to explain the intermittent cholera car- 
riers. The liver showed a marked biliary stasis due to the 
cholangitis. Therefore the bile containing the vibrios only 
reached the intestines at intervals. 

Grieg (14) records the largest series of bacteriological exami- 
nations of the bile for cholera vibrios. He examined 271 cases 
and found the vibrio in 80. In 12 (4.4 per cent) of these there 
were distinct pathological changes. One of these cases was 
recorded in detail in 1912(15) and another in 1913.(14) In the 
latter case the gall bladder was shrunken and contained a small 
quantity of dirty, brown bile. The mucous membrane was con- 
gested. Histologically the sections stained for the vibrios 
showed their presence not only in the mucosa, but also deep in 
the submucosa. 

In another article (16) Grieg tabulated the results of 235 
cholera autopsies at the Medical College, Calcutta. Ten cases 
(4 per cent) showed to the naked eye some signs of inflamma- 
tion of the gall bladder. He notes that the macroscopic changes 
observed in the gall bladder were the following: Slight thicken- 
ing of the wall, mucosa congested, and on section the submucosa 
was red. The microscopic changes he noted were that the 
inner layer had almost entirely disappeared; in the submucosa 
there were polynuclear and mononuclear cell infiltration, new- 
formed vessels/ and haemorrhages ; in the middle and serous 
layer foci of round cells were seen. In sections specially stained 
he found the cholera vibrio in the mucosa and deep in the 
submucosa. 

In the cystic, hepatic, and common bile ducts, and in a lesser 
degree in the biliary passages in the liver, the same pathological 
changes were found, and a pure culture of the comma bacillus 
was obtained. 

Table I shows the condition of the gall bladder and biliary 
passages as taken from cholera autopsy records of the Bureau 
of Science on file at the College of Medicine and Surgery, Univer- 
sity of the Philippines. 



388 The Philippine Journal of Science me 

Table I. — Showing condition of the gall bladder and biliary -passages. 



Year. 


Cholera 
autop- 
sies. 


Signs of inflam- 
mation. 


Stones. 


Gall 
bladder. 


Bile 

ducts. 


1908 


108 

123 

98 

1 



79 

226 




1 




1909.. -„ . . .. 


1 




1910 




2 


1911 






1912 








1913_ 


3 

»8 






1914 




2 


Total 




635 


12 


1 


4 





a Thirty-nine of the gall bladders in the 1913-14 series at the time of autopsy were tied off 
at the common duct and sent to the Bureau of Science, Manila, where they were examined by 
Dr. Otto Schobl. He records his results in a recent paper. The cholera vibrio was found in 
17 of the cases on bacteriological examination of the bile. Three cases showed macroscopic 
pathological changes in the gall bladder, and in two hydrops cystis felleas was found — that is, 
distended gall bladder containing mucus, bile of light amber color, and flaky sediment. One 
showed thickening of the wall with distended blood vessels, desquamation of the mucosa, and 
round-cell infiltration. 

Table I shows that in the last two years — 1913-14 — there were 
13 cases in 305 that showed signs of inflammation of the gall 
bladder, or about 4 per cent. In order to demonstrate if there 
were microscopic pathological changes in cases with no macros- 
copic lesions of the biliary passages, and to demonstrate the 
exact location and condition of any cases with gross or minute 
pathological changes, the following method was adopted. For 
histological examination five sections of the gall bladder and 
bile ducts were taken as follows: 

1. Common duct. 

2. Hepatic duct near the hilus. 

3. Hepatic duct and liver tissue halfway between hilus and border of 

liver. 

4. At border of liver. 

5. Wall of gall bladder. 

These sections were fixed in Zenker's solution in separate 
bottles, imbedded in paraffin in the usual manner, and cut and 
stained with hematoxylin and eosin. Twenty-eight unselected 
cases were examined in this manner. One of these cases (No. 
3609) showed some gross pathological changes: namely, the gall 
bladder was dark gray and filled with thick, black bile and the 
blood vessels were injected. On microscopic examination the 
epithelial layer of the mucosa was found to be desquamated and 
the blood vessels of the submucosa were distended. There was 



x, b, 6 Coulter: Gall Bladder and Biliary Passages in Cholera 389 

no round-cell infiltration. These changes were only in the gall 
bladder ; the other four sections of this case showed no changes. 
The sections were all stained specially for the cholera vibrio 
with carbol fuchsin and Loffler's methylene blue, with negative 
results. 

