THE OUTBREAK OF CHOLERA IN THE PHIL- soldiers in the islands, and in the absence of any cholera IPPINES IN 1905. being reported anywhere in the , there was no reason for the cases further. THE METHODS USED IN COMBATING WITH STATISTICS particular investigating IT, In view of the however, that the of some TO JAN. 1906. fact, diagnosis 1, of the later cases that occurred at the fort was bac- VICTOR G. HEISER, M.D. teriologically confirmed, the earlier diagnoses of vino poi- Passed Assistant-Surgeon, United States Public Health and Marine\x=req-\ not have been correct. Hospital Service; Chief Quarantine Officer for the Philippine soning may Islands; Director of Health. The military medical men at once commenced active , P. I. measures, and the comparatively few days during which the the is another ex- According to the official records on file at the Bureau cholera persisted at fort excellent of how can eradicated when of Health for the Philippine Islands, the last case of ample readily the disease be cholera of the pandemic which commenced March 20, sanitary principles are intelligently applied. On an woman 1902, was reported to have occurred March 8, 1904. Dur- August 25 American residing at the in the was and died ing that period 166,252 cases, with 109,461 deaths, were Grand Hotel, walled city, attacked, in a few hours. same an American reported. Reliable observers are of the opinion that at On the day residing least one additional case occurred for each one that found on San Sebastian Street, in a section of the city nearly its way into the official records. two miles from the previous patient, was seized and died several hours afterward. No connection could be traced From March 8, 1904, until Aug. 23, 1905, no cases the two nor could obtained are known to have occurred. From time to time during between cases, any history be that the same of this latter cases, which re- articles food, which would be likely to period suspicious clinically the had been eaten these two victims. sembled Asiatic cholera, came to the attention of the convey infection, by Insular Board of Health, but the diagnosis could not be Cases in Manila occurred as follows : confirmed bacteriologically. For the two weeks imme- TABLE 1. diately preceding August 23, the number of suspicious August 23 2 September 1.17 cases increased. In one occurred in San Pedro August 24 1 September 2.12 Manila, 25 3 3.27 a one in a in one in August September Macati, suburb; bakery Paco; August 26 8 September 4.18 the San Miguel district; one case was that of a soldier August 27 10 September 5.12 in Cuartel de and several in the province of August 28 6 September 6. 10 España, 29 9 . The cases in Manila were all carefully exam- August September 7. 8 ined and the intestinal contents August 30 5 September 8. 7 postmortem, subjected August 31 7 9.'.....'... 4 tests observers as Dr. September to bactériologie by such competent September 10. 3 R. P. of the Government laboratory, and his Strong From this the cases about one a assistants; and the case of the soldier was carefully in- period averaged day the medical and until the end of the year; the total cases, from Aug. 23 vestigated by military authorities, speci- to mens examined at the Army laboratory which is main- Dec. 31, 1905, inclusive, being 255. tained in connection with the First Reserve Hospital of The characteristic tendency of the outbreak continued the weeks of the viz. : No connec- Manila. From both of these independent sources the during early scourge, tion could be traced between the cases ; no two cases oc- results were reported as negative. curred in any one house, nor did two cases occur in any THE FIRST RECOGNIZED CASE. one group of houses. A case almost invariably occurred in a section of the far distant a On 23 a case in Bilibid city from previous case, August developed prison and it will be noted that next which was a clinical of cholera. After furthermore, the case did typical picture not occur in the same section until the a few hours the victim succumbed. At the likely incubation postmortem had Another examination the ileum was found to be deeply injected period expired. especially noteworthy and filled with rice-water-like and the bactério- feature about the outbreak is that while the greatest material, of examination made Dr. R. P. revealed the number cases occurred in the slum district, this sec- logie by Strong the was cholera of Koch. Thus occurred the first of- tion of city not infected until during the latter spirillum of the outbreak. ficially recognized case of cholera of the present outbreak. part At the commencement of the of 1902, cases This was in an institution which is epidemic patient practically in Manila were reported as follows : cut off from the remainder of the world ; where all food- TABLE 2. stuffs are permitted to enter only after the most rigid and where all food served, that could possi- March 20 . 4 March 30 .Il inspection, . March . is cooked at all times. On account 21 6 March 31 6 bly convey cholera, March 22 . 4 April 1 .17

