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Causes of Death.-In October there were 363 deaths, or 14.5 per cent of all, from diseases of the circulatory system (heart disease, etc.), and 352, or 14.1 per cent, from tuberculosis of the lungs and other organs. For September the proportion was slightly higher for various forms of tuberculosis than for heart disease and allied ailments. Other important causes of death each month were violence, diseases of the nervous system, of the digestive system, of the respiratory system, and cancer. The proportions for pneumonia and other diseases of the respiratory system were somewhat higher in October than in September.

Typhoid fever was the most fatal epidemic disease in the State each month, though the number and per cent of diseases from this cause was considerably less for October than for September. Diphtheria and croup, plague, and whooping-cough were next in order among epidemic diseases each month.

The following table gives, for both October and September, the number of deaths from certain principal causes as well as the proportions from each cause per 1,000 total deaths :

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Geographic Divisions. The table which follows shows the number of deaths from main classes of diseases in the several geographic divisions of the State for both October and September:

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This issue of the Bulletin is mostly given over to the plague and fleas, not that we consider there is any great danger of a serious epidemic, for we do not, but our belief is based on the fact that every one knows the existence of the disease, and the effort being made that all may know the means by which it is spread and how to avoid it.

There are a few facts which can not be too strongly impressed into the minds of all, and the first is that there is nothing in the climate of California or of any other State that will inhibit the spread of plague. Heat or cold is all the same to it; wet or dry makes no difference; it accommodates itself to the conditions. The second important fact is that it is a rat disease primarily, and that it will flourish where they are, if once introduced. No rats, no plague. A third point is that rats live where they are invited; that is, where they are fed and given shelter. Make basements and cellars rat proof and keep all food from them and they will not stay with you. Their great source of livelihood is foraging from the garbage barrel; hence, all waste matter should be put into a closely covered tin or iron can, and all food kept out of their reach. If every one would trap and poison the rats about his own premises, plague would soon be wiped out of existence. The cases are growing constantly less, but the work of cleaning and destroying vermin goes on with increased vigor all over the State.

No cases have been reported outside the area originally infected. Up to date (November 18th), there have been 96 verified cases in San Francisco, with 60 deaths. In Alameda and Contra Costa counties there have been 8 cases and 7 deaths.

All ships and boats are being fumigated every fourteen days, and the organized work of cleaning, disinfecting, and destroying vermin has extended to surrounding counties and into practically all the cities in the State. Not only will plague be kept from spreading, but the general health of the State will be improved.

BUBONIC PLAGUE.

By Passed Assistant Surgeon Rupert Blue, United States Public

Health and Marine-Hospital Service. Plague is an epizootic disease attacking rats and other rodents and communicable to man through the agency of the flea. It may also be transmitted through the respiratory or digestive systems or through skin abrasions.

Plague occurs in three forms: the bubonic, the pneumonic, and the septicemic. The terms pestis major or pestis minor are simply used to express the severity of the disease.

The disease is caused by a short bipolar bacillus with rounded ends. It stains well with carbol-thionin and decolorizes by Gram's method. It grows well on most media and shows typical stalactite cultures on bouillon and bizarre forms on salt agar. The bacillus is mechanically carried from the plague-sick rat by the flea, which by biting man inoculates him with the disease. All ages, all races, all classes are attacked. There are no exemptions.

In the bubonic form the pathological findings are those of a severe toxæmia with hæmorrhagic necrosis of the lymph glands. These are usually firmly bound down and surrounded by an area of hæmorrhagic cedema. The spleen and liver are enlarged and softened. The capsule of the spleen shows minute underlying white necrotic spots. The heart is dilated and shows muscular degeneration. All of the organs, including the skin, may show hæmorrhagic ecchymoses or petechiæ.

The pneumonic form resembles an ordinary lobular pneumonia. Only small patches of the lung may be involved. These are seen as small red areas surrounded by healthy tissue.

The findings of the septicæmic type are identical with those of any "vere septic infection plus internal glandular involvement.

The attack is ushered in by chilly sensations, backache, headache, fever of moderate severity, great prostration, and swelling and tenderness of the affected lymph nodes. The right inguino-femoral glands are most often attacked; next in frequency are the axillary and cervical glands. The gland is not easily outlined and is surrounded by an oedematous area. Petechiæ may be distributed on any part of the body. The pulse is rapid and bounding, but easily compressible; becoming dicrotic, and as the disease progresses almost imperceptible. The fever shows a sharp initial rise and falls by lysis. The tongue presents a red tip and edges, with a white coating on the dorsum, turning brown as the disease progresses.

