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THE PHILIPPINE
JOURNAL OF SCIENCE.
ALVIN J. COX, M. A., Pu. 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, Pu. B.
VOLUME X
1915
WitH 15 PLATES AND 89 TEXT FIGURES
MANILA
BUREAU OF PRINTING
1915
186701
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CONTENTS
No. 1, January, 1915
Munson, E. L. Cholera carriers in relation to cholera control........
SCHOBL, OTTO. Observations concerning cholera carrieYs.............--...--
WHARTON, LAWRENCE D. The development of the eggs of Ascaris
JIRA) FN LONG SS) ees cee atl al ne Mi AA le hae Re SA
RUEDIGER, E. H. The occurrence of Bacillus coli communis in the
Peripherals blood wor mane CUT OTe) eee neers eee cence ene eee
Three text figures.
RUEDIGER, H. H. The preparation of tetanus antitoxin ......................
Highty-five text figures.
CALDERON, FERNANDO. Czsarean section in the Philippine Islands....
WoopwArD, R. B. Case report of obstructed labor and Czsarean
ESTE OUELUGH aN ate Ra IN a Sse a (Mh lL ea vee
THORNBURGH, RoBERT M. Adenocarcinoma of the cecum, compli-
Catedaby; intussusception sss. t8 enone cs ee ae ees
DuMgEz, A. G. Two compounds of emetine which may be of service
in the treatment of entamoebiasis .....................:ceeececeeseceeceeeeceeensenes
ALBERT, JOSE. The treatment of infantile beriberi with the extract
OL guGLQU= Ci cy UT te Sm ey re er Bt NS flee ee aera epee
PHILIPPINE ISLANDS MEDICAL ASSOCIATION. Minutes of the Eleventh
Annual Meeting, held at Manila November 4—7, 1914....................-
EDITORIAL. Progress in the investigation of vitamines........................
VE OAYE DON esse hae i ee ca ae em ee en ee Nero ye ee Ee
No. 2, March, 1915
WILLIAMS, R. R., and SALEEBY, N. M. Experimental treatment of
human beriberi with constituents of rice polishings.......................-
Two plates.
WILLIAMS, R. R., and CROWELL, B. C. The thymus gland in beriberi....
ScHOBL, OTTo. Practical experience with some enriching media re-
commended for bacteriological diagnosis of Asiatic cholera..........
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
POMP LEDGES Wee cuseetan eee creel ee cin RUM iene eae ate aud A SRE Se sco
BARBER, MARSHALL A., and JONES, CHARLES R. A test of Coccoba-
cillus acridiorum d’Herelle on locusts in the Philippines............
Page.
1
11
19
25
31
65
69
71
73
81
87
95
97
99
121
127
145
iv Contents
No. 3, May, 1915
BarsBer, 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...
Two plates and 1 text figure.
No. 4, July, 1915
CROWELL, B. C. Pathologic anatomy of bubonic plague........................
Five colored plates.
No. 5, September, 1915
RoBERG, DAvip N. The réle played by the insects of the dipterous
family Phorid# in relation to the spread of bacterial infections.
Experiments on Aphiocheta ferruginea Brunetti with the cholera
VAIO Sececleceseccctecacessenseceesescen te ose secs twancdd eee eee
WILLIAMS, RoBERT R., and JOHNSTON, JOHN A. Miscellaneous notes
and ‘comments ‘on sberiberi cocecesces eee eee
SCHUFFNER, WILHELM. Pseudotyphoid fever in Deli, Sumatra (a
variety of Japanese kedani fever) .........2..........:cssceeeeceeeserenneeeeeeeeenee
Three plates.
PREVIEWS) | feiss cececsecccctees ole seesre tens Seen cetera te aad occas cen Rte eren eee ea a
No. 6, November, 1915
DENNEY, OSWALD E. The treatment of the retrogressive skin lesions
of deprosy with basic/fuchsin' 22 ee
Three plates.
JOHNSTON, «SOHN (As, Leprosy. ec cccee can oon eee cece cece ee nee ee ee
CALDERON, FERNANDO. ‘Tropical obstetrical problems.........................---
CouLter, J. S. A study of the pathology of the gall bladder and
biliary passages “Vin cholera/en 2a Ae ee eee
TONED? ace. oes ceesicc ees ee ke ee
Page.
177
249
309
337
345
355
857
865
371
Pia, ae
LA 5.57 ee
on dita PA ~
\in FANG Ay A %
2 one hh Pa ey ‘i, es onl
( r ' ; ee. Se i a ie | :
4 P
f
i
7) “y
He
‘tn ‘ 1
'
°
’
it
c
-
i A
a) ‘ 2
rh Ke
Lhe Heit
oy Vou. X, Seo. B, No. i ‘ ie | i aes ~ JanuaRy, 1915
THE PHILIPPINE
; JOURNAL OF SCIENCE
2s, ALVIN J, COX, Mw. A Pes D.
GENERAL EDITOR ;
- wens - Section 5.
- TRoPICAL, MEDICINE
EDITED ne THE COBPERATION « OF
JOHN A. ‘JOHNSTON, M. D., Dr. B i.
‘STANTON YOUNGBERG, D. V. M.
Pani _ Committee on Experimental Medicine
hi D. LONG, ‘A.M, M. D.; W. E. MUSGRAVE, M. D.
i hey ae OL CROWELL, M.D.
Committee on Clinical Medicine
: RB ” MoGREGOR, AL Bs H. E. KUPFER, PH. B.
en
mes. Ps
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THE PHILIPPINE
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B. TROPICAL MEDICINE
Vou. X JANUARY, 1915 No. 1
CHOLERA CARRIERS IN RELATION TO CHOLERA CONTROL?
By HE. 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-
east 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-
*Read at the annual meeting of the Philippine Islands Medical. Associa-
tion, Manila, November 4—7, 1914.
182195
2? 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 Science,
July—October, 1914.
July. | August. September.
Source of specimen. | Posi axe l Parlin al
} ‘osi- | Nega- | ‘ Posi- | Nega- | Posi- | Nega-
| Total. tive. tive. | Total. tive. tive. Total. | tive. / tive.
ATs | bral: Rs | é
Health station— | ) | | j |
I x 288 27 | 2a | 1,927 43 | 1,282| 3,539! 69 | 8,470
UAE ERS ae s1| 799| 4,851] 118] 4,788| 5,467) 73) 6,898 |
PAs Soe ae | soa] 18] a9n| sav} a7] 620} 1,796] 26] 1.770 |
Pic ee ee 95 5 90| 736 | 18} 718| 1,414 | 21} 1,398
Dee tes i OM WR ea PD Una a
| 7, 641 | 208 | 7,488 ) 18,056 | 205 | 12, 851
Mota leper aeee aera | 1,644 77 | 1,467
Met Munson: Cholera Carriers
TABLE I.—Stool specimens examined for cholera at the Bureau of Science,
July—October, 1914—Continued.
October. For the four months.
Source of specimen. Trae Posi .
| osi- | Nega-| Nega-| Posi-
Total. tive. tive. tive. tive. Total.
Health station— i |
|
DP es es Ep Tae NOE ENS MN ae a et 1,158 6{ 1,147 | 6,257 | 147 6,304
PAR te AS EU oe ee a Be 2,800 22| 2,778 | 18,948 244 | 14,192 |
(Og ee a Be ee ahs oe ee ae 1, 489 4) 1,485] 4,236 70 |. 4,166 |
Tees Sa Urs Dense aera en NUNES Rh eA leno 4) 509) 25768 48| 2,806
isa mes i pena ee Se SS UE ed | AAG 2 Shs ee | 1,192) 2,189 17 | 2, 206
Potala east eee aol Ri ee eh eee 7, 147 36 | 7,111 | 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 smailer 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 1915
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 Il.—Number of examinations for cholera made at the Bureau of
Science and number found positive for four months in 191}.
| eau Speci- |
nations mens
Tad | for | found
| cholera. | positive.
Tidy. LN EN ha Yr TE a eed a eer | assed? ae
Anis tee Bk Ta A I et a Se eee ee ge 9,994; 652 |
September= 3-2-0245 -5 2h RE ee Se a oe ee ee eee 24, 402 989
| October. anne nnn ee et ean ence omens | 32,824] 191
|
| Potale rece sts. Sees nea Ae ee oS ee ula es | 70,552 | 1,969
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 feecal 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, 1 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 codperation 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 fiood water which could be boiled with difficulty from
Jack 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
8. 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 1915
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, diarrhea, dysentery, infantile beri-
beri, and pulmonary tuberculosis. The codperation 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 feces 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
Bureav 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-
xX, B, 1 Munson: Cholera Carriers 4
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 seveloiyes! 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.
is Month. Males. |Females.
Days. | Days.
!
DAML G re ae ee i oe i eg RS Sc 7 | 8 |
'
ATU SS Ces oe oe eee eee ee eee a 5 oe eee ek ee ener eet 8 6
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
epiy tl ’ 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 *
By Otto ScH6BL
(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? 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, 1912-1914.
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
*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 1915
Pfeiffer * mentions only 2 cases of from forty-eight to forty-
nine days’ duration; Stiihlern-Zeidler,? 1 case of ninety days;
Jakowleff * gives 1 case of fifty-six days; and Creel,® 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 feces 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 diarrhea 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 ® 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’ 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
* Cited from Jansen, Klin. Jahrb, (1910).
*Cited from Kulescha, Klin. Jahrb. (1910).
® Journ. Am. Med. Assoc. (1912), 187.
*See footnote 2.
“See footnote 4.
xB, 1 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 (feces 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 feeces.
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:§
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 feces
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 hematogenous 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 gail 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,
* See footnote 2.
14 The Philippine Journal of Science 1913
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 Schiirmann’ 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 Gaftky.
Greig ?° believes that the infection of the bile passages is
of hematogenous origin. He found cholera vibrios in a focus
in the lungs.
Kulescha 1! 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 hematogenous 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. Ina
preliminary note Greig ** reports 8 positive findings of cholera
vibrios in the urine (55 examinations). Several cases analogous
to that of Liefschiitz-Jakowleff came under my observation
during the outbreak. The results of these examinations are
summarized in Table II.
* Cited from Kolle und Wassermann, Handbuch der pathogenen Micro-
organismen. Gustav Fischer, Jena.
See footnote 2.
™ See footnote 4.
% See footnote 2.
x) 1 Schobl: Concerning Cholera Carriers 15
TABLE II.—Haamination of embryos from cholera mothers for the presence
of cholera vibrios.
[The cause of death in the mothers was Asiatic cholera.]
Sey. eer
Elaveutal Heart. \Intestine.| Spleen.
Case. Waters. |
|
|
40a |
Pah lserowmichild es a etseee mele oe 0
hi |
| |
0 | 0 = \ = |
Ra ero wy CHiN oe ee 0 | 0 | 0 | _ | = |
| Se NOS HUNT SRO Wien a ne teens eee Sari 1 Nt Ais | = | 0
4, Foetus 24.centimeters.. 20-20 ne _— | _ | = | — | 0
BePAIOS ELON ero Wats see eine ee eee | | | — | b—
8 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.
Time Cholera vibrios.
/ Date of | between
No. | Patient. examina. deathand on
| wens | autopsy. | | dder, |ntestine.
1913. Hours. |
et Se SS a eee eee ae ee ee Sept. 22 16° |) sate +
("op arms yacth ie OS a Aa al Leta ee Ode 4 Mt =
Sf 85 Gilet ee Re ee Se ee eee eens Oct. 6 Jal | — +
PMN ic ed PR ih tL, ctw Se ges Meee Cited Oct. 5 ists,| 20k + |
Bl See Fe RR rh IN et a Oe ee de Oct. 9 4 . — + |
PAL 8 ei ope ek A EN eel ew ey 28 ha! Sido we TEN re a
TR aD Ate eee ey ae eee eee dors} 7 35 ap
S/S carp pelea aR C LIE. eal Sleek cee a Oct. 11 20 = a
9) De RR Bre elite 2 ie ee a ee ee ees Set =a Sedo ss} 5 + | +
10) |) Vi: (Season a ee ae oe ee ee eee Ledow sat 3 | Se | ata
11 || GAGs pe See al Mees oe ee Ol mE Oct. 13/ (2) 2a
|) TB | AL cE Sees eee ee eee ee eee Oct. 14 4, = ee |
MCT iow eaath: Mteas Pe de Ueovaa re me Ne 510 Reece Br ol ieee eT et a
| ga Vi Gli Meteo BL OUT Te dae 2 Par oc eae
BL NL Ae Seat cae Nae pe aCe Eee etal eae ce Oct, 14 16. 1. =O aes
16) |. A Le Ran ar es Pala Se ee Label Eee pe idor tes 3.5/ — +
| 2c Ve ED ee SE eee Sie ee er oe eee Oct. 18 6 | — +
| TRIG aoe See ie Sa bd ea ae ees ESdo)- 522 11 | eh |
aie Lit fs Dist sce eine SS ee ER Bee el, ieee! | Oct. 16 [ae eee + |
|: S20 greens oe S90 ORE NRE Mage ah Ta Ba S gomeee Wee Ls Oct. 17 eo) =
{Yo | Any Sieh hee © tae i ee Soya i ks eee ies (ae 4 = | 3.4
PLR A el RE eis pa Pee Tg UE wo omnlae Lha et Ea Oct. 20 1 - si
DB UNT OMesoe se oe eee CN a Ue Us Sc eS we doen 2 _ +
| gat RAG SAW YER Bie SEE SES AREER U NE Eee Meee See oe edo eee & 4 + ze.)
[58] en PRS as Sane ek SA A Ee ee Oct. 23 2 a+- + |
I. GN isis Ae ke RII A NE SE ae ere, Nov. 26} (2) b+ +
| 14. | .
Pan I i eet Pec eae) Suenos RW uA Ne Bienes delle oy 8 July 11 20 + =
Mtl IR Oars (=a Cee Pe STS ep ube Ae creeks eet ES July 14 0 an +
TM Hees Denies tides sete Spas Nol oc a ae oe Te ee June 14 0 + ae
SOU ME Sten MDs ee 8 oe Nes EN i a oes July 16 0 + +
ASS UO DAES GO Reece So kas ok St ot is ee BE eat IR 0 + +
| 82 De Zale ee a ee ae ee July 24 0 — +
[iB cA a oa" te see AN Ee AR ee J eae a July 28 0 = +
14.) Sal VON Rc alt NLA ae Bt Bs Gon ee te ae MG th ee 0 a + |
| (Bb | A pet eee ene eee coe aN aes Seidl July 29 ee +
VPoB6.| TAU t 2 Sacer tere Le i Sei er ae July 31 Opty Net +]
NST Cua es one Sea ce sence a opto Og 0 / | +
OSS AG Zee ee oe eee I ee OPE Sera ae ee Ae GS Aug. 7 Oar) — |
Gs 3 | ARO oe secon x tee 2. Cea as WR SEE EP Le Sede 0 | - 4
!
« Hydrops. 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.
\
Bet Schobl: Concerning Cholera Carriers ily
TABLE 1V.—Showing the results of examinations of urine of cholera patients
for the presence of the cholera vibrio.
Cholera vibrio in—
| Date of |
Patient. CxaMUNA-leeme 9, aide ky
| tion. | Urine. Feeces.
tte | 4 | aan eae
| aGYBE. |
DiC Sept.30| — fo
Oct. 1] = +
Oct. 8) ad =>
| Oct. 11 = +
Oct. 17 = =F
Bess tee eee Sept. 30 = SS
Oct. 1 = ar
DSU: Sis I SI AL Ee do ae == ar
Oct. 8 = an
FE eae ee 3 | Oct,). Lt = | ai
Oct. 24 = =
Pe eee a Oct. 11 — sits
Minbece See ee Oct. 17 = +
Dye SN ee ee Let dor ss = ni >
Oct. 238 = ==
Oct. 24 = ar
| ieee es Be ies ae Bl Oct. 22 = ar
te eke Sees Bee eee: Ke mame aoe =p
TENE Sos Soe 2 ERdoye-i%: = an
Mori ese Sedo = at
Oct. 24 = ==
’ SSE Sho ce bes Oct. 22 Se he
| Oct. 24 = +
Montes: Se Oct. 23 == 4
Oct. 24 = a
Oct. 25 = ae
eo Cap Pe eae Oct. 23 = ==
Oct. 24 = =
Qain’ wee ada = ae
NEE eae ne edor sees = +
1s (gd Bie nn Spe eS Oar ee = a
Lape sets Noy. 17 = ==
GO} teres ee SL Edo = +
Tomaro ere ee dope = =
MES en eel GaSe) = +
1914. |
Pp Be wre orie July 22 | _ =
| July 24 = | =
Nick prem en EY s July 22| — —
July 24 | = i
| SAE Glenn ae =e LSE (ops = ae
VM ee ee =A dors = | Ae
SAME Ss otecese Ee adoeeee == =
UD Ss se eee 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——2
i y
ye?
“eS
4
ns) *
THE DEVELOPMENT OF THE EGGS OF ASCARIS
LUMBRICOIDES *
By LAWRENCE D. WHARTON
(From the Zodlogical 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 feces. The commonest form is the
typical oval egg consisting of a rounded mass of protoplasm
*Read at the annual meeting of the Philippine Islands Medical Associa-
tion, Manila, November 4—7, 1914.
19
20 The Philippine Journal of Science 1915
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 feces 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.” 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
* The most rapid development I have found reported is by Leuckart, who
developed the eggs in fourteen days by keeping them in an incubator at
30° C.
x By 1 Wharton: Eggs of Ascaris lumbricoides 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
ae The Philippine Journal of Science 1915
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 lahbo-
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 alge a
great many of the eggs hatch, but the young worms die very
soon.
In a recent paper A. Martin * 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 feces. 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
* Ann. d. Sci. natur. (1918), Nos. 1 and 2.
XB, 1 Wharton: Eggs of Ascaris lumbricoides 22
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.
iY
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oe whe
od
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(Ss,
THE OCCURRENCE OF BACILLUS COLI COMMUNIS IN THE
PERIPHERAL BLOOD OF MAN DURING LIFE?
By E. H. RUEDIGER
(From the Section of Sera and Prophylactics, Biological Laboratory,
Bureau of Science, Manila, P. J.)
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-
muris during life have been reported. Brian” reported 6 cases
and Tidy* 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 colt communis.
* Read at the annual meeting of the Philippine Islands Medical Associa-
tion, Manila, November 4—7, 1914.
* Deutsch. Arch. f. klin. Med. (1912), 106, 379.
* 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, amcebiasis, broncho-
pneumonia, ulcerative gastroenteritis, trichuriasis. A bacterio-
[914 B. Cou in Broon No. 2
Seer. Tots Tals Tela Te fe of etistratvs felts [rs [eol2t fez tas |aulastecledesierieel
cc
Seseseceeecessesereeercce/seserecntronseecersestsssesarrzsez2
ied it: eee ee
A FREER Rea
Spee
PAC RCA
: Wy saane QO
EAN
= 4
BEE
38
Sa
il
Cece
B= SERRA 0RGR88
HEHE Perse tt
4
aman
ine
PEELE EE
Fic. 1. Showing 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
fdas use soueeeoneeuee
PCE
a
va
tv"
a
Fic. 2. Showing temperature of case 8.
epididymitis. On September 27, 1914, the temperature rose
to 88° 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,1 Ruediger: Bacillus coli communis in Blood of Man Poe
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 4.—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,
B. Cour in Biooo 2
ESS rad 0 Ee Wa 15 PPIGATA (a
aa SSeS SEEEEES oo oo fooe FREER EERE
Seeese rer costes eter fea faed fa ft on ere Gere Ce OT AEDECTEDETOE
Poa AE SUE secceeseaesescesscstee
Eevefmisee(a Fee {Bg BSR EH uee! ene] er Se SeaeEEEnenee
pa EULA oe A 5
eteauauiceite a SEES
Fig. 3. Showing temperature of case 4.
| Va
aT
Seescaeceacaeaee: ae EEE agg EEE NAA
EH EERE BERLE Ve PEE PEE So oe oe ooo EH
HH -|
35
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. 8, chart for case 4).
CONCLUSIONS
1. Microdrganisms 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.
23, 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.
Nene Pome temperature of case 3.
he a showing temperature of case 4.
"THE PREPARATION OF TETANUS ANTITOXIN |
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 horxses
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 anaérobic 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
(zarely 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
* Read at the annual meeting of the Philippine Islands Medical Associa-
tion, November 4-7, 1914.
* Kraus und Levaditi, Handbuch der Technik und Methodik der Immuni-
tatsforschunge. Gustav Fischer, Jena (1909), 2, 139.
31
2° The Philippine Journal of Science 1915
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. His method is as follows:
1:7 ivMiedastilled watery.) ..2 5 seen eee at i aeviney i 1,000 c.c.
IN@Clln (CRP Sie wa ee Ree et ee ee 5 gr.
Peptony (Wachee ee a ee eee 10 gr.
Beef Extract (Armour’s soluble beef) ...........-..--. 5 gr.
Dextrose \(GCommerciall) Wa ees ee ce ee eee 10 gr.
MgCoO; (finely powdered commercial) ...........-........------------- 5 er:
2. Determine gross weight.
8. 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.
Add 2 gm. MgCO; and mix thoroughly.
Pour into Florence flasks to shoulder.
9. Cover to a depth of 2 em. 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.
pons
HORSE 1
Horse 1 in this series was given about 1,000 units of tetanus
antitoxin* 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. (1918), 2, 98.
“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 each,
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-I, for horse 1).
GAM TeTANus Nha, fo B
JUNE 1) ES 3,4] 51647 8} 7 |/O} ss 112413 14 | 19 416 | /7 4/8 11/9 420 4 21 (22123 124 [25126 127128127430
°C.
37
=a 5 5 5 5 ae 3 z
3’ ; So (ey S S 2 °)
RS & il 4 5 os S 4
ae 3 Gel > be) oO] w Nw os
Fic. 1. Temperature chart of horse 1 for June, 1911.
191] TETANus No.1 8
Juiy}/J2]3 4,4) 5) 647} 849 | sel i} s2[13 [4 s5j fe) 7418 1/9 420121 [22423 [ay jasiac j27\25 [27 | 40131
°6.
38
37
1/0,
wy
~
300,
400,
o s Ss s 2
x 2 = 2 SI
Fig. 2. Temperature chart of horse 1 for July, 1911.
132195——3
+
ones
ay.
1915
The Philippine Journal of Science
34
ares} cee 229] artes
HH
eet ef
sian
ERE SH Et |
CECE ree} | SEE |
Cope | THERGSEBEEp aan S EHS
ECC |
»
>
\
Bicneane
et
a
SEC
Str
aera —2 |
Baaese ae ie =e eee
CoC ce > 5 as>neee
S14 | 2 2 [Stree eH oa
sttte |e | eS S espa du eae
[=H ae : =| r "a
snecisnt : |
SE i
4 >
Fic. 3. Temperature chart of horse 1 for August, 1911.
Fic. 4. Temperature chart of horse 1 for September, 1911.
Fic. 6. Temperature chart of horse 1 for November, 1911
patents fete
Hogna
caea
noe
Seaece
eee
S=oz ml
cH
=
J
[stst7]
ee
HBG |
Loree
ret
WI
l
eee
mt
Sepr-lid
oc:
38
37
iG. 7. Temperature chart of horse 1 for December, 1911.
aE; Ruediger: Preparation of Tetanus Antitoxin 835
17/2 Tetanus ‘ aie ieceela!
Pee [zfs [9 [rola [iz [is [ee os [ie [a7 Tir Pra P20 [zs [22 [23 [24 al Ena Ea
oa, FE ee EHH af CELE
39 Sree ste seek
b
Y HASH HH |
LOT
foeaumn
a fae faoee Ee EEEEEESRRVEP EE ae
SER BRIA aaa
5
XQ
3 OT ie dal TO
ny
ey NLL
aan aaa
‘oS Ree
HEE
“see CRMRERE
_ Fic. 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 filtrate 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-I, for horse 2).
Tetanus ee
~
a it
a EESEEEEE |
PREC
SEZERERER
§ 780.0 Pig titty
=
=
=
Ty
a
=
4
=
EI
=
=
=
.
°
8,
“
Fic. 11. Temperature chart of horse 2 for August, 1911.
xB, 1 Ruediger: Preparation of Tetanus Antitoxin 37
No. 2
Ecza Vea EX a CEA EAC CA a EE
Fic. 12. Temperature chart of horse 2 for Septemher, 1911.
TETANUS
Fig. 18. Temperature chart of horse 2 for October, 1911.
191] TeTANus No. 2
ees ENEa aes go SSS SSS
nn =
Fic. 15. Temperature chart of horse 2 for December, 1911.
i re
The Philippine Journal of Science 1915
38
Fic. 16. Temperature chart of horse 2 for January, 1912.
Fic. 17. Temperature chart of horse 2 for February, 1912.
Units per cubie centimeter by
Chart showing the antitoxin curve for horse 2.
Fig. 18,
S.
month
HORSE 3
same time as that
of horse 2, and the two received practically the same treatment.
This horse produced much stronger antitoxin than did horse 2
in
Immunization of horse 3 was begun at the
February, 1912, when the serum of horse 2 contained 150
serum of horse 3
units of antitoxin per cubic centimeter, the
XB, 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 38 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-I, for horse 3).
wiv Ie TANU 2 No. see A
ee Ea a ee ee FE 7 g aH
a ane seeaere ae FEEEEEE
i Pio ‘2 |=" | tt EEE
38
3 aias ae a
aa LT |
Tetanus NOS 3B.