that all water was ster- . of dysentery, it is said drinking March 23 8 April 2 . 4 ilized. Therefore, it would seem that the routine pre- March 24 .14 April 3 .13 cautions taken against dysentery should also have af- March 25 .15 April 4 .13 March 26 . The .12 April 5 9 forded protection against cholera. commencement March 27 .11 April 6 .11

manner was . of an outbreak in this insidious most puz- March 28 6 April 7 . 9 zling, and the prospects of combating a disease whose March 29 . 5' origin was so obscure were not encouraging. By comparing this table with Table 1, it will be seen On the following day six cases, suspicious of cholera. that at the end of the second week there had actually were reported by Major Wales, from Fort William Mc- been more cases during the outbreak of 1905 than dur- Kinley, which is located about seven miles up the Pasig ing that of 1902. River, from Manila. For the week preceding August In the meantime, a telegram received August 26 from 23, about eight cases, with profuse diarrhea and vomit- Jalajala, province of Rizal, through the Army Medical ing followed by collapse, had occurred at the fort. The Department, contained the following information: symptoms were the same as those usually found in vino Cases of a disease resembling cholera have developed in poisoning which is so common among the United States Jalajala, the first case being registered on the 21st; from that

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/09/2015 date to the 25th, 16 cases and 12 deaths have been registered, TABLE 4. the illness lasting from twelve to twenty-four hours. On August 26 another telegram, received from the Age. Deaths. Mortality. president of the Provincial Board of Health at Pasig, one Under 30 days 0 reported suspicious case followed by death, in that 1 to 2 years 3 100.0 town. A of the Insular Board of 2 to 5 years 20 100.0 representative Health, 5 to 10 years 14 100.0 and another from the Bureau of Government Labora- 10 to 15 years 11 78.6 to 20 vears once to 15 17 73.9 tories, proceeded at by special launch Pasig and 20 to 25 years 28 84.8 for the of the cause of 25 to 30 years 28 84.8- Jalajala, purpose investigating 30 to 35 years 38 90.2 the outbreak in these places. The result of this investiga- 35 to 40 years 19 79.2 tion did not shed on the of 40 to 45 years 17 94.4 any light origin the infection. 45 to 50 years 8 100.0 made the resulted in 50 to 55 years 11 100.0 Inquiry by inspectors only showing 55 to 60 years 1 100.0 that at least one week prior to August 23 more deaths 60 to 05 years 6 100.0 had occurred in than and vic- 65 to 70 years 0 Jalajala usual, that the 70 to 75 years 1 100. Ó tims had diarrhea and died a few hours after the 75 to 80 years 1 100.0 profuse 80 to 85 years 1 100.0 symptoms manifested themselves. Unknown .... 2 100.0 An investigation made by Dr. L. T. Hess, captain and assistant surgeon. United States Army, of the records on The number of cases of cholera that occurred by race, file at Muntinlupa and Binan, situated in Rizal and between Aug. 23, 1905, and Dec. 31, 1905, and the date provinces, respectively, and on the opposite shore of the last case, are shown in Table 5. Table 6 shows the classification of cases of Lake Laguna from Jalajala, showed that death cer- by occupation. tificates had been filed during the week preceding Au- TABLE 5. gust 23, for a number of cases than in which (less 12), Mor- of of the cause of death was as diarrhea." Race. I Deaths Ratio Date given "suspicious Cases. tality, 1 Case to Last Case. The following table will show the order in which other per cent. towns in the and provinces became infected the number Americans 11 I 6 54.0 339 Oct. 10 of cases up to Jan. 1, 1906 : Filipinos 220 200 90.9 862.6 Dec. 31 Chinese ... 4 I 4 100.0 5307.5 Oct. Foreigners 20 16 80.0 227 Nov. TABLE ¡S.