In the autopsies of cases in 1913-14 that were examined in the 
pathological laboratory of the College of Medicine and Surgery, 
University of the Philippines, the histological sections of the 
gall bladders were available for examination. By specially 
staining the sections for bacteria with carbol fuchsin, comma 
bacilli were demonstrated in two cases (autopsy Nos. 3557 and 
3751). These were in all probability the cholera vibrio, but 
Grieg, (18) in a recent paper, cautions against error in diagnosis 
between the cholera vibrio and choleralike vibrio. These comma 
bacilli were in the mucosa and submucosa, and many resembled 
the involution form mentioned by Kulescha. The sections showed 
desquamation of the epithelial layer of the mucosa and round-cell 
infiltration, but no such marked changes as were recorded by 
Kulescha. In the cases of 1913-14 the pathological changes 
were not so marked as seen by Kulescha in many of his cases, 
but showed a catarrhal inflammation. The percentage, 4, is the 
same as that recorded by Grieg. 



(1 
(2 

(3 
(4 

(5 

(6 
(7 

(8 

(9 

(10 

(11 
(12 
(13 
(14 
(15 
(16 
(17 
(18 



REFERENCES 

Kulescha. Klin. Jahrb. (1910), 24, 137. 

Pirogoff. Die Pathologische Anatomie der Cholera, St. Petersburg 

(1850). 
Netschaeff. Bolnicznaja Gazeta Botkinw (1892). 
Nicati, W., and Rietsch, M. Arch, physiol. norm, et path. (1885), 

III, 16, 72. 
Doyen, E. Ibid. (1885), III, 16, 179. 

Kelsch, A., and Vaillard, L. Ibid. (1885), III, 15, 341. 
Tizzoni, G., and Cattani, J. Centralbl. f. med. Wissensch. (1886), 

24, 769. 
Raptschevsky, J. F. Russkyi Vratch (1886), No. 4, 5. 
Rekovsky, L. P. Arch. sci. biol, St. Petersbourg (1892). 
Defressine, C, and Cazeneuve, H. Compt rend. Soc. biol. (1912), 

72, 933. 
Sawtschenko. Russkyi Vratch (1893), No. 21. 
GiRODE, M. J. Compt. rend. Soc. biol. (1893), 5, 568, 570. 
Brulloff. Russkyi Vratch (1910), 9, 1821. 
Grieg. Ind. Journ. Med. Res. (1913), 1, 44. 
Idem. Lancet (1912), 2, 1423. 
Idem. Ind. Journ. Med. Res. (1914), 2, 28. 
Schobl, O. Phil. Journ. Sci., Sec. B (1915), 10, 11. 
Grieg. Ind. Journ. Med. Res. (1914), 2, 604. 

136701 3 



INDEX 



Adenocarcinoma of the cascum, complicated by 

intussusception, 71. 
Alabajar, 368. 
ALBERT, JOSS;, The treatment of infantile 

beriberi with the extract of tiqui-tiqui, 81. 
Algeria, experiments in, on grasshoppers with 

Coccobacillus acridiorum d'Herelle, 175. 
Allantoin used in treatment of beriberi, 100. 
ALLEN, W. H., Review of Pyle's An interna- 
tional system of ophthalmic practice, 355. 
Alpalea, 374. 

Anatomy, pathologic, of bubonic plague, 249. 
Animals, observation on, when inoculated with 

tuberculosis from lepers, 157. 
Anopheles ludlowii, 229. 

(Myzomyia) febrifer, 177. 
(Myzorhynchus) barbirostris, 177. 
(Myzorhynchus) sinensis, 177. 
( Ny ssorhynchus ) maculatus, 177. 
(Pseudomyzomyia) rossii, 177. 
wilmori, 233-. 
Anophelines, the distribution of the commoner, 

and the distribution of malaria, 177. 
Antitoxin, tetanus, preparation of, 31. 
Aphiochseta ferruginea Brunetti, experiments 

on, with the cholera vibrio, 309. 
Ascaris lumbricoides, 296. 
Ascaris lumbricoides, the development of the 

eggs of, 19. 
Asiatic cholera, see Cholera. 
Asuang, 371. 
Avirulent tubercle bacilli, immunization of 

guinea pigs by the inoculation of, in agar, 

145. 