PaANe auare fis [ieji7 le ae. 2% cel EE 26(27)28)29130]3/
oo
ry
if
I
ee
rte
See ee Ree
aca
|
chy
ew
IK!
te
Fig. 21. Temperature chart of horse 3 for September, 1911.
40 The Philippine Journal of Science 1915
’
Fic, 22. Temperature chart of horse 3 for October, 1911.
Fic. 23. Temperature chart of horse 3 for November, 1911.
Fig. 25. Temperature chart of horse 3 for January, 1912.
xB, 1 Ruediger: Preparation of Tetanus Antitoxin Al
1912 TETANUS Noes) i
Fea-J/ J2fsziag ts feof 75s pe fro} st | iz} i314 |/s | rb [iT fis fio [20 fas [22423 [24425 [261 27[27 429
E : ECEr A
40 HEE - : a
Sere FEEL : PEEEE
39
38 an
37 : =
2 3 =| fey
= S | SS |S5 | { PERE
Ne i 1 q jr ae hs 8j
[MONTHS| 7] 2739141] 5 | Sa
Fic. 27. Chart showing the antitoxin curve for horse 3. Units per cubic centimeter by months.
HORSES 4 AND 5
On June 1, 19138, 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, 1918, 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
4? 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).
| :
EEC<00R00
SOGeP eee
_
ff
on
am
=
s
5
2-
wt
C4
| Bee
a Be Ruediger: Preparation of Tetanus Antitoxin 43
da Tetanus
Fic. 30. Temperature chart of horse 4 for August, 1913.
Tetanus No. D
Seer] [273 fats[et7[s [2 Jeoln [2 [ia [fis [ee] capa oe eeeeeeee a [27 {301 |
EEEEEH EEE
Spestarteceues ul ere EME ae FH y eH 7 sue
AaaUMAEAAUAMACUAGRAEEAMMAIEE
Fic. 31. Temperature chart of horse 4 for September, 1913.
Tetanus
se Tor.
ae
“oF ae ae aed
¥\
EBV Lin Hoa Bey,
EEC rT
Fic. 32. Temperature chart of horse 4 for October, 1913.
1712 Tex
ANUS
TR 2S 2 ea Ee Es EE
feafec|os]
so EEC EE Ten MERE E CUE
EEE Aer
eeetrereeseccreee ae
388 4 eee ee
iV
ee
Fic. 33. Temperature chart of horse 4 for November, 1918.
1915
Journal of Science
ippine
The Phil
44
6
No. 4
Tetanus
BEER EEE EEE
a
Is]
=
:
S|
:
|
B
BE
|
oi
=|
a
Vv
:
(=)
1913.
Fic. 34. Temperature chart of horse 4 for December,
1914.
Fic. 35. Temperature chart of horse 4 for January,
1914.
Fic. 86. Temperature chart of horse 4 for February,
Taste [7s To Tofu Tr]
[2 Ta]
Fig. 87. Temperature chart of horse 4 for March, 1914.
X, B, 1 Ruediger: Preparation of Tetanus Antitoxin 45
Fic. 38. Chart showing the antitoxin curve for horse 4. Units per cubic centimeter by months.
The injections of toxin were continued on horse 5. Jn 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).
Tetanus No.5 A
[zel27[2s]2y [so] |
ra 1A = aan
TAY A
ae Pk, Sreiate
a WAT
fH yey
aL
Cy
Fic. 39. Temperature chart of horse 5 for June, 1913.
|
1915
46
The Philippine Journal of Science
ie)
tol |
a
=
a
©
8
a
E
BEeoces
No. 5
TeTANus
[vo | Jaz [0s [ra Tes [re [iz [os Tie [20 [ar faz [es [eu
Br)
~
e
ed
juey Ts Jataty[sfel7 [es [a]
EEE
EEE
Fi cI
= PEEP ES
Coo i
Coon
Coon
oan
Coo
EEC
i
fee
:
E
FEFH
a
i
ra aa
1A
ae TaN
Nh
vi
aa
ane
ce
a
Iv
beter
SSS Stine!
aH sare La
SSCCcocosvHattistt
HE
Sead
PRT
ae
aoa
prs
i=
iy
TT
Temperature chart of horse 5 for July,
Hy
Ty
Ty
yl
%
Per
rH
Fic. 40.
1913.
Tetanus
1713
eee
oe
Fig. 41. Temperature chart of horse 5 for August, 1913.
M5 D
to
“
5
Tetanus
a
anaes:
Oenaean:
Snges=s
Fic. 42. Temperature chart of horse 5 for September, 19138.
St
EES aueee
suaue Geen
secbes set ie
1913.
Temperature chart of horse 5 for October,
Fic: 48.
EEL EXI ERS EYS ECS EATS EA
oe eacaacee
‘s
a nae sai Ee
REE EE COTA tal
= eee
BRU Eticreers ace
Eee noe
Fic. 44. Temperature chart of horse 5 for November, 1913.
Tetanus
ae
FACE
{4 [c:]
qa eauiagr
LALA 7 EE
cisee
neaas
Fic. 46. Temperature chart of horse 5 for January, 1914.
1414 Teranus iy
Fes. |/ 2Z}~3 14 fete TLS 59 POF UE LIZA IZ PIA IS] 16 PIT 8 PIF F200) 21 [a2 23\24 2S\26527|28
i — rt
20. al fife SESeSoosaS
—. =
| aa It
40 { Fe ~ - = a | fa
39 : : BI i
38 Nw / i = EEE
37
400.
Ss S S
6 Ss S
g Gr »
Fic. 47. Temperature chart of horse 5 for February, 1914.
48 The Philippine Journal of Science 1915
Fic. 48. Temperature chart of horse 5 for March, 1914.
TETANUS
Fic. 49. Temperature chart of horse 5 for April, 1914.
Tetanus
Fig. 50. Temperature chart of horse 5 for May, 1914.
x, B,1 Ruediger: Preparation of Tetanus Antitoxin 49
Fic. 51. Chart showing the antitoxin curve for horse 5. Units per eubie 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-
132195——4
1915
The Philippine Journal of Science
50
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).
toxin.
Temperature chart of horse 6 for November, 1913.
a2.
Fic.
ERRREe iaeaa
a
wv
2
2
<
b
uw
es
713
Fic. 58. Temperature chart of horse 6 for December, 1913.
bel] s{al
a
Temperature chart of horse 6 for January, 1914.
Fig. 54.
GE= % ~
Fie. 56. Temperature chart of horse 6 for March, 1914.
1914 Tetanus No. b F
Aer [ep 2} aja} s}etris [9 jvol jz tis try jis |e fais ta | 2027 [22)23 [24 }2s|2el27|2ei29 [30
39
38 a
} io a
a7 aE j
: 33 4 4 :
S ee Be a S s
~ ae 3 a Oo) >
Fic. 57.. Temperature chart of horse 6 for April, 1914.
ie
(G14 TETANUS Nob &
May lila2lalalslel7isl¢ lolw 2 lealalsve lye l/7[zol2z 1222s [2y[2s)26 (27 [2ze)27[30)ar
j
a I f i |
40 | | t
| a
it
39 SeSSee EH
i fe] I cit
38 oe = a rf
i i
f if
87 5
Ss S Ss Geile
iS ~o S am[se
Fic. 58. Temperature chart of horse 6 for May, 1914.
IGE) TetANusS No. b H
JUNE I 2S al 5} 6 a BY | 0} sf i2 113 | 4p US] 761/718 4/9 (20) 21 (221235 | 24) 25}26 127129427130
aE i_
40 |
f | 1 iE | {
39 t |
im a
38 F :
37 =
Ss s S s a jPs
= © 8. 3, E488
Fic. 59. Temperature chart of horse 6 for June, 1914.
52 The Philippine Journal of Science 1915
IF/4 TETANUS o. 6 1
a
I'tc. 60. Temperature chart of horse 6 for July, 1914.
AULT EE
Fic. 61. Chart showing the antitoxin curve for horse 6. Units per cubie 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
Za 1913.5
The injection of tetanus toxin was begun with a dose of 1
* Although for the want of space antitoxin and toxin are recorded under
different dates on the charts, these were given simultaneously, 1,000 units
of antitoxin and 1 cubie centimeter of toxin on November 10, 1918, 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 cubic
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).
EAT)
rae ial iz
ia
|_|
Eee
HH
(cana
WO
Mee
a
om
p
pa
Sd
D000n eee
an
ese reereek
i ceceenas
LUT Ts
UN tneaaeeccndanon ed
Fic. 62. Temperature chart of horse 7 for November, 1913.
1915
54
The Philippine Journal of Science
Fic. 63. Temperature chart of horse 7 for December, 1913.
No.T ©
TeTanus
”
a
a
EB
5
EB
BE
:
8
e
S|
2
E
ag
|
B
g
[2 {3 ta) stelz7 [3]
1714
[Jan.[ 7 |
1914.
64.
Fic.
Temperature chart of horse 7 for January,
No. T D
[iz |rs Jz ]20 [zi fazfasfev[esfze]azies}] ||
Tetanus
[ster te la fol [2
s
8
B
=
eae
E
Fic. 65. Temperature chart of horse 7 for February, 1914.
2
1914.
for March,
7
Fic. 66. Temperature chart of horse
BEORED:
CASH |
Temperature chart of horse 7 for April, 1914.
xB, 1 Ruediger: Preparation of Tetanus Antitoxin 55
TETANUS
a Sg grea es ee seea eae aa eeUa EE eae aor oa su eneeeseeeeeeee g
|_|
eae “HE eH AH BGSGiian a
corns nen
a
Fic. 69. Temperature chart of horse 7 for June, 1914.
1714 TetaNus ° 5% No. T I
Jurylijz{3]}a}s}ey7}3 19 jiols jz 413 [4 jes [16 | 78 [79 [20 [21 [22 [23 [24 [25 j26 [27 123 127 | 30 [31
a0;
38
37
Beg st,
{
ceo 72, &,
SER. 2. L.
,400,000.U,
S00. URC,
12,750,000.U,
500.
750
700 U, PERCE!
3,$00,000.U,
BLED 10.4,
SER. Y. L.
hoor ee
2, 400, 0000,
7O0U.FEAES
SER. Sk,
Fie. 70. Temperature chart of horse 7 for July, 1914.
_TeTAnus
Fic. 71. Temperature chart of horse 7 for August, 1914.
56 The Philippine Journal of Science 1915
TETANUS
Fic. 72. Temperature chart of horse 7 for September, 1914.
[MONTHS] /T@ [ols so] e6ét7 [él ¢ lola {2
PT
ELAN
RRRREP GRANGE
ELA
HAE ERY
EE
Fic. 73. Chart showing the antitoxin curve for horse 7. Units per cubie centimeter by months.
HORSE 8
The immunization of horse 8 against tetanus toxin was begun
on November 10, 19138. This horse was fortified with 2,000
.
X, B, 1 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, 1918; 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 Philippine 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).
TetANus
TETANUS
2413 [4 [is [re [77] We EOE ED Ee EN EXD ESET
BRREBEe
BEBE foooee
HSER BEER eee
sacace ze = BEB
Ss
ae APA seiais
7 A Senerec!
ETM TMT
G. 75. Temperature chart of horse 8 for December, 1913.
TETANUS
Tetanu co No. 8 ae
Te SO eg TS EE LS ee [is | [ee Ter [is Ya Taofzs [22 ]23 fav fas]es far fas
aos EE
He ea
eae
Fic. 77. Temperature chart of horse 8 for February, 1914.
Fic. 78. Temperature chart of horse 8 for March, 1914.
1914
Tetanus
Fig. 79. Temperature chart of horse 8 for April, 1914.
(714
May [i [2z}3,4fsjel7]|s ja
TETANUS
en
WZ} IAP IH IIS 416 PIT AIT AT 420 fat
|
22123424525 [26 127123 127 | 30 {31
No. § &
Heh
40
39
38
37
400.
)
Ss
»
Ss
Ss
~o
3
»
DS
Fig. 80. Temperature chart of horse 8 for May, 1914.
1915
LENCE
Journal of Se
ippine
iL
i)
The Ph
60
Be
x
mG:
2 eH
s
babs raed ieee
PET TTT faeces
E
B
a5
me
El
B
H
t
Ei
H
a
e
B
E
E
M.8 H
SHEESH EERE eee
Senes ones Sseset iol
eee
) HHS
SRRE0 80008288
Tetanus
7 Vs fa Profan fiz} is | va]
Tetanus
[C7 [e [9 [rot [2] os [rates [re fot Tis Pig [20 [2s [22 [2s [24 [as] 26 [a7 [2s Jz }30 [54 |
TeTANUS
8
=
E
=
Fig. 81. Temperature chart of horse 8 for June, 1914.
Fic. 82. Temperature chart of horse 8 for July, 1914.
Fic. 88. Temperature chart of horse 8 for August, 1914.
Ls |e |
LV j2t3 fet ste]
Ta EREn
1714
20:
40
39 eS
38
37
G14
Aus.
i
JULY
8 for September, 1914.
rature chart of horse
4. Tempe
8
Fe.
x, B,1 Ruediger: Preparation of Tetanus Antitoxin 61
MONTHS] /| 27374757677 7879 [ol |/2 |
aN eQRGORE
Oe sean
BN
os
Fic. 85. Chart showing the antitoxin curve for horse 8. Units per cubie 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
to 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-I for horse 2.
19 to 27. Charts 3—A to 3-I for horse 3.
28 to 38. Charts 4-A to 4-K for horse 4.
89 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
CAESAREAN SECTION IN THE PHILIPPINE ISLANDS '
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 Cesarean section performed
in the Philippines in the treatment of placenta previa. 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 Czesarean section which were performed for the
treatment of contracted pelvis and for eclampsia, so that at that
time 14 cases of Czxsarean 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 Czsarean section, although a spectacular operation, is
simple and should be more frequently resorted to in cases of placenta
previa.
2. Hysterotomy is a treatment which can best guarantee the life of both
the mother and the child in those cases of placenta previa in which the
cervix is not dilated and the amniotic sac cannot be reached.
3. In infected cases Porro’s Cesarean section is to be performed rather
than hysterotomy.
4, In cases where the cervix is widely dilated, the rugturing of the bag
of waters or the perforation of the placenta, followed immediately by the
extraction of the fcetus, 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
*Read at the annual meeting of the Philippine Islands Medical Associa-
tion, Manila, November 4-7, 1914.
1321955 65
66 The Philippine Journal of Science 1815
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 Czsarean
section were performed, giving the following results:
TABLE I.—Results of Cesarean section in cases in the Philippine Islands.
mee ab eee * = ae
fe Num-;| Per
a
g
A
Operated for placenta przvia: j
Recovered) 2c his: ie oe see ae os a ee se ee eee ee ae | 42 ose |
Died ote ts STNG Bike Ze soe Ne Ed a eR ee a re 3) eee |
Operated forieclampsia, recovered =s-8 a en ee 2, Bee oat |
Operated for premature separation of placenta, died.____________________________ 1 | coe. =
TotaliCzesarean sections! s 25) ee a cee eee ee ee ets Ee © eee eee EY GO Herc ee
Votalimaternalid cath as a. ee ee eee ee eee ae a eee ee ee 4 23
Babies:
Tavin gies 2 2S seed ARN Ps fer See ees ae Soe een sees eee eee 5 29
Diediseveral hours/atter birth kere eee eee ye es ee ee ee 7 41
Stillborn) 25s. 5122.42 3522-32 es Sa ee ee a eee 5 29 /
The fact should not be forgotten that the majority of the
patients coming to the hospital with placenta previa are already
exhausted by loss of blood and that they come to the hospital
only as a last resort.
Of these 17 Ceesarean 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. Czsar-
ean section was performed, and both the mother and the feetus
were saved. In this particular instance, we can readily see
that, besides placenta previa, Ceesarean 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
Cesarean section.
Another indication for abdominal Cesarean section is given
by those women who have contracted pelves and who always
x,B,1 Calderon: Cxsarean Section in Philippine Islands 67
deliver a stillborn fetus. I know of some of these cases in
Manila, and I hope that as the use of Cesarean 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 Cesarean 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
Cesarean 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
hemorrhage has been profuse and the patient shows the symp-
toms of acute anemia, 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. k
‘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 Czsesarean
section.
CASE REPORT OF OBSTRUCTED LABOR AND CASAREAN
SECTION *
By R. B. Woopwarp
(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 foreeps 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 hemorrhoidal
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 was 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 O. 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 anesthesia
digital dilatation of the cervix was attempted with no result.
At 7.30 in the morning, under ether anethesia, high forceps was
tried and an honest effort lasting fifty-five minutes was made
to induce progress. None was made, and under the same
anesthesia the patient was conveyed to the hospital and a Sanger
*Read at the annual meeting of the Philippine Islands Medical Associa-
tion, Manila, November 4~7, 1914. E
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? 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 Cesarean sections, 10 high forceps, 5
embryotomies, 5 tamponades for post-partum hemorrhage, and many other
operations necessary. There were 3 deaths.
Andrew’s collection of 395 cases adds 36 cases of Caesarean
section.
That frequency of abortion, difficult labor, post-partum hzem-
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 CA&ICUM, COMPLICATED BY
INTUSSUSCEPTION *
By Rosert 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 entameebic, 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 gonorrhea 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.—tintense 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 czecal 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.
*Read at the annual meeting of the Philippine Islands Medical Associa-
tion, Manila, November 4-7, 1914.
71
We, The Philippine Journal of Science
The patient was put on diluted milk diet and improved stead-
ily; on February 138 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 hemoglobin.)
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 cecum was invaginated, car-
rying the normal appendix with it. The cecum was enormously
thickened and formed a ball-valve, completely occluding the
ileocecal valve. The condition was so manifestly malignant that
immediate resection was decided upon. The cecum 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 ENTAMGEBIASIS +
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 entamcebiasis 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®* 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 cephaéline.
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 ° to be neither
astringent nor antiseptic. The presence of 5 different alkaloids
*Read at the annual meeting of the Philippine Islands Medical Associa-
tion, Manila, November 4—7, 1914.
*Purchas, His Pilgrimes. London (1625), 4, 1811.
* Wootton, Chronicles of Pharmacy. Macmillan & Co., London (1910),
SAY
*Ipecacuanhic acid was first isolated by Willigk in 1850. Journ. jf. prakt.
Chem. (1850), 51, 424.
*Arch. internat. de Pharm. et Tox. (1908), 405.
73
74 The Philippine Journal of Science 1915
has been reported: namely, emetine; cephaéline; psychotrine;
ipecamine, isomeric with psychotrine; and hydroipecamine, is-
omeric with caphaéline.* The pharmacology of emetine and cep-
haéline was worked out by Wild,’ 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 ® reported the results obtained in 25 cases of enta-
meebiasis 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 entameebiasis, we are indebted to
Vedder for pointing out its probable use in this connection.
In 1911 Vedder ® published an article on the effect of ipecac,
deémetinized ipecac, and emetine on the entamcebe 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 entamcebz found in dysenteric stools.
He noted that entamcebee 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 entamebiasis.
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. Cephaéline and psychotrine were isolated
by Paul and Cownley, the former in 1895, the latter a few years later.
Pharm. Journ. (1895), 25, 111, and Am. Journ. Pharm. (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, 8387-842.
*Vedder showed that deémetinized ipecac was without harmful effect
upon the entamoebe, but that the destructive properties of ipecaec were
greater than its emetine content would indicate. From which we may
infer that cephaéline is also toxic to the entamebe. Bull. Manila Med.
Soc. (1911), 3, 48.
x,B1 DuMez: Emetine in Treatment of Entamebiasis 15
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.—Showing the results obtained in cases of dysentery treated with
ipecac and with emetine hydrochloride.
Died. ; Discharged.
Treatment. t oe
| Within | After |Ofother| Very Not Gured ae
| 3 days. | 3days. | diseases. bad. cured. A
Mpecse Sa iene Ge uonoss 4 (hal ca eel 2 4 13 30
| Emetine hydrochloride__ PEN a ete ea ed 7 ih aoe e TS Ss Beh) 21 25
The observation of Rogers have been corroborated in a meas-
ure by Baermann’®? 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-
mebiasis 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 ™ in the alkaloid as obtained on the
market or whether it is due to our inability to bring the remedy
in contact with the entamcebe in the proper concentration for a
* Miinchen. Med. Wochenschr. (1918), 50, 1132.
“ Five different commercial samples of emetine hydrochloride examined
in this laboratory showed the presence of cephaéline when tested with
Freehde’s reagent. As cephaéline 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 1915
sufficient length of time,’* 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** with
Mayer’s reagent,” 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.'°
* Wherry found that emetine killed the entamcebz in dilutions of from
1: 20,000 to 1: 100,000 only after 24 hours at a temperature of from 36°
to 88° C. Journ. Infect. Dis. (1912), 10, 162-5.
* Willets has pointed out the fact that entamcebic dysentery in an in-
fected individual can be prevented and that prophylaxis against carriers
of Entameba histolytica can be obtained by expelling the pathogenic enta-
moebe from the intestines of infected persons. He found ipecae more
efficacious than emetine for this purpose. This Journal, Sec. B (1914),
9, 94.
“The emetine hydrochloride obtained from Merck and Co. and labeled
“Nach Paul” was found to contain cephaéline. The cephaéline 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.
* 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 mereury sulphide collected,
washed, dried at 100° 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,B1 DuMez: Emetine in Treatment of Entamcebiasis ret
TABLE II.—The composition of emetine mercuric iodide.
Found.
|
Caleulated for
Constituent. 4 (CsoH4oN205) Tease Tania metean, |
(10HD (Hegle)s. 1 9
| Per cent.| Per cent.| Per cent. | Per cent.
NCoyo Wh aX Sy pe oe ee Aled ee MANNE oath Oe os sina ns reall a 2, 014. 40 43,43 43. 13 43. 03 43.08
ING) OTe a phn tee A a ae SL en A ee St Pe oe ae ee | 595.50 12. 84 12.53 12.48 12.50
15 RG) iNT 2 fb eae Lepr Pea cave att ee ee oe 10. 00 (0) 728) Oa eR a Fe 0.23
IMIG DIT CR sp Ne oh eee Rs Doe ai | 2,018. 24 ASU On| eens uees Deere aed Sake)
| 4,638.14 | 100.00 | 100. 90
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 Dragendorft’s * 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 '* 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.
“ Dragendorfi’s reagent was prepared by saturating a hot concentrated
solution of potassium iodide with bismuthous iodide (Bil:), and then dilut-
ing with an equal volume of a saturated solution of potassium iodide.
Zeitschr. f. anal. Chem. (1866), 5, 407.
“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 filtrate 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.S, dried at 100° C., and weighed.
The lowest of several weighings taken at intervals of a half-hour was
the figure used in the computations.
78 The Philippine Journal of Science 1915
TABLE IiI].—The composition of emetine bismuthous iodide.
ee ATOR Bt gos a a
‘ Calculated for | TR
Constituent. (CsoHaoN20s) |—-——~————_| Mean.
|
| (SHY) (Bils). | 4 2
|
| Per cent. | Per cent. | Per cent. | Per cent.
Todine 22.2440 5s bee ee te sts 8) A 00T20 | beds 7 168,801) beeen
Bismuth a0 cd node i mates cemeome 206.90 } ° 12.00 | 42.52 | 12.20] 12.36
HS Uo ae) of) Pia eg et Rp ie i tea ie es 8 ee 5. 00 L355 40 et aie PE) eal a 0.30 |
Mmetine t .oweete keen Oa SI 504. 56 | $29: 27 [oops [See 29.08
| | 100.00
em
| 1,723.66 | 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 entameebiasis, 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 **
states, it enters the circulation. Therefore we should expect
the combined action of both emetine and the mercury compound
upon the entamoebe.
Insoluble salts of bismuth are converted into bismuth sulphide
after passing the pyloris.*® 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.”
In addition, in this case, emetine will probably be liberated
* Cushny, Pharm. and Therap. Lea and Febiger, Philadelphia (1911),
641.
> Bastedo, Mat. Med. and Therap. W. B. Saunders Co., Philadelphia
(1914), 494.
71 Journ. Am. Med. Assoc. (1918), 61, 885.
x,3,1 DuMez: Emetine in Treatment of Entameebiasis 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 1V.—The effects of emetine mercuric iodide and of emetine
bismuthous iodide upon dogs.
ia Substance. Notane! Dose. | Time given. Vomiting.
\ | Kilos. Gram.
Emetine mercuric iodide __-__ _________- 8.7 0.057 | 10.25 a.
m. | None at 2 p. m.
PER Cy BRS Sse POT: WOU ge a eA AT | 8.8 0.092 | 10.83 a.m. | At 11.26 a. m.
Emetine bismuthous iodide____-_________ | 7.8 | 0.066 | 10.38 a.m. | None at 2 p.m.
eRe ese cae UM a acd | 6.3| 0.075 | 3.22p.m. | None at 5.30 p. m.
m. | At 11.50 a. m.
TDs Sis ones ie ve Ys cane Satie oe aN tS | 9.8 0.012 | 10.40 a.