TABLE 6. To January 1,1906. Date of Town and Province. first case. Ameri- No. of Filip. Japanese, Chioese. Foreign. pinos. cans. Cases. Occupation. 1. Jalajala, Rizal .Aug. 20 28 F. M F. M. F. M. F. M. F. 2. Guadalupe, Rizal .Aug. 24 1 3. Taguig, Itizal.Aug. 25 (IS 4. Pasig, Itizal.Aug. 27 59 5. Santolan, Iiizal.Aug. 28 1 6. San Pedro de Macati, Rizal.Aug. 28 4 7. Taytay, Rizal. .Aug. 29 132 8. Guagua, Pampaiiga.Sept. 1 37 9. , Cavité.Sept. 1 1 10. San Mateo, Rizal.Sept. 2 16 11. Malabon, Rizal.Sept. 2 53 12. Bulacan, Bulacan .Sept. 4 12 13. Sangley Point, Cavité.Sept. 5 1 14. Pasay, Rizal.Sept. 5 1 15. San Felipe Neri, Rizal.Sept. 5 1 16. Pila. Laguna.Sept. 7 7 17. Cavité, Cavité.Sept. 7 22 18. Paranaque, Rizal.Sept. 8 1 19. Santa Rosa, Laguna.Sept. 11 9 20. Mariqulna, Rizal.Sept. 13 4 21. . Rizal.Sept. 16 00 22. Morong, Rizal.Sept. 16 23. Antipoio, Rizal.Sept. 17 56 1 24. Meycauayan, Bulacan.Sept. 23 1 1 25. Los Baños, Laguna.Oct. 2 19 14 26. . Cavité.Oct. 3 159 27. San Francisco de Malabon, Cavité. .Oct. 5 12 28. Carmona, Cavité.Oct. 6 1 29. Caloocan, Rizal.Oct. 13 4 30. Luchan, .Oct. 12 4 31. San Pablo, Laguna.Oct. 18 1 32. Binan, Laguna.Oct. 16 111 33. Pagsanian, Laguna.Oct. 20 3 34. , Laguna .Oct. 21 3 35. Naie. Cavité. .Oct. 21 48 36. Bay, Laguna .Oct. 22 | 1 37. Santa Cruz. Laguna.Oct. 23 41 38. Ma.1ay.iay, Laguna.Oct. 24 15 30. , Laguna .Oct. 28 o 40. Calamba, Laguna.Oct. 31 (14 4" 41. Hagonoy, Bulacan .Nov. 1 197 1119 42. Noveleta, Cavité.Nov. 1 7 i 4il 43. Macabebe, Pampanga.Nov. 6 9 7 44. Magdalena, Laguna.Nov. 6 4 3 1 4.'). Lilio, Laguna.Nov. 8 2D 16 n 31 I I 3 46. Nagcarlang, Laguna.Nov. 9 1 1 29 47. Tanauan. .Nov. 20 1(1 (1 Total Il14 86

The cases and deaths in the of from city Manila, Au- Prom Table 5 it will be seen that in to their 23 to December were proportion gust 31, distributed by age as fol- number, more foreigners (Japanese and lows: Europeans) contracted cholera than any other nationality : that the

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/09/2015 Americans ranked next, but had the lowest death rate, cutta and in Bombay. In the case of the two last men- and that the least number occurred among the Chinese. tioned ports, the sailing time to Manila by the most The mortality of 100 per cent, among Chinese may direct steamers is at least nine or ten days from Cal- be attributed to the fact of the very few cases that oc- cutta, and at least fifteen days from Bombay. The fact curred, and that those patients who recovered probably that the incubation period is only five days, that no escaped detection by the health authorities. That no sick were found on any of these vessels, and that, from further cases occurred among Americans after October laboratory experience, it has been ascertained the 10 was probably due to the fact that as soon as they be- class of vegetables and other cargo which come from lieved the disease to be actually present, they observed these ports will not serve as media for the growth of the the prophylactic measures against cholera more strictly. cholera bacilli for a greater period than five days, shows The high percentage of Americans and Europeans at- that for practical purposes these two ports may be dis- tacked may also be more apparent than real, because it missed from further consideration. At any rate, the is quite probable that all those persons of this race who only importations from India are rice, onions, potatoes, were attacked medical advice and thus textiles, ivory goods and other articles not at all likely promptly sought to were reported, while among the natives and Chinese, in convey cholera organisms. all probability cases occurred in which the patient re- No cholera was reported in Hong Kong, and none was covered, and thus were not reported. known to exist in Canton, but in view of the fact that status the In Table 7 is given the death rate per thousand the actual of public health in Canton is not well known can not for Manila, for all diseases, for the years 1903 and 1904, at any time, that place be excluded in which no cholera was The death rate for with any degree of positiveness. The time from Can- reported. ton to be at the same months in 1905, which 250 Manila, by way of Hong Kong would least during period from four to five but in view of the fact that deaths from cholera were reported, is also given : days, only and such other as are TABLE 7. onions, potatoes, garlic vegetables necessarily forwarded in a dry state, were shipped from these it is not that cholera could 1903 1904 1903 ports, likely organisms have been introduced with them ; furthermore, since Can- ton vegetables are used freely aboard vessels which en- tered the from and since no B Philippines Hong Kong, sick were found on these vessels, it is reasonable to ex- fi a a 3 W ô o clude that from the list of to been Cr¿0 g » g port places likely have

