10 



a stud}' of a nrnnber of cases which came to post-mortem examina- 

 tion in Manila. 



It has been nw purpose in the preparation of this report to 

 furnish a scientific contribution to the subject and to bring out, 

 if possible, some new points, which might be of interest and value. 

 However, another practical object has never been lost sight of, 

 namely, to provide a guide for those who might be called upon to 

 make a post-mortem diagnosis of the first case of suspected plague 

 in a district. This will always be a matter of great responsibility 

 and sometimes one of considerable difficulty. Unless circumstances 

 compel the contrary, the diagnosis of a plague case, being the 

 first of its kind in a communit}', on board of a ship, etc., should be 

 confirmed by one well trained in general pathology and bacteriology ; 

 or, still better, by one also having experience in the recognition and 

 examination of plague cases. 



The importance of promptly diagnosing the first case of plague 

 can not be overestimated. This disease does not make its initial 

 appearance as a widespread epidemic, as is often the case Avith 

 Asiatic cholera, when caused by a contaminated water supply or 

 from other sources of infection. Eather, it begins very insidiously 

 from one or several imported cases. It is frequently easy to hold 

 the plague in check, provided it is recognized and properly fought 

 at an early stage. This has been proved by the observations made 

 in the cities mentioned above and in Manila. 



In studying the histopathology of plague a highly interesting 

 change was found in the kidneys, namely, extensive and frequently 

 occurring hyaline fibrin thrombosis of the glomerular capillaries. 

 As it appears that this change has not been described in the study 

 of the microscopic anatomy of the disease, it has been considered 

 somewhat at length. The histologic examinations in their entirety 

 have led to the conviction that plague in its most common bubonic 

 type should not be looked upon as a hemorrhagic septicemia, 

 because according to all appearances the infecting bacilli remain 

 practically localized until the agonal stage of the disease is reached. 



One of the cases examined and herein reported in detail sug- 

 gested the possibility, if not the probability, of an infection through 

 the agency of pediculi. This led to the study of the role which 

 insects may play as carriers of plague. The ones which have 

 been accused particularly of being the most important, factors in 