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 entamoebe for a comparatively longer
time than is true with the forms in which it is administered
at present. i
THE TREATMENT OF INFANTILE BERIBERI WITH THE EXTRACT
OF TIQULTIQUI*
By JOSE ALBERT
(From the College of Medicine and Surgery, University of the Philippimes)
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 ease 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.
* Read at the annual meeting of the waoeae 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, Bréaudat 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 Bréaudat’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. 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. Soc. (1912), 4, 26.
X, B,1 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 * 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, polypnceea, 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 diarrhcea 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.
* One peso Philippine currency equals 50 cents United States currency.
Q4 - The Philippine Journal of Science 1916
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 hard 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 has
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
Bt 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 polypncea 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 constityites 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 codperation 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 genera! 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 1915
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 codperation 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 cedema 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.
nay 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 fuli will appear in abstracts.
The following scientific program was presented and carried
out in the order indicated:
SECOND SESSION, NOVEMBER 5, 10.30 A. M.
COLLEGE OF MEDICINE AND SURGERY, 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 Schoébl.
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
LEAP e YO @ ekSMRR ee LAE SMR AACR tee anecad ete at ie Dr., B. C. Crowell.
Bacteriological findings peaking on the epidemiology of cholera.
Dr. Otto Schobl.
Cholera carriers in relation to cholera control.
Maj. E. L. Munson, U. 8. Army.
Whole at Exit OTe: mec: ay ILO A De oe Dr. J. W. Smith:
Observations on cholera in Manila, 1914.
Drs. A. P. Goff and O. 8S. Denney.
Notes on Philippine water supplies.................... Mr. G. W. Heise.
Monstrosities and abnormalities........ Dr. Maria Mendoza-Guazon.
FOURTH SESSION, NOVEMBER 6, 7.30 A. M.
PHILIPPINE GENERAL HOSPITAL, CALLE TAFT
SSIMOUC ACURA CH bey dele ATA Bela ye MOM ee se Dr. P. K. Gilman.
90 The Philippine Journal of Science 1915
FIFTH SESSION, NOVEMBER 6, 4 P. M.
COLLEGE OF MEDICINE AND SURGERY, CALLE HERRAN
Medical and sanitary public welfare work in the Philippine
Tslands.::.-\5: a aceey EA eS de ee Dr. L. Booth.
Malaria in the Philippine Islands..............-..... Dr. M. A. Barber.
The sperochetal infection of ulcers in China...Dr. H. E. Eggers.
The treatment of infantile beriberi__...................... Dr. José Albert.
The experimental treatment of beriberi with the constituents
of rice polishings:
Chemical preparations....................-.. Mr. R. R. Williams.
Case (FeCOtdS IR 2 erie a ee Ne een 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 entame@biasiso-s 45 ee Dr. A. G. DuMez.
SIXTH SESSION, NOVEMBER 7, MORNING
Exhibition of a field hospital of the Medical Corps of the United
States Aqmiys eyes ele ey Col. M. W. Ireland, U. S. Army.
[Nore.—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 Ariston 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. 8. Army.
The occurrence of Bacillus coli communis in the peripheral blood
of man during life, =. lee Dr. E. H. Ruediger.
The germicidal power of glycerol.................... Dr. BE. 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.
nati Philippine Islands Medical Association 91
Cezesarean section in the Philippine Islands.
Dr. Fernando Calderon.
@eeserean’ Section! :-.-..220.2s..2-: Surgeon Woodward, U. S. Navy.
Cancer of the ccecum with intestinal intussusception.
Maj. R. M. Thornburgh, U. S. Army.
leiver abscessi 2 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: ae NACH SRE
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 1915
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, sufiicient evidence has been produced to show that extracts of rice
polishing, 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 98
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.
i —_ f
(ii ae As a ee
y A Aol
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
erying 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’! (isolated from rice polishings) which were
promised in June, 1913, and “a method which will be described
later on”? (for obtaining the vitamine fraction from yeast)
which was referred to a year ago.
R. R. WILLIAMS.
* Journ. Physiol. (1913), 46, 179.
*Thid. (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]
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in the tropics.
MARY POLK.
182195——7 97
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THORNBURGH, ROBERT M. gencencelanmey of the Cexcum, Com-
i
Me a A
plicated by. Tritussnsdepwon st kel eee ei coe ae ole ag ;
DUMEZ, A. G. Two Compounds of Emetine Which May Be of Bervine! in ¥
the Treatment of Hnitamoebiasis. 325-330 ce fee ee ee a 73
ALBERT, JOS#. The Treatment of Infantile Beriberi with the Extract pone
rep Mira WU VU Feas Cui haere Sas Ad ba RAPE eA RRA rae y x MS Peck Rat I SR aes See yt es.) Say
PHILIPPINE ISLANDS MEDICAL ASSOCIATION. Minutes of the F
Eleventh Annual Meeting, held at Manila November 4-7, 1914.0... = 87
EDITORIAL. Progress in the Investigation of Vitamines 85
REVIEW (0... Oe ee le
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THE PHILIPPINE
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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,? 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
* 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.
* Bull. Manila Med. Soc. (1912), 4, 26; Albert, This Journal, Sec. B
(1915), 10, No. 1.
132716 99
100 The Philippine Journal of Science 1915,
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? 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‘ by another method,
and its curative powers tested on fowls. He reported that
allantoin frequently relieved the prostration and prolonged life.®
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. 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 (1918), 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 Beribert 101
ally beriberic. CMdema 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 anemic, 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 diarrhcea 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 cedema
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 anemic. Cidema
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 cedema 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 cedema 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 anzemic 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 refiexes very slightly sluggish.
‘G@dema 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
anemic, had little appetite, and felt dizziness and painful op-
pression in the chest. There was some cedema in the legs, no
x, B, 2 Williams and Saleeby: Treatment of Human Beribert 103
cedema 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
amore 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, in-
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. Dyspncoa 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 1915
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.
José Bantug, of Malolos:
CASE 6
Symptoms before the treatment.—The patient was anemic, 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 18.—Still with slight palpitation and profuse sweating.
Result of treatment: markedly improved.
Case 8 was treated and observed by Dr. Canuto Reyes.
CASE §
A woman, aged 383 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 cedema, 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 Beribert 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 dypsnoea 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 dypsnoea 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 1915
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. Ctdema 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
dyspnea, 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 cedema 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 Castaneda. 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 anemic. 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 1915
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, dyspneea, difficulty in swallowing, and headaches.
The patellar reflexes were greatly diminished, and a slight ceedema
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 cedema
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 Beribert 109
She was given 15 cubic centimeters of hydrolyzed 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 anesthetic. 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 cedema 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 cedema 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 cedema, 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 apparéntly
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 Beribert 11
diagnosed as beriberi and treated with extract of rice polishings
by Doctor Castafieda. When seen by us, the child was somewhat
cedematous 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 19
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 cedema, 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 cedema 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 cedematous 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.
IW The Philippine Journal of Science 1915
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. Ctdema 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 diarrhea, and was very peevish.
She was treated for the diarrhcea 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 cdema. 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 cedema 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
diarrhcea; 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,’ with
minor modifications, which experience suggested. The chemical
methods will be discussed fully in a later paper.
* Journ. Physiol. (1911), 48, 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 anemic 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 refiexes 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 1915
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 dyspnea, 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 25
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 cedema, 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 Beribert 115
knee reflexes were sluggish. The patient walked with difficulty
on account of pain in the calves. Cidema 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 refiexes 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 codperation of Dr. José 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. Dyspncea 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 cedema 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 improvement in the condition of the
132716——2
116 The Philippine Journal of Science 1915
patient was noticeable before the administration of the second
dose, the dyspncea 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. José 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 cedema 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 dyspncea 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. Cidema 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 dyspnea and heart
condition was apparent. The cedema was also much diminished.
At the end of forty-eight hours after the first dose the edema
x, B, 2 Williams and Saleeby: Treatment of Human Beribert 117
had practically disappeared, the heart enlargement had markedly
diminished, especially on the right (Plate IJ), 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® 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. (1918), 46, 178.
uals? 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 coéperation 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.
ill)
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Se AE, aki Cs Aa my ae oy Ape ye a cee ats Ps one
YY Cit See eae eae — C2Ck. uns Sy ch eas arses
cates ecKeaat te Oo Daas Tet 0 oe
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i eae
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WILLIAMS AND SALEEBY: TREATMENT OF BERIBERI. | [PHiu. Journ. Sci., X, B, No. 2.
PLATE |. CASE 27. THE HEART IMMEDIATELY BEFORE THE ADMINISTRATION OF VITAMINE,
WILLIAMS AND SALEEBY: TREATMENT OF BERIBERI. | [Prim. Journ. Scr., X, B, No. 2.
PLATE II. CASE 27. THE HEART FORTY-EIGHT HOURS AFTER PLATE | WAS TAKEN.
THE THYMUS GLAND IN BERIBERI*
By R. R. WiLuiaMs 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* 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
* Received for publication November 16, 1914.
? 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,* a further study of thymus tissue
seems advisable. Extracts of thymus tissue give the blue color
reaction with phosphotungstic acid and alkali® 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.
*Funk, Journ. Phys. (1912), 45, 491.
* Folin et al., Journ. Biol. Chem. (1912), 11, 265; (1912), 13, 868.
x,B,2 Williams and Crowell: 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 on
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
1915
vence
Journal of Sci
ippine
il
The Ph
124
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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.
Time Loss in weight.
| re- d
Addition to daily diet of 50 grams | 242° | Length
OG ANS: of white rice. tore: Baca’
if Total. | Daily.
neu-
ritis.
Days. | Days. | Per ct. | Per ct.
Dee aes Reh ee = Os mpeet hyn Ss) = ee 34 37 28.5} 0.77
CF) ae a ee es (6 Ko), Se ee OE ee 32 37 BEET I OEEh
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OPE Rs Sek BN soe eee Pee (6 (0) gee Ree eee a eg 52 58 20 0.66
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PRACTICAL EXPERIENCE WITH SOME ENRICHING MEDIA
RECOMMENDED FOR BACTERIOLOGICAL DIAGNOSIS
OF ASIATIC CHOLERA *
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 feces. As a consequence of
this study Ohno advises the use of peptone of three different
reactions which correspond to the reaction of the cholera feces:
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 feeces 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 Dieudonné’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
*Received for publication December 28, 1914.
% 127
128 The Phiippine 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 Dieudonné’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,” 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,CO,), 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.
} Cholera colonies present.
any few. Less than half a dozen.
Few. About one dozen.
Morethanafew. About 50.
Numerous. About 200.
Very numerous. More than 200.
PROTOCOLS OF EXPERIMENTS
One loopful of cholera feces 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 Schébl: Diagnosis of Asiatic Cholera 129
TABLE I.—Hnrichment cultures incubated eighteen hours.
_ Enrichment. Growth
pupae: Remarks.
Medium. Reaction.| agar.
du =— |
+1.5 = on acid producers present besides cholera.
+1 ==
+0.5 +
—0.5 aR Their number decreases toward the alkaline end of
= a the series of peptone. Platesmadefrom peptone |
S15) + +2, +1.5, and +1 overgrown by acid producers.
—2 +
|
TABLE II.—Same arrangement of experiment as in Table I.
i}
Enrichment. Growth |
jon plates. |
} Dieu- Remarks. |
Medium. bea cone 5
IReptoness eee ae a +
)OX0) ee es es eee +1.5 a |
I DY yee ae es tome eae 54] — Overgrown by a motile bacillus growing fairly well
DOr eee eee, eck | +0.5 — on Dieudonné’s plates. One single colony found
Tare She ea ee | (us — |{ on the plate made from +2 peptone. It proved
1D) eats ee | = = || to be one of cholera vibrio.
1D) See ee tab Soa ja
1D) eee ee eee | —2 | = |
i
TABLE III.—Same arrangement as Table II. Both lactose agar and Dieu-
donné’s plates used. Incubation of peptone culture, eighteen hours.
Enrichment. Growth on plates.
Ey = Dieta Remarks.
: . actose | Dieudon-
Medium. Reaction. sre, aOR aE.
=r Few acid producers from +2. The num-
4.5 ber of red colonies decreases toward the
aril alkaline end of series. No blue colonies
+0.5 except cholera.
=1 Cholera colonies most numerous on plates
=e made from peptone of from —0. 5 to —1.5
= reaction.
Sed | Sear | + ae one cholera colony +2 plate. Plates
6 ER meee =F show pure growth of cholera.
tal oP
+0.5 t
0.5 iE Cholera colonies most numerous on plates
so made from peptone of from —0. 5to— 1.5
Tis [LT] E |p eect
a) | eae +
130 The Philippine Journal of Science
TABLE 1V.—Same arrangement as Table III.
Enrichment.
Growth on plates.
Medium. Reaction.
Lactose
agar.
Dieudon-
né’s agar.
=
Remarks.
+2
+1.5
aul
+0.5
—!!
—1.5
=
+2
+1.5
shal
+0.5
ll
el is)
=
>
Reaction +2 exclusively red colonies.
Red colonies decrease toward the alka-
line end of the series butare still present
on the plate made from peptone —1. 5.
From +2to—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. |
TABLE V.—Same arrangement as Table IV.
[ Enrichment.
Growth on plates.
Medium. Reaction.
Lactose
agar.
Dieudon-
né’s agar.|
+2
+15
+0,5
Remarks.
Exclusively red colonies in +2. Morered
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.
1915
x 8, 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.
¥ y i Remarks.
Medium. Reaction. acer leaeesor.|
+2 aa | ee oe Ce oe Few red colonies; no cholera.
Srl Gath | ies Seen ees Overgrown with red colonies; no cholera.
+1 eee Do.
+0.5 == Do.
O80 3 More than a few cholera colonies. Red
colonies predominate.
1D oeeene moe er eae =i! =e a | ete ee Same as previous, only cholera colonies
more numerous.
Done ee ee —1.5 =f rip | Cece aes Se Very numerous cholera colonies; few small
white and yellow colonies.
1 Dio Sa aN =? Sil hy easeeaesed Numerous cholera colonies; few white and
yellow colonies.
BHIGHTEEN HOURS’ INCUBATION.
IReptoney 2 =o +1 pat # Wl ese Exclusively red colonies.
Docts sacar eee +0.5 | crept uric eee oo Do.
1D oe See eee =0).5 <6 AWM Fes eee Few cholera colonies; red colonies pre-
dominate.
WO oe —il iy | hed ees Numerous cholera colonies; only few red
ones.
1D Yn) eee oes =) Sn eee ee ree Do.
Ba) i ae erage ees chile econo res --
Dore? #2 sere AOL GS eee aes aie Very few cholera colonies, pure.
Vt fee See es ae Numerous cholera colonies, pure.
era Cm eee ete tee 3F Very numerous cholera colonies, pure.
cay it | eee me ete Soe + 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. macuye Seer
Peptone js == ees ceee +2 = One subtilis-like colony; no cholera.
Day sat 5 Se eee aril = Mostly red colonies; few blue spreading
colonies; no cholera.
DD) Oar eee ee = eee ar (0), 5 Bae Ae iS Spee Se Overgrown by red colonies; more thana
few blue spreading colonies; few cholera.
Dose toe se 0,5 Ht jl eee eo Only few red colonies; numerous blue
| spreading colonies more than a few
cholera. Y
1 D Yo eae en =i ay gees See eee Overgrown by blue spreading colonies;
more than few cholera colonies.
Worse ase =2 | Stef atta led 2 eee rae Same as — 1.
132716——3
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. Reactions) 1 acne | Tne ong |
iPéptone = tee a see aril Bo ty lee eeceoses Mostly red colonies; few blue spreading
ones; no cholera.
Doe nase ee +0.5 = giletetecnsee Same as + 1.
Dornan eee | (Nb SA (eee, Numerous cholera; few red colonies; few
j blue spreading colonies.
Doe ee ea =i) Se eee ee Very numerous cholera colonies; 12 red
ones; more than a few blue spreading
| colonies.
Dot esos cekaeseaes = ch eal 222s ee No red colonies; more than a few blue
| | spreading colonies; more than a few
| cholera.
Dows ero se Sse os gy en eee ees = No growth.
Dos22222e aoe OLD) ee seems =n Seven cholera colonies, pure.
Doro 3 See OAD) [seme memes + Numerous cholera colonies, pure.
Does eee | SAH ae ee + | Very numerous cholera colonies, pure.
Worse saes Bee ae a) ak a ae + More than few cholera colonies, pure. |
Soeteeereeetee —-—— ———— ae J —- ae =
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.
FE Growth on
Enrichment. plate. 4
z = = Remarks. :
‘on- ac- jeu-
Medium. Reac- centra-| tose /donné’s
ion. .
BIO tion. | agar. | agar.
= No growth.
Red colonies exclusively.
= oh tee Few red colonies; numerous cholera
colonies.
oh ay be eee 5 | see Very numerous cholera colonies; about
a dozen white ones.
= 2 Na Ree = ee ee Numerous cholera colonies; about a
half-dozen white ones.
ig Bac oad 5 + .-------| More than a few cholera colonies; same
number of red ones.
os see 10 + .......-| More than a few cholera colonies, pure.
ees 15 ae .--.----| No growth.
a 20 = eee © Do.
Lp ere a Se [pe eee Do.
X, B, 2
Schébl: 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. Gromer
‘ Reac- | Con- | Lac- | Dieu- Remarks.
Medium. er centra-| tose donné’s
: tion agar. | agar.
Per ct
IReptoness22 eee set geet LF cere ma, {| Ree poke Very few red colonies; no cholera.
DOs ae = Os Bri] ees er Bee eee ee nee More than a few red colonies; no cholera.
DOP eee es ON B yl eeeeno erie Mill LA RyereeeeTSt Numerous cholera colonies; about a
dozen red ones.
Dome ee =, | ee Peete Same as —0. 5.
DO Rie See s An | 1 eee ere pas We} eee he More than a few cholera colonies; very
few red ones.
RNAI Siete sa 2 ee See 20 em (8 ee Sea Two blue colonies; no cholera. |
De as Seen een | SEE 16 Shy | er eel Small white colonies; no cholera. |
WD Oya ore AAS 10 Sa none: More than a few cholera colonies, pure.
1D Yo see eee el eee 5 Era er eee Numerous cholera colonies; very few
red ones.
Ottolenchits)2 ose. oe ee Shige jes | Few cholera colonies, pure.
Peptone:-.-2-=--=---- ail es aes ee | ee = }
WOace tno aes Uae eee el eee eee =F About a dozen cholera colonies, pure. |
Woes. een Ss lO) a | eee eM Numerous cholera colonies, pure.
Wows sh 5-22 earl | Peace aie oe SF Same as —0. 5.
(Dosa see aes ee: Oa | oe ea eer ee =f More than a few white cholera colonies,
pure.
DO ease o2 ett 254 20) |e esse = No growth.
Movser none ee aS Eyer = Do.
10 ee eae ee LO NK Aes + More than a few cholera colonies, pure.
TD) overran ana ae aoe |e = ya) Pees ar Numerous cholera colonies, pure.
|! (QV et ya) (GreVad 014s) = Se IE Oe |e + Few cholera colonies, pure.
TABLE IX.—Same arrangement as Table VIII. Plates inoculated after six
hours’ and eighteen hours’ incubation.
SIX HOURS’ INCUBATION.
Enrichment. Growenen
} Reace Con- | Lac- Dieu- Remarks.
Medium. tion centra-| tose jdonné’s
B tion agar. | agar.
me) Yeas cme Two red colonies; no cholera.
cate Less on Se More than a few red colonies; no cholera.
sles Ml(aeeeacne Numerous cholera colonies, pure.
Fr see Very numerous cholera colonies, pure.
“iy eee ee More than a few cholera colonies, pure.
==") eae eek No growth.
=! | jane ese Do.
Say eee More than a few cholera colonies, pure.
=e, Beebe Numerous cholera colonies, pure.
No growth.
ll
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. oe
; Rene Con- | Lac- Dieu- | Remarks:
Medium. ean centra-| tose |donné’s
tion. | agar. | agar. |
Per ct
Pep tonets seen sees Nitro Ysa eee. | eee es | Red colonies exclusively; no cholera.
Dow eee ei OE 29 | a 7a | eee More than a few cholera colonies, pure.
IDO eae ODN eee = ih ah aes Same as +0. 5.
Do eee Sal eee 3 a eee Numerous cholera colonies, pure.
Dobe ene S2in eeeee Ape fd esaeees More than a few cholera colonies; few
small white colonies.
ea lenerer es No growth.
cee Few small white and yellow colonies;
no cholera.
Age yas Seam Few cholera colonies; same number of
small white colonies.
2 Coe oe ee Same as 10 per cent.
= \lweosese Few yellow colonies; no cholera.
has Ste No growth.
eee = Do.
ae ia Numerous cholera colonies, pure.
Bee eae + Very numerous cholera colonies, pure.
LO ae rea + | Numerous cholera colonies, pure.
pees et = No growth. |
teed = Do.
ee Lise ae More than a few cholera colonies, pure.
~=-2-—= |Sae ae es or eva oe More than a few cholera colonies; more
than a few small blue fluorescent col-
onies; few small white colonies.
4° Same as bile.
=P More than a few cholera colonies; same
number of small white colonies.
ofa Gees More than a few cholera colonies; very
few small white colonies.
Few small white colonies; no cholera.
No growth.
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. Groves
& x. = Remarks.
seta, | Rese Orn, | Eas, [Dieu
tion. agar. agar.
Per ct
Peptone= 2-2 at O15 | Speee sae eee = No growth.
LD Yoyo nloe Ce on Me ——=() ey | eeemene gene | ieee etree +. Numerous cholera colonies, pure.
Do eee ec 8 |r pee ace =F Do.
Does 2- ee eee A he eet [i tee =f Do.
Ottolenghi;s= == 220 see a | ee ee eee =f Do.
Kraus’s AF Do.
Doe ee SF Do.
Soda peptone =F Do.
Doss ee eee = No growth.
IDO era ee eee = Do.
TABLE XIII.—Same arrangement as Table XII. Plates inoculated after six
hours’ and twenty-four hours’ incubation.
SIX HOURS’ INCUBATION.
A Growth on
DINNER latest
Con- | Lac- | Dieu-
Medium. Heae centra-| tose |donné’s
tion agar. | agar.
Per ct |
Reptone:2- === Sy et ee |e Saree eemea dh
eee ee ee Oso hell ee ood
Dosts2. cee OND) | eaeeeees oe eee ae
Doyssse ese 2teckee ot ee eee ap i eae se
Dojsehacke= Se stiid eae Peeters ae i see seee
Otbolenghi}sy2e eee ee ee -
Kiralis'sieanash oe Sc Phe Soe 10 =ts
Doss sects eke ood 5 7 aetna ta
Soda peptone ________ nly i poe ene ae ee
Does eee rend eal Pee ear a (ere er
Do tind teceest —3 1 ete tent) te, Sem
Remarks.
No cholera; numerous small blue opal-
escent colonies; few white ones?
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 colonies.
Few blue opalescent colonies; no chol-
era.
%, B, 2 Schébl: Diagnosis of Asiatic Cholera 139
TABLE XIII.—Same arrangement as Table XII. Plates inoculated after sia
hours’ and twenty-four hours’ incubation—Continued.
TWENTY-FOUR HOURS’ INCUBATION.
Enrichment. ayn
: Rone Con- Lac- Dieu- Remarks.
Medium. eon centra-| tose donné’s
= tion. agar. | agar.
; Per ct |
PReptonei ==. eo. ied het a eee ae | | No cholera; more than a few white col-
onies.
Do eens eso ees SF Osballeseneans Qi lease sce =
Domes estes sce Un |lesceseen OFF eeeceee
Dow ee i ie eres =e ne aee Bo Very few small white colonies; numer-
| ous cholera colonies.
10h) eee ne ee OR | eee SE eas See More than a few cholera colonies; more
than a few small blue opalescent col-
onies.
Mptolenoiiss yee a es |e oe ener ep (ae ae rk Few small white colonies.
Kraus’s 10 acti od | ose Few cholera colonies; numerous small
blue opalescent colonies.
1D GY Soe See ee Sea enema ae 5 cr a Ree eee More than a few cholera colonies; nu-
merous small blue opalescent colonies.
Soda peptone ________ al We eee eh es os | [ees ee Same as 10 per cent. F
(Dope s ee eee a OE es oh eee Same as —1.
Dope eae cns! kt | eee + _._.----| No cholera; few small white colonies.
Peptone_________ ee [eco ori Dale (Oke eee See = No growth.
Dope ee ee OND R eres |e es = Do.
Digs ee ——()0 5p Pe eee eRe Be oo = Do.
Dopeene ee aoe SS ee ee eee eee + Numerous cholera colonies, pure.
1D Xe) Se eee me) Iie cere hte allt es sh + More than a few cholera colonies.
Ottolenphits, poses |e ae ee ee 8 aS No growth.
KG a7 Bye ee | eee AOBIEA Sse ar Few cholera colonies, pure.
22 5a | Meee = = ae Very numerous cholera colonies, pure.
Fa iy |e eee Sh eee ar Do.
aed see eee oe ee ar 1 Da:
OM | aed el See = No growth.
TABLE XIV.—Same arrangement as Table XIII. Plates inoculated after six
hours’ and twenty-four hours’ incubation.
SIX HOURS’ INCUBATION.
Enrichment. peoener
t Reace Con- Lac- | Dieu- Remarks.
Medium. tion, |Ccentra-| tose |donné’s
tion. | agar. | agar.