- Si

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/09/2015 sons likely to ingest foreign food, this last contingency been useless. The cost of maintaining such a quaran- would also seem remote. tine, in the salaries for guards and delays and losses to would have been enormous. FIGHTING THE EPIDEMIC. business, It may be contended that the infection this time was In mapping out a campaign for the suppression of milder in character, and for that reason did not spread, the disease, the work was divided into four parts: but when it is remembered that the mortality was over 1. Isolation of the sick in the cholera hospital, and 90 per cent., and that nearly all the victims succumbed the rigid disinfection of their houses and effects. in a few hours after the first symptoms appeared, and 2. The protection of the city water supply, including that almost without exception the disease spread rapidly the closing of wells located in the city of Manila. unless prompt disinfection was done, it will be seen that 8. Prohibition of the sale of foodstuffs likely to be- this contention has very little basis in fact. come contaminated, and the proper protection, with The beneficial effect of not alarming the populace, and fly screens, of the remainder. thereby causing a great emigration from the centers in 4. The education of the public in the precautions to which the disease appears, can scarcely be overestimated. be observed in order^to avoid the disease. By the plan followed, cases of cholera, instead of being The carrying into effect of the isolation of the sick, carried far and wide in every direction, were confined and their treatment at the cholera hospital, was so well largely to Manila, where the patients could be promptly organized as the result of the experience gained in the isolated and the necessary disinfection performed; the former epidemic that this particular feature worked consequence of which, of course, was that there was lit- very smoothly; but in other respects the work was at- tle danger from the spread of infection in such cases. tended with considerable difficulty on account of the The one idea that was kept constantly in mind was to strong antipathy of the Filipinos to be treated elsewhere so arrange the inspection system that the disinfectors than in their homes. could reach the cases in the shortest possible time. The The native daily papers took the matter up and drew disinfection was made as simple as possible, and strict a vivid pen picture of the mental agony that would be instructions issued that nothing must be destroyed or endured by the relatives and friends of those who should damaged, with the exception of the prepared food which be unfortunate enough to be stricken with cholera, and was found in the houses; the stools of the patients and separated from them by being compelled to go to the the places where they were thrown and the clothes whiifh cholera hospital. The direct effect of the publication of they soiled were diligently sought for and thoroughly such articles was that many cases were concealed, and disinfected with a 1 to 1,000 solution of bichloride of just so many infected centers remained undiscovered. mercury, or a 5 per cent, solution of carbolic acid. The The newspaper attacks were borne patiently, and con- floors and walls were thoroughly saturated with the stant endeavors made to show prominent Filipinos and same solution, by means of a pump. the the representatives of the press magnificent manner All containers in which water was stored, as, for in- in which the cholera hospital was equipped, and how stance, water coolers, earthen jars, filters, barréis, wells, much the chances of recovery from an attack were in- etc., were treated with potassium permangante. "Con- creased by hospitalization, and the fact was particularly tacts" were to take an bath. The of the required antiseptic pointed out great injustice done to the patient by disinfecting carts were used in much the same as him chances way depriving of these increased for recovery. the apparatus of a fire department. The horses were a number of Fortunately, well-known citizens recovered kept hitched up, night and day, and as soon as a case at the cholera hospital about this time, which had the was reported, the disinfectors reached the infected house effect of at least silencing the critics, after which the a few minutes later. The fact that no second case oc- work of isolation was carried on with much less hin- curred in any house shows most effectively how effi- drance and with ever-increasing effectiveness. ciently the disinfection was