B 

Bacilli, avirulent tubercle, experiments on the 
immunization of guinea pigs by the inocula- 
tion of, in agar, 145. 
Bacillus "A," 319. 

anthracis, 320. 

"B," 319. 

coli, 316. 
Bacillus coli communis, the occurrence of, in 
the peripheral blood of man during life, 25. 
Bacillus enteritidis, 320. 

fluorescens liquefaciens, 316. 

fluorescens non-liquefaciens, 316. 

lepra?, 367. 

mucosus capsulatus, 270. 

paratyphosus A, 351. 

paratyphosus B, 351. 

pestis, 253. 

pestis bubonicse, 273. 

prodigiosus, 165, 316. 



Bacillus proteus vulgaris, 319. 
pyocyaneus, 318. 
radiciformis, 316. 
subtilis, 316. 
typhosus, 27, 317, 351. 

Bacterial infections, the role played by the 
insects of the dipterous family Phoridse in 
relation to the spread of, 309. 

Bagabaga, 373. 

Bainbridge, William Seaman, see Reviews 
(book). 

Baliuag River, malaria outbreak in camp on 
banks of, 226. 

BARBER, MARSHALL A. I. Experiments 
on the immunization of guinea pigs by the 
inoculation of avirulent tubercle bacilli in 
agar. II. Observations on animals inocu- 
lated with tuberculosis from lepers, 145. 

BARBER, MARSHALL A., and JONES, 
CHARLES R., A test of Coccobacillus acri- 
diorum d'Herelle on locusts in the Philip- 
pines, 163. 

BARBER, M. A.; RAQUEL, ALFONSO: 
GUZMAN, ARISTON; and ROSA, ANTO- 
NIO P., Malaria in the Philippine Islands. 
II. The distribution of the commoner ano- 
phelines and the distribution of malaria, 177. 

Basic fuchsin, treatment of the retrogressive 
skin lesions of leprosy with, 357. 

Bataan Province, descriptions of malaria and 
Anopheles surveys in, 205. 

Batangas Province, descriptions of malaria 
and Anopheles surveys in, 204. 

Bed nets and malaria, 243. 

Beriberi, human, experimental treatment of, 
with constituents of rice polishings, 99. 

Beriberi, infantile, treatment of, with the ex- 
tract of tiqui-tiqui, 81. 

Beriberi, miscellaneous notes and comments, 
337. 

Beriberi, thymus gland in, 121. 

Biliary passages in cholera, a study of the 
pathology of the gall bladder and, 385. 

Buboes, axillary, in plague, 279. 
cervical, in plague, 279. 
femoral, in plague, 273. 
plague, cases of suppuration of, 275. 
popliteal, in plague, 278. 
primary ( ?) iliac, of plague, 277. 

Bubonic plague, pathologic anatomy of, 249. 

Bulacan Province, descriptions of malaria and 
Anopheles surveys in, 205. 



Cascum, adenocarcinoma of the, complicated 
by intussusception, 71. 

391 



INDEX 



Adenocarcinoma of the caecum, complicated by 

intussusception, 71. 
Alabajar, 368. 
ALBERT, JOS£, The treatment of infantile 

beriberi with the extract of tiqui-tiqui, 81. 
Algeria, experiments in, on grasshoppers with 

Coccobacillus acridiorum d'Herelle, 175. 
Allantoin used in treatment of beriberi, 100. 
ALLEN, W. H., Review of Pyle's An interna- 
tional system of ophthalmic practice, 366. 
Alpalea, 374. 

Anatomy, pathologic, of bubonic plague, 249. 
Animals, observation on, when inoculated with 

tuberculosis from lepers, 157. 
Anopheles ludlowii, 229. 

