LESSONS TO BE LEARNED FROM THE PRESENT OUT-
BREAK OF YELLOW FEVER IN LOUISIANA. |
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BY JAMES CARROLL, ASSISTANT SURGEON, U. S. ARMY, WASHINGTON, D. C. ✓ The present seems to be a suitable occasion to invite attention to
several points in connection with the epidemic occurrence of yellow
fever in the United States at the present as well as at other times. In
the discussion of the symposium on yellow fever at the meeting of the
Association in Washington, in 1903, the writer called attention1 to the
necessity during the epidemic season for requiring physicians, in cities
where yellow fever is prevailing or likely to prevail, to report promptly
to the authorities all cases of fever of any kind, coming to their notice.
This is necessary in order that there may be no delay in the institution
of proper measures to protect the community against extension of the
disease if it be yellow fever, for this extension will almost surely take
place in the more southern latitudes if the patients are not protected
from mosquitoes at the outset. If all cases of undetermined fever were
promptly reported and at once protected from mosquitoes2 it would
hardly be possible for the disease to spread if it were yellow fever; on
the other hand, where the physician waits for the appearance of black
vomit the golden opportunity passes by, for it has been shown that in
practically all cases the disease cannot be communicated after the fourth
day of the fever. For this reason the diagnosis should be anticipated,
and all febrile patients should be immediately protected from mosqui-
toes until it is shown by actual demonstration that they are not cases
of this disease. Epidemics do not follow every introduction of yellow
fever; mosquitoes becoming infected may die before they bite a non-
immune, or the patients may happen to be treated in a locality free
from Stegomyia. A group of cases of yellow fever occurring without
black vomit usually receives the designation bilious remittent fever, a
diagnosis that should be erased from our text books. Bilious remit-
tent fever, acute in type and of short duration, appearing in the United
States, is yellow fever, and it should be so regarded. Bilious remittent
fever was formerly regarded as a type of malarial remittent, but that ---------- 1Report of the Proceedings of the American Public Health Association,
Vol. XXIX, p. 291. Since this paper was read, I have been informed by Dr. E. Liceaga, presi-
dent of the Superior Board of Health of Mexico, that the line of procedure
indicated is now being followed in his country. 272 |
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YELLOW FEVER IN LOUISIANA.
273 was before the use of the microscope was found to be necessary for a
positive diagnosis of malarial infection. We know now that malarial
fever is not a disease of cities, but of outlying districts, while the
bilious remittent fever, so-called, has been recorded in the cities, in
epidemic form, and in such intimate association with yellow fever that
by some, the diseases were declared identical, and by others, the latter
was said to be only a modification of the former. Most interesting
and important in this connection is the statement cited by La Roche3
in his chapter on bilious remittent fever, that "The morbid appearances
revealed on dissection are the same in remittent as in yellow fevers."
This statement, however, was not wholly accepted by him, for he calls
attention to the bronzed appearance of the liver in certain remittents,
a condition that we know results only from malarial pigmentation.
Now that we can so easily differentiate malarial remittent and typhoid
fevers from yellow fever the diagnosis is much less difficult, except
where yellow fever occurs as a complicating infection. Our confreres in Havana have demonstrated to us that it is possible
to prevent the epidemic occurrence of yellow fever, even while occa-
sionally admitting cases of the disease into the heart of a city in which
the climatic and other conditions are known to be most favorable for
its extension in epidemic form, and in which there are more susceptible
persons now than ever before. The method suggested here is in many
respects similar to, and is based upon, the one adopted during the
American occupation of Havana. Since then it has been sufficiently demonstrated in 1903 and again in
1905, that under the lax system heretofore and now in vogue, yellow
fever can easily secure a firm foothold in certain of the southern states
and escape recognition until it has passed almost completely beyond
control. On both the occasions cited the outbreak was suppressed or
limited only by the intervention of the general government, which
through the energetic action of the United States Public Health and
Marine Hospital Service, finally succeeded in checking two epidemics
that threatened to become little less than national calamities. Great
credit is due to those officials for the success that was attained in spite
of the extreme delicacy of the situation and the passive opposition
encountered from many quarters. Our experiences in Cuba have shown that for the exclusion and sup-
pression of yellow fever absolute hygienic control is necessary, not
only of the people at large but of the patients as well, and especially
of the practicing physicians. The aim of modern medicine is the pre- ---------- 3 Yellow Fever, La Roche, Philadelphia, 1855, Vol. 1, p. 590. 18 |
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274
YELLOW FEVER IN LOUISIANA. vention of disease rather than its cure, and the safety and welfare of
the thousands of persons exposed demand that the proper measures be
instituted and rigidly enforced. No valid argument can be brought
forward to show why the United States should not be kept as free from
outbreaks of yellow fever as the city of Havana, its former endemic
home, has been, during the past four years. To attain this result the following requirements seem to be essential:
1. Our physicians, or at least those who are in control, must disa-
buse their minds of the impression that black vomit necessarily occurs
in the majority of cases of yellow fever.
2. During the epidemic season, viz.: from May 1 to October 31, and
in the epidemic zone, physicians should be required to report to the
health authorities, immediately, all cases of fever of any kind that
come under their observation, whether among their patients or not, and
failure to do so should be made punishable under the law.
3. The board of health should be authorized to appoint, with proper
compensation, a commission of three experts, all of whom should be
men of high reputation as diagnosticians. It should be the duty of this
commission to visit without delay all cases of fever reported to the
health authorities, and the onus of diagnosis should rest upon the com-
mission and not upon the attending physicians. They (the commis-
sion) should visit each patient daily until the diagnosis is established
or the patient sent to a hospital, and they should forward promptly
to the health department a written report at each visit. The commission
should determine whether or not the patient shall be treated as a possi-
ble case of yellow fever and their decision should be final and obligatory
upon all concerned.
