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become replaced by ordinary pyogenic cocci. It must be remembered that the bubonic variety of plague is only a manifestation of the septicemic disease. The organisms are present in the blood and multiply in the blood, and are scattered broadcast by such infected individuals through their excretions and secretions. Therefore such types of plague are not to be treated lighty. In my opinion, each of the varieties of septica nic plague is to be regarded as dangerous and capable of spreading the disease, the actual spread of the infection being occasionel indirectly.
The question of prophylaxis becomes a serious one when we have to deal with the second type of plague, namely, primary plague pneumonia. Fortunately this variety of plague has not often appeared in Hongkong. Each case of primary pneumonic plague must be regarded as a new focus of the disease. This form of plague spreads with great rapidity, producing family epidemics, to be followed by epidemics of congregations of people, and lastly often appearing as a dreadful national plague and disaster such as was found during the middle ages.
Only one other disease, namely, Influenza, can be compared with primary plague pneumonia in regard to infectivity and tendency to pandemic extension. In all cases of primary pneumonic plague, the drop infection of FLGGE plays the predominant part in the conveyance of the infection.
So different are the two types of epidemics found in plague, that for ages they were regarded as distinct diseases. The septicemic type with the presence of bubonic swelling was formerly known as "oriental plague," the pneumnonic type of the disease being called "Bali," or "Lung pest.
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Recent research has shown that individuals who have apparently completely recovered from pneumonic plague may harbour plague bacilli in the sputum for a considerable period of time.
The lessons taught us by the various epidemics of plague during recent years show very clearly the modes of development of these different types of the disease. It has been shown that in endemic plague foci as well as in recently infectel areas, the disease appears first in the rat. Kat plague is the primary type of the disease. And further this outbreak amongst the rats is usually the result of conveyance of infection through plague ship rats.
Again in endemic areas the more benign type of the disease is usually found. Primary pneumonic plague can usually be traced, through the benign type of the disease, to a primary affection of rats.
These preliminary data are necessary in order to formulate the principles underlying the special prophylactic efforts against the disease in its various forms.
The methods at our disposal for the prevention of the spread of the dise ise to other parts, have already been dealt with under "General Prophylaxis." Supposing, however, a case of plague occurs in a previously healthy area, prophyaxis has a double duty to perform. In the first place, it must carefully guard against a possible outbreak of primary pneumonic plague, and secondly it must cope with the already existent rat plague.
Outbreaks of lung pest, either isolated or epidemic, can be dealt with simply. Here man alone is the carrier of the infection. The rat has nothing to do with it. Therefore the enforcement of the strictest isolation and the thorough disinfection of all discharges fulfil all that is required.
Not only have cases of pneumonic plague to be isolated. but also all instances of the septicemic disease. The discharges from these cases have to be regarded as
equally dangerous.
As a general rule, all cases of plague, no matter what variety of the disease is present, ought to be isolated.
Special precautions have to be enforced when dealing with the primary pneumonic type of the disease. Here rigid isolation is necessary, even from cases of the other types of plague. Something of the nature of a mosquito net ought to be used, not to prevent the access of mosquitoes, but mainly to guard against the aerial distribution of the minute particles of sputum which are so dangerous. Doctors
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