PLAGUE IN THE AMERICAS (Continued)”

VIII. PARAQUAY Paraguay was the first of the American countries in which the pres- ence of bubonic plague was rep0rted.l

The country lies close to the heart of the South Ameritan continent, from 800 to 1,600 miles up the La Plata River and its tributaries (between about 19”30’ and 28” South Latitude and 54 to 63” West Longitude). It covers an area of some 169,000 square miles and has a population estimated at l,OOO,OOO,of which about 20,000 are Indians. The eastern part of Paraguay is rolling or hilly, and forested; the western half is made up of grassy plains with occasional wooded hills, and is crossed by numerous tree-fringed streams. The climate is sub-tropical, with three hot months, December, January, and February (and sometimes March and November). Summer lasts from October to March and winter from April to September. The mean temperature varies between 71 and 73 F, with a maximum of 98 F. The heaviest rains occur about March, but some rain falls every month. The industries of the country include agriculture (cotton, tobacco, yerba mate, coffee, rice, sugar, oranges) in forest clearings, stock-raising on the plains, and lumbering. As noted elsewhere (See General Review), the first case of plague in Paraguay seems to have been that of a sailor arriving on the Argentine coasting steamer Centauro, which had taken on at Montevideo, Uruguay, a cargo of Indian rice from the Dutch sailing vessel ZezYer. Four sailors fell ill during the voyage, and three of them died in Asunción, April 28 (two days after the vessel’s arrival), May 1, and May 4, 1899.2 These first cases were not diagnosed as plague, although characteristic symptoms were observed.3 The disease continued to spread slowly among the scattered inhabitants of Asunción, and the corre& diagnosis .

* See General Review. 1 Kinycun has pointed out thd plague wa~ prcbebly present in California befcre 1899 (see General ‘Review, Note 35). Rodrfguez also disputad Paraguayan pricrity, expressing the opinion that the Cm- tauro left plague infection in the Argentine ports which she touched befcre reaohing Asunci&, and that clima& conditiom mere respomible fcr the delayed appearmce of the disease in the tormer localities. (Rodrfguez, M.: Rev. Son. dililitar, Paraguay, May 1929, p. 2153: BoE. OJ San. Pan., Sept. 1929, p. 893.) His conclusions mere based cn B study of Agote and Medina’8 wcrk (Agote, L., & Medina, A.: “La Peste Bubónica en la República Argentina y en el Paraguay, 1899-1900.” Buenos Aires, 1901). Agote and Me- dina, however, ststed thnt “Tha vess& wbich at that time leftksuncibn [that fs, in the period between tha outbreak cf plague and its accurate diagnosis, cr April tc September, 18991 weresurely those which sowed the plague germ along cur coa&. . :’ (Ibid., p. 40).

* A U. S. Consular report cf the period ravesls the reaoticn to the appearance cf plague in Amrmibn: “There is a kind cf disease existing here said to be peculiar to Paraguay. It seema that the physiciam do not know what it fs. It kills in fcrty-eight hcurs; if nct, afta that time there is hope. It is safd ti take the glands; that is, causts them to swell. It seems to have ita origin in filth, and began in the soldiers’ bar- ra& . , . . At presenta bnderiolcgical rtnrilysis is being made. In EIfew days it is hoped & scientific opinion will be reached. Schools have been dismissed today to be cleaned and painted imide; the Government buildfngs are undergcing the sant? prcoess. The soldiers from that part of the barra& whioh was affected will be sent cutside the oity. The hospital papera mncunce ll sick soldíers, 8 conv&aoing snd 3 stiU VB~Y lcw. Don% think the diseme will develop cr increase . . .” (Pub. Eedth Repwts, U. S., Oct. 27, 1899, p. 876). 1149 1150 PAN AMERICAN SANITARY BUREAU [November was established September 14, 1899, with the cooperation of an Argen- tine commission, though some persons continued to claim that the dis- ease was not plague.4 PLAGUE IN PARAGUAY

I 1

600 -5* This first epidemic was also the severest and most extensive which Paraguay was to suffer. A total of between 89 and 100 deaths in 1899 have been estimated from records and personal testimony,E with 14 more in January and February,