Per ct
Peptonen aus een Seif ie, ll anew oe =r i ieieee tae ea No cholera colonies; numerous red
colonies.
Doyen ss = See sent ict i035) ||eocenete CN eee Do.
Does see low ane —— (Obi | i eee iL Ete yl (ee oe Numerous cholera colonies; numerous
blue spreading colonies; cholera
predominates.
Doe. eee sae fh py een a eee Same'as —0.5, only cholera more nu-
merous.
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. | Seren
TC ae a aS, Remarks.
: Renee Con- | Lac- | Dieu-
Medium. tion, |Centra-| tose donné’s
tion. agar. | agar.
Per ct. |
Peptones<22-24--=sec — ee eyes seo Seema Cholera colonies numerous; few blue
spreading colonies.
Ottolenchits == e— |---| pao —_ |e No cholera colonies; few small white
colonies.
Kraus 8 -o os ece a= ee jeaee ae 10 eal ee Same as —0. 5.
Dv Year Ses ates] panes Sey 5 | ae ee Very few cholera colonies; numerous
| ; | blue spreading colonies; numerous
| red colonies.
Soda peptone ________ oe | eee geese Vesta Sean Numerous cholera colonies; a few blue
| spreading colonies; very few white
| colonies.
| Downes ese Ay | Mera a ic Eee Very numerous cholera colonies; very
few white colonies.
Domes = ee ee eee ee St eee eee More than a few cholera colonies, pure, |
TWENTY-FOUR HOURS’ INCUBATION.
Peptone===— ca al Reet Pea aes | Pe oe ene No cholera colonies; a few red colonies.
Doves. eee eee er OYE) feat a eae ee
Doye. se 24 eee === (VN DIIE See See | ee ee eee See
Does ee —— Ty meme nes + _...--..| Very numerous cholera colonies; very
few red ones.
i 0 Yo eee ee Oe eee Sa) Sse More than a few cholera colonies; very
few red colonies.
Ottolenghils}2-22-e55 | ese ee eee ee et ee Few small white colonies; no cholera.
iralis’s coo. 3- ase eee tebeeees 10 = ee eee More than a few cholera colonies;
numerous small blue opalescent colo-
nies; very few red ones.
Doyo oe eee 5 7 etl (sae et Same as 10 per cent.
Soda peptone ________ rll a 4] ee ele) S23 S2See More than a few cholera colonies; very
few small white colonies.
Wohin ct Bayes Sa eee Eau, Do.
Woteese see 75 ae eet acre =a. |lcpoaeee No growth.
Reptonesso--escee ee apt ig ee ee See ee = Do.
Dose eeeeaee at! 1535) eae eee =F More than a few cholera colonies, pure.
| DY yee eee eee SU ee Sel Ke See + Numerous cholera colonies, pure.
Dope ae eee Sd ea oe oe =F Do.
Dowsectes wah Bn Ae eee nee occ ee +- Do.
Ottolenghilaiesescscce |orce ea | meee ea = No growth.
Kraus's = Numerous cholera colonies, pure.
Dose eee eee ts Do.
Soda peptone + More than a few cholera colonies, pure.
Doissoseeec cess + Do.
Donde ae Sa it | Mee nee an, ee Re => No growth.
2
Gb;
Schobl: Diagnosis of Asiatic Cholera
141
TABLE XV.—Same arrangement as Table XIV. ' Highteen hours’ incubation.
Enrichment.
Growth on
plates.
5 Remarks.
Con- | Lac- | Dieu-
Medium. eae: centra-| tose |donné’s
‘i tion. | agar. | agar.
Per ct.
heptoness-ees- a= es Sh ikl eerie Pes ko ll ee Few red colonies; no cholera.
Dower fens ae eS Sees | es ot et More than a few cholera colonies; more
than a few red ones; cholera predomi-
nates.
Woysseas seks ord WG Nese hs sl eis ae ee eee Few cholera colonies; more than a
Ottolenghi’s
Doe
TABLE X VI.—Same
few small latter
predominate.
white colonies;
More than a few cholera colonies; few
small white ones; 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.
arrangement as Table XI. Highteen hours’ incubation.
Enrichment. | Seen
i ee 7 : Remarks.
Medium. Hac: cou ae eee
% tion. | agar. | agar.
Per ct
Peptoneee nese eee Sep ed ae Ee eee ee Few red colonies; no cholera.
SHO Heenan! Bisel | able Das] Few cholera colonies; few red ones;
latter predominate.
1D eee eee nee eee Srey | Sepeerere sal =n oes 8 More than a few cholera colonies; few
red ones.
DO meee ee nae A ef | ae oe teeny | eee see More than a few cholera colonies; few
spreading colonies; cholera predom-
inate.
Ottolene hips yess ee A |e = -.----.-| Few small white colonies.
Kraus’s 15 + Numerous cholera colonies; few small
; white ones.
142 The Philippine Journal of Science 1915
TABLE XVI.—Same arrangement as Table XI. Eighteen hours’ incuba-
tion—Continued.
| i
Enrichment. ere | |
|
| a eae | | K | =, - Remarks.
Medium. | Tec centr Ts ldonné’s|
: tion. | agar. | agar. |
nue ieee
| |
Per ct.
Kraus’ spo owes |t Sea | 10 jo AR [eesessce More than a few cholera colonies; equal
number of red ones.
DY Reeias ar ie See eS Sos eS Dal een een | Few cholera colonies; equal number
| of red ones.
Soda peptone ________ 1 eee: ae Sf | ee ee More than a few cholera colonies; few
| white ones.
Do Seas wee ee <2 eee Sear | a tall See | Few small white colonies; no cholera.
Domes Se ees) ate |e gs eg eet tea Do.
Peptone!sene eee | ey (ae ee oe np eae ee = | No growth.
Do estes a oes = Oi 52a eee [Sie ame + | More than a few cholera colonies, pure.
Do = ees } —1 | Sa ae i oe + | Do.
Doss see ee | —2 eeoeae 1 ak + | Numerous cholera colonies, pure.
Ottolenwhitss: 220 ood ae ee a eee ee = No growth.
SEN USES aera eet eae | es te GSH ee ee ee + Very numerous cholera colonies, pure.
Dosa arenes poate Sn ALO) eee + Do.
Dye se aoe ge {So eee GS | eee + More than a few cholera colonies, pure. |
Soda peptone ________ | —— 1 oe eee Se Ree + Numerous cholera, pure. |
Do ee eee Wet ety eet pear 2! = No growth.
| Dot een a ri Pita ae ee = 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 Dieudonné’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 Dieudonné’s medium
(Tables: 1V,; Vi,. Vil, X,. XI, XI, Na RA, AV Cie
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 148
spreading, colonies. Although the inhibition of growth by Dieu-
donné’s medium is evident in some cases, they do not grow on
alkaline ox-blood agar (Tables II, VII, XI, XIJ, 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 Dieudonné’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 tiber verschiedene
Choleraelektivnahrbéden. Arb. a. d. kais. Gesundheitsamte (1912),
40, 357.
PILoN, P. Blut-soda-agar als Elektivnahrboden fiir Choleravibrionen.
Centralbl. f. Bakt. etc., Orig. (1911), 60, 330.
NEUFELD-WOITHE. Uber elektive Choleranahrbéden insbesondere den Dieu-
donnéschen agar. Arb. a. d. kais. Gesundheitsamte (1910), 33, 605.
BoccutA, I. Ueber den Wert der neueren Methoden zur bakteriologischen
Diagnose der Cholera. Centralbl. f. Bakt. etc., Orig. (1911), 60, 434.
SGAuirzeR, M., and L6wy, O. Ueber die Verwendbarkeit der Blutalkali-
bouillon als Anreicherungsmittel fiir Choleravibrionen. Centralbl. 7.
Bakt. etc., Orig. (1918), 69, 556. ’
KROMBHOLZ, E., and KuLKA, W. Ueber Anreicherung von Choleravibrionen
insbesondere tiber Ottolenghi’s Galleverfahren. Centralbl. f. Bakt. etc.,
Orig. (1912), 62, 521.
GOLDBERGER, J. Some new cholera selective media. Bull. U. S. Hyg. Lab.
(1918), No. 91.
Horer, G., and HovorKA, J. Versuche zur elektiven Ausgestaltung des
Dieudonnéschen Choleranahrbodens. Centralbl. f. Bakt. etc., Orig.
(1913), 71, 108.
I. EXPERIMENTS ON THE IMMUNIZATION OF GUINEA PIGS BY
THE INOCULATION OF AVIRULENT TUBERCLE BACILLI IN
AGAR. IU. OBSERVATIONS ON ANIMALS INOCULATED
WITH TUBERCULOSIS FROM LEPERS *
By MARSHALL A. BARBER
(From the Biological Laboratory, Bureau of Science, Manila, P. I.)
In previous experiments” 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
* Received for publication November 24, 1914.
* 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 (‘“Tbhag A” and “Tbhag 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 +, +4,
+-+-+ 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.
Weicht, |Aug. 6, 1912;16days) Sept. 23, 1912; 110
Virulent dose, Dec. 20, 1911. June 5, after virulent days after virulent
, 1912. In- dose. dose.
Guinea ee ee = oculated
pig No. anil
Strain. Wels Weebl Manes | mena.) Weight. | PBURAll Weighe.
cc. g g. 9 0
6080) |) “Lbhas Avan _- = - 3 400 460 St BOOUN S- 2 das eS Sle Somes oe
(ROB ee dope aes 3 460 610 ae 640 APP 640
OBR Hesceel GOP ea esate ne 3 6400) Sse S| ee See Se a ae le Jee
GOSSue|aaeee (600) ee eae Zap 490 500 ar 480 ar 410
6034 | Emuls avian only__.. 1 390 560 + 610 BF 670 |
60385 | Thag He ____.._.____ 3 450 | 650 + 620) | eeao |
| 6086 |____. dopeeen ee ua 3 660 630 + 650| ++ | 660 |
OE eet (so) Se rere Sm 3 420 410 = 480 srapar || 520 |
GOSBR i se (6 (0), DE eee ee 8 || 500 | A10 ts 450 Ir | 450
6089 |--do ie Bes) De ee) 0) | Seo |
Average_._____|___.___- [aso Aa a iy |e ee |
Nov. 16, 1912; 164 | Dec. 19, 1912; 197 Autopsy.
days after virulent] days after virulent
dose. dose. Died ti
Guinea =e after |. Ratio of
piste I inal A | ee Boy Spleen. Tesiona. rents
neuinal) Weight. | meuinal) weight. ee roa,
g- - g. Days. g. g.
SURO | pceneceee RRS Pe rete freee eae ae Lees es a 88 360 0.6 Tb. 0. 0016
6031 aa beh Sas eee Se ee 179 510 4,2 Th. 0. 0082
DUBVA 9 fers eee ese eer a a pee py ee Be eee see oe (Db) Ae ene
CUI) Ns 2 ee ee el eee ee 133 320 2.5) Tb. 0. 0078 |
6034 + 680 SF 640 349 480 B15) Tb. 0. 0073
6035 SSF 690 Sie 740 377 580 1.6 Tb. 0. 0027
6036 ar ar 650 sae 640 311 470 2.6 4loy 0. 0055
6037 simaieaia 470 a aR ae 420 | 222 370 3.5 Tb. 0. 0095
6038 ar 410) | oct le ese 187 340 5.4 Tb. 0. 0159
6039 =F 740 sear 730 283, 620 2.0 Ao 0. 0032
Ah Seas Ee oS TS Go REG |sonceccecnce eee aca
—
8 Tbag A and Tbhag H refer to mixtures of agar with avian and human types of bacilli,
respectively. ; ,
> Sacrificed.
Series 2, Table I1J.—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,
“Tbhag 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 1916
TABLE II.—Series 2. Animals receiving larger doses.
} Inocu-
Apr. 29, 1912; | lation | aug. 6, 1912; | Sept. 23, 1912;
Avirulent dose. Jan. 30,1912. | 90 days after |). 4p | 61 days after | 110 days after |
avirulent dose. es virulent dose. | virulent dose.
Guinea 1912.
pig No.
: Vol- - B 2 | Ingui- | A Ingui-
Strain. ee Weicht. Tumor. Weight. Weight.| nal |Weight.| nal Weight.
|glands. glands.
i | :
ce. Ge || Cb Ae | g. g.
6074 | Thag A*.__-____ 3 570 0 640 | 650 ~ 690; ++ | 700
(05 | doeesct = 2a 3 510 0 580 | 560 + | 560) + 590
6076 |_____ domes 22st 3 500} + 590 | 620 sia eM se ||. eee
(OM |= does 3 430 0 570 | 600 + 660} + 670
6078)|aaee dott 3 540 | ++ 610 | 620 - 660} + 670 |
6079 |_____ dots ee 3 7 Oty | enka [ee eA oe ee a
6080 |_--_- donee 3 390] +a 420 | 440 + 520; + 600
G0 | s douse 3 420} +a 580] 550 | + | 630} + | 640
6082 |_____ dose 2.5 430 | +a 530} 560 | + 630; + | 630
5889 | Tbag B_____-_-- 1.5 410 0 590 | 600 om 610| ++ | 630
5891 |_____ domes 3 540} ++ 620} 640 | + 680} + 700
ED | doe ae 3 560 0 740 | 740 ~ 750! ++ 790
6083 |__-_- do: ee 3 470 0 570 | 620 + | 650} ++ | 660
GOs eee deca 3i 400). +: | 500|| 500) || + 550| ++ | 560
6085 |_---- dozer 3 340 0 450 | 490 om 530 | + + 550
6086 |_____ Cs a 3 300 0 ie 370 | 390 + 460 - 530
5887 | Thag A 3 420 0 570 | 580 ++ 620} ++ 620
5888 3 520 0 640 | 640 + 680 | ee peeeeeest
6043 3 480] ¢ 660 | 680 + | 70)| tot) cone
6087 3 470 0 610 | 630 + 690} ++ 710
6088 3 410} ++ | . 540] 550 - 580; + | 620
6089 0.5 580 | + + 610, 610 + 670; + 730
6090 1 510/ 0 580 | 590 + 660; + | 670 |
6091 0.3 400 0 | 510] 510 _ 560| ++ | 570
6092 ut 500 0 560) 550 | +? | 610) + 640
6094 0.5 520 | +a 580| 560 | + | 620) ++ | 620 |
6095 0.5 430 0 540| 560 | ++ | 640) ++ ' 630
6096 0.5 AAO Babes sone tase | Cera ees aR |. ee
6097 1 410| + 520 | 550 + | 610) ++ / 630
6098 wee es SOs: 570 | 570 | +? |--------|-------- =
Averages. |-c--% 2e.| S24 .05. [age || cc B7S52) |--eee Weert 5 eee | eee |
if
xB, 2 Barber: Experiments on Immunization 149
TABLE II].—Series 2. Animals receiving larger doses—Continued.
Nov. 16, 1912; 164 | Dec. 19, 1912; 197
days after viru- days after viru- Autopsy.
lent dose. lent dose. |
: = Sanna! EIT | Died af-
bis No. | lene Ratio of
sue Weight. eu Weight. ets Spleen. | Lesions. weight
Weight.
g. g. Days. g. g.
GO TAS | est eee kan Se le Oe es eee es 160 700 Tea! Fibs 0.0101
6075 =F 590 + 580 354 400 3.0 Tb. 0.0075
GOTG 7 | Beene ss | Se eee | eee rs |Pee oe o |eeeeen oe || Moe Sos | Seek sce (aye = eee
6077 ar 620 oF 700 456 550 2.8 Tb. 0.0051
6078 + 680 SF 720 812 500 1.0 Tb. 0. 0020
OAS) ee ee ee ee eee el ease ee See 47 G|beeseece=s (bp Eee
6080 ar 430 =F 490 255 420 4.1 Tb. 0. 0098
6081 SF SF 670 alo 690 319 560 4.5 Tb. 0. 0080
6082 | ++ 4+ 600 + 620 240 570 4.3 Tb. 0. 0075
5889 SRF 610 =F 570 238 470 7.8 Tb. 0. 0166
5891 ate 690 ata 710 418 600 3.0 Lb) of, 0. 0050
+ 5892 + 760 SF SF 770 228 720 2.6 Tb. 0. 0022
6083 | + + + 640 | + Ff 650 313 580 2.4 Tb. 0.0041
6084 == 580 Slag 570 282 450 x iL Tb. 0. 013838
6085 se SF A900 ESS eee [Pa eee 203 430 3.3 zDD: 0. 0077
6086 =F 540 sf 540 300 390 4.0 Tb. 0. 0103
5887 Se SF 610 + 600 227 490 2.9 Tb. j{ 0.0059
Sfeft 3) Se ees | PS es ee ee ee ee a a (a) eee
6043 | ++ + 690 45 SP 690 256 550 1.2 Tb. 0. 0181
6087 ae ae . 700 =F 740 380 610 1.5 ibs 0. 0024
6088 ap 600 SP SF 600 234 540 6.2 Noy 0.0115
6089 =P 730 ia 750 345 400 3.2 Alloy 0. 0080
6090 SF O4e (MY) SR Se 620 246 530 2.0 Tb. 0. 0038
6091 ap AF 570 a5 560 304 490 4.0 Tb. 0. 0082
6092 ae 690 seu 700 270 550 4.1 ib: 0. 0075
6094 ar SF 630 SF SF 630 315 490 952 Tb. 0. 0188
6095 SP a 630 AF SF 610 264 550 4.8 Ado, 0. 0088
(PORNS {pe eo ll ee ee a eo dl ee ee eee as ee eens CO) eta eee Sed
6097 ar ar 630 SF SF 610 300 410 5.0 Tb. 0. 0122
OSES) me ee Nee Ne Re | Oe eS ee ee ae ee { €2) ely WPA ep se aes
ae ag pe A ee ee eee eee BU2 SN |peeeet aces |. ee era eeen eee cen|, ROSO084
Ee
a Plague.
b Sacrificed.
¢ Intercurrent disease.
150 The Philippine Journal of Science 1915
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 hb,” 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 IJ].—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 85 cubic centimeters of agar. One animal received a thin
emulsion without agar.
s.0B, 2 Barber: Experiments on Immunization 151
Three animals (Nos. 5990, 5991, and 5992) received this dose
intraperitoneally; animal 5989, both intraperitoneally 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, II, 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
1915
TABLE III.—Series 3. Animals receiving 2 immunizing doses.
| |
Apr. 29,|
Aug. 6, 1912; 61
First avirulent dose. Second avirulent dose. Z
Dec. 11, 1911. Jan. 30, 1912. 1912; 90| Inocu- | days after vir-
days | lation | lent dose.
after of vir-
Guinea 2d ulent |
pig No. dose. Thal q
i Vola oe : J Tumor June5,| Ingui- |
Strain. THe. Weight Strain. ec. | Weight jat point 1912. nal Weight
| of inoc- Weight) glands.!
ulation.
i |
Bx 9. 9. g-
5980 | Thag __.____ 3| 350 a20| ++ | s20 | + 510
BOS Tan seen does U8) 440 + 600 | + 670
BOBZ ieee Cs Ce eyes 3 410 + | “gp | == 380
5988 |__-.- Go eaeee 3 450 sh =e 650 Se 670
5984 |_____ dows. 3 660 + 560 | ++ | 580
beheby |P-seaa doie-= = Z 600 0 690 | 4 700
BORG mn | saa do eeeee== 2 630) (22 Sooo ses ee ne | eee eo | Senenee | ones owes [boeeeeee | oe ee eee
DOS mal eee do 2s 2 410 =e | 430 + 530
5988 |__--- dome 2 350 + 630: | eS 680
GHEE) Hes doe 3 600 SRse 670 | ar 690
59908 |___-- GO ;asveaee 3 430 +++] 640 mala ee
59914 |_____ dosaress 3 360} (ES. doe al aS)" AGO seen ee ee ee | eee
59924 |_____ dojse2 3 570 0 680 | + 700
5994. | Emulsonly-_| 2| 630 = 710 | +2 | 760
‘Average G52 o|225 Sess s|oe SoS eee ee eee eee | 595.0 | ae | Las aoe
Sept. 23, 1912; | Nov. 16, 1912; | Dec. 19, 1912; Autopsy
110 days after | 164 days after | 197 days after ;
virulent dose. | virulent dose. | virulent dose. | Dieg | j j
cue ses ) re
pig No. . : 2 ulent | Body L spleen
met lweight| wal |Weight| “igal’ |weight| dose. |weight.|SPI°e™ sions. ———
glands. glands. glands. | | wash: rf
ee — — = | = ——_ =. |e
g. 9. g. | Days. | 9.
5980 + 420 hea Ee eee joao Re 110 420 2.7 Tb. 0. 0064
6981 ar GE) | ar ar 690 | ++ 690 | 239 580 4.0 | Tb. 0. 0069
rete fd Pero LEI Nad eel ipa od Ug | Md ha ee ae |. 21] Tb. iimet
5983 ar 690 se 670 = 710 | 842 500 10} Tb. 0. 0020
5984 pias BION etaeate 500) 2s een ee 183 440 5.2| Tb. | 0.0119
5985 ap ae TR) || Spr 680 | ++ 610 | 212 530 LALO fe aa. 0. 0182
PRES y lost iets aioe cond pSessces|sssesase) sec seae| sep osecl|ssecccs = JSiaq=See [sazaces- QO) |S
5987 af 580 + 580 cr 580 | 291 640 4.2] Tb. | 0. 0078
5988 + 670 | + + 670} +4 700 | 380 520 | 2.0) Tb. | 0.0038
5989 ++ 690 |+ + + 600) |S =o cole eee 189 | 550 8.11) Tb. | 0.0147
59904 ar 620 ae 590 36 610 | 271 | 550 2.0 bs 0. 0036
Gey Ie Fears eel ase eel eee os eel (Bee pstceveed| beeen \eoeoneee poosece. (©), |e
59928 + SO) ieeects 720) + 730| 453 | 650 | $2) Tb / 0. 0049
5994 =f OOM tists NOOM osteiats 710 | 248 |e 27) Eb | 0.0081 |
eet eee CN Dadar Radar Ms fi co Eff [a 0.0072
|
> Died from sepsis 2 days after first inoculation.
¢Intercurrent disease.
* First dose intraperitoneal; all other doses subcutaneous.
X, B, 2 Barber: Experiments on Immunization 153
TABLE 1V.—Controls of series 1, 2, and 3.
i: .
=| Aug.6, | Sept. 23,| Nov. 16, | Dec. 19, | Apr. 14, a Autopsy.
| 1912; 61 | 1912;110 | 1912; 164 | 1912; 197 | 1918; 3138] 3 HA Sib eaeraen
aS days after |days after| days after | days after | days af- 2 ae
virulent | virulent |} virulent virulent |ter viru- oO ou
= anal Tl aC ay A !
egies dose. dose. dose. dose. |lentdose.| ‘5 2
© oN ‘7 : fay
ee toa =e weve 2] Pall
to pes |e =. = = = e a) =) |
S Petal Sa kt Sal lh Sia oe Sal te SRI elie 9 alata . | Os
e (egies e fest ees | Seo ees es ae | Eig | a) ae |
2 |35|28| @(28| @| es] me] 28] @ les | o |e] 8 | & | ges
5/83] *a| S ) a) © | we! ol ee] S eae] S| 8) S| e | eee
S |SehE eles | ele Pelee] Ss ye] wa | se
3 us = : 2 = i aah AER =
g. > ae g g. g g. |Days.| g. g.
6252 | 480 ae 500; + | 580 aF 550 + 610 | + | 630 j512 670 | 2.8 Tb. |0.0057
6253 | 480 | + 540 |} + | 590 ar 540 a 590 | + | 550 361 470 | 1.7 Tb. \0.0036
6254 | 480 Se AOD) Jl se aay pee ee lemaser aan See esa 159 ' 400 | 2.6 Tb. |0.0065
6255 | 610 + 600 | + | 650 ar 600 + | 640 | + | 630 |460 440 | 1.8 Tb. ,0.0041
6256 | 590 Se |) GEO Srey) NK) an 540 ar 580 | + | 465 \465 560 | 1.9 Tb. |0.0035
6257 | 500 AF 550 | + | 560 ar 520 ar 540 | + | 600 497 450 | 1.0 Tb. 0.0022
sts |) SEO ap 2 Se ) AAD Wessel oe ele satel bop dyed |132 390 | 8.7 Tb. jC. 0223
62598430) eat e=s (ese ee SPE, cd ie Ped re Pl Balai leeciel ee eee 33110) jee (@) ekeSsesss
|
6260 | 600 ar 600 | ++] 620 | ++ | 550! ++ | 480 |____|_____ 202 460 | 3.1 Th. |0. 0067
6261 | 580 | ++ | 570] + | 600 + 670 oF 600 | + | 650 482 500 | 7.5 Tb. |0.0150 |
6262 | 540) + LOT ete ROOM nee | Se eee Pa ae Bea ae 136 450 | 8.2 Tb. |0.0182
ER 200 ea eee Pc eo eb ee el Shae (eee 21 cent | (Oss eee
BOY [ies tops ke So ee ls | wo ie ela | ee tees 5.4 0.065) | ee (BOB |eeece 0. 0088
8 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.
vee Aver-
“in ni- age
Series. Table. ae a ea
vival.
4 | Days.
