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I 



PUBLIC HEALTH 

PAPERS AND REPORTS 

VOLUME XXXII — PART I. 

PRESENTED AT THE THIRTY-FOURTH ANNUAL MEETING OF THE 

American 
Public Health Association 

Mexico City, Mexico 

DECEMBER 3, 4, $, 6. 7 
1906 



COLUMBUS, OHIO : 

Press off Fred. J. Hssr 

1907 



By Dt CHAMPS O.. PRpftST. 

Sbcsktary AumiAj^P&bc HbaIth Association, 

Columbus, OHia 

All R ig hts R eskrvep, 




TABLE OF CONTENTS. 



PAGE 

Address of the Presii^nt, by Prof. Frankun C Robinson 1 

Organized Sanitary Work in Dealing With Overcrowding and 

Pauperism, Due to Immigration, by Dr. Peter H. Bryce 12 

PuBUc Health and Prophylaxis of Diseases, by Dr. Oscar J. 

Mayer 26 

Contribution to the Study of Problems of National and Inter- 
national Sanitary Legislation, by Dr, Jose Mesa y Gutierrez 30 

Yellow Fever, by Dr. Eduardo Liceaga 38 

To What Extent are Infected Mosquitoes Present on Shipboard? 

BY Dr. a. H. Doty 44 

A Short Account of the Sanitary Department of the Isthmian 

Canal Commission, by Dr. W. C. Gorgas 62 

The Diagnosis and Prevention of Yellow Fever, by Dr. Joseph 

Goldberger 58 

Brief Notes on the Propagation of Yellow Fever, by Dr. Ernesto 

DUPLAN 74 

The Origin of Svgradic Cases of Yellow Fever at Long Periods, by 

Dr. Manuel S. Iglesias 83 

The Yellow Fever Epidemic of 1905 in New Orleans, by Dr. 

Quitman Kohnke 89 

Notes on Yeulow Fever, by Dr. M. P. Colmenares 95 

Notes on the Hygiene of Yellow Fever, by Dr. Alfred J. J. Austin . 96 

Geography of Malaria in the Mexican Republic, by Dr. Antonio 

LOAEZA 98 

The Way to Stamp Out Malarial Fevers, by Dr. Eduardo Lamicq. . 102 

Something About the Etiology of Malarial Disease, by Dr. Jesus 

Chico 110 

Prophylaxis of Paludic Diseases, by Dr. Juan Brena 112 

Action of the State Against Tuberculosis, by Dr. Jesus Monjaras. 119 

The Essentials of the Crusade Against Tuberculosis, by Dr. 

Lawrence F. Flick 128 

The Relation of the Physioan to the Tuberculosis Problem, by 

Dr. Hugh A. Cowing. 136 

The Spread of Tuberculosis Through Factory Skim Milk, by H. 

L. Russell 139 

The Problem of City Milk Supplies, by Dr. Charles Harrington... 153 

The Dairy Industry in its Relation to the Gastro-Intestinal 
Organs of Young Children and Convalescents from Certain 
Affections of the Same Organs, by Dr. Juan Enriquez y 

Terrazas • 160 

The Water Supply of Cities, by Dr. Enrique del Bosque 164 

Drinking Water in Relation to Typhoid Fever in Rural Communi- 
ties, BY Dr. B. H. Stone ITl 



TABLE OF CONTENTS. 

PA«E 

Notes on the Detericinatiom of Iron, by R. B. Dole 183 

A Fkw Bacteriological Notes That Will Conrrm the Existence 

OF Typhoid Fevwsl in Mexico, by Dr. Jose P. Gayon 189 

Result of Revaccination in Mexico, by Dr. Francisco i» F. Ber- 

nalobz 192 

The Jenner Vaccine, by Dr. Everardo Landa 19^ 

Anchylostoiciasis in Mexico, by Dr. Ricardo E. Manuell 201 

The Prophylaxis of Typhus, by Dr. J. I. Salom a 206 

The Rains and Typhus, by Dr. Alfonso Pruneda 209 

The Bubonic Plague, by Dr. Eduardo Liceaga 215 

The "Mal del Pinto" from a Hygienic Point of View, by Dr. Jesus 

Gonzalez Ururna 219 

Ametropia in its Reij^tions to Ocular Hygiene, by Dr. Jose Ramos. 223 

Trachoma in Mexico, by Dr. Lorenzo Chavez 280 

A Case of Recurrent Fever Observed in Havana, by Dr. Mario G. 

Lebredo •. . . . 238 

Program of Sanitary Health Works in the Valley and City of 

Mexico, by Miguel Quevedo C. E 248 

Evolution of the Hygienic Conditions of the City of Mexico Dur- 
ing THE Last Fifteen Years, by Roberto Gayol, C. E 259 

The New School Buildings in the City of Mexico, by Dr. M. Uribe 

Y Troncoso 264 

Sanitary Inspection of Dwelung Houses in the City of Mexico, 

BY Dr. I>omingo Orvananos 271 

The Problems of Car Sanitation, by Dr. Thomas R. Crowder 278 

Report on the Condition and Prospects of Vital Statistics in the 

United States, by Dr. Cressy L. Wilbur 294 

Observations on the Census and Mortality Tables of the Oty of 

Mexico, by Dr. J. Millan Ponce 311 

Notes on Preventive Measures Against Hydrophobia, by Dr. M. 

GoDOY Alvarez 31T 

Veterinary Hygiene, by Dr. Silvio J. Bonansea 320 

Official Report of the Proceedings of the 34th Annual Meeting. . 325 

Constitution i 

By-Laws of the Executive Committee vi 

Officers and Committees ix 

Laboratory Section xv 

Revised List of Members xvi 

Members Elected^ 1906 xxviii 

Members by Geographical Distribution xxxiii 

Sanitary Authorities and Assooations xIy 



^ J/'\ 13 1909 ^ 




ADDRES^Og ^»^J5£SIDENT. 
Professor FRANKLIN C ROBINSON, L. L. D., Brunswick, Maine. 

Your Honor the Governor, Dr, Liceaga, Ladies and Gentlemen. 

The American Public Health Association has now been formally 
welcomed to Mexico. But its individual members did not need to hear 
the words spoken so eloquently this evening, in the presence of this 
distinguished audience, to be assured of their welcome. For several 
days already, we have been showered with your kind attentions, and 
so filled with the banquets of delight which you have spread before 
us, that, metaphorically speaking, there is danger of that calamity 
mentioned in Holy Writ, When new wine is put into old bottles. It is 
to be hoped that the quieting influence of the meetings now begun, will, 
avoid such a calamity. 

You have shown us how you are practically carrying out the 
principles which this Association stands for, in your new water supply, 
your system of sewers, your clean streets, your beautifully appointed 
hospital, your well regulated penitentiary, and, to relieve the strain, 
have taken us to that fairy land, Xochimilco. 

Thus while we feel very grateful for this meeting to welcome, by 
words, we feel even more grateful for those deeds of welcome which 
have preceded, and which speak even louder than words. We only 
wish that our thanks for it all could be given to you as effectively as 
your welcome has been given to us. 

But really we are not surprised at your treatment of us. We really 
expected it for almost exactly fourteen years ago, this Association met 
in this beautiful city, and undoubtedly it is the memory of that meet- 
ing which brings us here again. That was the first long distance 
meeting which the Association had held, and I remember well with 
what misgivings it was looked forward to by many members. The 
Republic of Mexico had but recently united with us in public health 
work ; we were delighted with the zeal and efficiency of its representa- 
tives, but had hardly known them long enough to feel on easy visi- 
ting terms with them. We felt a little as though we might be in- 
truding by accepting their invitation upon so short an acquaintance. 
But hardly had the Mexican border been passed, when all doubts as 
to the wisdom of coming were removed, and all who took that 
pilgrimage have ever since regarded it as one of the happiest ex- 
periences of their lives. 

1 



2 ADDRESS OF THE PRESIDENT. 

Before that meeting many said that we could hardly expect to 
meet so far away oftener than once in twenty-five years, but since 
then it has been evident at every meeting that the Association was 
determined to go to Mexico again, just as soon as it decently could 
do so. I almost think that the trip to Cuba was due primarily to the 
memory of that Mexican meeting, that we went to Cuba as a sort of 
compromise. It was not quite time to come here again, but that was 
the next thing to it. And very close to it it certainly proved to be. 
In fact, some who did not go to Mexico before were quite sure that 
nothing could exceed that Cuban meeting. But, however that may be, 
it is certain that the trip to Cuba did not lessen the determination 
to come to Mexico again, but rather added fuel to that flame, so 
that I verily believe the trip could not have been put off any longer. 

Yes, friends, we are here because you asked us, of course, but 
also because we had to come. I do not know what would have hap- 
pened if you had not invited us at that Boston meeting, last year; 
there is no use in speculating about that, for most fortunately, you 
gave the invitation and here we are, pleased and happy, and more than 
ever convinced that "all things work together for good," to us and 
this Association. 

I have said "we" throughout these remarks, as though all of 
us had been here before, but of course such is not the case. But so 
strongly has that other meeting been impressed upon us by our ac- 
quaintance with those who came, that it certainly seems to me, and 
I doubt not, to others, that we actually were of that party of fourteen 
years ago. 

But there is a certain real sense in which this is a first and not a 
second meeting here of this Association. The personnel of the Asso- 
ciation has almost entirely changed during the intervening years. Our 
total membership is not far from what it was fourteen years ago, but 
scarcely ten per cent, of the names then upon our rolls now appear 
there. Death is responsible for a part, but not the chief part of this 
change. Indeed, it would be most surprising if an Association, devoted 
to improving public health, should itself have a mortality rate of 
ninety per cent, in fourteen years ! When we think of those who were 
with us th^n, those who took a prominent part in the meeting here, 
fourteen years ago, who have "ceased from earthly labor," it seems 
as though death had made great inroads upon our membership. No 
association could lose such men as Gihon and Kedzie and Smart, and 
others of like power, without feeling the loss keenly. But close in- 
spection shows that our loss, by death, has not been numerically large. 
Evidently the chief reason for this great change in our membership 



ADDRESS OF THE PRESIDENT. 3 

is voluntary withdrawal, or loss of memSership by failure to pay dues. 
And this is to be expected ; it is the necessary result in such an Asso- 
ciation. We are not like a professional or technical society, where 
practically all the members are making a life work of its principles, 
and owe it to their professional standing to keep up their member- 
ship. Public health work, as a profession, is c(Mning more and more 
to the front, but it will probably be many years yet before the member- 
ship in that profession can be very large, and certainly very many 
years before the best places in it will nol? be filled by those who are 
taken from the regular medical profession. Our membership, at any 
given time, is thus largely dependent upon the last place of meeting, and 
long continuance of membership has been the exception rather than the 
rule. This does not mean that the majority of our members are but 
temporarily interested in the work, but that very many have other 
association interests which they regard as more important to keep up. 

Thus it happens that we are here today, the old Association in name 
and spirit, but new almost entirely in individual makeup. And there 
are some advantages in this rapid loss and regeneration. It insures, 
always, a fresh, healthy, interested body, not weighed down by 
tradition nor too much bound up by precedent. This should make it 
clear to our entertainers, also, that everything they show us will be 
new to practically all of us, even though exhibited at our previous 
meeting; and that they need not go to the trouble of providing any 
new and novel entertainment lest we show weariness at the repetition. 

But while we thus state the fact of our practical newness of mem- 
bership, and even rejoice in it, we are also proud of that faithful few, 
old in service if not in years, whose names our rolls have borne so long, 
and will bear, we hope, as long as they live. We rejoice especially that 
so many of those members of long continued service are citizens of this 
Republic of Mexico, and are here to welcome us. I cannot speak their 
langfuage, I do not even know the names of all of them; but their 
faithfulness has been an inspiration to me for many years, and without 
them our annual meetings would never seem the same. 

To ont of them, also, we owe something more than the inspiration 
which his faithful attendance and valuable contributions give. We 
owe to Dr. Liceaga, chiefly, the experienced delights of. that former 
meeting, and the anticipated pleasures of this. Long may he live thus 
to faithfully serve his country and his friends I 

4e « 4e 

It is a sign of the times that associations and societies are impatient 
at long presidential addresses. They seem now as out of place in 
gatherings like this as the old long sermons and prayers would seem 



4 ADDRESS OF THE PRESIDENT. 

in a modem church service. And this is not simply one of the results 
of the present rapid movement of things, of the hustle and bustle of 
this strenuous modern life, it has a foundation of reason in the great 
growth and specialization of knowledge of all kinds, and especially 
scientific knowledge. Not very many years ago one man could, within 
the limits of a single address, give a fairly complete and valuable 
summary of the conditions and accomplishments in any great field of 
knowledge. That is no longer possible, except, perhaps, to a man of 
the greatest genius. Let a man of my capacity attempt it, and he in- 
evitably wearies, beyond measure, a large part of his audience by the 
length and content of his effort. 

I knew also when I set myself seriously to this task, that the very 
conditions under which I must speak would cry aloud for the greatest 
brevity. I knew that most of my audience would be unable to under- 
stand my words, and most of those who would be able to understand 
me, would be in a condition to be readily wearied by what I might say ; 
for we have been together for a week or more, in that, most trying 
and testing of positions, that of fellow travelers, and I have always 
believed that the old saying about familiarity and contempt must have 
been spoken originally by a traveler at the end of a journey. 

But most of all I knew that what I should write would be spoken 
amid scenes of great novelty to myself and to most of my companions : 
that new air, new voices, new beauties would be around us, from the 
time when we should first enter this wonderful land till we should leave 
it again ; that the spell of it all would lie over us, a spell which we 
could not shake off if we would, and would not if we could. How 
manifestly out of harmony with such conditions would be a mere 
catalogue of accomplishment, especially if compiled by one to whom 
such a task is most distasteful! 

The time and place would seem to demand the presentation of some 
new problem worthy of both ; for the time is the beginning of a new 
century, when the whole civilized world is aquiver with the hope of pro- 
gress, and the place is that country which perhaps more than others, 
under its present enlightened ruler, is determined to bring that hope to 
realization within its own borders. But alas! I soon found that I 
could not rise adequately to such an occasion. I had no problem which 
I felt worthy to present, and so I was rather forced to take refuge in 
certain general principles, to the contemplation of which I shall ask 
your attention for the few remaining minutes I stand before you. 

And after all, is not the contemplation of general principles some- 
times as valuable as the actual solving of problems ? Or if not actually 
as valuable, may it not be next in value? And do not most of us find 



ADDRESS OF THE PRESIDENT. 5 

as we grow older, that we have to be content with doing the next 
best things, even if we come as close as that to our earlier ideals? 
Has not experience borne in upon us the truth of such lines as these : 

''The thing I set before me, to do in the days gone by, 

Is still undone, and before me the shards of its dreaming lie; 

But the dawn sweeps up from the Eastland; the day I sought is a- wing. 

So I shape my hand to the toiling, and do the next best thing. 

I sweep my hand o'er the harp strings, which thrill with earth's unwritten song, 

But they fail me, those hands that are stiffened by gripping the levers too long. 

And so to another that music; to me 'tis enough that I sing. 

The joy I find in doing, earth's needed and next best thing." 

First let us contemplate for a moment the changes which even a 
few years have wrought in the material and the methods of public 
health work, or perhaps more exactly in the attitude of people towards 
public health work. This is reflected by the meetings of this Associa- 
tion and by the actions of people in general. Compare, for example, 
the program of this Association when it met here fourteen years ago, 
with that of its last meeting in Boston. The volumes of proceedings 
are about equal in size ; the number of papers presented approximately 
the same ; but the character of the papers and discussions, as a whole, 
is very different in the two volimies. At the earlier period there was 
greater diffuseness and generality of treatment. The papers were in- 
cUned to point out evil conditions quite specifically and denounce them 
vehemently, but the remedies were not so specifically given as now, 
and even when given, it was quite plain that the writer did not expect 
them to be used. For example, in that volume of fourteen years ago 
are strong papers by strong men on such subjects as "The Ground of 
Safety," "Communication of Disease in Public Places," "The Funda- 
mental Conditions of Public Health in Civilization." These topics 
were treated in an interesting manner, but rather academically. The 
conditions described, were bad, but there is rather an assumption that 
they will remain so; and one can almost draw the inference that the 
authors would hardly want to be called upon to supply details for 
changing them. 

In sharp contrast with the discussions just referred to, are the 
leading papers of the Boston meeting. Instead of a paper on the 
general subject of "The Ground," specific details about the ground are 
treated ; for example, the purity of the ground waters of a given state, 
and how ground waters can be purified and are being purified. In- 
stead of speaking in general of public places as a source of disease, 
there are papers describing methods of making railroad cars and 
public places more hygienic. And not content with recognizing funda- 



6, ADDRESS OF THE PRESIDENT, 

mental conditions of public health in civilization, several papers at 
Boston dealt with the carrying out of educational details which will 
change these conditions. Another contrast between the meetings of 
one year ago and of fourteen years ago is that at the earlier meeting 
there was no Laboratory Section, because, indeed, there were few 
laboratories where systematic study was made of things bearing upon 
public health. 

In short, fourteen years ago, there was a knowledge that things 
were wrong, there was a most earnest demand that they be made 
better, there was some idea along what lines the betterment would 
come, but there was a lack of confidence in entering those paths which 
were as yet but glimmeringly outlined by the oncoming dawn. All 
that is now changed, in fact we have now gone almost to the other 
extreme, for where but a short time ago there was hesitation and lack 
of confidence, there is now almost overconfidence, and we start forward 
on a dimly lighted path with as much assurance as if it were a well 
known macadamized road lighted by the full rays of the sun. 

In this we but follow the spirit which is working everywhere the 
same in modem life. On every side, in every department, there is a 
demand for results, and for quick results. Let any man who can get 
the ear of any considerable number of people, — and loud enough 
talk will generally accomplish that, — claim that a certain thing ought 
to be done, that it would be for the financial or physical advantage of 
a community that it be done, and he is liable to find himself almost 
embarassed by being taken at his word and provided with the means 
for carrying out his ideas. The alliterative motto "Bigger, Busier, 
Better," is everywhere hung upon the walls, replacing those now 
antiquated ones in which the old fashioned cardinal virtues were promi- 
nent. There is more than a suspicion, too, that the third word of the 
new motto is generally regarded as unnecessary and redundant, a con- 
cession to conventionality such as the name of the Deity was in the 
mottoes of the old knights. If a place is bigger and busier it must 
necessarily be better, — such is apparentfy the general assumption. 

I do not state these conditions in order to condemn them. In many 
respects things are better than formerly, such is my profound belief, 
for I am, by nature and cultivation, an optimist. What I want to do 
is, to contemplate them with you to see what their bearing is upon 
our work as individuals and in the Association. It is this spirit which 
gave us our laboratories, and we should be' ungrateful indeed if we 
had now nothing but criticism of it. 

But there are some features of this present condition which may well 
give us concern, especially us of the United States of America, who 



ADDRESS OF THE PRESIDENT. 7 

are actively engaged in public health work. One of them is that de- 
mand for immediate and impossible results. Men's minds are so 
charged with the belief that money will do anything, that when once 
a well equipped health laboratory has been provided, supplied perhaps 
with everything that its trained director may wish for, they expect 
it to produce, in short order, methods by which the public health will 
be improved by leaps and bounds. They expect from a public health 
laboratory the same kind of help and service that a laboratory gives 
to a big steel plant, an ability to advise unerringly and within a short 
time how to make the best product in any given line. 

It is not realized as it should be that man is not an alloy. He has, 
it is true, in his body, about the same elements in number and kind as 
a piece of complex steel, — the carbon, nitrogen and oxygen, silicon, 
phosphorus and sulfur, calcium magnesium and the alkali metals 
are present in both, — but the process which makes one in a few 
minutes utterly destroys the other. The old alchemists and adepts 
gave to the initiated processes couched in mystic language, whereby 
the mercurius philosophorum was mixed with the auro phUosophorum 
and the mixture digested in a crucible of peculiar form until the 
"raven's head" and the 'white swan" and finally the "golden lion" 
appeared, which latter cured all sickness whether of animate or inani- 
mate things. If such a claim were made today even the "yellowest" 
of the journals would denounce it, and yet almost equally absurd de- 
mands are made upon our health laboratories. There are, in fact, 
certain bad conditions connected with water supplies and the recog- 
nition and prevention of contagious diseases which a laboratory can 
correct at once, but when those are corrected its work will seem slow 
and its accomplishment small, perhaps, for considerable periods of 
time, because the problems before it for solution are exceedingly com- 
plex. When this stage is reached, what will be the attitude oi the 
people towards supporting our laboratories? Unless by that time they 
are educated enough to see the matter in its proper light, or new prob- 
lems come up for solution, we may expect restriction of appropriation 
if not abolishment of laboratories, or at least a confining of their 
activity to merely routine work. 

This leads to a contemplation of the next things in public health 
work. When pure air and pure water are assured to all ; when the 
bacilli of infectious diseases are all determined and warded off from 
us: will that be the end of our effort, the goal of our desires? Per- 
haps you will say that we are far enough from that goal, and that it 
will be time to think of another when that comes in sight. I admit 
fully the force of that reasoning, but nevertheless I shall continue my 



8 ADDRESS OF THE PRESIDENT. 

contemplation, for, as I said at the beginning, I am dealing in 
generalities rather than cold facts, and I am sure that you will have 
so many of the latter to consider before the week is over that any I 
might bring forward at this time and do not, will "never be missed." 

In the dedicatory addresses at the opening of the new buildings of 
the Harvard Medical School, it was emphasized by President Eliot 
and others that the work of the physician in the future must differ, in 
a marked degree, from the work in the past. They said he must add 
to his work of healing actual disease, the work of providing new 
defences against the new risks which civilization and modern society 
are bringing in. Now it seems to me that that will be work demanded 
more of the health officers, of the members of this Association, than 
of the private practitioner. The main work of the latter must be, in 
the future as in the past, the healing of disease. It will be mainly 
when he acts as a health officer, or member of a health board or 
adviser to one or the other, that he will use his knowledge in the 
way suggested by those speakers towards any but individual patients. 
I believe, and most profoundly, that along that line are the "next 
things" for us and that we should not longer delay in our special 
consideration of them. 

In a more primitive state of society there is no doubt that the 
greatest danger to health lurked in air and water and other distribu- 
tors of infectious matter, and there are great dangers in such things 
still for these more civilized times. But I do not think we realize 
enough how many other risks to public health the so-called progress of 
civilization has created. I very much fear that we should find, even 
if we could suddenly protect our communities from all the bad effects 
of impure water; and also could banish frc»n their midst the well 
known infectious diseases: that the death rate would still be much 
higher than we should have hoped. Excess in eating and drinking, 
in the gratification of appetite and passion ; over stimulation by drugs, 
by reading, by theatrical performances, by games and sports, by nerve 
racking noises, by the demands of society in general ; to say nothing 
of the depression caused by crowded factories and workshops: all 
these are having an effect on the death rate which may soon be com- 
parable, if not already so, with that produced by those well known 
things against which our efforts as health officers are now chiefly 
directed. It is in vain that we supply pure food and pure water to 
systems unable properly to assimilate them. It is in vain that we. keep 
out the bacilli of typhoid, diphtheria, or tuberculosis, from persons 
whose blood is impoverished and nerves shattered by these "new risks 
of civilization." 



ADDRESS OF THE PRESIDENT. 9 

How shall we attack this problem ? We know these things ; there 
are probably many before me who have denounced them publicly 
and privately, and with little or no result. 

Here again, I take refuge in my statement that I am not offering 
solutions so much as contemplating conditions, and certainly any one 
who attempts a solution of this problem needs a refuge of some kind 
from the wrath which is likely to be poured upon him. Most of the 
elements of this problem are rooted in the appetites and passions of 
men, and fostered by the desire of gain. It is a very different matter 
to denounce the typhoid bacillus from denouncing the excesses of 
modern life. The typhoid bacillus, so to speak, "has no friends" and 
no standing in society, — away with the outcast and Pariah! But 
the gilded saloon, the crowded factory: ah I That is another thing; 
there is money in them, go very slowly and softly there. "Are you 
sure of your facts? Are you not interfering with private rights? 
Passing sumptuary laws? Or doing some similarly dreadful act which 
will cause 'the people' to rise and suppress you?" 

But there is one way of attacking such problems, which I certainly 
do not advocate, and that is by promiscuous denunciation. Such is not 
the proper method of the scientific sanitarian. He first gets his facts 
by scientific investigation and then uses them in a scientific manner. 
What is the scientific manner? It is to marshal facts in such a way 
as to show unerring cause and effect ; to make it as clear that certain 
effects on the public health follow certain methods of life and in- 
dulgences as it is that typhoid fever is caused by the typhoid bacillus. 
Perhaps the chief work in this direction will not be carried on in our 
laboratories, but I am sure that there are lines of related work along 
which the laboratory must prove of the greatest assistance. Especially 
must it be determined in the laboratory exactly how the normal func- 
tions of the body are being interfered with, and thus what the definite 
"risks of civilization" are. But a large part of our facts must come 
from the scientific collection of vital statistics, and in my opinion, there 
is no more important move that this Association can make at the 
present meeting than to welcome to our assistance those engaged in 
the compiling of vital statistics, and to encourage them to form a 
separate section if that is their desire. It is the work of the laboratory 
to determine, what the effect is, and of the statistician, who is affected. 

There are elements of discouragement connected with the realization 
that a problem we are trying to solve, grows more and more complex, 
the longer we work upon it. But such has been man's experience 
through all time. The more we know about any subject, the more we 
see there is to learn, and the less complete and satisfactory is our 



10 ADDRESS OF THE PRESIDENT. 

first conclusion about it. Ifi has been the dream of men through alL 
the ages that the universe is at the bottom simple in construction. 
They have evidently believed that all its mysteries could be unraveled. 
if they could but once get hold of the end of the yarn, as in the case 
of a knitted garment With every new discovery in science they have 
seemed to see the final revelation of that simplicity which they are 
seeking. But thus far they have been doomed to disappointment, and 
I am sure will continue to be. 

Our own branch of knowledge illustrates this perfectly. When this- 
Association was first organized, its main propaganda was against filth. 
"Qean up your houses and city streets !" was the cry, "And the bless- 
ings of public health will be yours." It was to be a very simple matter 
to bring in the hygienic milleniunL But this simplicity disappeared 
as time went on, and at present he is a bold man who attempts to write 
any simple formula to meet the case. And this complexity of the 
general aspect of our work extends to all its details, and constantly i§ 
growing greater rather than less. No sooner is a discovery made 
which seems to settle a point definitely, than some others are made 
which modify and qualify it. Once, for example, we thought we- 
knew all about drinking water, and especially thought that we had 
tracked typhoid fever to its lair in that substance. Now we know 
that water is only one of its hiding places, and we do not feel at air 
sure that all the others have been discovered; and the things which. 
we do not know about the relation of water to health in other par- 
ticulars far exceed those which we do know. 

Personally I should not be surprised if it is found later that our 
present belief as to the simplicity of the spread of yellow fever would 
later come by necessity to be expanded in a similar manner. Of course 
these expansions of knowledge are not necessarily antagonistic to our 
first discoveries ; they simply extend these first discoveries and thereby 
complicate the problem. 

Over the door of the temple of Isis, the goddess of wisdom, ith 
ancient Egypt, were these words : "I am that which was, and is, and 
ever more shall be, and no man may lift my veil." Ultimate wisdom: 
still stands veiled before us, and the lifting of that veil seems as 
impossible as when those words were written. I do not ask you to 
contemplate this fact in order to discourage you or to lessen your just 
pride in past achievements, but rather by pointing out the struggle that 
is before you to help arm you for the fight. I wish also to impress 
upon you the obvious lesson that the highest kind of training is needed 
to meet, successfully, complex conditions, and it is for this Association 
to insist upon that training; to work earnestly in raising the standard 



ADDRESS OF THE PRESIDENT. U 

of those who are to carry on the work. To this end, work to streng^en 
the Association in every way. Let it become, as it should, a stronger 
and more compelling force in the public health work of the different 
countries. A committee appointed at the last meeting will present a 
report on this subject. Give that report your most careful considera- 
tion, and if it seems to you as it does to the committee, that it is a 
movement in the right direction; that it will strengthen the Associa- 
tion and thus the work of public health advancement, give it your 
support next year when it comes to a vote. In the same line is the 
movement for a National department of public health, with a cabinet 
minister at its head. 

The early European voyagers along the Atlantic coast of North 
America believed that from the summits of the Appalachian Mountains, 
which they could see not many miles inland, the waters of the Pacific 
Ocean could be discerned. But when even the highest peak, Mount 
Washington, had been climbed and only an unbroken wilderness to* 
the west greeted the eyes of the disappointed travelers, it detracted 
nothing from what they had done to comprehend, in some measure,, 
what mwe must be done before those waters could be seen. They 
realized, too, that the completion of that task must be done by other 
travelers with different equipments from theirs. So let us, as we 
succeed in climbing the heights of knowledge which we may discover ; 
and fail to see, as we probably shall, the end we longed for; and come 
to feel that strength will fail us to go further: let us give then to* 
others the benefit of our experience, and stand behind them while they 
push on into that new and pathless region. Thus, somehow and some- 
time, our successors may emerge from all difficulties and sit themselves 
down on the shores of content, with the quiet waters of a placid sea at 
their feet 



ORGANIZED SANITARY WORK IN DEAUNG WITH 

OVERCROWDING AND PAUPERISM, 

DUE TO IMMIGRATION. 

Dk. peter H. BRYCE, a. M., M. D„ Chief Medical Officer, Department 
OF Interior, Ottawa, Canada. 

About a year ago I prepared a paper on Immigration in Relation to 
Tthe Public Health, and pointed out the significant fact that the United 
States, in recent years, have had to deal with the influx, annually, 
of immigrants to the extent of i to every 70 of the population and 
that for several years past, Canada has had to absorb i to every 30 
vof her population. During the past fiscal year, the extraordinary com- 
mercial prosperity of this continent has resulted in an increase over the 
preceding year, of some 20% in the number of immigrants entering 
each of these countries, there having bejen, however, one notable dif- 
ference, namely that of those entering the United States, only i in 
every 8 was Anglo-Saxon, or English speaking, while, of those enter- 
ing Canada from Europe, there were, roughly speaking, 2 British 
for every i frcwn the Continent, while 57,796 additional English-speak- 
ing immigrants went into the Canadian Northwest from the neighbor- 
ing States of the Union. 

Further, there has been another remarkable difference in the fact 
that the United States, according to the American Passenger Associa- 
tion's report for 1904-5, received 1,024,000 immigrants, of whom but 
15,863 were sent to the 6 new Western States (N. Dakota, S. Dakota, 
Texas, N. Mexico, Arizona and Oklahoma), and 18,343 to Minnesota, 
-while 874,080 went to the Eastern States, as follows: New York, 
.317,541; Pennsylvania, 222,298; Illinois, 79,139; Massachusetts, 
71,514; N. Jersey, 58,951; Ohio, 51,242; Connecticut, 26,852, and 
California, 21,166: while of those which entered Canada from Europe 
and Asia, 49,038 went to the North-western provinces ; 52,746 went to 
Ontario, and but 31,119 were destined for Quebec and the Eastern 
Provinces. Moreover, the 57,796 Americans who went into Western 
Canada were practically all agriculturists and 38,594 of those from 
across the ocean were entered as agriculturists, 31,110 as general 
laborers, 36,085 as mechanics, in all 105,789, leaving but 25,476 of 
clerks and ill-defined classes. Hence, while, as is probable from these 
:figures, over 100,000 immigrants went to the farms of Canada, leav- 
ing less than 100,000 to be absorbed by the cities — a very large 
number inndeed — yet when we consider the 874,080 who went to the 9 

12 



ORGANIZED SANITARY WORK. 1* 

States, so largely industrial, of whom 611,353 went to New York, 
Pennsylvania and Massachusetts alone, it is apparent that the problem 
of how this half -million annually is to be first controlled and then 
absorbed, is of the utmost possible importance. It is quite true that 
in 1900 there was an urban population in New York, Pennsylvania 
and Massachusetts, of over 9,000,000, but notwithstanding this fact, 
it means that one immigrant to every 15 of this number must be dealt 
with, while, if we assume that 25,000 went into Ontario urban munici- 
palities, it would be into a population of 900,000, or i immigrant, of 
whom by far the larger number were English-speaking, to be absorbed 
by every 35 of the population* I have thus set forth, in a statistical 
form, for the consideration of every sanitary officer, every police 
officer, every sociologist and every legislator in both the United States 
and Canada, the problem, the solution of which dwarfs every other 
which these two nations have to deal with. 

When it is further remembered that England and Wales had last 
year, 750,000 paupers and that the rate per 1,000 has been much the 
same for a century; that the census of Mtmich, an average city of 
Germany, in November 1904, gave 2% of the male population as un- 
employed, and that excepting France, Norway and Sweden, the millions 
of Austria, Italy, Russia and other countries, are poorer than in 
Britain and Germany, it is apparent that the movement of the unem- 
ployed, the partially employed, and the ambitious, to the fields of new 
opportunity on this continent, which never ceased during the past 
century, and which has showed a momentum of greatly accelerated 
velocity during the past five years, which will increase rather than 
diminish and which could not be prevented if one would, demands 
the most serious consideration of every member of this Association 
who in any degree realizes what the situation is. 

It is quite apparent that from the standpoint of an Association, 
whose members are largely executive health officers, the problem has 
direct relations with Federal, State or Provincial and municipal ad- 
ministration and executive control. 

As regards its relation with the Federal administrative work, it is 
apparent that this will depend directly upon the policy of the govern- 
ments of the United States, of Canada, and, so far as it affects it, of 
Mexico, in relation to immigration. How delicate must be the immigra- 
tion policy of any country which has commercial relations with the 
other nations of the world is every day made evident. For instance, 
a year ago the Chinese proclaimed a boycott of American goods, today 
the treatment of the sdiool children of the Japanese in California Is 
the subject of diplomatic correspondence, while in Canada interest is 



14 ORGANIZED SANITARY WORK, 

demanding, on the one hand, the exclusion of oriental labor, and on 
the other, its admission. 

But whatever may be the commercial rivalries to be met and what- 
ever the delicate international questions to be adjusted and rights to 
be maintained, public opinion in all the countries represented in this 
Association is at one as to the necessity for protecting this continent, 
not only from the acute contagious diseases dealt with by our 
quarantine laws, but also from those more insidious and chronic 
diseases especially dependent upon the social and moral conditions 
which are so intimately related to the industrial status and national 
prosperity of any people. 

The laws of both the United States and Canada absolutely exclude 
the insane, the epileptic, the feeble-minded, the criminal and the pauper, 
and only conditionally admit those who may be partially disabled or 
temporarily affected with a minor infectious disease. 

Both countries have gone further and are exercising the right of 
<:ompulsory deportation within two or three years of any person who 
may become an inmate of either an asylum, a charitable institution or 
a prison. 

Hence it appears evident that legislation cannot go further in regu- 
lating this alien immigration unless it advanced to the point of ex- 
clusion, and this for many reasons will be found, as it has been found 
in the United States, impracticable. Since then the situation is one 
created by the very force of things, it becomes essentially the duty of 
state and municipal authorities to measure the problem with its many 
factors, and to realize not, only its magnitude, but also to determine 
what comprehensive and well considered legislation will be possible 
for limiting the evils of a sanitary, social and moral character grow- 
ing out of this enormous immigration. Although this Association 
has been accustomed to deal with problems belonging rather to 
physical than to social science, yet inasmuch as sanitary science, in its 
older and larger meaning, includes, not only those physical sciences 
dealing directly with public health, but further with those other sciences 
which enter into the study of social and economic conditions, it must 
be apparent that the members of this Association can very properly 
follow the example of the founders of the science of public health, 
Howard, Franklin, Wilberforce, Rumford, Chadwick, Simon, Bowditch 
and others, and realize what they ought and must do if they will 
fulfill the dreams of its founders, widen the scope of their studies, 
enlarge their horizon until they view public health work, not alone 
as a means of preventing contagious diseases, supplying good water 
and disposing of sewage properly, but further of dealing with those 



ORGANIZED SANITARY WORK. 15 

more complex problems, such as the overcrowding of tenements, 
the ventilating of factories and woric-shops, the employment of 
<:hildren in factories and the compulsory half-day system of schools 
for such, the establishment of playgrounds for down-town children, 
and the study of the diseases peculiar to school children of these 
districts, whether due to over-crowding, defective lighting, or in- 
sufficient or unwholesome foods. This surely is a programme 
sufficiently comprehensive for this Association, but one not at all too 
ambitious for a Society, whose members more than any other have, 
or ought to have, the most intimate knowledge of the lives, occupa- 
tions and health of the people of their several communities. I can 
understand the busy health officer saying that he has enough to do 
to take scarlatina cases from houses, without studying their origin, 
and that the most he ought to be expected to do is to get notification 
of tuberculosis and distribute literature for limiting its dangers; but 
never so will he stamp out scarlatina or greatly lessen consumption. 
He, more than any or all others, can at first-hand get the primary 
facts with regard to the population under his charge, and he, more 
than any other, can be the guide, counsellor and friend of every 
official or non-official agency having for its object the amelioration of 
the social condition of the people. 

I am perfectly aware that as things go, whether in the United States 
or Canada, the sanitary officer, who attacks severely, say the smoke 
nuisance of factories, the over-crowding of tenements or the over- 
working of children, will find often that his life, like that of Gilbert 
and Sullivan's policeman, — "is not a happy one !", but scarcely need 
it be said that no health officer, or indeed any officer, can reform evils 
without a struggle. It is the appointed way. He must say, as Brown- 
ing makes his Paracelsus speak : 

"I have a life 

"To give; I singled out for this, the One." 

But to enter more into detail, I would recall how closely Sanitary 
work was associated with charity work in those days, when the great 
father of sanitation, Edwin Chadwick, wrote, in 1832 and following 
years, papers on "Preventive Police," "Public Charities in France," 
*The Slums of London," became Secretary to the Commission for 
revising the Poor Law, was first Registrar of Births, Marriages and 
Deaths and Secretary of the first London Board of Health. Today 
we find a great Charity Organization Society, consisting of 38 
District Councillors in London (one or more in each Poor Law 
District) and a Central Council at which every council is represented 



16 ORGANIZED SANITARY WORK. 

and branch societies in the counties and towns of Great Britain to 
the number of 120 and 180 aflSliated Societies in the United States and 
some 50 others in almost every country in the world. 

"The object of the Society for 'Organizing Qiaritable relief and 
repressing Mendicity' is 'To improve the condition of the poor/" 
Curiously enough, not a word is found anywhere about sanitation^ 
but every clause deals with some phase of either the distribution of 
charity or of obtaining funds for the work. Everywhere the primary 
idea of the Society seems, when organized, to have been cttre or relief 
and not prevention. But as the work has gone on developing, whether 
in Great Britain, the United States, or elsewhere, the uselessness of 
much of the relief work done has become so apparent that everywhere 
one finds creeping into charity work, the essentially scientific idea of 
prevention. For instance, the last report of the "Charity Organization 
Society" states four things as essentially necessary in Charity Organi- 
zation : 

1. Administration of charity with a definite, well understood policy, 
tending to promote independence. 

2. Charity should be a recognized ally of public administration, to 
carry out work and deal with individuals, where this cannot be reached 
or done satisfactorily by public authorities. 

3. Workers in charity should accept the now proved laws of social 
action taught by experience. 

4. Those who undertake to administer, should qualify themselves 
by education through the knowledge of the thoughts and life of those 
with whom they may have to deal, and that which comes from a study 
of the science of the matter. 

The whole force of the report of this charity council is brought to 
show that the dwindling of the crowds seeking charity, whether in the 
way of food, lodging or medicine, in any city will be the measure of 
the effectiveness of real charity work. Real charity work becomes a real 
part of Public Health work, or as we say, of Preventive Medicine. 
The corollary to this in the report is that the positive work, which is to 
restore the recipient of charity to the rank of the non-dependent, in 
order to be more efficient, must first become more personal. In a 
word, the problem is to effect a change both in the character of indi- 
viduals and in their relation to life. As this work must be done by 
individuals, it is apparent that friends and charity workers will pre- 
vent much being forced upon public officials, who in the nature of things, 
cannot reach all cases or do the work so well. But they can assist 
Moreover the most potent factor in the elevation of society is through 
the cultivation of an altruism, which is the real measure of the moral 



ORGANIZED SANITARY WORK. 17 

plane on which the people of any community are living. As Shakes- 
pear says in the "Merchant of Venice" : 

"The quality of mercy is not strained. 

"It droppeth as the gentle rain of Heaven, 

"Upon the earth beneath: it is twice blessed, 

"It blesseth him that gives and him that takes. 

"'Tis mightiest in the mightiest and becomes 

"The throned monarch better than his crown; « 

It will be at once apparent that, if the views thus outlined are the 
correct underlying principles to be applied in this work, the great 
part of poor relief, whether of official Poor Law Guardians or of 
municipal charity committees, has in the past been wrong in principle 
and has positively hampered results. As it has been neatly put, the 
functions of such have seemed to be rather "to assist poverty than to 
relieve destitution." They have not recognized, or have lost sight 
of, making prominent "deterrent conditions" in giving relief, and are 
in danger of attracting people toward dependence. 

Probably nowhere is this tendency seen so positively developed 
as in what is now termed hospital abuse. I can instance the single 
case of the Province of Ontario, with an increase of population of 
not more than 13% in twenty years. The hospitals receiving a govern- 
ment grant, rose from some 12 to 60 and the hospital population from 
4,000 to 40,000. These illustrations make the first point of the need 
for cultivating independence very evident; but the method of doing 
charity work and understanding its true meaning is now being taken 
up by Schools of Philanthropy in which the study of institutions, 
as hospitals and refuges, is carried on; how to care for needy 
families is considered and yet better constructive social work is 
evolved. 

The special directions in which practical philanthropy stand related 
to the work of public health will be readily indicated by referring to 
publications, such as the London Charity Organization Review, and 
"Charities," published by the Associated Charities of New York, which 
calls itself a weekly journal of Philanthropy and Social Science. 
I have grouped the subjects discussed in a few numbers of these 
magazines : 

A. Charity Work Problems — 

1. Orders of Charity. 

2. Workers in St. Giles. 

3. Guild of Help movement. 

4. Hospitals subscribers' letters of recommendation to patients. 

5. Case work and Registration. 

2 



18 ORGANIZED SANITARY WORK. 

6. Congestion and unemployment work. 

7. Dundee operations and child labor. 

8. Poverty an excuse for child labor, — Child scholarship. 

B. Construction Charity Work — 

T. Labor colonies and vagrancy. 

2. Feeding school children. 

3. Copartnership in Housing, — Tenants' Society. 

4. Housing problem in New York, Chicago, London, etc. 

5. Co-operation and profit sharing in business and housing in 

Holland. 

6. Massachusetts Town and Village Betterment League. 

7. School playgrounds and improving of environment of children. 

8. Federated Church Societies. 

9. Childrens* Aid Societies. 

ID. Distribution and care of Jewish Immigrants. 

11. Dealing with Dependent Children and Family Desertion. 

12. Stock-yard Workers. 

13. Chicago Institute for Immigrants. 

14. Pure Milk Association. 

15. The United Cities League of America. 

16. Co-operation between Organized Labor and Organized Phi- 

lanthropy. 

17. Stratification of sympathy. 

18. District Committees. 

19. Statistics of membership of Charity Organizations. 

C. Medical Charity Problems — 

1. Families of Feeble-minded. 

2. Reception Hospital for Insane. 

3. State Commission on Lunacy. 

4. Sanitary conditions of hop pickers and berry pickers in rural 

places. 

5. Dispensary for Consumptives. 

6. Sanatoria for Consumptives. 

D. Educational Charity Problems — 

1. Education in Temperance and Hygiene. 

2. Lectures on Social Subjects. 

3. Sphere of the Home and the School. 

4. Prison Reform. 

5. Education of the Adult Immigrant. 

The mere reading of the list seems to plunge us at once into the 
midst of a struggle involving the most pressing sanitary, educational, 
moral, and religious problems, and the very principles of our Science, 
the very objects of this Association and indeed our continued ex- 
istence as leaders in public health thought and work, demand that 
we must be a part of this struggle, and not alone expert chemists. 



ORGANIZED SANITARY WORK, 19 

l)acterioIogists and engineers. The proverb is true, — "Not to ad- 
vance is to retreat." 

The practical phase of the relation of Sanitary Authorities to 
Charitable Societies has been dealt with in a very recent paper by 
X>r. C. S. Loch, read before the Medical Officers of Health at Bath, 
England, in July, 1906. He very neatly points out that society has 
for its protection three organized means: (a) those for preserving 
the public health, (b) those for providing habits of social preserva- 
tion, as prevention of destitution, and (c) the care of the poor under 
the Poor Laws. Illustrated by the following death-rate, as in London, 
where it was 16.5 in 1903, Loch argues for the effective work and ex- 
tended character judged by results of State hygiene. Nevertheless, 
the number of assisted paupers in England per 1,000 remains much 
the same and so Loch is led to remark : "We realize that our business 
is not with a few small factories over which we can exercise but a 
limited control, but with movements, which rightly directed, should 
make a deep impression on national vitality and character/' 

Proceeding to illustrate how health workers and charity workers 
must co-operate, he points out how much good can result from in- 
spectors and workers amongst the poorer classes, or on the other 
hand, how much evil may follow bad methods. Thus assist with 
money one family in a tenement and in a few days all report them- 
selves in want. As is the case of our northern Indians, "they may 
have plenty of fish on hand, but without tobacco and tea they are 
starving." On the other hand, A being encouraged and keeping his 
room bright and clean, makes B's appear dirty and so improvement 
goes on. To the influence of imitation can further be added persua- 
sion, and it is here that the health visitor, or lady sanitary inspector, 
produces the greatest results. 

In all cases, spontaneity and independence must be encouraged, 
not weakened. The remarkable weakening of such independence may 
be witnessed in even prosperous communities with us in America, 
where health authorities often pay the entire cost of isolating and 
treating smallpox in families, who instead should have been punished 
for neglecting vaccination. 

Illustrating how far sanitary work ought to go, he speaks of the 
ill-health growing out of neglect to keep rooms clean, to protect the 
child's milk and prepare the food properly. By whomever done, 
education along such lines is really sanitary work. If anyone has 
any doubt, even as to the official extent of sanitary work, he has 
only to read the statutory duties of Medical Officers of Health. Thus 
such an officer shall, — ( i ) Inform himself of influences affecting 



20 ORGANIZED SANITARY WORK, 

or threatening the health of his district. (2) He shall advise and re- 
port to the Sanitary Authorities regarding such conditions. Inasmuch, 
however, as the amount of work such an officer has to do is most 
extensive, whilfs too often his staff of officials is limited, he must 
make common cause with and effective use of all sorts of charity^ 
societies and district visitors. We have Charity unions in wards^ 
and parishes which ought really to be a part of the bureau of health, 
and although un-official, should be given office-room there and be 
constantly communicated with. Dr. Loch points out that in London, 
in the 26 Charity Districts, there were some 7,500 unpaid voluntary^ 
visitors and 900 paid visitors of the Education, Charity and Sanitary 
Committees. He points out how their co-operation will depend upon 
their not reporting to several but to some one central body, thereby 
preventing confusion. Thus at such a centre, all cases dealt with by 
a worker of any of the several committees should be registered, after 
which officers of the several committees can together determine upon 
what is to be done and the matter would be referred to the particular 
committee. Thus to illustrate. A family living in a one-roomed 
tenement is found with a consumptive daughter, other children not 
going to school and perhaps a drunken father. It is apparent that ta 
deal with such a case, action by the Tenement House authorities, by 
the Education authorities, by the Sanitary Inspector, and by the 
Charity and Morality Department would all have to be taken. Aiter 
citing several actual cases, some worse than the above common in- 
stance, Loch says the problem is really the regeneration of a whole 
family and that any degree of success can only be gained by co- 
operation. With regard to an important point, Dr. Loch very wisely 
urges that to say that a sanitary authority should tolerate cases of 
overcrowding because of high rents as an excuse for inaction is only 
to perpetuate evils. Houses will be built if demanded, while the dis- 
persion of inmates of crowded tenements, inevitably results in the 
erection of new buildings under modern tenement house laws. 

Such are the ideas of a working Medical Officer of Health in the 
London Metropolis, and such are applicable to the conditions of all cities 
and towns. But we on this continent have multiplied difficulties where, in 
addition to what may be termed the normal growth of population, we 
have in many centres very many thousands added annually to urban 
populations. In dealing with such, new problems present themselves 
and new difficulties must be met. Such are illustrated by the titles of 
the articles already referred to. For instance, a Jewish Society has 
been formed for the distribution of Hebrew immigrants and institutes 



ORGANIZED SANITARY WORK, 21 

are being formed in New York and Chicago for their education in 
English and in the various occupations. Italian societies are under- 
taking similarly to do something for their people. And yet the great 
number of foreign immigrants will naturally drift into the slums of 
our cities and must be dealt with by the municipal, organized charit- 
able, sanitary and educational authorities. Primarily such immigrants 
will probably come into touch with the sanitary authorities through 
outbreaks amongst them of contagious diseases, but this is temporary 
and indeed must partake largely of sanitary police work. It is, how- 
ever, a starting point. The sanitary police could, with such co-opera- 
tion as that suggested by Dr. Loch, report to a central bureau, could 
give the number of children in a household and those of school age, 
whether they were being employed and in what sort of places, and 
could state what employment the father had and whether the home 
conditions as regards housing and food were tolerable. To allow such 
classes to congregate in congested centres, to form practically foreign 
communities in our cities, introducing not only foreign customs, but 
habits often inimical to good citizenship, whether viewed politically, 
socially or morally, is to allow to grow up dangers to the body politic, 
which must be viewed only with alarm. Remembering that to public 
health officials insanitary and overcrowded tenements present the 
greatest difficulties in maintaining or improving the health through 
their effects upon children due to the impure air, unwholesome food 
and lack of exercise and to adolescents and adults from the debilitating 
effects of crowded work-shops, long hours and defective sunlight, it is 
apparent that it must be only through the most persistent presentation 
of the known evils, whether to the public or to their elected represen- 
tatives that such a mass of educated public opinion can be created as 
will result in reforms adequate to prevent or remove these evils. 
This cannot be done except by the union of every organization, whose 
objects are the amelioration of the conditions we have spoken of. Cor- 
porate selfishness and individual greed in land owners and landlords 
must be combatted, the ignorance, the immorality and brutality of 
classes and individuals must be overcome; while clear views as to 
remedies and scientific knowledge as to their application must be the 
possession of public health officers, if the problems are to be success- 
fully solved through their activity. 

That we are hardly entered upon our work, that we ourselves and 
still less the public have as yet but imperfectly realized the extent of 
our task, or had a full conception of our duties must be apparent to us 
all; but it will be in proportion to the position we take with regard 



22 ORGANIZED SANITARY WORK. 

to all these problems and our insistance upon their being a part of 
public health work, that the voice of public health officers will be heard 
and their demands receive adequate recognition. 

That either we have not shown our practical interest in the charity- 
side of public health work or that our relation thereto has been dis- 
regarded would seem to be shown from the results of a published 
enquiry into the occupations of members of District Committees in 
Charitable Work in New York, Boston, Philadelphia, Baltimore^ 
Washington and Chicago. Thus 539, or 45% of the whole number,, 
were women, and 106 or 10% were men of leisure and business men. 
Of 201 professional men, 100 were clergymen, 51 were doctors, 38' 
lawyers and 12 of other professions. Of 73 teachers on the commit- 
tees, Baltimore has 52 and but four are salaried officials of institutions. 
Settlement or institution workers are 36 in all, while only two trades- 
men are found in a total of over 1,000 members. That there should have 
been, but four college professors in the whole list is a commentary in 
itself, while the fact that only two tradesmen are included would seem 
to indicate how far apart are the classes of the people in even the 
centres of rampant democracy. 

Amongst the practical measures, which organizations of this sort 
can most properly urg^, along the broad lines which have marked our 
work in the past, there is one which in my judgment dominates all 
others so far as the work of the municipal health officer is concerned. 
It is that of the distribution of the immigrants who month by month 
and year by year pour into our cities. The task is of all probably the 
most difficult, and depending as it must upon State and Municipal leg- 
islation, requires the development of a strong public opinion before it 
becomes possible of solution. The **Aliens Bill'' introduced in the 
British House of Commons in 1904 contained the essence of the prin- 
ciple that the Local Government Board could by order direct that 
within an area whose limits would be defined in the Order, not more 
than so many persons could be resident and of this number no more 
than so many of any foreign nationality. We have in this idea a broad 
basis for action along lines such as we have referred to. Assume, for 
instance, that a block of New York or Montreal houses has already its 
quota, from the sanitary standpoint, of a foreign population, and it 
does seem possible with police assistance to prevent more immigrants 
from being allowed to inhabit these houses. 

State and Provincial laws should endue the State and Provincial 
Boards of Health with the fullest powers to institute enquiries when 
they deem it proper, as well as when requested by Local Boards of 
Health, and to demark such areas by an order compulsory upon the 



ORGANIZED SANITARY WORK. 23 

Local Board of Health and penal upon householders who might vio- 
late the Act. I have examined the very full provisions of the Tenement 
House Regulations, adopted under the Greater New York Charter of 
1900, but find no clause which is so nearly a primary condition of 
tenement house sanitation as the above. The Commission has power 
to take a tenement house census, to vacate infected and uninhabitable 
houses, whether from disease, bad plumbing or other nuisance, to pro- 
vide for the light and ventilation of new houses, but apparently there 
is no clause dealing with overcrowding. Turning to the Factory Act 
of Illinois, I find quoted in the Annual Report of the Inspectors for 
1902, the provisions regarding tenement house manufacture of cloth- 
ing, etc., as demanding a certain air space and sanitary house con- 
ditions before a license for home manufacture is granted. The report 
then goes on to say, "That women and children are employed in this 
more than in any other large industry may be seen by turning to the 
tables of this report ;" also, "It has been shown repeatedly that an in- 
evitable amount of disease is communicated through the clothing made 
by this system and it is impossible that it should be otherwise . . . 
These houses are crowded with children of the poorest classes and the 
clothing and those working on it are directly exposed to every disease 
current among them, and infection of all the clothing passing through 
the employee's hands is almost sure to follow . . . The reports 
of this department show that the manufacture of clothing was unabated 
in 1894, even at a time when there was scarcely a tenement without 
its case of smallpox . . . yet nothing has been done since that 
time to enable the authorities to stamp out this constant source of con- 
tagion and disease amongst the people of the State." 