(Myzomyia) febrifer, 177. 
(Myzorhynchus) barbirostris, 177. 
(Myzorhynchus) sinensis, 177. 
(Nyssorhynchus) maculatus, 177. 
(Pseudomyzomyia) rossii, 177. 
wilmori, 233-. 
Anophelines, the distribution of the commoner, 

and the distribution of malaria, 177. 
Antitoxin, tetanus, preparation of, 31. 
Aphiochaata ferruginea Brunetti, experiments 

on, with the cholera vibrio, 309. 
Ascaris lumbricoides, 296. 
Ascaris lumbricoides, the development of the 

eggs of, 19. 
Asiatic cholera, see Cholera. 
Asuang, 371. 
Avirulent tubercle bacilli, immunization of 

guinea pigs by the inoculation of, in agar, 

145. 

B 

Bacilli, avirulent tubercle, experiments on the 
immunization of guinea pigs by the inocula- 
tion of, in agar, 145. 
Bacillus "A," 319. 

anthracis, 320. 

"B," 319. 

coli, 316. 
Bacillus coli communis, the occurrence of, in 
the peripheral blood of man during life, 26. 
Bacillus enteritidis, 320. 

fluorescens liquefaciens, 316. 

fluorescens non-liquefaciens, 316. 

lepras, 367. 

mucosus capsulatus, 270. 

paratyphosus A, 351. 

paratyphosus B, 351. 

pestis, 253. 

pestis bubonicse, 273. 

prodigiosus, 165, 316. 



Bacillus proteus vulgaris, 319. 
pyocyaneus, 318. 
radiciformis, 316. 
subtilis, 316. 
typhosus, 27, 317, 351. 

Bacterial infections, the role played by the 
insects of the dipterous family Phorida? in 
relation to the spread of, 309. 

Bagabaga, 373. 

Bainbridge, William Seaman, see Reviews 
(book). 

Baliuag River, malaria outbreak in camp on 
banks of, 226. 

BARBER, MARSHALL A. I. Experiments 
on the immunization of guinea pigs by the 
inoculation of avirulent tubercle bacilli in 
agar. II. Observations on animals inocu- 
lated with tuberculosis from lepers, 145. 

BARBER, MARSHALL A., and JONES, 
CHARLES R., A test of Coccobacillus acri- 
diorum d'Herelle on locusts in the Philip- 
pines, 163. 

BARBER, M. A.; RAQUEL, ALFONSO; 
GUZMAN, ARISTON; and ROSA, ANTO- 
NIO P., Malaria in the Philippine Islands. 
II. The distribution of the commoner ano- 
phelines and the distribution of malaria, 177. 

Basic fuchsin, treatment of the retrogressive 
skin lesions of leprosy with, 357. 

Bataan Province, descriptions of malaria and 
Anopheles surveys in, 205. 

Batangas Province, descriptions of malaria 
and Anopheles surveys in, 204. 

Bed nets and malaria, 243. 

Beriberi, human, experimental treatment of, 
with constituents of rice polishings, 99. 

Beriberi, infantile, treatment of, with the ex- 
tract of tiqui-tiqui, 81. 

Beriberi, miscellaneous notes and comments, 
337. 

Beriberi, thymus gland in, 121. 

Biliary passages in cholera, a study of the 
pathology of the gall bladder and, 385. 

Buboes, axillary, in plague, 279. 
cervical, in plague, 279. 
femoral, in plague, 273. 
plague, cases of suppuration of, 276. 
popliteal, in plague, 278. 
primary (?) iliac, of plague, 277. 

Bubonic plague, pathologic anatomy of, 249. 

Bulacan Province, descriptions of malaria and 
Anopheles surveys in, 205. 



Caecum, adenocarcinoma of the, complicated 
by intussusception, 71. 



391 



392 



Index 



Csesarean section, case report of obstructed 
labor and, 69. 
in the Philippine Islands, 
65. 

Cagayan Province, descriptions of malaria 
and Anopheles surveys in, 204. 

CALDERON, FERNANDO, Csesarean section 
in the Philippine Islands, 65 ; Tropical ob- 
stetrical problems, 371. 

Calliphora erythrocephala, 320. 
vomitoria, 310. 