4. All patients presenting the symptoms of yellow fever, and all
cases not diagnosed but remaining under suspicion, should be promptly
removed for treatment to a hospital especially located and provided
with wire screens and mosquito nets, and the whole or a portion of
which has been set apart for that purpose. The yellow fever wards
or hospital should be under the direct control of the senior diagnosis
commission and the patients should be treated by physicians appointed
only on their recommendation and acting under their direction.
5. In exceptional cases, to be determined by the commission, patients
under observation awaiting diagnosis could be treated in their homes
beneath mosquito netting, and in rooms properly protected with wire
screens, until the nature of the case had been finally settled to the sat-
isfaction of the commission. The commission and not the attending physician should be held re-
sponsible for the enforcement of all clinical measures necessary for the
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YELLOW FEVER IN LOUISIANA.
275
protection of the community, and they should be empowered to employ
such help as seemed in their judgment to be required. They should
also be assisted at times by sub-commissions appointed on their rec-
ommendation. Under such a system, conscientiously carried out, the occurrence of
an epidemic of yellow fever in any city would become an impossibility.
Objection cannot be made on the ground of expense if the members of
the diagnosis commission are paid only for every visit to a patient;
under such an arrangement the cost to the city would be trifling when
compared with the losses now sustained by individuals and the whole
community through the failure of practicing physicians to recognize
and report mild cases of the disease. And herein lies the crucial point.
The diagnosis must be anticipated and the proper precautionary meas-
ures be taken before the disease has fully declared itself. Diagno-
ses of malarial remittent, and above all of bilious remittent fever,
must not be accepted as conclusive until the presence of malarial
or other parasites has been demonstrated to the satisfaction of the
members of the diagnosis commission. Attention was called two
years ago4 to the fact that over and over again, since the time of
Benjamin Rush, yellow fever has stalked abroad in our cities, un-
recognized, under the guise of bilious remittent fever. The time
has come when a diagnosis of bilious remittent fever should no longer
be accepted for there is no such disease per se. We may have mala-
rial fever complicated with jaundice, but this should not change
the diagnosis of malaria any more than an accompanying icterus would
change a diagnosis of typhiod fever. Similarly, a complication of mala-
ria no longer justifies the diagnosis of typho-malarial fever, and that
term has properly been discarded. In numerous instances it is stated in
the records of the older epidemics of yellow fever that the disease was
preceded by, or began as, a bilious remittent fever, just as in more
recent times physicians have believed that typhoid fever began as
malarial fever. The conclusion is equally untenable in both cases, and
the deduction is obvious that cases of so-called bilious remittent fever
must be regarded and treated as cases of yellow fever, unless a satis-
factory specific cause for the condition can be demonstrated beyond a
doubt. It is proper to mention here, that in every one of the twenty-
two cases of yellow fever purposely inoculated by the Army Board in
Cuba, a diagnosis of bilious remittent fever would have been justified
if it had not been known that they were produced from true cases of ---------- 4 Journal of the Association of Military Surgeons, 1903, (No. 4), Vol. XIII,
pp. 193, 199 and 200. |
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276
YELLOW FEVER IN LOUISIANA. yellow fever, for, although some of them were severe, black vomit was
absent from all. It may seem unnecessarily severe to require physicians, under pen-
alty, to report all cases of fever coming under their observation, but no
other means will attain the desired results, and the enormous interests
at stake demand that the methods instituted be thorough and that they
be rigidly carried out. The appointment of a board of diagnosis as has
been suggested will relieve the attending physician from the odium that
accompanies a diagnosis of yellow fever in a doubtful case, and the
board, fully appreciating the responsibility that rests upon them, may
be relied upon to do their duty. During the discussion upon yellow
fever before this Association at its meeting in Washington, two years
ago, already referred to, in my remarks, which were badly misquoted,5
I urged the necessity for requiring physicians, under a penalty, to re-
port all cases of fever in order that they might be examined by a board
of experts (as was done in Cuba), and treated as cases of yellow fever
until the diagnosis was established. Only last month in a conversa-
tion upon this subject with a physician from a large city in Texas, he
laughingly remarked. "We never report our cases of yellow fever until
we have about a dozen of them!" The present epidemic in and about New Orleans only serves to em-
phasize the necessity for such regulations as are here suggested, and
this necessity is further emphasized by the statement in the public press
of September 5, that "Inspector Brady attributed the continued spread
of the disease to the unwillingness or inability of physicians to diagnose
mild cases of yellow fever, and that physicians of standing and ability
look for black vomit before making a diagnosis." I have elsewhere6
cited the occurrence of the same difficulty at Key West in 1899, and
I again assert that these physicians may be thoroughly conscientious
and able men, but they are baffled by the differences between the aspects
of the disease as they actually find it and as they have been taught by
the best authorities to expect to find it. It is the manifest duty of local
health authorities therefore to relieve the physician of the burden of
diagnosis and to leave that and the adoption of protective measures
to the board of expert diagnosticians. In this connection I beg to be permitted to call attention to the pres-
ent situation at Jackson Barracks, a station of two batteries of coast
artillery, in New Orleans. By the 7th day of the present month a ---------- 5 Reports of the Proceedings of American Public Health Association, Vol.
XXIX, 1904, p. 291. 6 Journal of the Association of Military Surgeons, 1903, Vol. XIII, No.
4, p. 201. |
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YELLOW FEVER IN LOUISIANA.