But more than enough has been quoted to show that, bad as tene- 
ment house conditions are, no great improvement is likely unless the 
preventive measure of stopping the ever-increasing congestion is first 
taken. Are we to wait till the conditions of New York and Chicago 
are everywhere reached before we advocate and urge action? This is 
a national matter, indeed an international matter, and we in this con- 
gress are representing the united health conscience of a continent. 
Here is one point at any rate, where federal, state and municipal officers 
may think together, may feel that they can act together and that they 
ought to speak out so loud that all in the three nations shall hear. 
Surely we are here to do more than merely deal with cases, to be con- 
cerned only with the details of our routine work ! We are here in the 
best sense as legislators! This is our health parliament! What we 
do not say here lacks, if said at home, the essence of finality, but pre- 
sented, discussed and adopted here, it has in the past and will in the 



24 ORGANIZED SANITARY WORK. 

future yet come to pass. It is now ancient history to some of us, 
to some it will be new, to recall the discussions on federal rights, state 
rights and municipal rights, the difficulties of knowing what diseases to 
quarantine, and how and when; how to deal with international and 
inter-state and civic questions, as of smallpox or yellow fever and 
many equally unsettled health problems. Such problems are still with 
us only altered in their special character and become more complex in 
their nature. What is demanded of us are clear, definite opinions and 
as clearly indicated lines of action as to how such will be given effect. 

Imagine, if properly organized, what a force of opinion we can 
supply. The whole experience of the medical corps of our armies and 
navies ; the large and extended experience and studies of hundreds of 
quarantine and immigration officers at a hundred ports and in almost 
every climate; the yet more numerous state and provincial officers 
with their more numerous and more exacting problems, and associated 
with them thousands of municipal health officers. We have further 
got the whole body of officers of public institutions, whose daily duty 
it is to deal with the wrecks of human life, the castaways, the widows 
and orphans and pensioners of society. We have, last and greatest of 
all, educated, organized and ready for action the thousands of prac- 
tising physicians, who in every community can be aroused, as altru- 
istic work is ever a part of their daily lives. We have, yet more and 
more powerful, that great human heart dwelling in the bosom of 
every Christian community, and indeed in every people who recognize 
the fatherhood of God and the brotherhood of man. Find them lead- 
ers, indicate the way, and in spite of human selfishness, inertia, and the 
daily round of duties, we shall see the people of our hundred communi- 
ties responding to the call. In many years' observation I have found 
that wherever was a born medical health officer there was enthusiasm, 
optimism and invariable advance. They become recognized uncon- 
sciously as the local leaders of all sorts of social reforms and through 
them the gospel of health is daily preached. 

In conclusion, one has only to express the hope that the compre- 
hensive, dominating and responsible character of the work which lies 
within the scope of public health officers may be reognized by all, and 
especially by the younger men, better trained in the exact sciences, now 
entering upon public health work as a profession and life work, and 
at a period when the long life-time of opportunity is before them. The 
Sanitarian is the medical man, the engineer, the chemist, the bac- 
teriologist, the statesman ; but he must be more than this. He must 
be as that founder of our sanitary religion, Sir Edwin Chadwick, the 
apostle of Public Health, of whom Lord John Russell said : 



ORGANIZED SANITARY WORK, 26 

"For the relief of the destitute and prevention of pauperism, the 
improvement of the public health and the physical condition of the 
population, there was no one to whose zeal and assiduity the country 
is more indebted than Mr. Chadwick." 

It is quite clear that while as an Association we have done much 
to educate public opinion along scientific lines toward good doing and 
good being ; and while as individuals, we may have endeavored in our 
several communities to maintain ever alive that enthusiasm, which alone 
can keep the people laboring at the infinite task of removing social 
evils and of uplifting our fellows, yet we must all realize how much 
there is to do, how little we have accomplished. And yet the struggle 
has coimted for something. To use the words of Browning's "Andrea 
del Sarto": 

"Ah, but a man's reach should exceed his grasp, 
Or what's a heaven for?" 

Our confession and our faith must be those from Tennyson's 
'Trincess": 

"Have patience I replied, ourselves are full 
Of social wrong: and maybe wildest dreams 
Are but the preludes of the truth. 
For me, the genial day, the happy crowd, 
The sport half-science, fill me with a faith. 
This fine old world of ours is but a child 
Yet in the go-cart. Patience, give it time 
To learn its limbs; there is a hand that guides." 



PUBLIC HEALTH AND PROPHYLAXIS OF DISEASES. 
OSCAR J. MAYER, M.D., Mexico, D. R, Mexico. 

It is difficult to select a new theme with which the members of this 
learned society would not already be familiar. For this reason I have 
selected a subject which, by no means new, has been argued more or 
less by the medical profession of the United States of America for 
more than ten years. It may not be unwelcome to this body, repre- 
senting as it does, all the countries of the North American continent. 

The establishment of a department or commission of public health 
has had its advocates for more than twenty years, and as long as nine 
years ago resulted in the drafting of a bill presented to the Congress 
of the United States, known as "A Bill to Establish a Department of 
Public Health and to Define its Duties." There is reason to believe 
that within a short time this bill, with all its provisions, will become 
a law, inasmuch as the various medical bodies representing a large 
majority of medical practitioners are all unitedly working for the 
passage of this bill. While this bill treats only of the federal quar- 
antine laws and such legislation that protects the country at large, 
there is no reason why other matters of local, municipal and state inter- 
est cannot be included, or at least come under the general supervision 
of the chief of department thus created. While the work of public 
sanitation and prophylaxis of diseases has steadily advanced to the 
public's interest, you will agree with me that much can be done if in 
each country represented there would be a well organized department 
of public health, with practically the same laws, which in the light 
of modern medicine and the sanitary sciences, cannot differ radically^ 
this department removed from all political influence. 

There is no question that the work of the Marine Hospital Service 
which now practically discharges the duties of the federal authorities, 
has been of inestimable value to the country. Freer in its action than: 
the public Marine Hospital Service, with practically unlimited power 
in the decision of questions of national importance regarding public 
health, the "Consejo de Salubridad Superior" has done work which 
was universally admired by its results, as well as quickness of action, 
preventing a dire calamity threatening the invasion of plague into this 
country. There is no question that at times of threatened national 
calamity, the boards of health or any other service entrusted with the 
welfare of the countr\^ at large, is not only endowed with extraordinary 
powers, but also supplied with an almost unlimited amount of money 

26 



PUBUC HEALTH AND PROPHYLAXIS OF DISEASE. 2T 

necessary to combat the invasion in the quickest manner possible. We 
have seen this repeat itself in San Francisco as well as New Orleans,, 
and also in Mazatlan in this country, not to mention the work and the 
amount of money spent in combating yellow fever in Havana and this 
country. 

We all know the quick public change from an indifference regarding 
public health to one of frenzied apprehension in the face of an invad- 
ing calamity. Why should the medical profession, in the face of this- 
experience, sit calmly by and only act in response to this public appre- 
hension? Would it not be best in this case to apply the "ounce of 
prevention to the pound of cure," as done in many other instances? 
The permanent establishment of a department of public health with 
a chief officer occupying a seat in the cabinet of the executive of the 
represented country, would give more power and more protection than 
any institution so far created in any of the countries represented here. 
To relate all the advantages to be gained, would occupy too much of 
the valuable time at the disposal of this meeting. The public at large, 
as well as the profession, would benefit by this innovation. The pub- 
lic at large, as taxpayer and subject, have a right to demand protection 
in health as well as in safety from bodily violence and personal belong- 
ings, while the public, uneducated and practically indifferent to per- 
sonal danger when they cannot realize to see it, are slow in clamoring 
for aid ; nevertheless it is the duty of the properly constituted authority 
to provide as healthful a condition for the progress of the nation. 
Many people are only clamoring for the progress that they can realize 
materially, forgetting how much the medical profession has done ta 
help commerce at large, build up national prosperity and acted as a 
promotor of vast wealth and enterprises that otherwise would not have 
been contemplated. Who can estimate the amount of prosperity, both 
national and individual, caused by the entire eradication or reduction 
to a minimum of yellow fever in Cuba, as also the Gulf States of this- 
country? What has the invasion of yellow fever cost in the Gulf 
States of the United States in the last year, not to speak of the 
misery and loss of life to the afflicted families? What has it cost to 
stamp out the plague in Mazatlan, and what was its immediate effect 
on the whole country when the report was sent out that all Mexico was 
threatened with the bubonic plague? Commerce is slow in recog- 
nizing the benefits it derives from sanitary measures adopted not only 
for the prevention of disease, but you might say for the prevention of 
interfered traffic and its consequent loss to commerce. We may truly 
say here that a "Nation's Health is a Nation's Wealth," and the 
liberties and rights of an individual stop right there where they inter- 



28 PUBLIC HEALTH AND PROPHYLAXIS OF DISEASE, 

fere with his neighbor's liberties and happiness or where they endanger 
his personal safety. We may take for example typhus fever that has 
practically been endemic to this valley since time immemorial. The 
Consejo de Salubridad Superior has vigorously proceeded to stamp 
out this pestilence by means of ascertaining every new focus of dis- 
"case and the number of cases, but it made the false impression that of 
late years this disease is increasing, while in truth it is very much de- 
creasing. What protection has the citizen and his family who observe 
all the personal care that modem hygiene puts at his disposal? His 
servants are obliged to go into the open market to buy provisions; 
his servants of necessity coming from the lower classes, visit and 
intermingle freely with their families in the poorer quarters of the city ; 
in spite of all care the citizen who is anxious to observe the most pains- 
taking precautions has no escape from a possible infection. All that 
can be done to protect the community at large by education has been 
done by the board of health, but the board of health has no power to 
oblige the vendors of the market place to present a clean appearance, 
and to observe the laws of personal hygiene. It may form laws that 
their houses be cleaned at times of a reported case of typhus, or under- 
take it at its own expense only to be neglected again thereafter. It 
has no right to disturb the sanctity of the house in which there is a 
concealed case that serves as a focus to many other cases. The board 
of health may clean up any number of houses, spend vast amounts of 
money in such work, but it cannot compel the house owners to keep 
clean premises. If a commissioner of public health could sit with 
the other officers constituting the cabinet of the executive of the 
nation, and there propose and promulgate such laws as would at once 
put all the machinery of each and every department in motion, and 
assure harmony of action, there is no question that typhus could be 
made to disappear quicker, than yellow fever did disappear from the 
infected Cuban ports. 

Everybody that will only take the trouble to study public hygiene 
and its process in this country in the space of a comparativdy 
•very short time, especially if they will persue the wise laws promul- 
gated by the Consejo de Salubridad Superior, must at once agree that 
nothing more perfect could be desired. However, when we look at 
the carrying out of all the rules and regulations to the many laws 
applied, we at once see its shortcomings. This holds not only good in 
this country, but all the rest included. If we get at the true reasons 
for this, we will in many cases find that a board of health, a marine 
iiospital service, or any other constituted body that is hampered in 
its very workings by red tape of officialdom, cannot achieve the results 



PUBLIC HEALTH AND PROPHYLAXIS OF DISEASE, 29^ 

desired. For this reason we should endeavor to combine our forces 
with other organizations and work to the end of getting a special 
department of public health with an executive head an accred- 
ited physician thoroughly versed in the sanitary sciences with a seat 
in the cabinet of the executive of the nation. 

Much time is devoted to the researches in bacteriology and other 
sanitary sciences; everybody is agreed that the immediate benefits 
derived by curative medicine as yet amounts to very little outside of 
antitoxine for diphtheria and that for tetanus. How much on the 
other hand has been done for preventive medicine, and of that how 
much has been neglected in thorough application by the bickerings and 
clashes of constituted authorities ? All this under proper arrangement 
as stated, could be prevented and the benefits applied in its proper 
channels. Not only the prevention of disease can thus be thoroughly 
policed and safeguarded, but the educational supervision of the col- 
leges as well as of physicians could be regulated. 

In regard to medical education, I claim that the State has not only 
a right, but a duty, to perform, to see that those licensed to practice 
the art and science of medicine must come up to a certain standard^ 
and this standard should be more or less under government super- 
vision, as a guarantee to those who cannot judge for themelves to 
be provided with properly educated medical men. 

At present in spite of the good work of the Association of American 
MediaJ Colleges, the standard of the different colleges varies greatly, 
as only recently shown by the publication of percentages of failures of 
the various colleges of the United States, ranging from ^% to as high 
as 60% and over. In other countries there is no attempt made to show 
the percentage of failures, nor is there any standard set under which 
medical education is conducted. 

There surely would be no lack of work to be laid out for a depart- 
ment of public health in the manifold branches in which it would be 
called upon to work. If agreed to by the representative members of 
this Association, I should like to see a motion made to have a com- 
mittee selected from members of this society, representing each coun- 
try of the North American continent and Cuba, to work with other 
associations interested in the creation of a department of public 
health, and as a stimulus let the representative of each country do all 
in his power to succeed in establishing such a department with an 
accredited physician and sanitarian at the head, holding a seat in the 
cabinet of the executive of the country. 



CONTRIBUTION TO THE STUDY OF PROBLEMS OF NA- 
TIONAL AND INTERNATIONAL SANITARY 
LEGISLATION. 

Dr. J. MESA Y GUTIERREZ, Mexico, D. F., Mexicx). 

If it is true that, in ultimate analysis, ideas do really move the world, 
no idea should be such a powerful motor, for the present generation, 
further and further removed from the sea of the unknown, to cross 
which we have, as Littre says neither bark nor sail, as the idea of 
prophylaxis, that is, in its widest sense, the prevention of evil of any 
kind whatsoever, the preservation of health, that priceless treasure 
which makes of life a power instead of a burden and which is for 
nations more valuable indeed than mines of gold and cotton fields, 
because it means virility, certainty of welfare and the perfection of the 
race, with a never ceasing source of wealth and energy. 

Legislation on prophylaxis is as important as the very idea of pro- 
phylaxis itself. In fact, if we are allowed to say on any subject with- 
out hesitation, that customs do not make laws, but on the contrary it 
is laws that must organize and modify customs, we can safely say this 
on the subject of hygiene and prophylaxis. The truth of this asser- 
tion is apparent from the fact that the evolution of such ideas takes 
place in the minds of a selected group of high talented men, who 
entirely devote their lives and energies to mankind's improvement. The 
result of their valuable investigations should receive their immediate 
and practical application in the shape of laws, for the benefit of the 
community, who have neither time nor opportunity to be taught these 
things, and consequently are not able to modify their habits through 
their own efforts, until such modified habits acquire the strength of a 
law. 

Legislation on these matters must be so efficient as protect the people 
against their own ignorance, and it is the precept itself that must serve 
as a means of instruction. The vital importance of the subject re- 
jects the idea of anything like sentiment in the matter of legislating 
thereon and not unfrequently minor interests ought to be sacrificed 
for the sake of the main subject. Legislation must go so far as to 
intrude itself into the sacred privacy of home and should be powerful 
enough to rise itself haughtily and confront the authority of any 
other country. 

The executive power that has to carry out the rulings of such a 
■legislation, should be carefully organized, furnished with plenty of 

30 • 



NATIONAL AND INTERNATIONAL SANITARY LEGISLATION 31 

money for every purpose, and with a numerous and highly efficient 
staflf of officers and likewise invested with powers practically unlim- 
ited, because it is a matter of life and death for the country as well 
as for the race. 

It is with pride that I take the liberty of saying in the presence of 
this distinguished assembly, that these principles are thoroughly 
understood in our country, and that based upon them as if upon an 
unmovable foundation, the Mexican legislation has been built up. 

Imperfect however as our legislation may be, and more criticised 
than really imperfect by all those whose petty interests are more or 
less hurt by it, yet it is very solid, more liberal and broad-minded than 
that of other countries, and above all it is capable of indefinite im- 
provement, because its true foundations are already laid, and the sci- 
entifically acquired principles, and the most essential of all of them, 
that of authority, are recognized as irrefutable and have been accepted 
forever. This legislation is now like the net work of a canvas on 
which the law-nmkers of the future will draw more and more fine 
designs, perhaps undoing some of those previously drawn, but they 
will always preserve its meshes intact so wise such a legislation is. 

The Superior Board of Health and its immediate legal instrument, 
the Sanitary Code, are the first and most beneficial issues of the appli- 
cation of fundamental principles of sanitary science in our country. 
They represent the first successfully reached summit in an unprece- 
dented evolution, the first victory won by a hard fight against all kinds 
of prejudices and deeply rooted interests. Both of them have been 
developed under the influence of the talent, the energy of will, the 
thorough knowledge of administrative organization and the diplomatic 
spirit of a superior man. 

The Superior Board of Health watches over the beginning and 
spreading of any alarming epidemy at foreign ports, through Mexican 
consuls, who are sent as sentinels, and in our country oversees the 
interior of homes, by imposing on every physician the duty of report- 
ing every merely suspicious case of a contagious disease; inspects 
with equal interest passengers coming in Pullman cars, as they being 
possible carriers of a contagious disease, as well as the humblest hut 
of our poor laborers at the coast, with the view of preventing the 
spread of the dreadful yellow fever. Also inspects meats, milk and 
drinks in towns; fruits and vegetables in markets; cattle imported 
through the border; visits drug-stores in which a special installation 
and certain supplies are required by law, as well as theaters which 
must have ample capacity and thorough renovation of air, and also 
special conditions in order to protect such buildings against possi- 



32 NATIONAL AND INTERNATIONAL SANITARY LEGISLATION. ' 

bility of fire. The above mentioned body anxiously cares for the 
conditions in which children must be at schools and workmen at fac- 
tories ; and for the welfare of the latter, it goes as far as setting forth 
a limited working time, not to exceed in any case a certain number of 
hours per day, knowing that to this effect no stronger reason than 
that of health could be invoked, and thus trying to prevent that labor- 
ers induced by socialistic ideas, be carried up to the extreme of de- 
manding from their employers said advantage by means of dreaded 
strikes which have so terrible results for all concerned; also requires 
certain hygienic conditions for a house before it can be inhabited or 
for a church to be opened; it protects both the newborn infant who 
according to law is subject to vaccination, and the newly arrived for- 
eigner who is so specially exposed to smallpox, and on this account is 
warned by every possible means and advised to be revaccinated. With 
the same paternal feelings, knowing the truth of the old saying, "Quien 
bien te quiere te hara Uorar" (He who loves you truly will make you 
weep), builds up lazarets to isolate persons suspected of having con- 
tracted a contagious disease and furnishes them the proper means for 
medical cure, which they would lack otherwise. 

Furthermore, in the spirit of the most liberal ideas, and desirous 
of placing the least possible restrictions to traffic of passengers and 
merchandise, the board siibstitutes the hated quarantine for the scien- 
tific and healthful disinfection. 

Finally, guided by the best scientific discrimination, this institution* 
takes advantage of prophylactic proceedings well known as efficient and 
only of them. With this end in view it isolates man from that Stego- 
myia so as to prevent yellow fever ; prosecutes and exterminates filthy 
rats, carriers of bubonic plague; and in the case of an epidemy of 
unknown etiology as typhus, it applies the most advisable and prudent 
proceedings, in the hope of being able to restrict them, when the cause 
of the disease will be scientifically known, and to this effect the proper 
investigations are started and carried out. 

But when the high qualities of its organization shine with un- 
equalled splendor is during epochs of public calamities such as an epid- 
emy threatening to invade the whole country. In cases like this the 
first thing it does is to assure diagnosis, by means of its specialists as it 
happened at Monterrey and Mazatlan; and knowing that the best 
results are obtained from the quickest action, its vigorous fight is 
started with full authority, unrestricted and foreseeing tactics, attack- 
ing the enemy in its strategic redouts, expelling it from them, besieg- 
ing it, compelling it to perish by lack of nutriment, setting fire to its 
abodes when it is found impossible to expel it, and tenaciously pro- 



NATIONAL AND INTERNATIONAL SANITARY LEGISLATION. SS 

longing this war in spite of victory proclaimed by the most distrustful 
people, until it is entirely evident that all danger is over. 

To emphasize these achievements we may mention the brilliant cam- 
paigns called in history the confinement and stamping out of bubonic 
plague at Mazatlan and that of smallpox at Torreon, the subduing, the 
almost reduction to nothing, of yellow fever in the Gulf coast at the 
same time that it was raging in New Orleans. The first of these ex- 
ploits cost $3,000 per day, making a total amount of $350,000. The 
last one amounts up to now to $400,000. And what does such a 
bagatelle mean when we think of how much more we would have lost 
in lives, interests and progress in civilization had we not been suc- 
cessful ? 

But neither money liberally spent nor the scientific knowledge 
judiciously applied has been the only means of attaining victory in 
these cases ; but some other secret and efficient measures have been put 
into action. Do you wish to know them? They are, unity of action, 
absolute authority, full power and entire responsibility. 

Honorable and distinguished American colleagues whom I have the 
honor to address : now that we are entirely at ease knowing that any 
conquering ambition on the part of your great country against ours is a 
myth; now that thanks to our everlasting peace we joyfully watch 
how American capital, enterprise, energy and good will are coming 
to Mexico, to co-operate in the evolution of our country which in the 
near future will, like that of Japan, astonish the world, now we know 
that we still have much to learn from your proceedings, and we 
willingly devote ourselves to the task of reaching your high standard. 

But I may presume that this is also the occasion for telling you that 
you may have something to learn from us. You have not a sanitary 
institution capable of putting into action the measures to which I 
have referred ; with sufficient authority and responsibility and broad- 
minded enough towards your own country and neighboring nations. 
Had you had such a powerful institution, the bubonic plague would 
not have reached our port of Mazatlan imported from its focus at 
San Francisco, concealed as it was, by the local authorities, nor would 
our board have had to fight the empirical quarantine measures taken 
not long ago in Texas, without being able to meet at the northern side 
of Rio Grande a competent authority to deal with. 

And why is it that American members of the American Public 
Health Association, who since long ago have been striving to obtain 
such a sanitary institution, have not been successful thus far ? 

In my humble opinion, the very reason why this attempt has re- 
sulted in a failure in the United States, contrary to what has happened 



34 NATIONAL AND INTERNATIONAL SANITARY LEGISLATION, 

in Mexico, is found in the special peculiarities of character of each 
race. Among Americans the development of personal contrivance, of 
individual energy, of spirit of association spread everywhere, is highly 
prevailing. And although thanks to these brilliant qualities American 
people can rightfully boast of wonders of civilization, such as their in- 
dependent universities, on the other hand and for that very reason, the 
regional character of legislation becomes more apparent; each state 
of the Union tries to preserve its state laws, and it is so much more 
difficult to create a new power with equal jurisdiction over all the 
states. Here in Mexico, on the contrary, we need and in fact we 
have a truly paternal government, in the political sense of the word, 
which greatly facilitates the creation of new powers and the uniformity 
of legislation ih the whole country on new subjects. It is in this way 
that the idea conceived by a superior man could be easily carried out 
on account of its justice and usefulness ; whereas in the United States 
it will be necessary to harmonize the opinions of the different associa- 
tions as they are proposed to the nation. But the opinion is now ripe 
enough to be proposed, since its fundamental scientific principles are 
practically the same for every country in the world. 

However we must acknowledge that in spite of its remarkable or- 
ganization and its fruitful effects upon the country, our Superior 
Board of Health has not reached yet such a point as to be the model 
institution we need and the one that could be set as an example for 
other countries to adopt. Judging by its name (Consejo Superior de 
Salubridad)) it might seem that it is a mere consulting body: in fact it 
is not only that, but also an executive power. For instance it is the 
board of health that judges of the alarming character of an epidemy, 
and the same body conceives and carries out the efficient plan of cam- 
paign so as to prevent its spreading ; it is the one that determines the 
sanitary works required in a house and performs them at the cost of 
the owner when the latter refuses to obey. The structure of said useful 
institution is thus admirably well shaped as it ought to be, both of 
good judgment and of prompt action, in order that its work may have 
the quick and efficient character of a reflex movement. 

But on the other hand its authority is subordinate, when it should 
be more independent than any other one, and although practically in 
moments of danger its power is sufficient and responsible, it makes how- 
ever the impression of being a provisional one. This institution will 
not have all necessary perfections, which the taxpayers are entitled to, 
in order to be more fully protected, until such a time when the same 
body will be promoted to the rank of a department of state with its 
chief official having a seat in the president's cabinet, and will have 



NATIONAL AND INTERNATIONAL SANITARY LEGISLATION. 36 

tinder its jurisdiction many subjects which are wanting at the present 
time. 

Let us rapidly consider the advantages which might result from its 
intervention in some matters of this kind: 

It is an undeniable and sad fact, the lack of cletnliness among our 
lower classes, and to such an extent that they have rightly deserved the 
impleasant surname of "greasers" on the part of some foreigners vis- 
iting this country. The Superior Board of Health does its best to 
remedy such serious evil, compelling by means of law such fellows to 
bathe. Is that measure adequate enough? Is it not true that the 
dwellings of that poor class are as their own bodies and clothes, a den 
of filthiness? 

It is certain that such an unfortunate state of affairs can only be 
efficiently modified by education, but the latter would be quidc if 
forcibly imposed by the law. And what a magnificent work it would 
be, especially in this city, that of inducing landowners to build cheap 
and dean dwellings for our laborers, by granting landlords excep- 
tional concessions, and even starting the construction of such comfort- 
able houses wi account of the government. 

Another very efficient means of education and at the same time an 
urgent and beneficial precept would be the restriction in number of 
bar-rooms and pulque shops, a measure that would undoubtedly be 
highly praised by the better class of our society as it has happened with 
the restriction in hours granted for selling intoxicating liquors. Hav- 
ing in view public health, the proper department could contrive to find 
the scientific method of elaborating pulque and consequently the rais- 
ing in price and the acquisition of some good qualities of that bad 
smelling and nauseous beverage contaminated from its very source, 
a fit incubator for saprophitic and pathogenic germs, and a generator 
of the homicidal mania, which is sold in horrid dens that spoil the 
beauty of our important city in almost every one of its streets, which 
furnishes the large "Juarez Hospital" with wounded people, the clin- 
ics of the "General Hospital" with people suffering from tuberculosis 
dysentery, liver diseases, etc., and the city jail with murderers ; which 
finally is elaborated much to our shame, in the most primitive and 
dirty manner one can imagine. 

A department of State with sufficient authority and in the sacred 
name of public health would be the only one that could check the 
malicious influence that prevents the removal of that stain in our 
civilization; the only one that would be capable of stopping such a 
routine and prove to the wealthy plantation owners who speculate with 
that beverage, without minding the degradation of the lower class out 



36 NATIONAL AND INTERNATIONAL SANITARY LEGISLATION. 

of which naturally should come forth the middle class, that it would be 
to the haciendados own interest to make a pure and wholesome drink of 
it; teaching and compelling them to do so, since they, through their 
negligence, do not act by themselves as they should. 

It is a matter of no less importance and urgence to regulate the 
practice of medicine in Mexico. Our society is seriously afflicted by 
the ever increasing rush of quacks who on account of our Uck of 
legislation on the matter, find here their paradise; the invasion of 
audacious unlearned and unskilled charlatans, who mistify credulous 
people, taking advantage of the fascination resulting from a foreign 
name, a fictitious diploma and illegitimate advertising. Such a calam- 
ity makes itself felt not only directly upon the largest part of the com- 
munity, who by the very reason that tfiey pay their taxes are entitled 
to be prQtected by the government who ought to prevent that people 
not able to judge by themselves, be led into error by brilliant false- 
hoods ; but it also indirectly does harm to the true physicians, who are 
contaminated by the evil in view of the easily acquired profits due to 
those vicious proceedings. All of them deserve protection ; the former 
in their health and interests and the latter in their decorum. 

In the sacred name of public health, France, mad with liberty, cut 
off thousands of heads. Why in the name of the same sacred principle 
taken this time in its true and rightful sense, should not Mexico, wise 
and provident, should be allowed to shut its gates to harmful quacks ? 
A department of public health could use its valuable influence to 
show and correct the evident contradiction which is now so very prom- 
inent, between the remarkably paternal character of our laws and that 
liberty of asking for help in such a delicate matter as health is, to 
those impostors; a liberty only similar to the one that would be al- 
lowed to a ship captain for giving up his vessel into the hands of a non- 
licensed pilot. 

With the same provident power which checks evil and promotes 
welfare in matters of such undeniable interest, the department to 
which I refer could start in Mexico the establishment of the Red 
Cross Society, a benevolent institution so widely known throughout 
the world, from which we would immediately draw the priceless ad- 
vantage of opening new and splendid fields of activity for the Mexi- 
can woman, so suitable on account of the brilliancy of her mind and 
her natural devotion to the fulfillment of her duties, to exercise that 
important profession which in English is called by the sweet name of 
"nurse," a name that up to the present time has no proper equivalent 
in Spanish, a very expressive name which rightly conveys the idea 



NATIONAL AND INTERNATIONAL SANITARY LEGISLATION 37 

of the tender eagerness which is so necessary for taking proper care 
of the sick. 

It wotdd be an endless task to merely point out all the other ad- 
vantages which would be derived from the improvement of our present 
board of health by its promotion to the rank of a department of 
State; in fact this institution only wants some finishing strokes for 
readiing the summit we desire, and to this end everything seems 
to be in readiness. 

Allow me before closing to merely mention another important ad- 
vancement; it is one of an international character. The promotion of 
said board to the rank of a department of State would make of it a 
model institution, which would probably be in a near 'future adopted 
by the United States, for their welfare as well as for ours, taking into 
account the close and friendly relations which bind the two countries. 
And I think there should be no objection whatever to Mexico being, 
at least once, a leader instead of a follower. 

Honorable gentlemen: Goethe in the last moments of his fight for 
life asked for light, light and more light; so we, in our anxiety for 
health, ask for more light and more power granted to the institution 
in charge of protecting public health in each one of the countries so 
well represented in this honorable assembly. Let these ideas so lofty 
by themselves but so poorly expressed, be like the spark starting a fire 
from which light will be produced. 



YELLOW FEVER. 
Dr. EDUARDO LICEAGA, Mexico, D. R, Mexico. 

Once more I come to comply with the engagement I assumed with 
this Association from the year 1893, to report yearly on the progress 
of yellow fever throughout the whole of the Mexican Republic. The 
data presented in this paper, cover the period from the i6th of Sep- 
tember, 1905, to the present date. 

In the campaign undertaken against yellow fever, the sanitary 
authorities of Mexico have strictly adhered to the doctrine which was 
laid down by the American physician, relative to the transmission of 
this disease by means of the Stegomyia mosquito; but modifications 
have been introduced in the practical application of that doctrine to 
the crusade against the disease. This campaign includes the measures 
ordered and followed with great perseverance by what we may call 
the official element, such as those which are intended to inculcate on 
all classes of society, the doctrine of the transmission of the disease, 
and of the efficient means for combating the same. 

The official element consists of the staflf that was appointed by the 
Federal Government with an appropriation from the national reve- 
nues, together with the contribution which was furnished by the states 
of Veracruz and Yucatan, in which yellow fever has existed for many 
years past in an endemic form.' 

Before going any further, I want to pay a debt of gratitude to the 
states of the Mexican union which delegated their authority to the 
Federal Government in all matters relating to the struggle against 
yellow fever. This splendid example was first given by the western 
states which occupy the vast extent of our Pacific littoral, when dur- 
ing the winter of 1902 and the spring of 1903, the bubonic plague 
developed in the port of Mazatlan of the state of Sinaloa, and the 
same example has been given, for the purpose of combating yellow 
fever, by the states of Oaxaca and Chiapas, on the same coast, and 
by those of Tamaulipas, Veracruz, Tabasco, Campeche and Yucatan, 
on the Mexican Gulf Coast. I can never weary of praising the patri- 
otic conduct of those states, which have not considered that they 
prejudiced their sovereignty by resigning their authority into the 
hands of the Federal Executive, in sanitary questions which inter- 
ested the entire country. 

Thanks to this highly efficient co-operation, and to the acquiesence 

38 



YELLOW FEVER. 39 

of the states I have just referred to, the action of the Federal Exe- 
cutive is exercised in a direct manner in all the localities which were 
invaded by yellow fever during the epidemic of 1903, and in the old 
foci of endemia which are found in the states of Veracruz and Yu- 
catan. 

The map which you have before you, shows with red points the 
places in which the Supreme Board of Health had sanitary brigades 
working up to the 31st of October last, in accordance with the plan 
adopted for the suppression of the disease during the summer. 

As no case of yellow fever has been observed in Tampico since the 
3rd of November, 1903, we have confined ourselves there to reinforcing 
the delegation and establishing the defense against sea importations 
by removing the sanitary station to the bar at the mouth of the River 
Panuco. 

In Veracruz, which has been a focus of endemia for the last three 
centuries, we have established one of the most important services, 
dividing the city into districts according to the number of non-immunes 
who reside in the different parts. 

There is a physician in charge of each one of these districts, with 
a competent number of sanitary agents and servants, which staff is 
occupied in preparing a schedule of the non-immunes, and making 
periodical house to house visits in order to discover all sick persuns 
from the first moment, who are at once isolated; in inspecting and 
cleaning the water tanks and other deposits which may contain larvae, 
spreading oil on the largest and draining those which cannot be so 
covered, and lastly, in disinfecting the dwellings in which confirmed 
or suspected cases of yellow fever are observed. These operations are 
carried out in the manner indicated in my report of last year; but 
naturally, experience has taught some slight modifications that in- 
crease the efficacy of the service. For the information of those who 
were not present at our meeting in Boston, I will here state afresh, 
the methods in which we have introduced some innovation, over those 
which are adopted in other countries as follows: 

I. We form a schedule of the non-immunes. 

II. We visit them day by day in their houses, in order to discover 
any sick person on the same day on which the disease commences. 

III. We use no mosquito curtains, because they would be ineffic- 
ient for the purpose of isolation, but we at once place the patients 
in wards that are previously fumigated, supplied with wire gauze 
windows and double wire gauze doors. 

IV. In order to ascertain that the disinfection has been efficacious, 
we place "witness mosquitoes'' under the most unfavorable conditions 



40 



YELLOW FEVER. 




YELLOW FEVER. 41 

possible, where they can be reached by the action of the disinfectant. 
If, on terminating the operation, these mosquitoes are found dead, 
we can then feel certain that the disinfection was well carried out. 

V. We take measures to prevent the escape of the mosquitoes from 
the dwelling or room which is to be disinfected, even though it may 
only be a hut with walls and roof built of branches, grass, or other 
permeable material. 

VI. We have sanitary agents traveling on all trains that run be- 
tween the towns in which cases of yellow fever have been observed, in 
order that the passengers who are sick or suspected may be isolated 
before they reach the town which has not been invaded. 

A small epidemic developed in Merida, as shown in the respective 
diagram, and after a study of its origin, it was found that the staflF 
which composed the brigade assigned to that town was insufficient 
to make the house to house visits and the destruction of the larvae in 
the 30,000 small water tanks which are in that city. In view of these 
deficiencies the staff was increased, and the good results of that mea- 
sure were demonstrated by the fact that even the sporadic cases which 
extended up to the first weeks of October last have now disappeared, 
and I can assure this Association, that since the 25th of that month, 
not a single case of yellow fever is to be found in any part of the 
Mexican territory. In Merida the service is at present carried out by 
four physicians who are charged with the supervision of the districts 
into which the city is divided, with a staff of 28 agents and 38 ser- 
vants, for which purpose we can count on the resources of the federa- 
tion and the powerful support of the governor of the state and other 
local authorities. 

As I do not wish to enter into details regarding the methods of 
working employed by each one of the brigades assigned to the cam- 
paign against the disease I am treating of, because that would give 
this paper an unreasonable length, I will confine myself to the state- 
ment, that each one of those brigades carries its activity to a longer 
or shorter distance, and that besides those which have been estab- 
lished in diflferent places, a flying brigade was organized, which is im- 
mediately transported to any place in which a suspected or confirmed 
case of the disease makes its appearance. 

There were brigades in Veracruz, Merida, Progreso, Coatzacoalcos, 
Santa Lucrecia, Tehuantepec, Salina Cruz, Tierra Blanca, and Cor- 
doba, which worked over the railroad lines of the Isthmus of Tehuante- 
pec and of the Veracruz and Pacific Railway, whilst the flying brigade 
extended its action to Tuxtepec and Valle Nacional, on the one side, 
and to Qmealca, Montzorongo, Cordoba and Orizaba on the other. 



42 YELLOW FEVER, 

In each of the railroad stations, persons were placed to watch the 
arrival of trains, and traveling sanitary agents incessantly traveled 
on the trains between Veracruz, Cordoba, Tierra Blanca, Santa 
Lucrecia, Coatzacoalcos, Tehuantepec, Salina Cruz, Merida and 
Progreso. 

Temporary hosjHtals have been distributed in such a way that all 
persons who are discovered with fever on the trains or anywhere else, 
can at once be taken to them. 

Since the first of November last, and in view of the fact that not 
a single case of yellow fever could be found in any part of the Mexican 
Republic, the services have been reorganized as follows: 

In Veracruz, Merida and Progreso, the brigades continue their 
service with the same resources that they had during the past summer. 

In order to attend to the emergencies which may arise during the 
winter months, three flying brigades have been organized, whose 
respective head quarters are in Tuxtepec, Coatzacoalcos, and Salina 
Cruz. The first is intended to watch over the zone which extends 
from Tuxtepec to Valle Nacional on the one side, to Cordoba on 
another, and to Santa Lucrecia on yet another, including the entire 
length of the Veracruz and Pacific Railway. The brigade in Coatzaco- 
alcos will attend to the zone which is included between the port and 
Santa Lucrecia, which is half way across the isthmus, and is also a junc- 
tion between the Tehuantepec Railway and the Veracruz and Pacific 
Railway, whilst the third brigade, with its headquarters at Salina Cruz, 
will take care of the zone which extends between that port and Santa 
Lucrecia above referred to, with special attention to the towns of 
Tehuantepec and San Geronimo, the latter of which is the terminus 
of the Pan American Railway. The map which I present will give a 
better idea of the distribution of these flying brigades and of their 
radii of action, which is shown by the different points with which 
each brigade is distinguished. 

What I have just said, includes the official organization of the 
campaign against yellow fever. 

In order to interest all classes of society in tHe campaign I here 
treat of, circulars have been addressed to the local authorities and 
physicians who practice in those places in which yellow fever has 
appeared; to the railroad companies and railroad constructors, to the 
agriculturists, principally to those who are coffee planters and wha 
contract laborers for their work who are brought down from the cen- 
tral table land of Anahuac, and are therefore non-immune to yellow 
fever; and finally, popular instructions have been addressed to all the 
inhabitants of those regions, in which they are given a knowledge of 



YELLOW FEVER, 



43. 



the doctrine of the transmission of yellow fever by means of the mos- 
quito, of the efficient resources which they have at their disposal, o£ 
the way to isolate sick persons from the moment the fever conraiences,. 
of the methods to be employed in destroying the larvae of the mos- 
quitoes as well as those which might be infected. I take pleasure 
in presenting to the members of this Association, copies of the circu- 
lars and instructions I have above referred to, and I beg very strongly 
to reccttnmend to the consideration of our Mexican colleagues, the de- 
sirability of spreading the knowledge which we have acquired through- 
all classes of society, in order that all may co-operate in the destruc- 
tion of the larvae of the mosquito and in the prompt declaration of 
the non-immunes who may be suflfering from fever, whatever may 
have been its origin. 

I hope that all my Mexican colleagues, and more especially those 
who are practicing on our Gulf coasts and through the Isthmus of 
Tehuantepec, will take pains to spread this knowledge in their 
respective localities, thus contributing to the patriotic end of driving 
yellow fever out of our country and to the humanitarian end of driving 
it oflF the face of the earth. 

I also present a numerical table which represents the cases and 
deaths from yellow fever which have appeared from the i6th of 
September, of last year, up to the present date, and by means of a 
magic lantern, I will throw a diagram that covers the same dates. 

Yellow Fever in Mexican Republic. 



Cities. 



States. 





us 


s 


6 




rt 


6 


(S 


1 


1 


6 


2 


49 


34 


5 


5 


9 


1 


16 


7 


2 


1 


6 


3 


17 


8 


8 


7 


48 


27 


132 


72 


1 


1 


3 


1 


303 


150 



Last Case Reported. 



Salina Cruz (*) . 
Tehuantepec (*) 

Tuxtepec 

Cordoba 

Coatzacoalcos ... 

Omealca 

Orizaba 

Soconusco 

Tezonapa 

Tierra Bknca .. 

Veracruz 

Merida 

Progreso (*) ... 
Valkdolid 



Oaxaca . 

M 
U 

Veracruz 



Yucatan 



ToteL 



March 27, 1906. 
March 31, 1906. 
October 8, 1906. 
December 12, 1905. 
December 8, 1905. 
October 16, 1905. 
January 7, 1906. 
October 19, 1905. 
December 6, 1905. 
September 25, 1906. 
September 28, 1906. 
October 25, 1906. 
August 8, 1906. 
September 7. 1906. 



* The cascfl of yellow fever in Salina Cruz, Tehuantepec and Progreso, were imported. 



TO WHAT EXTENT ARE INFECTED MOSQUITOES PRES- 
ENT ON SHIPBOARD? 

Dr. a. H. doty, Health Officer, Port of New York. 

It was formerly believed that clothing, bedding and other textile 
fabrics and also certain articles contained in the ship's cargo were 
active agents in the transmission of yellow fever and in accordance 
with this belief thorough disinfection was regarded as one of the most 
important means of preventing the extension of this disease. We now 
know that yellow fever is transmitted only by a variety of mosquito 
known as the Stegomyia and that disinfection in connection with the 
treatment or prevention of yellow fever is unnecessary. The relief 
thus extended to commerce can only be fully appreciated by those who 
are practically familiar with quarantine work. Unfortunately however 
our present knowledge of this disease with the consequent changes in 
quarantine regulations has not entirely relieved commerce of the 
serious detention of vessels and their cargoes and also of passengers 
and crews, as at some seaports it has been deemed necessary to treat 
vessels coming from yellow fever areas with sulphur dioxide, formal- 
dehyde, etc., for the purpose of destroying presumably infected mos- 
quitoes on shipboard. This procedure at times becomes almost as much 
of an obstruction to commerce as the methods of disinfection formerly 
employed. While there can be no just criticism of reasonable quar- 
antine regulations instituted for the protection of the public health, 
the serious delay and expense to commerce, which the treatment re- 
ferred to involves, is not justifiable if such action is based on theory 
alone. 

Public health officials are apt to forget that modem sanitation 
does not and cannot guarantee one hundred percent of safety. Eflforts 
to do this are largely dominated by theory and are certain to cripple 
commerce, alienate the support of the public and defeat the end in 
view. 

Whatever difference of opinion may exist among sanitarians regard- 
ing the danger from infected mosquitoes on shipboard, it is certain 
that this subject has not received practical and scientific consideration, 
although it is one of the most important factors with which we must 
deal in the prevention of yellow fever. Therefore it is very necessary 
that all who are associated with quarantine work should present their 
experience in regard to this matter in order that we may arrive at 
some definite and satisfactory conclusion. 

44 



INFECTED MOSQUITOES ON SHIPBOARD. 45 

The port of New York probably receives one-half or more of all 
foreign vessels coming to the United States. A large number of these 
are constantly arriving from yellow fever ports, consequently the 
records presented by the New York Quarantine Station regarding the 
presence of infected mosquitoes on shipboard must be accepted as 
valuable evidence in this direction. Besides the Stegomyia is not under 
ordinary conditions fotmd in this section of the United States and 
therefore yellow fever does not propagate here. This condition would 
more clearly serve to identify the origin of a case of this disease than 
in a community within the yellow fever zone where it is known to 
propagate. 

The official history of the outbreaks of yellow fever occurring in 
New York, between 1793 and 1822, a copy of which is in my pos- 
session, presents reasonable evidence that the disease was introduced 
into this city from sailing vessels arriving principally from Cuban 
ports. It is shown that the outbreaks referred to were closely associ- 
ated with the arrival of vessels from infected ports frequently having 
on board presumably yellow fever, or a history of one or more mem- 
bers of the crew having died of this disease, while in transit during a 
long and tedious voyage. The subsequent appearance of yellow fever 
among the residents of houses situated on the water front in the 
immediate vicinity of wharves where these vessels were docked indi- 
cates that vessels coming from infected ports not only brought this 
disease but also infected mosquitoes and breeding places on board. 
The official reports constantly refer to the perishable, decomposed and 
oflFensive cargoes and also the offensive bilge water which was found on 
these vessels. This material was usually thrown overboard or pumped 
out at the wharf on arrival in New York. In Dr. Townsend's official 
report of the outbreak of yellow fever in New York in 1820 he says: 
"We have direct and positive proof that two of these vessels, at least 
those in which several of the crew died, contained the poison in all its 
virulence." The severity of some of the outbreaks of yellow fever in 
New York and Philadelphia may be shown by the mortality which 
occurred and which is shown in a report made by Dr. Hardie in 1798: 

Year. Deaths. 

Philadelphia 1793 4041 

New York 1795 732 

New York 1798 2086 

Philadelphia 1798 3506 

Also Dr. Townsend's report: 

New York 1803 606 

After 1803, and until 1856, outbreaks of diminishing severity quite 



A6 INFECTED MOSQUITOES ON SHIPBOARD, 

frequently occurred in New York, Philadelphia and other ports in this 
section, and then none again until 1870, when a very limited out- 
break appeared. Since that period there have been no outbreaks of 
yellow fever in New York or in this vicinity, although persons who 
have been infected in other ports have developed the disease here. 
Official reports also present evidence that yellow fever appeared in 
epidemic form in New York City as far back as 1700, and that these 
outbreaks were associated with great loss of life. It is shown, how- 
ever, that after 1822, the outbreaks were less formidable and 
that since 1870, a period of thirty-six years, no outbreaks have oc- 
curred here. The striking significance of this lies in the fact that this 
change, or the disappearance of outbreaks of yellow fever in this 
section has taken place in the face of an enormous increase in the 
commerce between New York and yellow fever ports. In analyzing 
this subject we must bear in mind that the Stegomyia or yellow fever 
mosquito for some reason is not found in this section of the United 
States, although the outbreaks in this city already referred to furnish 
proof that if the Stegomyia is brought here in sufficient number, or in 
the larval form, its propagation during the warm weather may follow. 
However there is good reason to believe that it is not perpetuated in 
this section by hibernation during the winter months, either in the 
form of the egg, larvae or winged insect, but disappears in the fall and 
reappears only in the form of a fresh importation. 

Careful investigation has also shown that the Stegomyia is a home 
mosquito and remains in close proximity to its breeding place. 

There can be no doubt that in the early period and under the con- 
ditions already referred to infected and non-infected Stegomyia fre- 
quently existed on shipboard. There is equally good evidence to show 
that the danger from this has gradually disappeared and that the 
presence of infected mosquitoes on shipboard is now of rare occur- 
rence. I believe that the explanation of this change is as follows : 

The commerce between this country and foreign ports was formerly 
carried on by sailing vessels, which usually remained in port for a 
long period in order to secure a full cargo. Their sanitary ccHidition 
was almost always bad and their cargoes frequently consisted in part 
of perishable material and the hold of the vessel contained more or less 
water, which furnished breeding and feeding places for the mosquitoe. 
The residential portion of Cuban, as well as other seaport towns, in ear- 
lier times was commonly along the water front. Therefore, a vessel and 
its crew became practically a part of the community and there was no 
reason why the breeding places of the mosquito, and also infected mos- 
quito, should not have been found on these vessels, nor if yellow fever 



INFECTED MOSQUITOES ON SHIPBOARD. 47 

existed at these places why members of the ship's crew should not 
have contracted it, and subsequently transmitted it to others on shore 
or on shipboard. There can be no doubt that these vessels on their 
arrival at New York after a long voyage frequently brought with 
them cases of yellow fever, infected mosquitoes, and also breeding 
places for the mosquito and it is not difficult to understand why people 
living along the water front in the vicinity of the docks where these 
vessels were moored should have been infected inasmuch as cases of 
yellow fever, infected and non-infected mosquitoes and their breeding 
places were transferred to the shore from the vessel. 

It is also significant that the outbreaks of yellow fever in New 
York, Philadelphia and other ports in this section of the United States 
practically disappeared when a radical change took place in the char- 
acter of vessels engaged in commerce. Sailing vessels were replaced 
by steamers, which made quick voyages, were kept in comparatively 
good sanitary condition and with little or no opportunity for mosquito 
breeding on board. In late years as the result of the great increase 
in commerce, the water front at the different ports have been appro- 
priated for docks, storehouses, etc., and the residential portion of these 
towns have been driven further into the interior. As it is in the latter 
section that yellow fever appears, and as the Stegotnyia remains in 
close proximity to its home, it is reasonable to suppose that infected 
mosquitoes from the shore do not often reach vessels lying at the dock; 
besides great advances have been made in the enforcement of sani- 
tary regulations for the protection of the public health which in many 
ways tend to make the presence of infected mosquitoes on shipboard 
of rare occurrence. 

An occasional account is given of the appearance of one or more 
cases of yellow fever, believed to be due to the presence of infected 
mosquitoes on shipboard. That it is possible for this to occur, I am 
quite sure no one doubts, but I am satisfied that it occurs in rare 
instances only. Those which are regarded as secondary cases of 
yellow fever on shipboard are not infrequently reported on the arrival 
of vessels at this station. Thus far in each instance either the clinical 
evidence or blood examination have shown them to be malarial fever 
or some other disease. It is noticeable that since blood examinations 
have been made to determine the presence of malarial fever reports of 
cases of yellow fever, due to the presence of infected mosquitoes on 
shipboard are not common. 

Many vessels arrive at New York from Cuban, South American 
and other ports where more or less yellow fever is almost continually 
present. To my personal knowledge not a case of yellow fever has been 



48 INFECTED MOSQUITOES ON SHIPBOARD, 

removed at this place from an incoming vessel during the past twelve 
or fifteen years^ the infection of which could not be traced to the 
port of departure. During this period yellow fever existed in Rio 
Janeiro and Santos in an epidemic form ; however, no case of this dis- 
ease has reached here on vessels constantly arriving from these ports^ 
although evidence has been presented by the surgeons or masters of 
these vessels to show that within three or four days after leaving 
the above ports, cases appeared which from the history submitted were 
evidently yellow fever. These usually proved fatal after an illness of 
three or four days, but in no instance have cases of this character ever 
reached this station from the section just referred to. It may be 
stated that these vessels are about three weeks in transit, which would 
give sufficient time for infected mosquitoes on shipboard to transmit 
the disease. Vessels from these ports have often arrived with sus- 
picious cases on board, but in every instance careful investigation has 
proven that they were not yellow fever. Does it not appear strange 
that if yellow fever not infrequently occurs on shipboard as a result 
of the presence of infected mosquitoes that some evidence of it is not 
presented at this port. Further evidence that infected mosquitoes are 
rarely found on shipboard is shown by the fact that vessels which 
carry many passengers are daily arriving at New York from Havana 
and other Cuban ports. Cases of yellow fever have frequently been 
removed from them, but in no instance has the disease subsequently 
appeared among those who were fellow passengers, or members of the 
crew of said vessels and the disease in all cases has appeared within 
six days after leaving the infected port. If infected mosquitoes invade 
vessels, why during this long period with thousands of passengers 
coming from infected areas to this port, has not some evidence been 
presented to indicate their presence? The passengers on these vessels 
are mainly New Yorkers, or residents of other sections where yellow 
fever does not propagate and the crews are more or less permanent 
and under close observation. Therefore if yellow fever subsequently 
occurred as the result of infection on shipboard, ft would I am quite 
sure be detected. 

It has been stated that infected mosquitoes are sometimes con- 
cealed in the cargoes of vessels particularly of those carrying bananas, 
and that by this means the disease has been introduced into seaports. 
It has been suggested that recent outbreaks in New Orleans and 
Havana occurred in this way. For many years vessels have been arriv- 
ing at New York from Central American and other ports with cargoes 
of bananas and other fruit, but in no instance has evidence been pre- 
sented to show that those who have unloaded these <3irgoes, or have 



INFECTED MOSQUITOES ON SHIPBOARD. 49 

had to do with the vessel while here have contracted yellow fever. As 
I have already stated, evidence presented at the port of New York is 
of more value in deciding this question than evidence presented at 
New Orleans, as the appearance of yellow fever among men employed 
in New York to unload a fruit vessel from an infected port would be 
reasonable evidence that it was contracted from infected mosquitoes- 
on shipboard inasmuch as yellow fever does not propagate in New 
York and there would be no reason to believe that there was any other 
way of contracting it providing the patient had not been out of the 
city. On the other hand a person in New Orleans employed in unload- 
ing fruit vessels probably would be exposed to other means of con- 
tracting the disease, inasmuch as New Orleans is in the so-called yellow 
fever belt and it has been shown that the disease has frequently existed 
in different sections of the said city unknown to the authorities. So far 
as the danger from infected mosquitoes in baggage, packages, etc., is 
concerned, I may say that careful and thorough investigation was 
made at the New York Quarantine Station regarding this point. 
Boxes, canvas bags and other receptacles were filled with clothing, bed- 
ding, etc. Mosquitoes were introduced, which were secured with great 
care from horses taken to mosquito infested districts for this purpose. 
The mosquitoes were captured while on the horses by placing over 
them glass test tubes. These tubes containing the insect were very 
soon afterwards introduced into the packages referred to and care- 
fully withdrawn in order to release the mosquitoes without injury — 
at least less injury to them occurred in this way than would follow 
their imprisonment during the process of packing. An accurate ac- 
count was kept of the number of mosquitoes in each package and 
although many of these tests were made covering over a period of 
three or four months, it was found that in no instance did the mosqui- 
toes survive after a confinement of thirty hours. 

If infected mosquitoes reach vessels lying at yellow fever ports and 
constitute a menace to those on board, or at the port of destination, is 
it not imperative that efforts should be made to destroy them at the 
time of departure from an infected port or promptly afterward instead 
of at the port of destination, and thus avoid the danger of infection 
which delay of this treatment would involve? Furthermore if this 
treatment is necessary, in what manner are we to determine in which 
apartments on shipboard the presumably infected mosquitoes are con- 
cealed? If this cannot be done, is it not necessary then that every 
apartment should be similarly treated? This manner of treatment I 
am satisfied is not carried out. Any agent, such as sulphur dioxide, 
which could be depended upon to destroy mosquitoes, is incompatible 

4 



60 INFECTED MOSQUITOES ON SHIPBOARD. 

with respiration in the human being. Furthermore in a large steam- 
ship containing first, second and third cabin accommodation, forecastle 
for crew, holds, ets., the apartments are so numerous and so freely 
opening into the external world that to properly seal them and carry 
out the treatment referred to would entail such expense and delay that 
it would cripple commerce fully as much if not more than the disinfec- 
tion formerly required. If this treatment is necessary, and if it is not 
properly performed there is good reason for just censure. 