4 Tbe Argentine scientista, Agote and Medina, after quoting Ricardo Jorge’s expwiences in Oporto, report that similar opposition wa8 encountered in Asunción, Rosario, and even Buenos Aires: “Here. . . it was also neoessary, in arder ta satisfv popular clamor. to have recoure to the opinion of ‘foreign experta,’ and when tbeir opinion completely coofirmed that of our own bacteriologists and clinicians oonnected with the investigation. the opposition simply denied their competence in the field.” (Supra, p. 19.) 6 Agote and Medina give 100 deaths (64 from April thmugh September and 77 cases 46 deatba from October through December, 1899) (Ibid., p, 36). Tbis figure hss been aocepted by Paraguayan writers. (See Table) 19411 PLAGUB 1151

1900, when the epidemic temporarily ceased, to reappear in July. These figures do not include deaths in the railway towns of Tembetary (suburb of Asunción), Trinidad, Luque, Tacuaral (Ypacaraí), Itagua, Paraguarí, and Villarica, which were also infected. Since 1900 th ere have been about 15 limited outbreaks and some sporadic cases, including the occurrence in December 1909 of 30 suspicious Plague in Paraguay - Icsfrhn’s data* Additional Reporte T - Month kctha Deaths

1899 Apr.-Dec. 100 1900 Jan.-Feb. 14 12 2 July 24-31 %b. Health Reports. 1901 Jan. 7 1 June 23 II 1902 Mar.-Dec. ti 1903-04 0 1905 Jan.-Dec. 2 1906 Feb.-S&. 14 1907 Oct.-Nov. 3 8 Jan. 3, Concepeibn ‘< Feb. 6, Asunción II 1908 Dec. 1 1909 Apr.-Nov. 8 1910 Feb.-De& 5 30 w 3OW Dec. 10,1909-Feb., 1910, Northern Paraguay 1911 July 20 23 14 Aug.-Sept. 1912 July-sept. 15 1913 Jan-Dec. 21 1914 Mar.-DW. 6 3915 Jan.-Apr. 3 1916-18 0 1919 Oct.-Nov. 7 1920 0 1921 0 1 Feb. 4. ticínity of rae infeated mar& 1922 0 1923 0 4 Dec. 18, Preass reporta OdY 1924-26 0 1927 Od. 10 1928 Aug. 2 oct. II Apr. 1; July 10; Aug. 3 ?ositive plague diag- noses, Natl. In&. Par- asitology, 1928 5-6 ?&i& Total 242 56

* InsfrBn. José V.: Bol. Of. San. Pan., Oct. 1935, p. 928. t There wero at least 10 cases and 5 oì 6 deaths from plague in Aauncibn in 1928, according tc the recol- lection of Dr. Rati Peña (Personal ccmmunication, October 9, 1941). At lea.& 3 of the cases were pneu- monic plague. A suspiciow case reported in 1936 proved cn bscteriolcgic examination to be lymphogranuloms, not plague. Insfrán gsve August 28, 1928. as the data of the last pla.que death in Asuncibn. (S) = Suspicious only. deaths in Northern ParaguayG; a flare-up in Asunción in July-September, 1911, with some 20 deaths; and 21 deaths in 1913, 15 in the last half of 1912, and 14 in 1906. No cases mere reported for 1903-04, 1916-18, and 1923-27; the last recorded outbreak was in 1928 (6 cases, 2 deaths June-August; 3 cases, October). The total number of deaths reported was 298, including some unverified reports, and the total number of cases was probably not over 500. (See Table)

6 Pt&. IleoU Repds, 1910. These cases aro apparently not included in the Paraguayan reporto; 1152 PAN AMERICAN SANITARY BUREAU [November

In addition to the towns from which plague cases were reported during the original outbreak, Patiño-cue (1900 ?), Villa del Pilar (1900 ?), Villa Concepción (suspicious cases, October 1900, later declared not plague),’ Areguá, Carapeguá,8 and Puerto Pinasco (Oct. 1927)g have been listed as having had plague at some time.