Cebu Province, descriptions of malaria and 
Anopheles surveys in, 205. 

Chaetoneurophora calignosa Meigen, 811. 

ora curvinervis Becker, 311. 

Cheyletus, 347. 

Cholera, a study of the pathology of the gall 
bladder and biliary passages in, 385. 

Cholera, Asiatic, practical experience with 
some enriching media recommended for bac- 
teriological diagnosis of, 127. 

Cholera carriers in relation to cholera con- 
trol, 1. 

Cholera carriers, observations concerning, 11. 

Cholera vibrio, experiments on Aphiochseta 
ferruginea Brunetti with the, 309. 

Coccobacillus acridiorum d'Herelle, a test of, 
on locusts in the Philippines, 168. 

CONCEPCION, I., Review of Stewart's A 
manual of physiology, 356. 

Conicera atra Meigen, 311. 

COULTER, J. S., A study of the pathology of 
the gall bladder and biliary passages in 
cholera, 385. 

CROWELL, B. C, Pathologic anatomy of bu- 
bonic plague, 249 ; see also WILLIAMS, R. 
R., 121. 

Culex, 190. 

Culion Leper Colony, treatment of the retro- 
gressive skin lesions of leprosy with basic 
fuchsin in, 357. 

Cutaneous plague, 258. 

D 

Death rates and morbidity rates, annual, from 

malaria in the P. I., 1909 to 1913, inclusive, 

235. 
Deli, Sumatra, pseudotyphoid fever in, 345. 
DENNEY, OSWALD E., The treatment of 

the retrogressive skin lesions of leprosy with 

basic fuchsin, 357. 
Dipterous family Phoridse, the role played by 

the insects of the, in relation to the spread 

of bacterial infections, 309. 
Dohrniphora abdominalis Fallen, 311. 
Drosophila ampelophila, 310. 
DuMEZ, A. G., Two compounds of emetine 

which may be of service in the treatment of 

entamoebiasis, 73. 

E 

Emetine bismuthous iodide, in the treatment 

of dysentery, 77. 
Emetine hydrochloride, results obtained in 

cases of dysentery treated with, 75. 
Emetine mercuric iodide, in the treatment of 

dysentery, 76. 



Emetine, two compounds of, which may be of 
service in the treatment of entamoebiasis, 73. 

Entamoeba histolytica, 76. 

Entamoebiasis, two compounds of emetine 
which may be of service in the treatment 
of, 73. 

Extract, hydrolized, of rize polishings in treat- 
ment of human beriberi, 106. 

Extract, unhycjrolized, of rice polishings in 
treatment of human beriberi, 110. 

G 

Galamayamo, 375. 

Gall bladder and biliary passages in cholera, a 

study of the pathology of the, 385. 
Grasshoppers, experiments in Algeria on, with 

Coccobacillus acridiorum d'Herelle, 175. 
GUZMAN, ARISTON, see BARBER, M. A., 

177. 

H 

Harston, G. Montague, see Reviews (book) . 
Hilot, 375. 
Homalomyia brevis, 310. 

canicularis, 310. 
Hookworms, 296. 
Hyalomma, 347. 

Hydrolyzed extract of rice polishings in treat- 
ment of human beriberi, 106. 



Immunization of guinea pigs, experiments on 
the, by the inoculation of avirulent tubercle 
bacilli in agar, 145. 

Infantile beriberi, treatment of, with the ex- 
tract of tiqui-tiqui, 81. 

Insects, relation of, to leprosy, 368. 

Intestinal plague, 257. 

Intussusception, adenocarcinoma of the cae- 
cum, complicated by, 71. 

Ipecac, results obtained in cases of dysentery 
treated with, 75. 

J 

JOHNSTON, J. A., Leprosy, 366 ; Review of 
Bainbridge's The cancer problem, 356 ; see 
also WILLIAMS, R. R., 337. 

JONES. CHARLES R., see BARBER, MAR- 
SHALL A., 163. 

K 

Kalan, 376. 
Kayas, 375. 

Kedani fever, comparison of, with pseudoty- 
phoid fever in Deli, Sumatra, 345. 