It has been recommended that sulphur dioxide or formaldehyde be 
introduced into the hold before the cargo is removed to destroy what 
mosquitoes may be present there. Those who are practically familiar 
with ship disinfection know that this cannot be done, and that neither 
the cargo or hold of a vessel can be properly treated or disinfected until 
after the former is rem^ytii. ^ ' 

When we consider rfig-feubj^et from a prA^ical standpoint it will be 
appreciated that the/ treatment of a vessel tk insure destruction of 
mosquitoes which ar4 presumed to be on boam is an exceedingly for- 
midable and expensiVe^ action -^involvinjg a iong delay both to com- 
merce and the traveling'^^^ic and should' tc required only when there 
is satisfactory evidence that Itinrecessary. The theory that infected 
mosquitoes are concealed in vessels and their cargo and thereby con- 
stitute a menace to the public health derives its support largely from 
the fact that outbreaks of yellow fever, the origin of which is unknown 
not infrequently appear in seaports. In these instances the theory 
above referred to offers an easy explanation of the presence of the 
disease. I believe that outbreaks of this kind are due to mild, ambu- 
lant or unrecognized cases and that the methods which have been em- 
ployed in the past for the examination of those arriving from yellow 
fever infected ports are not sufficiently thorough to detect the pres- 
ence of these cases. Each year furnishes additional evidence of the 
truth of this statement. Furthermore we must bear in mind that evi- 
dence of this disease does not always present itself prior to the fifth 
day. During the summer of last year (1905) a number of cases of 
yellow fever was removed at this station from vessels arriving from 
Colon. These vessels are usually seven days in transit Three of the 
cases removed presented themselves at the inspection of the vessel on 
its arrival, stated that they were well and had not been side during 
the voyage. This was somewhat confirmed by the fact that they 
appeared at the breakfast table on the morning of their arrival at the 
New York Quarantine Station. However, when the thermometer was 
used, it was found that their temperatures were considerably above 
normal and they were removed for observation. Two of the cases died 



INFECTED MOSQUITOES ON SHIPBOARD, 61 

within four days after removal to Swinburne Island Hospital. These 
persons after reaching the hospital frankly admitted that they had not 
been feeling well for two or three days. Cases of this character cannot 
be regarded as uncommon. The fact that the disease may not be ap- 
parent or may be concealed until the seventh or eighth day undoubtedly 
gives rise to the theory that infection may have been communicated on 
shipboard. 

Persons arriving at New York on vessels from yellow fever infected 
ports are subjected to the most thorough and careful investigation. 
Those who do not present satisfactory evidence of inununity arc 
removed for observation provided the vessel has not been five days or 
more in transit from the last infected port and then are only released at 
the expiration of the fifth day from the time of departure provided their 
temperatures are normal and they are otherwise well. Even if the 
vessel has been five days or more in transit and all on board are well 
the thermometer is used and those whose temperatures are above 99I, 
or those who present any symptoms of illness are removed for ob- 
servation. Neither the vessel or its cargo is subjected to any treat- 
ment whatever. This has not been done even when yellow fever 
exists on shipboard and no effort is made or would be made to destroy 
mosquitoes unless a vessel had been a long time in transit and there 
was reasonable evidence that secondary cases had occurred as a result 
of the presence of infected mosquitoes, then the most careful and thor- 
ough treatment would be carried out. This condition has not yet pre- 
:8ented itself. 

I believe that the facts do not justify us in crippling commerce and 
ousing detention of persons by attempts to destroy presumably in- 
fected mosquitoes on vessels arriving from yellow fever infected ports 
unless in each instance where this treatment is proposed there is reas- 
onable evidence that infected mosquitoes are present. I further 
believe that a more thorough inspection should be made of all persons 
arriving from yellow fever infected ports to discover the presence 
of mild or irregular cases of the disease which so far as the public 
health is concerned constitute one of the most dangerous factors with 
"which we have to deal. 



A SHORT ACCOUNT OF THE SANITARY DEPARTMENT 
OF THE ISTHMIAN CANAL COMMISSION. 

W. C GORGAS, 

Assistant Sukgeon-General U. .S Army, Chief Sanitary Officer Isthmiait 
Canal Commission^ Ancon, C. Z. 

I though it might be interesting to describe, briefly, the organiza- 
tion of the sanitary department, our aims, and what we actually had 
accomplished. 

The prime object of our sanitary work in going to Panama, was the 
eradication of yellow fever, and after eradicating it, to keep it out. 
Secondly, to limit malaria as much as possible. And beyond tfais^ 
to improve the general health conditions of the force, so that the 
canal might be built in this tropical jungle with as little loss of life 
as might be. 

To accomplish these objects, practically, requires an organization 
with many more ramifications, than one would at first think, and 
many more branches than would be necessary in any similar depart- 
ment at home. 

We have to care for all the sick, look after all contagious diseases 
here, maintain quarantine at the two ports, provide health depart- 
ments for the towns of Panama and Colon, and similar departments 
for the small towns along the Zone; see to the disposal of garbage 
in all these places, and also all night soil; look after the drainage 
with regard to mosquito breeding, etc., etc. 

To accomplish these objects, the Sanitary Department at present 
is divided into the following bureaus : 

A Quarantine Bureau which has charge of the maritime quarantine 
at Colon and Panama. Its duties are to prevent the introduction of 
infectious diseases from the outside, and this more particularly applies 
to yellow fever on the Atlantic Coast, and yellow fever and bubonic 
plague on the Pacific Coast. 

This bureau has been organized under the supervision of Doctor 
Perry of the Public Health and Marine Hospital Service, who has 
in his bureau a force of three physicians and about 30 other employes. 
We have a well equipped quarantine station at Panama, with a good 
disinfection barge and launch for boarding purposes, and a detention 
hospital of some 50 beds. At Colon we have a detention hospital of 
some 200 bed capacity, and tentage capable of holding some 600 more 



THE ISTHMIAN CANAL COMMISSION 5S 

This, so far, has sufficed for all our needs. We allow no non-immunes 
to come in from ports around us, infected with the yellow fever, un- 
less they have passed six days from leaving the port. With regard 
to bubonic plague, we require a five day period from an infected port. 
Infected ships are disinfected or fumigated, but not detained. 

Second: The Health Bureau of Panama. This bureau is super- 
vised by Doctor Pumell, the health officer of the city. Doctor Pur- 
nell is well known in Mississippi as a health officer, and has had long 
experience in these matters. He is assisted by three physicians, and 
has under him a force of some 300 men. This bureau has a sub- 
division which does the street cleaning, and attends to the removal 
of garbage; another which attends to the house cleaning and the 
cleaning of the yards. We require house holders to keep their own 
property clean, but if after being fined, the premises are not cleaned, 
we put our men in to do the work, and charge it to the property. 

Another division for the free distribution of water: In 
this work we have 15 carts constantly employed. There are a 
considerable number of houses in Panama which have not yet been 
supplied with water. We have agreed with these people, that as we 
destroy their receptacles for containing rain water, we will supply 
them with a fixed amount of water. 

Another division, the Stegomyia Brigade: This division makes 
semi-weekly inspection of all premises, to look after the breeding of 
Stegomyia, and reports upon the premises with regard to its con- 
ditions. 

The Anopheles Brigade: This brigade looks after all the outside 
mosquito work, such as filling holes, removing tanks, looking for 
cesspools, making and cleaning ditches, oiling wells and pools, cutting 
grass and similar work. 

The Disinfection Brigade: This brigade looks after all disin- 
fections and fumigations. We disinfect for tuberculosis, pneumonia, 
beri-beri, smallpox, leprosy, t)rphoid fever and dysentery, and fumi- 
gate for yellow fever. 

We have had no cases of yellow fever in Panama, since November, 
1905, but a year ago from the present time, we had over 400 men in 
this disinfection brigade, and have used in Panama somewhat over 
a hundred tons of pyrethrum and 200 tons of sulphur. 

The Sick Inspection Division visits every house in Panama, where 
a non-immune lives, daily. If a non-immune is sick, the fact is re- 
ported to the office and a doctor is sent to see what is the matter. . 

Third: Health Bureau for the City of Colon: At the head of 
the bureau is Doctor Ernest Wheeler, formerly of the volunteer 



M THE ISTHMIAN CANAL COMMISSION. 

medical service of United States Army. He has with him one 
physician and some 300 men. The organization is the same as that 
for Panama, with such exceptions as local condition render necessary. 
Colon being built over a swamp, we have to have the dry earth system 
of closets for the disposal of night soil. This requires a division with 
a considerable number of men, which is not needed in Panama. 

Fourth: The Health Department of the Zone. This takes in all 
the territory of the Canal, except the area occupied by the towns of 
Colon and Panama. It is a territory 50 miles long, about, and ten 
miles wide, and contains a population of some 40,000 people. It is 
supervised by Mr. J. A. Le Prince, who had charge of similar work 
in Havana, Cuba. He has under him some 20 inspectors and 850 
men. This department is divided into some 15 districts and each of 
these districts has about the same organization that we have at Colon 
and Panama, except, of course, on a much smaller scale. The towns 
and laborers camps along the Canal route are really country villages. 
The principal sanitary work is the ditching and keeping down the 
luxurious vegetation, but at the same time the water supply has to be 
attended to, removal of night soil, garbage collection, etc. 

Along the Zone there is very little breeding of Stegomyia, so that 
we do not have to have a Stegomyia Brigade in this department. On 
the other hand, the breeding of AfWpheles in our many camps and 
villages is very extensive, and the Anopheles Brigade makes up more 
than half the force in this bureau. All the cemeteries of the Zone 
are controlled and maintained by this bureau, so that our knowledge 
and record of deaths occurring is absolute. We, however, get death 
reports from several other sources. 

Eventually the commission expects to have all these villages and 
camps supplied with water and sewered, but until this can be done, 
we can get along very well with pit closets, and the dry earth system, 
and the various local water supplies which were used by the French. 
At present we have a large reservoir at the head waters of the Rio 
Grande River. This supplies everything from the divide to, and 
including the city of Panama, some 12 miles of Canal line. On the 
Atlantic slope from Culebra to Colon, we have three other reservoirs 
made by damming the head waters of streams which run into the 
Chagress. This will supply all the country between the divide and the 
Caribbean Sea including the city of Colon. They furnish excellent 
water. 

Fifth: The Bureau of Hospitals: This bureau is supervised by 
Dr. Henry R. Carter of the PubUc Health and Marine HosfMtal 
Service, who has under him some 80 physicians. In the department 

Along the 2tone there is very little breeding of stegomyia, so that 



THE ISTHMIAN CANAL COMMISSION. W 

we have at present about 2,000 beds, which are distributed among 
several hospitals. A large hospital at the Pacific end and located on 
a mountain just back of the city of Panama, Ancon Hospital, 520 
beds. This hospital is well equipped for all kinds of work with a 
sufficient corps of physicians and trained female nurses from the 
United States to look after the sick. 

Colon Hospital, 550 beds, located at the Caribbean end of the 
Canal, in the town of Colon, built over the sea, raised on piers, and 
getting the full benefit of the Atlantic breeze. 

Miraflores Hospital, 250 beds, located at the town of Miraflores, 
on the railroad, about six miles from Panama. This was formerly 
one of the French towns. The whole town has been turned over to 
the Sanitary Department and is used exclusively for hospital purposes. 

Taboga Hospital, 60 beds. This is a hospital for convalescence. 
It is located about 12 miles from shore, in Panama Bay, on the Island 
of Taboga. Taboga is a mountain which rises out of the Pacific some 
thousand feet. The hospital is beautifully located on a beach at its 
base, about 50 feet above sea level. 

Along the line of the Canal, between Panama and Colon, we have 
8 small hospitals containing irom 20 to 50 beds. The Hospital 
Bureau has two cars which run across the isthmus daily, each one 
bringing the sick to the two general hospitals, Ancon and Colon. 
The line hospitals being only intended to keep the sick until they 
can be properly transferred. 

Santo Tomas Hospital, 300 beds. This is under our control, but 
the expenses are paid jointly by the Commission and the Republic 
of Panama. This bureau has practically the care of all the sick on 
the isthmus including the towns of Panama and Colon. The Com- 
mission have agreed to look after all their sick employes without 
charge, the sick of any contractor working on the Isthmus, and 
also the sick from the towns of Colon and Panama. But for citizens 
of the Panamaian Republic, the Commission is reimbursed by the 
Republic at the rate of 30 cents per day. All the insane and lepers 
both on the Zone, and of the Panama Railroad on the same terms. 
Ail the sick from the municipalities along the Zone upon the same 
terms, so that we have the sick from fully 80,000 people to look after. 
For this purpose we have 2,000 beds, which have never yet been 
quite filled. 

The Bureau for the Health Department of Bocas del Toro: Bocas 
del Toro is a town some 100 miles west from Colon, on the Carribbean 
Sea, and in Panama territory. It has a very close communication 



56 THE ISTHMIAN CANAL COMMISSION 

with Colon, and has been several times infected with yellow fever, 
since we have been here. 

At our request, the Panamaian Government has appointed one 
of our doctors, health officer of the town, and we have a health 
department here similar to that of Colon, also a quarantine just as 
at Colon. The town has about 2,000 inhabitants. We have succeeded 
in getting rid of yellow fever at Bocas del Toro, which is a great 
protection to Colon. 

In the whole Sanitary Department, we have now swne 2,500 em- 
ployes, about 100 of these are physicians. At the date of this presicnt 
writing, we have in our hospitals some 1,400 patients. The present 
organization represents the work of two years. In July, 1904, when 
we took charge, there was no organization on the isthmus of any 
kind whatever, for doing the work at present done by the Sanitary 
Department. The organization has accomplished very substantial and 
practical results. We have gotten rid of yellow fever. Have not 
had a case in Panama since last November, and have had only one 
case on the Isthmus during the year 1906. During 1904 we had 
a good deal, but its moral effect was out of all proportion to its 
real damage. It had a great effect upon our employes, causing many 
to go home, and rendering it difficult for us to get men to come down. 

If we were now having it to the same extent as the French did, 
I believe the construction of the Canal would cease. 

The white employes of the French suffered very severely. In June, 
1886, when they had on their rolls, 2,200 white employes, they lost, 
from yellow fever in Ancon Hospital alone, 44 of those white em- 
ployes, and the general rate during the work was about the same. 

If we, for one month, in our main hospital at Ancon, should have 
100 Americans die of the yellow fever, I am pretty sure there would 
not be a hundred of our 5,000 whites left to begin the next month 
with. 

We have controlled malaria within reasonable limits and this is 
a much more important work than yellow fever as far as the actual 
loss in working powers is concerned. Our highest sick rate dunng 
the past year was in the month of July, when, from each 1,000 men 
on our rolls, we had 42 daily on our sick report. We have, at present, 
30,000 workmen, and for the year their sick rate will not average 30 
per thousand. This is as small as our sick report would be, if wc 
were building the Canal in the United States. 

We have had one outbreak of smallpox, sc«ne 35 cases with two 
deaths, occurring in one neighborhood. At the end of two months 
work this was entirely eradicated. It had come in from a child 



THE ISTHMIAN CANAL COMMISSION 67 

brought from Cartagena in Colombia. Cartagena is less than 24 
hours from Colon by water. The child was vaccinated, when she 
past the quarantine, but developed smallpox about a week after her 
arrival. This occurred last June, and we have not had a case any 
where on the Isthmus since August 25th. 

We had two cases of bubonic plague, both of which died, occur- 
ring at La Boca, the Pacific terminus of the canal and railroad. 
Plague is very general in the Pacific ports to the south of us. The 
town was at once quarantined, the rats killed, and the whole town 
carefully disinfected. No secondary cases occurred. 

I think I can safely say that in the two and one half years of its 
existence, the Sanitary Department has accomplished all that was 
expected of it. 

It has eradicated yellow fever, kept out smallpox, kept out plague, 
and made the sanitary conditions such, that among our 4,000 white 
Americans on the Isthmus, no more die from disease than would 
occur among a similar number in the United States. 



THE DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 

JOSEPH GOLDBERGER, 

Passed Assistant-Sxtrgbom, U. S. Pubuc Hkalth and Marine Hospital 
Servicb, Washington, D. C. 

A study of the history of yellow fever epidemics in the United 
States shows that there are two essential steps in their production, 
namely, — first the evasion by the infection of our quarantine guards 
and second, its establishment of a domicile in infectible territory. The 
deduction is, of course, obvious, viz., that to prevent the occurrence of 
an epidemic all that is necessary is to take such measures as will pre- 
vent the infection slipping by the first line of defense — the quar- 
antine. 

Experience has shown, however, that in spite of the enforcement 
of scientific regulations, the disease in the body of either of its hosts 
will, at times, evade the vigilance of the sanitary guard. Further on 
I shall touch on some points which may, in some instances, explain 
the way in which the disease may elude the most careful and consci- 
entious of inspectors. 

Though the infection has passed the first line of defense, no mis- 
chievous consequences need necessarily result unless — and this is the 
important point — it is able to establish itself in the new environment* 
It becomes then of prime importance to study how this may be pre- 
vented. 

Experience has shown that the spread of the disease can certainly 
be prevented by the proper isolation (screening) of the first case and 
the destruction of all infected mosquitoes, but experience has also 
shown that the greatest obstacle to carrying out these simple measures 
is failure to recognize the first case, in other words, failure to correctly 
diagnose the disease. 

Yellow fever may, in some respects, be compared with the solar 
spectrum, .for when clearly defined there should be no difficulty in 
recognizing either, except for such as are color blind or will not see. 
The number of the former will be reduced with improved teaching as 
to the clinical character of the disease, while the latter will be elim- 
inated by the growth of an enlightened public opinion. As we move 
away from this well defined area we meet at first a series of cases 
which the trained clinician is able to recognize by careful study, but 
ultimately a point is reached when even men of the widest experience 
may be unable to decide whether the case is one of yellow fever or not, 

58 



DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 



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DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 61 

The affections with which yellow fever is most frequently confused 
are dengue and malaria. The points of differentiation between dengue 
and yellow fever most relied upon are the presence of an eruption 
and the absence of jaundice and albuminuria in the former disease. 
While these signs are undoubtedly of value, they are of no help whenr 
we most need help; for in the group of cases of yellow fever I have 
in mind, the jaundice may be exceedingly doubtful if not altogether 
absent and the albuminuria very slight and transient and may readily 
escape detection, while the absence of the eruption has practically no 
positive value in view of its great variability and fleeting character 
in the disease which it characterizes. 

It has occurred to me that the results of recent work on the differ- 
ential count of leucocytes in dengue may prove of value in helping 
to distinguish the disease from yellow fever. Carpenter and Sutton^, 
working on the Isthmus of Panama, report differential counts in i6 
cases of dengue. These counts show the polymorphonuclears in the 
second stage of the disease to vary between 23 and 54 per cent. Stitt*, 
working in Manila, reports an average of 42 per cent. pol)rmor- 
phonuclears in the later stage of five carefully studied cases. These 
results are in marked contrast to the differential leucocyte picture in 
yellow fever, in which the percentage of polymorphonuclears is, in 
general, not reduced below the normal. Cabot, in his "Guide to the 
Clinical Examination of the Blood," records differential counts in 
twelve cases of yellow fever in which the lowest gave 73 per cent, 
polymorphonuclears. Sodre and Counto' record counts in thirteen 
cases in which the pol)rmorphonuclears did not go below 76 per cent, 
and Guiteras* states that he has found them to vary between 60.5 and 
79.5 per cent. Additional observations will be necessary in order to 
determine the practical value of this difference in the two diseases. 

Malaria vies with dengue for the premiership as the cause of con- 
fusion and error in the diagnosis of yellow fever. The mischief of 
course results from calling yellow fever malaria. Early in certain 
cases the two diseases are exceedingly alike and the unsuspecting 
clinician, who has not learned to use the microscope and has not the 
facilities of a laboratory at his command, is in great danger of com- 
mitting the error in which he may be conrmed should he encounter 

1. Carpenter and Sutton. Journ. Am. Med. Assn., 1905, vol 44, p. 214. 

2. Stitt, E. R. Philippine Journ. Sci., Manila, 1906, vol. 1, no. 5. 

3. Sodre and Couto. Nothnagcl's Specielle Pathologic und Therapic, Band 
5, 2 Halfte, p. 181-186. 

4. Guit^ras, Juan. Buck's Reference Handbook of Medical Sciences. Vol. 8. 
New York, 1904, p. 594. 



42 



DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 



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64 DIAGNOSIS AND PREVENTION OP YELLOW PEVER, 

one of those types of yellow fever in which, with a distinct inter- 
mission in the fever on the second day, the associated symptoms are 
not severe. 

Considerable differential value is attached by some writers to the 
time of onset of the disease; it being stated that the onset in yellow 
fever is more commonly at night, while malaria is more likely to set 
in during the day. Of twenty-five cases of yellow fever in which I 
carefully noted this point, seven gave a history of being taken sick 
between midnight and 6 a. m.; nine between 6 a. m. and noon; seven 
between noon and 6 p. m. ; and two between 6 p. m. and midnight. 
It appears then that the onset in 64% of these cases was between & 
A. M. and 6 p. m., and only 36% between 6 p. m. and 6 a. m., that is- 
during the night. Reference is made to this, because it is illustrative 
of a mischievous tendency frequently met with, to unduly magnify 
the diagnostic value of isolated signs or symptoms. Another illus- 
tration of this tendency is seen in the dogmatism with which it is stated 
that in "all cases" of yellow fever there is at the time of each visit 
a decrease in the pulse rate or that it at least remains stationary while 
the temperature rises one to three or four degrees. I have failed to* 
observe this in some instances, while I have occasionally seen the 
pulse fall or remain stationary, with a rising temperature in uncom- 
plicated cases of malaria. It is trite but it cannot be too frequently 
repeated that a careful study of the history and all the signs and 
symptoms of a case is necessary for making a diagnosis and that 
failure to detect any one symptom, whatever that may be, does not 
exclude yellow fever. 

The temperature line in yellow fever will be found, on scrutiny, ta 
conform to one of two general types ; in one the fever after reaching 
its acme within the first twenty-four or thirty-six hours, declines pro- 
gressively (see charts i, la, 2 and 2a) with more or less marked even- 
ing exacerbations, until it reaches normal, which ordinarily happens in 
from 3 to 7 days after the onset. In the other, the temperature con- 
tinues, with daily oscillations of variable degree, for 3, 4 or 5 days at 
or near the point to which it first rises (see charts 8 and 9). The 
cases which fall in the latter group are usually the more grave and 
more likely to be fatal, but some of the most rapidly fatal cases, the 
so-called foudroyante cases of the French, belong in the former cate- 
gory (See chart la). 

Frequently the temperature suffers a more or less marked remissiott 
within the first twenty- four hours (charts 6 and 7), a fact to which 



DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 



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DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 67 

Guiteras* was the first to call attention. This early remission may 
occur, however, in both of the above groups. Occasionally the first 
remission may be repeated, without evidence of internal hemorrhage, 
so that a truly remitting type is presented (chart 7). 

Another perturbation to which the fever curve is subject and the 
importance of which appears thus far not to have been recognized, is 
an intermission of variable duration occurring within twenty-four to 
thirty-six hours of the onset (see charts 3, 4, and 5). The frequency 
with which this occurs probably varies in different epidemics, but it is 
probably not very rare. Of twenty-two cases produced by experi- 
mental mosquito inoculation in which I find the temperature curve 
recorded in the literature, this early intermission was exhibited in 
two. Its occurrence has at times been attributed to the favorable 
effects of treatment; at other times it has escaped notice because of 
its occurrence before the case came under observation or because it 
tricked the observer, especially in mild cases, into calling it malaria. 
The way in which this error takes place may readily be seen by refer- 
ence to chart 3. 

This was a mild case. The patient, a young American with pre- 
vious history of intermittent fever, was taken while at work, with 
dizziness and headache, September 22 at about 2 p. m. He was able 
to continue and finish his work and about 5 p. m. went home, took a 
purge and drank some coffee. He was not nauseated. He went to 
bed after taking a hot foot-bath, feeling much better. In the morning 
(September 23) his head and back ached and he had fever. The phy- 
sician who might have seen him now would have found nothing in his 
appearance to arouse suspicion that this was not a case of estivo- 
autumnal fever. His complexion was sallow; lips bluish; scleras 
negative ; no epigastric nor muscular tenderness ; the tongue broad and 
pale. He was without appetite, but had no nausea. Under such cir- 
cimistances the physician would probably order calomel and quinine 
and leave j>romising to return next day. The following morning (Sep- 
tember 24) he would have found his patient without fever and feeling 
much better. This would, in the physician's mind, confirm the diag- 
nosis of malaria and the recurrence of the fever the next day would 
not be at all inconsistent with an estivo-autumnal infection. This while 
described to indicate how very naturally such error might arise, is an 
actual case which came under my observation during the epidemic of 
1905 in Louisiana. The subsequent development in this case showed 
that though mild it was undoubtedly yellow fever and so capable of 

•Buck's Reference Handbook of the Medical Sciences. New York, 1904, 
voL VIII. 



68 



DIAGNOSIS AND PREVENTION OF YELLOW FEVER^ 










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DIAGNOSIS AND PREVENTION OF YELLOW FEVER, 



having served as a focus of infection. Another very important and 
practical bearing which such a case has is the possibility of its occur- 
rence on board ship and of arriving at quarantine during the afebrile 
period. A vessel with such a case among the passengers or crew arriv- 



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CHART 7. 

Yellow fever; remitting type; mild, with remission 24 hours after onset. 
Experimental by intravenous injection of filtered blood serum. — Rose- 
nau, Parker, Frances and Beyer.* 



*U. S. Public Health and Marine Hospital Service, Yellow Fever In- 
stitute, Bulletin No. 14. Washington, 1904. 



ing at any of our ports before the season of closed quarantine, would 
in all probability pass the most careful and searching inspection even 
should the captain, as rarely may happen, report the case to the in- 
specting officer. After passing inspection the case just described 
would probably still be infective for a period of twenty-four hours. 



DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 



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DIAGNOSIS AND PREVENTION OF YELLOW FEVER. 73 

I oflFer this as a possible explanation of how yellow fever may some- 
times be introduced into the United States. 

While careful examination of the blood in such a case as just cited 
would have excluded malaria, the finding of the Plasmodium in a 
case of fever by no means excludes yellow fever. The diagnosis of a 
dual infection can generally be made after careful observation of 
the case provided the possibility of its occurrence is not forgotten. 

It is of course natural to expect that the symptoms characterizing 
yellow fever, though in some respects perhaps masked, will be agg^- 
vated by. the active malarial infection and so make the detection of the 
former less difficult, but this is by no means invariably the case. May 
it not happen even though rarely that the malarial element may so 
dominate and mask a mild yellow fever as to make the detection of 
the latter impossible? A definite answer to this question as to some 
others which have been more or less directly suggested by this brief 
discussion, will not be possible until science discovers some positive, 
infallible criterion of yellow fever. 

From the foregoing discussion intended to emphasize some of the 
difiicidties and, at times, the impossibility of a diagnosis in yellow 
fever one might hastily infer that the recurrence of epidemics was 
inevitable; but the rational deduction which should form a basis for 
•scientific preventive measures, is to regard as suspicious and as poten- 
tially, yellow fever, every case, in child or adult, presenting a rise of 
temperature above the normal. This means that in the Stegomyia zont 
every case of fever should, with the least possible delay, be placed 
^behind mosquito bars. A rigid application of this principle would 
make the spread of yellow fever impossible, but practically the sani- 
tarian can not expect more than a more or less remote approximation 
to this ideal. 

Appreciation of this important fact makes imperative all measures 
aimed at the extermination of the mosquito. The destruction of all 
Stegomyia would likewise make the spread of the disease an impos- 
sibility, but this too except in urban communities is an ideal which 
though devoutly to be wished can be, for the present, only more or 
less remotely approximated. It is failure to appreciate these prac- 
tical considerations that is responsible, on the one hand, for some of 
the opposition with which the new doctrine of transmission has still to 
contend, and on the other, for the disappointment of those who 
expected that the application of the principles of this doctrine to the 
control of epidemics would see their immediate extinction. 



BRIEF NOTES ON THE PROPAGATION OF YELLOW 

FEVER 

Dr. ERNESTO DUPLAN, Puebla, Mbxico. 

I do not claim in these brief notes, to present anything that might 
imply originality, to this learaed Association. 

My object in writing this paper is to contribute, as far as my powers 
go, in carrying to the minds of the persons who do not believe or doubt^ 
conviction of the transmissibility of yellow fever by the sting of the 
Stegomyia fasciata mosquito, after it has been infected through having 
stung a yellow fever patient. 

The data that I have collected as the result of my own observations 
are sufficient to carry conviction; but combined with other complete 
data which have been collected by other observers, they will serve to 
complete the studies of the American Commission which I had the 
good fortune to witness, and the strict scientific truth of which I can 
testify to, when I attended, in the character of Mexican delegate, the 
third Pan-American Congress which was held in Havana in 1901. 
And they will carry more influence still if we consider these studies 
as an explanation of the ideas of many observers who studied the 
subject before the discovery of the transmission of the disease by the 
mosquitoes, and who expressed their conviction that yellow fever was 
not a contagious disease, that is to say that it could not be passed from 
the sick to the healthy man by contact. 

It is very true that there always have been persons who sustain the 
contagious character of the disease ; but it is very possible, that their 
little meditation and want of repeated observations in various media 
and different localities have led them to believe in the contagious 
character of a disease, which they saw attack a member of their fami- 
lies, who had acquired it in another locality when traveling, and a 
few days after saw another person who attended to the patient fall 
sick without having left the house and still less been in another place 
which could be considered a focus of the disease. 

Those who thought the question over could not pass over the fact 
that the clothing which had been soiled by the matter vomited and 
the excreta of the patients, when carried without previous disinfection 
to other houses, never reproduced the disease. The same thing was 
observed by others with respect to the live or dead bodies, which in 
themselves were as incapable of reproducing the disease, and all this 
gave rise to the necessity for a theory that would explain the spread of 

74 



NOTES ON THE PROPAGATION OF YELLOW FEVER, 76. 

yellow fever by other means than contagion, as at that time nobody 
understood as we now do, the office that is filled by the Stegomyia. 
Once we established the transmissibility of yellow fever by the stingy 
of the mosquito, ever3rthing was explained, and all the difficulty which 
formerly appeared inexplicable then disappeared. Even the history of 
former epidemics is now satisfactorily explained by the new etiology^ 
if we do not lose sight of the geographical distribution of the 
Stegomyia, which only exists and is reproduced between the forty- 
third parallels north or south, being identical with the distribution of 
yellow fever either in endemic or epidemic form. 

Naturally, even today, the physicians who do not or will not admit 
the doctrine of the mosquito, and to whom the case of the patient 
above referred to is presented, find themselves obliged to explain it by 
the theory of contagion, as otherwise they would have to accept the 
theory of the mosquito, seeing that it would be absurd to return to- 
the theory of the transformatlion of the germ in the soil, which 
obtained when it was impossible to explain the spread of the disease 
by contagion, but is now entirely eliminated by the mosquito theory. 

Probably we do not remember that some years ago, the learned" 
Dr. Coronado of Havana, a short time before the now undisputed 
doctrine was admitted, thanks to the labor of the English and Italian 
physicians of the propagation of malarial fever by the Anopheles mos- 
quito, told us that this fever was contagious. He supported his 
opinion by citing the case of a child who after contracting malarial' 
fever, was carried to a place in which a case had not been observed for 
a long time past, and yet shortly after another child, a playmate of the 
former one, presented symptoms of malaria. Unless we accept the 
intervention of the mosquito, how could we explain this case except by 
contagion? But now we understand that the presence of the Anopheles 
mosquito in that locality was sufficient to infect other persons with* 
malaria as soon as a patient suffering from this disease was taken- 
there, and the new patient would in his turn transmit it through the 
mosquito to other persons. 

We now see that the theory of miasma has disappered, as malaria 
and yellow fever were the two diseases specially held to be mias- 
matic. 

As the idea of the non-contagious character of yellow fever can 
exercise a great influence over the unanimous acceptance of the doc- 
trine of its transmissibility through the sting of a mosquito, I wilF 
cite the opinions of authorities, which have been pronounced a long-- 
time before we even suspected the office filled by the Stegomyia fasciata 
in its etiology. 



76 NOTES ON THE PROPAGATION OF YELLOW FEVER, 

But first I want to mention some reflections which I developed dur- 
ing a study of the first epidemic of yellow fever which spread in 
Orizaba in the year 1899, where I had an opportunity to make a 
<:areful study of this disease, at a time when the American Commis- 
sion had not commenced its studies of the mosquito in Havana. I 
read this paper before the Faculty of Medical Science of the State of 
Veracruz in 1900, and it was referred to several times by my friend Dr. 
Gregorio Mendizabal in his work entitled, "Some considerations rela- 
tive to the epidemic which prevailed in Orizaba," and which was read 
before the Academy of Medicine of Mexico on the 23rd of May, 1900. 

In the paper I refer to, amongst other things I said as follows : 

"But it appears to me so important to decide this often disputed 
point of the non-contagious character of yellow fever, that I will here 
state some ideas that I have held for a long time on this pathogenic 
subject and that in my opinion are of convincing importance to incline 
us to one or other belief. 

"The opinion of authors who have written on this subject are divided 
.and in order to decide this question we must study the mechanism of 
the contagion in other diseases that are unquestionably contagious, 
and reasoning by analogy deduce from them the necessary conse- 
quences and place ourselves on the side of the most logical deduction. 
Measles, smallpox, etc., are contagious diseases in the true sense of 
the word, as the tears, the nasal secretions of the first stage of 
measles, when transported to a third person who is predisposed, repro- 
duce the disease. In 1842, Catona inoculated ninety-three per cent, of 
1,222 cases on which he experimented with measles, s(xnetimes using 
blood mixed with other fluids, and on other occasions tears. Maire 
states that he has produced the disease by the use of the nasal mucosity, 
directly applied to the mucous membrane of children. Brandt asserts 
that Monroe and Lock reproduced the disease with the scales from the 
skin, with tears and with saliva. 

"As regards the reproduction of measles by inoculating a healthy 
person with the blood of a patient, placing that blood in contact with 
a small wound or with the skin from which the epidermis had been 
removed, there is a perfect uniformity of opinion, and the same thing 
may be said with regard to smallpox. 

"It was formerly the custom in China to introduce the scabs of the 
pus into the nostrils for the purpose of inoculating the disease, and 
"in India, to rub the matter on the excoriated skin. 

"These diseases are certainly contagious in the fullest sense of th^ 
word, that is to say, that the matters which are thrown oflF by the 
patients undoubtedly carry the germ of the disease, in an entirely fit 



NOTES ON THE PROPAGATION OF YELLOW FEVER. 77 

condition to reproduce itself if introduced into any other system, that 
is to say, that it does not require to undergo any transformation or 
metamorphosis either in the outside air or in any other medium of 
cultivation outside of the human system. This facility for discovering 
the germ in the fluids or products, of patients already prepared to pene- 
trate into another organism, is general to all manifestly contagious 
diseases. The same thing cannot be said of yellow fever. None of 
the fluids of the diseased system nor any of its products, such as vomit, 
urine, feces have up to the present date given positive results in the 
way of inoculation. 

"I desire to call attention to this special characteristic of all con- 
tagious diseases, in that they are universal and do not admit any con- 
siderations of geography, climate, etc. It could not be otherwise, as 
in order to pass from one individual to another the germ requires no 
modification or transformation whatever. It issues from the infected 
system, entirely prepared and ripe for its change of domicile. The 
human system maintains its heating mechanism on a balance, so that 
the temperature of the body is the same in Siberia as in Senegal and 
the germ of measles, for example, does not require anything from the 
surrounding atmosphere or the help of any outside element to reach 
a perfect development and maturity for which it finds the temperature 
of the body and other conditions of the life there encountered entirely 
sufiicient, and therefore the disease of measles cannot be confined to 
any fixed conditions of temperature, elevations, etc., which are neces- 
sary to the germ that requires to live for a certain time outside of the 
organism at the mercy of the exterior influences and which must 
utilize the conditions of life that are offered in the locality in which 
it has fallen. 

"If yellow fever were contagious, that is to say, if its pathogenic 
agent did not do more than pass directly from one individual to an- 
otfier, it would be logical to presume that it could be propagated in 
both Mexico and Russia, once the germ was transmitted and the same 
in winter as in summer, seeing that the same cosmic conditions, if I 
may be allowed to say so, exist in the organism which it attacks as 
in that which it abandons. At the same time it appears to me natural 
to suppose, that if, notwithstanding the similarity of the organic me- 
dium in the two individuals, the germ of yellow fever is detained 
by conditions of climate, elevations, etc., it must be because it requires 
that those conditions should be favorable to its existence and this 
implies that it has to live for a longer or shorter period, exposed 
to outside influences. 

"From the considerations I think we can logically reach the follow- 



•78 NOTES ON THE PROPAGATION OF YELLOW FEVER, 

ing proposition: Before a disease can be classified as contagious, it 
is necessary that it should be able to develop in all parts of the world, 
once the germ has been transported." 

Up to this point I quote the paper above mentioned. 

But we at once understand that everjrthing I have above cited 
with respect to geographical distribution, specific conditions of tem- 
perature, climate, elevation, etc., for the development of the yellow 
fever germ outside of the human system, should now be applied to 
the osmic conditions which are necessary to the existence of the Steg- 
omyia fasciata mosquito, the sole agent for transmission of yellow 
fever. 

This necessity for favorable climatic conditions shows that those 
were in the right who always denied the contagious character of this 
disease. 

I here present some of those opinions : 

In his treatise on medical pathology, Jaccoud says as follows : "Tlie 
yellow poison is entirely distinct from the cholera poison in the details 
of its reproduction. Everything tends to show tiiat this takes place 
outside of the patients and there is no fact to prove the presence of 
the regenerated poison in the products thrown oflF by the patients. It 
is not really himself that is the agent for the transmission, but his per- 
sonal clothing, his bed clothing, the place in which he has lived, or 
in other words, the personal transmission is not proved, whilst the 
impersonal transmission is established beyond any doubt." 

And although he mentions the bed clothing, dress, etc., as the 
transmission agent, this is understood from the moment that he does 
not ignore that the disease is transmissible, and as the idea did not 
occur to him that it could be transmitted by inoculation he found 
himself obliged to accept that transmission by what he calls impersonal 
contagion. But what excites our attention is, that an observer of his 
l)erspicacity should accept the theory of contagion by the clothing, 
which undoubtedly would have acquired that property by contact 
with the patient, whilst his body would not be capable of producing it. 
Besides this, if the clothing could produce the disease, I suppose that 
they would do the same thing whether placed on the patient or sep- 
arated from him, and in the first place, how can we assert that it was 
not a case of personal contagion ? These contradictions and hesitations 
prove that Jaccoud understood that the disease was not contagious and 
that he required in some way to explain the cases of reproduction. 

In his article on yellow fever in the medical treatise published by 
Pepper, W. Gilman Thompson defines yellow fever as follows: "An 
acute and very infectious disease, but not contagious, characterized 



NOTES ON THE PROPAGATION OF YELLOW FEVER. 79 

by an acute paroxysm of fever^ black vomit, jaundice and retention of 
urine." Further on in page 453 he says: "Provided the clothing is 
<lisinfected the disease is not propagated by either the live or the dead 
bodies/' 

This leads us to the same reflections as the opinion of Jaccoud ; how 
can an author of such ability admit that neither the live nor the dead 
bodies without disinfection can propagate a disease which can be 
propagated by the clothing, which really do not come within the case 
as they are dead bodies, but that naturally must be less saturated with 
the poison than the real body ? 

Sanarelli, who has made a careful study of yellow fever, although 
he made a mistake as regards his Bacillus icteroides, when he came to 
-define the disease in his monograph, says nothing whatever as to its 
contagious character. 

In his lectures on medical pathology and therapeutics, Liebermeister 
defines yellow fever as follows : "Yellow fever is an infectious disease 
whose characteristic lesion consists in a degeneration of the hepatic 
parenchyma," and further on, on page 157, he says: "Yellow fever 
4oes not appear to be directly transmissible from one person to an- 
other." In page 158 he says: "It is probable that the infectious germ 
is to be found in the substances vomited or discharged in one or other 
manner by the patients, and which undergo certain changes and 
certain phases of development outside of the system in the closets, on 
the ground, in the holds of the vessels, and that afterwards penetrate 
other individuals either in the air, or in the drinking water." 

This is the theory that best agrees with the facts that have now been 
-definitely ascertained by scientific process, with the only diflference that 
the germ does not undergo the transformation in the soil, etc., referred 
to by the author, but in the organism of the mosquito, and the latter 
in its turn undergoes that transformation, as was suspected by Lieber- 
meister it did in the soil, the closets, the holds of ships and in every 
place in which stagnant waters can be found, in which they can 
deposit their eggs and develop their larvae. As regards the holds of 
the ships, where it was supposed the germs of the disease were best 
preserved, so much so that Sanarelli declares that they preferred the 
darkness and humidity even better where there was rust, we can now 
perfectly explain to ourselves how these ideas arose, by reflecting 
that those are precisely the special conditions under which mosquitoes 
prefer to live and which led Jaccoud to say that the vessel itself had 
yellow fever, seeing that however much it was disinfected the non- 
immunes who penetrated the hold contracted the disease, as it is very 
difficult to expel those insects from those places. 



80 NOTES ON THE PROPAGATION OF YELLOW FEVER. 

The Brazilian physicians relate, that the unacclimatized foreigners- 
who go to live in Rio Janeiro (merchants, diplomats, etc.), go to live 
in Petropolis, a city situated 800 metres above sea level in order to 
avoid the danger of yellow fever, and although these persons go to 
Rio Janeiro every day, they pass through an epidemic of ydlpw fever 
without dny trouble, always provided that they do not remain for a 
single night in the capital city, and they also tell us that the neglect 
of this rule has cost the lives of many imprudent persons, of which 
numerous examples have been observed in the history of the epi- 
demics of Rio Janeiro. 

It would be a very strange thing that a really contagious disease 
should only be so at night, and this idea fits in very well with that of 
the transmission by the sting of the mosquito, as it would also fit in 
with the miasmatic theory if it could survive ; but we well know that 
once it is fully proved that neither yellow fever, malaria, cholera or 
bubonic plague can now be considered as miasmatic, that theory has 
been entirely destroyed. In the same manner we can explain what 
we have several times heard from the late Dr. Lucio, that in traveling 
in Italy, any person who sleeps in crossing the Pontine marshes con- 
tracts malaria, but that he escapes if he keeps awake during the cross- 
ing. The traveler who is awake very naturally defends himself from 
the mosquitoes, a thing that he cannot do if he falls asleep. 

Every thing that I have said refers to the period previous to the 
discovery of the propagation by mosquitoes and is solely founded on 
observation. 

But it was Dr. Charles Finlay, a learned Cuban physician who for 
the first time propounded the idea in 1881, that yellow fever was 
propagated from a sick man to a healthy one by inoculation, and that 
the agent for this propagation was the mosquito of the genus ''Culex" 
His discovery is all the more praiseworthy because it was made nine 
years before Laveran and Ronald Ross proved that the propagation 
of malaria was caused by the sting of the Anopheles mosquito.' 

The principal conclusions of the American Commission which were 
presented to the Third Pan-American Congress which met in Havana 
in 1901, and which unquestionably established the truth of Dr. Fin- 
lay's theory, and converted it into a doctrine, were very shortly after- 
wards confirmed by Guiteras, Parker, Bevery Pothier and later <mi 
were still further confirmed by Marchoux, Simon and Salimbeni, who 
were commissioned by the French Government to make investigations 
in South America. 

In closing this paper I will add to the above the results of my own 
limited observations during the second epidemic of yellow fever 



NOTES ON THE PROPAGATION OF YELLOW FEVER. 81 

which prevailed in Orizaba in 1902 and after we had acquired the 
knowledge of the work done by the mosquito in its propagation. 

During this epidemic I had occasion to attend and observe over 
sixty patients. Whenever I attended a patient for the first time in a 
house in which he was the first case, I took pains to investigate the 
presence or absence of the Stegomyia and of the larvae in the waters 
that might be found in the yard, etc., of that house. 

In those wards which were scourged by the epidemic I always 
observed that the new cases which presented themselves after the 
first, in persons who had not been exposed to the contagion outside 
of the house, always fell sick fourteen days after the presentation of 
the first case. In those houses in which I did not find the mosquito, 
and there was any patient who unquestionably had contracted the dis- 
ease outside, it never was reproduced. The disease did not spread to 
the center of the town, notwithstanding that cases were observed in 
which the disease was contracted in the suburbs or brought from 
Veracruz or Cordova, and neither I nor any of the other physicians 
with whom I spoke, ever found the Stegomyia or its larvae in that 
center. 

It is a well known fact in Orizaba that in the Hospital of "La Llave" 
in spite of its bad conditions, the disease never spread, notwithstand- 
ing that during the first epidemic of 1891 many sick were taken there 
without any precautions whatever being taken against the mosquito, 
as at that time that etiological doctrine had not been established. 
The same thing happened in the lazaret which was arranged to re- 
ceive the patients in the second half of that epidemic. Well now, 
subsequently and during the second epidemic, when I had acquired a 
knowledge of the mosquito doctrine, I took occasion to make inves- 
tigations and convince myself that the Stegomyia mosquito was never 
found in the Hospital of "La Llave" and that in the building which 
was adapted for the purposes of a lazaret, those who lived there were 
never troubled by mosquitoes of any kind. 

These observations taken in a city, that has only twice been in- 
vaded by an epidemic of this disease, once before and once after the 
discovery of the mosquito as an agent for transmission of yellow 
fever, appeared to me to lend their support to the previous studies, and 
to contribute something to carry conviction to the minds of those who 
still doubt that doctrine by bringing before them the perfect harmony 
and consistency which exist between the facts and the modem studies 
relative to this question; and which are called fashionable theories 
by those who have not been thoroughly penetrated with their import- 
ance and do not understand the care with which they have been car- 



82 NOTES ON THE PROPAGATION OF YELLOW FEVER, 

ried out, thus retarding the progress in the direction of an efficacious 
prophylaxis of this disease. 

If I have extended this paper somewhat beyond what may appear 
necessary for my purpose, it is because I know that there are still 
physicians who not only doubt, but also combat the truth of the etiolog- 
ical doctrine of the propagation of yellow fever by the mosquito, and 
because I believe, that in order to reach the ideal to which this learned 
Association aspires, which is the prevention of the propagation of 
transmissible disease, no argument, however insignificant it may ap- 
pear, which might contribute to the uniformity of opinions, is useless, 
especially in this case in which in view of the etiology of the disease, 
it is particularly adapted to precautionary measures, to such an extent 
that we may be able to obtain its disappearance from the world. 



THE ORIGIN OF SPORADIC CAjSES OF YELLOW FEVER 
AT LONG PERIODS. 

Dr. MANUEL S. IGLESIAS, Veracruz, Mexico. 

In those localities in which^ after a vigorous, well directed and 
successful campaign, yellow fever has been stamped out; in those 
places in which it held absolute sway and cut short numerous lives, 
besides paralyzing commerce and industry, isolated cases still present 
themselves whose etiology we do not know, whose origin we can not 
discover however earnestly we make attempt to do so, cases which 
appear to challenge the per^Mcacity of the observers and laugh at the 
pride of its conquerors, as if to show that the endemie has \^n beaten 
but not destroyed. 

At the end of July of this year, a case of 3relkyiir fever was observed 
in a sugar plantation called ''Mercedes" in the district of Guareiras, 
six miles from Colon, in the island of Cuba. The patient was a 
Spanish immigrant who had arrived on the island six months before 
and from the date of his arrival had remained on the plantation with- 
out returning to Havana. The village of Campiiia Real is near that 
plantation, and there a case of yellow fever was observed on the nth 
of December of last year, and therefore the sanitary authorities believe 
that the contagion was found there, that being the only focus of in- 
fection which the patient had recently visited. The patient was taken 
to the hospital at Colon on the 31st of July, in a somewhat advanced 
stage of the disease, and there he died on the ist of August, the 
diagnosis being confirmed by a postmortem examination which was 
made on the subsequent day.^ 

I could multiply cases of this nature which have been observed in 
the Mexican Republic; but I prefer to take this fact which was ob- 
served on the island of Cuba as a starting point for my study, so as 
to preclude all criticism which might be made as to our methods of 
observation, or as to the efficacy of the campaign we are now carry- 
ing on against yellow fever. 

In presence of this isolated fact, it is only natural to ask : Whence 
did this disease arise ? Where was the mosquito infected ? How came 
•this man to contract the disease? Seeing that there were no patients 
round the place where he worked, and the only place in which he could 
have acquired the disease, had not had a case since the nth of Decem- 

(1) Public Health Reports of the Public Health and Marine Hospital Ser- 
mce, of the 17th of August, 1906, page 967. 

83 



84 ORIGIN OF SPORADIC CASES OF YELLOW FEVER. 

ber of the previous year, that is to say, for more than seven months, ot 
to be still more exact, for more than 220 odd days, there being no re- 
ports as to the exact date on which the disease commenced. 

I do not in any way attempt to throw blame on the learned 
sanitary authorities of the island of Cuba, because they did not have 
any news of the previous case through which the mosquito was in- 
fected, which transmitted the disease to the patient I refer to, even if 
such existed, and still less do I want it to be believed that this paper 
implies any accusation of negligence against those distinguished 
officers, as the entire world knows the ability, efficiency and strict 
method with which they have carried, to a successful issue, thdr 
campaign against yellow fever. With this observation, which appears 
to me called for, I will proceed to analyze the fact in question, in 
order, if possible, to come near the truth with respect to the origin 
of this case. 

To begin with, we must entirely discard the idea that this Spaniard 
was infected by a mosquito, who had received the infection from 
the other patient in December, 1905, amongst other reasons, for the 
most important ; because 220 days and more had elapsed between the 
two cases, and the life of a mosquito has been proved by experiment 
not to extend for such a long period as that. 

It may have happened that the case in question had its origin in a 
case of slight intensity that might have passed unperccived ; but even 
then we can only go back to the date and the questions already asked, 
and apply them to this case of slight intensity, and if we accept this 
origin, we came to the result, that between the case in December, 
I905> and that in July, 1906, there must have been cases of a mild 
form which were unknown to the sanitary authorities, and if that 
fact is possible once, we cannot admit the supposition that it was re- 
peated several times. 

Assuming that the disease took its origin in some of the houses 
in Havana or Matanzas, and that the infection was transmitted to 
one or more persons of whom nobody had any knowledge, through 
the time and space to reach Colon which is approximate 120 miles 
from Matanzas and a still greater distance from Havana, we come 
to what is practically a "reduciio ad absurdum," or else something 
that up to a certain point implies an accusation of negligence as re- 
gards the sanitary authorities of the island of Cuba, and this I am 
very far from admitting. In my opinion we can only find two ex- 
planations that will give a satisfactory answer to the above questions, 
and these I have the honor to submit to the learned consideration 
of this meeting. 



ORIGIN OF SPORADIC CASES OF YELLOW FEVER. 86 

First: The infection may have proceeded from children suffering 
from very mild attacks of yellqw fever, such as they sometimes have, 
and which attacks have been unknown through being confounded 
with some of the many feverish diseases to which infancy is liable. 

Second: The infection may have been contracted through some 
other channel than that of a patient suffering from yellow fever. 

The first proposition has the support of observed facts. The learned 
Dr. John Guiteras, of Havana, in a luminous and well reasoned 
work which he published in the "Review of Tropical Medicine" of 
Havana, for April, 1902, and to which he gave the title of "Infantile 
Yellow Fever and the Extinction of the Endemia," has demonstrated 
in a perfectly clear manner, that children are susceptible to attacks of 
yellow fever, and that it is to this cause that we must attribute the 
immunity which is enjoyed by the natives of those regions which arc 
desolated by that scourge, and as no precaution is taken, as it oug^t 
to be, to isolate every child suffering from any feverish reaction, it 
is very possible, so possible we can almost categorically affirm it, 
that it is in these children, if not in all those who are suffering from 
feverish symptoms, at least in many of them, that the mosquitoes 
find their infection, and thus produce those sporadic cases whose 
origin cannot be traced ; and as no disinfection is made of the rooms 
occupied by patients of this class so as to destroy the mosquitoes, the 
presumption that they constitute the origin of such cases, has all the 
appearance of truth. 

My long practice in the city of Veracruz, one of the principal foci 
of yellow fever, corroborates, in all its parts, the assertion made 
by Dr. Guiteras, and for that reason I accept his well proved ideas. 
In insisting today on this point, I do not claim to add anything new, 
and if I do so, it is with the object of insisting on the proposition, 
that every child who presents feverish symptoms ought to be isolated, 
just as we isolate every patient who is suspected or proved to have 
yellow fever, in order to avoid the appearance of these sporadic cases, 
and the possible, although not probable, appearance of epidemics, 
as happened in the city of Havana during the last months of the 
past year, and the first months of the present. 

The second proposition, that the mosquito may be infected through 
some other channel than that of a sick person, is entirely theoretical, 
a simple hypothesis, founded on the following considerations: To 
begin with, we have to go back many years and we naturally ask: 
where did the mosquito which caused the first attack of yellow fever 
acquire the germ thereof? In the light of science, we cannot accept 
the idea that the disease has spontaneously developed in the first sick 



86 ORIGIN OF SPORADIC CASES OF YELLOW FEVER. 

man or in the first infected mosquito, because that would give rise to 
the presumption that the disease went through an evolution in the 
course of years, the germ passing through its sporozoic generations, 
alternatively through the mosquito species and the htmian species, 
and these considerations, form a presumption in favor of the hypothe- 
sis tfiat the insect can be infected through some other channel, llie 
question is. Where? In other animals, that may be susceptible to the 
disease; in organic matter in a state of decomposition; foul waters, 
garbage, animal refuse, etc. 

As far as my knowledge on the subject goes, I do not know of 
any experiments that have been made for the purpose of resolving 
these two problems in the etiology of the disease; but the fact that I 
have not been able to find any allusion to them in the books within 
my reach, leads me to suppose that they have not been made, and if 
we have no positive facts which would enable us to affirm or deny 
that the mosquito may acquire its infection through another channel 
than that of a patient, the hypothesis becomes simply a subject for 
discussion and investigation in the etiology of the disease. 