Rats and Mice.-Dead rats were conspicuous during the original outbreak of plague in Asunción (they were found on the Centauro, and then in the vicinity of the Customs-house some 15 days after her arrival).lo Anti-rat measures have been a part of subsequent control campaigns. According to Insfrán, the two rats fouad in Paraguay are the gray rat (Mus decumanus or Rattus norvegicus), living in burrows and sewers; it is the domestic rat and the most abundant; and the black rat (Mus rattus), living in roofs, walls, and trees.‘l Fleas.-There do not seem to have been any studies of the fleas connected with plague in Paraguay, although Xenopsylla cheopis is probably the most common, according to Peña.12 Seasonal Distribution.-The original epidemic lasted from the intro- duction of plague in April, 1899, through February, 1900, with the heav- iest incidence from August to October.13 The disease apparently reappeared in July and again in October, 1900.14 While the available later statistics do not always give the month of the outbreak, they seem to show a majority of cases occurring between July and February, and especially between July and Octobei-. Agote and Medina, studying the temperature and humidity curves for Asunci6n, stated that the “mild temperature and low humidity . . . of late winter and spring” (that is, from about July to September), were favorable to the develop- ment of plague.16 The average temperature of Asunción they found to be about 74 F, ranging from 60.2 in June to 81 in December; with the highest temperature ranging from 106 F in December to 89.8 in June, and the lowest from 32.3 F in June to 60 in January. The hu- midity varied from a minimum of 62yo in September to a maximum of 77% in May, and dropped steadily from May to September.

’ Low, R. B.: “Reporta and Papenì. Bubonic Plague,” Local Governing Board, London, 1902, p. 428. 8 InsfrLn, Jos5 v.: “La peste en el Paraguay,” Bol. Oj. San. Pan., Oct. 1935, p. 925. (Presented to the Ninth Pan Ameritan Sanitary Conference by the Paraguayan DeIegate, Dr. Cayetano Masi.) 9 Urizar, Rogelio: An. In&. Na. Para&oZosia. Val. 1, No. 1, 1928, p. 295. 10 The mortality among the rata around the Customs-house was so great that ene of the employeea declared that “the Custome warehouses, whioh. liko al1 such, had heen plagued with rats, are today eo free of them thd we csnnot find a single ene.” (Agote & Medina, suva, p. 26.) 11Inefr&n, J. V.: supra. 14Peña, Raúl, personal communication, October 9.1941. The lack of detailed investigations may well be due to the fact that the Iargest and best studied outbresk occurred before the relation of tleaa to plague had been thoroughly worked out. 18April, 1 death: May, 3; June. 1; July, 6; August, 22; September, 22; October, 26; November, 12; December, 8: January, 1900, 10; February, 4. (Agote & Medina, supnz, p. 32. The diagnosea from April through September were retrospective.) 14Uriarte, Leopoldo: “Sur Iea epid&niea de peste bubonique 8. I’Aesomption et au Rosario,” Bnn. Inst Paateur, xv, 1901, p. 867. 16Supra, p. 108. 19411 PLAGUE 1153

Kinds of Plague.-Insfrán has stated that the pneumonic form of plague has been prevalent in Paraguay, although bubonic and septi- cemic cases were also reported, and that the mortality has been about 50Y&16 The mortality from October through December, 1899, when every possible effort was made to secure an accurate count of cases and deaths, was 59%, although it was recognized that numerous cases might have escaped observation.17 There were ll known cases of pneumonic plague in the original epidemic, all of them fatal (7 members of a single family from Itaguá, five of whom fled to Asunción and died there, and 2 Sisters of Charity who were caring for plague patients).18 Two pneumonic cases were reported in October, 1928.1s Of 6 cases reported in June-July 1928, 4 (2 fatal) were said to be septicemic.20 Agote and Medina reported a case of plague seen in Asunción, originally bubonic, which on the eighth day developed a papular-vesicular eruption all over the body, especially on the face and arms; the right eye was aIso affected, with ulcerations of the cornea. They also saw cases of “walk- ing p1ague.“21

Urizar has cautioned that in making a microscopic diagnosis of plague in Para- guay, one must “keep very much in mind the involution forms, which are those habitually found, especially during the warm season . . . and small, lanceolate coccobacilli, joined at the ends.“*z