done. To the American press of Manila too much credit PROTECTION OF WATER can not be given for the manner in which it pointed out SUPPLIES. the danger that existed in concealing cases. A few days after the outbreak of cholera in Manila, No attempt was made to quarantine "contacts," nor a few isolated cases of the disease were carried to the was any attempt made to institute a land quarantine at water-shed from which Manila obtains its drinking any place in the islands. This was a radical departure water. These cases probably came from Taytay, a from- the manner in which, in 1902, the campaign small town in Rizal province, located near the water- against cholera was conducted. The infection was fol- shed. The importance of properly guarding the water lowed from center to center; the sick were isolated, and supply of a city of 219,000 inhabitants will be readily was every practicable measure taken to destroy the in- appreciated. Arrangements were promptly made for . fection and thus to prevent its spread. It is believed that sending an adequate patrol to the Mariquina Valley, to this method was of more value than an attempted quar- prevent the pollution of the water. Through the cour- antine would have been, as the latter would necessarily tesy of the Commanding General of the Philippines Di- have had to be too despotic to have been of any perma- vision, four troops of the Eighth Cavalry were promptly nent value. The policy was to educate rather than to ordered to the valley, and remained there until long after antagonize, and what has been lost in some respects has the time that the last case of cholera was reported. The been more than compensated for in others. water-shed is inhabited by about 10,000 persons, and By comparing the disease during this epidemic, with from time immemorial it has been their custom to bathe that of the previous one, it will be seen that the disease and wash in the Mariquina River, from which the Ma- actually spread more slowly this time than before. To nila water supply is drawn. To deprive them, suddenly, quarantine effectually the infected area in and around of this privilege produced great opposition among the Manila, not to mention the provinces, would have re- people, and made it difficult for effective work to be done. quired from 30.000 to 50,000 armed men, and unless For that reason, to the American troops great credit is this quarantine had been made effective, it would have due on account of the great patience which they exer-

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/09/2015 cised. The fact that the river was not polluted, al- in the neighborhood it is quite easy to conceive how, though many cases of cholera occurred immediately sooner or later a person who has cholera organisms on along its banks, shows most conclusively how effectively his or her fingers, will come in contact with the buyo the troops carried out the duties to which they were leaves. To prevent the sale and use of the betel nut assigned. and this buyo leaf is probably one of the most difficult As an additional protection, during the time that the things which the Bureau of Health had to attempt. Con- cholera on the water-shed was at its height it was deemed firmed betel-nut chewers are almost as insistent on hav- advisable to place a sufficient amount of copper sulphate ing their chewing material as the average opium habitué in the city reservoirs to make a solution of 1 to 2,000,000. is in obtaining his supply of opium, and they will go to Subsequent experiments made at the laboratory with the every possible trouble and risk to obtain it. regular city water, however, showed that a solution of Street peddling was entirely forbidden. The sale of at least 1 to 50,000 would be required to kill cholera fruit that grows well above the ground, as, for instance, organisms with certainty in thirty minutes' time. As those fruits grown on trees, exemplified by bananas, this would be unsafe for drinking purposes, for contin- cocoanuts, mangoes, etc., was not interfered with to any ual use, it is of course obvious that cholera organisms great extent. These fruits, fortunately, are not handled can not be successfully removed from the public water very much by prospective buyers, IJefore being bought, supply of Manila by the use of copper sulphate. and, therefore, are not likely to become contaminated. the which are In the city of Manila there still remain a great many Some of cheaper articles, absolutely indis- wells which, ostensibly, are used only for the purpose of pensable to the poorer classes, were permitted to be sold, sprinkling streets, washing carriages and other uses; provided the shopkeeper agreed to keep the product but the danger is always present