This same hypothesis arises with respect to malaria fevers, and the 
opponents of the theory that this endemia is propagated by the mos- 
quito, have not hesitated to call attention to the fact, that without 
the presence of a patient, but with mosquitoes present, cases of that 
disease have been observed; and although they have confined them- 
selves to placing the fact on record without attempting to give the 
explanation, this may be founded on one of the propositions above 
stated, and which far from disproving the mosquito theory, as claimed 
by its opponents, lends it great support when it can be demonstrated 
by experiment, and deprive those opponents of one of their principal 
arguments. A hematozoon has been found in the blood of certain 
birds, that some authors assert is the same that produces the polluted 
infection in the human species, whilst others assert that it is entirely 
distinct; but without entering on a discussion on this point, I men- 
tioned the fact in order to remind my hearers, that if there is no 
certainty that the germ which generates malaria can be transmitted 
from the animal to the human species, that transmission is at least 
possible. That which is still a debatable point as regards the origin 
and transmission of malaria, and that in the course of time may be 
decided in the affirmative sense, can serve to support the hypothesis 
presented in dealing with yellow fever, seeing that the means of trans- 
mission is the same in both diseases, and that the last investigation 
pves us good ground to suppose that the yellow fever germ is a 
coccus of identical nature, or very similar to that of malaria. 



ORIGIN OF SPORADIC CASES OF YELLOW FEVER, 87 

Both in the animal as well as in the vegetable kingdom, all or* 
ganized beings with few exceptions, have their localities which are 
specially adapted to their existence and propagation, so that they can 
neither exist nor flourish in any others which do not fulfill the adequate 
conditions; and what we can dearly understand and experimentally 
prove as regards the species that are more or less elevated in the 
natural scale, must necessarily apply to those others which are found 
on the last steps of that scale, as the laws of biology are of general 
application. It is a well-established fact in medical nosography, that 
cholera, bubonic plague and yellow fever, have their foci in perfectly 
well defined sources, in which the germ (well defined microbes in the 
first two) are bom, increase and multiply in decomposed organic 
matter, in perfectly well known spots, under adequate conditions such 
as cannot be found combined elsewhere, even though organic matter 
in a decomposed state is found all over the surface of the earth, and 
although in all parts of the same, those diseases can easily be propa- 
gated. 

The enthusiasm that was caused by the demonstration of the mos- 
quito theory, has led us to overlook, as regards yellow fever, those 
ideas that have been preserved as regards the other two exotic 
diseases, so that instead of looking to them in search of one of the 
possible causes of infection, and attributing to them the origin of the 
sporadic cases, studying the ways to prove whether the mosquito does 
or can acquire the germ of the disease in those decomposed organic 
matters, as it takes it from the sick person, we demand that the above 
named theory should give us the explanation of that which it cannot 
explain. 

As we have no positive data to prove this hypothesis, we must not 
unconditionally accept it, but at the same time, having no positive 
data to warrant our throwing it aside, we ought to keep it in mind and 
undertake studies with the hope of reaching a real and positive solu- 
tion of this dilemma. The existence of a case in Santiago de Cuba 
during last year, and the reappearance of the endemia in the city of 
Havana at the end of the same year, are attributed, although without 
any exact and explicit proof, to importation from abroad ; but such a 
thing is not credible if we remember the rigorous precaution with 
which all persons are examined on arrival in the ports of the island. 
The case of New Iberia, La., of the 19th of August of the present 
year, that in Colon which I have cited at the beginning of this paper, 
and a multitude of similar cases which are too long to enumerate, 
give a certain appearance of probability, putting on one side all 
preconceived ideas, to the hypothesis I have propounded; that the 



88 ORIGIN OF SPORADIC CASES OF YELLOW FEVER, 

mosquito can be infected through another channel than that of a 
diseased person, and as I consider the subject well worth attention, 
I have thought it timely to submit to the consideration of this learned 
body. 

If, in the course of time, we are able to demonstrate either of the 
above, or other means which promote the spread of yellow fever, its 
transmission by means of the mosquito, will become an unquestionable 
truth and scientific. 



THE YELLOW FEVER EPIDEMIC OF 1905 IN NEW 

ORLEANS. 

Dr. QUITMAN KOHNKE. Covington, La. 

An Illustrated Address. Dr. Kohnke was Health Officer of New Orleans 
from September 1898 to September 1906. 

The conditions obtaining in New Orleans, in the summer of 1905, 
with regard to the possibility of yellow fever, were such as followed 
the utter disregard of the expert advice of its constituted sanitary 
authorities by the legislative branch of government during the preced- 
ing several years. Had the advice, wamingly given, and persistently 
and insistently urged, been heeded, there would not have occurred the 
disaster of 1905 ; — it would have been impossible to inflict upon New 
Orleans an infection of yellow fever of any considerable extent. 

The advice was, however, not acted upon, the warning was not 
heeded, and the conditions pointed out as a menace to the city's health 
and prosperity remained incorrected. Perhaps an all wise Providence 
intended a display of the city's resourcefulness and the splendid 
energy of its people when thoroughly roused by the actual presence 
of danger. 

It is my purpose to describe, in pictures, the conditions in our city 
at the time of yellow fever invasion, to describe the character of 
preventive measures adopted against the spread of infection, and to 
show the results obtained by their operation. 

I employ pictures, because pictures constitute a universal lang^uage 
and facilitate the conveyance of thought. It is my sincere regret that 
I am unable to express myself in the language of this country, and it 
is a fault of my education which I hope to correct by acquiring this 
accomplishment; though the need for it in this cosmopolitan city is 
scarcely perceptible. 

Never before was so large a battle successfully fought against 
yellow fever as in New Orleans in 1905, and never before was so 
marked a victory won in the face of such dire predictions of defeat. 

In Havana, a few years previously, there was achieved by the 
military power of the United States and an inexhaustible federal 
treasury, the first victory over epidemic yellow fever. 

In New Orleans, in 1905, the people, by their own effort and with 
their own treasury, successfully fought the greatest battle ever won 

89 



90 YELLOIV FEVER EPIDEMIC IN NEW ORLEANS. 

by sanitary science against disease ; and the victory marks an epoch 
in the world's advancement. 

For the final acceptance of what is called the mosquito doctrine of 
disease conveyance, as applied to yellow fever there was needed an- 
object lesson, planned on a large scale ; and New Orleans was offered 
up in sacrifice to furnish the demonstration. 

(Lantern slide picture thrown on screen about 20 feet in diameter.) 
No. I 

This is a map of New Orleans. You may be familiar with the 
contour of our city. It is the oldest part of New Orleans that con- 
forms to the convex curve of the river bank which gave to the town 
the name of the Crescent City. It was in this, which is now regarded 
as the foreign quarter, because it is occupied mainly by a foreign 
population (mostly Italian) that the fever was first observed as an 
infection and is supposed to have first appeared; but exactly where 
it first appeared and how it was first introduced will probably never 
be known. Deductions have been drawn from observations made, and 
guesses have been ventured which may be correct, as to the first in- 
fection and its introduction ; but I am dealing, at present, with ascer- 
tained facts only. The map is colored red and green to show (in red), 
the portions of the city infected, the green part indicating the unin- 
fected portion. It so happens that the red corresponds to the built up 
sections and the green corresponds to the unimproved lands. The in- 
fection was widespread, but not intense save in the district where it 
had prevailed secretly for a period long enough to gain a firm foot 
hold. 

No. 2. (Lantern slide in colors.) 

This is a map of the early infected district showing more plainly 
the location of the French Market, United States Mint, St. Louis 
Cathedral, Jackson Square, and the first emergency hospital. 

The first emergency hospital which was, at the time of its selection, 
and with regard to location and construction, the best building avail- 
able within the then known infected district. 

The building was unoccupied at the time, and in course of re- 
novation. It was forcibly seized by the health officer, and was con- 
verted from a sailor's boarding house into a modem screened hospital, 
with a capacity of 80 patients. All furnishings were new, and the 
work of preparation was completed to receive patients up to its full 
capacity, in 36 hours. Those of you who are familiar with the In- 
stallation of an infectious disease hospital know what this means. No 
case of yellow fever originated in this hospital although non-immune 



YELLOW FEVER EPIDEMIC IN NEW ORLEANS. 91 

visitors were almost constantly present and the hospital internes were 
not selected for their immunity. 

No. 3. (Lantern slide in colors.) 

Here we see the cisterns, the main source of supply in the greater 
portion of New Orleans of drinking water, and the principal source 
of supply of the yellow fever mosquito. Instead of being below the 
surface and constructed of masonry, they are above ground and made 
of wood, and they offer an inviting shelter to any flying insect in 
search of stagnant water. 

No. 4. (Lantern slide.) 

We might, with profit, rapidly consider the essential features of 
what is called the mosquito doctrine of yellow fever conveyance, for 
it is on the lines suggested by this doctrine that our fight was made, 
though many of our prominent good and well-meaning citizens 
fatigued themselves unnecessarily by the removal of dirt thus en- 
couraging a continuance of belief in the fomites theory, and placing, 
by their example, serious obstacles in the way of the general accept- 
ance of the truth. 

This picture shows the egg of the yellow fever mosquito which the 
adult female deposits on the surface of still water ; preferably such as 
is found in cisterns, barrels, and similar containers near to human 
habitations. 

No. 5. (Lantern slide, colored.) 

The larva of mosquito which issues from the egg in about two days. 

No. 6. (Lantern slide, colored.) 

Pupa, which developes from larva in about three days. 

No. 7. (Lantern slide, colored.) 

The adult mosquito of the yellow fever variety issues from the shell 
of pupa in about two days. 

From the egg to the adult requires about one week — one-third the 
period usually observed in the development of the Anopheles or mala- 
ria bearing mosquito. 

The period of growth varies with temperature and environment. 

No. 8. (Lantern slide, colored.) 

This is the male of the yellow fever mosquito, which is more 
elaborately plumaged than the female, and is not a blood sucker, be- 
cause of the peculiar construction of its proboscis rendering it im- 
possible for it to pierce the skin. 

No. 9. (Lantern slide, colored.) 

The female mosquito, because it is a blood feeder, is capable of 
transmitting the disease. 



«2 YELLOW FEVER EPIDEMIC IN NEW ORLEANS. 

Let us consider, briefly, the manner in which yellow fever is con- 
veyed from person to person. 

The germ of yellow fever, if discovered, has not yet been accepted, 
and we will employ, for illustrative purposes, the malarial germ, which 
is demonstrable and which we know must be similar in its character- 
istics to the yellow fever germ by the similarity of sanitary observa- 
tions in both diseases. 

No. 10. (Lantern^ slide, colored.) 

This picture is a micro-photograph, enlarged and colored, of blood 
taken from a malaria subject. The malaria germ is seen in the center 
of the field floating free in the plasma. 

No. II. (Lantern slide, colored.) 

The malaria germ is seen inside a red blood corpuscle having pene- 
trated the capsule. The blood cells are colored red in the picture and 
the germ is observed as a dark spot within the red disk. 

No. 12. (Lantern slide, colored.) 

The germ is pictured as it is multiplying by subdivision or segmen- 
tation, and as the normal contents of the cell membrane are bemg 
•destroyed. 

No. 13. (Lantern slide, colored.) 

The cell membrane is shown so full of germs that the membrane 
has burst, and, in nature, each one of the germs liberated by the 
bursted cell is ready to attack a red blood corpuscle and repeat the 
process of multiplication, development and destruction, illustrated by 
the micro-photographs. 

No. 14. (Lantern slide, colored.) 

This diagramatic sectional view of the mosquito is intended to show 
how the blood of its victim enters the stomach of the insect from which 
the germs, (undergoing certain changes, not necessary to elaborate) 
migrate through the intervening tissues to the salivary glands, from 
which, during the act of feeding, they may be injected into the blood 
stream of a subsequent victim, there to multiply and give rise to the 
symptom picture called malaria. 

A mosquito injects saliva at the time of feeding for the purpose 
of thinning the blood and rendering it more easy to secure. 

No. 15. (Lantern slide, colored.) 

That the migration of germs in the manner that I have superficially 
described, is a fact that can be easily demonstrated. Here is shown 
the stomach of a mosquito, micro-photographed. Spots of inflamma- 
tory swelling are seen where the germs are boring their way through 
the stomach coat, which is normally smooth. 



YELLOW FEVER EPIDEMIC IN NEW ORLEANS. 9a 

No. i6. (Lantern slide, colored.) 

Here is shown a micro-photograph of a sectioned thorax, and the 
germs are seen on their way through the tissues of the mosquito. 

No. 17. (Lantern slide, colored.) 

This is another sectional view, showing the salivary glands and the 
poison glands the colors of the several organs being different to facili- 
tate perception. 

One of the salivary glands is enlarged by the presence of malarial 
germs and the inflammation set up by this entrance through its walls. 

I need not rehearse, here, the evidence upon which is based the 
mosquito doctrine of yellow fever conveyance save to say that, as a 
result of elaborate and repeated experimentation, the following im- 
portant facts have been discovered and formulated into a doctrine. 

Yellow fever is conveyed in one way only. The Stegomyia mosquito 
obtains the germ of the disease by feeding on the patient during the 
first three days of illness ; the germs reach the salivary glands of the 
insect in twelve days, and not until then is the mosquito infectious; 
therefore, — to keep mosquitoes from biting a patient during the first 
three days of his disease will prevent infection of mosquitoes; to 
destroy mosquitoes already infected prior to the expiration of the 
twelve day period will prevent infection by them of persons. 

No. 18. (Lantern slide, colored.) 

Ejiowledge of the way in which yellow fever is spread points 
logically to its prevention; but it is a far cry from the discovery of 
a scientific truth to its general acceptance by a community, and the 
hardest of our work was the instruction of the ignorant and the re- 
moval of prejudice against the new doctrine. 

The main source of supply of Stegomyia mosquitoes is our cisterns ; 
you see how close to our living rooms they are situated. 

No. 19. (Lantern slide, colored.) 

You see here the same cisterns, covered with cheese-cloth to pre- 
vent the entrance of mosquitoes after the oiling of the water surface 
to kill those not yet developed into adults. This picture is a little 
too intensely colored, but everything about New Orleans was highly 
colored at that time — especially the libelous statements against the 
health authorities, extensively published by many of the yellow 
journals, and^ I regret to say, by a portion of the medical press. 

No. 20. (Lantern slide, colored.) 

Infected rooms after being made vapor tight were fumigated with 
sulphur to kill mosquitoes. 

No. 21. (Lantern slide, colored.) 

A typical dwelling and inmates in the first infected quarter showing 



9^ YELLOW FEVER EPIDEMIC IN NEW ORLEANS. 

the large number of people living in a small house, and the water 
barrel standing under the hydrant faucet; the only water supply be- 
ing unfiltered river water, requiring to be kept in barrels to be cleantd 
by the settlement of the silt and mud. 

No. 22. (Lantern slide, colored.) 

A laundry in the district the water supply of which is contained in 
barrels, mainly, each of which, uncovered, furnished yellow fever 
mosquitoes. 

No. 23. (Lantern slide, colored.) 

Gallatin Street, at the French Market, where the first cases are sup- 
posed to have occurred, about six weeks before the first suspicion was 
entertained that yellow fever had entered the city. 

No. 24. (Lantern slide, colored.) 

The landing place on the river bank for the Havana steamers; one 
sh6rt square from Gallatin Street. The distance between Gallatin 
Street and the street facing the river, which is called Levee Street, is 
so short that the houses, between, open on both streets, and an en- 
trance on Gallatin Street may lead to a room facing the river. 

Dengue prevailed in Havana before yellow fever was suspected in 
New Orleans, and no measure of quarantine protection was operated 
against Cuba at the time. I do not know that Havana was the source 
of our infection. 

No. 25. (Lantern slide, colored.) 

The chart shown here illustrates by the coloring — yellow and red — 
the difference in results between the epidemic of 1878 and that of 
1905, both of which seem to have begun at about the same time. The 
intensity of yellow corresponds with the height of the epidemic in 
1905, which was about the middle of August (Aug. 12). The in- 
tensity of red shows the height of the epidemic of 1878 to have been 
about the middle of October. If no attempt had been made in 1905, 
more efficacious than the efforts put forth in 1878, one can readily 
imagine what a terrible calamity our city would have suffered, and 
that the fever was controlled, despite the fact that no preventive steps 
were taken until the fever had gained considerable headway (unknown 
to the authorities) is a brilliant demonstration of the correctness, in 
actual practice, of the doctrine of the mosquito conveyance of yellow 
fever. 



NOTES ON YELLOW FEVER. 
Dr. M. p. COLMENARES, Oeizaba, Mexico. 

SUMMARY. 

Intravenous injections of colargol in the treatment of yellow fever. 
Constant curative results. Invitation to those physicians who practice 
in places where that disease is found to undertake that treatment 
in accordance with the technique which I have employed. Hygieni- 
cally speaking, colargol is also of great value because as it sterilizes 
the blood of the patient it commences by suppressing the focus of 
infection in the very place of its birth. It would be of vital interest 
to Mexico and America in general to have a commission undertake 
to verify the facts that I have witnessed on a small scale. In the 
event of the experiments with mosquitoes demonstrating that they 
are not infected when they sting a patient in whom colargol has been 
injected (a fact that is not far from possible and logical) the present 
practice of putting them into screened rooms should be abandoned, 
as it greatiy depresses the morale of the patients, and I have seen the 
rate of mortality increase probably by this method, which is so highly 
depressive on the nervous system. 



95 



NOTES ON THE HYGIENE OF YELLOW FEVER. 
Dr, ALFRED J. J. AUSTIN, Cuidab Mier, Tamaulipas, Mexico. 

ABSTRACT. 

The term "Hygiene" is used by the author in its most ample in- 
terpretation with respect to yellow fever, not only as regards the 
preservation of health, but also with regard to ever3rthing which 
may indirectly disturb it. 

As the micro-organism which is the cause of yellow fever has not 
as yet been discovered, but is known to be transmitted by the 
''Stegomyia fasciata/' the destruction of this mosquito and of its larvae 
should preferently occupy our attention in those places which are 
invaded by yellow fever. This mosquito is probably that which most 
abounds in this part of the Republic (state of Tamaulipas) and accord- 
ing to my observations, is found all over the state. 

Once an epidemic of yellow fever is declared, the general and 
systematic fumigation of all buildings, whether public or private, is a 
matter of the first importance, as well as the sterilization of abandoned 
wells and other places where the mosquito searches for humidity 
and shade. The drainage or filling up of the swamps or the appli- 
cation of petroleum to their surface as well as over all water tanks, 
wells and pools are measures of well known utility. 

I have obtained very satisfactory results in practice by leaving in 
inhabited houses and shady places where no drafts were felt, vessels 
of white crockery or glass full of water, for the purpose of inviting 
the females to deposit their eggs therein so that they could be at once 
destroyed in that condition or after they had developed into larvx. 

The destruction of weeds and useless plants as well as of the 
rubbish which can give shelter and shade to the mosquito near the 
dwelling houses, are steps to be recommended, as well as the daily 
cleaning and dusting of the dwellings. 

If in normal times it is necessary to inculcate personal cleanliness, 
temperance, a methodical life and moderation in ever3rthing, with 
mudi greater reason should we observe these rules during an 
epidemic of yellow fever, and as far as possible cultivate a tranquil 
mind.- 

, We must attend to all feverish symptoms and especially those of an 
intermittent type, because I have noted as a general thing that cases 

96 



NOTES ON THE HYGIENE OF YELLOW FEVER. 97 

of intermittent fever came at the commencement and end of an 
epidemic of yellow fever and I believe that it is worthy of our atten- 
tion to study in the laboratory whether the blood of an intermittent 
fever patient under certain atmospheric conditions of humidity or heat, 
can or cannot produce the germ of yellow fever. 

The isolation of the patients, the segregation and vigilance hy 
means of a sanitary cordon of the houses or districts which are in- 
fested and of their inhabitants are precautions to be insisted upon and 
carefully watched over. 



GEOGRAPHY OF MALARIA IN THE MEXICAN Ri' 
Dr. ANTONIO LOAEZA, Mexico, D. F., Mexico. 

I am moved by several motives to raise my voice before t 
assembly of physicians from different American coimtries on 
ject I refer to. The first is that I desire to contribute with n, 
of sand, by imparting some information as to the geogr^hic 
tribution of malaria in my country, and which I have acquired tl. 
having under my charge the climatoiogical investigations of tht 
tional Medical Institute. The second is, that I hope to raise the . 
of my colleagues in order that with their unquestioned love of scie 
and their valuable experience, they may throw some light on a subji 
which is of such great interest to this Republic, as I propose here 
inform them, as far as my knowledge goes, of what has been done 
this matter and also give my opinions as to what remains for sdem 
to do. At the same time, one of my principal desires in preparing thii 
paper is to extend my own knowledge by submitting the facts which 
I here relate to a discussion which I hope will be allowed on the sub- 
ject of this paper. 

I will commence by relating what I have ascertained during a study 
of many years on the subject I bring before you, and begin by stating 
that the Mexican Republic is an eminently palustrine country, and 
that it is so precisely in the richest and most fertile sections, on the 
extensive eastern and western coasts that are washed by the great 
oceans. With respect to these Mexican territories, we may use the 
words which Dr. Herrick wrote with respect to the lands in North 
America which occupy the delta of the Mississippi, "those enor- 
mously fertile lands which are worth from loo to 200 francs per hec- 
tare and which might be worth ten times as much." I declare that the 
Mexican lands which are scourged by malaria, could perhaps multiply 
their value one hundred fold if they found themselves free from that 
endemia. It is also well to remember, that in view of the extensive 
zones of our territory which are ravaged by malaria, it causes a greater 
loss of life and greater injuries than typhus and yellow fever together. 
For this reason all Mexicans ought to unite their efforts in order to 
reach the desired end and stamp out malaria in our territory', espe- 
cially if we bear in mind that we have to deal with a disease against 
which we can now combat with success. 

I will never weary of repeating, that the most interesting point in 
the case is to acquire a knowledge of the exact geographical distri- 

98 



MALARIA IN THE MEXICAN REPUBLIC, 99 

fcution of the disease as it is understood by modem science. In order to 
designate a place as subject to malaria, it is necessary in each case of 
the disease to verify the existence of the Laveran bacillus in one of 
jts many forms and it is also necessary to determine the form in ques- 
ticMi. According to Dr. Ross it is necessary to verify the existence of 
the Anopheles mosquito, so as to comjxlete the mathematical formula 
which explains the evil in each locality as follows : the Anopheles plus 
the malaria patient, establishes malaria. I would refer those who de- 
sire any further information on this point to Vol. VIII of the "Annals 
•of the National Medical Institute" for March last, in which the inves- 
tigations carried out in our country on this interesting point are re- 
corded. 

It is also necessary to decide in each case and in each locality, the 
:so-called endemo-epidemic period, that is to say, the time of year in 
which the more serious cases arise as well as the more numerous. In 
this manner we will be in a position to know how and when it is pos- 
sible to go to each infested locality without any great danger. 

And lastly, it is indispensable to know in each locality which has 
been classified as malarial, the exact physical and natural conditions, 
such as topography, hydrography and meteorology, which are capable 
of creating or favoring the development of the Anopheles, which in 
jreneral terms, consist of a constant and sufficiently elevated tem- 
perature, stagnant and clean water, and a little permeable soil. Unfor- 
tunately, I do not know what is the truth as regards these varied 
•questions so as to indicate with full certainty the malarial geography 
of Mexico and I fulfill one of my objects by begging the Mexican 
physicians who are present to unite their efforts, so as to get a better 
loiowledge of the same. 

It would perhaps be very desirable that every municipality which 
is suspected or known to be in malarial territory, should be obliged to 
procure a microscope, which in every case would facilitate the studies 
•of the resident physicians, and also that the latter should be obliged 
to report every case of malaria which they observe to the local authori- 
ties, together with the details which they might think suitable, besides 
teaching the people of the neighborhood the measures which they 
^ould take to prevent the attacks of the disease. 

For my part I may state, that I have personally observed with the 
microscope the blood of malaria patients who are natives of many 
<iifferent states of the Republic and which I have therefore noted as 
undoubtedly subject to malaria. As regards others I have the micro- 
scopic proofs referred to, that have been furnished me by honorable 
.and competent physicians and for this reason I place them in the same 



100 MALARIA IN THE MEXICAN REPUBLIC, 

category. As regards other localities I have the reports of trust- 
worthy physicians, who believe, although without microscopic proof, 
that malaria exists there and with respect to other localities I have no 
trustworthy data. For further details I refer to my paper above 
mentioned. 

I therefore consider the geographical distribution of malaria in the 
Republic as follows: States in which microscopic proof has beea 
obtained by myself or others: Yucatan, Veracruz, Tamaulipas, and 
the whole of the Gulf littoral; Oaxaca, Guerrero, Michoacan, on the 
Pacific Coast; Coahuila, on the northern frontier, and the states of 
Queretaro and Morelos in the centre. The Territory of Quintana Roo 
has also been proved malarial by microscopic examinations. 

The states of Sonora and Sinaloa, together with Chiapas, Tabasco, 
Campeche, Puebla, Hidalgo, Guanajuato, and San Luis Potosi very 
probably are malarial, although I do not know of any microscopic 
proof and therefore I put them into the second category. 

The Federal District and City of Mexico do not suffer from this 
disease, as has been fully proved. 

As far as regards the other states or territories I can affirm noth- 
ing in either sense for want of data. 

We therefore see that out of the thirty-one political divisions of 
the Republic, twenty are malarial and as regards the remaining eleven 
I have no knowledge. Of these, four which are the States of Jalisco 
and Colima, as well as the territories of Lower California and Tepic, 
must have the disease, seeing that their conditions are in every way 
similar to those that I have above noted as malarial, thus making a 
total of twenty-four political divisions in which it exists and leaving 
only seven in which it is possible that it does not exist. 

From this we can deduce the truth of my fundamental assertion^ 
that our country is specially malarial, and therefore the necessity that 
we should unite our efforts to care for the lives of our own countrymen 
and foreigners so as to protect all the enterprises that operate here, 
because the greater number of inhabitants we have, the greater will 
be the active operations, or in other words, the greater will be our 
welfare, because human labor implies wealth and this is converted 
into welfare. 

I will not neglect the exceptional opportunity which is offered by 
this brilliant scientific meeting, to insist on tiie importance of the 
study of national precautions against malaria, for the protecticm of 
our own countrymen and foreigners, because even though they have 
failed up to the present we may perhaps find some that will be effi* 
cacious. From- the general study that I made in the medical Institute, 



MALARIA IN THE MEXICAN REPUBUC. 101 

the only plant which I found to promise some good results was the 
purple heliotrope (Heliotropus Peruvianus.) See paper on the sub- 
ject in the Annals, Vol. VI, page 382. 

Not to abuse your patience any further, I will present the following 
summary of my ideas : 

1. It is urgently necessary to make a scientific study of the geog- 
raphy and climatology of malaria in the Mexican Republic. 

2. It is in every way indispensable to oblige our physicians to re- 
port all cases of acute or mild malaria which they may observe in 
their practice. 

3. The diagnosis must be verified by a careful microscopic exam- 
ination. 

4. In each malarial locality it is necessary to demonstrate the pres- 
ence of the Anopheles, 

5. It is also urgently necessary to persevere in the study of the 
national anti-malarial remedies. 

6. Meanwhile, the entire country should be taught the advantage 
of taking small daily doses of quinine as a wise precaution to prevent 
malaria in those regions in which it prevails, especially in the endemo- 
epidemic season, and particularly the foreigners who live in those 
localities. 

7. All classes of society should also be taught the use of metallic 
gauze and of mosquito curtains to avoid the sting of the Anopheles, 

8. It would be very advisable to form a centre for the study of 
malaria in the Republic, similar to that which was formed by Dr. 
Celli in Rome, under the name of "Societa per le studi de la malaria." 



THE WAY TO STAMP OUT MALARIAL FEVERS. 
Dr. EDUARDO LAMICQ, Mexico, D. F., Mexico. 

When we think of the heroic efforts which are made by the sanitary 
authorities in their struggle against epidemics; when we understand 
the brilliant successes which they have obtained, whether in deal- 
ing with the bubonic plague, yellow fever or other diseases of that 
character, it is only natural to desire that the same science and energy 
should be brought to bear against another disease, which is perhaps 
of greater importance than the ones mentioned, and which is known 
by the name of malarial fever. 

As a matter of fact, malaria prevails in an endemic form over a 
large part of the earth, and if we limit ourselves to our own continent^ 
we can safely assert that the greater part of its littoral and the whole 
of the so-called torrid zone suffer from this endemia, which prevents 
the development of those regions. These sections, which are undoubt- 
edly the most fertile in the continent, are almost abandoned and 
uncultivated, for the reason that the fevers decimate the inhabitants, 
and even if they do not die, many of them are left in a sick and 
debilitated condition, and therefore incapable of making the efforts 
required for the advancement of those regions. The immigrant very 
reasonably is afraid to go to those countries, and if he does, he very 
soon falls a victim, and becomes more or less incapacitated for any 
work, loses his energy, and in order to escape with his life, fre- 
quently finds himself under the necessity of leaving those fertile and 
rich lands on account of the unhealthy conditions that render them 
uninhabitable. In this manner, the malarial fevers constitute the prin- 
cipal cause of the backward condition in which these sections are gen- 
erally found, and if we could only suppress this plague, we would 
render the richest territory in the whole world inhabitable so that it 
could be worked, and undoubtedly would enormously increase the wel- 
fare of humanity. 

I am far from thinking that I can solve so difficult a problem in 
this paper, but I simply desire to present it and express my opinion 
as to the best and perhaps the only manner to deal with it in a suc- 
cessful way. 

To begin with, I desire to state that I will not take up your time 
with a discussion of those means which, like mosquito netting, fumi- 
gations, etc., are unquestionably of great use in diminishing the ter- 
rible effects of this scourge, but which are not in themselves capable 

102 



THE WAY TO STAMP OUT MALARIAL FEVERS. 108 

of suppressing it in an absolute manner. I shall only speak of the 
means which have been recommended as susceptible of radically 
stamping out the endemia of malaria. 

Theoretically speaking, there are three courses that suggest them- 
selves as capable of finally suppressing the malaria in those places, 
and they are: firstly, the suppression of the hematozoon; secondly, 
the suppression of the means of transmission, and thirdly, the inmiuni- 
zation of all those who temporarily or permanently reside in the sec- 
tions where malaria prevails. Each one of these methods has found 
its defenders, and it is therefore worth while to make a careful study 
of them before coming to any conclusion. 

Suppression of Hematozoa. — A German commission presided over 
by Prof. R. Koch, proceeded to New Guinea in 1900^ to study the 
malarial fevers and came to the conclusion that this was the method 
and that it was the best adapted to obtain the suppression of malaria 
in those places. The commission was so convinced of the practicability 
of this method, that Dr. Koch, its president, in his fourth report says 
as follows: "I believe that we can now come to the conclusion, that 
by applying the method I have indicated, we can render all the ma- 
larial regions absolutely or almost absolutely healthy, according to 
the circumstances of each."^ 

The method he refers to, consists in the suppression of the parasite, 
and if we start from the principle that malaria is exclusive to the 
human being and that for its evolution the parasite necessarily re- 
quires to pass through the body of this being, we come to the conclu- 
sion, that if, within a given time, we combat all the cases of malarial 
fever which may then be found within a region until they are radic- 
ally cured, that is to say, until we have completely destroyed the 
germs in those patients, we interrupt the hain or cycle of life of that 
parasite, and consequently obtain its suppression. But we must per- 
fectly understand that a radical cure of the disease will be necessary, 
and not only of its manifestations, because as we all know, this disease 
has the same characteristics as syphilis and others, that it gives way to 
adequate treatment within a short time, as far as regards its outward 
manifestations, but that to cure the patient in a radical manner a 
much longer time is required. As we can see, this method is founded 
on the assumption that malarial fever is limited to the human being, 
and further on we will see that this assumption is not admitted by all 
students. But granting that this is true, can this method be applied in 
practice? The German Commission carried out its studies on an island, 

*La Medicine Scientifique, 1900, page 118. 
'La Medicine Scientifique, 1900, page 148. 



104 THE WAY TO STAMP OUT MALARIAL FEVERS. 

and if we grant that it was feasible on that island, I do not believe 
tliat it would be so on a continent, as there it would be materially 
impossible, on account of its great area, to recognize and apply the 
remedy at the same time, to all the sick who might be found scattered 
at great distances throughout its territory. So that, even assuming 
an international agreement and the best good will to carry it out, not 
only would there be many isolated individuals and nomadic tribes left 
unattended, but also entire towns, and all of these would preserve the 
germ, from which the disease would take a fresh start. Beside this, 
the germs which during this campaign might find a lodging in the 
bodies of the mosquito, etc., would not be destroyed. How could we 
prevent these from again infecting the non-immunes? But even as- 
suming that all the difficulties were overcome and the success obtained 
how could we maintain that successful condition, and prevent the 
germs again penetrating the continent, when we well know that in 
certain stages of the disease the parasite cannot be found in the blood 
of the patient? It would be enough for a single fever patient to pass 
unperceived or for an infected mosquito to get loose, for the disease 
to develop afresh and to propagate itself to such a degree, that in a 
single moment we would lose all the fruits of the campaign, under- 
taken against such enormous difficulties, and overcoming obstacles 
that are practically insuperable. In one word, I believe that even 
granting that all the assertions made by Dr. Koch are correct, it will 
be in practice impossible to suppress by this means the malarial fever 
in a continent with anything like completeness. 

Suppression of the Means of Transmission. — The English 
Commission which was sent to the Lower Niger by the School of 
Tropical Medicine and Medical Parasitology of Liverpool, for the pur- 
pose of studying, the most efficacious method of preventing and cur- 
ing malaria in those regions of British West Africa, formed the 
opinion that this means; that is to say, the destruction of the mos- 
quito*, is the most adequate. But if we carefully examine the report 
of that commission, we will see that this method presents even greater 
difficulties and less probabilities of success than tihe previous one. In 
fact, it has been said that the Anopheles is a necessary and indispens- 
able means of transmission of this disease, and we will see that this 
is not exact. But even granting for a moment that it is so, how can 
we destroy it when, as we all know, it is found distributed throughout 
an entire continent? Attempts have been made to obtain this result by 
destroying the larvae found in all stagnant water. But is this feasible 
in a continent with large areas of uninhabited and unknown lands, 

'Semaine Medicale, 1901, page 206. 



THE WAY TO STAMP OUT MALARIAL FEVERS. 306 

which have never been penetrated by man, and frequently are covered 
by thick impenetrable forests; is it possible to canalize all the water 
<x)urses or cover them with a layer of petroleum, when we know that 
«ven the depression or hollow that is left by the tread of an animal, 
by the passage of a wagon wheel, etc., and which is afterwards filled 
with rain water and thus forms a small puddle, furnishes a suitable 
lodging and breeding place for the mosquito? But let us assume that 
we have been able to do all of this, and that not a single pool is left 
on the continent which is not covered with petroleum, and let us even 
suppose that all the Anopheles are exterminated, will malarial fevers 
then disappear? It is almost certain that they will not, as it has 
already been demonstrated that the Anopheles mosquito is not the only 
means of transmission for this disease. There are already many per- 
fectly well proved cases, in which the infection was made through 
other channels, and by way of example, Dr. Vincente* relates one, 
in which it was clearly proved that the "aspidiatus nerii" which lives 
on the rose laurel was the means through which the germ of an old 
malarial fever was transmitted to a healthy individual who was later 
on cured with quinine, and in proof of this, the germ was found in 
the body of the insect. We thus see that the Anopheles is not the only 
<:hannel and is not always indispensable, as has been shown by the 
numerous experiments made by Gerhardt', and repeated by Laullig. 
Others have demonstrated, that by introducing a few drops of blood 
from a malarial patient into a healthy individual, the latter acquires 
the disease, and Celli has seen that it is only necessary to scratch the 
skin with the needle of a Pravas syringe on which there is some blood 
from a malarial patient, to communicate the disease. As we see, the 
germs in these cases do not require to pass a part of their existence 
in the body of another animal in order to communicate the disease to 
the individuals to whom they transmit it. The truth is that the same 
thing has happened with the discovery of the means of transmission 
as almost always happens with all discoveries; that the enthusiasm 
which is produced by it is exaggerated, and it is only afterwards that 
a cool observation reduces those discoveries to their just limits. The 
discovery of the hematozoon in the body of the Anopheles and the 
experiments which demonstrated that the insect so affected is capable 
of transmitting the malaria, has led us to overlook the other means, 
which the experience of centuries has taught us can also produce it 
The same thing has happened, for example, with water, whose pow- 
ers of transmission have been perfectly demonstrated through numer- 

*La Medicina Gentifica, 1901, page 158. 
* Semaine Medical^ 1902, page 161. 



106 THE WAY TO STAMP OUT MALARIAL FEVERS. 

ous and exact observations*, to which I will only add another, per- 
sonal to myself. When I had the honor to serve as sanitary delegate 
in the port of San Benito, I found malaria prevailing there in an 
endemic form, and with such intensity, that the public administratioa 
was carried on under great difficulties, and especially the preventive 
service, as all the employes who were sent to serve in that place fell 
sick within a few days and had to be replaced with others, a thing 
that could not always be done. 

It was impossible to extirpate the mosquito there, as the town was 
surrounded by extensive swampy lagoons and impenetrable forests 
that stretched for kilometres into the country. It would have re- 
quired an enormous expense, not to exterminate the mosquito which 
would always come from the neighboring country, but even to dimin- 
ish its numbers to an appreciable extent. But there were other causes 
against which we could make a struggle, and one of these appeared 
to me of the greatest importance and consisted of the water which 
was drunk, and which was drawn from shallow wells in the sand, for 
which reasons its drinking qualities were of the worst. The rain water 
which ran off the sheet iron roofs of the custom house building, if 
carefully kept covered so as to prevent its infection, was for some time 
used and kept in iron tanks which were well covered. The result was 
remarkable; I may not say that no cases of the disease were after- 
wards observed, but I can say the cases decreased in a marked manner, 
and that on observing the difference, the inhabitants of the town 
begged as a favor that they should be allowed to take some of the 
water. In this case all the factors continued as before, with simply a 
change in the water, and this was sufficient to make a notable difference 
in the endemia. I therefore think it only logical to infer that this dif- 
ference in the water exercised an appreciable influence in the spread of 
the disease. On the other hand, why should we be surprised to find 
that the water was capable of originating the malaria, when as we well 
know, it is always searched for by the mosquitoes. Is it not to be sup- 
posed that the infected Anopheles that there lose their lives, and whose 
bodies float on the water, liberate there the hematozoa which were 
in their bodies, so that when this water is drunk later on, it pro- 
duces the fever in the person who has drunk it, in the same way 
as happens in the cases of typhoid fever, cholera morbus and other 
diseases. This is nothing but a simple supposition, as in these waters 
we have fouAd amibas and elements endowed with flagelous, which 
are only distinguished from the hematozoon by the absence of pig- 

• Laveran-Traitc dc paludisme, 1898, page 115. 



THE WAY TO STAMP OUT MALARIAL FEVERS. 107 

ments/ but as is noted by Laveran, the hematozoon derives its pig- 
ment from the hamatias, which being still free, cannot as yet have 
them. 

In one word, it is practically impossible to extirpate the mosquito 
in an extensive continent, but even supposing it to be entirely de- 
stroyed, this would not be sufficient to stamp out the malaria, as it 
has already been demonstrated that it is not the only channel of 
transmission, and that even that channel is not absolutely indispens- 
able, and that other means, principally infected water, are capable 
of producing this disease. 

Immunization. — In view, therefore, of the fact that the two 
previous methods are impracticable and inefficient in their restdts, we 
can only appeal to the third, that is to say, to immunization. As the 
application of this method does not require that it should be resorted 
to on all non-immunes at the same time, there can be no doubt that 
it is practicable, and that its results, if it is applied with energy and 
perseverance, would necessarily have to be successful, as sooner or 
later it would end by granting immunity to all the inhabitants of 
palustrine regions, and then, not only would they be secured against 
malaria, but the hematozoon whose evolution requires that it should 
pass some of its life in the human body, would find this impossible, 
and its cycle of life would be interrupted in such a way that it would 
eventually disappear. It is true that some are of the opinion that 
malaria is not one of the diseases from which immunity can be con- 
ferred, and Glogner goes so far as to say, that the individual who has 
once suffered from malaria has always a predisposition to a second 
attack. But all those who have made a careful study of this question 
maintain that immunity certainly exists, and as regards the relapses,, 
Koch explains them by sa)dng that they are due, either to the indi- 
vidual not having been radically cured, so that, rather than a relapse, 
it is a recrudescence of the disease, or else that the quinine has arti- 
ficially interrupted the course of the infection and prevented the devel- 
opment of the immunity.* I believe that this is the truth, but the 
investigations of the German Commission, which on this point have 
been proved by those of the English Commission, have demonstrated 
that in malarial regions all the children under two years of age are 
invariably attacked by the disease, as shown by the hematozoa which 
are contained in their blood; but that when they go beyond that 
age, the frequency of the attacks diminishes, and that beyond five 
years of age, or ten at the utmost, the malaria does not attack the 

* Laveran-Loc. cit, page 86. 
*Semaine Medicale, 1901, page 46. 



108 THE WAY TO STAMP OUT MALARIAL FEVERS. 

natives, always provided that they have not^taken any qtiinine. Ac- 
cording to Koch, the same thing has been observed with respect to 
the immigrants, who within a short time after arrival, generally speak- 
ing three or four weeks, are attacked by the disease and continue 
^ick for a longer or shorter period, but after a stay of four or five 
years they can be classified with the natives as already immune; but 
always supposing that the quinine has not interrupted the natural evo- 
lution of the immunity. If, therefore, all the natives of those regions 
fall sick of malaria before reaching the age of two years, and are 
always found in good health when they have gone beyond the age 
of ten, in spite of their continued residence in the midst of all the 
conditions that cause malaria, and that continue to cause it in the immi- 
grants, it is evident that if they no longer acquire the disease, it is 
because they have become immune and I can understand in no other 
way how, after being stung by infected mosquitoes, they could remain 
in good health. An attempt has been made to explain this, by saying 
that these individuals are of a nature that is antagonistic to the dis- 
ease, that is to say, that they are immune, not through having suflFered 
a previous attack, but because they are so by nature, or in other words, 
that they were born immune. But this natural immunity has not been 
proved, but on the contrary, as already stated, all children under 
two years whose blood has been studied by the German or by the 
English Commission, in absolutely all cases was found to contain 
hematozoa, which shows that not a single case of natural immunity 
was found amongst all the inhabitants of those regions, of over ten 
years of age. In view, therefore, of all these obligations, I believe we 
must accept as an undoubted fact, that malaria is a disease against 
which immunity can be conferred. The difficulty therefore consists in 
finding a proper serum, that without the dangerous sufferings, etc., of 
the disease itself, will confer immunity, and although this is difficult, 
it is by no means impossible. Modem science has obtained this ad- 
vantage with regard to other diseases, and we can therefore believe 
that it will also make the discovery as regards malaria. It is true 
that great difficulties will have to be overcome before this serum is 
discovered, and it appears that malaria is exclusively confined to 
the human species, as up to the present day we have not been able 
to transmit it to any of the lower animals, and according to Laveran, 
the hematozoon has never been found in the blood of animals which 
were believed to have died of malaria. Nevertheless, in some parts 
of Africa, such as the Soudan, horses are frequently attacked by a 
fever which presents some clinical and anatomo-pathological symp- 



THE WAY TO STAMP OUT MALARIAL FEVERS. 109- 

toms that are similar to those of malaria, and Pierre* states that he 
has found very similar semi-lunar or crescent shaped bodies in the 
blood of those animals, which are very similar to those of malaria,, 
but according to Laveran^^ these are tripanosomes and not malarial 
germs. Another diflSculty, which is also of great importance, is that 
we have been as yet unable to cultivate the hematozoon and still less 
isolate the necessary toxine for the investigations of this character. 

In spite of all these difficulties, attempts have been made to dis- 
cover the manner of producing that immunity, as is shown by the 
experiments of Kuhn, of Celli and Santori, as well as others; but 
tmfortunately without any positive results that would allow us to take 
advantage of them for the benefit of the people who suifer from this 
plague. 

In view, therefore, of the great difficulties which this study presents, 
and especially of its immense importance to the progress of those 
regions, as well as to the welfare of humanity in general, I would 
propose that the governments which are interested in the suppression 
of this plague should offer a considerable prize for the discovery of 
a suitable toxine, that without any danger or gpreat inconvenience, 
would confer immunity against malaria. 

*Dti palndisme chez le cheval-Rek. de Med. veter, 1896-80 Mars. 
• Lavcran-Loc. cit., page 91. 



SOMETHING ABOUT TH,E ETIOLOGY OF MALARIAL 

DISEASE. 

Dr. JESUS CHICO, Guanajuato, Mexico. 
(Abstract by the author.) 

Begging to be excused by physicians, the writer of the paper — 
who has also made this abstract of it — explains for those hygienists 
and sanitarians who do not belong to the medical profession that by 
"etiology" of a disease, a physician means the first agency which 
gives rise to it and that by "pathogenesis," it is meant the way oc 
ways in which that agent acts upon the economy. 

The agent of malarial or paludic ailments is a microbe discovered, 
by Dr. Laveran, a wide-world known and respected French scientist; 
but while everybody agrees upon Laveran's microbe being the cause 
of these complaints, there are many different ideas about its nature* 
May it be whatsoever it is, the way in which it finds an inlet to get 
into the patient's body has, for a long time, remained mysterious; 
but in the last eight years, the effort of scientists, especially those of 
the Liverpool school, have succeeded in demonstrating that mos- 
quitoes of the genus Anopheles by taking the germ out of the water 
of the marshes, while they are in the stage of their development, 
known in English as wigglers, or, as perfectly developed insects, 
pumping that microbe out of the patient's blood. Once provided 
with the germs, the mosquito, when pricking the victims skin, ejects 
a small portion of irritating fluid that it may cause a congestion which 
may increase the amount of blood to be sucked in the spot that has 
been bitten: that fluid carries Laveran's microbe into the economy 
of the infected person who shall afterwards suffer from the effect 
of the poisons developed by that microbe within the patient. 

To destroy the wigglers in pools, marshes and cisterns and to pre- 
vent mosquitoes frc^n biting healthy persons is the way of fighting 
malaria. Much has been achieved in this line and the measures of 
attaining the object in view are described at some length in the 
original paper. 

Nothing more would be said after these lines were it not for the 
fact that in a great deal of malaria invaded conuntuiities of the 
Mexican highlands no mosquitoes were to be found before 1885-1888 
and even now they have not succeeded in getting into several towns 
where malaria is undoubtedly prevalent. So there can be no doubt 

110 



THE ETIOLOGY OF MALARIAL DISEASE. Ill 

upon this question: "Mosquitoes are not the only channel of pene- 
traHon for malaria germs into the sufferer^ bodies: Many things 
point to the fact that unripe tropical fruits of certain kinds or some 
others, however ripe they may be, are one of the vehicles of mahria." 
That being the case to all the sanitary measures against mosquitoes, 
another directed to prevent healthy persons from eating suspected 
fruits. These measures and many details of this question are dis- 
cussed at some length in the original paper which will be published 
in due time. 



PROPHYLAXIS OF PALUDIC DISEASES. 
Dr. JUAN BRENA, Zacatecas, Mexico. 

Long before Laveran's discovery in 1880, a causative relationship 
was acknowledged as established by experience between the vicinity 
to stagnant waters and the prevalence of a particular nosologic group^ 
named in regard to its origin, paludic disease. 

From this etiological notion naturally arose the hygienic precepts of 
desiccating, channeling or of leveling in some way marshy lands and 
to place between them and the mens quarters, dikes or trees with a 
view to check the winds, which in the traditional language of science 
were said to be the vehicles of virulent exhalations. 

Modem hygiene does not eliminate from its prophylactic resources 
these ancient precautions. It does not circumscribe itself to all these 
rules of sanitation only, nor does it avail itself of them with the idea 
of getting rid of any noxious element propagated by the winds. 

We do not admit today as a factor, on the incidence of the periodic 
fevers any unaccountable or mysterious element, as the effluvia or 
emanations of the climatologists of old. The vague casual terms 
''aria ottima, buona, sospetta, malaria, aria cattiva, pessima/' so 
familiar to Italy's physicians and throughout the world, have no 
practical meaning at all, in case they do not specify quantitative dif- 
ferences of mosquitoes polluting the air. 

The term "malarial" used in this paper in accordance to established 
custom ought to disappear from nosologic technicism, and be sub- 
stituted by another that shall be allusive to the deleterious influence 
of the Plasmodium, or simply by the already known, "paludism" or 
"paludic diseases," which means, without bias, a morbid state induced 
by stagnant waters. Lately, and chiefly from 1903 to 1904 the 
advances have been so remarkable in our knowledge of many 
interesting details pertaining to the anatomy and physiology of the 
anopheles, as first noticed by Laveran and brought to prominence 
through Golgi's works, who distinguished Monson's and Ross's dif- 
ferent entomologic species, Ihus acquainting us with the change of 
host, McCullum's discovery of its sexual organs, and Schaudin's (i) 
very recent researches about the Plasmodium vivax, the insect which 
carries with it the tertiary fever. The direct corollary of such most 
interesting works is practically represented by the precautionary steps 

^Arbeiten aus dem Kaiserlichen Gesundheitsamte, Baud XX. 

112 



PROPHYLAXIS OF PALUDIC DISEASES. 113 

that are already being successfully taken to reclaim the unhealthy 
marshy lands. 

These precautionary steps, I may briefly state as follows: 

I. — The sanitary modifications of all tracts of land that are suitable 
breeding places of the Anopheles mosquitoes. 

II. — Precautionary steps against the bite of such diptera. 

III. — Precautions to be imposed upon infected persons and which 
are liable to spread contagion. 



The favorable typical sites, as brooding nests for the larvae and 
nymphic stage of Anopheles is to be found on marshy lands that are 
thickly grown with the lower species of vegetation. Large well curbed 
ponds which clean water are not sought for by this sort of mosquitoes. 
The channeling, desiccating or filling up in some way all hollows, 
holes or swampy ditches especially near the city is therefore of great 
importance. In districts infected by periodic fever, the public welfare 
requires the action of the lawmaker in order to compel the owners of 
such unhealthy lands to improve the same; and if they are of the 
public domain, to see that they should be appropriated by parties that 
may keep them in a healthful condition. The faithful observance of 
the first of these prescriptions, would be sufficiently warranted, first 
by obliging all parties in the neighborhood of an infectious center to 
ask and obtain, through due process of the law, the acquisition of 
such land; and second, that, in case the owners of the fever-germ 
producing land are careless to keep it in a sanitary condition, the 
proper law officer should declare said land forfeited to the public 
welfare. Coal oil, is popularly known to be the most toxic sub- 
stance for mosquitoes and their larvae; but its application is rendered 
prohibitive on account of its high price. It is not practical for the 
great and even small swamps, to be effective as a good layer of said 
liquid is necessary on the surface of the water and weeds. Sisifo's 
works committed to the coal oil irrigating brigades are rejected as 
unpractical and relegated to the catalc^e of the unsuitable measures. 

The usefulness of coal oil, on the contrary, when applied to disinfect 
the homes is a self evident proposition. In mosquito infected 
districts, neither the homes of the poor nor those of the rich should 
escape the supervision of the health officers; and the sanitary in- 
spectors' calls should be more frequently made in epidemic seasons 
than during normal conditions. All sewers, ditches and gutters in 
general should be lined with brick or cement, filling up even small 
8 



114 PROPHYLAXIS OF PALUDIC DISEASES. 

cracks. Ponds, springs, barrels, pails, etc., should be emptied at 
regular intervals, at least twice a month, and the inner sides saturated 
with coal oil for one or two days. The keeping of water in cisterns, 
tanks or vats, etc., should only be done when the surface is covered 
with wire netting or with the film of coal oil on the surface to prevent 
the germs from breathing. It is several years since the mechanical 
prophylaxis we are now dealing with, has not received any additional 
precepts worth mentioning. Notwithstanding this, by employing the 
aforesaid means, the improvement of some localities have been 
achieved, such as railroad stations and provinces formerly deadly on 
account of some prevailing grave and even pernicious fevers. 

In the year 1904 an attempt was made to reclaim the famous 
Pestum plain of Italy by means of what was termed hydraulic im- 
provement. The experiment did not produce successful results, and 
the Italian society having the matter under study, consigned in its 
report of that year, that such improvement even carried to perfection 
is not synonymous of sanitary purification. To resume the perse- 
1 verance in works of drainage, desiccation or leveling of marshes, and 
the riddance of primative vegetation in congested localities, are to 
this date the best and most efficacious mechanical means for the ex-» 
termination of the mosquitoes. 

The inoculation of the hematozoa caused by punctures is only 
avoidable by placing obstacles to the approaches of the houses. No 
precaution answers the purpose better than the placing of door and 
window frames with wiregauze on every way of communication to 
the inside. They have the quality of not preventing the renewal of 
air, nor the comfort of the dwelling. Wherever this sort of 
prophylaxis has been closely and strictly followed, be it against the 
Anopheles or the Stegomyia, the endemic disease has entirely disap- 
peared; and even when its application has been only partially or in- 
completely used, it has not failed to show a proportional decrease in 
the number of persons attacked. Dr. Batesti, a member of the Corsican 
League against Malaria, has thus obtained a reduction varying from 
n and 60% till 47%. One of the most remarkable facts which has 
been conceded to the unquestionable advantage of wire nettings as a 
barrier against mosquitoes was the immunity enjoyed six years ago by 
Drs. Lanson and Leed during their stay in "Campagna Romana" 
during a full malarial season. Their habitation was a tent that had all 
its exits provided with wire gauze sashes. No less decisive were the 
results obtained through the same dispositions by Professor Celli in 
the same plain, by furnishing the apartments of railroad employees, 
with sleeping berths such as those called in England "Mosquito 



PROPHYLAXIS OF PALUDIC DISEASES. 115 

proof sleq>ing rooms/' the same as has been appointed by the English 
government to its railroad employees in Western Africa, chiefly at 
Lagos and Sierra Leone, and which constitute the complement of the 
precautionary prescriptions against mosquitoes. The beds in such 
sleeping-rooms are covered with a curtain or paviUon, made with stuff 
of reticular web which does not prevent the renewal of air. The 
curtain is seven feet long, seven in height by three in width. Toward 
the lower part or at least for three feet from the bottom, the texture 
4s closed as that of calicot and not in the form of netting. The 
principle explaining the transmission of paludic diseases through the 
introduction of the protozoa into the body of the Anopheles, and conse- 
quently into the vertebrate animals is universally accepted. Never- 
-theless as the most resplendent facts do not obliterate traditional pre- 
occupations but slowly, the safeguarding of public health requires the 
sanitary authorities to dictate coercive measures that under prudent 
penalties, oblige the inhabitants of mosquito infected localities to pro- 
tect, by wire-gauze sashes, their respective dwellings. The proper 
sanitary protection of a community that may be exposed to con- 
tamination through the instrumentality of the wayward or apathetic, 
anust be taken as a sufficient legal basis to take such a stand. 