Control.-Plague control work in Paraguay has sometimes consisted chiefiy of extermination of rats, isolation and treatment of cases, vac- cination, and general sanitation measures after an outbreak, but the legislation in forte provides authority for permanent anti-plague work, and this has been carried on with varying degrees of intensity according to the resources available. The agency in charge is the Ministry of Public Health. Among the legislative provisions are23 the compulsory reporting of plague, and authority for general measures against it and other contagious diseases (Law No. 153, Sept. 15, 1915); Decree No. 53,738, requiring public cooperation in the kihing of rats; Municipal

16Imfdn, mbpra,p. 925. 1’ 77 cases 46 deaths (Agote & Medina, supra). 18Ibid., p. 144. ‘9 Bol. Of. San. Pan., Dec. 1928, p. 1525. The diagnosis 7~88 made by Dr. Rati Peña, then an idem, who became suspioious when the daughter of a patient who had died at the Clinical‘Eospitrtl of what had been thought to be pneumonia, reported that her father was very ill and that her brother had dfed twooì three days previously. Since bubonic plague cases had been reportad from the Campo Grande barracke a few months before, the possibility of pneumonio plague waa evident, and examination of blood from the lung revealed the bacilli. Preventive injections of antiplague serum mere immediately taken by the has- pital personnel. There were some severe reactions ta the serum, but none of the attendanta developed plague. (Personal communication of Dr. Peña, October 9, 1941.) 20 An. Inst. Paras., Val. II, No. 2,1929, p. 125. 21Agote & Nedina: supra, pp. 159, 167. 2’ Urizar, R.: supra, p. 298. *a hfr&n, J. v.: aupra, p. 925. 1154 BAN AMERICAN SANITARY BUREAU [Novcmbar

Ordinances regulating general sanitation (No. 30, July 1891) ; house construction (No. 46, July 1894) ; building regulations (No. 47, Decem- ber 1894) ; requiring the placing of gratings across sewer openings to prevent passage of rats (No. 72, January 14, 1905) ; stable regulations (Nos. 242, and 1390 of Feb. 5, 1923, and 1408, of March 1923); and requiring the use of rat-proof garbage cans. Furthermore, Paraguay has adopted the anti-plague measures recommended in an International Sanitary Convention entered into with neighboring Republics in 1904,24 and those of the Pan Ameritan Sanitary Code.

As described in 1934,26the activities of the anti-plague service include a survey of dwellings and surroundings to determine which are in need of sanitation, rat- proofing, or deratization; the distribution of poison and loan of traps (the cage and snap types) and fumigators; encouragement of the keeping of rat-killing cata and dogs; and closing of burrows with cement and hroken glass, after fumigation. In 1933 the number of rats killed in Asunción was 1,105; in 1938, 4,411;26and from January through August 1940, 2,012 (by poisoning).27 The health authorities hope to begin soon the regular examination of rats, at least those from the port area. Hydrocyanic acid gas and sulfur and sodium nitrate combinations are used for fumigation, according to the place to be fumigated; the Clayton apparatus (sulfur) is generally used for ships. White phosphorus, barium carbonate, ar- senic, gypsum, and strychnine, mixed with flour, powdered fish, bacon, cracklings, and anise, are the poisons commonly employed. Vaccination and serum-therapy.-The Institute of Bacteriology (later the Institute of Parasitology) of Paraguay was founded in 1900 for the manufacture of plague serum and vaccine, and its products have been used in subsequent outbreaks of plague. The use of serum was believed by the Argentine commission to have saved the life of one of their number?* In June and July 1928, plague broke out in the barracks at Campo Grande, Asunción, and vaccination of al1 the regi- ment and the Asunción garrison was resorted to, in additionto such effective anti-rat measures that no mice and rats were seen during the following year. There were 6 cases with 2 deaths (one of the deaths was in an unvaccinated person, the other in a soldier who had received the preliminary injection).2s

