94 HEISER. 



attacking the problem will have to be devised. The fact that the disease 

 seems to reappear in the city of Manila in a form which clinically 

 resembles cholera, apparently offers a key to the problem, especially as it 

 is coujded with the other fact that the study of the organism at the " 

 Biological Laboratory of the Bureau, of Science by different workers 

 shows that considerable change in its morphology takes place. Clinic- 

 ally, such cases give a history of sudden onset with vomiting which lasts 

 for a period of six to twenty hours, marked diarrhoea with stools not 

 typical of cholera, extreme collapse, severe cramps in the arms and legs, 

 profuse sweats, subnormal temperature, rapid pulse, anuria, and other 

 evidences of intense intoxication, for which active stimulation, external 

 heat, hypodermoclysis, intravenous transfusion of salt solution, or serum 

 are of no avail. On post-mortem these cases show marked rigor ; dryness 

 of the abdominal cavity; intestinal contents not typical of cholera; the 

 ileum and large intestine studded with small, bead-like elevations; evi- 

 dences of intense acute nephritis and punctiform hemorrhages upon the 

 serous surfaces of the heart, and cultures made by such competent ob- 

 servers as the chief of the Biological Laboratory and his assistants fail to 

 reveal cholera organisms. However, each succeeding case gradually ap- 

 proaches more and more the findings of cholera both clinically and at 

 autopsy, until finally the autopsies are typical and the cholera organism 

 is recovered from cultures taken from the intestines. When this stage 

 is reached, the disease also spreads much more rapidly throughout the 

 city, the number sometimes reaching as high as 70 cases per week, with 

 a mortality of 90 per cent; this then gradually declines, and the mor- 

 tality drops to 40 or 50 per cent. An outbreak of this kind extends 

 over a period of from two to three months. After the organisms once 

 become recognizable, there is no difficulty in identifying them until the 

 disease completely disappears, although there is considerable change in 

 their morphology, which will be shown in a subsequent paper by H. T. 

 Marshall. 



The fact that the cause of the outbreak of cholera in the provinces of 

 the Philippines seems invariably to be traced to Manila, the disease either 

 being transmitted by the infected persons or foods, and since the first 

 cases in Manila after 1904 are not traceable to any outside source, it is 

 evident that some conditions must exist in this city favorable to the 

 continuance of the cholera organism which do not obtain in other portions 

 of the Islands. It does not appear probable that the organism remains 

 in a quiescent stage in the intestines of the residents, because in that event 

 there certainly would be many outbreaks in other portions of the Islands 

 of the same heretofore inexplainable kind as these which have occurred 

 in Manila. It seems certain, to judge from our knowledge of the cholera 

 organism, that it could not exist in a dry state and since a constant, wet 

 medium is indispensable, it appears probable that the old sewer system 