II. 

The sick, able to impart tainted blood to the mosquito bite and 
therefore apt to diffuse fevers, may be classified into three groups. 

(a) Those recently attacked under some acute form ot inter- 
mittent fevers. 

(b.) Persons, who, having acquired the sickness in some former 
irruption, still have it in a latent form and suffer relapses at regular 
intervals, especially during an epidemic. 

(c) Children, who, as may be readily understood, are by far an 
easier prey to the attacks of the Anopheles. 

(a) The new principles on the causes of paludic infection clearly 
suggest the including of this class of ailments under the category of 
those that imply the duty of boards of health to be made acquainted 
by the delegated physicians of the case existing in the locality. 
Patients should be isolated in apartments provided with wire-gauzed 
sashes and subjected to the classical treatment of quinine salts. In 
every case the patient or whoever represents him as tutor or guardian, 
if a minor, should be compelled to conform himself to the medical 
prescriptions against the malady, and likewise in all that may foment 
its diffusion. The notion as to the contagiousness of paludic diseases 



116 PROPHYLAXIS OF PALUDIC DISEASES. 

in whatever shape, should be seriously brought home to the popular 
mind, and seeing that intercourse or association with the infested is 
dangerous to the community, it is without doubt that either omitting 
treatment or growing careless and lax in the rigorous segregation of 
the patient must be rationally considered punishable. 

(b) The importance of obtaining a radical cure of cases that may 
be reputed residuals of former inoculations and in which the parasite 
still lingers in the organism, is obvious, seeing that this purpose 
means to extinguish or reduce the number of the agents of infectioa 
as far as possible. These cases have been called reiterating or re- 
lapsing fevers. Quinine in combination with hygienic care, mainly 
against cold, over-eating, etc., and the prevention of the patient's 
further inoculations are the chief and most powerful therapeutic re- 
sources. Iron, so much recommended against anaemia and general 
organic feebleness, inherent in cachetic constitutions is not indispens- 
able as all its invigorating qualities may be obtained by means of 
quinine. The use of arsenic is incongruous and may be even noxious 
on account of its irritating action on the digestive tract as well as 
for the dermatosis, neuritis, etc., to which it occasionally gives rise. 

Medical authorities are not agreed as to the best method and do^i- 
fication to be preferred in the antiperiodic agent for the cases to which 
we are referring. Some authorities, as Professor Koch, think that 
the treatment called pre-epidemic is, suflBcient, that is, the treatment 
begun a little before the beginning of the season when the epidemic 
fever breaks out. My experience in some parts of the Mexican Re- 
public compels me to differ in this opinion and to follow that of many 
other authorities who prefer to prescribe the treatment of latent 
malaria throughout the year with the same energy that should be 
employed during the endemic season. The daily dose of 40 centi- 
gramos, 6 grains, daily is sufficient in this climate to avoid new in- 
fections as well as to produce, prevent, and extinguish all possible 
relapses. 

(c) The childrens' aversion for quinine on account of its bitter 
taste renders it particularly difficult to apply this treatment to them. 
This circumstance, together with the scant effort of pharmacologists 
to repair this organoleptic inconvenience, are the main cause of the 
greater mortality during paludic fevers among infants than adults. 
To say that the infection is more difficult to control in children, 
means that the contagion is exceptionally lasting in them. Now the 
number of children that suffer attacks of paludic diseases, is so con- 
siderable that, according to Prof. Koch, their number should be taken 
as the endemic-index of the locality. It is, therefore, of practical use 



PROPHYLAXIS OF PALUDIC DISEASES. 117 

to ascertain it precisely, and very careful investigations should be made 
to canvass it. The diagnosis in doubtful cases may be verified by the 
microscopical examination of the blood, remembering that sometimes 
the parasite is not found in the peripheric circulation, and then we 
have to investigate whether there are any liver congestions, or swell- 
ings of the urinary bladder, or, and particularly, of the spleen, seeing 
that such phenomena are path(^;onomonic symptoms of the infection. 

Sick children must be obliged to take quinine as well as adults. 
Several pharmaceutical formula are found today in trade, such as 
tablets, in which sugar and some cocoa hide enough of the harsh taste 
of the medicine, -which may be taken without perceiving it. A 
sufficient daily dose for children is that of 20 centigrams or three 
grains. Except in very urgent cases or nauseating susceptibility of 
the stomach, recourse may be had to hypodermic quinine injections. 

Against Dr. Crudelli's opinion, who maintains that quinine habit- 
ually taken as a remedy is truly a poison to the vaso-motor* system, 
stands to the contrary the general opinion of the expert physicians in 
treating tropical diseases. They all acknowledge that the anti-periodic 
drug is not harmless but markedly stimulates the activity of the 
stomach. Prof. Koch goes as far as to say that if the inhabitants were 
saturated with quinine the mosquitoes might be left undisturbed. The 
convenient merely preventive dose, seems to be consigned in Dr. 
Gray's* method, who fixes it at 10 to 15 grains in two successive 
days with an interval of 8 to 9 days before taking the subsequent doses. 
The basis of this prescription consists in that the cycle of the 
parasite's life consists nearly always of 48 hours and that after the 
infection a lapse of about 8 or 9 days has to take place before they are 
sufficiently numerous to produce a fever attack. So that if quinine is 
taken every 8 or 9 days, it will destroy the fever germs before an 
access is possible. No matter how effective and of immediate prac- 
ticability we may consider the several legal dispositions to which we 
have heretofore referred, the education of the masses by means of con- 
ferences, periodical literature, pamphlets, etc., are undoubtedly neces- 
sary to inculcate in their mind the capital importance of the strict 
observance of the medical police regulations dictated in compliance 
with the revolution that the works of the bacteriologists have effecte3 
in etiology, epidemology and pathogeny of paludic diseases. With the 
greatest satisfaction must consign the fact that the Superior Board 
of Health of the city of Mexico, or to speak more truly, Dr. Liceaga, 



'Dr. Angelo Celli in UOrganizazicMie della Guerra a'lla Malaria. Mar. 1, 
1906. 

•Lancet Dec 30. 1906. 



118 PROPHYLAXIS OF PALUDIC DISEASES. 

realizing the benefits that would result of such a patriotic and humani* 
tarian task, has published a pamphlet since the year 1902, entitled^ 
"Instructions how to avoid Yellow Fever Intermittent, etc/' and 
again a new one in 1905, "A Circular to the Local Authorities where 
Yellow Fever and Malaria prevail." We are not in a position to state 
that such preaching or others of like nature may successfully illustrate 
the public mind so far as to familiarize and make accessible to all 
classes the great public hygienic questions, nor much less the technical, 
to verify and demonstrate used in bacteriology for the solution of 
the complex and delicate problems of paludic diseases. But it is 
evident that clear methodical synopsis : concise and within the compre- 
hension of all capacities as those written by Dr. Liceaga's learned 
pen expounding the alterations that have been introduced in the 
popular medicinal creed by the new investigations, and the rules of 
order and administration deduced therefrom, insure to the constituted 
powers not only the abolition of direful opposition to the beneficial 
social influence of medicine, but brings therewith an assurance of 
success, that is the diligent co-operation of land lords, farmers, rural 
towns, colonists contractors etc. who will unite their efforts to those 
of the hygienists, being persuaded that they are working for the 
preservation of the most universal and precious interest: health and 
life. 



ACTION OF THE STATE AGAINST TUBERCULOSIS. 
Dr. JESUS MONJARAS, Mexico, D. R, Mexico. 

The prophylaxis of a transmissible disease should have as a basis 
a profound knowledge of the pathogenic agent which produces it as 
well as of the medium in which it develops. If it is desired to under- 
take a successful struggle against tuberculosis, the first thing to be 
done is to acquire as good a knowledge as possible of the Koch bacil- 
lus, of the conditions which favor or prevent its development, its 
preservation and dissemination. 

The Koch bacillus is at the same time, the cause and the witness 
of the existence of tuberculosis. It is a small cellular stick, curved like 
a comma, with a length of two to six thousandths of a millimetre and 
a thickness of three to four thousands of a millimetre which occupies 
one of the lowest steps of the vegetable scale. It is classified amongst 
the acid-resisting microbes ; is cultivated with some difficulty and when 
well cultivated produces toxines. Heat rapidly kills the tubercule 
bacillus when moist; ebullition and a stay in the autoclav perfectly 
obtained this result. When the heat is dry a long time is required, as 
it can resist a temperature of ioo° for three hours without being 
destroyed. 

Cold has no destructive effect on the tuberculous bacillus, because, 
like others, it can maintain itself alive in the ice. Neither does putre- 
faction have much influence over it, as the bacilli which have been 
found in decomposed organs have continued in activity for over 150 
days. 

The sanitary schedules which have been formed in all countries 
have shown that the unhealthy dwellings which are damp, ill-venti- 
lated, and beyond the reach of the sun, are the best adapted to the 
development of the tubercule bacillus. A few clots of sputa from a 
tuberculous patient are sufficient to multiply this bacillus and to in- 
crease it to an indefinite degree, and in this way it enters into the 
system of some predisposed individual, is cultivated in his tissues and 
the breed propagated by the sputa thrown out on the floor, on the walls, 
or on the outside of the furniture. These unhealthy dwellings after- 
wards transmit the disease to subsequent tenants who may be predis- 
posed to take it; the floors are swept with brooms which raise dust, 
and this is another very suitable means for mixing the dry sputa with 
the air, so that it is deposited in the larynx, in the bronchial tube and 
other organs which form the doors to give entry to transmissible 
diseases. 119 



120 ACTION OF THE STATE AGAINST TUBERCULOSIS, 

If we study the distribution of this disease in the cities, we find 
that certain houses and certain rooms are intense foci in which the 
disease is permanently reproduced; that these foci radiate through 
their neighborhood, in such a manner that the more or less immediate 
proximity of large healthy spaces, such as avenues, squares, gardens 
and even parks, do not exercise any influence over its intensity. These 
breathing spaces, which are separated by compact blocks of houses, are 
not sufficient to prevent the spread of the contagion as the dark, ill- 
ventilated dwellings afford a good lodging in themselves to the enemy. 

The most energetic disinfectants, such as sublimate at two per cent., 
carbolic acid at five per cent, and Javille water at one-tenth, are the 
only chemical agents which have any effect on the tuberculosis bacillus. 

It is a specially strong bacillus, against which only a single physicad 
agent can be successfully employed and this consists in the rays of the 
sun. 

Under a direct light, Solly says that a few minutes are enough to 
destroy the germ. Koch has seen the tubercule bacillus die by a 
direct solar light in a period that varied between a few minutes and 
some hours according to the thickness of the exposed layer, and our 
prophylaxis ought to take advantage of this circumstance. 

This bacillus is found in great numbers almost everywhere; it is 
found in the sputa of persons suffering from a confirmed case of the 
disease and there it is contained in an astonishing quantity; a single 
expectoration may contain thousands and even millions of these small 
organisms. When tuberculous persons expectorate they throw the 
bacillus out on the pavement of the streets, the floor of the theatres 
or churches, on the road, on the floors of houses, on the hangings of 
furniture, on the curtains, and in either coughing or speaking they 
even throw it directly into the mouths of the persons they are speak- 
ing to. This microbe is virulent, that is to say capable of reproducing 
the disease even when dry. As it is very light, a little less than the air, 
it is blown about when dry and carried to every place which the wind 
can penetrate. When damp and held by the saliva or in sputa, the wind 
cannot separate it, but small animals such as flies, mosquitoes, rats, 
mice, etc., take it from those emulsions and deposit it on the skin of 
mucous membranes of the lungs or on the food prepared, such as 
milk, broth, meat, etc. 

The tubercule microbe is also found in the tissues, organs and 
secreted liquids of certain animals which furnish us our food, such as 
meat, milk, etc., and there are strong reasons to presume that if these 
articles of food are swallowed, under certain conditions, they are 



ACTION OF THE STATE AGAINST TUBERCULOSIS. 121 

capable of carrying the disease through the microbe which they bear 
into the intestine. 

This particular germ is not reproduced, even though purposely in- 
oculated, except in those organisms that in consequence of their special 
distesis elaborate a substance in the cellular protoplasm which hardly 
commences to be isolated by the chemico-biological reagents which serve 
as media for specific cultures of this microscopic organism, or to delay 
the phagosithary action of certain cells with which we are amply pro- 
vided and the destructive action which is also special to those cells 
chat are provided with liquids elaborated in that cellular protoplasm. 

These conditions which are indispensable for the reproduction of the 
disease under study have been furnished by the individuals through 
certain intemperate habits, such as alcoholism, privations, special social 
conditions, insufficient vitality, fatigue and certain diseases which 
develop chloro-anemia, or else by the heredity which can transmit a 
weakness that facilitates the necessary elements above referred to for 
the cultivation of the specific agent of tuberculosis. 

The scoriation or door of entrance which is necessary for the intro- 
duction of the parasite, is obtained by the great quantity of dust 
which is breathed or swallowed together with the air that forms a ve- 
hicle for the parasite. 

The most exposed mucous membrane is that of the larynx and 
bronchial tubes, which receive the parasite by inhalation, that is to say, 
by breathing the air which is charged with dust, mixed with that 
parasite. 

After this comes the gastro-intestinal mucous membrane which re- 
ceives the parasite when introduced with the food, the saliva, the nasal 
mucosities, the sputa, etc. The skin also receives by inoculation 
through a wound. In the Veterinary Medical Congress which met in 
Cassel on the 20th of September, 1904, von Beherin suggested the idea 
that pulmonary tuberculosis in' adult persons might very well be noth- 
ing more than a delayed manifestation of an intestinal infection con- 
tracted in youth. 

By means of experiments, Calmette and Guerin obtained convincing 
results in favor of this hypothesis. They placed young and adult goats 
under observation in parallel cases, by means of an esophagal catheter 
which they introduced into the stomach, (in order to avoid all acci- 
dental contamination of the first respiratory organs) with a small quan- 
tity of culture of tubercule bacillus of bovine origin, as finely divided 
as it could be in the milk or in the sputa of a tuberculous patient. The 
animals imder observation invariably developed tuberculosis within 
twenty-five or thirty days, and whilst in the young animals the pul- 



122 ACTION OF THE STATE AGAINST TUBERCULOSIS. 

monary form appeared to be delayed and the ganglionary lesions pre- 
sented themselves in an exaggerated form, in the adults no such gang* 
lionary lesions were observed, and the pulmonary forms manifested 
themselves at once even after a single contaminated meal. 

We thus find that the propagation of tuberculosis requires the pres- 
ence of the the Koch bacillus which produces it, of a suitable organism 
that favorably cultivates this parasite and a solution of continuity, ex- 
coriation of the mucous membrane or of the skin of this same organ. 

In undertaking a campaign against tuberculosis we must keep all 
these circumstances before us and not forget that we are struggling^ 
against a specially strong microbe ; that the disease produced by it has 
no well defined cycle and which after completing its evolution, leaves* 
the patient in good health and even immune against a fresh attack. 
Except in the last stage of the disease, the tuberculous patient does not 
take to his bed, but carries the evil with him wherever he goes, con- 
taminating every individual who comes into contact with him under the 
necessary conditions of receptivity; that we cannot isolate him as we 
can persons suffering from other disease which oblige them to lie in 
bed nor can we properly and in due time disinfect the contaminated 
rooms or articles. 

For these reasons, we must procure the direct destruction of the 
sputa before it dries and is converted into dust, at the very moment in 
which it is expectorated, and for this it is necessary to count on the 
energetic will of the patient himself, which can only be awakened when 
he is given the knowledge of the magnitude of the evil done by him 
when he discharges his sputa in any part ; and for this it is first of all 
necessary to discover the patient, and convince him of this necessity for 
his own sake, as well as for the sake of the members of his family and 
of all persons who may come in contact with him. 

In order to obtain this individual action it is necessary to prepare a 
schedule of persons suffering from the disease, distinguishing those 
who suffer from open tuberculosis from those who suffer from closed 
tuberculosis. To this schedule contributions will be made by those who 
are legally bound to declare the cases of this disease which might come 
under their care ; but this declaration has not given all the results that 
are obtained with respect to other diseases and for this reason it has 
been considered necessary to make it obligatory in some countries. The 
tuberculosis dispensaries are, in my opinion, more efficacious. These 
dispensaries have the advantage of discovering tuberculous patients 
with great ease, making them declare their disease for themselves with- 
out any necessity of employing the coercive measures which the legis- 
lator has found it necessary to place within the powers of the sanitary 



ACTION OF THE STATE AGAINST TUBERCULOSIS. 123- 

authorities in order to enforce the declaration of transmissible dis- 
eases, because they offer gratuitious food and medicine to those tu- 
berculous patients, many poor people^ in the hope of obtaining this 
charity, present themselves sick even when they are well. They are 
examined by the physician and if they are found sick, they are attended 
and made to eat an abundance of nourishing food, their residence is 
noted so as to be reported to the sanitary authorities so that the disin- 
fection may be ordered and other sanitary precautions taken. 

Once the tuberculous patient is known through the means above 
indicated, and we count on his willing assistance in the destruc- 
tion of the sputa by warning the patient of the danger to himself and to 
all others who may ccwne in contact with him and principally to his 
family, of expectorating anywhere outside of the model cuspidors, such 
as he is obliged to use during his stay in the dispensary, or else in 
simple covered pots that contain some antiseptic liquid which will de- 
stroy the expectoration and also by giving him instruction on the 
methods to avoid the transmission of his disease. 

The wealthy patients will be advised to employ pocket spittoons 
outside of their houses in order not to expectorate on the pavements,, 
or in spittoons which are not dedicated to receive the expectorations 
of tuberculous patients which must always be destroyed or mixed with 
antiseptic liquids. 

Every tuberculous person should therefore always expectorate in a 
receptacle properly arranged for that purpose. This receptacle should 
be preferably made of metal, in order that it may not easily break, 
and should be half filled with water or with a disinfecting liquid in 
order that the sputa may not dry. In the absence of metallic spittoons 
a proper receptacle should always be within the reach of all as is now 
done with the urinals. 

Persons suffering from confirmed tuberculosis, and who have reached 
the last stage of the disease, whose sputa cannot be isolated or de- 
stroyed, should be isolated themselves in special institutions in spe- 
cial wards of general hospitals, or in their own dwelling houses when 
there is some guarantee that the isolation will be effective. 

In any case, the dwelling as well as the articles belonging to such 
patients must be considered contaminated, and they must be disinfected 
as frequently as possible and without fail as soon as the patient suc- 
cumbs. 

However good may be the results obtained in the struggle against 
the Koch bacillus, its complete extermination will never be possible, 
even though we may know all who are suffering from the disease, 
because they do not all lend themselves to the precaution here recom- 



124 ACTION OF THE STATE AGAINST TUBERCULOSIS. 

mended and which only they themselves can take, nor is it possible ta 
isolate all tuberculous patients or count on the efficacy of the disin- 
fectant as with other contagious diseases, because its employment with 
this is much restricted. It is therefore necessary to zealously pro- 
cure the sterilization of the medium which this parasite requires for 
its development and as these organisms are preferrably found in the 
school and in the workshop, it is to these places that we must direct 
our plan of campaign. 

The notable works of Prof. Grancher, of Paris, relative to this sub- 
ject, have shown us the great number of children who attend the 
school with ganglio-pulmonary tuberculosis, suffering from tubercu- 
lous trachic-bronchial adenitis. These diseases may remain latent un- 
til the period of adolescence and develop under the influence of the 
advancement in growth, fatigue, special studies, the workshop, etc. 
With the assistance of other physicians the professor I have men- 
tioned has examined 896 children attending the schools of Paris. This 
examination included the weight, height, thoracic perimeter of the chil- 
dren, and especially an investigation to discover any latent pulmonary 
tuberculosis. 

For the purposes of this investigation, Prof. Grancher proceeds as 
follows : the child is made to bare his breast and is then examined as 
to his general condition of nourishment, the color of his skin, and its 
vitality, the condition of the frame, the conformation of the thorax; 
the thoracic indication of the right and left side is taken, with a double 
metrical tape, along the mammary line. After examining the throat, the 
ganglia of the neck, of the arm pits and the groin, and lastly the lungs 
which is the principal point of the examination. 

A thorough examination of the lungs by auscultation allows a diag- 
nosis to be made with all exactitude of any incipient tuberculosis, with 
a comprehension of the modifications which this may have brought 
about. 

To begin with, it is necessary to entirely isolate the sick from the 
healthy and cure them by the well known methods that are now found 
efficacious. As regards the suspected persons there is no objection to 
allowing them to attend the schools and there mix with the healthy per- 
sons, subjecting them to general gymnastic and respiratory exercises 
in the open air, making them live in clean and well ventilated rooms by 
which means they are completely cured. In the more severe cases, we 
should procure their prolonged stay in the country, where special 
schools would be established for them. 

The above methods can also be applied to workmen. 



ACTION OF THE STATE AGAINST TUBERCULOSIS, 125 

The character of the dwelling can also exercise a,, great influence on 
the development and propagation of tuberculosis, as that is where man 
passes a great part of his life, where he breathes, and the climate of 
which surrounds him. 

The disease has a special connection with the unhealthy character 
of the dwellings; there is the place in which it may be developed 
through crowding or tmclean conditions which debilitate the vitality of 
the system and render it more susceptible to the influence of a patho- 
genic agent, and where the absence of solar light facilitates the cultiva- 
tion of this microbe. 

We have already said that the studies made of the Koch bacillus 
have shown us that it acquires a greater development in the dark than 
in the light. In the struggle against tuberculosis, our best arm consists 
in the supression of the sunless, narrow and dirty dwelling, because 
tuberculosis is above all things a disease of obscurity. 

In those dwellings which are infected by tuberculous expectora- 
tions, a few minutes are enough to kill oflF the bacillus if the sun and 
air are abundantly allowed to penetrate the room. 

Marie Davie, who has made a study of the mortality of tuberculosis, 

in its relation with the number of doors and windows in Paris, has 

observed an appreciable disproportion between this and the number 

of deaths. 

* ♦ ♦ 

After what has been said, the struggle against tuberculosis demands 
two concurrent actions, the action of the State and the action of the 
community. It is useless to demand of the State the destruction of the 
bacillus, as this is impossible. No authority, however well organized 
it may be and however numerous the staflF at its disposal, could follow 
every person suflFering from tuberculosis wherever he might go so as 
to collect and disinfect his sputa ; nor could it disinfect all the dwell- 
ings contaminated by the sick as fast as they are infected ; nor could 
it confine all the sick in the isolation hospitals. It would be difficult to 
make the public understand the desirability of destroying the sputa at 
the moment it is thrown out or the best method for doing so. It would 
also be difficult to disinfect every house that has been inhabited by a 
tuberculous patient before it is again occupied, or organize societies 
that by means of lectures in the schools, in the workshops and wherever 
people are brought together, would inculcate the best methods for cur- 
ing and preventing this terrible evil. 

With those who are victims to this disease, coercion is of no use, but 
persuasion may do something and this resource comes well within the 
scope of the mutual or benevolent societies as well as of the manage- 



126 ACTION OF THE STATE AGAINST TUBERCULOSIS. 

ment of workshops and factories. This has been understood by those 
nations which have made progress in this study and in this way we 
see how in Germany, in which social science has made great progress, 
a great number of hospitals and sanatoria have been erected by mutual 
aid societies composed of workmen; companies to insure against the 
disease for invalids and old people, which are maintained both by the 
forced contributions of the workmen as well as by those of the em- 
ployers, who contribute to the expenses without receiving the benefits. 
In this way the workman sees that the proceeds of this tax do not enter 
into the public revenues for general purposes, that in the event of acci- 
dent or on reaching old age, he can count on resources that do not pro- 
ceed from either individual or State charity, but from his own savings^ 
and as he is the principal shareholder, it is to his own interest to avoid 
disease even amongst his comrades and so prevent any depletion in 
the funds of his own business. This is how these institutions carry out 
hygienic measures and become the best prophylactic resource against 
disease. 

It is on the dwellings that the public administration can exercise 
an immediate and decisive action: it is the dwelling with which we 
have to commence and it is with respect to this dwelling that we can 
enact laws and regulations which will subject building operations to 
this principle: "That the maximum height of the houses shall not 
exceed the width of the street on which they are built and that the 
courtyards in those houses shall have a minimum width equal to the 
height of the living rooms that surround them." 

This campaign has already been undertaken by our authorities with 
surprising success, as can be observed in those parts of the city which 
are called "new colonies" and the widening of the streets and sanita- 
tion of the first and second wards of this city will soon be completed, 
having been initiated by the intelligent members of the Supereme Gov- 
ernment Board of the Federal District. 

Alcoholism is one of the most predisposing causes of tuberculosis 
on account of the increase in the spinous process which it causes and 
all the other physical defects which are preceded by that vice. For this 
reason it is also necessary to undertake a campaign against alcoholism 
as well as against tuberculosis. The State can assist in this by making 
drunkenness on the public roads an offence; by prohibiting the en- 
trance of minors into the saloons ; by allowing the sale of drinks under 
specific conditions which would be determined by well organized 
physiological studies ; by prohibiting the sale of liquor to persons in a 
dnmken condition; in one word, the State should make use of its 
authority in accordance with the teachings of science, as to what re- 



ACTION OF THE STATE AGAINST TUBERCULOSIS, 127 

sources it can employ and under what circtunstances. The temperance 
societies, the anti-alcoholic leagues should also exercise their persu- 
asive powers, from the period of childhood in the school, in the work- 
shop, in the home, raising a sense of dignity and inducing the man 
to become a member of societies in which the good example and in- 
struction will dissuade him from the practice of this pernicious vice. 



THE ESSENTIALS IN THE CRUSADE AGAINST TUBER- 

LOSIS. 

Dr. LAWRENCE F. FLICK, Philadelphia, Pa. 

The modern crusade against tuberculosis is the logical outgrowth of 
modern knowledge. Unlike crusades against disease in the past, it 
is based upon exact knowledge, and not upon empiricism. The cru- 
sade against leprosy, for example, was based upon one idea — con- 
tagion — and in consequence was accompanied by many hardships be- 
cause the only measure which could be thought of was complete isola- 
tion of the patient and the destruction of those things which had been 
touched by him. 

Our knowledge of tuberculosis brings us in to a very broad field 
of prevention. We really are overwhelmed with a flood of ideas of 
things which might be done, and have some difficulty in selecting those 
things that are of most importance. Much energy has been and is 
wasted in minor measures which could be much better expended in 
major measures. This is particularly true with people who have only 
a superficial knowledge of tuberculosis and who in their anxiety to 
accomplish results devote themselves to the first thing which comes into 
their heads, that promises results. 

In the light of present knowledge it is quite evident that prevention 
cannot be predicated upon the destruction of the tubercle bacillus 
alone. Whilst the tubercle bacillus is the primary cause, there are 
many secondary causes in social customs, in habits of life, and in every 
department of civilization. Some of these have a greater, and some a 
less influence upon the spread of the disease, but all have an influence 
which must be kept in mind in formulating plans for the prevention 
of the disease. 

It goes without saying that the ideal plan for the prevention of 
tuberculosis, including all measures which can be thought of, is im- 
practicable in the immediate present. Such a plan would mean a 
complete revolution of everything, a complete change of customs and 
laws, and a remodeling of society from every point of view. The 
undertaking is too gigantic to be thought of. 

Fortunately the prevention of tuberculosis is easy and the essen- 
tial measures will in time stamp out the disease without attention to 
many details. Implantation of the tubercle bacillus after all is not an 
easy matter. Whilst a very great many people are in a sense exposed 

128 



THE CRUSADE AGAINST TUBERCULOSIS. 129 

to contagion, a comparatively few get an implantation which ulti- 
mately develops into a fatal disease. It may be laid down as a gen- 
eral proposition that for the implantation of tubercle bacilli in suf- 
ficient quantity to produce an active disease, prolonged, intimate ex- 
posure to a fairly intense contagion is necessary. Ordinary casual ex- 
posure to an attenuated contagion need scarcely be thought of when 
planning practical measures for the prevention of the disease. 

Essentials in the crusade against tuberculosis may be enumerated 
as follows: First, the control of contagion; second, the disinfection 
of infected places and things; third, life in the open air; and fourth, 
proper food. With these measures tuberculosis can be wiped out in a 
compartively short time. 

The control of contagion undoubtedly is the most important item 
in the prevention of tuberculosis. If all contagion could be con- 
trolled nothing further would be necessary, as no new cases could 
arise. It is self-evident, however, that all contagion cannot be con- 
trolled. With a disease so wide-spread as is tuberculosis and assum- 
ing such diverse forms, it would be impossible to control all con- 
tagion even though the best system of registration and inspection could 
be established. Many cases would escape detection and some cases 
under supervision could not live up to the rules laid down. Much 
can be done, however, and all that can be done should be done. 

For the purpose of control, the first step necessary is registration of 
all cases of tuberculosis. Against this there has been objection made 
by the members of the medical profession ever since the matter was 
first talked about, and whilst this objection is dying out it is still a 
potent obstacle to progress in many places. Without registration, con- 
trol of tuberculosis is impossible. The first thing necessary is to know 
where the case is before proper supervision can be given, and with- 
out supervision there can be no control. It has often been said by those 
who object to registration that proper control can be exercised by the 
attending physician. This is a plausible, catchy argument which has 
no foundation in fact. The general practitioner does not know how 
to control tuberculosis, and if he did know, would not take the trouble 
to give the detailed instruction and supervision necessary. I think 
that I can safely say that I have as yet to encounter the first consump- 
tive who has been instructed and trained in the prevention of tuber- 
culosis in a way that would protect others by a general practitioner of 
medicine. Occasionally a consumptive comes to me who has received 
a general instruction from his physician, but has failed to put into 
practice methods of disposing of his expectoration which mjjces him 
safe to others. It is evident in such cases that the man who in- 



130 THE CRUSADE AGAINST TUBERCULOSIS. 

structed him, although earnest and anxious to do the right thing, did 
not know enough about the subject to train his patient properly. 

In order that the patient may be harmless to others it is necessary 
that he destroy all broken down tissue in such a way that he can 
contaminate neither himself nor anything about him. He must dispose 
of his sputum or broken down tissue, without soiling his hands, his 
lips, any part of his body, his clothing, the floor, the furniture, or 
indeed anything about him. The bacilli must be destroyed just as 
they come from him, without contaminating person, place or thing, 
This can only be done when the matter is immediately deposited in a 
receptacle which can be burned without any of it going astray be- 
tween the place of exit and the place of deposit. Whatever parts are 
soiled during this process must at once be cleansed and the material 
used in cleansing them must be scrupulously destroyed by fire or by 
some powerful germicide. 

The receptacle for sputum may be a paper pocket spit-cup, a square 
paper spit-cup in a tin box or a china cup. It should be held to the 
mouth so that no sputum can be sprayed during the act of expectora- 
tion. When the china cup is used, lye and water should be placed in 
the cup. All paper cups, when filled should be burned. Tin holders 
should be boiled once a day. China cups should be washed and boiled. 
The contents of china cups may be burned or sterilized and emptied 
into the sewer. When coughing the patient should hold a paper nap- 
kin close to his -mouth in order that there may be no spray scattered 
about. 

If the broken down tissue comes from some other part of the body 
than the lungs, it should be taken up carefully with absorbent cotton, 
and immediately destroyed. When the patient expectorates he should 
wipe his mouth carefully with a paper napkin after expectoration, fold 
the napkin so that he may not soil his hands, and deposit the napkin 
in a paper bag, using a napkin only once. When there is an accumu- 
lation of napkins the paper bag containing these napkins should be 
burned. When broken down tissue by accident is ejected somewhere 
else than into a proper receptacle it should at once be taken up and 
destroyed and the place on which it lighted properly disinfected. 

The second step for the control of tuberculosis is supervision. This 
undoubtedly can best be done through inspection and instruction by 
trained nurses. The moment the whereabouts of a case of tubercu- 
losis is known, an inspectress should be sent to visit it for the purpose 
of placing rules in the hands of the family and the afflicted one, and 
explaining the rules. Only a person who has been specially trained 
for this work can do it properly. The inspectress should go into every 



THE CRUSADE AGAINST TUBERCULOSIS, 131 

detail, and should fully explain to the patient and to those who are 
about him what the rules mean, why they are made and what their 
observance means to the patient and others. In this way intelligent 
co-operation can be secured. A copy of the rules should be left in a 
conspicuous place in the house, and the inspectress should return at 
intervals to see that the rules are observed and to give further instruc- 
tions about them when this is necessary. The inspectress should 
report to higher authority what she observes in the places she visits, 
and a careful record should be kept of her reports. 

Along with the inspection and supervision must go material assist- 
ance. Many poor patients have not the means to buy what is neces- 
sary for the proper disposal of sputum, and in such cases it is neces- 
sary to supply requisite material. Sputum cups, paper naptcins, paper 
bags, and disinfecting material should be supplied in such cases when 
necessary, and the patients should be carefully instructed in their use. 

The cost of material for the prevention of tuberculosis is not very 
great and can be easily supplied by boards of health or by organized 
societies for charity. When work of this kind is done on a large scale 
the cost need not exceed four mills per patient per day for the ma- 
terial used and five mills per patient per day for rent and the service of 
the inspectresses. 

To many of the very poor assistance in the way of food has to be 
^ven if proper co-operation is to be secured. The best food to give is 
milk and eggs. In some instances medicine also may have to be sup- 
plied. The entire cost of dispensary control of tuberculosis need not 
-exceed eight cents per patient per day. 

Disinfection of places and things is an important measure in the 
crusade against tuberculosis in as much as control of contagion is 
imperfect. Even when patients are under constant observation thor- 
ough cleansing or disinfection should be practiced at intervals. The 
room which is occupied by a consumptive should be scrubbed daily 
and, if this cannot be done, disinfected at least once a month and 
the things which are used by him should be boiled and washed often 
or disinfected at very short intervals. All boilable materials should 
be carefully boiled and washed, and all material which cannot be 
boiled should be carefully scrubbed. Things which cannot be boiled 
and cannot be scrubbed should be sterilized with steam or with for- 
maldehyde. Formaldehyde disinfection is perhaps the most eflScient 
method of sterilization laiown at the present day. It can be applied to 
rooms by carefully sealing up a room and filling it with formaldehyde 
either from a formaldehyde generator or by combination of formalin 
and permanangate of potash in the proportion of eight and one-half 



132 THE CRUSADE AGAINST TUBERCULOSIS, 

ounces of permanagate of potash to a pint, overflowing measure, 
of formalin for every thousand cubic feet of air space. The formalin 
is to be put in a vessel first and the permanangate of potash added; 
and the vessel into which these are put is to be placed inside of 
another larger vessel to protect against overflow. Clothing can easily 
be disinfected with formaldehyde by saturating it with formalin and 
placing it in a tightly closed chest for twenty-four or forty-eight hours. 
When there has been very gross contamination with sputum this 
should be dissolved with lye first and then carefully washed out with 
water. Nothing short of complete removal and destruction of material 
containing tubercle bacilli can be accepted as sufficient. 

Life in the open air can be made a potent factor in the crusade against 
tuberculosis under existing conditions if universally adopted. Con- 
tamination with tuberculous matter is much less potent for evil in the 
open air than in a closed room. It is doubtful indeed whether im- 
plantation of tuberculosis can take place in the open air. Tubercle 
bacilli do not live long in bright light and fresh air and where there 
is a constant circulation of air usually do not accumulate in sufficient 
quantity to make air a factor for implantation. Every living thing 
subject to tuberculosis apparently has a certain resisting power to 
the disease" and can dispose of a certain number of bacilli with 
impunity, only succumbing to implantation when a larger number of 
bacilli gain entrance into its organism than it is capable of disposing 
of or when entrance of bacilli is so continuous for a period of time 
as to overcome normal resisting power. 

Enclosures with bad ventilation are essential factors in the spread 
of tuberculosis, and universal knowledge of this fact is of great im- 
portance in the crusade against the disease. It is possible through 
the ordinary channels of education to teach an entire population the 
value of fresh air in the prevention of disease and the part which 
proper ventilation of houses plays in bringing fresh air within the 
constant reach of human beings. This idea of fresh air for all living 
air breathing things should be made to so permeate the public mind 
that it will revolutionize the building of houses and the daily routine 
of life. It should be made to enter into and modify every kind of 
philanthropic work to the end that all eleemosynary, reformatory and 
penal institutions, not only would be built in harmony with it, but be 
managed according to its dictates. It should so affect public sentiment 
that all churches, meeting places, and establishments which harbor 
men and women and have to do with their daily lives would be modi- 
fied and managed in accordance with it. Let light shine into all dark 
places and God's fresh air enter into every nook and comer in which 



THE CRUSADE AGAINST TUBERCULOSIS. 133 

a human being or a living thing which is of value to man takes 
breath. 

Proper food can be made a factor in the crusade against tubercu- 
losis in much the same way as fresh air. Food and air play practic- 
ally the same role in the maintenance of health and resistance to dis- 
ease. They are essentially co-factors for the same end. The entire 
resisting power of a living organism against parasitic life depends 
largely upon normal nutrition and normal nutrition hinges upon main- 
tenance of the equilibrium between consumption and supply of energy. 
When a deficit occurs a weakened resistance to parasitic life ensues and 
a gradual deterioration of the organism sets in, thus establishing a 
vicious circle which leads to a downward path. A few parasites find 
lodgment and grow upon the tissues ; the consumption of energy by 
these parasites, together with the damage to the machinery in the 
organism, still further reduce its working capital and make it an 
easier prey to its foe. 

Not only the quantity but also the quality of food enters into this 
problem. Unless food can be properly changed into tissue it does 
damage in addition to being inadequate. That which is not available 
for use of the organism becomes a burden. A double injury follows 
in the lack of nutrition and the burden of throwing off debris and 
products of fermentation. The extra labor breaks down the functions 
of organs and still further interferes with proper nutrition. Descent 
upon the downward path is difficult to check. Food of the right kind 
and in the proper amount is therefore necessary for the maintenance 
of health, and when health has been lost for its restoration. People 
who are properly nourished when exposed to tuberculosis and some- 
times even when an implantation has taken place resiist the development 
of the disease. 

In order that proper food may play its destined role in the crusade 
against tuberculosis much educational work will have to be done 
through our schools and philanthropic societies in educating the people 
upon the value of foods and upon their proper preservation and prep- 
aration for consumption. Among the poor very few know how to 
select food for its nutritive value. They buy things at high prices 
which have low nutritive value and they reject things at low prices 
which have high nutritive value. They do this partly through ignor- 
ance and partly through obedience to their cravings. Their systems 
need certain food elements and not knowing how to make the com- 
l)ination to give them these elements they buy that which is tasty and 
which apparently supplies the craving. 

Lack of knowledge of preserving food often leads those engaged 



134 THE CRUSADE AGAINST TUBERCULOSIS. 

in the distribution of food to methods and use of materials which are 
prejudicial to health. Lack of knowledge about preparing food leads 
people engaged in cooking and serving food into grievous errors^ 
which are far-reaching in damage to organisms fed upon such food. 
The storehouse and the kitchen really are sources of many of the ills 
of modern times. Education in the preservation and preparation of 
food should be made part of the training of youth, and should be in- 
augurated by philanthropic societies for adults wherever possible. 

How can the essential measures for the prevention of tuberculosis 
best be inaugurated? What measures shall first be used? These are 
practical questions which many communities are propounding to them- 
selves at present. 

The registration of tuberculosis and the disinfection of persons and 
things which have been contaminated, are essentially governmental 
functions, and should be performed by boards of health. Where 
boards of health do not exist, something may be accomplished by 
organized private eflFort. A local society, for the study, treatment, and 
prevention of tuberculosis, is perhaps the best form under which such 
private eflFort can be made. 

Education in the value of fresh air and proper food in the crusade 
against tuberculosis can perhaps best be carried on by such a society. 
Societies of this kind are springing up all over the country, and 
should be organized in every community, large and small. Plans for 
the organization of such societies can be obtained from the National 
Association for the Study and Prevention of Tuberculosis. 

Application of the essential measures for the prevention of tuber- 
culosis is feasible in every community. In some it will be easy, and 
in some difficult, according to the amount of organization which al- 
ready exists and the state of public education in regard to tuberculosis, 
but in all it is possible. Probably the best plan is to combine private 
organized eflFort with public governmental eflFort. Every individual 
in a community should do what he can, and the government every- 
where should aid, legally, morally, and financially. 

In communities where the government is not prepared to establish 
registration and carry on disinfection, much can be accomplished by 
private effort through the establishment of hospitals, dispensaries, san- 
atoria and convalescent farms. Of these the hospital undoubtedly is 
the most efficient measure for the prevention of tuberculosis, as it re- 
moves patients from the community during the period when the dis- 
ease is in the most contagious form. Every community should have 
at least a few beds for advanced cases of tuberculosis. 

Next to the hospital the dispensary is the most efficient measure for 



THE CRUSADE AGAINST TUBERCULOSIS. 136 

the prevention of tuberculosis, and dispensaries should be established 
in every community where money can be raised for that purpose. The 
dispensary enables you to get into the home of the patient and to get 
control of his environment. It opens the way both to the prevention 
of contamination and disinfection after contamination has taken place. 
It enables private effort to do what the government might do legally, 
but what no one else can do legally, and what therefore must be done 
with the consent and co-operation of those afflicted when the govern- 
ment is unwilling to do it. 

If the means can be gathered together, sanatoria and convalescent 
farms for consumptives should likewise be established. Institutions 
of this kind can do much for the cure and the prevention of tubercu- 
losis, and for this reason usually meet with popular approval, and 
readily command means for their support. In many communities it 
would be perhaps easier to establish a sanatorium than any other form 
of institution, and where the popular mind runs more in this direction 
than in another, it is well to establish a sanatorium first, and endeavor 
to build from this to other institutions. Governments likewise take 
more kindly to sanatoria than to the other forms of institutions, so 
that in many places it will be easier to get help for the establishment 
of sanatoria first. 

So far as possible, the work in a community should be led by pri- 
vate effort, and supported by the government. This not only gives 
greater resources in that it has a government's support in addition to 
contributions from private sources, but it is also much farther reach- 
ing in its educational influences. People are apt to think more about 
things which cost them something than about things which are given to 
them gratuitiously, and the greater the sacrifice which people are 
asked to make in the interest of the crusade against tuberculosis, the 
more rapid will be the progress of this crusade. Joint action of pri- 
vate effort and government support will undoubtedly give the best 
results. 

Education in the value of fresh air and proper food should be 
inaugurated everywhere and carried on in the school room, in press 
and on the platform. All philanthropic societies should make it part 
of their programme. 



THE RELATION OF THE PHYSICIAN TO THE TUBER- 
CULOSIS PROBLEM. 

HUGH A. COWING, M. D.. Muncie, Ind. 

Sanitarians need the constant co-operation of the medical profession 
in the warfare against tuberculosis. Without this assistance any 
campaign against the disease will be defective. The final solution 
of the tuberculosis problem must come through the intelligepce and 
training and efforts of the medical profession. The physician should 
engage actively in this work, ready to lead and instruct. 

But the modern treatment of tuberculosis has not yet found general 
endorsement among physicians. And even where it is accepted, it is 
too often deemed impracticable. Obsolete methods of treatment con- 
tinue. Dr. G. W. Goler, of the Municipal Hospital, Rochester, N. Y., 
stated recently that in the majority of patients with tuberculosis, 
examined for admission, only a small percentage of them had been 
directed by their physicians to sit out of doors, or to sleep with their 
windows open. 

It is the duty of this organization and kindred bodies to make 
possible a more rational relation between the physician and the tuber- 
culous. 

One of the serious hindrances to success is the failure of the 
physician to make an early diagnosis of tuberculosis. It is not alvy^ays 
a lack of knowledge nor skill that causes the physician to fail to 
detect tuberculosis. Frequently it is due to a lack of interest and a 
lack of care in examination. Superficial, hasty, and hap-hazard 
methods are too prevalent. The many guises of tuberculosis should 
warn the physician to be constantly on guard. The absence of cough 
proves but little. We know that with stealthy approach, the disease 
may appear in the skin, the bones, the joints, the kidneys, the glands, 
the throat and many other parts of the body. If the physician is 
hurried with stress of work he will do well to have the patient return 
at an early date for a more thorough examination. Repeated physical 
and sputum examinations may be necessary in incipient cases to 
establish a positive diagnosis. Much precious time is lost in many 
cases in the early stage of tuberculosis. Among many such instances 
I recently learned of a case where a young man passed into a hopeless 
stage of pulmonary tuberculosis under the care of a prominent 
physician who had failed to discover tuberculosis after several weeks 

136 



THE PHYSICIAN AND THE TUBERCULOSIS PROBLEM. 137 

attendance. The physician had never examined the chest nor the 
sputum. 

Having made a diagnosis, the patient and family should be apprised 
of the condition at once. This is not always done. Our profession 
is disgraced by the charlatan who filches the pockets of the poor con- 
sumptive while proclaiming that his lungs are sound, and that the 
<»ugh emanates from catarrah of the stomach. 

In the last annual report of the Henry Phipps Institute, it is 
forcibly shown that the house is an important factor in the implanta- 
tion and development of tuberculosis. Housework, millwork, shoe- 
making, tailoring, waiting and weaving, supply vastly the majority of , 
the cases. Generally there is a close association between the mor- 
bidity rate of tuberculosis and indoor life, hardships and want. Dr. 
Flick, in this report, states that of the patients treated, about one-half 
were working, and most of them were working indoors. With the 
modem teachings about tuberculosis, one would expect that the people 
suffering from the disease would seek outdoor employment. But the 
lack of opportunity for outdoor employment is the great obstacle. 

In the opinion of Dr. Lichty, Rockford, 111., the home is the placa 
-where our preventive work must be carried on and in view of the vary- 
ing conditions which surround all people in every walk of life, it is 
the place where we must eventually solve the problems of the disease. 

But we must remember that the lack of nearness and control so 
often makes the physician's work ineffective in the tuberculous home. 
Our need of the sanatorium is apparent. It is the ideal exponent of 
.modem treatment. It is a schoolmaster, teaching right methods to 
physician and layman. The modem sanatorium, according to Trudeau, 
represents the most favorable environment attainable for the con* 
sumptive, and depends, for its efficiency on the following factors: 
a good climate, buildings specially adapted for this method of treat- 
ment, and for protecting the iranates from infection, facilities for 
living an outdoor life in all kinds of weather, good food, and strict 
medical discipline so far as rest, exercise, and the details of the daily 
life are concerned. 

Unfortunately, under present conditions this ideal environment ma)r 
be secured for only a few who have tuberculosis. Most cases must, 
through necessity, remain at home for treatment. We can not too 
strongfy condemn the practice of sending indigent consumptives far 
from home, often among strangers, to endure the discomforts of 
poverty. The modem treatment of tuberculosis may be only im- 
perfectly employed in many homes, but the physician can do much 
to improve present methods of treatment. Telling the patient to live 



188 THE PHYSICIAN AND THE TUBERCULOSIS PROBLEM. 

in a tent or shack, and making a visit once every week or two wilt 
result in failure. The improvement resulting from weeks of care 
may be neutralized by some indiscretion of the patient. The physiciaa 
should keep in close touch with the patient. So far as possible modify 
favorably his environment. Regulate his habits relating to fresh air^ 
exercise, bathing, clothing, sleep and food. Weigh each symptom 
carefully. Patients convalescing from tyi^oid fever and other diseases 
need the counsel of the physician to prevent tuberculosis. 

In the tuberculous home, the physician should aspire to the ideal 
in prevention and treatment. With favorable environment, tuber- 
culosis may be cured at home in any climate. Not so easily as at a 
sanatorium because of many home and neighborhood influences that 
interfere with salutary treatment. It is here that the educating in- 
fluence of the physician should be felt by the patient, and in the home 
and community. His enthusiasm, and confidence in modem treat- 
ment will do much to secure the co-operation of the patient and his 
friends. 

The physician should lend his influence to all reforms that tend to 
decrease tuberculosis. His technical training, his advice and influence 
may do much to correct many evils and abuses that nurture tuber- 
culosis. 

This interest may cover a wide range: 

1. In the care of infant feeding, and food for adults. 

2. In the improvement of conditions which influence the health 
of the mother. 

3. In lessening the evils of intemperance. 

4. In active work on boards of charities and corrections. 

5. In improving tenement life; securing more light and better 
ventilation and less crowding. 

6. In using his influence for higher wages and shorter hours of 
labor, and for the improvement of all economic conditions which will 
increase resistance to disease. 

7. School life yet needs many reforms. The mental demands 
upon the child have been increased, studies multiplied, and not in- 
frequently the physical life of the child is ignored^ 



SPREAD OF TUBERCULOSIS THROUGH FACTORY 

SKIM MILK. 

H. L RUSSEIJU UNivERSiry op Wisconsin^ Madison. 

The most common method of transference of bovine tuberculosis 
is unquestionably through the purchase of stock affected in the earlier 
and unrecognized stages of the disease. In the improvement which 
has gone on in herds of cattle within recent years, through the intro- 
duction of pure-bred animals, this disease has been spread from herd 
to htrd, until at the present time, in most of our dairy sections, it is 
quite generally distributed. While this method of propagation of the 
disease accounts for the large proportion of cases as found today, 
another method of transmission has been recognized, t. e., the use of 
infected factory by-products, such as skim milk, buttermilk, and 
whey. The data submitted in this connection prove so strikingly 
this second method of dispersal, that.it has been deemed advisable 
to place the same on record. 

Naturally, the distribution of infection through skim milk cannot 
become effective until the seeds of tuberculosis have been spread for 
a considerable period of time. The disease must spread through the 
individual herd to a point where the milk supply becomes highly in- 
fectious before the skim milk from mixed creamery supplies will 
contain tubercle organisms in sufficient numbers to permit of direct 
infection through the use of this by-product. 

When one considers that many animals react to the tuberculin 
test which do not necessarily have tubercle bacilli in their milk, it is 
apparent that the disease must be present in a herd to a considerable 
extent before the mixed milk supply of that herd is likely to possess 
infectious qualities. Again, it doubtless requires the introduction of 
a considerable number of tubercle organisms by the way of the in- 
testines before the disease can be transmitted. Unquestionably a milk 
supply of a single animal infected with tubercle bacilli may be 
rendered harmless by dilution with a large volume of perfectly healthy 
milk, but in cases where the animal reaches an advanced stage -of 
the disease, especially where the milk-secreting organs become in- 
volved, it has been demonstrated that the dilution of such highly 
infected milk, even with a large volume of normal milk, may not 
eliminate the possibility of spreading the contagion. 

In the process of separation in the factory, some of the tubercle 

139 



140 FACTORY SKIM MILK AND TUBERCULOSIS, 

organisms go with the cream and the centrifuge slime, but the skim 
milk retains enough of these organisms so that the feeding of such 
refuse milk to young stock or hogs will cause the rapid spread of the 
disease to these animals. At the present time, the hand separator is 
being rapidly introduced on the farm, and where such is the case, 
naturally the distribution of the disease is restricted to the individual 
"herd in question. Where, however, the whole milk goes to the 
creamery or cheese factory and is not diluted to a point of safety, 
the possibility of rapid distribution is materially increased. Under 
5uch circumstances this second method of dissemination through 
factory by-products results in the explosive type of distribution, which 
is likely to infect, more or less thoroughly, the entire susceptible 
animal population subject to such exposure. 

The distribution of bovine tuberculosis here in America does not 
usually reveal a very large percentage of animals affected, and hence, 
it is especially important that foci in which this explosive method of 
disposal occurs should be early recognized. 

During the past season, a large number of tuberculin tests were 
made under our direction in southern Wisconsin, and it was eariy 
noted that an unusually large percentage of reacting animals was 
found in the eastern part of Dane County, one of the leading dairy 
counties in the southern part of the state. A more suspicious circum- 
"Stance was the fact that the young stock raised on the farm reacted 
in an unusually large number of cases, while very conunonly mature 
animals were free from the disease. A rec<^;nition of this condition 
led to a thorough investigation of the surrounding region, and a large 
number of tuberculin tests were applied to the herds in this vicinity. 

It was found that two adjoining creamery districts were badly in- 
fected with tuberculosis. These creameries (Medina and Oak Park) 
are midway between the villages of Deerfield and Marshall, in Dane 
County. They are surrounded by numerous other creameries, and 
a comparison of the amount of tuberculosis in this district with these 
outlying creameries shows positively that the spread of the disease 
in the first mentioned region was traceable to skim milk infection. 
The results of these examinations are incorporated in the tables here 
presented. 



FACTORY SKIM MILK AND TUBERCULOSIS. 



141 



HISTORY OF TESTS IN MEDINA CREAMERY. 

Table I — Results of Tuberculin Tests on Herds of Medina Creamery. 





1 




Post'Tnortem results. 


i 

o 

4J 






tt. 


^ 


51 






rt 




1 


.I'd 




History of reacting 


d 




1 . 


1 


°'2 


T3„ 


animals. 


z 


**4 


o . 


■si 




|| 




•a 


o 


te 


irt 




'si*£ 


tJ " 




u 




. c 


. rt 




■ 7\ ^ 


^ U 




V 


6 


Q.5 


O & 


6 L» 


OZ^ 


q/*^ 




ffi 


^ 


;2; 


;g; 


^ 


^ 


P^ 




239 


15 


13 


5 


7 


5 


4X 


All raised on place. Non-reac- 






tors fed pasteurized skim 
















milk. Has had no disease 
















for number of years. 


241 


26 


21 


7 


12 


2 (1 udder) 


4X 


Purchased 2 ; raised balance. 4 
of 5 non-reactors fed past, 
milk. Has had tuberculosis 






























on farm for a number of 
















years as he had killed cat- 
















tle for own use and discarded 
















them. 


296 


14 
22 
8 
30 
35 


3 

13 

1 

3 

24 


■'6' 




3 

7 
1 

1 


2 


2X 

3X 

X 

X 

4X 


All reactors raised. 


259 


3 


All raised on place. 


244 


1 


All raised on place. 