(ie eee eee & I 9 | 236.6
QEe ae eer | II 25 | 308.8
Shae fle aes ) II 11 | 292.9
Controls _---- IV 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.
pe
| | Aver-
2 4 | Ani- age
Bacillus strain. oily pad
vival.
| SS Se eS = |
| / Days. |
let bag ial tyes a) 11 | 335.7
Wel aye yt) ayaa eee Se 7 | 283.1
eo D premise eee | 4 | 291.3
“Tb emuls b” ____-_-. 3 | iad
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. ae | cs |
weight. |
ae = Ly |
| | Grams.|
Lh bn: Bees 9 | 544.4 |
ee ee 25 | 573.2 |
eee eee 11 | 595.0
| contol Ustad 10 | 539.0
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, 19138 710
October 1, 19138 : 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 oe
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.
1 | | |
Beene | Autopsy.
Gui- | =|" Died |= "4 i
pig | Weight Maat ocak inocu | ame
No. | |Tuber-| Weight lation. eee ‘Spleen se weight
| | | | weishite
| 9. 9. | Days. | 9. | bE
G202N | BOON Atrar =: see ekg ome | eee eee og) sa = ee rests
| e2050" '330) |ueeee dole El Eas + 400 | 173 300 |
6206 550 |.___- dove cet dees eg eas eee 91 | 5004
6207 | 410 |_____ Clo ae ae eee [Pe om: So es a 1 JG0is siseree [fates
6208 BNO) oe AO See oe ae Oe cen | Ee | ee | 7 ED ee
6209" |!" ASML AS walgnended Ss bak Jalen Meter Sie ee SIL Wee. 1
6210). 4800)| Sen dateeie semen ieee # 370 | 170 300
| 6211! 580 |_____ wees ok ee eae ed oa 73 310) | eee
[teeters raga eee Gta wees aldol ds + 410 | 106 350
62139) S40) eee Gok se. Ee on 420 | 132 132
6214 | 440 |____- ap ated Dear ee | +4 4300 | (106 cat sree,
6215a| 360 |_____ ion ee ree (PeakLe 2 inert 78 | 300
6215b, 400 |_____ donee eee ae ++ 430| 122 | 350]
6216) |) 500) |e owe SS eee eee 390 | 184 838
6217 | 600 |_____ dots b dw eT [Rel eh of Huse eat! PaO
Goies|| SRW) || Thani ne eee oats 400} 1909 | 340
6219 | 490 |_____ ge ee erect | Ore 114 440 |
6220} 340 |_____ dogs Sas Ue + 480| 154 | 420)
6221 | 420 |_____ Sgt ae ahwaes, seee + 430 | 104 410 |
6222 | 20h WAI arin oh ieee eee | 0 DOH eon = a eee | Fa eee! oe 5
| Asverage, oes "22 see jn----->- 12056 ye ee
: a Sepsis. bIntercurrent 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.
Sgr, 2 Barber: Experiments on Immunization 159
TABLE X.—Series A. Animals inoculated with material from enlarged
spleens.
~ ape) aT Peery go) OR
2g Weight. 5 Autopsy.
3 | | Ye |
ae — ° —— ae
S go | | = EO.
iS hake 5 oN se : +
a & 2 | Date of inoc- hl gq act a6 = 2 ob
3} 2 ulation. ss a Sp Po 3 2 Ds g
ie leRemes i i - : oa
g 2 |2¢ 1a leis. 5 a ga | Om
& i |) BS | pS $ fl te. > % S|] dg Or3)
3 o ] ad 8 ® a |S 8 S Rll Ales
SQ ii le 2) 2 | = 12 ca |) a i ell] |
. aaa ial |
g- 1912 g 9g. g. |Days.) 9g g
5221 | 680 | 6221 | Aug. 16.____- EXO) eee eee 98 | 410 | 18.2 | Tb. | 0.0328
5216 | 460 | 6221 |___-_ doje: 2 AZO) Reese Sus eo 96 | 410 | 12.5 | Tb. | 0.0305
6400 | 500 | 6218 | Sept. 7_.----- 470 | 480. |__--__ IGE} |) Sisto) ee D3 i|saee5 5225
6401 | 670 | 6218 |__-_- does BO) I} BY) fees 20M 510) 250) | abs 9050089
6426 | 410 | 6220 | Oct. 4 ---__-- 430 | 480] 420 201} 360] 5.6] Tb. | 0.0156 |
6427 | 450 | 6220 |.___- doen 330 | 350} 370} 222] 320) 1.6} Tb. | 0.0050
6428 | 450 | 6220 |____- dols-n22 460 | 490 | 490 | 224) 400] 5.0 Tb. | 0.0125
iene (eae Bae eecetoe | e peseetiseeaaci
IACVeT a eles Re eee ies (Ai | Eraser ol 656) Eee 0. 0167
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 XI.
TABLE XI.—Average ratios of spleen weights to body weights in all series.
=e
Aver- | Aver-
ageof age :
Table ratios,| sur- ao,
| Series. N Origin of tubercle bacilli inoculated. | spleen | vival
oO. . aver-
weight| after Aral
to body| inocu- | *2°°-
weight.| lation.
Days.
1 Yee aS 5 cen ee a oe ey I Sputum ee aera cee eer Lae | 0.0069 | 286.6 9
i re I a! MU iL 9 [ae (0 (0 eee ee a ene ee eS EN 0.0084 | 308.8 25
Bee eae eh ah eS ee WOH freee SVS ee main Sek aks EY ea ya 0.0072 | 310.7 11
Wontrolseee see ee eee Tees eae (6 (Gy See tein Re 0.0088 | 340.6 10
SNe Rh hE eB 8 BS 3 ae Vv Leperispleen? ees i Ss LL eS 0.0191 | 134.6 12
JN aoe eee tee aS ee WA (or) oe cee (Clete ee ns se ee ek eee 0.0167 | 173.7 6
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
lepree 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. Inone (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.
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ur t hi oy at oe y A a
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va > a fli g ye ;
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A ae Be :
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ri
A TEST OF COCCOBACILLUS ACRIDIORUM D’HERELLE ON
LOCUSTS IN THE PHILIPPINES *
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 diarrheal
feces. 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
* Received for publication November 13, 1914.
* This Journal, Sec. B (1912), 7, 521.
132716——5 163
164 The Philippine Journal of Science 1915
feeces 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 feeces 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 feces, 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 IT).
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 Jones: Coccobacillus acridiorum 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.
oe py |
Locusts dead or moribund at the end of—
Lo- if : res.
Lot Dose, about 2 cubic milli- SEIS
, a in- Hours. Days.
No. | meters of loeu- | ,
lated.| l t
| | MR, | PAs, | BY 25 3} 4 Ds le 17.
feealiStocke culture == === =ae | SO} 2h) 0) By) Bu BA) 40) Gu ze aan |
2___| Exalted strain, 14 insect pas-
RACES. A eee es 50 i 5 21 34 44 AGMM ATE eaten | scales
Sees WBrochialones =) ee ae ee BO ease 1 1 3 6 uf 7 || 1
4___| No inoculation ---_--_-_------ Oe oe 1 1 2 4 5 5 Sie, |
| A ni ia | 5
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 1915
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-
169
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170 The Philippine Journal of Science 1915
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 diarrhea 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 @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 Gdaleus nigrofasciatus DeGeer, and
Locusta migratoroides R. and F.2 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 O28 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
daa 9 13}:
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 Stawronoutus maroccanus, was obliged to obtain 56
passages before obtaining a coccobacillus sufficiently strong to propagate
the epizodtic 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.
2 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 8&7 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, 1914.
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, 1914.
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 Hurope. 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, 1914.
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
Wak DEPARTMENT,
BUREAU OF INSULAR AFFAIRS,
Washington, May 9, 1914.
From: Bureau of Insular Affairs.
To: Governor-General of the Philippine Islands.
Subject: Hxperiments 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, 1914.
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.) CHaAs. C. WaAtcurTtT, Jr.
Assistant to Chief of Bureau.
Copy for The Director of the Bureau of Science, June 12, 1914.
DEPARTMENT OF STATE,
Washington, May 21, 1914.
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 Barberand 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.
LOSE 92:
[First indorsement.]
BUREAU OF INSULAR AFFAIRS,
May 28, 1914.
To the Governor-General of the Philippine Islands, Manila, P. I.
co.
Incl. 6478-41.
[Second indorsement.]
THE GOVERNMENT OF THE PHILIPPINE ISLANDS,
EXECUTIVE BUREAU.
Le
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 virulent virus which had been transmitted through from 74 to
87 grasshoppers. Ninety-three liters of bouillon were sprayed with the
apparatus of vermorel [Vermell?] 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 Vermell, 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, 1914.
AMERICAN CONSULATE,
Algiers, Algeria, May 2, 1914.
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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THE PHILIPPINE
JOURNAL OF SCIENCE
B. TROPICAL MEDICINE
VOL. X MAY, 1915 No. 3
MALARIA IN THE PHILIPPINE ISLANDS
Il. THE DISTRIBUTION OF THE COMMONER ANOPHELINES AND THE
DISTRIBUTION OF MALARIA *
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) rosstui, 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. rossit, 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-
*Read before the Philippine Islands Medical Association, November 6,
1914,
* 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. - Der | Infected.
|
Per ct.
Anopheles febrifers>. +. ee ee eee ee ee eee eee 373 35+
Anophelesimaculatits= see ae ser ere en oe ee a a aE, 49 6+
Anopheles rossit pia eae ee ee eee ee es ee es Se 642 10—
Anopheles bar birostris 5 pace ee ie ee oe 205 | 3+
Anopheles svip|73t3 aS Se Re ela ee Sat eee a 18 0
With regard to sporozoites in the salivary glands the numbers
are as follows:
Salivary glands.
Species. | Infected.
Dis-
sected. |
Number. | Per cent.
Anopheles tfebriufer tc. 2-2ee 2 nese Ae eee eee ee ll 20 18+
Anopheles maculatus=-) 226-5 > Se Cee 2a eee 1 1 100
MAN ODNELES TOSSUD an sas ee ne ne ee el ee 125 0 0
| Anopheles i0G7, DU OStT:7S ae ae a ee ee 75 0 | 0
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 larve and
imagoes, and some experiments in the destruction of the larve
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.
xB, Barber et al.: Malaria in the Philippines 179
THE DISTRIBUTION OF ANOPHELINES
LARV4
In determining the number and character of the larve of a
locality, the following method for the most part was employed:
Larve 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. Anopheles rossi 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 larve 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.‘
* Loe. cit.
*Specimens of anopheles from larve 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
larves 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 mosquitoes were identified
by Mr. C. S. Banks, entomologist of the College of Agriculture of the
Philippine Islands, as Myzomyia rossi. In view of the rather indetinite
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 1915
Details as to the distribution of the various species in different
localities will be found in Table I, but in general, Anopheles rossi
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 alge 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 algze 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, 489, note]
specimens of Anopheles (Myzomyia) febrifer Banks were sent by us to
Doctor Ludlow, who identified them as Myzomyia christophersi Theobald.
Doctor Ludlow informed us by letter that this is the same species as that
reported by her from the Philippines as M. funesta. [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%,B3 © Barber et al.: Malaria in the Philippines Si
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 alge 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 larve 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 larvee become rare or absent. Where the same
brook becomes swiftly flowing again, the larve 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 larve 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 larve 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 larvee could be taken up at one dip of a small collecting pan.
The number of larve 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 alge at the center. We have sometimes found it in nearly
“pure culture” at the steep shaded margin of a large brook,
while A. barbirostris 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. rosszi 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 larvee of four species
of Anopheles in habitats arranged according to the amount of
decaying organic matter in solution in the water.
X, B, 38 Barber et al.: 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 larve 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
Small bayous from
clear brooks
and rivers.
Fic. 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 larvee
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 krook 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 larve 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 larve 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 larve of anopheles, apparently of
A. febrifer, during freshets, in eddies among floating débris.
Apparently enough eggs or larve 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,’ who give the following percentages for
females that took advantage of one opportunity to suck blood:
Per cent.
Anopheles rossu 63.6
Anopheles barbirostris 49.4
Anopheles febrifer 54.8
Anopheles maculatus 50.0
Anopheles sinensis 67.8
* Loc. cit.
X, B, 8 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-
walt 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. rossi 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. Larve 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 larve 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 rossti 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
larvee of A. rossi 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 larve of A. febrifer in small numbers
at the edge of this stream and some of A. rossi in the swampy
ground. The various streams and ditches have been faithfully
oiled, and the larve 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 larve. 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 anzemia, 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 33.8, 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 IJ. 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, 1914.
| Persons exam-
Mosquitoes caught. ined for mala-
Houses Dayson rial parasites.
, Gon ace
Barrio. aire visits l
mE)» || ORE A. bar-| A. ma-'| -
made. | A. fe- | A. ros-|*7". 2 | Num- | Posi-
: oe biros- | cula- | Total. | aes
brifer.| sti. ere, tus. | ber. tive.
=
Per ct.
A (aero eR ae Nene EN 6-8 il 166 34 0 0 200 48 | 33.3 |
Magbando)22222222-=-— 2-3 4 34 14 0 0 48 11} 18.2 |
iBugsangas oes see 15-20 10 20 110 0 1 131 16} 56.3
Mixid 0obeeeeen sean 125-150 15 13 122 0 0 185 127 | 37.0
Inu ban eye nets sues 710-75 12 17 69 1 Oi Sy 15 | 46.7 |
Dormitory H with }
Kitchen 22 eee 2o an Wek Bee 17 1 192 0 0 193: |__ Seer
Totals Lae aa ke lees eee) ee 251 541 1 1 794 217 | 37.3
ee oe Oe ee a i
TABLE II.—Anopheles caught in houses during May, 1914, in San Jose Estate,
Mindoro.
x |
Females. Females,
Species. | Males. | Total. aera
With | Emp- | Doubt- blood
blood. ty. ful. -
| =
| | Per ct.
Anophelesebruper sa ak et ee eee oa 232 8 13 1 249 98.5
Anophclesimossit ieee aren ena eee eee eee eee 452 30 37 58 572 87.1
Amoniveles OOTbU7OStTUS nea oe ee eee ee 1 0 0 | 0 1} 100.0
FAMODRELESUINACULALUS eee Hee nae ee ene 1! 0 0 0 1] 100.0
TS eal PSC ee EE Lue a BE en os a 686 33 | 50 54 | ag23| 89.2 |
ae : ee, eee (eee es) My oe A
8 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. Larvee of Anopheles rossi,
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 larve of A. febrifer, A.
rossu, and A. barbirostris 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 larve of A. febrifer
were found.
1915
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K,B,8 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 1V.—Cases of acute malaria admitted to Iwahig hospital during
three days of June, 1914.
Resi- : |
Date. are the te Residence when taken ill. Microscopical findings in blood. 7
colony.
1914. Yrs. mos.
June 22__| 7303 9 | Malamig barrio-_-------__--- Tertian +.
Do___| 5627 (ely ee OOF 4e3e. es Tertian, rare.
Do-___} 8123 5 (0) eae Gj) eee A Anzmia, parasites doubtful.
Do__-_| 9080 45 *Centraliae-2 2-2 .| Negative.
Do___| 8184 1 Ea ea ca do ee See Ease eee Afstivo-autumnal +--+.
Do___| 7734 CBee Goya aS a eS ae Tertian, few.
Do__-_| 2976 5 OF Eases OO eee tase se sv eennet ee AXstivo-autumnal +.
Do-__-| 6851 Ae ESS eS (3 (CS a A AXstivo-autumnal, few.
Do__-_| 8845 Le See (ho See eee ee A EE eae Do.
June 23__| 8398 1 | Malamig barrio____________- A®stivo-autumnal, rare.
Do-___| 8811 1 | Kabaloan barrio___-__-----_- Tertian +.
Do__-| 7077 1 | Esperanza barrio___-------- Tertian, rare.
Do___| 8701 2 | Malamig barrio_____________ Z®stivo-autumnal, rare.
Do___| 5455 1 | Esperanza barrio___-_----_- Negative.
June 24__) 8597 i); Balsahanybarrioe=--------—— ZXstivo-autumnal +.
Do___| 8657 4 | Malamig barrio_---_-----_-- Tertian +.
Do___| 8611 Grea Coys ee eee es sa eeeee Aistivo-autumnal with crescents,
rare.
Do_-__| 8784 1 | Esperanza barrio_-_-------- Asstivo-autumnal rings, rare, cres-
cents +.
Do___| 9016 (4 Vesa C0 Co ees ep ey ee ae | Do.
Do___| 8150 3 ||Quinina barrio) --— A‘stivo-autumnal, rare.
Do__-| 5906 3 OF) Beane (6 (pepe nee See Negative hemoglobinuria.
Do___| 6840 6: |(Centralets oie stivo-autumnal, rare.
Do-__-_| 6184 8 O)beeee dO sbacssesstee tae 2 A®stivo-autumnal +,
Do___| 8891 Cee eS AO) 22802 2 A aes Tertian, rare.
Do__-| 8567 i tg [ene dO sie sca esee ee eee A®stivo-autumnal +-.
SUMMARY OF TABLE Ty.
Examined ; 25
Parasites found 21=84 per cent.
Cases from barrios Y 15=60 per cent.
Cases from Central 10=40 per cent.
Average admissions per day 8.3
192 The Philippine Journal of Science 1915
According to the resident physician, Dr. José 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 larve 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.° When we compare the small number of this species
found in nets in Iwahig with the number of larve 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. ross. Only one specimen of A. maculatus was found in
‘Stephens and Christophers, The practical study of malaria, ete. The
University Press of Liverpool (1908), 169, 181.
X, B, 3 Barber et al.: Malaria in the Philippines 1938
houses (Bugsanga barrio, San Jose), but the larve 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 larve 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 larve 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 larve 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. rossi 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 1916
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 larve 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 larve 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 larve 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 cafon. 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).
LB, 8 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 methy! 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 hemoglobin 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 § and employed by Koch ® in the
examination for trypanosomes, has found favor with many in-
vestigators of malaria. It was modified by Ruge*® and employed
by Dempwolf."
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 hemoglobin 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.
* Rept. Thompson Yates Lab. (1903), 5, part I.
® Deutsch. Med. Wochenschr. (1907), 1889.
* Malariakrankheiten, 2 Aufl. (1906), 290.
* Arch. f. Schiffs- u. Tropenhyg. (1908), 12, 485.
* Proc. Canal Zone Med. Assoc. (April to September, 1911), 4, pt. I, 49.
198 The Philippine Journal of Science 1915
Muehlens," 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 ** 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
zestivo-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
8 Beih. z. Arch. f. Schiffs- u. Tropenhyg. (1912), 16, 46.
“ Journ. Hyg. (1913), 13, 49.
KU .3 Barber et al.: 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.
Slides Slides
exam- exam-
ued ed
Time examined before the preparation to) . * « °
as G@IEWEal HOSEN. qean Time required to find the first parasite. hich
time time
was was
taken. taken.
Ani NULESe ee eee SS ae Ss Oh immediately =o ee ee a see ee 13
a2; tor4./b) minitess 2-208 see) ey 230 |"biton O}Second Sj=saaeee see a ee eee ee 4
byminutess- 226 ea see 33 see 236% (NL bitorZbISeCONnG Sees ces a ee ees 8
BeZbitojosto nbs ae a a er AST SOKLOMoIseCONUS eae ae eee ee en 13
Gainiinutes sete: h2n5 3 Sees (SH Mllminuteysss sacar See Se Ae Ec Se See 6
6:25, to Gc 7ominutess-- sass ee ee 245 ie 2etowlsbiminu tes === aeeeeee ee a eee 10
TOUTE COS eee ee ST ep SE ee 19h Ohminubest te seas soet eee se Ses ee 3
TAS) iO) WANS eeovy ons) ee es SMIRZECDICOTAc DEO TELE S sere een eee yes 6
SamiInutesve = wees es ee ee OF | MSuminutesm-= ses se soe eee eS 2
S:2b, LOLs. O MUNG ess ee Ie iOe2bitolsepimMin bess a= ee 3
Ohmi tess=- 2 eee FN oe me! oe ASIAN TUTE Se eee ts er a yee ye ee 3
OOeMNINU bess aan een eee eee ee eee Da KAS eminuteses— aa es ee ee ee 1
HOjminiitess= sea Seas ey SS eyes 39220) Ato byminutes 4522 eee ee 2 ee 1
LOWS ymin utes ss = eee eee di (6iminutes) esis. ee et Se 1
HOpMINULe se sere a. ase es ee eee) in| Gub minutes. 2. eee oe 1
(ROWTINIUILGS See ee ee ee eee ene See PAG Pee sees cae 5 teensy d ieee thay eS AEN Bh dels Tak bie ci
LG Gea i eee eta a EN 463 Totalee cen cee er eee So Rp
Summary of Table V.
Time required for 463 negative slides 2,588 minutes.
Average time per negative slide ; 5.6 minutes.
Total number of negatives and positives 538
Percentage of positives 13.9
There were 538 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 1915
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 hemoglobin 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.
201
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217
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Barber et al.: Malar
X, B, 3
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Summary of Table VI.
The Philippine Journal of Science
1915
|
Parasites posi-
|
‘Spleen positive.
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-
| | tive.
| Exami- |
ape. nations.| | | |
| Num-| Per | Num-| Per
| ber. cent. | ber. cent.
All ages: | | |
Both spleen and parasites_-___.__|________________. -__ 45360) |Pose= tale eee jesse eee
Spleen’ only2-
Persons examined, all ages (deduct- !
ing for localities surveyed twice { |
or three times), estimated: | |
Bothispleentandiparapitessas es | ae eee 1 5349995 | Re. ae ee oe | ee
Spleen -only2s& 2455-222 ae ASE eee ee ee AORN Eee Ses (ae | bE 5 ek
‘Parasitesionlys sss see ee | See ee eee P45) | Soe |a=-3--3|-2-22-e eee
| |
TOtal eee eee | Ee eee eee 6,251 bse 2 |-e =. 2.26 ee
Total persons examined for |___._____-_--.--___- | AS 658i |p 22 Sx 445 See ee | bles wets Ll
parasites. Pees) ee
f 10 years and| 4,051} 466) 11.5! __. {cat
Children only, parasites_-___________ nde | | |
11 to 15 years_____ 695 115), 16.65 eee
Motes Si. jee) Bee hh |B ee ee ema 4,746 | 681 | “ia3)| 2 ee |
: 10 years and | 5046) Seen = a oe = 755 j 15.0
Children only, spleen -----.--------- inden | )
11 to 15 years_____ B55 spears (ee eae | 125] 14.6
| Total 22 0e. oe. 2.8 a ee ee 5 0010 |e eee SP { gg | 14.9
I. oS Se
Children only, one survey of each |{10 years andj] 3,545 366} 10.3 Beers | Se
locality included, thus eliminating under. ' |
all duplicate examinations. \(11 to 15 years_____! 568 | 85 15:0 |. 32 eee
Stal Sows eee PRs AY LRN a a 4s| 451| 120) 22
Children only, one survey of each (10 years and) 4,646 ________|________ 613 13.2
locality included, thus eliminating under.
all duplicate examinations. |(11 to 15 years_____ MEQ Ae Sa. eae | 113 | 14.5
| | —_——
Totaly 22. = eee jee ed Rit Sai ee 5, 4263 ||. see soca} coon es 5
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 * 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
* 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 * 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 48, or 6.7 per cent,
as at or below the umbilicus.
* Tbid., 18.
XB, 3 Barber et al.: Malaria in the Philippines OPAL
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+” (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.
29 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.
= ee ee = |
Positive at all 3 examinations_________ ef eee a OE] 4! 6.9
IPositiveatiziexaminavions Mera chy Gat ieee oe ee eee ae 17 | 29.3
Positiveratiltexamination, ener alu vie jet tices setae | 21 | 36.2
Nevativelatalligiexaminablon sasees= sees es sae She te cern eee Se Ses Ss | 16 27.6
4
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Positive atwirstiexaminationgs=2 ese -—-- se = eee aaa eee eee ne ee 9 | 15.5 |
Positiyerat second examination oo. <4. 255c—s = Bee ee 35 60.3 |
j
Rositivelat thir exe ri bl OM ee see rE 24 41.4
Positive:at.at.least: lexamination = 42-2 2.602 ok oe ee eee | 42 | 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
Rae, 8 Barber et al.: Malaria in the Philippines 992
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.
eae Name. | General surroundings. Ditches. geese
Vi.
25 Calambase = 2 e_ | Level plain; irrigated | One main; several laterals; | River, side of
rice country. flow comparatively slug- town.
gish. Water from rice
paddies. ,
OMEN Os omen = oo Hilly region near | Many laterals; clear water, | Brook, side of
mountains. mostly swift, but some town.
quiet places.
10 | Magdalena -______. Plain; coconut-palm | Very many laterals; clear | Brooks, one on
region. water; flow compara- either side of
tively slow. Much veg- town. Pools
etation. near market.
UGS) WEEN AGA, oe wo Hilly; near moun- | Many laterals; clear water; | Brook in and
tains; elevation, 275 flow swift with some near town.
meters. quiet places. Some
| vegetation.
224 The Philippine Journal of Science 1915
TABLE VIII.—“Ditch” or “canal” towns—Continued.
No. |
ae Name. General surroundings. Ditches. pa is eeriats
| VI.