M Signed by Argentina, Brazil, Paraguuay, and Uruguay, but never put in forca beoause not ratified, although aorne of the provisions wore earried out by the vsrious countries. Thc most recent knowledge on plague control methods was included, and reciprocnl notificetion required. (See Bd. Of. San. Pon.. Dec. 1940, p. 1222.) The text of the convention appears in “Recopilsción de Leves, Decretos, Ordenanzas y Reglamentos, Año 1919,” Depto. Nao. de Hig. y Asia. Pub., Asuncibn, 1921,58 pp., p. 14. 25InsfrBn: supra. ~0Off. Int. Hyg. Pub.: “Lea dératisations maritimes en Amérique pendaut I’annés 1936,” Bd. Of. San. Pan., Jun. 1938, p. 513. 27Bol. Min. Sahd Pzlb.. Aug. 1940, p. 112. 28 Dr. Malbrdn, who becnme exposed while examining pneumonic plague cases, 48 hours after receiving & preventive injection (0.10 CC) of serum. His illness became septicemic in type, with pulmonary con- gestion (although no pneumonicsymptoms oould bedetected), and herecoveled without incidont, having received curativeinjections of serum. (Agote & Medina, supm. p. 195.) 29Rodrfguez, M.: Reo. San. Mil.. May 1929; Bol. Of. S an. Pan., Nov. 1929, p. 1200; Urizar, R.: An. Inst. Parus., Vol. II, No. 2, 1929, p. 125. 19411 PLAGUE 1155

Research.-There seem to be no reports of plague research in Paraguay ex- cept for the epidemiological studies made by the Argentine Commission in 1899, and by Insfrán about 1933,30and for a bacteriological investigation made by the Institute of Parasitology in 1927, in which 5 strains of plague were recovered from 5 bubonic plague cases at Puerto Pinasco. A vaccine was prepared by the Insti- tute from the more virulent strains, and tested on guinea pigs, as was another vaccine prepared the following year after another outbreak.31 Vaccination of the affected regiment and Asuncion garrison with this national vaccine has already been mentioned. Martyrs.-Paraguayan victims of plague in the course of duty include the two Sisters of Charity who died of pneumonic plague during the original epidemic; Dr. Candia and a priest, who were fatally stricken about 1907, and Dr. Manuel Pérez, who died of plague while caring for victims of an epidemic about 1913. There may have been others.32

Rural medicine in Mexico.-Beginning in 1936, the Department of Health of Mexico has established 121 Rural Hygiene and Social Medicine Services, of which 69 are in zones previously having no medical or sanitary attention for farmers, 25 in regions inhabited by Indians, and 28 in areas where existing services were prohibitive in cost, for farmers. Where economic conditions permit, the Services are financed cooperatively, with fees ranging from $12.00 per family per year in corn-growing areas to $24.00 in cotton, sugar, and wheat regions. Elsewhere, and in the Indian areas, the Federal Government assumes the full burden. The basic staff of each unit consists of a medical officer, a nurse who is also a licensed midwife, a pharmacist, and an assistant, al1 full-time; additional personnel may be added where needed. Services range from out-patient clin& minor and emer- gency surgery, home visits, deliveries, and free filling of prescriptions, in units entirely supported by the government, to the provision of such additional services as maternity wards, emergency hospitals, dental clin& laboratories, infirmaries and general surgery wards, polyclinics, general hospitals, special diagnostic and treatment facilities, and medical research, in that order. Where death rates are high, curative medicine is given the most attention, up to 70%; as immediate problems are attended to greater time is given to preventive work. Important measures are vaccination against smallpox, typhoid, and diphtheria; water supply improvement; rabies treatment; control of carriers; early diagnosis; maternal and Child services, including prenatal and premarital hygiene; health education; nutrition, industrial hygiene; and construction of sanitary latrines.-DEPART- MENT OF PUBLIC HEALTH: “Rural Hygiene and Social Medicine Services,” Mexico, 1941, 14 pp.

Definition of social service.-“The old concept of philanthropy, alms, or charity, has long since disappeared, to be replaced by the idea of the inescapable duty, the simple obligation, of all men to each other. The term service is derived from servo-servitium abstractum a servo-the designation used in ancient Rome for compulsory labor, and the adjective which accompanies it implies that this labor must be performed by all of society. Solidarity has thus become a quasi- science, with a highly technical nature. “-Miguel Couto (15641934), the Brazilian Osler, as quoted by A. C. Pacheco e Silva, “Servicos Sociais,” São Paulo, 1937, p. ll. 10Supra. 81 An. Iml. Paras., Vd. 1. No. 1,1928, P. 298; Vd. II, No. !¿,1929, p. 125. 31Personal communication by Dr. Raúl Peña,October 9, 1941.