214 




Reactor raised. 


60 




Has had disease at least 6 years. 
















Sold some this year to local 
















butcher but were found af- 
















fected. 


109 


22 


1 





1 


1 udder .. 


X 


Reactor raised. 


148 


26 


16 


8 


8 


8 mes. or 
liver, 2 
udder . . 


4X 


3 purchased, 1 from known tu- 
berculous herd. 13 reactors 
raised 2 to 10 years old. 


115 


16 


6 


5 


1 


1 


2X 


5 raised 3-6 years old ; ; 1 






bought from known tubercu- 
















lous herd. Calves non- react- 


F. S. 


25 


8 


5 


8 


2 


4X 


ing. 
5 reactors (young) raised; 3 

purchased. 
All reactors raised on place; 4 

young stock, balance aged. 






196 


20 


12 


3 


8 




3X 






243 


17 


7 


4 


3 




2X 


All reactors raised; 3 young 






stock. 


124 


23 


5 


2 


3 


1 udder .. 


2X 


All raised or bought as calves 
2 to 5 years ago. All present 
young stock free. 


256 


9 
25 



20 



16 



3 








165 


7 mes. and 
















liver . . . 


2X 


Disease introduced by purchase- 
about 8 years ago. Has lost 
animals at times ever since. 
Disease mesenteric, rather thair 
pulmonary. 



142 



FACTORY SKIM MILK AND TUBERCULOSIS, 



Table I — Continued. 



^ 



4; 





^ 


1 


i 






♦* 


(0 










^ 


g 








c 


a 


OS 


C8 






«4M 


«4M 




*« 


d 


d.S 


;2: 


;? 



Post-mortem results. 



lA 

;2: 



a a 






SB 






^ 



04 



History of anim&b re- 
acting. 



295 
E. H. 

306 
64 
88 

240 

238 

C W. 
275 

262 
169 



149 
255 



307 



242 

228 
258 



15 
25 

20 
14 
14 
28 

28 

26 
25 



48 



2 udder 

3 mes. 
1 liver 
8 liver and 

mes . . 



3X 

4X 

X 
X 

3X 
X 



3 liver and 
mes .. 

1 udder 
6 mes & 
Uvcr. 



6 mes. and 
liver . 



X 

2X 



X 
4X 



3X 
X 



3X 



Reactors mostly young stock; 
all raised except 3. 



Resided on this farm 3 years. 
Herd of previous tenant badly 
affected. Bought two that 
now react. 

2 year old heifer had mesen- 
teric gland affected. 

1 reactor bought when calf, 
other raised 

All raised but 3; all ages af- 
fected. 

Both reactors purchased; owner 
moved to this farm from 
Deansville during previous 
faU. 

This herd came from Cottage 
Grove the year before. 



Moved to this farm few months 

previous. Diseased animals 

probably brought from near 

Waterloo. 
All animals raised on farm. 
All aged cattle raised on farm 

reacted. Some young stock 

free, also cows whidi were 

bought. 
Reactors all raised. 
Reactors raised. Reactors 2 yrs. 

old have remained out of 

doors all the time. 
Sing[]e reactor raised on skim 

milk. Took cream only t« 

factory. 
Bought most of herd from away 

within two years. 
Raised. 

Most reactors raised. 6 out of 
8 non- reactors fed pasteurized 
skim milk. 



FACTORY SKIM MILK AND TUBERCULOSIS. 143 

Table I — Concluded. 





•4-» 
CO 

1 

d 

2; 


1 

1 

*s 

o . 


Post-mortem results. 


c 
o 

1 

¥ 






(A 

J 

1* 


en 

eg 

1^ 


No. of Mesen- 
teric infections 
(glands). 


History of animals re- 
acting. 


211 


17 

33 
14 


1 

5 
6 


1 

2 
5 




2 

1 




X 

2X 
2X 


Patron of this creamery since 

January 1, 1906 only. 
All reactors, young stock. 

3 reactors, raised on farm: 3 
purchased. 


177 




A. H. 


1 general- 
ized 


Total ., 


784 


271 


105 


123 









*The severity of the outbreak in individual herds as determined by post- 
mortem findings is designated as follows: 

X — Slight 
2X — Moderately bad. 
3X — Bad. 
4X — Very bad. 

As is apparent from the history of these individual herds, it is 
noteworthy in most cases that the reacting animals were raised on the 
farm, and in some cases all of the animals in the herd were so raised. 
In a limited number of instances, the affected animals were purchased. 
These reacting animals were condemned and shipped for immediate 
slaughter, in accordance with the state law, and in a relatively large 
proportion of cases, it was shown that the disease was more or less 
generalized, very frequently in the body cavity. In several herds 
contributing milk to this creamery, little or no disease was found, and 
a study of these affords fully as important proof as to the manner 
of distribution as the positive findings. Only three herds out of 36 
tested, remained entirely unaffected, and in two of these cases, the 
owners had moved on to their respective farms within the last year 
and had brought all of their animals with them. In the case of 
another new occupant of a farm, the two reacting animals found in 
a herd of 28, were both purchased from outside of this creamery 
district. 

Another patron of this factory, who had only one reactor in a herd 



144 FACTORY SKIM MILK AND TUBERCULOSIS. 

of 48, took only his cream to the factory. The single reacting animal 
in his herd was, however, fed on skim milk secured from the factory. 

Of the 784 head of cattle here examined, 271 reacted to the test. 
These 784 head were distributed among 36 different herds, and of 
this number, 33 herds were found to contain reactors. At the time 
the test was performed, these herds were found in a very bad con- 
dition, and in twelve instances over one-half of all the cattle tested 
in each herd, including the young stock, reacted. 

The result of the post-mortem examination of this stock, made 
under federal inspection showed infection of the udder eight times, 
and over 70 cases in which the body cavity (mesenteric lymph glands, 
or liver) was affected. Of the 228 animals on which post-mortem 
examinations were made, 123 were condemned as unfit for food, 
while the balance were passed as suitable for use, thus mdicating that 
the disease was not only widespread, as to numbers, but was well 
generalized in a large proportion of individual animals. 

HISTORY OF TESTS IN OAK PARK CREAMERY. 

In making these examinations among the patrons of the Medina 
creamery, naturally the surrounding farmers were also interested in 
having their herds tested, and a considerable number of examina- 
tions were made in another creamery district (Oak Park) lying im- 
mediately south of the Medina factory. Among the earlier tests made 
in this district, one herd was found in which practically the whole herd 
was rejected (24 out of 26). This induced the majority of the patrons 
of this factory to apply the tests to their own herds, with the results 
as expressed in Table II. 



FACTORY SKIM MILK AND TUBERCULOSIS. 146 

Table II — Results of Tuberculin Tests ok Herbs op Oak Park Creamery. 





to 

1 

C 
ei 




1 

CO 

1 


Post-mortem results. 


1 

.s 

1 




1 

•s 

X 


en 

%m 

1 


1 

i 

8 

d 


1 


History of animals re- 
acting. 


60 
C M 


26 

4 
14 
10 
18 
16 

6 
19 
25 

22 
21 
19 
19 
19 
15 

30 

28 
29 
11 

25 
10 
3 
21 
19 


24 


3 

2 


3 
9 


3 
2 
2 

1 
.0 

29 

11 
4 
8 





2 


6 


3 

1 


3 
3 


3 
1 

1 



4 
2 

5 





2 


18 




1 



4 




1 
1 
1 


25 
8 

2 








15 mes., 1 
udder ... 


4X 


6 animals in this herd died of 
tuberculosis last year. Owner 
had boiled milk for his own 
family ; sold balance to cream- 
ery. 


328 
L. S. 


1 mes. . . . 


X 


Raised reactors. 


47 
281 


1 mes. ... 


X 


Raised reactors. 


P. T. 








144 




X 
4X 


Raised reactors. 


143 
E. H. 


4 mes 


All reactors aged animals and 
raised on place. 


34 




X 
X 
X 
X 


Reactors raised. 


L. S. 


1 mes 




179 


One reactor raised. 


178 
197 


1 mes 


Reactor raised, — 7 years old. 
Used hand separator for past 
year. . , 

The only non-reactor was pur- 
chased 2 months prior to test. 

Raised all reactors but one. No 
young stock affected. 

Reactors— 1 mature, 2 young 
stock; most stock raised. 

Raised 6 reactors; all but 1 3 
years old and over. Bought 
2 remaining reactors. 


183 

260 
323 
333 

*A. G. 


13 liver & 
mes .... 

2 mes . . . 
2 mes .... 


4X 

2X 

X 

3X 


A. S. 








*H C. 








P. K. 
P. H 




X 


Raised all his stock. 










429 


103 


34 


61 

















♦Herds tested with proprietary brand of tuberculin later found to be ineffi- 
cacious. 



10 



146 FACTORY SKIM MILK AND TUBERCULOSIS, 

In this creamery district, 429 animals were examined, among 24 
different herds, with the result that 103 reactions for tuberculosis were 
found. Of the 24 herds tested, 10 were found entirely free from the 
disease, while of the 14 remaining, only four herds were found to be 
in a bad condition. In two of these cases the conditions were 
abnormally severe. In one case, 24 reactors were found in a herd of 
26. This farmer had lost six animals the year before from tuber- 
culosis, but did not appreciate the gravity of the problem on his hands. 
Fearing the possible effect on his own family, he had boiled the milk 
used at home, but had taken the unheated balance to the creamery. 

In another case, 29 in a herd of 30 were condemned. In fact, the 
only animal which escaped infection in this case was one which was 
bought two months prior to the time the test was applied. 

While the balance of the affected herds show but a limited number 
of reacting animals, it was early noted that in general the reactors 
were raised on the farm, rather than purchased. Of the 61 animals 
condemned upon federal inspection, over 40 of these showed in- 
fection of the liver, or lymph glands of the body cavity. In this 
instance the severity of the disease was not as marked as in the case 
of the Medina creamery, yet the history of the majority of the cases 
left no question as to the source of infection. 

From the records of the State Live Stock Sanitary Board, it ap- 
pears that in this same district a herd had been wiped out three years 
before, in which 2y reactors out of 30 had been found. The post- 
mortem examination of this herd at that time revealed a large per- 
centage of cases of severe infection. The foregoing table shows a 
number of cases in which the reacting animals were fairly mature, 
and yet raised upon the farms. This fact, taken in connection with 
the history of this severely affected herd, would seem to date back 
the origin of infection, several years, to a time when the milk of this 
herd was used at the factory. Inquiry of the factory officials de- 
veloped the fact that for the past two or three years, the skim milk 
had been pasteurized during the winter months, but not during the 
summer. The chain of evidence in this case seems quite as conclusive 
as in the case of the Medina factory, that skim milk infection was the 
means whereby the disease was spread. 

DISTRIBUTION OF TUBERCULOSIS IN SURROUNDING CREAMERIES. 

The conclusions above deduced are materially strengthened if we 
compare the tuberculin test data collected on herds in the vicinity of 
these two creameries. In Table III are incorporated the results of 



FACTORY SKIM MILK AND TUBERCULOSIS, 



147 



tests made in eleven surrounding creameries, seven of which were in 
immediate contact with the Medina-Oak Park area under considera* 
tion. 



Table III — Result op Tuberculin Tests on Herds Supplying Difperent 

Creameries. 

A. creameries immediately adjacent to oak park and MEDINA DISIRICTS. 

Pierceville Creamery, 





1 

Ji 
1 




Post-roortero resulta. 


Q 


" 


1 


1 
1 

1 
1 


6 




History of animals re- 
acting. 


257 
W. P. 


29 

14 
9 
11 
18 
13 
19 

28 

6 

16 

32 
18 

13 
15 
10 
59 

18 

7 


1 





1 

2 

1 
1 

1 

1 

15 

2 
2 







2 
1 

1 
1 
4 

1 
2 

1 
1 



1 




1 




• • • • 



8 

1 









generalized 
case — 


X 


1 reactor bought from Lake 
Mills. 


F. W. 








M. L. 

G P 


1 mes 


X 
X 
X 
X 

X 
X 

2X 

X 
X 

X 
X 


Reactor bought at auction. 
Bought both at auction. 
Raised reactor 


236 




194 
'W B. 




Raised all stock; reactor two 

years old. 
Bought from infected herd. 
Reactor raised. 


27a 




27 




Lost cows in '05 from disease* 


J. H. 
212 


1 bad mes. 


11 of 15 reactors bought with- 
in few years, most of which 
from diseased herds. 

Bought both reactors. 

Bought 1; raised 1, 3 years old; 
no lesions. 

Raised, 8 years old; no lesions. 

Bouflfht at auction 


210 




H. E. 




T. M. 






284 


1 






X 
X 

X 


Bought from known tubercu- 
lous herd. 

Bought 2 reactors, 3 and 5 years 
ago. 

Rais^ reactor 


40 


I 


4 







389 
















325 


35 


18 


5 









148 



FACTORY SKIM MILK AND TUBERCULOSIS. 



Table III — Continued. 
Deansville Creamery. 





t 

U 
1 


1 

1 


Post-mortem results. 


1 

c 
o 

1 




1 
1 


1 
1 

1 


1 
6 




History of animals re- 
acting. 


224 
225 


20 

14 

15 

2 


1 






.... 


— 




X 


Bought two years ago. 


234 












28 


























51 


1 


.... 


.... 










Marshall Creamery, 



204 
235 
320 

J. P. 

C J. 
321 



308 
324 
283 
205 
254 
324 
A. W. 



24 
11 
23 
53 
23 
37 




2 


1 
2 


















1 


1 




1 X 






.... 


..J. 




X 
X 




' 


171 

39 
4 
17 
14 
14 
1 
22 


5 

2 



1 

1 
2 













2 


Bad 


X 













1 


Mes 


X 



2 


1 



1 mes . . . 


X 

X 






282 


11 




.... 




1 



Reactors bought at auction. 



One reactor bought Oct '06, the 
other March, 'OC. 



Raised. 
Bought. 



Bannon Creamery. • 



231 


23 


289 


15 


269 


15 


41 


38 


341 


13 


36 


14 


232 


18 


49 


2 


A. S. 


26 



1 

1 

1 


110 



1 


10 



.... 


1 




X 
X 

X 






4 


6 


1 mes. and 6 
3 liver... 


3X 


















4 


6 


mes and 3 
liver . . . 


3X 



Raised. 

Bought reactor of August 

Schlueter. 
Raised. 



All raised. 
Reactor raised. 



Part raised; part purchased. 



FACTORY SKIM MILK AND TUBERCULOSIS, 



149 



Table III — Gmtintted. 
Bannon Creamery — Concluded 





1 


1 


Post-mortem results. 


CM 

.s 


History of animals 






1 


•S 


1 

^1 


re- 


d 


Hi 


t 


s. 


•?=; 


acting. 




^ 


u 


v« 


u 




*«^.s 








£ 


£ 


£ 


8 


^s 


g 






•H 




B 


8 




c 


ti^ 






«^ 




zs 


9 


o' 


o* £ 


V 






W 


^5 


Jz; 


:? 


Jz; 


^5 


Q 






129 


31 


2 


1 


1 


marked 










24 
33 


6 

8 


6 
2 





case 

Slight .... 
1 mes 


X 
X 

2X 






F K. 




A B. 










252 


40 


.... 


.... 









332 


8 

15 
17 
23 
22 
7 

30 
22 
17 


3 

1 
1 




3 







1 mes. and 
liver .... 




J. T. 
A. B. 


1 




1 


2X 
X 




X 


247 






21 










342 










102 










265 


8 







X 


45 


















161 


8 


.... 


.... 








DeerHeld Creamery. 

Purchased all three reactors. 
Took cream only to factory. 



Bought all 3 reactors at auction. 



Nora Creamery. 



154 
9 
8 

266 
95 

160 



276 
213 

121 
300 



16 
11 
25 
25 
20 

7 




1 
1 
2 


1 
















X 








X 


.... 


.... 




X 








X 










104 


5 




.... 







Reactor raised. 

Both reactors 2 years old. 

Used hand separator for last 

two years. 
Bought 3 years ago. 



Ridge Creamery. 



22 
15 

20 
17 


2 
4 





1 


.... 




X 














1 










74 


6 


.... 


.... 




1 



All herd raised. 

1 purchased 2 years ago; other 
raised. 

All raised on place. 



160 FACTORY SKIM MILK AND TUBERCULOSIS. 

Table III — Concluded. 

B. CREAMERIES NEAR BUT NOT IMMEDIATELY ADJACENT TO OAK PARK AND MEDINJI^ 

DISTRICTS. 

London Creamery. 







ha 


Post-mortem results. 


1 












1 






1 


1 


1 


1 


i| 


Is 


History of animals 


re- 


6 


♦- 


& 


a. 


« 


*?! 


acting. 




Z 


1 


u 


.K 


g 


O y 


£ 






"S 


g 


g 


g 




c 








4) 


g 


s 


2 


n 


o ii 








a 


^ 


:zi 


^ 


^ 


:§ 


Q 






181 


22 
88 
19 



4 

4 










C. S. 


4 







X 
X 






180 




Raised. 




283 


22 


2 




.... 




X 














101 


10 


.... 









Utica Creamery. 



278 


18 
15 



1 








250 


1 





X 








28 


1 


.... 


.... 





Raised. 



York Creamery, 



A. W. 


17 
10 
17 
12 

7 




8 
4 
2 










329 










880 








X 


336 








X 


337 


.... 






X 




63 


9 


.... 


.... 








Bought 2; raised 1. 



Purchased reactors. 



819 1 26 



Excelsior Creamery. 
I I X 



It is at once apparent that the disease in these surroundings 
creameries is far less widely disseminated than in the two factory 
districts previously under consideration. For purposes of direct com- 
parison, in Table IV the total results presented in the foregoing 
tables are summarized. 



FACTORY SKIM MILK AND TUBERCULOSIS. 



151 



Table IV — Summary op Tuberculin Tests. 
A. Oak Park and Medina Creameries. 





«0 


(0 


0) 


(0 




Results of 




Wi 




1 


1 


i 


slaughter. 






1 




**-4 


VM 


CM 




S 


M 




Name of Creamery. 


o 


o . 


o 





£ 


s. 








S? 




tM) 






*o 




11 

6^ 


Is 




•§1 


4J 

P 




|| 




S-5 


S u 


S3 ^4 


5J u 


t 


9 


s-o 




:z 


iz; 


^ 


iz; 


Cl< 


iz; 


:z; 


Medina 


36 
24 


33 
14 


784 
429 


271 
108 


34.5 
24.0 


105 
34 


123 


Oak Park 


61 






Total 


60 


47 


1,213 


374 


30.8 


139 


184 



B. Creameries immediately adjacent to Oak Park and Medina. 



Picrceville 
Deansville 
Marshall .. 
Bannon ... 
Deerfield . 

Nora 

Ridge .... 



Total. 



18 
4 
13 
12 
9 
6 
4 



66 



15 
1 
7 
9 
4 
4 
2 



42 



325 
51 
282 
252 
161 
104 
74 



1,249 



35 
1 

11 

40 

8 

5 

6 



106 



8.5 



18 



3 

17 

4 



6 

12 

1 



C. Creameries not immediately adjacent to Oak Park and Medina. 



London . . 

Utica 

York 

Excelsior . 

Total. 



12 



101 
28 
63 
26 



218 



10 
1 
9 

1 



21 



10.0 



From the data presented in Table IV, it appears in the 6o herds 
tested in the Medina-Oak Park district, 47 of these contained cases 
of tuberculosis. In these two creameries 1,213 animals were tested, 
with 374 reactions, — in the Medina district, 34.5 per cent., and 
in Oak Park 24 per cent, of all the animals responded. In the eleven 
outlying creameries immediately adjacent, or relatively near the Oak 
Park-Medina district, 1,467 cattle were tested, with 127 reactions, or 
an average of 8.7 per cent. 

In testing the herds supplying these eleven creameries above 
referred to, doubtless the owners who had any suspicion as to tH^e 
condition of their herds would be the first to employ the test. Of 



152 FACTORY SKIM MILK AND TUBERCULOSIS, 

the 78 herds tested that were tributary to these creameries, only three 
showed any high percentage of reactions. In most cases the number 
of reacting animals was quite small, and these were found in a large 
majority of instances to have been purchased, rather than raised. 
Reference to Fig. I. shows the relation existing between the reacting 
and non-reacting animals in this region much more closely than can 
be indicated by tabular data, and a study of this diagram would seem 
to leave no question as to which factor, purchase or skim milk in- 
fection, was responsible for the widespread distribution of this 
disease within the confines of the Medina-Oak Park district. 

It is, of course, possible to prevent the distribution of this disease 
in this manner by efficient pasteurization of factory by-products. By 
the use of the exhaust steam the factory operator can raise the 
temperature of the skim milk in a thoroughly practicable manner to 
a point which will destroy the tubercle bacilli, and thus insure against 
the further distribution of the disease. This custom has already been 
introduced voluntarily into a large number of creameries as the im- 
proved condition of the skim milk makes it worth while. Iowa and 
Minnesota already bear compulsory pasteurization of skim milk at a 
temperature of 176** F. This temperature is considerably higher than 
is actually necessary to destroy the tubercle bacillus, but in the en- 
forcement of this law, Storch's test* is used as an index to determine 
whether or not the factory by-product has been heated, and this can 
only be satisfactorily interpreted on milks which are heated to this 
temperature. 



* Beret. Konig. Vet og Land. Lab. Laudokon, Forsog. (Copenhagen) 1898. 




C 



c 






o 

CO 



THE PROBLEM OF CITY MILK SUPPLIES. 
Dr. CHARLES HARRINGTON, Boston, Mass. 

The dairy industry of this country is one whose immensity and 
importance cannot be measured by mere statistical data, for besides 
the economic value of the several chief products, and apart from the 
fact that it is the sole source of income to thousands and tens of 
thousands, and a chief, or, at least, an important contributing source, 
to far larger numbers of our general population, there is another side 
of the subject that only of late years has begun to be appreciated by 
the thinking public, who are now recognizing the influence which it 
is exerting upon the life capital of this country and of all others. 

Our dependence upon the products of the dairy for the purposes 
of nutrition is too well-known to need more than passing mention; 
yet we could bear being deprived of our supplies of butter and cheese 
without great suflfering and certainly without the slightest possibility 
of the loss of a single life ; but it is otherwise with milk, which can- 
not, like butter, be imitated in composition, taste, and appearance, 
and which is, or should be, the sole, as it is the absolutely indis- 
pensable, food of the very young, the main reliance of many of the 
sick, and a desirable and nourishing component of the daily diet of 
young and old, rich and poor, strong and weak, well and sick. 
Recent investigations have shown a per-capita daily consumption, in 
some of our larger cities, of more than four-fifths of a pint. To 
those who have given the subject of mass-feeding little or no thought, 
this per-capita demand does not sound large; but when we come to 
multiply it by the population, divide the product by the average daily 
yield of the average good milker, we ascertain how large a herd 
is necessary to produce the needed supply of a given city. Take, for 
example, a city of half a million people ; allowing a per-capita demand 
of four-fifths of a pint, and allowing two and a half gallons of milk 
as a good average daily yield for a cow, we find that such a city 
requires the product of a herd of 20,000 cows. And right here, one 
of the most important facts in connection with public milk supplies 
makes its appearance — important to the producer, to the middleman, 
and to the consumer — namely, that such a vast herd, split up into 
small groups, requires enormous areas of feeding grounds ; and herein 
enters the element of distance. Allowing ten cows per farm, we have 
2,000 farms from which to draw. Many farms are, of course, near- 
by, but so also are other communities which must have their daily 

153 



164 THE PROBLEM OF CITY MILK SUPPLIES. 

supplies, and so it comes about that a large city must reach very far 
out into the rural districts, in some instances even hundreds of miles. 

The great extent of this gathering ground introduces a number 
of important factors into the problem of large milk supplies. One 
of these is the cost of transportation. The longer the haul, the greater 
the charge ; and since there is ordinarily a uniform gross rate paid per 
gallon, the greater the distance to market, the smaller the net return 
to the producer. 

Distance introduces necessarily the element of time. The longer the 
haul, the greater the time required for transportation, and the older the 
milk when received for distribution to the consumers ; and unless the 
cans are properly iced during transit, the richer the milk in bac- 
terial contamination. 

The most important difficulty connected with the wide geog^phicat 
distribution of the contributing farms is the practical impossibility 
of efficient control of the local conditions under which milk is pro- 
duced for public sale. The authorities of a city may exercise strict 
control over the dairies situated within city limits and may place a 
ban upon the product of the farm where insanitary conditions are 
known to obtain ; they may establish standards of purity and cleanli- 
ness, and exclude from sale all milk failing to conform thereto; they 
may pass regulations in respect of conditions under which dairies 
from without shall be conducted in order that their product may gain 
admittance to the local market ; but however great their vigilance, the 
market cannot, under the usual existing conditions, be free from a 
considerable influx of milk produced under the vilest conditions. 

For the control of conditions in the strictly rural districts, the 
strong arm of State authority, with the co-operation of local authori- 
ties, is necessary; and even then the problem is beset with difficul- 
ties innumerable, to which I shall return. 

I have spoken of the economic importance of the dairying industry^ 
To the sanitarian the hygienic side of the milk problem is the one 
of paramount interest and importance, and evidence is not wanting of 
a steady, although slow, growth in interest in this phase of the subject 
on the part of the consuming public. But the public needs a great 
deal of education before it can fully comprehend the vastness of the 
importance of the influence of a sanitary milk supply. 

Turning to the report of the last national census, we learn that the 
three leading causes of death in the registration area of this country 
are tuberculosis, pneumonia, and diarrhoeal diseases. At least two 
of these three main causes are very largely preventable. Concerning 
one of them, tuberculosis, the public is rapidly acquiring an educa- 



THE PROBLEM OF CITY MILK SUPPLIES. 166. 

tion; and the knowledge that thousands of lives which might have 
been saved by proper precautions and simple methods of treatment 
have been sacrificed annually, and that the loss is still going on, has 
led to a world-wide movement for the establishment of public and 
private sanatoria, and of hospitals for the care of advanced cases. 

The diarrhoeal diseases are far more easily preventable than tubercu- 
losis, if the public but knew it and understood wherein lies their princi- 
pal causes. 

From the registration returns, we learn that in the large cities and 
towns of most countries, and partictdarly in those centres of indus- 
trial activity in which large numbers of women are employed in fac- 
tories, 20, 25, 30, 35, 40, and even higher percentages of the infants 
bom in any one year die within the year. 

Here are some recent figures from European sources : 

Between 20 and 25 per cent.: 

Berlin, 

Strasburg, 

Manchester, 

Prague, 

Leipzig, 

Magdeburg, 

Dresden, 

Vienna, 

St. Petersburg. 

The Empire of Germany. 
Between 25 and 30 per cent. : 

Rome, 

Meissen, 

Freiberg, 

Marienberg, 

Cologne, 

Budapest. 

Bavaria, 

Saxe-Altenburg, 

The Empire of Russia. 
Between 30 and 35 per cent. : 

Zwickau, 

Chemnitz, 
Between 35 and 40 per cent. : 

Munich, 
Between 40 and 45 per cent. : 

Munich (once within recent years). 

For the German Empire, the rate is about 20 per cent. Two mil- 
lion infants, born yearly, — 400,000 of them lost in their first year. 
In a recent month, eight German cities had an infant death-rate of 



166 THE PROBLEM OF CITY MILK SUPPLIES. 

imore than 333 per 1,000 births. And how is it in our own country? 
Unfortunately we cannot know, for with us, except in ten states and 
the District of Columbia, the registration of the vital statistics has been 
neglected ; but outside the registration area are many cities and towns 
which do that which their states neglect; and so it comes about 
that we know that at least one American city loses 42 per cent, of its 
annual births ; that at least nine lose from 30 to 40 per cent. ; that at 
least 10 lose between 25 and 30 per cent.; and that at least 38 lose 
between 20 and 25 per cent. 

From what diseases do these gr^t numbers of infants die? The 
causes are many, but there is one which stands forth and compels our 
-attention — Epidemic Diarrhoea. Wherever this factor in the death-? 
rate is carefully investigated, it appears that the g^eat majority of the 
victims have been denied their natural food and have been fed on cows' 
milk. It is so in this country, in Great Britain, in France, in Germany 
— everywhere where inquiry is made. 

The most extensive investigation of this sort with which I am 
familiar is that which is conducted continually in Berlin, where, during 
the past five years it has been demonstrated that less than 10 per cent, 
of the decedents are breast-fed. 

From the many returns at hand, but one conclusion can be drawn, 
and that is that ordinary market milk contains the exciting cause 
of disease and death; and since market milk as commonly produced 
is a more or less filthy food, we must conclude that the exciting cause 
is introduced in preventable filth. In this conclusion we are fortified 
"by the fact that the lowest infant mortality rates are those which 
obtain in those countries which are noted for their clean methods of 
dairying, namely, Norway, Sweden and Denmark. 

When we ask ourselves how this annual sacrifice of infant life can 
be stopped, the answer is simple, but the methods necessary for its 
abatement are complicated and beset with g^eat difficulties. First 
<x)mes the creation of strong public sentiment which must lead to laws, 
ordinances and regulations. The public must be stirred to demand 
these and their proper enforcement. It must be stimulated to some 
sacrifice in the matter of expense. It must be shown that the pro- 
ducer is entitled to a fair return for his labor, for feed, and for care 
of his stock. If his returns are meager, he cannot maintain his plant 
in a proper condition of repair; he cannot afford the best of help; 
lie cannot give to his stock and to his utensils that care which is 
necessary to the production of a clean and wholesc«ne supply. 

The education of the public is not an easy matter, although at first 
•sight it may seem to be. Ask any person of intelligence which he 



THE PROBLEM OF CITY MILK SUPPLIES, IST 

prefers — milk containing preventable filth or milk so produced as to 
be quite free therefrom, and his answer will be in favor of the latter. 
Ask him if he will pay an additional cent or two per quart, in the 
way of insurance from disease, and in a majority of cases interest in 
the subject wanes at once. Tell him about the myriads of bs^cteria 
in every teaspoonf ul of ordinary market milk ; tell him of the dangers 
that reside therein; tell him of the annual preventable deaths due 
thereto, and more often than not, he will conclude that you are indulg- 
ing in hyperbole, and that you are a faddist and a crank. He has had 
no experience which can tend to convince him that you, as a scientist, 
know nx>re about the matter than his so-called common-sense can 
teacli him. And, beside, he is paying as much now as he can afford 
for milk. 

For his education, he needs something more than words and sta- 
tistics; something more than lectures and essays; something more 
than figures of bacterial richness, so great as to be beyond compre- 
hension. You cannot give hinl an adequate education through his ears ; 
you must appeal to his intellect through his eyes. You must show 
him diagrams and photographs; you must show him much that will 
disgust and much that will stand out conspicuously in contrast. You 
must show him conditions as they exist, and conditions that can be 
made to exist. He must be made both to hear and to see. And this 
can best be done by means of exhibitions and lectures, similar in gen- 
eral character to those which have done so much for the movement 
against tuberculosis. 

When the American public feels that it is being treated unfairly, 
it begins to take measures for its protection, and one of its first 
demands is for law. Here, we come to our second great difficulty. A 
given community comes to the conclusion that it needs some additional 
legislation for the protection of its health, and it begins agitating 
therefor, and submits a draft of a bill. Be it for pure foods, for pure 
water supplies, or protection against the patent medicine fraud, for 
general vaccination, or free public distribution of diphtheria anti- 
toxin, for clean milk, or for anything else that is a public necessity, 
there is almost sure to be strong opposition from those who feel that 
their private interests and constitutional rights are about to be im- 
paired and violated. 

Repeated attempts to secure the much desired legislation may be 
necessary, but finally the law is passed and the people feel secure. 

Let us suppose that the demand for a law against the sale of adul- 
terated and unclean milk has been successful; the second great ob* 
sacle has been overcome, but now we come to a third. 



158 THE PROBLEM OF CITY MILK SUPPLIES, 

No law, however perfect it may be, works automatically. Scxne- 
body must be charged with the duty of its enforcement; and for the 
proper discharge of this duty, an adequate force and liberal appropri- 
ations are needed. Certainly, such are needed in the enforcement of 
a general milk law. 

Where it has been tried, experience shows that provisions against 
the sale of adulterated milk are far more easy of enforcement than 
are those against bacterial richness due to filth and improper methods 
of handling, storage, and transportation. 

City and town milk inspectors, having the sjrmpathy of the public 
and the backing of the courts, can bring, if they try, the practice of 
adulteration down to an apparently irreducible minimum. They cannot 
drive out of business every rascal who cannot be reformed, any more 
than a large police force can make jails unnecessary; but they can, 
and many do, bring about enormous improvement. The task is far 
from easy, however, and the bed of a conscientious city milk inspector 
is not of roses. He has many difficulties, of which the public has 
no conception. The public knows that he sends men out to collect 
samples, and that on the findings of the department chemist he takes 
such action as seems to be necessary. It reads in the papers, every 
week or so, that a number of dealers have been haled to court and 
have been compelled to pay fines ; but it knows nothing of the subtle 
influences at work in attempting to corrupt his nqt-too-well paid staflf 
of agents ; it knows nothing of the worries which are an incident of 
his everyday official life. 

But with or without worries, the fight against fraud is easy in 
comparison with the fight against dirt. In this field of work are 
far more numerous difficulties and far greater difficulties. , In the first 
place, the geographical distribution of the sources of supply and the 
number of these sources must make the labor of inspection enormous. 
Efficient and repeated examination must necessarily call for a larger 
measure of assistance than often can be granted. And in this woiic 
one meets all kinds and conditions of men, all possible forms of filth, 
all manner of large and small difficulties. 

A certain fairly large proportion of milk producers are not and 
never can be educated to a proper sense of decency in the conduct of 
their dairies. Filthy in their persons and dress, slovenly in their 
ways, with no sense of thrift, though penurious in their daily lives, it 
can hardly be expected that their cattle, their cow stables, or their 
utensils will be otherwise than filthy. This class is hopeless, even 
under repeated admonitions. Occasionally, however, we may see ex- 
amples of the beneficent influence of a good, keen business sense in 



THE PROBLEM OF CITY MILK SUPPLIES. 169 

transforming an apparently hopelessly filthy establishment into an 
almost model dairy. This filthy class does not belong to any one race 
or nationality. They are by no means necessarily of the brutish off- 
scourings that come to us from certain foreign countries, where they 
have been practically bondmen and serfs. You will find among them the 
degenerate descendants of those who came here when the country 
was in wilderness ; and these are harder to deal with than the refugee 
peasantry of Russia, for they have very fixed notions of their rights, 
among which they conceive, is the right to do as they like with what 
is their own — to be dirty if they like, to keep their own cows in 
their own way and to sell the product to the buying public. 

At present, all over this country, except in certain small areas, here 
and there, they appear to have this right, with absolutely no restriction. 

You may not give even the smallest dose of ordinary poisons in 
food ; to put a broth culture of typhoid fever germs into a can of 
milk intended for public sale would be regarded as a most heinous 
crime and properly punishable. You may, however, neglect to take 
measures to exclude the cause of epidemic diarrhoea or of other milk- 
borne diseases from your milk and thus may be responsible for many 
infantile deaths, but yet not open to punishment therefor. Your milk 
may, when the conditions are favorable, receive specific pollution from 
hands that are taking care of the discharges of a typhoid patient, and 
cause an explosive outbreak of that disease among your customers; 
and still you may not be punished, for is it not an inalienable right to 
be dirty if you prefer to be? 

But the majority of milk producers want to do right. They 
do not know that dirty milk is dangerous ; they will try to do right, 
if somebody will only tell them to. With some, a mere suggestion is 
enough; with others a little coercion is necessary; with still others 
there is but one course to pursue, and that is a very drastic one, for 
if a man cannot be taught, induced, or forced to produce wholesome 
milk for public sale, he should not be permitted to engage in the 
business in any capacity. 



THE DAIRY INDUSTRY IN ITS RELATION TO THE 

GASTRO-INTESTINAL ORGANS OF YOUNG 

CHILDREN AND CONVALESCENTS 

FROM CERTAIN AFFECTIONS 

OF THE SAME ORGANS. 

Dr. JUAN ENRIQUEZ Y TERRAZAS, Chihuahua, Mexico. 

I only desire to record in the proceedings of this learned body, 2 
fact which I have been able to prove on repeated occasions, during 
my practice of over 40 years. 

There can be no doubt that with the confidence usually held in 
milk as a perfect and excellent article of food as well as medicament^, 
it is a resource which is often appealed to in treating serious path- 
ological disorders of the gastro-intestinal organs, in which the life 
of the patient runs some risk. It appears beyond a doubt that nobody 
can censure the recourse to this heroic treatment which we call Milk 
Diet, in the great majority of cases. 

If milk, from a therapeutic point of view is considered as not 
only a food but as a true medicament, and if from the moment it 
issues from the mammary glands until it reaches the intestines of 
the patient, it only passed through competent hands, as happens with 
the anti-diphtheritic serum and similar remedies, we would have abso- 
lutely nothing to say on this head. 

But the fact is that here in Chihuahua, and as far as I can under* 
stand, in the greater part of the Republic, the dairy industry 
is generally found in the hands of persons who have absolutely no 
idea of what that industry should be from a hygienic point of view. 
The great majority of those who enter into this business, are rustics^ 
who may be very honorable but who are only guided by their desire 
to get the largest possible profit out of that business. 

In the neighborhood of this city of Chihuahua, there are in- 
numerable dairies, and in the first hours of the day, we see what 
looks very like a pilgrimage of people who come into the town, carry- 
ing the milk in clay jars or tin cans. 

Without insisting, for the present, on the very rudimentary methods* 
employed in these small and rustic dairies, I will only say that in 
those cases we do not see the slightest precautions taken, in the way 
of asepsis and antisepsis, and still less do they attend to the simplest 
rules of cleanliness. As a matter of fact, when the milker rises of 

IGO 



THE DAIRY INDUSTRY AND CAST RO -INTESTINAL DISEASES. 161 

a morning, to ccmimence his daily work, far from cleaning his sticky 
and soiled hands, he uses them for the purpose of discharging the 
mucous frcmi his nostrils that has accumulated there in the course 
of the night, and after that filthy procedure, rubs his fingers on a 
stick, a stone, or on the back of the cow or calf, to get rid of what- 
ever may have adhered to those hands. With his hands thus 
varnished with filth, he commences and continues his delicate task. 

I must apologize for having brought to your imagination, a re- 
membrance of these repugnant and disgusting scenes; but I know 
very well as every one of you also knows, that in the operating rooms 
and dissecting classes, the bodies must always be naked. We also 
know that in the clinics and on the operating table, the most infected 
and disgusting sores must always be uncovered. 

After this not very agreeable preamble relating to the rural milk- 
man, we come to deal with the utensils of the industry: the jars, 
cans, strainers, etc., whose cleaning and disinfection cannot be said 
to be even of a rudimentary character. 

During winter, the greater part of these rustic dairymen milk their 
cows late in the afternoon, and this milk is preserved to be mixed 
with that which is drawn from the cows early on the following day. 
The result is that the milk which is brought into the city in the early 
morning, is stale, drawn without any, cleanliness and preserved in 
vessels that are not properly cleaned and are impregnated, with the 
disagreeable flavor of sour milk. 

If to this we add that these establishments do not contain more 
than a single large yard for the cows, and one or two rooms in which 
a family of 12 to 15 persons live, crowded together in the winter* 
nights, and that the vessels containing the milk are also placed in 
those rooms; whilst on the other hand, it very often happens that 
amongst the members of that family there are one or more persons 
suflFering from measles, erysipelas, scarlatina, smallpox, typhus, 
diphtheria, tuberculosis, etc. In such cases, what happens to that milk, 
and what happens also to the individuals who drink it? 

The answer is perfectly clear; the sound healthy people must lose 
their health and the sick people necessarily aggravate their suffer- 
ings. 

In fact, such cases, unfortunately, are not very rare in practice, 
and if the effects of such milk are to be feared when treating a 
person who is sick and convalescing from an attack of typhus or 
typhoid, the consequences are still more disastrous when such foul 
milk is drunk by children who are teething, and suffering from 
diarrhea or even simple catarrh. This milk hardly reaches the gastro- 
11 



162 THE DAIRY INDUSTRY AND GASTRO INTESTINAL DISEASES, 

intestinal organs of the patient when it coagulates in blocks, that, far 
from serving as food, simply constitute foreign bodies that irritate 
the intestine and aggravate the situation. 

The matter might at first sight be considered trivial and almost 
unimportant ; but nevertheless, no one can deny that certain trivalities 
frequently bring on great disasters, or lead to brilliant successes. A 
small screw which is neglected in a large machine, very frequently 
becomes the source of a complete breakdown. In any complex combi- 
nation, we must not lose sight of the smallest detail. What physician 
can ignore the fact that milk is one of the most delicate articles of 
food that we have? And which of us can doubt that milk in a bad 
condition, far from being a benefit, is a dangerous poison? Nobody 
can, and yet, in spite of this intimate and well founded conviction, 
we frequently observe tHe most unfortunate results and receive the 
most painful disappointments. 

As a matter of fact, it is not a rare thing for the physician to find 
that after having recommended that the patient should drink pure milk 
as the only treatment, he is called on the second or third day and 
requested to come with urgency, or even that another physician is 
called on. These facts are well authenticated and frequent, as the 
patient or convalescent then presents really alarming and dangerous 
symptoms ; the teething child who has been left almost out of danger 
from a catarrhal enterocolitis or green diarrhea, is found suffering 
from vomit, a diarrhea which is really cholera infantum and some- 
times congestion with symptoms of true cerebral meningitis. Fatal 
relapses are also frequently observed in convalescents from typhus 
or typhoid. 

What these patients then discharge in the vomit or diarrhea, U 
nothing more than undigested milk, converted into fermented blocks 
of casien which are excessively acid and disagreeable. It very often 
happens also that these blocks are covered with a mucous and streaks 
of blood, which almost always indicate an ulcerous colitis or a true 
dysentery. In such cases, the responsibility does not lie with the 
physician, and probably not even with the family, as in my opinion 
the disaster is simply caused by criminal negligence that occurs in the 
rural dairies. 

On leaving the house of his patient, after recommending that he 
should be put on a milk diet, it is natural to suppose that the 
physician intended that the milk should be of good quality and 
perfectly guaranteed. The mother in perfect good faith buys the 
milk from the first milkman who goes past, and with hopes of realiz- 
ing the doctor's prognosis, anxiously pours that milk between the 



THE DAIRY INDUSTRY AND GASTRO-INTESTINAL DISEASES. 163 

lips of her child. The patient at first tolerates the milk, but on the 
second or perhaps the third day, his nature rebels and then 
the doctor is called again and finds himself in presence of the terrible 
symptoms above sketched. 

I would like to insist even more on this interesting and very im- 
portant subject; but probably the time allowed by the r^^lations 
will not allow me, and I therefore repeat, for the present, that my 
only wish is to put on record in the proceedings of this Association, 
the facts that I have briefly sketched on this important point. I have 
desired to contribute my grain of sand to prevent a circumstance 
that appears insignificant, such as a slight failure in explanation from 
being the cause of bringing to the border of the g^ve, certain 
patients who have reached the stage of frank and full convalescence. 

It is necessary that in all parts where the dairy business presents 
the deficiencies above noted, the physician who is attending con- 
valescents in general, and especially children suffering from intestinal 
disorders, should not confine himself to ordering that they should 
be given good milk, but that he should expressly prohibit their being 
given milk, such as that brought by the rural milkmen in jars and 
cans. 

Reserving to other occasions the further details of this question, I 
will only say for the present, that in the cases referred to, it is 
necessary to inculcate certain habits of strict cleanliness on the milkers, 
and if possible, that the milk should be drawn into a receptacle made 
of glass and disinfected by the family of the patient, in accordance 
with instructions given by the attending physician. 

If we have a certainty that the cow is perfectly healthy and free 
from the tuberculous germ, both the child and convalescent patient 
can drink it raw when recently milked, and the balance must only be 
preserved by boiling. Leaving details for another occasion, I will 
then report the success tliat has Been obtained with certain children, 
who, although they have never tasted the maternal milk, have never- 
theless been perfectly well brought up with cows milk.^ 

We will then see how, by a careful graduation of food, the delicate 
infantile stomachs not only tolerate, but nourish themselves perfectly 
with cow's milk. Once they get accustomed to it, it is much easier 
and certain, less dangerous and troublesome for the bringing up of 
those little ones with cow's milk under certain conditions, than to 
struggle with the bad service, useless and almost always very 
dangerous, wet nurses. 

*A11 this doctrine will apply to the milk of donkeys and goats. 



THE WATER SUPPLY OF CITIES. 
Dr. ENRIQUE DEL BOSQUE, Mexico, D. F., Mexico. 

When tribes congregate together they form hamlets and villages 
over the surface of the earth, and nature herself provides them 
with the means of defense for the preservation of their health. The 
air which they breathe is pure; the water which they drink is also 
pure, whilst the soil on which they tread transforms their organic 
refuse and the detritus which the rain waters bring down into useful 
elements. 

But as these hamlets and villages increase in size, the groups become 
more compact and the area which they occupy is also increased, so 
that the crowding of human beings is greater, and causes arise which 
bring about unhealthy conditions. Nature begins to find herself im- 
potent for the destruction of the organic refuse which is deposited 
on the soil, the air which is breathed undergoes profound changes in 
its composition, the oxygen which it contains is diminished whilst 
the water vapor and carbonic acid are increased; a multitude of 
organic particles, products of the human life and activity, appear to 
vitiate and poison the atmosphere, contaminating everything which 
nature furnishes for the use of man. Then arises the necessity of an 
artificial life, of the defense and preservation of the human species 
and of the preservation of health by means of problems that are every 
day more arduous and more perfected in direct ratio with the growth 
of those great cities; processes that in the aggregate constitute the 
hygiene of cities, with their precepts and laws that now form what is 
called "Sanitary Science." 

On account of its direct action on our systems, water undoubtedly 
takes the first place amongst those elements at the disposal of hygiene 
for the preservation of health and the prevention of disease. From 
very remote times, all people have instinctively taken measures to pro- 
cure drinking water in as pure a condition as possible and for that 
purpose have placed their public fountains under the protection of 
divinities, and have even erected temples over natural springs. Not 
to go any farther back, ancient Rome, in the time of Trajan, had no 
less than nine aqueducts with a length of 443 kilometres, with 49,500 
metres of arches and 2,400 metres of underground work. Some of 
these arches reached up to thirty-two metres in height and these 
aqueducts supplied 947,200 cubic metres of water per day. During 
the reign of Constantine Rome had up to thirty-four aqueducts, fifteen 

164 



THE WATER SUPPLY OF CITIES. 165 

hot springs and 856 public baths. The city supply amounted to two 
cubic metres of water per day per inhabitant* 

This great volume of water is really astonishing and it is difficult 
to imagine what those great works must have been and the perfect 
organization which secured their constant and efficient operation. Dur- 
ing the Republican period the censors and aediles were the officers 
charged with the supervision of the water supply. The office was con- 
sidered so honorable, that the highest functionaries were not above 
filling it, and during the reigns of Nero and Trajan, Frontin resigned 
the chief command of a Roman army in Britain in order to go back 
and assume the office of curator of waters in Rome. 

The use of water for the public and private necessities of the citi- 
zens was carried to a wasteful degree ; the authorities gained the favor 
of the people by appropriating large sums of money to the construction 
and maintenance of new aqueducts and public fountains, and no sacri- 
fice was too great for the procuring of an abundant supply of water. 
Remains of these g^eat works are still to be found in Italy, France 
and Spain, and in France we can cite the aqueduct of Nimes and the 
famous Pont du Garde. In Spain we have the bridges of Segovia and 
Sevilla, whilst in Paris they still utilize the remains of the aqueduct of 
Arcueil, which was constructed during the period of the Roman domi- 
nation of Gaul and served to supply the baths of the Emperor Julian. 
The Hebrew, Persian, Egyptian and Greek nations also had a perfect 
distribution of drinking water and the Mosaic law abounds in hy- 
gienic precepts relative to the use of drinking water. 

Water was considered by the Greeks as one of the four elements of 
nature. Hypocrates, the immortal physician of that cultured people, 
attributed to the waters of the swamps an influence injurious to health, 
and recommended that no water should be drunk from the cisterns 
but from the natural fountains. The philosophers Plato and Aristotle 
considered an abundant supply of drinking water necessary for the 
preservation of health in every place where men were congregated 
and that the public authorities were in duty bound to give that element 
a preferent attention. 

With the advancement of civilization in our own days, the refine- 
ment of customs, the enormous growth of population in the great cen- 
ters, the progress of human life and of medical science in its investi- 
gations of the etiological causes of certain epidemic diseases, the im- 
mense importance of the water supply for the use of man receives 

* Historic data from the work of Bechmann : "Distributiones de'eau et Assai 
nissement. 



166 THE WATER SUPPLY OF CITIES. 

very careful attention as one of the indispensable factors for the 
preservation of public health and for the welfare of the inhabitants of 
great cities. In former times, when the world still ignored the 
existence of those pathogenic beings which we call microbes and the 
office which they now fill as the determinant cause of the greater part 
of transmissible diseases, we can easily understand that little importance 
was given to the quality of the water employed for domestic pur- 
poses, and that they confined themselves to the organo-leptic drink- 
able character of the waters and to procuring an abundant supply for 
their necessities. 

This has always been and always will be the constant endeavor of 
every cultured city, and if in former times, as I said a moment ago, 
the government supplies an abundance of water to their people, 
with still greater reason do they make those efforts now, when they 
understand the important office which it fills in public hygiene, and 
therefore they omit no expense whatever in furnishing for the neces- 
sities of human life, pure water in the strictest sense of the word in 
abundance for each of the inhabitants. From a hygienic point of view, 
the quantity of water distributed in any city is estimated by the num- 
ber of its inhabitants and of the litres daily supplied, that is to say, 
the total consumption per head is adopted for the purposes of com- 
parison. In order to obtain an idea of what the volume of water has 
come to be in the sanitation of cities, we need only consult the statistics 
on the matter of Paris, London, New York and Vienna, where we 
find that the consumption every day increases in astonishing propor- 
tion and that the works which were constructed eight or ten years 
ago are now insufficient to supply the volume of water which is 
required by the ever increasing population. The present requirements 
continually increase, and not only imply the use of water in every 
house, but also at a certain pressure in order that it may fulfill the 
sanitary duties with which it is naturally charged. 

In the city of Mexico, with a population of 326,000 in 1893, the 
supply amounted to 130 litres of water per day per head, according to 
the statistics prepared by the engineer Salazar, whilst according to 
the data furnished by the director of water supply, the city receives 
an average of 34,150 litres of water per minute, or say 52,591 cubic 
metres in twenty-four hours. Of this volume, 4,655 houses are sup- 
plied with soft water and 3,304 with hard water; but the population 
has now increased to nearly 400,000 inhabitants, so that the supply is 
now about 122 litres per head per day. 

To point out, according to my understanding, a perfect method for 



THE WATER SUPPLY OF CITIES. 167 

the distribution of drinking water in the cities and to indicate some 
of the causes for the unhealthy character of the present supply, is 
one of the principal objects of this paper. 

On account of its peculiar situation and the special ways of life of 
the greater part of its inhabitants, as well as the unmeasured greed of 
the proprietors of those filthy dwellings which are found in all quarters 
of the city from the colonial period, and which bear the symbolic name 
of apartment houses ; buildings in which human beings and domestic 
animals live crowded in promiscuity with the parasites of both; short 
of water, of light and air, the sanitation and urbanization of those 
quarters is an almost impossible task, but that has nevertheless been 
undertaken by our Supreme Board of Health with great energy, and 
which procures the disappearance of those foci of real infection in 
which all the infecto-contagious diseases, from exanthematic typhus 
to tuberculosis, reign in an endemic manner, so that we can say that 
in each quarter of the city we had a River Ganges which invaded 
and threatened with its deadly breath the center of the city which now 
fulfills the hygienic and comfortable conditions that are necessary in 
a cultured capital city like ours. 

The drinking water in some cities is still received in fountains of 
more or less size which are built on the pavement or in hollows, and 
which only fulfill the condition of impermeability without any care for 
the hygienic conditions which are necessary with respect to the liquid 
which is to be deposited in them, or the cleanliness which is so very 
necessary, and as the water issues from the spout it is infected by 
mixing with that which already exists, so that it is evidently unadapted 
for the purposes to which it is dedicated. Who knows how many 
pathogeni'c germs, products of the excreta of the inhabitants, arrive 
with that water^ or are deposited therein by the wind, by the dust, 
produced by the sweeping of the rooms or yards of those apartment 
houses, or that come with the articles that without any precaution 
whatever are shaken by the residents and deposit all the germs they 
contain on the surface of the liquid in the fountain ? The enumeration 
of these causes of contamination of the waters in all these houses would 
be sufficient to lead to the abandonment of that method of distribu- 
tion, that from immemorial times up to the present have been adopted 
in some cities, and we can easily imagine how many diseases, how 
many infections of the intestines, whose pathogeny is now unknown to 
us, proceed from the fountain and from the water drawn from it. And 
what can we say with respect to the public fountains which are estab- 
lished in the squares of the cities for the purpose of supplying drink- 
ing water to the inhabitants? We can easily understand that such 



168 THE WATER SUPPLY OF CITIES. 

water is in every way unfit for drinking, as more than that of private 
fountains it is exposed to contamination from the dirt in the public 
streets. 

The bacteriological analysis of the hard water that comes from 
Chapultepec, reputed to be the cleanest of those that reach the city, 
captured in the very place where the pumps have been erected to drive 
in into the city, which has been made in the offices of the Supreme 
Board of Health and published in its bulletin, show an average of 
200 to 300 micro-organisms per cubic centimetre, and in none of these 
analyses has the Bacillus colt been found. The bacteriological analyses 
that I have myself made in the laboratory of the General Hospital, 
of the same water taken from open fountains, have shown an average 
of 11,600 micro-organisms and 800 fungi per cubic centimetre. 
x\mongst the micro-organisms some produce aberthiform colonies, 
which on analysis are found to be Bacillus coli in the proportion of five 
to one thousand. This still further demonstrates the contamination of 
the drinking water and the bad results of the method of distribution. 

If our investigations were carried to greater perfection we might 
perhaps find in drinking water the pathogenic agent of the exanthe- 
matic typhus which commits such ravages in our public health, as 
in my humble opinion, typhus is a disease of fecal origin and water 
Its principal means of diffusion. 