16 | Nagearlan___._____ Billy) So ae ee Many laterals; clear water;| Brook near |
flow swift with quieter | town.
places. Somevegetation. |
AS isucbanes sce = Mountain; elevation, | Many laterals; clear water; | Brook in town.
425 meters. swift. Little vegetation.
AON etayabis esse irllytoaseae ree see Many laterals; clear water;| Brook near
mostly swift, but with town.
quiet places. Some
vegetation.
50) | '‘Sariayase sees Hilly; elevation, 195 | Not many laterals; mostly |____________________
meters. swift. Some refuse veg-
etation.
Malarial survey.
No. j 2
Tabl Anopheles survey. | Perernae PUES
vi a! ee
s Parasite.| Spleen.
2| A. rossi in ditch. A. rossii and A. bar- nee 18, 1914 52 0.0 0.0 |
birostris numerous in river. Aug. 6,1914 116 | 0.0 0.0
ane ; ’ Apr. 30,1914 | 54| 20.0 7.4
9 | A. febrifer in ee of walls of ditches, |e 19, 1914 | 50 | idiot fea
also elsewhere in ditches andin brook. = || apainases 150 ieee | L7
: bet _ |Mar. 28, 1914 | 137 19:0} |-==eeeee
10 | A. febrifer EERO Ue GHG R2E also in July 22,1914 | 18 57.8 | 39.1
bropke: A. sinensis (?) in ditch. A. ros- | Oct.-Nov., 1914 | avi gpg) eee
SULT DOOLS: bp Bg a oe Ue el oe lice douhitne pop | eae seks 70.9
erat _ |{Mar. 31,1914 | 49 | 8.2) ene
15 | A. febrifer in ditches and numerous in jase 18,1914 | 51 $5.5 |< eee /
DIRS. i cae Yea te | gag]... See
(Apr. 29,1914 | 58; 115] 94 |
16 | A. febrifer in ditches and in brook -_-_-_---- fav 20, 1914 } 52 22:9) | ae .
eat dome 112 |. eran
48 | A. febrifer in brook. None found in| Dec. 11,1914 112 3.6 14.4 )
ditches. January 7, 1915. | |
49 | A. febrifer in ditches _____-..--.------------ Dec. 10, 1914 10/ 29.1) 82.7
50 | A. febrifer in ditch in alley ---_--------_.--- Jan, 8, 1915 29 | 4.4 | 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 larve
X, B,3 Barber et al.: Malaria in the Philippines 225
of anopheles in this ditch yielded only a few specimens of A.
rossi. 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 larve 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 Il). 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
296 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. rossi 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 larve would be brought
up at one dip of the collecting pan. Anopheles febrifer was
220
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992 The Philippine Journal of Science 1915
also found at other points near the camp. Anopheles rossii
occurred in alge and in pools in the bed of the stream. A few
larve 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,” 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 rossu was plentiful, A. febri-
fer occurred in moderate numbers, and A. barbirosiris and A.
maculatus were few. With the exception of localities occupied
by A. rossi 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. rossi 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 1915
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 '§ 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. rossi 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
*% Ind. Journ. Med. Res. (1914), 4, suppl. 78.
RES 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 larve 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 larve 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 larve of any kind were found, but a few
larve, 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
larvee of A. febrifer and A. rossi 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 larve 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
larvee 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
larve 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.
239 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 larvee 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, Paranaque, 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, 38 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-
latus is relatively scarce, and probably plays a far less part in
the transmission of malaria than A. febrifer.:
Watson * 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
* Trans. Soc. Trop. Med. & Hyg. (19138), 59.
234 The Philippine Journal of Science 1915
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, 8 Barber et al.: Malaria in the Philippines 935
Annual death rates and morbidity rates from malaria in the Philippine
Islands, 1909 to 1913, inclusive.
| Year, “hom | qlettl | averaze, Cases, | Pople =
DASTOTS js eee a ee a25,751 | 179,355 14.35 | 216,516 |6, 331, 695 0. 26
OI O}e ee Soca o lee oe Se eee eek Lb 26,859 | 191,576 13.75 10, 225 |6, 956, 979 0.14
OT eee ene ee. ee eae 28,181 | 188, 412 14. 95 19, 363 |7, 007, 081 0.27
OT 2 eee area Selec eee ee 27,229 | 184, 639 14, 74 11, 555 6, 857, 892 0.16
NOISEAK CECEEE & oe Soe ee cud tee eee 17,619 | 147,544 11. 94 20, 378 |6, 770, 736 0.30
8 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 larvee 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
936 The Philippine Journal of Science 1915
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 larve 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 larve 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 larve breed.
Work of this sort has been done successfully at the Calamba
Sugar Estate.
Watson 7° 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 maculatus 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 larve 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 larve of A. febrifer, the
results of which are given in Table X.
* Loc. cit.
X, B, 8 Barber et al.: Malaria in the Philippines Di
TABLE X.—Haperiments with mosquito larvicides.
Ap- Preliminary survey.
Ex- : proxi-
ment Date. Locality. Nature of breeding place. width Coe aoa es
; | stream No. BRB ;
5 dips.
1914 Meters.
1| Apr. 14} Canlubang, Laguna_| Rocky brook with much |0.5-5 14 14 128
vegetation and jungle.
2| Apr. 15 | Santa Rosa, Laguna_| Swift clear brook; com- |2 -6 11 11 113
paratively little vegeta-
tion.
3 | May 16 | San Jose, Mindoro__| Small brook; moderate |0.5-3 10 10 65
amount of vegetation.
4| July 31) Magdalena, Laguna_| Narrow ditch; much NSS eee es 26 113
| grass. Water cut off
| half an hour before oil-
ing.
Inter-
ce ee eee ae
; mate | proxi | spray Baas
Hee mate jing and and after.
tance | time. | reéx-
Kind. Amount. |worked. erune Dips. | Larvze.| Before.| After.
Liters. | Meters.|h. m.| Hrs. |
Crude petroleum_) ) 1,000} 3 0O 20 | 200+ | 7 9.1} 0.035 |} 100:0.4—
Larvicide, Dar- 0 || 400 30 | 24) 137 38 10.0 | 0.280 | 100:2.8
ling. |
Crude oil________- 8) 60 ss) Rye 8 6.5 | (ce) |a100:1
| | 5| 81 1} 483) 0.012 | 100:0.3
Kerosene _______- 4.5 | 370 20 | 16 55 0 4.3 0. 00 100:0. 0
| (b) | many 0} 4.8] 0.00 | 100:0.0
8 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.
b19 days.
¢ After treatment larve found only two or three times along the whole distance and in
very small numbers. Exact data not recorded.
a Hstimated.
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 larve 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 larve counted. The dips
were made in places where by long experience in collecting we
knew that larve were likely to be found. The streams in all
experiments contained clear flowing water, and there were few
larve 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 larve 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 larve 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 larve 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 larve 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
GAB, 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 larvz to follow
the current down the stream, except when there is abundant
floating débris for them to cling to. In experiment 4 the treated
ditch was found practically free of larve nineteen days after
the ditch had been opened to the main ditch above, where larve
were plentiful. It is probable that if a portion of a stream is
thoroughly cleared it will remain so until a fresh supply of
larve 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 larve. 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 larve, and 78 additional dips above and below
the stations gave 95 larvee, a total of 131 larve. The average
numbers obtained per dip were 12.5 larvee before treatment,
1.5 larvee after treatment. The destruction of the larve 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 larve 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 larve, 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 1915
larvicide in mechanically in order to destroy the larve 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. rossu in this ditch, and the malarial index of the children of
the town is 0.
Watson?! 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”? 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.
** Loe. eit.
* Ind. Journ. Med. Res. (1914), 4, suppl. 64.
X, B,3 Barber et al.: Malaria in the Philippines P41
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
larve we have most often encountered a species of Ranatra.**
We have observed the insects and larve of a species of the
family Dytiscide?* feeding on mosquito larve in streams. In
a shallow pool containing Anopheles rossii we have observed
flies catching larve. The flies rested on twigs and on the
surface-tension layer of the water and seized the larve from
above when the latter came to the surface to breathe. In a
brackish pool in Palawan Province tadpoles were observed
catching the larve 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 larve were found in the upper part of its digestive
tract.
Where larve are protected by alge, grass roots, stones, or
floating débris, 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 larve 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 larvee-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 larve 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.
* Identified by C. S. Banks.
133057 5
YAP, 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 larve 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 larve 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
DAA 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 larve 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.
Filarize 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, filariz 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,3 Barber et al.: Malaria in the Philippines 9A5
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. larve 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.
eR? * a
i a)
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ILLUSTRATIONS
PLATE I
Fic. 1. A stream flowing through Bongabon, Nueva Ecija Province, Luzon,
a town with a high malarial index. Ancpheles 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. Larve 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
Fic. 1. Diagram, showing the relative abundance of the larve of four species
of Anopheles in habitats arranged according to the amount of
decaying organic matter in solution in the water.
247
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BARBER ET AL.: MALARIA IN THE PHILIPPINES. ] [PHIL. JOURN. Scr., X, B, No. 3.
Willy Ms tan -
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Fig. 1. A stream flowing through Bongabon, Nueva Ecija, a town with high malarial index.
Fig. 2. Baliuag River, Nueva Ecija. Larve of Anopheles febrifer were found in the grass at
the margin of the stream at the right.
PLATE I.
[Pui. Journ. Sct., X, B, No. 3.
AGDALENA, LAGUNA PROVINCE,PI.
FROM A MALARIAL SURVEY MADE IN LATE
OCTOBER AND EARLY NOVEMBER, 1914
—e ee
he sumbsls represent Cases of malaria in children
I5 years o age or less found in the houses
Subtertian @
Tertian A
Quartan wt
Negative °
Child not examined B)
Ditches containin te
clear flowing water =
100 50 100
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Church
CALLE CA/LLES
CALLE HERRERA
MAGDALENA, LAGUNA PROVINCE, PI.
FROM A MALARIAL SURVEY MADE IN LATE
OCTOBER AND EARLY NOVEMBER, 1914
mee
{Pui. Journ. Scr., X, B, No. 3.
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years of age or less found in the houses
Subtertian
Tertian
Quartan
Negative
Child not examined
Ditches containing
clear flowing water exe
vOxure
too 50 100
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CALLE L. JAENA
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PLATE Il. MAGDALENA, LAGUNA PROVINCE, LUZON, SHOWING THE RESULTS OF A MALARIAL SURVEY OF TI T
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CONTENTS
Page. x
BARBER, M. A.; RAQUEL, ALFONSO; GUZMAN, ARISTON;
and ROSA, ANTONIO P. Malaria in the Philippine Islands.
Il. The Distribution of the Commoner Anophelines and the % i
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THE PHILIPPINE
JOURNAL OF SCIENCE
B. TROPICAL MEDICINE
VoL. X JULY, 1915
PATHOLOGIC ANATOMY OF BUBONIC PLAGUE *
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.
Buboniec and pneumonic plague.
Septicemic 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-
ticzemia.
Femoral buboes.
LYMPHATIC GLANDS—Contd.
No. 4
Primary (7?) 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.
INTRODUCTION
—— —s,
7 AAnion tA <
s ens! of Peve K
wn
NOV 1 1925
thy
er) Aen
NVon 2 Miceu™ y
ial Musev®”
nee ae
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
* Received for publication May 7, 1915.
133736
249
,
250 The Philippine Journal of Science 1915
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 “septiczeemic
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 septicemia,”
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 O51
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.—tThe 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. || Age. | Cases.
| \} a8
Wnderikyenrth i eves. Wey fs 1) || 21't0,25syeans kee eleal 5. ea | yet
Isto yean sts te tok a eer EL 2) (p26itoiS0'years!-- 25 en ee 12
| Gitar Ory ears pa naer te Weeee eee ae alter endo wenn et en 14
Dstorlbyyearstss e222 sh. Pe eae | 9 i 41 to 50 years! 2-2-2522: 8-2. se Se eee 7
16'to}20 Vears ease) aie See ae oe eS | 15 | Sl yearsiand over so2¢¢! sees eee 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.
ofilinese,| Cases. ||opiinese,| Cases.
Days. Days.
1 5 9 1
2 10 3
3 15 1 0
4 12 12 0
5 9 13 0
6 6 14 i!
" 9 15 2
8 2 unknown) 4
|
|
|
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? and by Schdbl*®. 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 (1918), 8, 109.
* Ibid. (1918), 8, 409.
x, B,4 Crowell: Pathologic Anatomy of Bubonic Plague 258
a
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. 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
eutaneous 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,°> 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. (1918), 8, 426.
954 The Philippine Journal of Science 1915
SEPTIC4sMIC 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*® 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 septicemia, 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 septicemias just
described, are the cases of plague commonly spoken of as septicemic, 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 septicemie or toxemic,
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 septiceemic 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
septicemic 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 cedema 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 septiczemic type of plague is furnished by Childe.’
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 septicemic 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 cedema, its substance
is rather soft and can be easily scraped off with a knife, and sometimes
small softening areas were present. There was no hemorrhage in the
areolar tissue around this gland and at most only a little edema 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 hemorrhage or cedema 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-septicemia where death had occurred
shortly after attack, the glands were found slightly enlarged, of a dark red
colour and contained much blood and cedema fluid. This appeared to be an
earlier form of the characteristic pink plague glands described above. The
difference between the bubonic and septicamic 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, 568.
256 The Philippine Journal of Science 1915
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 septicopyzemic.
Concerning primary plague septicemia, the German Commis-
sion § reports:
Primary plague septicemia 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 hemorrhagic 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 septicemia 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, who had the opportunity of studying the
epidemic of primary pneumonic plague, reached the following
conclusion in regard to primary plague septicemia:
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 septicemia 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 '° opposed the classification of plague in man as a
general hemorrhagic septicemia. 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; (8) primary bubonic plague with secondary
plague pneumonia; (4) primary plague pneumonia; (5) primary plague
pneumonia with secondary septico-pyemia; (6) primary plague septicemia.
In regard to the presence of B. pestis in the circulating blood
‘Arb. a. d. kais. Gesundheitsamte (1899), 16, 75.
* This Journal, Sec. B (1912), 7, 180.
* Pub. Bur. Govt. Labs., Manila (1904), No. 23, 20.
x, B,4 Crowell: Pathologic Anatomy of Bubonic Plague 257
Schobl * 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 septicemia may be present at a comparatively early stage
of the disease and for a considerable number of hours before death, and
(2) the septicemia 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 septicemic 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 “septiceemic
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
pheumonic plague in this category. Therefore it would seem
more rational to include in this class only those cases (1) in
which septiczemia 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 septicemia or
septicopyemia.
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-
“This Journal, Sec. B (1918), 8, 418, 415.
VAsye) The Philippine Journal of Science 1915
tinguished another type of plague of this class. Wilm,” Hos-
sack,!? and Zuppita 1* have reported such cases, but no case of
primary intestinal plague has been unequivocally proved.
Childe % 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. ¢.,
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 ** reports on pestis minor or
ambulans as follows:
In addition to the three main types of plague which have been described
above (bubonic, septiczemic, 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 septicemic 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.
* Hyg. Rundschau (1897), Nos. 5 and 6 (quoted by Herzog).
* Brit. Med. Journ. (1900), 2, 1486.
“ Zeitschr. f. Hyg. u. Infectionskrankh. (1899), 32, 268.
* Report of the Indian Plague Commission (1898-99), 1, 368.
*Tbid. (1898-99), 5, 54.
x,B,4 Crowell: 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 septicemia or without superficial bu-
boes).
3. Laila 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 1915
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 hzemor-
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 septicemia 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.
Dieudonné and Otto ™ 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 feces, it is very possible that by
scratching the place the pest bacilli present in the feces of the flea may
be rubbed into the small wounds in the skin.
Dieudonné 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
“ Kolle und Wassermann, Handbuch der pathogenen Mikroorganismen.
Gustay Fischer, Jena (1912), 4, 207.
x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 961
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 resistentiz, which
favored infection through the blood stream.
Castellani and Chalmers state :5
The site of inoculation is sometimes marked by a vesicle, the contents
of which contain the Bacillus pestis in considerable numbers.
Albrecht and Ghon state:
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, cedema, necrosis,
hemorrhage, 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 petechiz. 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 zodgleal 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.
* Uber die Beulenpest in Bombay im Jahre 1897. Wien (1898), II B,
484.
262 The Philippine Journal of Science 1915
A few polymorphonuclear leucocytes are present. There is a small hem-
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 ”° states that the most frequent
alteration in the skin is the occurrence of multiple hemorrhages,
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 hem-
orrhages are scant or absent.
In my cases hemorrhages 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 hyperemic 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 8 cases these were
* Uber die Beulenpest in Bombay (1898), II B, 481.
x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 968
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 2623.—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 hemorrhage. 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 hemorrhages. This forms the primary bubo.
Case 2883.—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 puncte, 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 hemorrhages, papules, and carbuncles. The hemorrhagic
lesions consist of simple hemorrhages in the corium and sub-
cutaneous tissue. This hemorrhage is small and does not often
extend into the epithelial layer. In my cases there were no
large diffuse cutaneous hemorrhages such as have been described
in some epidemics. It was these large cutaneous hemorrhages
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 2385.—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 papille 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 1915
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 *! 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 hemorrhages 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 cedematous 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, 70.
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 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, 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 ceedema and hemorrhage
varies in different cases. Most frequently there are several
glands involved, and the tissues surrounding the glands are also
very hemorrhagic and cdematous, this condition involving
muscles, vessel walls, and fasciz (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 hzemorrhage, cedema, 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 ?? 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.
“2 1UOOs) CE, TOs ALIAS
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 cedema, hemorrhage, and necrosis is
less, and the glands are not as a rule matted together nor so
much enlarged. The cedema, 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
hemorrhage, surrounding cedema, 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. |
| Removal Gis: Sees 5 Soe eee A SS 2 31 | 24 | 1(?)) 55
Cenyitall oni ritbey Bice upper ect Jak el eels eel ee ale | Bac coda MU Rita |
Assillaryisce: sntcn cook the ts beet ete cect ne ee eee 2 eee 6 |
Wige Seca eee Pec ieee hen see cee ccie ee Bh oa eee A apace 1 3
Popliteasl cc. s =a 55< ee Soe ee eee See el i Bl eee a 1
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 edema. At the same time cedema 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 hemotoxylin. 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 1915
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 with eventual necrosis. The entire process thus
extends to the periglandular tissue, where the adipose tissue
may be seen to be infiltrated, heemorrhagic, 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 hemorrhagic 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
hemolysis.
The number of bacilli appearing in large masses in the glands
and pefiglandular 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 hemorrhage, cedema, bacterial masses, and necrotic
material. From such an examination one could not determine
whether the necrosis or hemorrhage is primary, but it would
seem in many instances, at least, that the necrosis of the vessel
walls appears before the massive hemorrhages 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 Crowell: Pathologic Anatomy of Bubonic Plague 269
may be summarized somewhat as follows: First, there is mul-
tiplication of bacilli; then follow congestion, cedema, ‘“catarrh”’
of the lymph sinuses, hyaline degeneration and necrosis of the
walls, migration of erythrocytes and leucocytes, necrosis of
glandular tissue, hemorrhage, 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 cedema 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 hzemor-
rhage and cedema may be the most-marked feature, while in
others suppuration. may occur. In slightly affected glands the
changes may consist only of bacterial multiplication, cedema,
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 hemorrhage and slight
necrosis. The involvement of the capsule and the periglandular
tissue is usually minimal or absent in secondary buboes.
BUBONIC PLAGUE WITH EARLY SEPTICA7MIA (SO-CALLED SEPTIC4=MIC PLAGUE)
The literature on septicemic plague has been quoted rather
fully in the intreduction. The evidence as to what exactly
constitutes a case of septicemic plague is rather confusing.
Strictly speaking, any case of plague in which the organisms
multiply in the circulating blood is a case of septiczemic 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 septiceemia 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 septicemia or septicopyemia. 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 1915
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 septicemia.
Case 2125.—Filipino, male, 20 years old. The duration of illness was
four days. The inguinal glands are somewhat enlarged, firm, dark, but
no hemorrhages are present in the surrounding tissues. The glands of
the left side are slightly more prominent than those on the right. Slight
cedema is present on both sides. On section these glands are dark red
and present small hemorrhages. The axillary glands are smaller, discrete,
and red, and show no hemorrhages 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 cdema nor
hemorrhage. 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 hemorrhages, nor is there surrounding cdema or hemorrhage. 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 hemorrhage nor cedema. At the bifurcation of the trachea
is one large hemorrhagic and much softened lymphatic gland. This case
had numerous cutaneous vesicles and extensive, secondary plague nodules
in the lungs.
Case 2878—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 cdem-
atous; the glands are not enlarged, but are somewhat red. The glands
in the left groin appear unchanged. The glands in both axille are red,
but there is no edema 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 1969.—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 Crowell: 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 cdema. 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 edema of the tissues surrounding these lymph nodes, and neither
the nodes nor surrounding tissue are hemorrhagic. 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 csophagus 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.
972 The Philippine Journal of Science 1916
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 strie 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 Schoébl, 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
bubonice. They were Gram-negative, nonmotile bacilli. Ageglutination
with antiplague serum was positive.
(8) 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, 82 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
“DSubonic plague with early septicemia.” The primary bubo was not a
prominent feature, whereas the evidences of septicemia were predominant
from both the clinical and anatomic aspects. The secondary focal visceral
lesions are weil 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-
974 The Philippine Journal of Science 1915
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 by 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 hemorrhages 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 cedema about the glands fre-
quently extends along the fascial planes well down into Hun-
ter’s canal. The amount and extent of the periglandular edema
and hemorrhage 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,p,4 Crowell: Pathologic Anatomy of Bubonic Plague 275
and sometimes softened. The hemorrhage and cedema about
these glands are generally not so marked as about the glands
forming the primary bubo of the first order; but the hemorrhage
and cedema 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 cceliac axis, and may extend
across the vertebrz, involving the glands of the opposite side.
The peritoneum overlying these glands may show punctate, or
larger, more diffuse hemorrhages. 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 hemorrhagic 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 septicemia is that in which the glands forming the
primary bubo of the first order show very little enlargement
and but little intra- or extraglandular hemorrhage or cedema.
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 hemorrhagic, but not much softened. There is very little
2716 The Philippine Journal of Science 1915
hemorrhage 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 2184.—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 fiuid, 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 fiuid 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 hyperemic but not hemorrhagic.
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 cdema of the fatty tissue in the anterior part
of the axilla, but there are no hemorrhages. 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 piague bacilli.
Case 8129.—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 OM AT
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 hyperzmic 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 hzemor-
rhagic fatty tissue. On section about four or five glands are found to be
involved, the largest being 2 centimeters in diameter. They are hzmor-
rhagie 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 (7?) ILIAC BUBOES
Extensive hemorrhagic 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)? there were also extensive changes
in the lumbar, mesocolic, and mesenteric glands and extensive
gastrointestinal hemorrhages. 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 hemorrhage. The right iliac glands were much en-
larged, hemorrhagic, and friable, with extensive hemorrhages
about them, extending along the lumbar region as far as the
coeliac 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 hemorrhagic 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
* This case is reported in full on page 296.
DR The Philippine Journal of Science 1915
cedema 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 ** 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 cedema of the tissues. About the deep vessels between the two
layers of the gastrocnemii are some much enlarged, deep red, softened,
hemorrhagic glands. The tissues about these are slightly hemorrhagic,
and the cdema extends up through Hunter’s canal. On section over the
right femoral region the edema is very great, and there is a large mass
of edematous 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 hemorrhage in the tissues about this gland. The
*Human Anatomy. J. B. Lippincott Company, Philadelphia and London
(1907), 984.
x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 279
other superficial lymphatic glands are somewhat enlarged, but not hemor-
rhagic nor cedematous.
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
oedema 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 °° 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
* This case is almost exactly analogous to case 18/XLVIII of the Austrian
Commission [Uber die Beulenpest in Bombay (1898), II B, 315], in which
cubital and axillary glands were similarly involved.
*Am. Journ. Med. Sci. (1901), n. s. 122, 405.
280 The Philippine J ournal of Science 1915
from that source of infection. Of all the buccal structures the tonsils
seem to he 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 7’ 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 ** 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 cedema associated with primary cervical
*“ Report of the Indian Plague Commission (1898-99), 5, 71.
* This Journal, Sec. B (1912), 7, 173.
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 ceedema 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 I1V.—Association of cervical glandular, pharyngeal, and pulmonary
lesions.
| ; Associated lesions.
ne 2 \Num- ‘
| Cas eo WBE ber. | Cervical | Pharyn- ea None of
| buboes. geal nary preced-
| lesions. lesions: ing.
Cervical buboes 05.02 s- 2 ts ee eee eae 10! | Rea 8 | 6
iPharyngeallesionsys-= 342 oee se o.8 ee eee 11 (2) tee eee | 7 1
Hocallpulmonarvalesions=o. 2 se. enn ae ee 13 6 G) | See ees 5
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, hemorrhage, and ulceration.
133736 3 3
932 The Philippine Journal of Science 1915
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, ceedema, exudation, hemorrhage,
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 288
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 ina 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 hemorrhages 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 cedema.
Some cases have been seen in which the capsule covering the
IQA The Philippine Journal of Science 1915
lateral and posterior portions of the tonsil has been infiltrated
in the same way as the tonsil itself, the cedema, hemorrhage,
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. B (1912), 7, 220.
x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague IR5
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 *° 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 cedema 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
“his Journal, See. B (92), 7, 172.