277 number of cases of yellow fever had appeared in the neighborhood and
seven of them in a block that approached within one hundred feet of
the officers' quarters. Still the garrison has not been removed and up
to the present time no single case has occurred among them; even
should a case or two appear an epidemic is not feared. The reason
for this is simply that the medical officers know that it is absolutely
within their power to prevent any epidemic extension of the disease;
they are constantly on the alert and all cases of fever are handled in
the beginning as though they might be yellow fever. Again at Fort McIntosh, in Laredo, Texas, in 1903 there were only
five cases of yellow fever in a command of one hundred and eleven
officers and men, while in the town along side them over one thou-
sand cases and more than one hundred deaths occurred. It was found
that the five men who became infected had violated orders by visiting
the town at night without wearing the prescribed mosquito head-nets,
leather gauntlets and leggings. If, in the presence of cases of yellow fever among and around them,
garrisons of soldiers can be protected from the infection in anything
like epidemic form, it necessarily follows that the same measures and
the same degree of vigilance will protect a community, provided the
physicians do their full duty, and they are properly assisted by the
authorities. The subject is one involving the lives and interests of
thousands of innocent persons and the secret of success lies in eternal
vigilance with the determination to allow no case, however mild and
doubtful, to escape the fullest precautions. |
SOME NEW POINTS IN THE ETIOLOGY AND SYMPTOM-
ATOLOGY OF YELLOW FEVER. |
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BY JUAN GUITERAS, M. D., HAVANA, CUBA. Proc Am Pub H. A 33 meet
Boston Sept 1905 ✓ MR. PRESIDENT AND MEMBERS OF THE ASSOCIATION: -- I am very
sorry that I have not a carefully prepared paper to present to the Asso-
ciation; but my duties in New Orleans, Pensacola, and through the
South, have prevented me. I can therefore only put together some
rather desultory remarks concerning new points that have been brought
out in the struggle with yellow fever during the present year or by
investigators in distant parts. The French Commission from the Pasteur Institute, working in Rio
Janeiro, report that they have produced a case of yellow fever by
applying to a non-immune a mosquito that had been raised from eggs
laid by an infected mosquito. This brings up the question of the
transmission of yellow fever by the progeny of infected mosquitoes.
This is entirely a new point and of great interest, as you may well
imagine. We thought that we had settled this matter in Havana in
the negative. Dr. Carroll, speaking for the American Commission,
and myself, speaking for the work I did at Las Animas Hospital, came
to the conclusion that this was not so, that is, that an infected mosquito
did not transmit infection to its progeny through the eggs. Though
neither the American Commission nor myself carried out any special
experiments in this direction, our experience, however, in the course
of other experiments shows that the mosquitoes raised from infected
insects were inoffensive. As a matter of fact, the majority of the
mosquitoes we had to deal with, all the Stegomyias which we worked
with in the laboratory at Las Animas Hospital were the progeny of
infected mosquitoes. We started with infected mosquitoes and raised
generation after generation from them. These were constantly fed by
non-immune persons, by assistants in the laboratory, and by several
men I had there ready to be bitten by mosquitoes. They were all non-
immunes. We did not take any special note of this fact, but, in a
general way, we were impressed with the non-transmissibility of the
disease through the eggs to the progeny. There is, then, experimental
proof of some value against the views of Marchoux and Simond, of
the French Commission. Furthermore, these gentlemen have had
positive results in one case alone, and, as they were working in infected
278
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ETIOLOGY AND SYMPTOMATOLOGY OF YELLOW FEVER.
279
territory, it is quite possible that this man was bitten accidentally by an
infected mosquito. There is another argument which I believe is of
great importance against the transmission of the disease by the pro-
geny. It seems to me it would have been really impossible for us to
have eradicated yellow fever as we did in Havana if the views of
Marchoux were correct. During the memorable campaign in that
city the cases were quite often not seen until the second or third day of
the disease, so that they surely had the opportunity of laying eggs
before being killed; and the infected mosquitoes that were actually
producing infections, they were laying eggs with but little hindrance,
for, it must be remembered, that during that campaign the reduction
in the number of Stegomyias in the city was scarcely appreciable.
Really, if the French Commission be right, the problem becomes appall-
ing, impossible of solution. We got rid of yellow fever in Havana
very easily, and at little expense comparatively; this would have been,
it appears to me, impossible if the progeny of infected mosquitoes had
been also infected. Another interesting point to which Marchoux and Simond, of the
Pasteur Institute, called attention is one that has already been studied
in this country. They seem to have ignored our work, or they are not
familiar with it. They believe they have discovered a new source of
infection of yellow fever in young children affected with mild forms of
the disease. This is old. Dr. Blair, of Guiana, a great student of yel-
low fever; Dr. Chaillé, of New Orleans, and myself, in Key West
and Havana, have shown previously that this was an important source
of infection of yellow fever; that there were a great many cases of
mild, unrecognized yellow fever amongst children; and that these were
frequently unsuspected sources of infection. In fact, it was a study of
this problem of yellow fever in young children in the yellow fever zone
that led me to call attention to and to insist upon the fact of the great
danger of mild cases of yellow fever. I have been insisting upon this
point for many years, not only in the case of young children but also in
adults, especially the colored population, who are apt to have mild
cases of the disease. These I have always considered as the most dan-
gerous transmitters of the infection. I shall now take up some new diagnostic signs of yellow fever.
We are all convinced of the importance of an early diagnosis of
yellow fever, and I wish briefly to call attention to points of interest
and of importance in enabling us to make an early diagnosis even in
mild cases of the disease; of course, acknowledging that there are
some cases in which an exact diagnosis is not possible, with our pres-
ent means, and without our knowledge of the parasite of the disease.