Laguna Province, descriptions of malaria and 

Anopheles surveys in, 201. 
Lagundi, 375. 
Lepers, observations on animals inoculated 

with tuberculosis from, 145. 
Leprosy, 365. 
Leprosy, treatment of the retrogressive skin 

lesions of, with basic fuchsin, 357. 
Locusta migratoroides R. and F., 171. 
Locusts, a test of Coccobacillus acridiorum 

d'Herelle on, in the Philippines, 163. 



Index 



393 



Loemopsylla cheopis, 26S. 

Lucilia csesar, 310. 

Lymphatic glands in plague, 864. 

M 

Malaria, annual death rates and morbidity 
rates from, in the P. I., 1909 to 1913, in- 
clusive, 2S5. 

Malaria in camp on banks of Baliuag River, 
226. 

Malaria in the Philippine Islands. II. The 
distribution of the commoner anophelines [ 
and the distribution of malaria, 177. 

Mangkukulam, 376. 

Mary J. Johnston Hospital, influence of, in 
obstetrical problems, 378. 

Media, enriching, practical experience with 
some, recommended for bacteriological diag- 
nosis of Asiatic cholera, 127. 

Medical Association, Philippine Islands, min- 
utes of the eleventh annual meeting, 87. 

Mediquillos, 373. 

Minamainitan, 374. 

Mindoro, descriptions of malaria and Anophe- 
les surveys in, 206. 

MUNSON, E. L., Cholera carriers in relation 
to cholera control, 1. 

Musca domestica, 310. 

Myzomyia christophersi Theobald, 180. 
funesta, 180. 
parangensis Ludlow, 179. 
rossii, 179. 



X 



Nueva Eeija Province, descriptions of malaria 
and Anopheles surveys in, 203. 

O 

Obstetrical, problems, tropical, 371. 
CEdaleus nigrofasciatus DeGeer, 171. 



Pagbubungkal, 372. 

Pagkaban, 374. 

Pagkukulob, 375. 

Palawan, descriptions of malaria and Anophe- 
les surveys in, 206. 

Pampanga Province, descriptions of malaria 
and Anopheles surveys in, 206. 

Pandakaki, 376. 

Panis, 376. 

Pathologic anatomy of bubonic plague, 249. 

Peripheral blood, occurrence of Bacillus coli 
communis in the, of man during life, 25. 

Pestis major, 254. 

minor or ambulans, 254, 258. 

Philippine Islands Medical Association, Min- 
utes of the Eleventh Annual Meeting, held 
at Manila November 4-7, 1914, 87. 

Phora aterrima Fabricius, 311. 
femorata, 310. 

Phoridse, in relation to the spread of bacterial 
infections, 309. 



Plague, cutaneous, 258. 
linal, 2.">7. 
pathologic anatomy of bubonic, 249. 
pneumonic, 253. 
septicemic, 251, 269. 
Pneumococcus, 296. 
Pneumonic plague, 253. 

POLK, MARY, review of G. Montague Hars- 
ton's The care and treatment of European 
children in the tropics, 97. 
Prentiss, Charles William, see Re views ( book ) . 
Proteus fluorescens, 316. 
mirabilis, 316. 
vulgaris, 316. 
zenkeri, 316. 
Pseudotyphoid fever in Deli, Sumatra (a va- 
riety of Japanese kedani fever) , 845. 
Pyle, Walter L., see Reviews (book). 

R 

Ranatra, 241. 

RAQUEL, ALFONSO, see BARBER, M. A., 

177. 
Retrogressive skin lesions of leprosy, treat- 
ment of, with basic fuchsin, 357. 
REVIEWS (BOOK) : 

Bainbridge, William Seaman, The cancer 

problem, 356. 
Harston, G. Montague, The care and treat- 
ment of European children in the tro- 
pics, 97. 
Prentiss, Charles William, A laboratory 
manual and text-book of embryology, 
355. 
Pyle, Walter L., An international system 

of ophthalmic practice, 355. 
Stewart, G. N., A manual of physiology, 
356. 
Rice polishings, experimental treatment of 

human beriberi with constituents of, 99. 
Rice polishings, hydrolyzed extract of, in treat- 
ment of human beriberi, 106. 
Rice polishings, unhydrolyzed extract of, in 

treatment of human beriberi, 110. 
Rizal Province, descriptions of malaria and 

Anopheles surveys in, 203. 
ROBERG, DAVID N., The role played by the 
insects of the dipterous family Phoridse in 
the spread of bacterial infections. Experi- 
ments on Aphiochseta ferruginea Brunetti 
with the cholera vibrio, 309. 
Romero, 374. 
ROSA, ANTONIO P.. see BARBER, M. A., 