236 The Philippine Journal of Science 1915
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 pleure 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 cedematous. 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 seyere pseudo-
membranous pharyngitis, tonsillitis, and laryngitis.
The lungs. The pleure 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 hyperemic. No hemor-
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 Crowell: Pathologic Anatomy of Bubonic Plague 2387
yellowish gray, and the areas are surrounded by a narrow red
hyperemic 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 hematogenic 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
IRS - The Philippine Journal of Science 1915
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 hemorrhages 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 hemorrhages, which may be very few in number or may
be numerous and scattered over both the parietal and the visceral
layers. Such hemorrhages 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. Hzmorrhages on both sides of the
epiglottis, and cedema, 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
29() The Philippine Journal of Science 1915
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 preéxisting 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 hemorrhages
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. Asa rule, the trabecule, smaller vessels,
and lymphoid follicles are not recognizable. Small hemorrhages,
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 Crowell: 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, cedema, 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 hemorrhages
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
hemorrhagic lymphadenitis (left lower cervical); acute pustular and
vesicular dermatitis (plague carbuncle) ; acute hemorrhagic lymphadenitis
(right upper cervical) ; acute pseudomembranous tonsillitis; acute splenitis;
infarcts of spleen and liver; petechial hemorrhages 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 trabecule 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 hemorrhages
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 hemorrhage
has occurred. Such hemorrhages, 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 1916
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 he 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. Hzmorrhages 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 trabecule show the same evidences of hyaline degenera-
tion and frequently necrosis, as has been described in the walls
of the blood vessels and the trabecule in the buboes. Small
localized areas of hemorrhagic 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 zodgleal 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 Crowell: Pathologic Anatomy of Bubonice 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 hzmorrhage, necrosis, endothelial prolif-
eration, and bacillary infiltration, with degenerative changes in
the walls of the blood vessels and trabecule.
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.
Hezemorrhages in the capsule of the liver and about the gall
bladder are a frequent finding. Small hemorrhages 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 1915
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. Hemorrhages 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
hemorrhages.
In 30 cases hemorrhages were noted in the mucosa of the
stomach, and in 27 cases in the intestine. Of all hemorrhages
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 rugz 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 ruge 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 hemorrhagic area. Twenty of the cases showed
these erosions of the mucosa in the stomach (Plate IV).
A general hyperemia of the gastric mucosa without hemor-
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 hemorrhages
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 Crowell: Pathologic Anatomy of Bubonic Plague 295
very thickly beset with punctate hemorrhages, 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*! and the Austrian Commission ”
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 hemorrhages 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 hyperemic 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 hyperemic 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.
“ 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 1915
The mesenteric and mesocolic nodes were slightly enlarged, firm,
and pink. Pnewmococcus 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 feces 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 HAMORRHAGES
Case 2024.—Filipino, male, 30 years old. Anatomic diagnosis: Bubonic
plague; acute hemorrhagic lymphadenitis, iliac (primary bubo), mesocolic,
mesenteric, and lumbar; retroperitoneal ecchymoses; hemorrhages, epicar-
dial, pleural, peritoneal, intestinal, and gastric; acute gastritis with
hemorrhagic 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 conjunctive and cornez 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 cedema 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 petechie. 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 cdematous. The lungs are somewhat re-
tracted, exposing a large precordial 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 petechiz 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 Crowell: 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 petechiz 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 cesophagus 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 fecal material. The mucosa throughout shows numerous
minute petechiz, but there is no suggestion of any membrane and no
ulceration. The large. intestine from the cecum 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
183736——4
298 The Philippine Journal of Science 1915
mucosa. On removal of this there are found very numerous petechie 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 hemorrhages. The cardiac end of the csophagus is absolutely
normal in appearance, and the sharp demarcation of the congestion and
hzmorrhages 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 hemorrhagic
condition which extends up as high as the celiac axis and outward over
the poles of both kidneys. On dissection into this hemorrhagic tissue there
are found numerous, enlarged, softened, and hemorrhagic lymphatie glands,
some of which show small yellowish areas. The tissues between these
lymphatic glands are so hemorrhagic 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 calyarium 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 axille shows normal lymphatic structures.
The report on bacteriological examination of material obtained by autopsy
was made by Doctor Schébl, of the Bureau of Science. Specimens subjected
to examination consisted of:
(1) Smears from the retroperitoneal hemorrhagic 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 hemorrhages
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 papille or villi in the areolar tissue between
the glands in both the stomach and intestine small hemorrhages
occur from the capillaries. These hemorrhages may involve only
the area between two glands or may include several papille. The
vessels in the lower stratum of the mucosa and submucosa show
engorgement. In simple hemorrhages no other change is seen.
In those areas in the stomach that have been referred to as
hemorrhagic erosions there is seen a severer change. Here the
hemorrhage 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 hemorrhage
below this, and there is always a zone of hemorrhagic glandular
tissue recognizable above the muscularis mucosze. 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 hemorrhage has occurred into -
it. A large number of polymorphonuclear leucocytes has been
noted in the hemorrhagic 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 hemorrhagic areas, but
I have never encountered them in very large numbers. Al-
though these hemorrhages 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 hyperemia 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 hemorrhages. 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 1915
buboes of the second order in the iliac and lumbar glands, in
which cases massive retroperitoneal hemorrhages may be found
about the iliac and lumbar glands, ureters, and kidneys, on one
or both sides. Discrete punctate hemorrhages may also be
found scattered over the parietal and visceral surfaces. These
hzemorrhages 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 hzemor-
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 hemorrhages,
to which reference has just been made.
CARDIOVASCULAR SYSTEM
PERICARDIUM
Practically the only lesion found in the pericardium consists
of hemorrhages, 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 hemorrhages 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 hemorrhages,
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 3801
Chronic inflammatory lesions of the endocardium and myo-
cardium have been found in a few cases, but these were indu-
bitably due to preéxisting disease.
The vessels show no macroscopic lesions attributable to the
plague infection other than the presence of hemorrhages from
them which are due to microscopic lesions, which will be de-
scribed with the histology. The presence of hemorrhagic 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 hemorrhages 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 hemorrhages separating the
muscle fibers. Cellular exudate from the vessels does not occur.
(Hidema 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 hemorrhages.
NERVOUS SYSTEM
Meningitis in plague has been reported by the Austrian ** and
German ** plague commissions and by Calmette and Selembini *°.
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- .
* Uber die Beulenpest in Bombay (1898), II B, 287.
“Arb. a. d. kais. Gesundheitsamte (1899), 16, 101.
® Ann. 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 fiuid 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 convyolutions 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 cedema. 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.
Hemorrhages 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 hemorrhages. In the
pelvic mucosa the hemorrhages may be punctate or massive so
—-)
x,B,4 Crowell: Pathologic Anatomy of Bubonic Plague 308
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 hzem-
orrhage, especially on the side on which extensive retroperi-
toneal hemorrhage occurs about primary buboes of the second
order in the lumbar glands. The hemorrhages 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 hemorrhagic 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 hemorrhages in and about them. Punctate hzmorrhages -
on the mucosa occur. Frequently the ureter on the side on
which the femoral bubo occurs is completely surrounded by, and
embedded in, hemorrhagic retroperitoneal tissue, and this heem-
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 hzemor-
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 cedema and hemorrhages, 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 hzem-
38304 The Philippine Journal of Science 1915
orrhages also occur in all parts of the kidney, beneath the
capsule, beneath the pelvic mucosa, and in the cortex and pyra-
mids. Cidema 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 hemotoxylin 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.
Hzemorrhages 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 fcetus, and
another uterus was enlarged, with adherent placenta and dilated
cervix, the patient having aborted a fetus of about the eighth
month the day before death.
x, B,4 Crowell: Pathologic Anatomy of Bubonic Plague 305
Scheube ** cites a case of intrauterine infection with plague
that was reported. by Leumann.
In my case (2481) of which the uterus contained a 6-month
foetus no pest bacilli were demonstrable in sections of the pla-
centa or umbilical cord.
HISTOPATHOLOGY OF THE TESTES
In two cases hemorrhages in the testes were noted macro-
scopically. These appear histologically as diffuse intertubular
hemorrhages, which widely separate the tubules from one
another. Much of the blood has undergone hemolysis. 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 hemorrhages
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. Hzemorrhages 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 hemorrhages 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.
* 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 hemorrhages 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 hem-
orrhages in the medulla occurred in 2 cases only.
The changes then that were found in the adrenals consisted
of degeneration, cedema, congestion, heemorrhage, focal necrosis,
and fibrin thrombosis.
ASSOCIATED LESIONS
Osler’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 ** 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.
* Krankheiten der warmen Lander. Gustav Fischer, Jena (1910), 267.
ILLUSTRATIONS
PLATE [
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 hemorrhages in bubonic plague. (Drawing by
T. S. Espinosa after Kaiserling preservation.)
PLATE LV
Stomach, showing hzmorrhages 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 hzmor-
rhage and necrosis of interglandular tissue. Case 1952.
2. Axillary bubo. Case 2048.
307
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THE PHILIPPINE
JOURNAL OF SCIENCE
B. TROPICAL MEDICINE
VoL. X SEPTEMBER, 1915 No. 5
I. THE ROLE PLAYED BY THE INSECTS OF THE DIPTEROUS
FAMILY PHORID IN RELATION TO THE SPREAD OF ~
BACTERIAL INFECTIONS. II. EXPERIMENTS ON
APHIOCHATA FERRUGINEA BRUNETTI
WITH THE CHOLERA VIBRIO *
By DaAvip 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(1) 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
*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,(10) Maddox,(11) Alessi,(i2) Celli, (13)
Uffelmann,(14) Sawtchenke,(15) Yersin,(16) Firth and Hor-
rocks,(17) Manning,(18) Hayward,(19) lLord,(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,(1) Hofmann,(29) Lord,(20) Hay-
ward,(19) Cobb,(80) and Buchanan;(22) anthrax by Cao;(31)
and plague bacilli by Yersin(16) and Hunter. (32)
Articles too numerous to mention here have been written on
the transmission by flies of typhoid fever, tuberculosis, cholera,
dysentery, infantile diarrhea, 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 cesar, 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 feces. 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 Sarcephaga tibialis.
In subsequent bulletins issued by Howard no other mention
is made of Phoridsz as a menace in the carriage of bacteria and
spread of infection. The Phoride, 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 work 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 Aphiochexta 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
mere 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 PHORIDA
The family Phoridz contains, according to Kertész,(34) 27
genera and 221 species. Malloch,(35) in reviewing the Phoride
in the United States National Museum, enumerates 79 species
under the genus Aphiochexta.
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 Phoridz 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: Truwpheoneura trinervis Becker,
T. perennis Meigen, Dohrniphora abdominalis Fallen, Chetoneu-
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, (86) who revised and monographed the North American
Phoridz, gives the following description of the family and of the
genus Aphiocheta.
Although a considerable number of Phoridz 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 1915
Kurope 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
Phoride 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. Antennz 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; cox 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 dise 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-
cheetz 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. Antenne 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 macrochete2. 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.
APHIOCHATA FERRUGINEA BRUNETTI
Aphiocheta ferruginea was described by Brunetti.(388) 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 feces of a European in
Rangoon suffering with myiasis. In the feces 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:
6 2. 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 8rd 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 ist 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 coxz, 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 ¢ dark, not prominent, bluntly conical, with a few hairs;
in @ the ovipositor is subeylindrical, 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 8rd 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 Aphiochxta 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 Aphiochzta, 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 larve 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 larve 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, (31)
in 1906, made observations upon the larve of the following
diptera: Musca domestica, Calliphora vomitoria, Lucilia cesar,
and Sarcophaga carnaria, they being feeders on putrefied meat
or carrion.
Feeding these larve 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
cedema bacillus, Staphylococcus aureus, an anthraxlike bacil-
lus, and a very virulent Proteus fluorescens.
The intestinal flora of the larvee 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 sarcine, Bacillus prodigiosus, the oidia, and
blastomycetes.
As a result of his investigations Cao came to the following
conclusions:
The bacterial intestinal flora of larve 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 larve 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 septicemia, and from flies as they deposit their eggs.
The interior of the eggs of flies is sterile, but the shell contains
many bacteria.
SBS Roberg: Bacterial Infections 817
Bacteria introduced into the intestinal tract of flies are passed
in the feces, 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 larve feeding thereon.
Pathogenic bacteria occurring in the pupa are transmitted
to the imago which in turn disseminates infection in its feeces.
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 feces, 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 feces infected with B. typhosus.
One fly 16 days old showed typhoid-contaminated feces; when
crushed it showed the same contamination.
Faichnie concludes that of 18 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 feces.
The results described by Faichnie are to be questioned, be-
cause there is no evidence in his paper that the larve fed on
the infective material were separated from the pupz 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 feces. (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 feces 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 The Philippine Journal of Science 1915
bacilli are weak in competing with the intestinal bacterial flora
of larvz 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 pupz 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 larvz were fed thereon.
Some of the larve were secured; their surfaces were disin-
fected by washing them in 5 per cent lysol for five minutes.
These surface-sterilized larvee 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 pupz 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 pupz 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 larve 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 819
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.”
Pupz 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 larvze 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 larve had just hatched. These cultures
showed growths of the following organisms: Bacillus “A,” B.
proteus vulgaris, B. prodigiosus, and a streptococcus.
Larve 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 larvze secured from
this mixture, when their surfaces were sterilized, gave pure
cultures of B. typhosus when crushed and inoculated upon plates.
Other larve were removed from this agar-human blood and
typhoid mixture, placed upon sterile sand, and allowed to pupate.
These pupz 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 larve,
B. typhosus could not be isolated from the pup or imagines,
until recourse was had first to the disinfection of the eggs.
When unsterilized eggs were used there appeared constantly
a typnoidlike bacillus. This typhoidlike bacillus, called Bacil-
lus “B,” thoroughly adapts itself to the conditions in the interior
of the larve, pupz, and imagines.
There was, also, evidence that B. typhosus, when isolated
from the interior of larve 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 (Sarcophagide) carry
and distribute pathogenic and other bacteria.
Larve of the blowfly were fed on meat artificially infected
with the spores of anthrax bacilli. Flies emerging from these
larvee were infected with anthrax bacilli and remained infective
for fifteen days.
Larvee were fed on meat infected with the respective nonspore-
bearing organisms, B. typhosus, B. enteritidis, B. prodigiosus,
Vibrio cholerz, 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(48) made more extensive ob-
servations along these lines and employed the larve of Calli-
phora erythrocephala, Lucilia cesar, and Musca domestica.
SERIES 1
Graham-Smith, failing to infect the emerging flies from larve
fed on artificially infected food, secured larve of C. erythroce-
phala and L. cesar 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 larve 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 larve fed on Morgan’s bacillus gave a
positive result. Of those emerging from larve 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 8321
vive long enough in the larval intestine to appear in the imagines.
Morgan’s bacillus, which is often a commensal in the intestine
of larve, 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 larve
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 feces, and in the third box un-
sterilized human feces. Eggs and larve grown on sterilized
food were placed in these boxes and infected separately with 5.
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 Phoride, which are abundant. No doubt
as a result of their minuteness they have been overlooked.
These minute Phoridex, 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 feces are available, they are the
more preferable. ;
Even though sanitary regulations be severe in regard to the
disposal of human feces, 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 feces.
Should the feces 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-
392 The Philippine Journal of Science 1915
charged with the feces, 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 feces, although safe against the common house fly, are
by no means safe against the ingress of these very minute inseets.
Aphiocheta 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 larve or eggs as being deposited in
the feeces 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 Phoride as
porters or carriers of bacterial infection, certain facts must be
established by experimentation regarding them.
In the experiments outlined in this paper Aphiocheta ferru-
ginea was chosen for the following reasons: (1) Its great fre-
quency as a breeder in human feces. (2) When once determined
it ean readily be recognized. (8) 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
5G, 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 neceiine of Aphiocheta,
little difficulty was met with. The minute Phoride 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 fiask inverted
over the upright funnel stem. When killed and mounted on
needles, they were found to be Aphiocheta 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 Aphiocheta ferruginea would
predominate greatly over others which might be present and
not recognized on account of their similarity to Aphiocheta.
Among these brownish yellow fiies could be seen a few which
324 The Philippine Journal of Science 1915
were entirely black and smaller in size. These were regarded
by Banks as males of Aphiochzta. Brunetti also states in his
description of Aphiochxia ferruginea that there is a variance in
color.
When a medium of sand was employed, containing food in the
form of sugar, bread, human feces, and bouillon, the eggs de-
veloped into a great number of flies, the great majority of
which were the brownish yellow Aphiocheta. 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-
chxeta; 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 Aphiocheta.
The period of development could be definitely ascertained,
because when the flies emerged they were secured and identified
as Aphiocheta.
In series II and III considerable difficulty was encountered
where experiments were performed to ascertain whether larve
when growing in a medium infected with cholera vibrios contain
these organisms in their intestines, and whether a transference
of vibrios occurs from the larve, through the pupe and into the
emerging imagines. -
Repeated attempts were made to keep larve alive on a medium
containing a pure growth of cholera vibrios. Larvz could exist
for only a day or two on growths of cholera vibrios on agar-agar
and Dieudonné’s medium. On agar-slant growths of vibrios to
which sand was added larve could subsist for four or five days.
Larve 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 larve, although living for
nine days, did not attain their full size nor did they pupate.
From this tube 6-day-old larve were removed with a sterile
platinum needle and examined to see whether their intestines
contained cholera vibrios. To remove the surface vibrios, the
KONG, 5 Roberg: Bacterial Infections 325
larvee were washed for five minutes in a 5 per cent solution of
lysol. The larve 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 Dieudonné’s
medium. Growths of cholera vibrios were looked for.
Three attempts to find vibrios in the intestines of 6-day-old
larvee failed by this method. It was believed that in killing the
surface vibrios with 5 per cent lysol sufficient liquid was ingested
by the larve to kill the vibrios contained in the gut. To pre-
clude any possibility of lysol entering the larval interior, the
larve were sealed by applying a red-hot platinum point to the
anal extremities, thus searing and closing the openings. Larve
treated in this manner and washed in lysol also did not reveal
the presence of any cholera vibrios. Failing to find vibrios
within the larve, the agar-slant growth was examined for vibrios -
and found to contain none, but did possess other contaminating
organisms.
To keep larve 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 larve 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 Dieudonné’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-
1352642
326 The Philippine Journal of Science 1915
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 Dieudonné’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 Dieudonné’s
medium. The growth on the Dieudonné plate was studied mor-
phologically by means cf 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
KB, 5 Roberg: Bacterial Infections 327
present, in order to isolate them on Dieudonné’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 Apiochxta 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 feces and melted agar, and a dead snail. In
the beaker was placed a mixture of human feces 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 feces,
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 feeces-agar mixture, which
they greedily devoured.
The bottle trap which, also, contained a feces-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 feces-
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 1915
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 Phoridz in
the Bureau of Science collection, identified by Professor Banks.
These flies corresponded with Aphiocheta ferruginea of that
collection and coincided with Brunetti’s description.
Before the present series of experiments was undertaken, !
had exposed, on March 4, a large gauze-covered specimen jar
containing feces. In this jar hundreds of small flies had
emerged. These proved to be Aphiocheta ferruginea, and were
saved as a stock supply for future experiments.
On April 1 great numbers of small larvz were seen crawling
about the feeces-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 feeces-agar mixture being
small and having a great number of larve measuring from 2 to
3 millimeters, the entire contents were placed into a large speci-
men jar containing sand, lumps of sugar, bread, feces, 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 larvz were pupating. Examination of larve 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 Aphiochxta
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.
KiB yb Roberg: Bacterial Infections 329
Summary of results—Specimens of Aphiocheta 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 larve takes
place five or six days after they are hatched.
By indoor-breeding experiments Aphiocheta ferruginea are
indicated as the commonest of the small flies which breed in
feeces.
SERIES II
To ascertain whether larvee 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 Dieudonné’s medium. This plate was placed in a large
glass-covered stender dish to await the hatching of the larve.
b. On the same day a similar plate culture of cholera was
placed in a large gauze-covered stender dish containing fzeces
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 Dieudonné’s medium in a hatched out
in twenty-four hours. The larvee lived for twenty-four hours
and then died from a lack of nourishment.
c. On April 2 three larve were secured from the bottle of
feeces-agar mixture (series I) and placed on the surface of a
cholera growth in a test tube of slanted agar. These larve
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 larve died.
SERIES III
In a, 0, and ec, of series II it was impossible to keep larve
alive longer than two days on a pure culture of cholera vibrios,
as there was a scarcity of nutriment in the agar and Dieudonné’s
medium.
330 The Philippine Journal of Science 1915
The following steps were undertaken to keep larvz 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 larve.
As these larve 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 larve were removed from the large jar and
placed in a sterile glass-covered stender dish containing sterile
sand. The sand and the larve 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 larve.
b. On the following day (April 11) no active larve could
be seen, as several of them had pupated.
One of these pupz 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 Dieudonné’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 Dieudonné’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 pup were secured and subjected to the same
steps asin b. The results proved identical.
d. A portion of the sand was inoculated into Dunham’s pep-
tone and later streaked upon Dieudonné’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 larve were noted.
These had not yet pupated.
One of these larve 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-
né’s medium, did not reveal the presence of cholera vibrios.
f. Sand inoculated into Dunham’s peptone, incubated and
plated on Dieudonné’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 f indicate that the vibrios had
been outgrown, not only in the sand but also in the intestinal
tract of the larve, it was necessary again to replenish the cholera
vibrios by the addition of 24-hour-old broth cultures to the
medium in which the larvze were developing.
The larve and pupz 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.
7. On April 18, as no flies had emerged, they were again
transferred and redrenched with vibrios.
7. 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 pupz 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 pupz 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 Dieudonné’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 Dieudonné’s medium. Examination of this plate revealed
the presence of cholera vibrios.
239 The Philippine Journal of Science 1915
SUMMARY OF RESULTS
Larve 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 larve to the pupz
and from the pupz to the imagines. This, however, is only
possible when the larve and the pup 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 larvee and by the bacteria which are associated with putre-
faction of the medium.
In b and e¢ 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 Dieudonné’s medium, on which
there was a good growth of cholera vibrios, was placed in a
large stender dish containing human feces 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 feeces 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 Dieudonné’s medium and
examined. The plate contained pure cultures of cholera vibrios.
so 18y Roberg: Bacterial Infections 333
The washed fiy 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 Dieudonné’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 Dieudonné’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
Dieudonné’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 re-
corded in 6 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-
donné’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 Dieudonné’s medium. Examination of the plate
showed pure cultures of cholera vibrios.
CONCLUSIONS FROM RESULTS
Aphiocheta 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 6,
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
Aphiochzxta. ferruginea is a species of fly which breeds in
human feces, and as indicated by indoor laboratory experi-
334 The Philippine Journal of Science 1915
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
fecal 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 diarrhcea; by
ingested food which has been contaminated by organisms from
the fly’s body surface and feces; 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
fiy do not exclude the Phoride.
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 Phoride.
The fact that cholera vibrios may be transmitted from larve,
through pupz, into emerging imagines is of importance from a
public hygienic standpoint only under exceptional circumstances.
This is possible only if feeces heavily infected with cholera vib-
rios should be deposited among larve which are due to emerge
as adults in a day or two.
Chantemesse, (21) 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 feeces. He demonstrated that flies
harbor vibrios in the tubes of their feet and in their feces 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 feces 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 Phoride are worthy of serious consideration.
=
—
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(16)
(17)
(18)
(19)
Roberg: Bacterial Infections 835
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NEWSTEAD. Preliminary Report, etc., of the Common House-fly as
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GRAHAM-SMITH. Some observations on the anatomy and function
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GRASSI. Gazz. d. Ospedali (1883), No. 59.
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CELLI. Transmissibilita del germi patogeni mediante le dejezione
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MANNING. A preliminary report on transmission of pathogenic
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HAywarp. The fly as a carrier of tuberculous infection. New York
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Lorp. Flies and tuberculosis. Boston Med. & Surg. Journ. (1904),
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CHANTEMESSE. Cholera and flies. Report of meeting of Acad. Med.
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FAICHNIE. Fly-borne enteric fever and source of infection. Journ.
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Cao, G. Sul passagio dei germi a traverso le larve di alcuni insetti.
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Orig. (1906), 11, 43.
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Mautocu. The insects of the dipterous family Phoride in the
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Bruges. Fam. Phoride. Wytsmann’s Genera Insectorum (1906),
44,
Brues. Trans. Am. Ent. Soc. (1903), 29, 337.
BRUNETTI. Description of Aphiocheta ferruginea, a hitherto un-
described species of Phoride that causes myiasis in man. Rec.
Ind. Mus. (1912), 7, pt. I, 83.
BRUNETTI. Notes on the life history of Aphiocheta ferruginea,
mihi. Rec. Ind. Mus. (1912), 7, pt. V, 515.
Bacot. The persistence of B. pyocyaneus in pupe and imagines of
Musca domestica. Parasitology (1911), 4, 68.
LEDINGHAM. On the survival of specific micro-organisms in pup2
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11, 3388.
GRAHAM-SMITH. Further observations on the ways in which artiii-
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GRAHAM-SMITH. An investigation into the possibility of pathogenic
micro-organisms being taken up by the larva and subsequently
distributed by the fly. 41st Ann. Rep. Local Govt. Board.-Suppl.