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280
ETIOLOGY AND SYMPTOMATOLOGY OF YELLOW FEVER.
These special symptoms we have brought out in recent work on yellow
fever in Cuba, and which have been confirmed in New Orleans, are:
In the first place, a high percentage of hemoglobin in the blood of yel-
low fever patients. That is a very important diagnostic sign of the
disease, especially as distinguishing it from typhoid fever, malaria and
influenza, three diseases that are frequently confounded with yellow
fever. In influenza, typhoid fever and malaria, the percentage of hem-
oglobin is low -- 70, 75, 80 perhaps. In yellow fever we have a high
percentage of hemoglobin, very often 100, sometimes above 100, during
the first three, four and five days of the disease, and rarely below 90.
If the percentage of hemoglobin should go below 80, and the case
should turn out to be one of yellow fever, we find almost always
some complication or the patient has been suffering previously from
malaria. Another diagnostic point has been of considerable help to me during
the present epidemic, especially in Florida, where we were confronted
with the existence of an epidemic of dengue, and where the question
came up quite frequently as to whether yellow fever was or was not
present. I refer to the diazo-reaction of Ehrlich. The diazo-reaction of
Ehrlich is an important diagnostic sign in typhoid fever in the first
days of the disease. It may be present in other infectious diseases,
but I doubt if it be ever present in uncomplicated yellow fever. On
two occasions my mind has been completely relieved as to the exis-
tence of yellow fever during the past summer in the South by find-
ing the Ehrlich diazo-reaction in the urine. I was able from my ex-
perience in Havana to exclude at once yellow fever. The Ehrlich
reaction was found occasionally in severe cases of dengue. Another diagnostic point that I wish to refer to is the albuminuria.
We all know that albumin in the urine is a very characteristic symptom
of yellow fever, but our judgment should be careful as to the interpre-
tation that is to be given to the presence of albumin in the urine. After
a careful study in Havana of many kinds of fever, we have found that
albumin in the urine is more common in other acute infectious diseases
than we thought. Albumin in the urine is common in influenza; it is
quite common in typhoid fever; it is not so common, but is occasionally
found, in cases of malaria. Albumin is found in the urine in cases of
dengue. That is an important point. Some have been inclined to
think that as long as we find albumin in the urine we have yellow fever,
and not dengue. The special point I wish to bring out is that the quantity of albumin
in yellow fever is entirely out of proportion to the other symptoms
present. |
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ETIOLOGY AND SYMPTOMATOLOGY OF YELLOW FEVER.
281 Let us take up the question from the point of view of dengue, which
is perhaps the most interesting. If you have a patient taken sick, with
a temperature of 104 degrees or more, and if the high temperature
should persist for forty-eight hours or longer, you are very apt to find
some albumin in the urine in dengue. But in yellow fever such tem-
perature is indicative of severe infection. A temperature of 104
degrees, lasting over forty-eight hours, in yellow fever, means a very
grave case, perhaps a fatal case, and such a patient is sure to have a
large quantity of albumin in the urine and to be in a very critical con-
dition about the sixth day, when the case of dengue will be getting
well. A case of yellow fever beginning with such high temperatures
will present the characteristic symptoms in a pronounced manner. Let me say a few words in connection with the methods of disinfec-
tion that are being employed in New Orleans. From the beginning,
understand clearly that there is a fundamental distinction to be drawn
between the battle that is being fought in New Orleans and the battle
that was fought in Havana. There is a fundamental difference between
the two problems, and it is this: In Havana we attacked yellow fever
at the beginning of the epidemic, a time when it should be attacked
always. We began our operations in February. In Havana we had
an epidemic of yellow fever, beginning every year in February and
increasing in March, April and May, to the full development in August
and September. In 1901 we began to attack this epidemic at the begin-
ning of February, when there were only two or three cases. On the
other hand, in New Orleans they began to attack the disease in the
midst of the epidemic. This has never been done successfully, namely,
to attack yellow fever and try to stop it in the midst of a great epidemic.
This has been done this year in New Orleans, and with wonderful suc-
cess. The epidemic has been checked; it has been brought to a stand-
still, although the authorities had to attack the epidemic under such
unfavorable conditions in the midst of a very large non-immune popu-
lation; probably the largest that was ever exposed to yellow fever
within the limits of a city. New measures were, therefore, necessary
to meet the circumstances and exigencies of the epidemic. In New
Orleans they have attempted to destroy all mosquitoes in the city.
They are fumigating all houses, whether they contain infected mos-
quitoes or not. Housewives have taken charge of this. It is perhaps
the only way to deal with the disease under the conditions prevailing
in New Orleans. In Havana, on the other hand, we did not fumigate any houses except
those that were infected, and those immediately adjoining. We ap-
plied the specific measures for the treatment of epidemics of yellow
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282
ETIOLOGY AND SYMPTOMATOLOGY OF YELLOW FEVER.
fever; we killed the infected mosquitoes, and no others; that is, mos-
quitoes about the patients and those which were supposed to have
bitten patients. Now, is it necessary to follow the example of New Orleans? I am
a little doubtful. I know that we are not able as yet to draw conclu-
sions, but I was rather impressed with the fact that the attempt to do
this great thing of disinfection of a city, of killing mosquitoes every-
where, rather weakened action against infected mosquitoes. A great
deal of energy was spent in fumigating the whole city that perhaps
might have been better employed if concentrated upon the infected
mosquitoes only. Another thing noticeable was that, after this great display of energy
it was rather discouraging to find that no immediate results followed.