177. 
RUEDIGER, E. H., The occurrence of Bacil- 
lus coli communis in the peripheral blood 
of man during life, 25 ; The preparation of 
tetanus antitoxin, 31. 
RUTH, E. S., Review of Prentiss's A labora- 
tory manual and text-book of embryology, 
355. 

S 

Saint Paul's Hospital, first obstetrical depart- 
ment at, 378. 
Saklap, 376. 
Salag, 373. 



394 



Index 



Salap, 376. 

SALEEBY, N. M., see WILLIAMS, E. R. ( 99. 

Sambong, 875. 

Sara, 375. 

Sarcophaga carnaria, 310. 
tibialis, 310. 

Sarcophagidffi, 320. 

SCHOBL, OTTO, Observations concerning 
cholera carriers, 11 ; Practical experience 
with some enriching media recommended for 
bacteriological diagnosis of Asiatic cholera, 
127. 

SCHtJFFNER, WILHELM, Pseudotyphoid 
fever in Deli, Sumatra (a variety of Japa- 
nese kedani fever), 345. 

Seasonal index of malaria, 233. 

Septieaemic plague, 254, 269. 

Skin, alteration in, from plague, 262. 

Skin lesions of leprosy, treatment of, retro- 
gressive, with basic fuchsin, 357. 

Spleen examinations for malarial parasites, 
219. 

Staphylococcus aureus, 316. 

Stewart, G. N., see Reviews (book). 

Stomoxys calcitrans, 310. 

Streptococcus pyogenes, 270. 

Suha, 375. 

Sulo, 375. 

Sumatra, Deli, pseudotyphoid fever in, 845. 

T 

Talbak, 375. 

Tanlad, 375. 

Tayabas Province, descriptions of malaria and 
Anopheles surveys in, 204. 

Tayabas Province, recent epidemic along con- 
struction line of Manila Railroad Company 
in, 229. 

Tetanus antitoxin, preparation of, 31. 

THORNBURGH, ROBERT M., Adenocarci- 
noma of the cascum, complicated by intus- 
susception, 71. 

Thymus gland in beriberi, 121. 

Tiqui-tiqui, treatment of infantile beriberi, 
with the extract of, 81. 



Trichuris trichiuris, 296. 

Trombidium, 346. 

Tropical obstetrical problems, 871. 

Trupheoneura opaca Meigen, 311. 

perennis Meigen, 311. 
trinervis Becker, 311. 

Tubercle bacilli, avirulent, immunization of 
guinea pigs by the inoculation of, 145. 

Tuberculosis from lepers, observations on ani- 
mals inoculated with, 145. 

Tutong, 372. 

U 

Unhydrolized extract of rice polishings in 
treatment of human beriberi, 110. 



Vibrio cholera?, 320. 

Vitamine used in treating cases of human 

beriberi, 112. 
Vitamines, progress in the investigation of, 

95. 

W 

WHARTON, LAWRENCE D., The develop- 
ment of the eggs of Ascaris lumbricoides, 19. 

WILLIAMS, R. R. (Editorial), Progress in 
the investigation of vitamines, 95. 

WILLIAMS, R. R., and CROWELL, B. O, 
The thymus gland in beriberi, 121. 

WILLIAMS, R. R., and JOHNSTON, JOHN 
A., Miscellaneous notes and comments on 
beriberi, 337. 

WILLIAMS, R. R., and SALEEBY, N. M., 
Experimental treatment of human beriberi 
with constituents of rice polishings, 99. 

WOODWARD, R. B., Case report of ob- 
structed labor and Cesarean section, 69. 



Z 



Zambales Province, descriptions of malaria 
and Anopheles surveys in, 205. 



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