Another of the troubles produced by the system of tanks and 
fountains as they at present exist, lies in the increased waste of the 
water; of that water which we might call our reserve and which in 
this capital as well as in other cities has no limit whatever, and which 
reserve is in accordance with the size of the fountain and the liberality 
of the proprietor. By a happy coincidence some one has compared the 
distribution of drinking water and sanitation of the cities to the cir- 
culation of the blood in the animals. In fact, the arterial system 
represents the water supply; the arterial blood which starts from the 
heart and is distributed throughout the entire system by channels 
and ramifications of decreasing size, until they are converted into 
capillaries, in which the blood undergoes exosmotic and endosmotic 
changes in order to fulfill the life giving office which is required of it, 
and having now been transformed into venous, injurious and useless 
blood by the organic refuse, nevertheless continues to circulate, at 
first through small conduits and afterwards through a smaller number 
of thicker conduits until at last it flows through larger blood vessels, 
which are charged with the duty of bringing it into contact with the 
renovating organs which purify and restore to it the beneficent qualities 
which it first possessed. This physiological action is represented by 



THE WATER SUPPLY OF CITIES. 169 

the drainage of the cities, by the lateral and main sewers, and .hence 
the necessity of the continuous circulation of the water through the 
cities, which is all the more necessary in proportion to the extent of 
the population which is to be supplied. 

The city of Mexico at present possesses a perfect system of drain- 
age for carrying off its refuse waters, of which it is proud and that 
raises it to the level of the modem nations of this century; a system 
of drainage that is connected with an ingenious system of flushing 
pumps which complete the great sanitary work so scientifically ar- 
ranged and directed by our learned hygienjst, Dr. Liceaga. 

A supply of drinking water which is subject to hygienic regulations 
must be considered under two aspects : firstly, as a public service, and 
secondly, as a private dwelling house service. On the public roads, 
the drinking water which is the only kind I refer to should be sup- 
plied by means of standpipes, as fountains ought to be excluded for 
the reasons above given. Of these standpipes, there are several 
models described in books which treat of the subject; but the one 
which appears to me best and easiest to manage, is that known under 
the name of Chameroy, which has given very good results in Europe 
and in the United States and is described in Bechmann's work in 
Chapter VIII, page 492, which was published in 1898. If these stand- 
pipes were adopted in this city they would give very good results as 
they act at will by means of a counterweight screw balanced by a 
double valve and arranged in such a manner as to give a jet of water 
that in half a minute can fill a vessel with a capacity of ten to fifteen 
litres. These devices must nevertheless be limited in their use as their 
present tendency is to disappear, because the modern systems of water 
supply require that it shall be introduced into all the dwellings. 

The private supply of drinking water should for every reason be 
subject to the strictest precepts of hygiene, that is to say that every 
source of contamination must be avoided and consequently, it must 
be collected in special receptacles, distributed according to the number 
of dwellings in each house, when it is an apartment house and accord- 
ing to the number of inhabitants in a private house. Data will be 
taken as to the quantity of water consumed in twenty-four hours in 
each house, with the number of dwellings and of inhabitants, and an 
average will be struck which will serve as a standard for all the houses 
in the city. Of this the half will remain deposited in the receptacles 
as reserve water, which receptacles will have a capacity equal to the 
average daily consumption and will be provided with a valve and float 
to prevent the issue of a greater volume than that assigned. 

These deposits or receptacles will be of cylindrical form, constructed 



170 THE WATER SUPPLY OF CITIES. 

of galvanized iron in such a manner as to prevent the contents beii^ 
contaminated from the outside and provided with a simple cock at the 
bottom so that they can be completely emptied and cleaned. They 
will be placed at a certain elevation in order that the water may nm. 
throughout the house with a certain pressure and thus better fulfill 
its sanitary office for domestic purposes. They will be connected one 
with the other by a suitable arrangement of pipes. 

This estimate of the average consumption of drinking water repre- 
sents its being supplied and sold as is now proposed by means of 
meters, which may perhaps give good results in other foreign cities, 
but which in this city would open the door to many afiiises, as we 
well know the greed of the proprietors of houses to let, whDst the 
poorer classes and even those who are better off would in this way 
feel themselves obliged to consume little water and the proprietors 
would even request their tenants to use as little water as possible for 
their own interest, thus giving rise to grave disorders in the public 
health. 

The city is now constructing an aqueduct for the supply of drinking 
water which is a monumental work and will still further prove the 
era of progress and of hygienic culture to which it has arrived under 
the protection of the wise government which now controls the national 
destinies. 



DRINKING WATER IN RELATION TO TYPHOID FEVER 
IN RURAL COMMUNITIES. 

B. H. stone; M. S., M. D., ButtUNGTON, Vermont. 

Water is as absolutely essential to every living thing as is air or 
food, and its distribution has been a determining factor in the 
location of the homes of man from the cave hut of the primitive man» 
the camp of the nomadic tribes, to the mighty aggregation of human 
beings in our great cities of today. 

The earliest engineering achievements were aqueducts, built to 
supply the increasing needs of a growing population with this neces- 
sity of life. Lake Maries, in Egypt, a storage reservoir fifty miles 
in circumference, connected with the Nile, by a canal twelve miles 
long and fifty feet wide, was built 2,000 years B. C, and furnished 
water for irrigation and drinking purposes to a population of twenty 
millions. Four thousand years ago the rulers of Assyria constructed 
immense storage lakes and threaded the plains of the Tig^s and 
Euphrates with canals, one of which was four hundred miles long 
and from two to four hundred feet broad. 

In India, New Mexico, and Carthage, we find remains of colossol 
hydraulic works. In Ceylon there exists today the remains of the 
largest system of storage reservoirs known to ancient or modern 
times. Ten years ago the restoration of one of the largest of these 
reservoirs, undertaken four years previously, was completed. Built A. 
D. 460, to supply Anaradupura with water, it contains an area of 
seven square miles. 

Rome was supplied with a system of aqueducts furnishing to the 
city, three and one-third million gallons per day, or three hundred 
thirty gallons to each inhabitant. 

As found in uninhabited regions, water is almost always wholesome 
and the people settling in a new land, as did our forefathers in 
America, have only to procure a sufficient supply with little thought 
for the quality. But with the increase of population and the wastes 
of advancing civilization, this requisite becomes more in demand and 
at the same time more likely to become unfit for drinking purposes 
by the accumulating wastes of the very population that must have it. 
Every year of habitation increases in geometric ratio the pollution 
and the consequent infectiveness of the soil over and through which 
the water must run. 

171 



172 • TYPHOID FEVER IN RURAL COMMUNITIES. 

The beginning of the nineteenth century found the problem of 
water sanitation absolutely untouched upon. Much had been done 
along other lines toward more hygienic methods of living, but a clear 
idea of this element as a cause of disease was not evident. 

Certain connection between grossly impure water and disease liad 
early been noted. Hippocrates wrote upon the value of pure water, 
some four hundred years before the beginning of our era. He 
advised boiling and filtering a polluted water before using it for 
drinking purposes. Pliny emphasized the blessings of pure water. 
During the middle ages, the liability of water to take into solution 
<:ertain metals (lead and copper) and poison the users was studied. 
But all these observations were made in a loose manner and the con- 
nection failed to attract much attention. This tardy recc^ition of 
the agency of water, which seems so obvious to us now, is not so sur- 
prising when we consider how little was really known of the etiology 
of these epidemic diseases. The germ theory which renders their 
spread so intelligible to us now, was entirely unproven and practically 
tmknown. 

A polluted water does not always present objective evidence of its 
character. It may be perfectly palatable; it continues to quench 
thirst and meet the immediate demands upon it as well as it ever did, 
and it takes severe lessons to convince the users of a supply that 
the water, which their fathers drank and which they have drunk since 
they were children, is dangerous. 

The growth of population and the segregation in the cities was 
gradual, and with these conditions the increase of the now known to 
be water borne diseases was also gradual, so that their prevalence 
came to be regarded as a matter of course. It was only with the 
collection of vital statistics that attention was seriously directed to 
the solution of the problem of the increased death rate which was 
made evident by these statistics. The question of fixing the guilt of 
spreading epidemics of typhoid and cholera upon water was not so 
easy when there were no pure supplies for comparison as now, yet 
polluted as all of the great cities' supplies were, some were worse than 
others, and once having a proof of the epidemic character of these 
diseases, and their increase, in the vital statistics, men were not long 
in working out the links in the chain of evidence. 

The history of London and its water supply is very instructive. 
The story of the cholera outbreaks in 1854 and 1866 and the in- 
vestigation of the Broad Street well are too familiar to all of you to 
need repeating. With the establishment of the germ theory, the 
connection between water and disease was much more intelligible. 



TYPHOID FEVER IN RURAL COMMUNITIES. 17a 

When men's minds were once directed rightly, there were plenty of 
instances to prove this connection. 

The epidemic of Lausanne, Switzerland, which was definitely traced 
to a case of typhoid occurring on a little stream which was found 
to feed, through a subterranean passage, the Lausanne supply served 
to clinch the evidence. From this time on up to the present time, 
the typhoid rate in cities has been closely followed and every epidemic 
of any size attracts much attention and its source is always sought for 
and usually found. 

You are all familiar with the presence of t3rphoid in epidemic form 
in recent years in Albany, Philadelphia, Baltimore, Lawrence, Chicago, 
Butler, Cleveland, Ithaca, Scranton, and many epidemics of smaller 
size traced to infected water supplies. So certain is the connection 
between polluted water and typhoid that the death rate from this 
disease is considered the best evidence, in advance of analytical data, 
of a city's water supply. It is now agreed on all sides that water 
it is not only the predisposing cause but is in great majority of cases 
the actual vehicle of infection of Asiatic cholera, typhoid fever and 
epidemic dysentery. Cases may be carried from person to per- 
son by other means but such cases are sporadic, and comparatively 
infrequent. On this continent, typhoid is more prevalent than cholera 
and this paper will deal more particularly with this disease. 

With the fact once established that water is the carrier of infection 
in typhoid and cholera, and with a definite conception of the maieriae 
morbi of these diseases, an attempt to find a remedy was naturally 
the next step and we find filtration early resorted to in London. In 
1852 an act of Parliament required that all water furnished for 
domestic purposes in London should be filtered. The first filtration 
plants were very imperfect, yet the improvement was so marked, that 
there never seems to have been an idea of abandoning this purifica- 
tion method. 

Since this time, the growth of water supply sanitation has been 
steady and this growth has been mostly in the way of perfecting 
filtration. This is the perfectly natural trend for, admitting that an 
unpolluted supply is always preferable to an artificial, purified one, 
the patent fact remains that it is more and more difficult to obtain 
pure supplies of sufficient volume to furnish large towns, and with the 
tremendous increase in population in America, a supply which is pure 
today may not be so tomorrow. 

A great impulse was g^ven to this method of purification by the 
experimental work of the state board of health, of Massachusetts, 
carried on at Lawrence. So far perfected has this method become. 



174 TYPHOID FEVER IN RURAL COMMUNITIES. 

that general epidemics of typhoid in the cities baring well constructed 
and operated filter plants, can be assured to be a thing of the past. 

Hazen has compiled statistics as to the use of filters which are 
of great interest. These figures gathered in 1904 show that the 
combined population of cities above twenty-five hundred (2,500) m 
the United States, is thirty-two million, seven hundred thousand 
(32,700,000) and that of this population three million one hundred 
sixty thousand (3,160,000) or nine and seven-tenths per cent (9.7%) 
are supplied with filtered water. In 1900, the population supplied 
with filtered water, in the United States, was sixteen times as great 
as in 1890. Since the time of compiling these figures, the growth of 
filters has been remarkable, so that it will be safe to assert that at 
the present time twenty per cent. (20%) of the total population in 
cities of more than twenty-five thousand X25,ooo) inhabitants is sup- 
plied with* filtered water. 

In addition to the population served by filters, constructed and under- 
construction, water of a more or less unsatisfactory quality is now- 
supplied to approximately fifty-two per cent. (52%) of tiie urban 
population of the United States in cities of more than twenty-five 
thousand (25,000) inhabitants, and while scune of these supplies will 
be replaced by those Trom unpolluted sources, it may be confidently 
expected that a gjeat majority of them will be continued in use, and 
that purification plants will be constructed for their treatment. The 
supplies of a further twenty-two per cent. (2Z%) while of a more 
satisfactory character, would be improved by filtration; and as the 
standard of purity is advanced, it is to be expected that filters will 
be installed for the treatment of a large number of them. 

The result of these costly filtration plants have fully justified the 
expenditure. An average reduction in the typhoid death rate of 
eighty-one per cent. (81%) between perio3s five years prior to in- 
stallation of plants and five years after, is the result in four representa- 
tive cities, two in Aknerica and two abroad. That this probably 
means that all the water borne typhoid is eliminated, is indicated by 
a comparison with the rates of three other cities under similar general 
conditions, which changed from a polluted to a pure gravity supply 
at about the same time with a resulting reduction in death rate of only 
seventy-four and two-thirds per gent. '(742/3%). Not only has the 
installation of filter plants been followed by a reduction in the t3rphoid 
rate, but the general death rate from all sources is also reduced in a 
remarkable manner. 

Hazen shows that the total death rate per hundred thousand, living 
in five representative cities, was reduced four hundred forty. The 



TYPHOID FEVER IN RURAL COMMUNITIES. 175 

normal reduction during the same period in cities similarly situated, 
with no radical change in the water supply, but due to general sani- 
tary improvement, was one hundred thirty-seven, showing a difference 
of three hundred three in favor of the cities with a purified water 
supply. ' 

Hazen concludes that the results "that have been achieved by filter 
plants, which have been best constructed and operated, have been all 
that could be desired. Waters polluted by sewage and most injurious 
to the health of those drinking them in their raw state, have been 
purified so that the resulting death rate from water borne diseases 
has been no greater than in cities of corresponding size and situa- 
tion, supplied with water from the very best sources. If any disease 
is caused by the water filtered in this way, the amount is too small 
to be measured or determined by the methods now at our disposal." 

Enough has been said to show that municipalities have come to be 
thoroughly impressed with the importance of a pure water supply 
and have discovered a means of assuring its purity. When once this 
stage in a sanitary reform is reached, legislative enactments to pre- 
vent pollution are sure to follow. Every state in the United States 
has such laws on its statute books which aim to secure pure water 
to its citizens. A thorough review of the various laws has been made 
by Goodell and published by the United States Geological Survey in 
Water Supply and Irrigation Paper No. 152. These statutes vary 
from simple provisions, making it a crime to poison wells or springs, 
to elaborate enactments designed to check and as far as possible, 
absolutely prevent all pollution of waters by mingling with them 
refuse products of animal life or wastes of human industry. Several 
states have adopted unusual and stringent methods to enforce the 
right of every citizen to unpolluted water. 

In Vermont, a measure has become a law whereby the state board 
of health can, if they see fit, force any municipality to provide itself 
with a pure supply, if the board has good evidence of the pollution 
of the supply in use. 

This law reads as follows: 

*'Said board shall have authority to prohibit any town, city, village, 
public institution, individual or water or ice company, from using 
water or ice from any given source whenever in its opinion, the same 
is so contaminated, unwholesome, and impure that the use thereof 
endangers the public health. And the court of chancery shall have 
jurisdiction and power, upon application therefor by the state board of 
health, to enforce, by proper order and decree, any order, rule or 



176 TYPHOID FEVER IN RURAL COMMUNITIES, 

regulation which said board may make under and by virtue of this 
section." 

Our state board has deemed it wise to exercise its prerogative in 
the case of five towns, Vergennes, St. Johnsbury, Enosburg Falls^ 
Swanton, and Burlington. Of these, Burlington, which, as many of 
you know, takes its supply unfiltered from Lake Champlain, about 
three miles from the entrance of its unfiltered sewage, resented this 
interference and at a public meeting, voted down a measure to install 
a filtration plant, the only feasible means of purification. The city- 
was posted and the faucets in public buildings were shut off by order 
of the board. The city has finally been forced to take action and has 
just voted to install a filtration plant. 

It may be granted that it is within the power of any municipality 
to prevent the spread of typhoid through its water supply. The re- 
sults of the sanitary work already done are evident in a generally 
lowered urban typhoid death rate. What has been accomplished in 
the cities already having purification plants has already been men- 
tioned. A study of the combined statistics of the whole country 
shows the influence of the house cleaning in these cities by a drop 
in the combined death rate. The death rate in the registration cities 
(including most of the large cities in the country) has dropped 
from fifty-one (51) per one himdred thousand in 1890 to thirty- 
six and six-tenths (36.6) in 1900. With the municipal water im- 
provement now in process of installation and the others contem- 
plated, once in operation, we can confidently predict a further material 
decrease. But even in those cities that have the best filtering plants, 
there still exists a fairly constant residual of typhoid. If t)rphoid is 
a preventable disease, why is this so? To remedy this evil the writer 
is firmly convinced that the city must go beyond her own doors. 
A study of the statistics as gathered by the census bureau reveals 
the fact that fifty-nine and eight-tenths (59.8) per cent, or about 
forty-five million, five hundred seventy-three thousand, eight hundred 
forty-six (45,573,846) of the population of this country is rural, 
living in towns of less than two thousand (2,000) inhabitants. This 
percentage varies from thirty-one and eight-tenths (31.8) per cent 
in the North Atlantic division to eighty-four and five-tenths (84.5) 
per cent, in the South Central division of the country; from five (5) 
per cent, in Rhode Island to ninety-four (94) per cent, in Idaho. 
These are the people who are outside the confines of the noisy, dusty, 
foully aerated city, living mid the surroundings generally considered 
to be conducive to health and vigor. Here we should expect to find 
a death rate much lower than in the city and this is true of the 



TYPHOID FEVER IN RURAL COMMUNITIES. 1T7 

general rate (fifteen and four-tenths (15.4) in the country to eighteen 
and six-tenths (18.6) per thousand in the city) and with the rate 
of every specific disease with one exception, that of typhoid. Con- 
sulting statistics of a decade ago, we find the city death rate for 
typhoid much in excess of the rural (thirty-nine (39) in the city to 
thirty-one and four tenths (31.4) per hundred thousand in the 
country) but the urban rate has steadily decreased while the country 
rate has remained nearly constant until it is now twenty-five and three 
tenths (25.3) in the city to twenty-five and five tenths (25.5) per 
one hundred thousand in the country. Taking the rural and urban 
rate in the registration states, whose statistics are most complete, 
[a rural rate of twenty-five and five tenths (25.5) and an 
urban rate of twenty-five and three tenths (25.3)], as a basis, 
and applying it to the whole country, we find that for every 
one hundred thousand dying of typhoid in the cities, one 
hundred and fifty-one and a fraction die in the country. That this 
proportion is actually higher is undoubtedly true, for in the g^eat 
South Central area with a few large cities, the typhoid death rate 
per whole number of deaths, is much higher than in the registration 
states and the diflference between the rural and the urban, much more 
in favor of the cities. This rural rate varies in the registration states 
from fifteen (15) in Rhode Island to thirty-one and seven tenths 
(31.7) per one hundred thousand in Vermont. These aggregate 
figures are startling, yet one rarely hears of rural epidemics for the 
population is so scattered and the total number of deaths for a given 
area so small in comparison to the city, that the situation rarely ap- 
pears to be alarming. One is apt to forget that one death in a village 
of one hundred (100) inhabitants is equivalent to ten thousand 
(10,000) in a city with a population of a million. In a little 
^village in Vermont with a total population of one hundred and 
seventy-five (175) souls, seventeen cases of typhoid fever have oc- 
curred this fall, a rate equivalent to four hundred thousand cases 
in New York City and yet little attention was called to the out- 
break even among the inhabitants of the town. It is safe to say that 
none of them realized that the town was suffering from a serious 
outbreak of typhoid. But for several reasons these statistics usually 
fail to do justice to the serious prevalence of typhoid fever in the 
country. 

Records are never as carefully kept here as in the city and many 
cases are not reported. 

The vacation habit is growing on the American people and more 
and more of the busy toilers of the city spend a greater or less part 
12 



178 TYPHOID FEVER IN RURAL COMMUNITIES. 

of their summers in the country. To such an extent is this so, that 
in son^e of our rural counties, the summer boarder furnishes a large 
per cent, of the annual income. These people flock back to the city in 
the fall and the typhoid which they contracted in the coimtry is credited 
by statistics to the city. In three thousand five hundred eighty-five 
(3^585) cases of typhoid fever which occurred in New York City in 
1895, Billings finds that fifteen per cent. (15%) acquired the disease 
out of town, while nine hundred sixty-six (966) or twenty-seven per 
cent. (27%) were infected by drinking water from the country. 
These migratory habits of our population render the rural sanitary 
condition of tremendous importance. 

Furthermore, the country is the great feeding ground for the city, 
furnishing milk, butter, meat and vegetables. Twenty-three (23) 
per cent, of the above mentioned cases of typhoid occurring in New 
York were infected by drinking milk and every bit of this milk came 
from the country. Fresh vegetables are often a source of epidemics 
and in this way again rural typhoid influences the city rate. In short, 
we may say that save for a few of our cities whose water supply is 
notoriously polluted, typhoid fever is now largely the product of 
rural conditions and rustic uncleanliness. 

Now what are the factors in this problem? Why is typhoid so 
prevalent in rural communities? The answer is clear. Typhoid is 
as much a water borne disease in the country as in the city, but here 
the problem is as infinitely more complicated than it is in the city, 
as there are more water supplies for the same niunber of people. 

Just so long as something over forty million people in the United 
States take the water most available in an economic way, with no 
knowledge or regard to its sanitary fitness, just so long will t3rphoid 
be prevalent in the country, spreading infection to the city. As 
Bashore aptly puts it, "Though these rural supplies come from many 
different sources, wells, springs, and small streams, scattered through 
the country, it has been found that they are very similar in one 
respect, their utter unavailibility for furnishing a suitable drinking 
water. Whether we take it in Canada, Pennsylvania, Florida or in 
Cuba, this unfitness in the rural drinking water is a striking feature-" 

In Vermont, with its largely rural population, and its rural typhoid 
death rate of thirty-one and one tenth (31.1), the country family is 
largely supplied with water from the family (shallow) well which 
was dug, in almost every instance, with an idea to convenience, close 
to the barn yard and out-house. 

In an examination of two thousand eight hundred forty-two 
(2,842) of these supplies, we have condemned two thousand three 



TYPHOID FEVER IN RURAL COMMUNITIES, 179 

hundred seventy-nine (2,379) or eighty-three and seven-tenths per 
cent. (83.7%) as polluted and dangerous. In the Vermont com- 
munity referred to above, with a population of one hundred and 
seventy-five and seventeen cases of typhoid, water from twelve 
water supplies was examined and ten found grossly polluted 
(of these, seven were wells, three streams, and two springs). The 
source of infection in these old wells is, of course, in most cases, in- 
fected ground water. They are usually constructed with an idea of 
keeping out the surface water. The cess pool, privy or sink drain 
is almost always in close proximity and the ground for many feet 
has become saturated with organic filth. IJnforttmately the soil con- 
ditions in very few localities are such that it furnishes effective filtra- 
tion. Much of the geological formation in the Appalachian region 
oxisists of upturned strata, admirably suited to conduct surface filth 
from a considerable distance into even deep wells. Much of the top 
soil is coarse gravel. Numerous examples of these conditions hav© 
come to the attention of all sanitarians. The countryman does not 
know of this danger and it is hard to make him realize it. He will 
Jay sickness to an3rthing before he will suspect the family well, which 
his great grand-father dur and from which his family has drunk ever 
since. The water which his grand-father drank is good enough for 
him. He fails to realize that since the time of his grand-father, the 
ground has become polluted in geometric ratio with advancing years, 
and that he is drinking the water which his grand-father drank and 
which he himself drank a few days before, in a more literal way than 
he imagines. 

Bearing in mind the occurwice of walking typhoid and the develop- 
ments of recent years with regard to retained typhoid bacilli in con- 
valescent cases, and reflecting that comparatively few cases of typhoid 
fever in the country have a trained nurse to watch out for the disin- 
fection of excreta, it is not strange that many of these wells become 
infected. They are, when once so infected, admirably suited to keep 
the specific germs alive the maximum time. Wheeler found the 
organism to live seventy-nine (79) days in well water protected from 
light. 

The possible factor of railroads in introducing typhoid into the 
country should be considered. It has been calculated that every mile 
of railroad in this country is traveled by an average of seventy-five 
thousand (75,000) people each year. It is not difficult to conceive 
that heavy rains may occasionally wash infected material from these 
roadbeds into places whence it may find its way into water supplies. 
Flies may be the vehicle for this transmission. 



180 TYPHOID FEVER IN RURAL COMMUNITIES. 

The prevalence of typhoid fever in the country is surely a problem 
worthy of attention of sanitarians and one which can not be n^lected 
much longer. The first step toward remedying the present condition 
must be educational. We must disillusionize the countr3m[ian. He 
must be taught to regard his old well with distrust until it is proven 
to be safe. This is no easy task, but once you have demonstrated 
to him in a conclusive manner, the danger, he will be as anxious to 
remedy the condition as is his city brother. The rural population of 
this country is made up largely of people of high intelligence and 
they are drinking these polluted waters with serenity simply because 
their attention has never been called to this danger. The country 
inhabitant is firmly grounded in the fallacy that the city is the great 
source of typhoid fever. He observes that individuals are sent into 
the country to recuperate; never from the country into the city 
unless it be to a hospital for surgical services. To accomplish this 
first step toward his education, he must be furnished with the means 
of ascertaining the condition of the water he is drinking. Free water 
analysis is essential to this end. Though in many cases the trained 
observer would need no analytical data to be assured of the danger 
from a certain well, the owner will not be convinced in any such way 
as this. He does, however, have a profound respect for the results 
of the analysis. In Vermont, these free examinations are provided 
for at the board of health laboratory. Any one can have the water 
from a private or public supply analyzed for the asking. The public 
is informed of this through the medium of the state board of health 
bulletin and individuals are encouraged in every way to avail them- 
selves of this opportunity. That this work is bearing fruit is 
demonstrated by the demand for these examinations. Our labora- 
tory force is kept continually busy with these requests. Polluted 
wells are condemned and we confidently expect to see a material lower- 
ing of the rural typhoid death rate as a result of this work by the time 
of the next general census. More likely than not, the farmer decides to 
have his well water analyzed to demonstrate to the city boarder its 
purity or to satisfy himself regarding some fancied medicinal quality. 
In nine chances out of ten, it is found to be polluted. The result 
usually comes as a shock to him, but when he fails to find any motive 
for deceit on the part of the analyst, he is convinced. He tells his 
neighbor about this result, and he in turn wishes the water from his 
well examined. You have now accomplished the first step toward the 
education of this man and you have started the process in the neigh- 
bor. The next thing to do is to suggest a remedy and here we have 
to deal with difficulties which are unknown to the city sanitarian- 



TYPHOID FEVER IN RURAL COMMUNITIES. 181 

The solution must be financially within the reach of the country 
household. In small villages of ten or a dozen houses, it is usually 
possible to find a spring source of purity at a distance which, by 
co-operation of the neighboring families, is not prohibitive, and this 
can sometimes be done in the isolated farm house. This solution 
should be advised in all cases where practical. More often than not, 
the distance to such a pure supply places this solution out of the 
question and the remedy must deal with conditions as they exist 
It is usually possible to dig a new well if the ground formation is 
such as to give any promise of improvement Unfortunately, this is 
too seldom the case and the question of purifymg the water in the 
existing well must be considered. This is a problem which furnishes 
little attraction in a financial way which probably accounts partially 
at least for the small amount of work which has been done on it by 
sanitary engineers; yet it is one which, by reason of its vital im- 
portance, not alone to the country but to the city also, should have 
careful consideration. If there is anything in the construction of 
these wells which will insure a pure supply, it should be perfected 
and made public. Several methods are mentioned in books dealing 
with rural hygiene; one known as Koch's method consists of placing 
a perforated pipe in the centre of the well midway between the sides 
and midway between the surface and bottom and filling the well with 
sand. This sand performs the mechanical function of a filter or 
strainer. Another method consists in cementing the sides in such a 
way that all the water must come through the bottom of the well, 
hence, must have passed through the earth a distance equal at least 
to the depth of the well. The possibility of rendering an infectious 
well innocuous by the use of copper sulphate should also be con- 
sidered. A domestic filter of the Berkfeld or Pasteur-Chamberlain 
type may possibly be adapted to country household needs. None of 
these methods are of very reliable efficiency and in case a spring 
supply of known purity can not be obtained, it is advisable under 
present conditions to resort to cistern water. With tin or slate roofs, 
water can be obtained in this way in a comparatively pure condition 
with a cistern constructed in a proper manner so that the water is 
filtered through sand before reaching the storage reservoir. 

The problem may be attacked from its other side by providing a 
safe and economic way of disposing of the dangerous wastes of small 
villages or isolated farmhouses. Especially should information re- 
garding the disinfection of the discharges from typhoid fever cases 
be made public. Too many of our small country towns are emptying 
their privy wastes into the bro<rfcs which are used by families, further 



182 TYPHOID FEVER IN RURAL COMMUNITIES, 

down, for drinking purposes. How can the village in* the narrow 
valley dispose of its sewage? The solution adopted in die city is 
completely beyond the resources of the hamlet. 

These are living questions and questions that are staring us in the 
face and demanding a solution. They are questions which are affect- 
ing every one of us in a more or less direct way. Questions which 
must be solved if we advance much farther in the work of eliminating 
these diseases which are known to be preventable and whose occur- 
rence is therefore a disgrace to civilization. 



NOTES ON THE DETERMINATION OF IRON.* 
R. B. DOLE, Washington, D. C. 

(Read before Laboratory Section.) 

In 1904 it was found necessary to adopt a procedure for the deter- 
mination of iron which would be practicable for field assay of water 
in the work of the Geological Survey. The following method was 
devised : 

To 45 c. c. of the water to be tested, 2 c. c. of concentrated nitric 
add were added and the mixture allowed to stand with frequent pour- 
ings from one tube to another, for about 20 minutes. Three cubic 
centimeters of a 2% solution of potassium sulphocyanide were added, 
the colored solution poured into the aluminum tubes used in the color 
determination^, and comparison made with colored glasses which had 
been standardized against iron solutions. The colored glasses were 
prepared by staining slips of colorless glass and firing them. It was 
found after some use that the colors were not permanent and that the 
slips were too fragile, besides being very expensive and incapable of 
duplication at short notice. Accordingly in 1905, an effort was made 
to secure other standard colors for comparison. Experiments were 
first made with dyed papers. The intention was to have two tubes, 
one of which, containing the sample treated with potassium sulpho- 
cyanide and nitric acid, would be held over a sheet of white paper, 
while the other, an empty tube, would be compared successively with 
the colored papers until the equivalent shade was found. It was 
immediately discovered that paper will not absorb a sufficient depth of 
color to represent standards higher than one or two parts per million ; 
accordingly, it was necessary to resort again to standards viewed by 
transmitted instead of reflected light. Slips of colored celluloid were 
then tried, and are apparently successful.^ The following experiments 
were made for the purpose of estimating the value and stability of 
these celluloid discs, and of determining other factors which may 
cause variations in the iron assay. 

The hues of the slips were matched with the color developed from 
iron solutions treated exactly as in the field methods outlined above. 

* Published by permission of the Director, United States Geological Survey. 

* Report of the Committee on Standard Methods. Proc. A. P. H. A., Vol 
XXX, Part II. page 22. 

' Invented and manufactured by Jacob Hahn, 670 Abbott Road, Buffalo, New 
York. 

383 



184 NOTES ON THE DETERMINATION OF IRON. 

An iron standard was prepared by dissolving C. P. iron wire in aqua 
regia, oxidizing with nitric acid, precipitating with ammonia, redissolv- 
ing in hydrochloric acid and diluting to the proper strengths. Samples 
of these solutions were preserved in the laboratory and used for test- 
ing the celluloid discs. Three sets of colored slips equivalent to from 
one to ten parts per million of iron inclusive were first examined. Two 
sets were in the form of wheels, at the perimeter of which the discs 
were inserted, and one set was in the form of ten separate discs, each 
surrounded by an aluminum ring. It was found that the correspond- 
ing discs in the different sets were practically identical in hue. Tripli- 
cate sets of iron standards, one to lo parts per million, inclusive, were 
compared with each color disc by using the regular aluminum color 
tubes which measure 20 centimeters from end to end and contain 
approximately 42 c. c. of solution. Discs 5 to 10, inclusive, were prac- 
tically identical in depth of color with the corresponding iron solutions. 
Discs I to 4, inclusive, contained the right amount of yellow but 
apparently not quite enough red. They were, however, a fairly good 
match and seemed to be near enough for practical purposes. An error 
less than 0.3 parts per million is caused by the difference. Later in 
the year two more sets were examined in which the first four discs had 
been corrected and the hue was practically identical with that of the 
colored solutions. 

No tests were made to determine the stability of the coloring mat- 
ter and its possible change of shade, for that is a matter which will 
better develop after a considerable lapse of time with constant use. 
Though it is not known what pigments or what process is used in their 
manufacture, it is claimed by the inventor of them that the colors are 
permanent. Since, however, the discs are celluloid, experiments were 
made to determine the effects of the reagents usually carried by the 
field man. Bits of the celluloid immersed in them for a period of 20 
hours showd: 

Ammonium hydrate. No effect. 

Potassium chromate. No effect. 

Potassium sulphocyanide. No effect. The addition of iron pro- 
duced a red stain, easily removed by cold water. 

Methyl orange. A slight stain, easily removed by cold water from 
the polished surface, but remaining along the broken edges, showing 
that the dye is absorbed where it has access to the fibres. 

Alkaline phenolphthalein. A purple stain easily removed from both 
fibrous and polished surfaces. 

Concentrated hydrochloric acid. Some solvent action. 

Concentrated nitric acid. Celluloid readily dissolved. 



NOTES ON THE DETERMINATION OF IRON. 186 

It is therefore readily apparent that the celluloid slips would be pro- 
tected from acid fumes by a tight case and that care should be taken 
during the determination to prevent acids from getting on them. 

The oxidation of ferrous iron appears to be the most likely source 
of error in the assay. Nitric acid in small quantity will completely 
oxidize ferrous salts to the ferric form if the solution is boiled for a 
minute or two. The oxidation proceeds more slowly in the cold. Ex- 
periments made with ferrous ammonium sulphate, a salt easily decom- 
posed, show that an interval of at least 20 minutes and frequent pour- 
ings from one tube to another are necessary for the complete oxida- 
tion of the iron in the cold ; it is probable that some iron compounds 
would require a longer time. It is believed that too much stress cannot 
be laid on the importance of completely transferring the iron to the 
ferric form, because otherwise the maximum coloration will not be 
developed. 

Assuming* the formation of the salt, Fc (CNS),. 9KCNS, one mil- 
ligram of iron is equivalent to about 21 milligrams of potassium sul- 
phocyanide; therefore, three cubic centimeters of a 2% solution of 
potassium sulphocyanide would be sufficient to develop the maximtun 
coloration equivalent to about 60 parts of iron, which is far above the 
ordinary limits of the determination. 

Through 20 centimeters of solution, it is not practicable to read col- 
ors produced by iron contents higher than 10 parts per million. In 
such cases it is desirable to dilute the sample. It is, of course, pre- 
ferable to use iron-free water for this purpose, but it is not absolutely 
necessary and is besides frequently impossible in field work. The iron 
contents of the sample under examination may be calculated from the 
following formula : 

a = A+(A-a') p 

where a = content of the sample, a' = content of the diluent and 
A = content of the mixture, all in parts per million of Fe. b = 
number of c. c. of the sample used and b' = number of c. c. of the di- 
luent. When iron-free water is used, a' = O and the formula becomes 

A _j_ Ab' 

D 

The dilution should always be done before the addition of potassiiun 
sulphocyanide, because water added after the reaction with that salt 

• Zur Spcctrocolorimetrischen Eisen, Bezw. Rhodan-Bestimmung. Ber. d. 
Dent Chcm. Gcs. 1889, Vol XXII, pt 2, p. 2054. 



186 NOTES ON THE DETERMINATION OF IRON, 

will decompose the ferric double sulphocyanide and render the deter- 
mination inaccurate. 

In the regular color set there are, besides the 20-centimeter, tube, 
a lo-centimeter and a s-centimeter tube, for use in case the readings are 
too high for the long comparison tube. The use of the shorter tubes 
introduces an error, because a lo-centimeter or a S-centimeter depth of 
solution shows a different hue from that evidenced when a depth of 
20-centimeters is used. In a water containing 10 to 20 parts per 
million of iron the error from this source amounts to about one part ; 
in a water containing from 20 to 30 parts it is about 2 parts. The use 
of the short tubes is not recommended when it is possible to dilute 
the sample. More accurate results can be obtained by diluting the 
sample than by using the short comparison tubes. 

Through a depth of 20 centimeters, o.i part per million of iron can 
be detected. The progressive differences in shade between 3.0, 3.1, 
3.2, 3.3, 3.4 and 3.5 are so slight that without the use of a more delicate 
tintometer it is not practicable to do more than to distinguish 3.0 
from 3.5 parts. Likewise, if the amount of iron is between 5 and 10 
parts, careful observation will detect differences of 0.5 part. It there- 
fore appears that in ordinary work, amounts between i and 10 parts 
inclusive may be expressed within 0.5 part ; that an amount less than 
0.5 should be called a "trace;'' that the terms **slight trace," "very 
slight trace," "almost none," etc., should be avoided as misleading. 
From the test outlined in the preceding paragraphs it appears that the 
celluloid discs may be prepared of sufficiently accurate shade for prac- 
tical work. The standards have been used by the Geological Survey 
in the field during the past year and have proved to be very satis- 
fatory. 

Tests were made to determine the rate of change in the intensity 
and hue of the red coloration. After the addition of potassium sulpho- 
cyanide to standards i, 2, and 3 parts, the contents of the tubes were 
thoroughly mixed and compared as rapidly as possible with permanent 
standards in Nessler tubes ; comparisons were then made between the 
same tubes and the permanent standards after intervals of i, 2, 3, 4, 
and 5 minutes. The first comparison, namely, that made about 20 
seconds after the addition of potassium sulphocyanide showed a com- 
plete development of the color and there was no apparent increase or 
decrease of color for five minutes. Next, standards o.i, 0.3, 0.5 and 
0.7 were examined in the same manner. The correct color developed 
immediately and did not change appreciably in 5 minutes ; at the end 
of 10 minutes there was a slight increase in color; at the end of 30 
minutes there was a marked increase; after the tubes had stood for 



NOTES ON THE DETERMINATION OF IRON, l«r 

several hours the solutions became colorless. When tests were made 
in Nessler tubes, using iron-free water, nitric acid and potassium 
sulphocyanide, a similar color was developed in lo to 15 minutes, 
which faded on standing. The phenomena are believed to be due to 
some reactions other than the formation and the decomposition of 
the ferric double sulphocyanide — probably to a decomposition product 
of potassium sulphocyanide in the presence of oxides of nitrogen. This 
reaction, however, does not interfere with the iron determination under 
ordinary conditions, because the secondary coloration appears only 
after the lapse of several minutes, while the true color of the ferric 
stdpho-compound is developed immediately. In order to determine 
the time which elapsed before the fading of the colors, standards i, 
2 and 3 parts were prepared, each successively at one-minute intervals 
for 15 minutes, then at s-minute intervals for 2 hours and compared 
with each other and with permanent standards. Fading was observed 
after 65 minutes. None of them showed any increase in color. Stand- 
ards 5 to 10 inclusive, were prepared at lo-minute intervals and com- 
pared with each other for one hour at the end of which time the tubes 
first prepared showed some decrease in color. The potassio-ferric sul- 
phocyanide is decomposed by mineral acids and by water. Nitric 
add decomposes it readily in a hot more slowly in a cold solution with 
the formation of ferric sulphate, potassium sulphate, hydrocyanic acid, 
and probably small quantities of persulphocyanides, sulphites, etc., and 
as a result the solution becomes colorless. The decomposition is 
progressive and observations made with more delicate apparatus than 
that employed in these experiments would probably have shown de- 
crease of coloration soon after the addition of potassium sulphocya- 
nide. 

During these tests it was found convenient to use the permanent 
standards recommended by the Committee on Standard Methods.* 
Comparison between them and the iron solutions showed barely de- 
tectible deviations for i, 3 and 5 parts per million inclusive in Nessler 
tubes measuring 19 centimeters to the 100 c. c. mark. Below one, 
however, the permanent standards differed appreciably from the iron 
solutions. It was found later that this deviation is due to the dif- 
ference in the length of tube used for the comparison. It is easily 
demonstrable that the depth of liquid is an important factor. Stand- 
ards can be made from the iron solutions and from the platinum- 
cobalt solutions which are an apparent match in hue through a depth 
of 19 centimeters. When, however, the standards are divided so that 
9.5 centimeters is the depth of liquid, the permanent standards are 

* Proc of the A. P. H. A., Vol. 30, Pt. II, paye 46. 



188 NOTES ON THE DETERMINATION OF IRON. 

-entirely too red. This was found to be the case with every strength 
of standard solution tested. It is undoubtedly due to the well-known 
difference in the absorption coefficients of spectral rays trans- 
mitted through colored solutions and this point is noted in Jackson's 
original article proposing permanent iron standards/ He recom- 
mends the use of Nessler tubes li inches (3 cm.) diameter, and meas- 
uring si inches (13.2 cm.) to the 100 c. c. mark. This important 
feature is not mentioned in the directions of the conunittee and the 
failure to have the proper length of tube has possibly been responsible 
for much of the difficulty experienced in the use of permanent stand- 
ards. 



•Tech. Quart. Vol. 13, 1900, page 316. 



A FEW BACTERIOLOGICAL NOTES THAT WILL CONFIRM 
THE EXISTENCE OF TYPHOD FEVER IN MEXICO. 

WORK OF THE NATIONAL INSTITUTE OF BACTERIOLOGY. 

Dr. JOSE P. GAYON, Mexico, D. R, Mexico. 

During a long period of time there has been a great discussion 
among the physicians of the Federal District on the subject of the 
existence of typhoid fever in the city of Mexico, as well as on the 
subject of certain cases of pirexias remitenies (remittent fever), a 
pathologic entity, very peculiar, that lasts from fourteen to twenty- 
one days, without complications of any kind, except in a few cases, 
in which there is a slight headache, and an insignificant epistaxis and 
drowsiness ; but in the majority of cases we notice only the persistence 
of the fever. We have to catalogue them also in the same group with 
typhoid fever cases, notwithstanding, according to the French school, 
we would designate them on acount of their benignity as "febricules," 

According to the first theory, we, all, or at least the majority of us 
admit the existence of typhoid fever here in the city, because there are 
many cases so complete in respect to symptomatology of the disease 
that the diagnosis comes without the necessity of resorting to the 
modem means in the clinical laboratory for their complete confirma- 
tion. But there are still some incredulous persons, because the truth 
is that the scientific proof of such cases of typhoid fever have been 
verified only by the autopsy of typhoid fever in very few cases ; per- 
haps not more than three in our hospitals. 

When Dr. Widal made known the phenomenon of the agglutination 
of the bacilli of typhoid fever by the blood of persons who were suf- 
fering from that disease, there was the belief that there was the 
simplest resolution to the problem, and many observers, one of which 
is Dr. Angel Gaviiio Iglesias, our director in the Institute of Bacteri- 
ology in this city, as the result of many experiments that he made pub- 
lic in his work presented to the congress of the American Public 
Health Association in the city of Buffalo a few years ago, he demon- 
strated that there is a possibility in many cases of the serum reaction. 

But if it is true that this phenomenon of the agglutinant-group, as is 
classified by the Germans, has important significance in the diagnosis 
of typhoid fever and that we have in every case to look for it, when 
we have the suspicion of being confronted with a case of that char- 

189 



190 THE EXISTENCE OF TYPHOID FEVER JN MEXICO. 

acter ; we can not agree that this has the character of a pathonomonic 
S3rmptoms. For the serums of para-typhoid cases as well as other 
factors are capable of producing the same phenomenon.. One positive 
reaction, says Besson, is obtained under the rules of stricr technic, con- 
stitutes a probability of certitude that there is the existence of typhoid 
fever ; a negative result obtained with the blood of suspicious patients 
only shows a probability against the diagnosis of typhoid fever, and 
especially if the investigation has been made in the few days after the 
diagnosis of the disease. 

As a result of this, I conclude that it is necessary to investigate the 
scientific proof of the disease to which I am calling your attention, 
by the separation of the bacillus of Eberth; but this investigation is 
surrounded by many difficulties: in the potable waters it is accom- 
panied by many other germs, specially the coli bacillus, more vigorous 
than the one of typhoid fever, and this is the origin of many mistakes 
made sometimes by the most expert bacteriolog^ts ; in fecal excre- 
ments it is still more difficult for the same reasons shown ; and in the 
blood until a few years ago, (5 or 6), it was admitted by the bac- 
teriologists, it was only in exceptional cases that the presence of the 
bacillus of Eberth were manifest in the blood of the patients. In the 
book, "Technique-microbiologique," by Besson, edition of 1902, it is 
stated : "The bacillus of Eberth does not enter the blood under nor- 
mal conditions; in the majority of instances the planting of large 
quantities of typhoid blood taken during life or after death, have been 
sterile. (Chantemesse, Widal, Besson). Fraenkel and Simmonds, in a 
large number of cultures of blood, only one time obtained a colony 
of the specific bacillus; in 18 cases of grave fever complicated with 
various kinds of hemorrhages suppurations, etc., the cultures of blood 
made in different periods by Besson always have been without posi- 
tive results. Also with the cultures of the blood of the "petequias** 
the opinion is very different, because as Neuhauss has found the ba- 
cillus of Eberth nine times in 15 cases, Besson has only obtained a 
cultivation with 54 cultures. 

Investigations of Schotmuller, Castellani, Courtmount and others 
have put beyond discussion that the Septicemia Eberthiana is a con- 
stant effect during all the typhoid suffering, and if the experiments 
have not obtained good results, this is owing to the fact that there is 
enough bacteriological power of the blood to destroy the bacillus of 
typhoid fever; but if the blood is taken with all the aseptic precau- 
tions and is cultured immediately in large quantities of bouUion, the 
result is sure. So it is evident that the culture of blood and the 
identification of the isolated bacillus actually constitutes the only strict 



THE EXISTENCE OF TYPHOID FEVER IN MEXICO. 191 

way of the diagnosis of t3rphoid fever, and destroys the mistake that 
can be occasioned by the sero-reaction (group-agglutination). 

Going further into this method we have made several cultures of 
typhoid blood in the National Institute of Bacteriology, and in 
the observed cases I am going to describe the following two, that I 
owe to the kindness of my partner. Dr. Girard, because they are very 
demonstrative. 

(i). In a young girl that was showing all the clinical appearances 
of typhoid fever (typhoid state, continuous fever, red marks, espleno- 
megalia, etc., etc.) the blood was taken to find the serum-action of 
Widal and a positive result was obtained to the degree of i % ; 5 cubic 
centimetres of blood culture in these conditions give place to the de- 
velopment of a mobile bacteria and with all the characteristics cor- 
responding to the bacillus of Eberth. 

(2). A young man after some days of having a slight discomfort 
and also fever, of a remittent form, blood was taken to find the serum 
reaction of Widal and there was obtained a negative result; on the 
contrary in the culture in boullion made the same day there was ob- 
tained a bacteria with the characteristics of the one of Eberth, and that 
notwithstanding it was not agglutinated by the blood of the patient. 
Eight days after blood was taken again from the same person and 
then there was g^oup-agglutination as well with the bacillus obtained in 
the culture, as with the one cultivated of the type of Eberths. In 
these moments^ the patient was presenting clinical marks of t)rphoid 
fever (continuous fever, color marks, etc., etc.) ; after this intestinal 
hemorrhages appeared and the patient died. 

The bacillus obtained from the culture of the blood, from the first 
as well as in the second case, were mobile. They did not take the 
Gram, the cultures in agar agar, gelatine and potatoes presented the 
characteristics corresponding to the Eberth's type; they did not de- 
velope gases, they did not ferment the maltose lactose, neither the 
"manita," they did not produce indol; as well as from the culture of 
agar with neutral red, they did not give place to any decoloration. 

So, we conclude that the agglutination of a group by the way of the 
blood of typhoid sufferers is clearly verified in using cultures of these 
bacilli or of an authentic bacillus of Eberth. 



RESULTS OF REVACCINATION IN MEXICO. 
Dr. FRANCISCO DE P. BERNALDEZ, Mexico, D. R, MEXica 

In previous works which I have presented to this learned American 
Public Health Association, I have stated that the class of vaccine which 
is administered in Mexico against smallpox is the humanized or Jen- 
ner vaccine ; that is to say, a vaccine which is preserved by number- 
less successive passages through the human system, which finally 
determines its degree of virulence as bacteriology has demonstrated 
with virus of all kinds. Bearing this in mind, we can easily under- 
stand what experience has already sanctioned, that human vaccine 
grants immunity for the entire life of the man. In spite of this con- 
viction which is powerfully rooted amongst the physicians who prac- 
tice in this locality, especially after the experiments which were car- 
ried out many years ago by the eminent Dr. Luis Mufioz, and by 
which it was fully demonstrated, that vaccination as practiced in Mex- 
ico confers immunity for the term of life and therefore renders re- 
vaccination useless, the Supreme Board of Health of this city proposed 
that this study should be again undertaken in its central vaccination 
offices, and since the year 1901, a special register has been kept of 
the persons who are revaccinated, giving their names, ages, sexes, na- 
tionalities, date of the first inoculation, character of the vaccine lymph 
employed (whether animal or humanized) and the results obtained 
by the first and following revaccinations. 

In order not to lengthen this paper beyond reason, I will simply 
give the results or conclusions of those statistics : 

From the year 1901 to November of the present year, 3,260 per- 
sons have been revaccinated, of whom 2,361 were either Mexicans or 
bom in Mexico, and the rest were foreigners of different nationalities. 
In this case, this division is of great importance, because at present 
Mexico is almost the only country which administers humanized vac- 
cine, and all foreigners are vaccinated or revaccinated in their own 
countries with calf lymph. Moreover, when the foreigners leave their 
countries, they have themselves vaccinated voluntarily or because it is 
so required by the transportation companies, so that when they reach 
the Republic they are within the 10 years of immunity which is con- 
ferred by animal vaccine, and therefore, the results of the revacdna- 
tion are necessarily negative, because it is to be noted that the foreign- 
ers who undergo revaccination here, are generally those who have only 
just reached the country, and who adopt the vulgar belief that the sea 

192 



RESULTS OF REVACCINATION IN MEXICO. 1«S 

voyage makes them lose the benefits required through vaccination, and 
that the smallpox infection in Mexico has a special predilection for 
foreigners, and that only the vaccine administered here, and no other, 
can prevent attacks of smallpox. 

The truth of all this is, that as foreigners are vaccinated with calf 
lymph, they lose the effects of it after ten years of immunity, and 
then become liable to contract the infection, which they attribute to one 
of the two causes above mentioned. 

Moreover, in all countries in which lymph preserved in glycerine 
is utilized for the administration of vaccine, they make large scari- 
fications, that result in the formation of extensive scabs, in wAich we 
cannot recognize the characteristics of the true vaccine pustule, and 
it is therefore impossible to assert, that the subject has been again 
immunized against an attack of smallpox, the probability being that 
in many of the cases so revaccinated, they do not acquire fresh im- 
munity, because if the vaccine lymph is badly preserved in glycerine, 
it does not keep its properties. It is for this reason that many of those 
persons who suffer an attack of smallpox attribute it to one of the vul- 
gar beliefs above mentioned, without reflecting that the true cause is 
that they have been badly vaccinated, and should be revaccinated on 
arrival in the country. 

After these necessary digressions, and coming back to the principal 
point of this paper, we find that out of the 2,361 persons who had been 
vaccinated for the first time in childhood with humanized lymph, only 
33 gave positive results on revaccination, that is to say, that in only 
those cases did the pustules present the characteristics assigned to real 
vaccination, so that from these observations we come to the conclusion 
that only in 13 per cent, of those persons was the immunity conferred 
by the first inoculation lost, after the lapse of 20 years, it being of 
interest to note that these 33 persons were all of age. As we see, these 
figures come to confirm the belief that the humanized vaccine con- 
fers immunity for almost the whole term of life, although with a few 
exceptions, as in the slight epidemic of smallpox which we had during 
this year, in which some cases were observed in persons already vac- 
cinated, it is believed that humanized vaccine as well as animal vaccine 
only confers immunity for a short period. 

I will try to give an explanation of this. In my previous papers and 
incidentally in this one, I have stated that before we can consider a per- 
son well vaccinated we require several conditions, and not presume 
the fact simply because he himself or his family say so, or 
because we find a more or less well defined scar on the arm, as it is 
sufficient for any vaccine pustule, even those of false vaccination to 

13 193 



194 RESULTS OF REVACCINATION IN MEXICO, 

suppurate and leave a scar, which is not always easily distinguished 
from that left by the true vaccination, and therefore, there is all the 
more reason to say that if the inoculation is done by the system of 
scarifications which always and in every case leaves extensive scars 
and even deformities ; the same thing can be said if the pustules have 
been scratched during their development, so that the only true criterion 
by which to judge whether a person has been well vaccinated or not, 
is an inspection of the pustules at the period of their full development, 
that is to say between the 7th and 9th day, so as to see whether they 
have the characteristics of true vaccination, and for this reason, I 
repeat, the method of scarification, in which those characteristics can- 
not be found, should not be adopted. 

Of the children who have been vaccinated in the offices of the 
Supreme Board of Health, only 55% return after seven days, and 
therefore it is only with regard to these, that we can state whether the 
vaccination was a success or not, and there are often cases of children 
who only present one pustule, or have received false vaccination, and 
who, when again inoculated with fresh lymph on the same pustule, 
present true characteristics after three or four days. We do not know 
how many of the children who are not brought back to the office are 
considered well vaccinated and nevertheless are attacked by smallpox, 
because the pustules of the false vaccination were mistaken for the 
real thing. It is therefore not to be wondered at, that the physician 
who in the presence of a smallpox patient inquires, and is answered that 
the patient has been vaccinated. Another error consists, in mistaking 
cases of varioloid for real smallpox, as it is well known that when 
any disease assumes an epidemic form, it is because its germs acquire 
a high degree of virulence, and that certain susceptible persons, even 
though vaccinated, acquire the infection although in a mild form, in 
some cases the form of varioloid, which in certain individuals may be 
serious on account of constitutional weakness. 

In confirmation of all the above, I here present statistics of the 
slight epidemic of smallpox which appeared in this city during the 
present year. 