The fever did not disappear rapidly. It was very discouraging, and
there was an inclination to cast some doubt on the efficacy of the mos-
quito doctrine. The final success, however, may justify the process. Another point to which I desire to call attention as new in the strug-
gle against yellow fever is the use of steam under high pressure for the
destruction of mosquitoes. That has not been used heretofore. The
method was suggested and carried out by Dr. Berry, of the Marine
Hospital Service. A fire engine was brought to the houses to be dis-
infected, and in certain places which were difficult to seal, as in court-
yards and in stairways, a jet of steam was thrown against the walls
and about the locality. In this way many insects were destroyed by
the direct action of the superheated steam and by the force of the
stream mechanically. That is an interesting departure. Coming to one of the suggestions that was made by Dr. Carroll, as
to the existence or appointment of a commission to make a diagnosis
of yellow fever, no more important suggestion can be made, and I
wish to speak decidedly in favor of it. It is the plan I adopted in
Havana during the American intervention. We had such a com-
mission then, and it is still in existence. This commission visits
all cases of suspicious disease, and the opinion of the commis-
sion is final as to whether a case is one of yellow fever or not.
There is, however, something more important than this commis-
sion, and that is the general education of the people. Take, for
instance, such a commission as Dr. Carroll wishes to have ap-
pointed. Do you know what would have happened in New Orleans
early this spring or this summer if there had been such a commission?
The commission would not have been called in to see the suspicious
cases. They would have been afraid to call it, because the people were
not properly educated. It is necessary to educate the people, so that
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ETIOLOGY AND SYMPTOMATOLOGY OF YELLOW FEVER.
283
the appearance of the first case of yellow fever may be reported at
once without causing any excitement. Then, and only then, will capital
cease to object to the timely reporting of cases of yellow fever. It is to be regretted that some commercial interests in the South have
thought that it was to their advantage to create the impression that
yellow fever had made its appearance in Havana. For a while they
succeeded in frightening Galveston and Mobile into quarantining
against Havana. It is a pity, because Havana stood as a great object
lesson to the South, and just when the South was beginning to believe
in and profit from this lesson these foolish people have raised a cloud
of doubt around the brilliant results that have been obtained, and are
obtaining, in Havana. |
YELLOW FEVER IN MEXICO. |
 |
BY DR. EDUARDO LICEAGA, MEXICO CITY, MEXICO. Proc Am Pub H. A. - 33 meet
Boston Sept 1905 ✓ As in former years, I come to give the Association an account of the
course which the yellow fever has taken in the Republic of Mexico
from the beginning of the year until the 31st of August, in order to
continue thus the report which I brought to the meeting which took
place in Havana in the month of January of the present year. Although at first sight it would seem useless to again present the
doctrine of the transmission of yellow fever, which has been accepted
by the scientific world, I believe myself obliged to do so, for upon that
doctrine is founded the procedure which we are following in Mexico
in order to do away with the disease. In order to transmit the yellow fever the concurrence of these three
elements is needed: a yellow fever patient; a mosquito of the genus
Stegomyia, which bites the patient, and a person not immune to receive
the bite of the mosquito. The problem of fighting the yellow fever consist then, in separating
these three elements, and I am going to demonstrate the way in which
these problems are solved in Mexico. ISOLATION OF THE PATIENTS. In order to separate a patient, the first thing to know is that the
patient exists, and in order to find him we proceed in the following
manner: In each village where there is yellow fever or it is feared
that it will develop, we organize a Sanitary Brigade. Some of its
members busy themselves in making a register of all the people who
are not immune and who live in the locality. In this register a note
is made of the age, sex, and nationality of each person and the place
of his residence. The Sanitary Agents who form part of this brigade,
divide the city or town, in which the fight is waged against yellow
fever in such a way as to be able to visit the non-immunes daily. When
one of these is found to have fever, whatever its origin may be, the
patient is separated immediately, being put in a room whose windows
have been provided with fine wire screens which will prevent the en-
trance of the mosquitoes, and a double door also of wire is provided,
and so arranged that when the outside door is opened the inside one
will automatically close and vice-versa. This can be done by means
284
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YELLOW FEVER IN MEXICO.
285
of a chain of a certain length which unites the two doors. This is
much more satisfactory than covering of the beds with mosquito net-
ting, for the latter has to be opened frequently in order to observe the
patient, to give him medicine, food, etc., and each time the curtain is
opened you run the risk of letting a mosquito in, or should the curtain
accidentally come in contact with the patient's body the mosquito can
bite the patient from the outside of the curtain; whereas if the patient
is in a room from which the mosquitoes have been previously driven
out, and where they cannot come in again, the contact with the patient
is impossible. This means of separation has another advantage, that
is, that you may put in the same room a patient who has already been
proved to have yellow fever and another whom they only suspect of
having it, without the latter being liable to catch the disease. As we have just seen, in our plan of campaign we do not wait until
we are satisfied of the existence of yellow fever, but we isolate the
patient from the first day that any fever appears, and consequently we
isolate him during the first three days, which are the dangerous ones,
and those in which the mosquitoes become infected. Experience has
demonstrated the sufficiency of the methods we have adopted for the
isolation of the sick. DISINFECTION OF THE HOME OCCUPIED BY THE PATIENT. During the time which elapses between the moment in which a
person takes the yellow fever and that in which it is discovered by our
agent, he may have been bitten by the mosquitoes and infected them,
so that they are ready to spread the disease. In order to prevent this
danger we proceed to disinfect the house as soon as it is left empty
by the patient. The disinfection in this case has for its only object the
destruction of the mosquitoes. In order to accomplish this we close
the room as it is ordinarily closed, pasting manila paper over all cracks,
and after this has been done we proceed to burn sulphur in the pro-
portion of twenty grams per the cubic meter of capacity. The sulphur
must be spread in a thin layer so that all will be burned. In this prac-
tice, which is so common and known to all, we have introduced another
innovation which seems to me of great importance, and it is this: As
it is very difficult to know whether the disinfection has been complete
or not, we take some mosquitoes which have not been infected and
which have been taken from the exterior of the room and put them in
the farthest room from the one in which the sulphur is burned. These
mosquitoes are put in open vessels, or which are only closed with a
coarse cloth, so that it will allow the sulphurous acid to penetrate into
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YELLOW FEVER IN MEXICO.