that they will be used under fly screens, and to prevent intending purchasers the same. for drinking purposes, and for that reason an order was from handling issued which directed the closing of all wells in the city With the aid of the police, these regulations were of Manila. fairly well carried out, and perhaps aided considerably in After the large city mains were protected, and the preventing the spread of the disease. were said with wells closed, it could almost be certainty THE EDUCATION OF THE PUBLIC IN THE PRECAUTIONS TO that no could take in the of large epidemic place city BE OBSERVED IN ORDER TO EVADE THE DISEASE. Manila, and this proved to be the case. Education of the public was probably the most import- PROHIBITION OF THE SALE OF FOODSTUFFS AND PROTEC- ant work that was done by the Bureau of Health, and the TION BY FLY SCREENS. success in controlling the outbreak was no doubt largely due For one who has never seen the local native markets, to the co-operation which was given. it will be difficult to understand the great variety and In order to place something practicable before the kinds of foodstuffs that are offered for sale, and the ideal public, something which required very little expense, culture media which they offer for cholera organisms. trouble or knowledge to carry out, the following rules Among them are snails, fish of various kinds, crabs and were printed in the newspapers and then issued in the other shellfish, cooked vegetables, etc. There are also form of a handbill, in English, Spanish, Tagalog, Ilo- many green vegetables which, of necessity, must be con- cano, Viscayan, and other native dialects: tinually watered in ordered to keep them in a fresh con- 1. Boil all drinking water and place it while hot in covered dition. The great amount of handling by prospective vessels. Do not dip up the water when needed, but pour it which all the foods in the public markets re- into drinking cups, otherwise cholera germs may get into the customers, water from hands. ceive, makes it clear that they are likely at any time to the 2. Do not touch water food hands become contaminated who are either in the drinking or with the by persons unless have been washed in water has been incubation stage of cholera or have come in contact with they just that infected material. boiled. 3. Eat only cooked food. Avoid all fruits, raw vegetables, The of the betel nut has been under sus- chewing long and raw fish. Dried fish may be made safe by thoroughly most manner picion as being perhaps the common by heating. Fruits may be made comparatively safe by dipping which cholera is propagated and continued in the Phil- them a few seconds into boiling water. ippine Islands. The betel is prepared for chewing by 4. Flies may carry cholera germs on their feet from human extracting the kernel from the nut, which is from 5 to 8 excreta to food; therefore, to protect it from flies, cover all centimeters long, with a diameter of 2 centimeters. The food immediately after it is cooked. outer cover of the nut is a thick husk, comparable to 5. If cholera appears, build smudges under houses to drive that of the green walnut or butternut of the United flies away. States. The kernel, when extracted, is cut into discs, 6. Boil all water used for diluting milk. each of which is wrapped with a piece of moist green 7. Cook all meats and fish thoroughly so as to heat the buyo leaf. It is in this leaf that the danger is supposed same throughout. to lurk. 8. Keep kitchen and table dishes thoroughly clean and scald them before using. In order to the leaves in are keep good condition, they 9. Keep the place in which you live, the under the in an earthen and with ground kept pot thoroughly sprinkled house, and everything pertaining to it, clean. water every few hours. As new of the leaves supplies 10. Outhouses, closets, and vaults can be made safe by are received at the the old water that accumu- markets, putting in lime or carbolic acid. When this can not be done is not lates in the bottoms of the vessels always replaced dejecta must be buried or thoroughly covered with earth. with fresh water. Each prospective buyer of the buyo, 11. Isolate all the sick. It is recommended that a house in leaf usually fingers all the leaves that are found in the each barrio be set aside for this purpose. pot in order to find those which are most tender. In 12. All the dead should be embedded in lime and buried three this way the buyo leaves in a given vessel are probably feet under the surface. handled by different persons many times each day before 13. Filth or vomit and the dejecta of the sick should be they are finally disposed of, and if there is any cholera promptly cleaned up with boiling water and buried.