1911-12 London (1912), 330.
GANON. Cholera and flies. Geneesk tijdschr. v. Nederl. Indie. 48,
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a
LE a,
MISCELLANEOUS NOTES ' AND COMMENTS ON BERIBERI?
By RosBert 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.
*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.
BaT
3388 The Philippine Journal of Science 1915
TABLE J.—Record of experiments with fowls.
{ Pe ea| ‘|
No.of | Gondition. hexper Ween | Day ctdcan | Sain aa
| i | =
| Days. | Per cent. | |
1 | White rice control___-|__________ Ah) Ab anaes tr | Typical neuritis.
iene (0 Ko peers eevee yo lee ee | —29.9 | Twenty-ninth _______- Do.
G} es Coe s-Ses ead. Bee See ee —21.7 | Twenty-second _______ Do.
Aue (o Reena ee ae Bh o | es ana —40.8 | Twenty-eighth_______ Do.
6 || Palay control__-_-_--~ | GORA ect AO) es Je Ae oe eee eee Alive and well at
| | end of 60 days.
Gilead Oe aes sane res 60 | Lee e tse oe somes. s eves os! Do.
(vier dortess: eae 60 a ek eee eae ee See OE oS Do.
yea do MARRS gt | G0 HOLE OU ELNAL AN LLene eee Do.
9 | White rice and 40 |-------___ et 2120)|(Seventhi=s= e222 es Apparent exhaus-
minutes exercise. | | | tion after exer-
1 cise.
No neuritis.
I) Wasa Mo: -S222si Gites tly oeree cies ——14-on et Ourth =. oases eee | Do.
dt SWihitemericessand sz) eee Sabyas || Uberti Se | Typical neuritis.
minutes exercise. |
1) lho a ig 2 SERS Tet SES —20.2 | Twenty-fourth _______ Do.
13 | Palay and 40 minutes 60 == 16!,0" | es Se ER oe wah | Alive and well at
exercise. end of experi-
| | ment.
Any ene Oe Sie eT Ae GO|) = GEG cocceececneesessaseae ss) Do.
15 | Palay and 20 minutes 60 = D186 )|/se 5 Se. eae se 2 Do.
exercise. {
Go| eee (s (oye en hs oe 60 == 10 Ol | Semen en a eee Do.
Ia eWihitemricelatiar cee. sae See || aaa ee Prostration with-
out neuritis.
18) [ eee 1 eae ene Sees, ee Bee SE Sy qraai kd) oo Typical neuritis.
(70) 19 |____- (0 (oye meres SOE S| a ei 64.2 | Thirty-third—_______-- Do.
C73) e201 | eaeee CORSE See 8 ee ee —— 3410) een une ee se wae ee ee ee | Prostration and
| | slight neuritis.
(Al) PAN |] TAAENY ans BIO 2 -- = 60 =| eee ee Alive and well at
| end of 60 days.
(92) 422) |2e2e2 Goeeeaaee ea eeee 60 ==. 838 || 22Et sce. cee taeee = Sa | Do.
23) Wihiteinice atl5o (222) -2ee ee SSRIS) AN ana eee Typical neuritis.
Bo | cece KY gu ae eee a aes —21.5 | 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 Beribert 839
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 cedema 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 * has shown that fresh milk
does not possess antineuritic properties in any extraordinary
degree.
In addition, Sawazaki* 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
* This Journal, Sec. B (1918), 8, 469.
* Mitt. Med. Gesell. Tokio (19138), 27, No. 3, Abstract in Zentralbl. f.
Biochem. u. Biophys. (19138), 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.®
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. B (1915), 10, 99.
*Funk, Zeitschr. f. physiol. Chem. (1914), 89, 373.
X, B, 5 Wilhams and Johnston: Notes on Beriberi 841
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 unpolisned 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’ 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.
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X, B, 5 Wiliams and Johnston: Notes on Beribert 3438
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.
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PSEUDOTYPHOID FEVER IN DELI, SUMATRA (A VARIETY OF
JAPANESE KEDANI FEVER)?
By WILHELM 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 clinica] 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:
* Received for publication May 7, 1915.
345
346 The Philippine Journal of Science 1915
TABLE I.—Incidence of kedani fever in Sumatra.
Month. Number. | Month. | Number.
Januarya sees se eee Wal). Pily toss ee ee eee } 19) 3
Nebruary 22-2 22-22 ss—2 ae eee 2) | ACI SUS tiea= =e ane oe. eaten nee | 19 |
March?-.29 = sep oes Sees LOS September > Seaesnae eae en eee 7 |
(APY ili. 52 ent eas oe tek i eee G3 ‘October Sasa stee a a ee ee 5
May 2 eae ee cre eae Br NGvember: 2-= see cease = ae eee 25
JUNC ee oe I SEs ene ee Nee 16. ||iecem bers 2" 202 = teens ee eee 19
J
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
ROB) 5 Schiiffner: Pseudotyphoid Fever in Deli 847
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 Kuropeans, 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,
848 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 infiammation 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 849
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 ali. 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 sufrers
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.—Showing blood counts in a typical case.
| | J.
Poly- | | - Large
|Total leu-| ‘>. | Lympho-| Eosino- | Mast-
Case No. 2071. cocytes. een cytes. philes. zellen. Bee /
| 1 | |
|
Per cent. | Per cent. | Per cent. | Per cent. Per cent. |
Sixteenth day of disease ---_-------- 6, 200 14 TB | naan 5 |
|) Tenthiday' of disease =--=2==22=—- == 10, 000 | 8 | bs) i Peet a (Ras or 6
Seventeenth (temperature has | |
fallen) eee ok ee eS oe 5, 250 25 | 68) (es. 2555-8. | ee 7
Twenty-second (convalescent) _____- 4, 400 34 5S | 3 1 / 4
! i]
TABLE III.—Showing blood count in a typical case.
= = ikea wa ails | Ge = at
| | Poly- | Large
~ Total leu- | Lympho-| Eosino- Mast- |
Case No. 2685: cocytes. | mules | cytes. | philes. | zellen. | aaeleee
|_| _ —
| Per cent. | | Per cent. | Per cent. Per cent.| Per cent.
Fourth day of disease __....-...---- 26, 300 | 32 | Gil ncaas ol pa 3
Seventh day of disease _________-____ | 14, 400 36 59 | O20 > ae 4
| Eleventh day of disease -_-_--------- 12, 600 27 Givinle™. Fhe | oe ee 12
Fourteenth day of disease__--______- 11, 050 14 85 04s See 1
Fifteenth day of disease -_______.-- | 12,380 18 77 | Uy eseerees 4
Twentieth (temperature has fallen) _| 10, 000 28 64 | 2.0 1 5
|
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 fer 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
Miyasima, M. Centralbl. f. Bakt——Ref. (1911), 50, 34.
SCHUFFNER, W., and WAcHSMUTH M. Trans. Bombay Med. Cong. (1909),
55.
Ipem. JZeitschr f. klin. Med. (1910), 71, 133.
TANAKA, K. Centralbl. f. Bakt. (1899), 26, 432.
©
A
TiS iC GOP TERR tat ripen va, teh oa mn iim
eg! |i Cbd Taco Tar AsDOD > edaiotieien een
ot Cntr Leer tReet peed asaiehestialae
cate Jaat jum deol dad —hebintse (phere
aes ll ei Sie Ot bine
: mnoninelisiiass Beate | sbeteabilacnad here A gaeees
i } ‘ . 5 0 Jdtaw sglatelqemoowet as liv bp anes
| | witelvoxt eta ie cPiteheond to abortisrelkioneeak ”
¥ MONEY Ob 1a tee Rites on lh pales ees
pee alton asgostte 2 sirnaledutveg A bale geo
) hibsie ohiitieeradeipelthwdt count eneigenme oping bilge
thimaioitaiosd: bra Ieiqesbiiinnw eld tcde eete ipa
inag bo hipaa tolett teltink alin ei? tehueeelo Sele
rss icid eevee: fre thgep couliveionites ew
cect nyaeed ee tive wtbsiaet edith pateenoo eetost ie
bt) ese Rh anely’d Poel ch ned Tipe bl en i | jagieg
PUY Oe teoil a fem Ws oi peiter a LP rsS6R TON bling. Ae
; . Ati RENGS oti art Hage Byes
elal mivee Jo) nolenumexs invitee 4
ixoive tefle Jotboyqed VAP ae ere ae
TRAM
! . \ 4
bey rae’ rings padoe zh g mtn Tu SiALRS : ne
. gimio [adiniis vennes at ait
; wh ‘JU Retaoortl ceed
| DOT ad geheth ately tart etoabive a
batanvinnednoh nea ead noltew Ali Gb ae
Sa brodeviohis may abt ae
oY TONE) Tote lacie f
¥ %s Hines. ay ie ae
} ood undeerted | aot idee sions
; tite bb
2 . Ge .{ i it lees ba
« wr aioett a0 Au wena hoa VF
{ (0402) sea kt, 4
wiis sy : Ds
BF VEL), TAga A Stevia aire
ScCHUFFNER: PSEUDOTYPHOID FEVER. ] [Putu. Journ. Scr., X, B, No. 5.
Fig. 1. Larva (Lrombidium sp.).
Fig. 2. Larva (Cheyletus sp.).
PLATE lI.
a |
bs
SCHUFFNER: PSEUDOTYPHOID FEVER. ] [Puiu. Journ. Scr., X, B, No. 5.
Fig. 1. Primary lesion in the axillary region.
Fig. 2. Primary lesion in the supraclavicular region. Lymphadenitis.
PLATE Il.
SCHUFFNER: PSBUDOTYPHOID FEVER. ] [PHm. Journ. Sct., 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 Ill.
Iniiee, il.
Inive, al,
ifries. te
ILLUSTRATIONS
PLATE [
Larva (Trombidium sp.).
. Larva (Cheyletus sp.).
PLATE II
Primary lesion in the axillary region.
. Primary lesion in the supraclavicular region. Lymphadenitis.
PLATE III
Primary lesion, front of leg, showing inflammatory halo. In this
case there was involvement of the femoral glands but no
lymphangitis.
. The same twelve days later. Healing has begun.
353
REVIEWS
An International System | of | Ophthalmic Practice | edited by | Walter
L. Pyle, A. M., M. D., Philadelphia | member of the American
Ophthalmological Society | Ophthalmic Semiology and | Diagnosis |
by | Charles H. Beard, M. D. | surgeon to the Illinois Charitable
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In his preface the author invites attention to the fact that
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work and the large type which render it really a pleasure to
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method of emphasizing words and phrases by the use of heavy-
face type.
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A Laboratory Manual and Text-book | of Embryology | by | Charles William
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Of particular interest is the chapter on the dissection of the
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855
856 The Philippine Journal of Science
to be very instructive to the student, who, after a few dissections,
can get a better fixed idea of the important embryonic relations.
Since most of the medical schools are now equipped with ef-
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THE PHILIPPINE
JOURNAL OF SCIENCE
B. TROPICAL MEDICINE
VoL. X NOVEMBER, 1915 No. 6
THE TREATMENT OF THE RETROGRESSIVE SKIN LESIONS OF
LEPROSY WITH BASIC FUCHSIN?
By OSwaLp 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 anzs-
thesias, and the lowered body resistance codperate 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.
* Received for publication September 28, 1915.
186701 257
i WA
j PR fy ec
THATS
i
X
358 The Philippine Journal of Science 1915
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,” 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 * 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 (Grtibler’s Fuchsin ftir 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.
‘Tbhid. (1918), 60, 1680-1682.
ee
A ili ae at
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:
. Ulcerated tubercles.
. Neurotrophic ulcers:
. Infected neurotrophic ulcers.
Simple burns.
. Infected burns.
Ulcers with sinuses leading to necrotic bone.
. Early gangrene (superficial).
. Late gangrene (deep).
Te pyesasce
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 septicemia
(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 anesthetic form of leprosy, and of the four cases selected
for treatment all quickly repaired.
f. 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 septicemia.
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.
a es
X, B, 6
Denney: Skin Lesions of Leprosy
361
TABLE I.—Résumé of cases treated with basic fuchsin at the Culion Leper
Colony.
6 Re- Im- Not im- .
Lesions. paired. | proved. | proved. Died. Total.
Wiceratediitubercless2-< 2 os 2e- eee nese eee 1 1 2 0 4
INeurotrophieiulcersiosese a eee eee 15 14 3 1 33
Neurotrophic ulcers, infected _____._--____.-_- 4 0 0 2 6
Simplejburnnispesss= se ao ee ee tee 10 0 y 0 0 10
infectedsburns'< 2-2") = Sereno een ee ee eee 125 8 39 1
Puerperalintection ose... e passe oes ee aes | 115 4 119 3
Operations:
MOrCep Si Sos oo eens an ack swt coco onc ouc ee eocaeees 158 69 227 6
Podaliciversionscsc2- os 5. Sees oS Re See ees 121 17 138 | 3
Wimbryotomy, <-.<=- 5s eee cece eee ote aeenenes pbyy ease eae A eee
Csssarean\section) 9 9c soe. ce sene seen eeeeenes 1G) eee 916 ann sone
Laparotomies for abdominal pregnancy--_-_-.-.-------|---.------|--------_- A eee ~
Maternal deaths: |
Placenta preevie ooeee wo oo See ace Cee eee ene ee Renee a ee ee 86 25
LOE) Leer ae retine moan Seema enter aaeemedl Rana ned Ea ae 18 | 45 |
Puerperal infection sce - eee e eee ac cere a oe ree | eee eee sere | 19 | 15
Obhericauses!2 i222 ke soec acd eteoe wee see poe enone ~--~-=~---|~=-------- ol (Sees
Tabet a NAEe SA Pee Sed See. ed eee |e Bees Soe 187 | a |
*Two post mortem.
X, B, 6 Calderon: Tropical Obstetrical Problems 379
We have had 4 per cent of placenta previa, as against 1 per
cent of eclampsia, which shows that placenta previa 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 previa. Placenta previa occurs in the majority of
cases in multiparz, 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 fcetal 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 hemorrhage, 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 fcetus 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 Cesarean section in all cases,
except one, on women with placenta previa, the exception being
a case of intrapartum eclampsia in a primigravida. In this case
Cesarean section was the best way to extract the foetus, as the
cervix was not dilated and rapid delivery was indicated. The
880 The Philippine Journal of Science 1915
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 Cesarean section is the best and safest procedure to
follow in all cases of placenta previa 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 Cesarean section we have always obtained
good results in cases of placenta previa 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 Cxsarean 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 Cesarean section
for placenta przvia have returned to us for delivery, and in
these three cases labor was perfectly normal in every way, thus
proving the conclusion that Czesarean 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, Cesarean 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 Calderon: Tropical Obstetrical Problems 881
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.
E pet einminon pec
Cm. Cm. Cm.
Diameter between the iliac spines____------__--_----_-------------- 25. 47 23. 90 1,47
Miametersbetweenitheliacicrestse = esse ase eae aoe eee eee 27.99 24, 90 3.08
Diameter between’ theitrochanters=—- ---=--=-- ---—------ ==. eee 30. 90 28.10 2.79
IB AUG SLO CCG renee ee ee ae a ee te Laer ate Unc uiy Soras et aed 19.71 17. 63 2.08
Diaconalicongucd tesa eee eee ee some e eens nse eee ee ete 12.26 12. 00 0. 26
Anteroposterior diameterjof outlet) --- 2 aot ee 12.50 10. 05 2.44
Htransyverseidiameter Or Outlets see oet eee eee eee ee 11.00 tS OO Seeaan eee
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 1V.—Comparative measurements of heads of new-born babies
of Filipinas and Americans.
A Amer- eyes Differ-
| Diameter. ican Filipino. anect
Cm. Cm. Cm.
Occipitomen tall 2 = s-os 8 2 eo oa es 13. 33 12.11 1.22
Oceipitofron tal ps se see eo etn SO ee CL ee ete oad 11.70 10. 96 0. 74
Sub-occrpitobresmatic vss ee ee ae eee ete ee Lee Ly ee ee Re 9.70 9. 28 0. 42
Biparietalece see Uee Ke tiie.. MEU ile Ree See I NS EA as 9.25 8.63 0. 62
Biternporale ste ye es coe Se ce eee a a as Cu ie a Oe, ow 8.00 6. 82 i oh
This diminution in the diameters of the fcetal 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.
889 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 8838 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
ra
x, 1h, G Calderon: Tropical Obstetrical Problems 883
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 ?*
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(1) 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(8) 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.(10) Sawtschenko,(11) in 1892, found cholecystitis twice
among 30 cholera autopsies. In a series of 28 cases recorded by
Girode, (12) vibrios were found in 14.. One case showed marked
symptoms of cholangitis and cholecystitis with vibrios present
on bacteriological examination. Brulloff(13) found vibrios in
76 per cent of his cases.
* Received for publication September 28, 1915.
385
386 The Philippine Journal of Science 1915
Kulescha, (1) in the cholera epidemic at St. Petersburg in 1908—
1909, performed 480 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 débris, 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
severe in the larger ducts.
Of the four cases, Kulescha(1) 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
eR a —- a” _ ——-an —P eee —————
a a
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 hemorrhages; 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.
BOON gs The Philippine Journal of Science 1915
TABLE I.—Showing condition of the gall bladder and biliary passages.
Signs of inflam-
Gholera mation.
Year. autop- |————_—_———___| Stones.
Gall Bile
bladder. | ducts.
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 Schébl. 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 fellee 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.
38. 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 889
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 Léffler’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
8751). 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.
REFERENCES
(1) KutescHa. Klin. Jahrb. (1910), 24, 1387.
(2) Prrocorr. Die Pathologische Anatomie der Cholera, St. Petersburg
(1850).
(3) NetscHArEFF. Bolnicenaja Gazeta Botkina (1892).
(4) Nicati, W., and RietscH, M. Arch. physiol. norm. et path. (1885),
JUN, WGp We
(5) DoyEeN, E. Ibid. (1885), III, 16, 179.
(6) KeuscH, A., and VAILLARD, L. Ibid. (1885), III, 15, 341.
(7) Tizzoni, G., and CATTANI, J. Centralbl. f. med. Wissensch. (1886),
24, 769.
(8) RAPTSCHEVSKY, J. F. Russkyi Vratch (1886), No. 4, 5.
(9) ReExKovsky, L. P. Arch. sci. biol., St. Petersbourg (1892).
(10) DEFRESSINE, C., and CAZENEUVE, H. Compt rend. Soc. biol. (1912),
72, 9388.
(11) SawTscHENKO. Russkyi Vratch (1893), No. 21.
(12) GiropE, M. J. Compt. rend. Soc. biol. (1893), 5, 568, 570.
(18) BRuULLOFF. Russkyi Vratch (1910), 9, 1821.
(14) Grizec. Ind. Journ. Med. Res. (1918), 1, 44.
(15) Ipem. Lancet (1912), 2, 1423.
(16) Ipem. Ind. Journ. Med. Res. (1914), 2, 28.
(17) ScH6si, O. Phil. Journ. Sci., Sec. B (1915), 10, 11.
(18) Grieg. Ind. Journ. Med. Res. (1914), 2, 604.
186701—3
INDEX
A
Adenocarcinoma of the czcum, 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, 356.
Alpalea, 374.
Anatomy, pathologic, of bubonie 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.
Aphiocheta ferruginea Brunetti, experiments
on, with the cholera vibrio, 309.
Ascaris lumbricoides, 296.
Ascaris lumbricoides, the development of the
eggs of, 19.
Asiatie cholera, see Cholera.
Asuang, 371.
Avirulent tubercle bacilli, immunization of
guinea pigs by the inoculation of, in agar,
1465.
B
Bacilli, avirulent tubercle, experiments on the
immunization of guinea pigs by the inocula- |
tion of, in agar, 145.
Bacillus “A,” 319.
anthracis, 320.
“By 819°
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.
leprze, 367.
mucosus capsulatus, 270.
paratyphosus A, 351.
paratyphosus B, 351.
pestis, 253.
pestis bubonic, 273.
prodigiosus, 165, 316.
Bacillus proteus vulgaris, 319.
pyocyanevs, 318.
radiciformis, 316.
subtilis, 316.
typhosus, 27, 317, 361.
Bacterial infections, the réle played by the
insects of the dipterous family Phoridz in
relation to the spread of, 309.
Bagabaga, 3738.
Bainbridge, William Seaman,
(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.
Basie 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, 248.
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, 3865.
Buboes, axillary, in plague, 279.
cervical, in plague, 279.
femoral, in plague, 273.
plague, cases of suppuration of, 275.
popliteal, in plague, 278.
primary (7) iliac, of plague, 277.
Bubonic plague, pathologic anatomy of, 249.
Bulacan Province, descriptions of malaria and
Anopheles surveys in, 205.
see Reviews
Cc
Czcum, adenocarcinoma of the,
by intussusception, 71.
complicated
391
392
Cesarean 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, Cesarean 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.
Chzetoneurophora 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 Aphiochxta
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-
bonice 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 Phoridz, the réle played by
the insects of the, in relation to the spread
of bacterial infections, 809.
Dohrniphora abdominalis Fallen, 311.
Drosophila ampelophila, 310.
DuUMEZ, A. G., Two compounds of emetine
which may be of service in the treatment of
entameebiasis, 73.
E
Emetine bismuthous iodide, in the treatment
of dysentery, 77.
Emetine hydrochloride, results obtained in
eases of dysentery treated with, 75.
Emetine mercuric iodide, in the treatment of
dysentery, 76.
Index
Emetine, two compounds of, which may be of
service in the treatment of entameebiasis, 73.
Entameeba histolytica, 76.
Entameebiasis, 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, unhydrolized, 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.
ecanicularis, 310.
Hookworms, 296.
Hyalomma, 347.
Hydrolyzed extract of rice polishings in treat-
ment of human beriberi, 106.
I
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 cr-
cum, complicated by, 71.
Ipecac, results obtained in cases of dysentery
treated with, 75.
J
JOHNSTON, J. A., Leprosy, 365; Review of
Bainbridge’s The cancer problem, 356; see
also WILLIAMS, R. R., 387.
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.
L
Laguna Province, descriptions of malaria and
Anopheles surveys in, 201.
Lagundi, 375.
Lepers, observations on animals
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.
inoculated
Index
Lemopsylla cheopis, 258.
Lucilia cesar, 310.
Lymphatic glands in plague, 264.
M
Malaria, annual death rates and morbidity
rates from, in the P. I., 1909 to 1918, in-
clusive, 235.
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.
N
Nueva Ecija Province, descriptions of malaria
and Anopheles surveys in, 203.
oO
Obstetrical, problems, tropical, 371.
C2daleus nigrofasciatus DeGeer, 171.
iz
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, 205.
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.
Phoridz, in relation to the spread of bacterial
infections, 309.
|
|
|
393
Plague, cutaneous, 258.
intestinal, 267.
pathologic anatomy of bubonic, 249.
pneumonic, 2538.
septicwmic, 264, 269.
Pneumococcus, 296.
Pneumonic plague, 263.
POLK, MARY, review of G. Montague Hars-
ton’s The care and treatment of European
children in the tropics, 97.
Prentiss, Charles William, see Reviews (book).
Proteus fluorescens, 316.
mirabilis, 316.
vulgaris, 316.
zenkeri, 316.
Pseudotyphoid fever in Deli, Sumatra (a va-
riety of Japanese kedani fever), 345.
Pyle, Walter L., see Reviews (book).
R
Ranatra, 241.
RAQUEL, ALFONSO, see BARBER, M. A.,
LT.
Retrogressive skin lesions of leprosy, treat-
ment of, with basic fuchsin, 357.
REVIEWS (BOOK) :
Bainbridge, William Seaman, The cancer
problem, 856.
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 réle played by the
insects of the dipterous family Phoride in
the spread of bacterial infections. Experi-
ments on Aphiocheta 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,
855.
Ss
Saint Paul’s Hospital, first obstetrical depart-
ment at, 378.
Saklap, 375.
Salag, 373.
394
Salap, 375.
SALEEBY, N. M., see WILLIAMS, R. R., 99.
Sambong, 875.
Sara, 375.
Sarcophaga carnaria, 310.
tibialis, 310.
Sarcophagidz, 320.
SCHGBL, OTTO, Observations concerning
cholera carriers, 11; Practical experience
with some enriching media recommended for
bacteriological diagnosis of Asiatic cholera,
127.
SCHUFFNER, WILHELM, Pseudotyphoid
fever in Deli, Sumatra (a variety of Japa-
nese kedani fever), 345.
Seasonal index of malaria, 233.
Septiczmie 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.
aN
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 cxcum, complicated by intus-
susception, 71.
Thymus gland in beriberi, 121.
Tiqui-tiqui, treatment of infantile
with the extract of, 81.
beriberi,
Index
Trichuris trichiuris, 296.
Trombidium, 346.
Tropical obstetrical problems, $71.
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.
Vv
Vibrio cholere, 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. C.,
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 Czesarean section, 69.
Z
Zambales Province, descriptions of malaria
and Anopheles surveys in, 205. z
O
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“CONTENTS |
eae Lae
“DENNEY, OSWALD E. The Trenton of the Retrogressive '
Skin Lesions of Leprosy with Basic Fuchsin.......... a A Lae 357
JOHNSTON, JOHN A. Leprosy Ne LHD, cette kar ae 365
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