the vessel and prevent the mosquito from getting out. These mosqui-
toes serve us as witnesses. If, at the close of the disinfection, these
mosquitoes which were in unfavorable conditions to suffer from the
action of the sulphurous acid are found dead, we have proof that all
the others in the same room and under more favorable conditions for
receiving the sulphurous acid are dead also. If, on the contrary, we
find them alive, it is a proof that the disinfection was not well done
and that it will have to be repeated. Already in the last meeting, I explained the way in which the huts,
which in our country are called "jacales," are disinfected. I will there-
fore not have to repeat it now, and it will be all sufficient to state this
fact, that there is not a house which cannot be made perfectly free of
the mosquito. In disinfecting Pullman cars, other railroad cars or any limited space
where there are delicate objects which can be damaged we used for-
maldehyde. In dry goods stores, where the sulphur, the pyrethrum and even the
formaldehyde might alter the color of the merchandise we have used
hydrocyanic acid, the result of which is as satisfactory as that of the
sulphur and has not the objectionable effect that this presents of injur-
ing the merchandise, but on the other hand it cannot be used except by
a person who is very skillful in its use. DESTRUCTION OF THE MOSQUITO LARVAE. Another group of the sanitary agents is employed in making a daily
house to house inspection of the cisterns which supply the families with
water. If the deposit is found to contain larvae it is emptied and the
place in which the water flows is covered with petroleum; the deposit
is washed and the inside surface is searched in such a way that not a
larvae is left alive, then it is filled with pure water and is covered with
a close fitting lid, with a wire netting, or with a layer of petroleum.
All the other deposits of water are covered with petroleum whatever
their size, even when they are very small. As you have just heard, those methods in which we have introduced
innovations over those adopted in other countries are the following:
I. Making a register of the persons not immune.
II. Visiting the houses daily so that the patient can be discovered
the same day that the disease begins.
III. The disuse of the mosquito curtains, because their use is insuf-
ficient to isolate the patient and the placing of patients in rooms whose
windows are screened and which have double doors of wire netting.
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YELLOW FEVER IN MEXICO.
287
IV. In order to convince ourselves that the disinfection has been
complete we put mosquitoes in the house under favorable conditions
so that they can be reached by the action of the disinfectant. If, at
the close of the disinfection the test mosquitoes are dead, we can be
sure that the disinfection was well done.
V. We have the means of making impossible the escape of the mos-
quito from the disinfected houses even if these are only huts whose
walls and roofs are made of grass, or of branches or of any other pen-
etrable material. To prevent the disease from attacking a place where there are Ste-
gomyia, we have proceeded in the following manner: In all towns of this class we establish an inspection upon the arrival
of the trains, and in other places where passengers reach the town on
horseback, on foot or in carriages. Each passenger who is to remain
in the locality is examined and is kept under watch by our sanitary
agents, or by the police for five days after his arrival. In the places
already invaded by the yellow fever, the same inspection is made of all
the passengers who take the trains and they are prevented from leaving
if they are ill and if they are not immune and have fever. Could not
the passengers take the trains between the points where the inspections
are made? The sanitary agent travels continually on the trains which
traverse the infected districts, which are at present the small towns in
the state of Veracruz and the towns traversed by the Tehuantepec
Railroad, so that agents travel between Veracruz and Tierra Blanca;
from Cordova to Tierra Blanca; from Tierra Blanca to Santa Lucre-
cia; from Coatzacoalcos to Santa Lucrecia; from Santa Lucrecia to
Tehuantepec and Salina Cruz. If a patient is found on any of these
routes he is taken to the nearest hospital and at night the Pullman or
railroad car in which the patient traveled is disinfected. Having thus organized our system of inspection we have followed
it in Yucatan, notwithstanding the fact that since the 27th day of the
month of November last not a single case of yellow fever has been
found either in Merida, in Progreso or in any of the other towns of the
state above mentioned. There has not been a single case of yellow
fever in Veracruz since December 29th, 1904, up to July 4th of this
year. In spite of the vigilance which we have exercised it is possible
that a patient who did not arrive by the railroad nor by the most fre-
quented roads has clandestinely entered the town and was able to re-
main hidden; and as he was not on the Register he was not visited by
the sanitary agent. This is the only explanation which we can give of
the appearance of this disease in the harbor of Veracruz. We have es-
tablished a sanitary brigade and a lazaret in Tehuantepec, notwithstand-
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YELLOW FEVER IN MEXICO.
ing the fact that the last case that originated in the town was observed
on the 5th of December last, since another case which was found in
April 26, was imported from Santa Lucrecia. Another service is estab-
lished in Salina Cruz where the last case registered was on October
27, 1904. Lastly, in Tierra Blanca where a small focus was formed.