The pneumonic type has all the symptoms of a true pneumonia, but the physical findings are slight in proportion to the overwhelming prostration of the patient. Dullness with intervening resonance may be found. The B. pestis may be isolated from the sputum.

The septicaemic type may supervene upon a bubonic case or may be primary. It is usually rapidly fatal. The symptoms are identical with those caused by a severe streptococcus septicæmia. Blood smears from such cases show the B. pestis.

Plague buboes may be diagnosed from those of venereal origin by the absence of other venereal lesions and the fact that syphilitic, chancroidal, and gonorrheal buboes are sharply defined. When any doubt exists buboes should be punctured with a hypodermic syringe and the fluid withdrawn, examined microscopically, and by guinea pig inoculation. Mumps should be excluded by the age of the patient, the mildness of that disease and the reaction of sour substances. True pneumonia may be ruled out by sputum examination and the disproportion between the physical findings and the great illness of the patient. Typhoid complicated by superficial hæmorrhages may be difficult to eliminate. The Widal reaction, the tongue, the intestinal symptoms, and the step-like gradations of the temperature in enteric fever should all be taken into account. The typhoid eruption is a roseola, while that of plague is petechial.

The blood of all septicæmias should be examined in plague times for the B. pestis. Ambulatory bubonic cases of mild type may be overlooked. Two such cases have recently occurred in San Francisco.

It should not be forgotten that plague may supervene upon a chronic disease and cause the death of the patient. Plague is a polyform disease, and the practitioner should always have it in mind when diagnosing obscure cases. Especial care should be taken when there is a primary delirium.

The prognosis in plague is very grave, 90 per cent of Asiatics and at least 55 per cent of whites attacked die of the disease. A critical change in temperature and an early delirium are bad auguries. Uncomplicated bubonic cases are the mildest and are most apt to recover. Secondary septicæmia is a very serious complication.

The treatment of plague falls into two divisions : specific and symptomatic. For the former, Yersin's serum is best. It comes in dry form and is prepared by dissolving the contents of the tube in 10 cc. sterilized water. Five tubes should be given as a preliminary dose and repeated if necessary. The symptomatic indications are to support the heart, and apply cold packs to the buboes. Temperature may be reduced by

sponge baths.

The remainder of the treatment will suggest itself to any intelligent practitioner. Buboes should not be incised unless suppuration occurs.

Persons who are about to be exposed to the disease should be immunized with Haffkine's prophylactic. This confers immunity for about six months. It should not be used on those who have already been exposed to plague, on account of the negative phase which it induces. Yersin's serum, if used for prophylaxis, should be given every ten days in doses of 10 cc.

The suppressive measures to be used against plague include the destruction of the rat and his parasites. All premises should be kept scrupulously clean and no food or garbage left about which might attract rats. The rats themselves should be trapped and poisoned. For the latter phosphorus paste, plaster of paris flour, and Danysz rat virus of high virulence should be used. Municipalities should encourage rat eradication by offering a bounty on rats, and all rodents so secured should be examined bacteriologically, as in this way infected localities may be discovered. Houses should be freed from fleas and other suctorial insects, by taking up the carpets, beating them in the sun and washing down the floors and baseboards with bichlorid of mercury 1-500, carbolic acid 1-40, or similar antiseptics. Care should be taken to prevent the reimportation of fleas into clean houses by sand in the shoes and on the persons of householders. All dwellings and places of business should be rendered rat-proof by the concreting of all basements and the closure of all openings through which rats could find ingress or egress.

When there is a suspicion that plague may exist, all dead should be examined before burial and necropsies made in case of doubt. Plague cases shouļd be buried in metal caskets with lime, or, what is more preferable, they should be cremated. When the body has been embalmed with formalin solution it is rendered sterile, hence these measures are unnecessary.

Persons suffering from plague should be isolated and all contacts subjected to daily examination for eight days. The house should be disinfected with sulfur 3 pounds per 1,000 cubic feet of initial air space to kill insects, the carpets removed after fumigation and well beaten, and the floors and baseboards washed down with antiseptic solutions. All sweepings from the house should be burned. Plague is a long-lived disease and may be perpetuated for years in a community in the body of the rat, the mouse or the ground squirrelhence when plague occurs in a locality it is the patriotic duty of every citizen to lend his hearty coöperation in exterminating all rodents and assisting the public health officers by every means at his command.

PRELIMINARY NOTE ON THE STUDY OF RAT FLEAS IN RELATION TO

BUBONIC PLAGUE. By M. B. MITZMAIN, of the University of California. Approximately eight hundred rats have been collected and examined, from ships in the harbor, stables along the water front, and from districts in San Francisco, Oakland, and Point Richmond where plague had been reported by the local Health Boards.

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