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/09/2015 14. Clothes and bedding used by sick persons must be either CEREBRAL SYPHILIS IN CHILDREN. burned or boiled. Do not wash any clothes near wells or ARTHUR WILLARD M.D. springs, nor permit surface water to run into any well or FAIRBANKS, Assistant Physician, Department for Nervous Diseases, Children's spring. Hospital. 15. and should Municipal presidents municipal councilors BOSTON. enact these rules as ordinances, and see that they are enforced. In this is based on the of somewhat 10. All school children are requested to inform their parents part, paper study of these rules, which, if observed, will prevent great loss of over 100 cases of undoubted syphilitic cerebral disease life. in children from the literature. A large number of other of similar have been The Bureau of Education sent these circulars to every cases, undoubtedly character, school teacher in the with instructions that the excluded merely because unequivocal evidence of syphi- islands, litic infection was rules should be to all so that could wanting, or postmortem examination taught pupils they had not been made. recite them, and then the pupils were requested to repeat them to their The of the Catholic The paper is really a consideration of hereditary parents. Archbishop cerebral Church of the Philippine Islands sent the circulars to syphilis, but it is thought best to employ the every priest, with instructions that they should explain broader title in deference to the opinion of certain well\x=req-\ their contents to their parishioners. The Aglipay Church known observers who believe that many cases of syphilis late in childhood are instances and other denominations did the same. Very large flar- developing of acquired ing red cardboard posters, with the rules printed in and not of congenital infection. A a number of cases from several languages, were posted in the postoffice, munic- study of large the literature and other the does not indicate that there is much ground for this be- ipal buildings, public places throughout the islands. a more advanced cholera circular was lief. Certainly, great majority of the cases are un- Later, doubted for the use of teachers. The information con- instances of inherited disease. There is no rea- prepared of tained in these later circulars enabled many teachers to son, however, why cerebral symptoms presumptive late in cope successfully with the disease when it made its ap- specific character, appearing childhood, may not in fact be the so-called of a pearance in the small towns at which they were at work. "tertiary" phenomena spe- cific infection in So as the Many thousands of Filipinos soon learned that they acquired earlier years. far could easily avoid contracting the disease. How different symptoms and the clinical interest of the affection are was this from that in when concerned, it makes but little difference when the infec- picture presented 1902, only tion fatalistic indifference was and the measures occurred. It is with the fact of the frequency of shown, only cerebral in and taken by the natives themselves consisted in re- syphilis childhood with the interesting nightly clinical and manifestations of ligious processions. With the exception of a few in- pathologic the disease that stances, in districts in which dense ignorance prevails, we have to do rather than with the question of the man- ner of infection. these latter are scarcely ever encountered. The number It is not to an of persons who boiled their drinking water was aston- possible obtain adequate conception ishing. of the relative frequency of this affection in the period CONCLUSIONS. of childhood, by judgment based on the space devoted to the in the text-books. It is a field of researcli 1. From the evidence obtainable at this it is im- subject time, as yet almost in literature. to state whether the cholera was reintroduced unexplored special pédiatrie possible but one which as time goes on will be recognized as of into the Philippines, or remained here in some latent the greatest interest and of form for the and a half which no cases were far-reaching importance. year during That the is of a in detected. subject deserving special chapter pediatrics is evinced by the large number of instances of 2. While there is no evidence to show that the disease the affection to be found in the and its other that of enteric literature, by spreads by means than fever, yet relation to other and common affec- the with which it makes its in unquestionable very rapidity appearance many tions in childhood, not usually regarded as of specific na- widely separated places, puts it in an entirely different ture. class, so far as it is concerned. combating successfully When we consider the frequency of these other condi- 3. Maritime quarantine can practically insure the pre- tions in childhood, and the probable specific character of vention of its sea. spread by many of them the entire subject assumes a position of 4. It is practically impossible to make a land quaran- the foremost importance in the study of disease in chil- tine effective, hence, it is useless to engender the opposi- dren, and may justify a brief study of the subject and the tion with which it is usually met, and the time and placing on record of a grouped and condensed summary money required by such a quarantine, will yield much of some of the cases. better results when put to the education of the public in The words of Fournier,1 in his treatise, page 422, may the manner in which the disease spreads. well be repeated as preface to any consideration of the 5. The education of the public is a much more effec- subject : tive measure in its suppression than methods requiring Avec les affections du système nerveux nous allons aborder force in their application. un chapitre des plus importants de notre, programme, et je 6. In order, finally, to make serious outbreaks of puis ajouter des moins connus. cholera in the Philippines impossible it will be necessary In the consideration of this affection wo must study to replace the present insanitary water supplies with first the clinical phenomena in each case : second, the artesian wells, or others sources from which infection by probable character of the morbid changes in the central surface drainage can be avoided, or to correct it by filters nervous structure, responsible for these phenomena. or other means where it does occur. There are three pathologic conditions in the brain, which, singly or in combination, may be responsible for I Strychnin in Shock.—Dr. Graeme H. Hammond, New York, states that whatever the effect of in Read in the Section on Diseases of Children of the American / strychnin surgical shock, Annual / in Medical Association at the Fifty-seventh Session, June, 1906. it is absolutely injurious psychic shock. 1. Fournier: Syphilis H\l=e'\r\l=e'\ditaireTardive, 1886. _

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