Tierra Blanca is a village at the junction of the three branches of the
Veracruz and Pacific Railroad. The village is composed of persons
not immune who are employes and workmen on the railroad. As the
village is cosmopolitan, and very poor and dirty, it has been truly diffi-
cult to completely extinguish the disease, and for that reason a brigade
has been established there. In the other places of the small infected zone, when isolated cases
appear a physician and sanitary agents of some experience are sent
immediately to proceed with the house to house inspection and to dis-
infect wherever it is necessary and to destroy the mosquito larvae. There were 635 cases and 197 deaths registered in the Republic from
January 1 to August 31, 1905. The success which has been reached in Mexico in the struggle against
yellow fever and the certainty that in a not far distant future the dis-
ease will be completely extinguished as has been done in the island of
Cuba, can be easily seen from the statements already made. |
OFFICIAL REPORT OF THE PROCEEDINGS OF THE THIR-
TY-THIRD ANNUAL MEETING OF THE AMERICAN PUB-
LIC HEALTH ASSOCIATION. |
 |
✓ MONDAY, SEPTEMBER 25, 1905. The Laboratory Section held its meetings at the Fenway, under the
Chairmanship of Dr. Wm. H. Park, of New York. TUESDAY, SEPTEMBER 26, 1905 -- FIRST DAY. MORNING SESSION. The Association met at the Young Men's Christian Association Hall,
and was called to order at 10 A. M. by the President, Dr. F. F. Wes-
brook, of Minneapolis, Minnesota. THE PRESIDENT.-- The first order of business is the reading of the
minutes of the last meeting. DR. HENRY D. HOLTON, of Vermont.-- Inasmuch, Mr. President,
as these minutes have been printed and probably read by all of the
members, I move that the reading of them be dispensed with. Sec-
onded by Dr. Montizambert, and carried. THE PRESIDENT.-- We will now listen to a report of the Executive
Committee by the Secretary. THE SECRETARY.-- The Executive Committee has only to report
this morning a list of applicants for membership which has been
acted upon by the Executive Committee favorably and recommended
to the Association for election. The Secretary then read a list of the applications for membership
which were recommended by the Executive Committee to the Associa-
tion for election, and, on motion of Dr. John Guiteras, the Secretary
was instructed to cast the unanimous ballot of the Association for the
names mentioned, which he did, and they were declared duly elected. THE PRESIDENT.-- We will now listen to a report by the Chairman
of the Local Committee of Arrangements, Dr. Durgin, of Boston. REPORT OF THE LOCAL COMMITTEE OF ARRANGEMENTS. DR. SAMUEL H. DURGIN, of Boston.-- Your Local Committee wishes
to announce, that on Wednesday morning we had an invitation from
373
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444
PROCEEDINGS -- THIRTY-THIRD ANNUAL MEETING.
a very important subject, and we are supposed to take interest in every
line of sanitary work, it would seem appropriate to take some action
which will go before the public in proper form. I would move, there-
fore, Mr. President, that a committee be appointed to present at the
next session a resolution expressing the feelings of this Association to
the effect that the bill now pending before Congress, and which has been
referred to by General Woodhull, be approved by the Association. The American Medical Association is endeavoring to make itself felt,
politically and otherwise, and while perhaps we cannot always agree
as to certain things or methods, at the same time, we should express
ourselves as a strong body of sanitarians. Perhaps by expressing our-
selves in the form of a resolution regarding the bill to which General
Woodhull has referred, and which we would all like to see passed, we
may gain some advantages in the next ten years. The resolution was seconded by Dr. Liston H. Montgomery, and was
referred to the Executive Committee. The President appointed on this Committee General Alfred A. Wood-
hull, Dr. H. M. Bracken, and Dr. Gardner T. Swarts. Dr. James Carroll, of Washington, D. C., then read a paper entitled
"The Lessons to be Learned from the Present Outbreak of Yellow
Fever in Louisiana." (See paper, page 272.)
✓ Dr. Eduardo Liceaga, of Mexico, read a paper on "Yellow Fever in
Mexico." (See paper, page 284.) Dr. Juan Guiteras, of Havana, Cuba, followed with "Remarks on
Some New Points in the Etiology and Prevention of Yellow Fever."
(See paper, page 278.)
✓ At the conclusion of the reading of the papers on yellow fever, the
Committee, appointed to draft resolutions in connection with yellow
fever in the South, presented the following report, which was referred
to the Executive Committee: WHEREAS, The results obtained during the present epidemic of yel-
low fever in New Orleans, by the methods of mosquito extermination
and by the prevention of the access of the mosquito to the patients,
have been far in advance of the results obtained by the older methods; WHEREAS, It has been possible by the new methods to hold in check
and to gradually reduce an epidemic that has taken a firm foothold in
the midst of the largest non-immune population that was ever exposed
to yellow fever; therefore, be it Resolved, (1) That the Association sees in these results a further
confirmation of the view that yellow fever is naturally transmitted
only by the bite of an infected mosquito. (2) That the Association is of opinion that an efficient plan of
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PROCEEDINGS -- THIRTY-THIRD ANNUAL MEETING.
445
defense against the propagation of yellow fever, at the beginning of
an epidemic, can be easily established upon the basis of this doctrine. (3) That the successful carrying out of such plans depends upon
a thorough understanding of the mosquito doctrine by the people, and
the support that they may give to the prompt and frank reporting and
to the proper handling of the first cases and of all suspicious cases. (4) The Association wishes further to congratulate the Public
Health and Marine Hospital Service for the brilliant work done by
Dr. Joseph H. White and his colleagues in New Orleans, and to urge
upon all concerned that the said service be called upon to take charge
permanently of maritime quarantine along the Gulf Coast. Regarding the visit of the President to New Orleans, the Associa-
tion would urge that the contemplated trip be postponed. Whilst it is true that the epidemic will be very much under control
by the 24th of October, so that there will be but little danger of infec-
tion, this danger would certainly be enhanced by the public life and
inability to surround themselves with proper safeguards that would
prevail in the case of the President. If the President were called to
New Orleans by some public duty connected with the epidemic -- if
he were, for instance, to reside in the yellow fever hospital and have
some special duty to perform in visiting the sick -- it would be very
easy to guarantee his safety from infection; but with a number of
public functions to perform, entertainments to receive, and numerous
places to visit, the Association does not believe that an absolute secu-
rity can be promised at a time when there may still be in existence a
number of active, infected mosquitoes. The Association is also of opinion that the large influx of strangers
that would attend the visit of the President would result in a tem-
porary increase of the number of cases. (Signed) JOHN GUITERAS, Chairman, PRESTON H. BAILHACHE, JAMES CARROLL, E. LICEAGA, WM. BAILEY. DISCUSSION OF THE PAPERS ON YELLOW FEVER. DR. LISTON H. MONTGOMERY, of Chicago.-- Dr. Guiteras in his re-
marks spoke of the authorities in New Orleans trying to exterminate
every mosquito, but he thought, if I understood him correctly, that this
detracted considerably from their work, and that they should concen-
trate their action or attack upon the infected mosquito. How can that
be determined? Would it not be better to exterminate all mosquitoes,
whether they are the harmless or infected ones?
✓ DR. JOHN GUITERAS, of Havana, Cuba.-- I expressed the idea that
considerable energy was being diverted from the proper and best chan-
nels. In answer to the question of Dr. Montgomery, I will say that it
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446
PROCEEDINGS -- THIRTY-THIRD ANNUAL MEETING.
is easy to determine which are infected mosquitoes from those that are
not. Infected mosquitoes are those found in the houses of patients, and
we should kill them. The yellow fever mosquito is a weak mosquito; it
is apt to stay in the same room, and certainly in the same house. DR. JAMES CARROLL, of Washington, D. C.-- Dr. Guiteras has taken
it for granted, without full justification, it seems to me, that my idea
was that this commission I have suggested should go down and stamp
out such an epidemic as prevails in New Orleans at present. I intended
nothing of the kind. I spoke of preventive rather than curative meas-
ures, and the idea I had in my mind was that if a commission, appointed
at the proper time, could take up the work in a proper way and prevent
or control the extension of the disease, at the season when the cases
were fewest, it would accomplish a great deal. This measure was sug-
gested by me upon the ground that if such a commission were in exist-
ence, and the proper laws were enacted, it would require physicians to
report their cases of yellow fever early, so that the disease could be
readily controlled, and then there would be no possibility of its further
extension. In regard to educating the people, did we wait for their education
before laws were enacted requiring proper disinfection to prevent the
extension of diphtheria? It has taken five years, and that has not been
sufficiently long to educate the physicians in some of our states up to the
point of believing in the mosquito theory fully, and it seems to me it
would be much less important to wait for the education of the people
when it takes some physicians more than five years to accept the mos-
quito theory. Reasoning on this basis, how many more years will it
require to educate the people up to that point? This is a matter of
protection of the lives and welfare of the people, and their personal ideas
and idiosyncrasies are not to be considered. We know absolutely that
if these measures are taken in proper time, any extension of the disease
can be prevented, and the only thing to do, in my opinion, is to take
such measures and thereby see to it, when the disease is found to exist,
or when the cases are at a low ebb, that proper measures are taken, and
that the possibility of any further extension of the disease be removed.
In this way the disease can be eventually stamped out, and once it is
stamped out, it is done with forever unless there is a fresh importation. On motion, the Association adjourned until 10 A. M., Friday. |
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PROCEEDINGS -- THIRTY-THIRD ANNUAL MEETING.
447 SEPTEMBER 29 -- FOURTH DAY. MORNING SESSION. The Association met at 10:10 A. M., and was called to order by the
President. THE PRESIDENT.-- We will listen to the Report of the Executive
Committee by the Secretary. THE . SECRETARY.-- The Executive Committee has acted favorably
upon the resolutions in regard to yellow fever in New Orleans, except
as regards advising the President not to visit that city, and recommends
their adoption by the Association A sub-committee will report upon
this part of the resolutions. (See resolutions on page 444.) THE PRESIDENT.-- You have heard the recommendations of the Ex-
ecutive Committee concerning these resolutions on yellow fever. What
is your pleasure? DR. WILLIAM BAILEY, of Louisville, Kentucky.-- I move that the
resolutions be adopted. Seconded and carried. The Secretary read a resolution offered by Dr. J. Ewing Mears (see
resolution, page 424), and said: The Executive Committee finds that a
similar resolution was recently adopted by the Association, and there-
fore it deems it unnecessary to take further action at this time. THE PRESIDENT.-- Will you confirm the action of the Executive
Committee, or do you wish to adopt this resolution? DR. HENRY D. HOLTON.-- I move that the action of the Executive
Committee be concurred in. Seconded by Professor Brewer, and carried. THE SECRETARY.-- The following resolution are offered as repre-
senting the sense of the American Public Health Association: RESOLVED, That this Association, recognizing the extreme value of
a properly organized and efficiently administered medical department
as an essential part of any army, cordially approves the proposal for
the greater efficiency of that department in the army of the United
States, as embodied in a bill brought before the fifty-eighth Congress
(Senate, 4838; H. R., 13998, fifty-eighth Congress, second session),
and earnestly recommends favorable action upon such a measure when
it may again be brought up for consideration; Resolved, That an official copy of these resolutions be transmitted
to the committees on military affairs of the Senate and of the House
of Representatives of the United States, and to the surgeon-general,
United States army. (Signed) ALFRED A. WOODHULL,
H. M. BRACKEN,
GARDNER T. SWARTS,
Committee. |