Confirmed cases of smallpox 328 

Corrected to varioloid 118 

Vaccinated individuals in whom smallpox was diagnosed and regarding 

whom there are no data to show whether they had smallpox or varioloid. 129 
Patients in whom smallpox was diagnosed, and who were not. found in the 

residences given in the physician's report 28 

Reports of smallpox cases which were found to be repeated 21 

Reported cases of smallpox which were found to be other diseases 11 



RESULTS OP REVACCINATION IN MEXICO. 196 

Age, Male, Female. .Total. 

to 1 years 17 16 32 

Ito 2 years 8 16 24 

2 to 5 years 39 29 dS 

6 to 10 years 30 10 49 

10 to 20 years 37 67 94 

20to30years 28 20 48 

30 to 60 years 6 17 

60 to 70 years 1 1 

166 168 323 

In closing I will call attention to the fact that many persons of over 
15 years of age are not vaccinated, because at the period of their child- 
hood the law of obligatory vaccination did not exist, which requires 
that children shoufd be vaccinated within the first four months after 
birth, and that is the reason why smallpox attacks many of those per- 
sons, and not because the eflfects of a vaccination which they never re- 
ceived have passed off. 



THE JENNER VACCINE. 

IT IS NECESSARY TO ESTABLISH OBLIGATORY REVACCINATION IN MEXICa 

Dr. EVERARDO LANDA, Mexico, D. R, Mexico, 

The prophylaxis of smallpox by means of humanized vaccine, has 
been practiced in Mexico from the beginning of the 19th century, when 
it was first introduced into the country. 

In the offices of the Supreme Board of Health in this city, the 
l3anph which is taken from the vaccinated persons is preserved and 
distributed, not only in this city, but throughout the Republic, and the 
same method of vaccination is employed in the principal cities of our 
country. 

Is humanized lymph better than the other? This is a much debated 
question, but many recognize that our vaccine gives better results than 
that derived from animals, as against the objections which it might 
have, such as the inoculation of syphilis, we have the immense ad- 
vantage that the immunity which it confers, lasts as long as the life 
of the vaccinated individual. 

In some papers which have been read before this learned Association^ 
and which are recorded in the proceedings of past meetings, this 
question has been treated, which is of such great interest for Mexico. 
It has been said that the immunity acquired through the use of 
humanized vaccine "is permanent," and that, therefore, no revaccina- 
tion is required as in other countries where animal vaccine is employed. 
It is also said, that the degree of immunity enjoyed by Mexicans, is 
much higher than that which is conferred by calf lymph, because 
when an individual is vaccinated with our lymph, the infection by 
smallpox is extremely rare, is always mild and never assumes the 
confluent form. These are the principal questions. 

But are the facts contrary to these assertions when investigated? 
All the physicians of this city are fully convinced, that smallpox finds 
many victims amongst individuals who were well vaccinated in child- 
hood, and certainly there is not one of us who has not seen a case 
of smallpox in some of its forms, under the conditions above men- 
tioned. It is not a rare thing for a physician to have vaccinated a 
person with satisfactory results, and later on to see that same person 
succumb to an attack of confluent or hemorrhagic smallpox. Never- 
theless, very few have studied this subject, so as to give the exact 
knowledge which is required of the real state of aflfairs. 

196 



THE JENNER VACCINE. 197 

The Clinical Medical Society of Mexico has given an earnest atten- 
tion to the subject and has acquired a full conviction that humanized 
vaccine,, like that derived from the animals, is incapable of conferring 
permanent immunity. This is demonstrated by different works which 
have been published in the "Revista* Medica" (Medical Review), as 
well as by many cases which are frequently related by the members, 
and which are recorded in the proceedings of the society. 

It is necessary to look upon this matter with all the interest which it 
deserves, in order to spread a knowledge of the facts that have been 
so well proved by the experience of years. If in many countries, 
especially in Germany, a triumph has been gained in the prophylaxis 
of smallpox, it is because revaccination has been imposed on the 
people. 

Many of those who in Mexico die of smallpox have been previously 
vaccinated and the mortality amongst them is greater. The statistics 
speak with eloquence as I will show later on. 

The "Demographico-Meteorological" Bulletin of the Board of 
Health, which publishes a comparative table of mortality that covers 
many foreign towns, shows 184 deaths in ten cities of the United 
States, of South America (159 cases in Buenos Aires) and in Europe, 
from the 31st of December, 1905, to the 29th of September, 1906, 
whilst in the city of Mexico, 414 persons of different ages have suc- 
cumbed during the same period of time. 

Certain considerations of a biological order that refer to the immu- 
nity, show that it decreases during a shorter or longer period until 
it is extinguished, and that in order to sustain it for any long time, 
it is necessary to submit the individual to a reinfection, or otherwise 
a revaccination. But it would be useless to enter on a discussion of 
theoretical questions, when the facts that we see every day prove 
beyond a doubt that the immunity conferred by the Jenner vaccine is 
lost, in the special case of smallpox. 

On the other hand, we must bear in mind that it is even possible to 
lose the immunity which is conferred by certain infectious diseases. 
There are individuals, for instance, who have had smallpox at least 
twice. I found in my statistics mention of a man 25 years of age, 
vaccinated, who has had varioloid three times, and of a lady who had 
also been vaccinated, who suffered twice from varioloid and on another 
occasion, from confluent smallpox. To the number of patients whom 
I have had opportunities of seeing, I have added those of many re- 
spectacle physicians of this city and outside towns, who have kindly 
contributed to my work with the data which they collected in their 
practice. 



198 THE JBNNBR VACCINE, 

Of each one of these cases I have more data than I have considered 
necessary for my demonstration. Therefore, there is no possible doubt 
as to the existence of the characteristic scars of vaccination in each 
patient, and neither can there be any doubt, in the majority of cases, 
as to the age of the vaccination and the nature of the Ijrmph employed. 

I also know of several cases of smallpox in foreigners who have 
been vaccinated; although I attach no great importance to these, 
because the immunity enjoyed by people in other countries is not 
effective in Mexico. It has been said that foreigners require to be 
vaccinated when they reach this Republic. The Spaniards, who 
brought smallpox to Mexico at the time of the conquest by Heman 
Cortes, have always paid a heavy tribute to the disease, and frequent 
cases are seen in the hospital of the Spanish Benevolent Society, of 
both confluent and hemorrhagic smallpox. 

As foreigners do not figure in my statistics, I will state in general 
terms, that ten patients of whom I have heard, Spanish, American, 
French and Italian, whose ages ran from four to twenty-five years, 
suffered from the different existing forms of smallpox. 

In Table I we have the statistics of the patients, who according to 
the form which the smallpox assumed with them, are distributed as 
follows : 

Hemorrhagic smallpox 8 

Confluent smallpox 55 

Mild smallpox 34 

Varioloid 22 

Total 119 

As a large proportion of the cases which figure in this table belong 
to the present year, it appears desirable to make a comparison with 
the smallpox mortality in this city for the present year. I have already 
stated that up to the 29th of September, 414 individuals have died, 
and their distribution can be seen in Table II. 

It is worthy of attention that the confluent form is that which 
predominates in the 119 cases I have above shown, and I would also 
draw attention to the correspondence there is between the two tables 
with respect to the maximum of cases between the ages of ten to 
twenty and of twenty to thirty years. In Table II we can see that the 
mortality increases up to 20 years and then decreases; and if there 
are many cases of death in the first ages, it is because many children 
are not vaccinated in time ; but afterwards, over the children who are 
vaccinated and attacked by smallpox, are the older individuals, who 
were almost certainly vaccinated in childhood. And this is almost 



THE JENNER VACCINE. 199 

certain^ because in Mexico, thanks to the eflforts of the board of health, 
the administration of vaccine is well organized. 

In Table II we see that many deaths take place before the age of 
ten, whidi proves that the great majority of those in that group were 
not vaccinated, because in Table I the first patients appear in the 
group between two and five years of age. It is also to be noted, that 
these cases were of varioloid or at most, of mild smallpox, which 
nevertheless reveals the vulnerable character of the system. 

To the above I must add thirty cases of mild smallpox which Dr. 
Marcos E. Juarez observed in the years 1898 and 1899 in some towns 
of the state of Tamaulipas, in persons who had been vaccinated and 
were not less than twelve years of age. This led Dr. Juarez to ^believe 
that our vaccine grants immunity for ten years at the utmost. 

Dr. Jesus Valenzuela, of Mexico, also declares that this year he has 
attended six smallpox patients who had been vaccinated and one of 
whom died. 

As regards the revaccination, I have details of twenty-eight persons 
ranging from eight to seventy years of age in whom that operation 
gave positive results. 

The inaugural theme of Dr. Delfino Victoria specifies six cases of 
positive revaccination in thirty-five pupils of the hygiene class of the 
National School of Medicine. 

As I desired to know whether the immunity is preserved with 
humanized vaccine up to at least twenty years of age, by having 
recourse to other means apart from the statistics of the patients, I 
revaccinated the sixty-six pupils of the deaf and dumb school of this 
city whose ages varied from 6 to 20 years of age, and using the lymph 
supplied by the board of health I obtained positive results in four 
males (11, 12, 18 and 19 years of age) and seven females (7, 10, 11, 
12, 14 and 17 years of age). I therefore obtained eleven positive 
revaccinations out of sixty-six. With twelve females I used animal 
lymph (Lancy vaxina) which proceeded from a vaccination institute 
in Berne. The old scars were well defined in all those I revaccinated 
and the new pustules were well developed. 

These results show that there is an exact correspondence of ages 
between the sick, the dead and the successfully revaccinated. 

I also refer to the information given to me by Dr. Joaquin Rivero 
y Heras, who has had opportunities to see that on the two occasions 
when the entire forces of the garrison of this city were revaccinated, 
only a few gave positive results. 

From all the above observations, we come to the following con- 
clusion and a proposition. 



200 THE JEN'NER VACCINE. 

1. The immunity against smallpox conferred by vaccination is lost 
after the lapse of a certain time. 

2. Humanized vaccine, like animal vaccine, does not confer per- 
manent immunity. 

3. The immunity is almost invariably lost ten years more or less 
after the first vaccination. 

4. The vaccinated individuals who lose their immunity and are 
attacked by smallpox do not always present the mild forms of the 
disease, and the confluent smallpox is the dominant form. 

5. In an appreciable proportion of individuals revaccination is 
positive before the age of 20 years. 

Proposition : 

It is indispensably necessary to establish obligatory revaccination 
in Mexico for both natives and foreigners. 

TABLE I. 
Shows the number of individuals attacked by smallpox, in spite of their 
having been vaccinated. The disease caused the death of many. The small- 
pox assumed the hemorrhagic (8) confluent (55) mild (34) and varioloid (22} 
forms. 
Ages. Male. Female. Total 

Oto 1 2 2 

1 to 2 

2to 5 1 6 7 

5 to 10 9 11 20 

10to20 22 32 54 

20to30 18 11 29 

30 to 50 4 8 7 

50 to 70 

Total 54 65 119 

Note : — The two females of to 1 year of age, had varioloid. 

TABLE II. 

Shows the number of deaths from smallpox in the city of Mexico, from 
the 31st of December, 1905 to the 29th of September, 1906, as recorded m 
the "Boletin Demogrifico Meteorol6gico." 

Ages. Males. Females. Total 

to 1 25 38 63 

1 to 2 15 21 36 

2 to 5 28 33 61 

5 to 10 30 23 53 

10to20 54 50 104 

20to30 39 34 73 

30 to 50 15 6 21 

50 to 70 1 2 3 

Total 207 207 414 



ANCHYLOSTOMIASIS IN MEXICO. 
Dr. RICARDO E. MANUELL, Mexico, D. F., Mexico. 

On the loth of September, 1902, I had occasion to observe, in the 
now demolished hospital of San Andreas, and under circumstances 
that I need not explain here, a highly anaemic patient, who led me to 
suspect the existence in Mexico of the parasitic disease called anchy- 
lostomiasis or uncinariasis. 

I at once proposed to undertake a series of investigations m order 
to ascertain whether my suspicions were well founded or not. The 
study which I undertook for this purpose, and which led me to con- 
clusive positive results, I carried out in the military hospital of in- 
struction; although I was unable to identify the first case of the 
disease until after the lapse of two months, partly because I had not 
sufiicient time disposable and partly through my complete want of 
ability, at that time, to investigate the habitat of the eggs of the 
parasite. But once the first case was identified, I found it easy to 
discover four others within a short time amongst the patients of the 
same hospital, who were looked upon as polluted anaemics. Of these 
five patients, two had acquired the uncinariasis in the peninsula of 
Yucatan, two in the Valle Nacional and the last in Pachuca, all places 
far from each other, for which reason it was to be presumed that the 
disease had already spread in our territory. 

I reported my discovery to the war department, which was pleased 
to reward my labors with favorable mention, and communicated my 
report to the other military hospitals, ordering them, in their turn, 
to undertake studies on the subject and report results. At the same 
time I presented a paper on the same subject to the Society of Qinical 
Medicine, which was published in No. 11, of Vol. IV, of the "Revista 
Medica," the organ of that society. 

In June of the following year (1903), a paper was presented by 
Dr. Andres G. Castro, in a modest and condensed form and at the 
same time full of information relating to uncinariasis, probably 
ignored by almost all Mexican physicians. On the 25th of November, 
of that year, a work written by Dr. Akitonio Matienzo was read in the 
National Academy of Medicine, relating to a cause of uncinariasis 
which had been observed in Tampico; and a little later on the same 
physician published that case and another which he had also observed 
in the same port of Tampico. On the 30th of April, 1904, the "Revista 

201 



202 ANCHYLOSTOMIASIS IN MEXICO, 

Medica" published a paper by Dr. Gonzalo Casteiieda Escobar, which 
had been read some months previously in the Society of Clinical Medi- 
cine, under the title of "Anchylostomiasis in the Mining District of 
Pachuca." The author of this work relates that the patients suffering 
from uncinariasis who had been found within a short time in Pachuca 
could at that time be counted by the dozen. In March, 1905, a new 
paper was published, which is as commendable for various reasons as the 
one previously mentioned. The author, Dr. Luis R. Lara, is the first ob- 
server in my countr>' to go directly to the bottom of the question, by 
searching and finding larvae of uncinaria in one of the many mines of 
the Real del Monte and Pachuca, which public opinion has already 
pointed to as foci of anchylostomiasitic infection. This observer 
estimates at 50% the number of persons affected by this disease, 
among the mining population of that district. 

Other physicians, amongst whom I may mention Drs. Terres and 
Pruneda, of the comparatively few who have any knowledge of these 
matters, and who have given the importance which it deserves to 
the serious question of the existence of anchylostomiasis in our 
country, have been able to diagnose the disease in patients observed 
in this city, but who have arrived from different points of the country. 

From the different cases which have been observed by myself or 
others, as well as those of which I have obtained knowledge up to 
this date, we may consider the existence of foci of uncinariasis fully 
proved in the states of Yucatan, Oaxaca, Hidalgo, Tamaulipas, 
Veracruz, Qiiapas, Guerrero, Michoacan, Zacatecas, and Guanajuato. 
I hope I will not be considered exaggerating, if I say that there are 
grave reasons to fear that all of the states of the Republic are in- 
fested, bearing in mind, on the one hand, the active movement of the 
population from one place to another in the country which has, for 
some time, been specially observed, amongst our wage earners, and, 
on the other, the favorable conditions presented by the air, humidity 
and temperature, for the preservation of the larvae of the uncinaria, 
by innumerable sections of the country. The numberless mines which 
are scattered through our territory and our extensive and torrid 
coasts, are more than enough to present inexhaustible breeding places 
for the larvae, and it would therefore be very surprising if any of 
our states enjoyed immunity from the disease. We can, therefore, 
understand how important it is, that a knowledge of the existence of 
an easily transmissible disease should be spread throughout the 
country, a disease that not only carries off a great number of victims, 
but leaves many more who for years are debilitated for all kinds of 
work, and at the same time converted into active sources for the 



ANCHYLOSTOMIASIS IN MEXICO. 2X^ 

propagation of the evil. In other words, it is necessary to under- 
stand that under the protection of our ignorance, I cannot say of our 
apathy, a disease which belongs to the class of preventables, is greatly 
spreading amongst us, and that it not only desolates the working popu- 
lation by death, but brings a great part of the rest to a state of health; 
that renders them incapable of producing the amount of work that 
can be given by healthy people. 

This question is not only of national but also of international 
interest and importance. Our laborers cross the frontiers of the 
Republic and it may well happen that through them an epidemic oF 
anchylostomiasis may spread in the neighboring countries. The* 
European laborers, who as Dr. Lara very justly supposes in the paper 
above mentioned, must have brought the infection to the Real del 
Monte and Pachuca mines, may continue bringing us a fresh con- 
tingent of the evil; and lastly, with the increasing immigration from 
the north, we may receive, if it has not already come, the new species 
of anchylostomia, that under the name of "American uncinaria" 
is described by Stiles, and which as yet has not been discovered 
in Mexico. I have as concisely as possible expressed in the above 
lines, what I may call the essence of the subject which I have desired' 
to submit to the learned consideration of this conference. If my 
ideas have merited this attention, I desire to keep it a little longer^ 
perhaps at the risk of detaining you from still more important sub- 
jects. I desire to answer the question that I feel certain is about to 
burst from your lips, as follows: treating of a serious transmissible- 
and preventable disease, whose many evils it is unnecessary to state, 
and against which all civilized nations adopt efficacious measures,, 
what has been done in that sense by the sanitary authorities of tKc 
Mexican Republic during the four years which have elapsed since 
the discovery of this evil, which literally corrodes the internal organs 
of so many thousands of workingmen? 

My answer is, nothing. But I hasten to add, that this abrupt 
answer is not complete, but should be accompanied by an explanation 
which, whilst it justifies, at the same time serves as a preventive 
against the ill-intended criticisms and unfounded censures which* 
might arise from some parts. If anybody thinks that as a Mexican 
I should be ashamed to put this answer on paper, I state that 
precisely for that reason I am proud to explain it in this way. My 
country is giving to the world the rare spectable of something like 
the realization of the miracle of the Phoenix, rising out of its own' 
ashes; but even miracles require time. I have absolute faith in the 
future of my country, because I see that every day it opens up as 



204 ANCHYLOSTOMIASIS IN MEXICO, 

new road or a new machine in the path of progress, and I forsec 
for the future a close net of roads that will s^rve to bring to the 
country a wonderful population. If the way which leads to tfie 
stamping out of the anchylostomiastic plague is not yet surveyed, it 
'will undoubtedly be so within a short time. The workers in this 
branch have had a great deal to attend to in oliher parts of a more 
urgent character; but I trust that by the next meeting of this Asso- 
•ciation we will not only know the road that has been laid out, but 
also the engine that is to travel over it. 

We have a mining code in which sanitary provision could be in- 
serted. The Supreme Board of Health keeps watch over our sea 
•coasts; there are sanitary authorities in all of the states, and I do 
not know from whence will come the impulse for the first labors; 
but I have every hope that the campaign which may be undertaken 
.against uncinariasis will honor my country, like that which stamped 
out the bubonic plague in Mazatlan. 



THE PROPHYLAXIS OF TYPHUS. 
Dr. J. I. SALOMA, Mexicx), D. R, Mexico. 

The propagation of contagious diseases obeys numerous and varied 
influences, of which some are of the mesological order, chemicological 
order, whilst altitudes, seasons, etc., tend to impress upon it its epi- 
demic, endemic, or pandemic character. Sometimes the diffusion of a 
disease is limited by the degree of immunity which is conferred by a 
previous attack. We thus see that the greater part of the eruptive 
fevers which belong to childhood, respect the adult, who having gone 
through those diseases in childhood, is rendered immune to the greater 
part of them. For the same reason t3rphus is rare in the last stages of 
life, as many old people, having suffered from the disease in their 
youth, acquire the respective immunity. 

Nevertheless there is a factor of greater importance than the above ; 
I refer to the exposure. If two individuals under equal circumstances- 
live with another who suffers from tuberculosis, the one who remains 
longest and in most intimate touch with the patient is the one who- 
runs greatest risk from the disease. It is on account of this greater 
exposure that the eruptive fevers in children appear highly contagious, 
as their character and inexperience keep them in long and intimate 
contact, and even the mother, who with difliculty is separated from 
her children, contributes to increase the effects of this exposure. 

The spread of typhus therefore is not exempt from this* law of 
exposure, and thus we see that it invades an entire family and some- 
times an entire neighborhood, when the people are poor, ignorant and 
apathetic, living in a single small room badly supplied with light and 
ventilation, and using without any precaution whatever, the objects 
contaminated by the patients. The contrary is observed in the case 
of cultured and careful persons. Whenever one of these is attacked 
with typhus, he is taken to the furthest and most independent room 
of the house, to which the bravest and most affectionate of the family 
only proceed by way of exception and for a few moments. Precau- 
tions are taken with all outsiders, and in one word, the exposure in 
these cases is greatly reduced, and consequently, the spread of the 
disease is almost entirely suppressed. 

In a study that was made in the general hospital of the city of 
Mexico during the last epidemic of typhus, the etiological importance 
of exposure was very clearly shown; in fact, of the non-immunes who 
lived in the typhus wards, tihe disease attacked 53 ; whilst only 7% of 

205 



:206 THE PROPHYLAXIS OF TYPHUS, 

those who daily passed an hour or less in the infected wards took the 
disease. 

That the contagious diseases, such as syphilis and tuberculosis, are of 
long duration, that they are difficult to recognize for the general pub- 
lic, which allows the patient for a long time to lead an active life, are 
customs that multiply the causes of contagion by their greater ex- 
posure, but if the diseases were of short duration, and if it were easily 
recognized by the public, and if he were prevented from continuing 
his ordinary life, we would see the results in the diminished propa- 
gation through less exposure. 

If typhus follows the same laws of diffusion as the generality of 
contagious diseases, its prophylaxis ought to be inspired in the same 
preventive principles, and as nature jx)ints out to us the unquestion- 
ably best method of prophylaxis, by putting him into bed during the 
entire course of the disease, and thus realizing his perfect isolaticm, 
let us imitate nature and if possible perfect it, by making that isola- 
tion more complete and effective, and with more reason, in view of 
our ignorance of the specific agent of typhus and its means of dif- 
fusion. 

The following examples, which were taken from many others, are 
•not models of prophylaxis, but imperfect and defective experiments 
which allow me to present in an objective manner some of the prin- 
•cipal precautions intended to prevent the spread of typhus. 

A yoimg man fell sick with fever on the 4th of September, 1906, 
.and four days afterwards I examined the patient and notified the 
family, that probably he was suffering from t)rphus, as was after- 
wards found to be the case. The family consisted of nine non-im- 
mimes, of whom the youngest was over 15 years of age. It became 
necessary to place the patient under the care of two of the younger 
•sisters, as in the event of either of them being infected, her age con- 
stituted a favorable element. The house contained three bedrooms and 
a kitchen which was also used as a dining room and the patient v^as 
installed in the most distant bedroom. The street door was kept open 
during the whole day and during the night was left slightly open; in 
the bedroom which followed, the two nurses remained continuously, 
v^ith the special recommendation not to remain in the infected room 
any longer than was absolutely necessary to administer the medicines, 
food or give the patient such assistance as he might need. The clean- 
ing of the room was done by means of damp cloths. Another member 
of the family slept in the following bedroom, and the rest of them 
were obliged to abandon the house entirely. 

When the disease began to give way and the skin began to peel, 



THE PROPHYLAXIS OF TYPHUS. 207 

the patient was given three general baths on alternate days, changing 
his clothing on each occasion, and after a convalescence of 15 days, 
the family was allowed to reunite, without any fresh case being ob- 
served amongst them. 

In the month of July, 1906, I attended another typhus patient who 
belonged to a very poor and numerous family, consisting of eight 
persons, of whom four were adults and immunes and four were chil- 
dren between 7 and 12 years of age, and non-immune. This family 
occupied a single room of small size and with poor light and ventila- 
tion. The mother, who as I have stated, was immune, undertook the 
care of the patient and the rest of the family left the house with orders 
not to return until 20 days after the disease had disappeared. The 
other precautions were similar to those of the previous case, and no 
antiseptic was employed. The disease did not spread. 

The following precautions which are founded on the experience of 
respectable authorities and on the scientific ideas of the present day, 
may serve as a starting point for the formation of a short set of regu- 
lations, of a simple character and within the reach of persons of all 
classes. The only intention is to do something for the general good, 
to which all private convenience must give way, and its principal 
basis is isolation. 

I. The patient should be placed entirely alone in a room as soon as 
possible, in the most independent, ample and best ventilated room in 
the house, in which the smallest possible number of articles will be left. 

II. In this room the temperature will be kept uniform, the air con- 
stantly renewed without draughts, and it must be kept thoroughly clean 
by means of damp cloths. Insecticides will be employed, preferably 
antiseptics. 

III. The patient should be put under the care of immunes, whose 
number should ordinarily be two, or in the absence of immunes, under 
the care of the youngest available, and who will remain in the room 
next to the sick room, and only enter the latter for the time which 
may be absolutely necessary for the performance of their duties. They 
will use special wrappers, and under no circumstances will they make 
use of the contaminated objects, or allow themselves to come into con- 
tact with the rest of the family. 

IV. If the house is not sufficiently roomy, the rest of the family 
will have to abandon it, and return at least two weeks after the fever 
has ceased. 

V. Whatever may be the treatment employed, the patient and per- 
sons who attend to him, before joining the rest of the family must 
take at least three general baths, and change clothing after each bath. 



208 THE PROPHYLAXIS OF TYPHUS. 

The clothing and other objects dedicated to the use of the patient and 
nurses will be subjected to the ordinary process of disinfection. 

VI. The attending physician will ccwnmunicate these rules to the 
family, by means of a printed leaflet, and will be held responsible for its 
strict obedience, by the sanitary authorities, except when such obe- 
dience is not possible, through the ignorance or poverty of the family, 
in which he will immediately report the matter to those authorities^. 
so that the patient may be at once taken to the hospital. 

VII. The sanitary bodies will be invested with full powers and 
granted pecuniary resources and a sufficient staff to enforce these rules, 
so that the infected houses may be visited at least every third day by 
sanitary inspectors, with the imposition of fines or imprisonment on 
transgressors. 

A regulation of this character would place physicians in a position 
to protect families in an effective manner against a disease that carries 
off many in the flower of youth. We would, as far as possible, attend 
to the request which is daily addressed to us by the public, which 
anxiously asks, "Doctor, what must we do not to fall sick of typhus?" 
We would thus comply with one of the highest offices of our profession, 
as we must not forget that the physician who attends to the patient 
and overlooks the family is only half a doctor. Let us bear in mind 
that the physician is the principal worker in that difficult task which 
has recently been assumed amongst us, and which is called Preventive 
Medicine, and that as the public wealth and welfare are the result of 
private wealth and welfare, so Public Hygiene is fundamentally based 
on private and individual hygiene, without which the greatest and 
best organized efforts of the State are found entirely useless. 



THE RAINS AND TYPHUS. 
Dr. ALFONSO PRUNEDA, Mexico, D. R, Mexico. 

One of the diseases that Mexican physicians are most interested 
in understanding, and more especially those who practice in the central 
table land, is undoubtedly exanthematic typhus, which is more com- 
monly called here "tabardillo," on account of the differences which it 
presents with the disease that is called typhus in the old continent. 
This interest has always been a powerful stimulus for those investi- 
gators who have followed each other in the study of the different 
aspects which are presented by the problem of the typhus, and some 
of which relate to the etiology and others to the symptoms of the 
disease. 

Nevertheless, amongst the things least known with respect to the 
disease I refer to unquestionably are the etiological factors, and tiie 
omission, as may be easily understood, is of the greatest importance, 
seeing that it is impossible to base a rational prophylaxis and adopt 
adequate hygienic measures when we ignore the different circum- 
stances that govern the appearance and development of any given infec- 
tious disease. More or less admissible theories, hypotheses that are 
more or less well grounded, assertions which are remarkable for their 
slight grounds, are all that made up the sum of our etiological 
information with regard to typhus, until the publication of the work, 
which I do not hesitate to qualify as fundamental, of our master Dr. 
Terres on this subject, and which came to put all this aggregation of 
opinions in their proper place, and give them their true value. 

One of the etiological factors of typhus which acquired its real 
importance through the study I have above mentioned, is the rainfall 
of which a vague notion was formerly held, without anybody taking the 
trouble to exactly define the influence which it exercised in the genesis 
of the disease. The investigations made by Dr. Terres demonstrated 
with logical rigour, that the indemia of typhus which is the scourge of 
our tropical city is governed in its progress by the pluvial precipita- 
tions^ and the observations collected in the course of many years, from 
the foundation of the Central Meteorological Observatory up to the pres- 
ent date, have demonstrated beyond a doubt, that the greater the' rain- 
fall the greater is the number of cases of typhus, and the lesser also the 
number of deaths from that disease, and vice versa. There is a 



' Etiology of Typhus, 2nd Edition, 1906, page 66. 
14 209 



210 



THE RAINS AND TYPHUS. 



similar proportion between the rainfall and the appearance of the epi- 
demics or the exacerbations of the indemia from time to time, which 
desolate our high cities, and especially the capital. The years when 
the rainfall is slight are followed by endemic exacerbations the vio- 
lence of which is in proportions to the scarcity of the previous rainfall. 
In the same manner there are still less probabilities of an epidemic of 

typhus when the rainfall has been good during the previous year. 

* * * 

The city of Mexico has just passed through an epidemic of typhus, 
which commencing in October, 1905, has not yet been stamped out, 
even though its force has been diminished. The object of this paper is 
to demonstrate how this epidemic constitutes a fresh proof of the 
etiological role which is filled by the rains, as regards typhus. In the 
iirst place, let us try to explain why the epidemic I refer to acquired 
such a development: The diagram, **A," which I present with this 
paper, will serve for that purpose. In this diagram I show^ by means of 
curves the general progress of the rainfall in our city, and which is 

DIAGRAM A. 



MONTHS] 


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The firm line shows the monthly average rainfall from 1877 to 1895. 
The dotted line shows the monthly rainfall for the year 1906. 



THE RAINS AND TYPHUS. 211 

itaken from the total monthly averages of the observations recorded in 
the Central Meteorological Observatory, from the year 1877 ^^ ^895.* 
as can be seen, the rainfall commences to increase in May, con- 
tinues increasing up to August, when it reaches its maximum, 
and then goes on decreasing until it reaches its minimum in De- 
cember. In August the total average rainfall is 123 millimetres, 
whilst in December it only reaches 3.8 millimetres, and the average 
total rainfall for the year is 581.9 millimetres. Well now, the year 
1905 was distinguished by the scarcity of rains, as is also indicated in 
the diagram I refer to, and the study of the corresponding curve 
teaches us, firstly, that the rains began to increase later than usual; 
-secondly, that the maximum precipitation was only observed in Sep- 
tember, and thirdly, the total rainfall for the year only reached 423.07 
millimetres, as can be seen from the following table : 

Months. Rainfall. 

January 5 .90 

February 2.50 

Jfciarch 19.20 

April •. . . . 6.50 

May 37.10 

June 26.02 

July 76.90 

August 54.10 

September 141 . 00 

October 48.10 

November 6 . 00 

December 1 .76 



J 



Total 423.07 millimetres' 

In view of the scarcity of the rainfall, it could have been foreseen 
from 1905, that the indemia of typhus would be exacerbated in an ap- 
preciable manner, much more than is ordinarily observed at the cessa- 
tion of the rainy season, which as before stated begins to decrease from 
September, and as a matter of fact this is what happened, as whilst in 
the month of September, 1905, there were 81 cases of typhus reported, 
in October there were 115, in November 155, and so on successively, 
as can be seen on diagram "B," which I also present with this paper. 
This diagram also indicates the progress of the epidemic during the 
year that has elapsed from October, 1905 (when it commenced), up to 
September last; and as can be seen there, the number of cases con- 
tinued to increase until it reached its maximum in March, and then 

• Etiology of Typhus, by Dr. Jos^ Terres, 2nd Edition, page 69. 
' Data taken from the Demographico Meteorological Bulletin of the Supreme 
Board of Health. 



212 



THE RAINS AND TYPHUS. 



commenced progressively to diminish from April on, with the exception 
of a slight setback in August. The exact figures are as follows : 

Months, No, of Cases. 

1905, October 115 

November 155 

December 23& 

DIAGRAM B. 



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The dotted lines refer to the cases of t>'phus observed from October 1905 to 
September 1906 inclusive. 

The firm lines show the total rainfall during the same months. 



1906, January . . . 
February .. 

March 

April 

May 

June 

July 

August ... 
September , 



612 
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ao9 

205 



THE RAINS AND TYPHUS, 21» 

This is the course that has been always followed more or less by 
the indemia, the exacerbation of which constitutes the epidemic; and 
in fact, the studies of Dr. Terres have shown us, that the disease gen- 
erally has its minimum in the month of September, that it commences 
to increase precisely in October and continues that increase until it 
reaches its maximum in March and goes on decreasing till September. 
But the very interesting proof, especially for the purpose of this paper, 
which we find in diagram "B," is the manifest and clearly appreciable 
influence which the rainfall exercises on the course of the epidemic. A 
glance, however rapid, at the lines which show the number of cases of 
typhus observed and the monthly rainfall, at once shows that whenever 
the rains are scarce, the number of typhus cases continues to increase, 
and especially if we note the opposition which exists between the vertix 
of the maximum of cases in March, which reaches such a high point 
and the low curve of rainfall for that month; and also the contrary 
proposition that whenever the rainfall is heavy, the number of typhus 
cases reported is notably diminished, which is the direct inverse between 
the maximum rainfall and the minimum of cases. 

There is another important consideration connected with the rain- 
fall in its relation to the epidemic of typhus which as yet has not 
really terminated, and which refers precisely to this circumstance; in 
other words, as already stated, the minimum of the indemia has been 
observed in September, and although in the present case, the same 
minimum has been observed in the month of September, 1906, it is to 
be noted that this number is much higher than for September, 1905. 
The diagram "C" appears to give some explanation on this point, as it 
shows the course of the rains in the present year of 1906 in connection 
with the general course, and from this comparison we reach the deduc- 
tion that the rains continued to be scarcer than common until August, 
when tKey reached a maximum superior to the average of that month. 
The rainfall therefore received a setback, or rather, its increase has not 
been rapidly gradual and progressive, as is the general rule, and this 
circumstance probably explains why the epidemic of typhus which 
started in October has not been entirely stamped out in the way that 
endemic is notably diminished in September, but rather that its effects 
continue to be felt, and now continues in an insensible manner with the 
exacerbation which the same indemia undergoes in the month of 
October. This exacerbation has already made itself felt, seeing that up 
to the moment of writing these lines (26th of October), there are 
already 212 cases of typhus reported for the month, whilst in the month 
of September last we only had 205 reported. 

What course will the epidemic run from October on? In order to 



214 



THE RAINS AND TYPHUS, 



answer this question, we may find some use for the data connected 
with regard to the rainfall during the present year, and which can be 
seen in the curves on diagram "C." . As already stated, the rains have 
continued scarce with the exception of the heavy rainfall observed in 
August, but in order to prove that scarcity, let us compare the total 
precipitation during the 8 previous months of 1906 with that observed 



DIAGRAM C 



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The firm lines show the average monthly rainfall from 1877 to 1895. (Terrcs.> 
The dotted lines show the rainfall for those months in 1906. 



during a similar period in the total annual average. The first amounts 
to 452.27, whilst the second rises to 47340. Now the fact that during 
the months which have elapsed of this year it has rained, although less 
than ordinarily, yet more than in 1906, seeing that in the whole of the 
latter year we only had 423.07 millimetres of rainfall, leads us to think 
that even though the epidemic has not been completely stamped out, 
neither will it again assume the proportions which it has had in 1906. 



THE BUBONIC PLAGUE. 

RULES FOR DEFENSE AGAINST ITS IMPORTATION AND FOR ITS SUPPRESSION 
IF DEVELOPED IN THE FORM OF AN EPIDEMIC. 

Dr. EDUARDO LICEAGA, Mexico, D. F., Mexico. 

Professor Robinson has done me the favor to request that I should 
present in this assembly some considerations relative to the bubonic 
plague, and I take pleasure in acceding to his request by utilizing the 
experience which I gained in the campaign undertaken for the pur- 
pose of stamping out the disease in the port of Mazatlan during the 
epidemic which developed in the month of December, 1902, and lasted 
till May, 1903, as well as in the measures which were adopted to 
prevent its spreading to the rest of the country. 

HOW WE DEFENDED OUR OWN AND FOREIGN PORTS AGAINST THE 
BUBONIC PLAGUE. 

We prepared the ports of Acapulco, Manzanillo, San Bias and Guay- 
mas in such a way that they would have sufficient resources to exercise 
vigilance over the vessels that arrived, to disinfect them as well as 
the goods and baggage and to destroy the rats and mice which might 
be found on board. We closed all the other ports of the Pacific coast 
against arrivals from Mazatlan, which were only allowed to enter 
such ports after being disinfected in one of the four ports above 
mentioned. The vessels which might arrive in Manzanillo, San Bias 
or Gua3rmas with confirmed or suspected cases of bubonic plague 
would have been sent without being allowed to enter to the port of 
Acapulco, in front of which is the island of La Roqueta, on which is 
a permanent lazaret which was prepared so as to receive any patients 
who might arrive; but, happily, we had no occasion to make use of 
that establishment as not a single person either sick or suspected of 
being sick was allowed to leave Mazatlan. 

The rules to which the vessels were subjected were as follows: 

If any vessel should reach any port with passengers who were 
known or suspected of having bubonic plague, she was sent to Acapulco 
as above stated. 

If the ship was under suspicion through having sailed from Mazatlan 
(where she would have been already disinfected), she was sub- 
ject to observation for ten days anchored at a convenient distance 
from the port, and on the expiration of that term a medical inspection 
was made of the passengers and crew, who were allowed to land 

215 



216 THE BUBONIC PLAGUE. 

if found healthy. The cargo was discharged and every package was 
carefully examined, so that if anyone of them was found to be in any- 
way broken, in such a way that fears might be entertained of its car- 
rying rats or mice in the inside, it was placed over a vessel full of 
boiling water and a jet of this liquid was directed into the inside of the 
package so as to force out the animals which might be inside and 
which necessarily would fall into the vessel with hot water, from 
which they would be withdrawn by means of tongs and incinerated. 

All rats and mice caught on the vessel would be destroyed and new 
disinfection made of the cabins and holds. 

As provisions and disinfectants became scarce in Mazatlan, these 
goods were brought from healthy ports. The vessel bringing them 
was detained at a long distance from the port and the delegate of the 
Supreme Board of Health went out there to receive the goods, but 
without communicating with anybody on board whilst the ship was 
dispatched with a clean bill of health. 

These precautions are set forth in the additions to Axt. 2 of the 
Maritime Regulations and serve to prevent the transmission of the 
disease by maritime traffic. 

In order to proceed in a similar manner to prevent the introduction 
of a transmissible disease, such as the plague, through the ports or 
frontier cities of a nation, it is indispensably necessary to reach an 
international agreement which would make it the duty of any country 
to declare the existence of the plague whenever found within its 
borders to all others with which it maintains commercial relations. 
Stipulations of this character are found in the Convention of Paris of 
December, 1903, between European nations, and already existed in 
Mexico and the United States, Peru and Costa Rica, under the Con- 
vention of Washington of the 14th of October, 1905, and it is to be 
hoped that they will exist between the other nations of the Western 
Hemisphere when the other republics give their adherence to the con- 
vention above mentioned. 

HOW THE FRONTIER CITIES CAN BE DEFENDED. 

In order to obtain this result there is no necessity of suspending 
traffic; it will be sufficient for the adjoining nations to bind them- 
selves to oblige the trains to stop on the frontiers so as to submit the 
passengers to a sanitary inspection which would only detain the sick 
or suspected, and make an examination of the goods under well de- 
fined conditions and also disinfect the passenger and box cars. 

In order to carry out these objects sanitary stations will be provided 
which will be equipped with disinfecting stoves intended to rapidly 



THE BUBONIC PLAGUE. 217 

purify the baggage ; with a chamber for carrying out the disinfection 
of the goods which may require it, and small lazarets, in which sus- 
pected persons can be kept perfectly isolated ; because confirmed cases 
will not be allowed to enter the country. 

A service would be organized to give notice to all the sanitary or 
executive authorities of the destination of all the passengers who 
appear immune at the time of the inspection, and those passengers 
will be kept under surveillance for ten days in the places of destination. 

MEASURES TO BE ADOPTED IN A TOWN ALREADY INVADED BY THE 

PLAGUE. 

The first precaution to be adopted is to obtain the departure from 
the town of the greatest possible number of inhabitants, but in order 
to prevent these from carrying danger to other parts a committee 
will be appointed to make a careful inspection of all who may depart. 
This committee will absolutely prevent the departure of sick or sus- 
pected persons and will send both to the places for isolation which 
are, referred to later on. It will enter in a book the description of the 
passenger and his destination, issuing to him a certificate in which 
those circumstances will be set forth with a declaration that he is in 
good health. These data will be communicated to the sanitary or 
executive authority of the traveler's place of destination or to the sec- 
ond sanitary stations which will be established at a little distance from 
the first and where the travelers from the invaded town will undergo 
a second inspection. Both the first and second stations will also serve 
to make an inspection of merchandise or baggage so as to prevent 
their carrying away rats or mice. In this Republic we obtained very 
good results from the establishment of third sanitary stations at points 
situated on the borders of the state of Sinaloa, as in this way w-e were 
able to prevent the spread of the disease to those states. Those in- 
dividuals who have been treated with the Yersin or Bedreska serum 
will be freely allowed to travel. 

Orders will be issued in the invaded town for the streets, squares, 
gardens, etc., to be swept and watered twice every day and for the 
sweepings to be daily incinerated. Special care will be dedicated to the 
cleaning of the slaughter houses, markets, etc., with a strong recom- 
mendation for the same preautions to be taken in the dwelling houses ; 
churches, schools, theaters and other meeting places will be ordered 
closed ; the city will be divided according to its topographical situation 
and area into as many districts as may be necessary, in order to place 
each one of them under the direct inspection of a physician with a 
sufficient staflf to prepare a schedule of all the inhabitants of the dis- 



218 THE BUBONIC PLAGUE. 

trict and make daily house visits so as at once to discover any person 
suffering from the plague or suspected of it, and in such cases make 
the disinfection of the house and even destroy it by fire, if it cannot 
be conveniently disinfected and is of little value, and also in order to 
destroy all the rats and mice that might be found there. 

A perfectly isolated hospital will be dedicated to the confirmed 
cases of bubonic plague. (In Mazatlan we established it on the island 
of Belvedere, near the port.) In the lazaret itself an isolated place 
will be reserved for the convalescents, where they will be kept for at 
least four weeks. 

Another hospital also isolated will be dedicated to the persons who 
are suspected of having the disease. 

All those persons who may have been in touch with the patient will 
be kept under observation for ten days in isolated camps outside of 
the city (in Mazatlan we established the camp on the hills of the Velo- 
dromo). In order not to injure those who are in this way isolated, 
they will be maintained during their stay in the isolation camps, and 
when they depart they will be given clean clothing and a certain amount 
of money so that they can commence work. 

It is necessary to order the destruction of the rats and mice by all 
known methods until they are entirely exterminated. In Mazatlan 
and in its neighborhood permanent committees were appointed to 
examine the rats and mice so as to discover those that might be sick and 
immediately destroy them by fire. 

The resource which gave the best results as a preventive against 
the disease, was the application of the Yersin and Bedreska serums. 
In the small villages of Villo Union and Siqueros, close to Mazatlan^ 
where foci of the epidemic began to appear, they were completely 
extinguished by the application of that serum to all the inhabitants of 
those villages. 

As it was not possible to find suitable premises everywhere for the 
establishment of lazarets and sanitary stations, they were improvised 
in private houses or industrial establishments. 

All the administrative authorities willingly submitted themselves 
to the sanitary authorities who directed the campaign ; a local charity 
board was organized which received the donations that were collected 
from all parts of the republic by a national committee with head- 
quarters in this capital. 

All these measures if rigorously carried out can stamp out the 
bubonic plague, as was done in Mazatlan, preventing its spreading to 
the rest of the Republic and to the national and foreign ports, and 
finally stamping it out in our territory. 



THE "MAL DEL PINTO" FROM A HYGIENIC PIONT OF 

VIEW. 

Dr. JESUS GONZALEZ URUENA, Mexico, D. F., Mexico. 

In the low and hot lands ol the Mexican Republic, we have a dis- 
ease which not only belongs to this country, but is also found to exist 
in others of Central and South America, and which is of the greatest 
interest to all students of hygiene, in view of the endemic, parasitic 
and contagious character of the dermatosis, combined with the re- 
pulsive deformity which it produces, its easy curability during the first 
period of its evolution and the very serious character which it gen- 
erally assumes when abandoned to itself. 

It is characterized by the production of disorders in the cutaneous 
pigment, which are revealed by the appearance of patches of different 
colors, blue, red, white, etc., which make their appearance over a 
large area of the outside teg^ument but respect the hairy surface. These 
patches are accompanied by a furfurfaceous scaling, by an oily hyper- 
secretion and a characteristic bad smell which renders the patients ex- 
tremely repugnant to other persons. The disease sometimes assumes 
the form of ulceration. 

In the central and southern states of Mexico the disease is called 
"Mai del Pinto,'" in Tabasco and Chiapas, "Tina,'" in Michoacan and 
Jalisco, "Jiricua;" in Colombia, "Carate," a name which the French 
have adopted. The Germans call it "KarataAeck,-" Dr. Leon "SyP- 
hyspyloria thelodermica;" Dr. Ruis y Sandoval "Dermatomicosis/^ 
whilst the ancient Mexicans called it "TzdzayanaHztle" 

The authors who have described this disease do not agree on alt 
its characteristics. They all agree that there are cases in which the 
blue patches predominate, in others red and in others white ; but some 
consider them different forms of the disease, whilst others believe that 
they are nothing more than different stages of its evolution. When 
the stains of different colors are found on the same person they will 
constitute the mixed form of the "Pinto,*' for those who consider them 
different, or otherwise the simultaneous presentation of its multiple 
phases for those who so describe them. 

The same disagreement exists with respect to the nature of the 
disease, while all have agreed on its parasitic origin, almost every mod- 
em author has thought that he discovered a different pathogenic 
agent. 

In the scales obtained by scraping Dr. Ruiz y Sandoval discovered 

219 



220 THE "MAL DEL PINTO." 

some spherical or ovoid bodies of six to twelve millimetres, at first sight 
black and transparent under certain lights, accompanied by remains 
•of tubes with a length of eighteen to twenty millimetres and a width 
of two millimetres. He called this fungus "Microsporon Hidalgo- 
ense" Dr. Iris described a filament like a white ribbon, without 
chlorophyle, transparent, with some granulations and thicker in some 
points. He has left this unnamed and considers the disease similar to 
a dermatomicosis. 

Dr. Gavino has believed that he discovered a micro-organism that 
in the subdermic cellular tissue appears in the form of a pigmented 
'Conglomerate, composed of innumerable micrococci, which when culti- 
vated in solid and liquid media produced cerbacilli which subdivide 
until they return to their primitive form. Dr. Montoya of Colombia 
"believes that the Karate of his country is produced by Aspergilloid 
fungi of different species for each variety of Karate, the pigment being 
included in the pathogenic fungi which gives to each its own color. 
Thus the cultures obtained from the scales of the black violet Ka- 
rate are of a brown violet color ; the Asperguillous of the blue is of 
the same tint and the black variety is caused by a spore of the color 
of charcoal. 

In order to strictly describe the pathogenic action of the different 
micro-organisms above described, we require proof of the experimental 
inoculations for the reproduction of the disease, as those made by Dr. 
Montoya in rabbits are not convincing. 

It is believed that certain insects such as the "gegen" a mosquito 
of the simulium genus, the culex and bugs of the acanthia genus may 
be responsible for the propagation of the evil, and the author I have 
mentioned, by means of a culture of the simulium mosquitoes, has ob- 
tained fungi of the black and violet Karate. 

Dr. Montoya has also found those parasites in the stagnant waters 
of the gold mines in his country, in some cereals and in many plants, 
and this would explain the frequency of the dermatosis in the miners 
and field laborers who go about their work in a semi-naked condition, 
and may thus be inoculated with a disease through the scratches of 
thorns, cacti, etc., which may have been infected with the ftmgi or 
^hen the bruised skin is wet with contaminated water. 

* * * 

The prophylaxis of the disease, which is the culminating point of 
hygiene, cannot be established on a solid basis until we have an exact 
knowledge of its etiology and pathogeny; but we can at once take 
those measures for the general protection of the individuals as well as 



THE "MAL DEL PINTO." 221 

of the community, which are already sanctioned by the experience of 
other similar disorders. 

The individual prophylaxis should consist in tEe proper treatment 
of those who suflFer from the disease and whom we call "pintos," who 
form the foci for the issue of the causal agent of the disease. They 
should be subjected to frequent ablutions, their personal goods should 
be sterilized, their clothing should be periodically disinfected and all 
the bandages, etc., which they employ should be destroyed by fire. It 
is an absolute duty to warn those persons who surround the patients^ 
of the dangers of contagion, exhorting them to take the greatest pre- 
cautions with respect to their bodily cleanliness and hygiene. They 
should be specially recommended to protect the skin against any- 
thing that could scratch them, against the sun, all kinds of thorns, 
avoiding waters from the mines, and the stings of insects. By these 
precautions they prevent the germs from introducing themselves under 
the skin. 

The suppression of the disease in its inception would be another 
prophylactic measure of great efficacy, as the cure of the "Mai del 
Pinto" is easy when it is confined to a few and recent patches, but on 
the contrary is very difficult when it is old and generalized. 

The measures of protection for the community are less easy of re- 
alization in view of the impossibility of completely isolating the per- 
sons who are attacked, when dealing with such a wide spread endemia. 
Nevertheless, by the foundation of hospitals and dispensaries dedicated 
to the cure of those suffering from the disease in its very foci we 
would make a great advance in that direction. The establishment of 
agricultural or industrial colonies under humane and scientific man- 
agement would greatly co-operate to the same end. 

CONCLUSIONS. 

1. There exists in the Mexican Republic a skin disease which is 
known as "Mai del Pinto," endemic in many low lying states with 
a damp and hot climate, which is characterized by the appearance of 
patches of different colors such as blue, gray, white, etc., scattered 
over the exterior tegument. 

2. Authors do not agree in its clinical description; but they all 
agree that it is contagious and parasitic, although without having 
identified the pathogenic microorganism. 

3. Certain insects, such as the mosquitoes (culex and gegen) as well 
as bugs, may be the propagators of the disease, and also the stagnant 
waters from the mines and certain cereals and plants. 



■222 THE "MAL DEL PINTO." 

4. This propagation is favored by bruises in the skin, by prolonged 
exposure to the sun, the scratches caused by thorns, the stings of 
insects, and maceration in water. 

5. In attempting to extinguish the evil in those places in which it 
is endemic, the following measures should be recommended : 

A. That the Federal Government of Mexico should appoint a med- 
ical commission in which there would be at least one specialist on 
skin diseases, in order that it might give an exact clinical description 
of the "pinto" and its producing agent, after a careful study in the 
foci whence it originates. 

B. That the Supreme Board of Health of Mexico should prepare 
and distribute through the governors of the respective states, a set 
of instructions regarding the precautions to be taken against the dis- 
ease, and which instructions will be founded on our present informa- 
tion. The sanitary and police authorities would watch over the fulfill- 
ment of the measures advised in these instructions. 

C. That the same governors should be shown the urgent necessity 
of founding hospitals and dispensaries in those places for the exclusive 
cure of the "pintos." 

D. That the same officers should be shown the immense advant- 
ages that would be obtained for the suppression of the disease, by the 
isolation of all persons attacked in agricultural or industrial colonies 
humanely and scientifically organized. 

In order to carry all the measures above proposed to a successful 
termination, a special section, annexed to the local board of health, 
should be appointed in the capitals of the states in which the "pintos" 
are found, who would be commissioned to undertake a real campaign 
against the disease. In order to give uniformity to all this work the 
Supreme Board of Health of Mexico would have the central direction 
of all. 



AMETROPIA IN ITS RELATIONS TO OCULAR HYGIENE. 
Dr. JOSE RAMOS, Mexico, D. R, Mexico. 

A knowledge of ametropia is of great importance to the student 
of hygiene, because if neglected it may be the cause of serious dis- 
orders in the organ of vision. The manner in which the various vices 
of refraction are distributed in diflFerent countries, their comparative 
frequency in different races and in different classes of society, the 
influence exercised on these visual defects by the habitual occupation, 
by the special medium in which a person lives and otHer circumstances, 
are other points that require study and to which many investi- 
gators who make a specialty of ocular hygiene have dedicated special 
efforts. 

In their constant evolution towards progress, the civilized com- 
munities have observed with astonishment that the number of cases of 
ametropia show a tendency to increase. This does not in any way 
imply that any blame can attach to the uninterrupted onward march 
of civilization, or that it can be accused of producing these important 
evils. Although it is true that a great part of the knowledge which 
man requires in order to be able to successfully struggle under mod- 
em conditions is acquired by study and by the use of his eyes, often 
for a prolonged period, and sometimes when they are unduly fatigued, 
it is also true that science which is so difficult to acquire furnishes ade- 
quate means to prevent those accident^ which might be caused through 
its acquisition under ill-understood conditions. 

Modem methods of education differ in a radical manner from the 
old methods, not only as regards the didactic methods, but also, and 
this is of great importance, with regard to hygienic methods that now 
form the basis of all kinds of instruction. In former times, the masters 
only attended to the production of learned men and occupied themselves 
very little with the thought that on completing the university course 
the student left the instiution exhausted by his excessive and often use- 
less studies, broken in health and energy and therefore incapable of 
producing any practical result through the knowledge he had ac- 
quired. 

Things are different now, as every attempt is made to procure the 
physical development side by side with the intellectual, thus obtaining 
healthy as well as learned men, properly prepared to carry on the strug- 
gle for life. It is desired that the whole of the organs should be pre- 

223 



224 AMETROPIA IN ITS RELATIONS TO OCULAR HYGIENE. 

preserved without any loss of their faculties and all in a fit condition ta 
fulfill their respective functions at any moment they are called upon. 

Very little notice was taken in former times of the visual organs ; they 
were worked without pity and without any scruple whatever, to such 
a degree that it often became impossible to continue utilizing their 
services for the purpose ol study. Without taking into account the state 
of the refraction in each case, and without obtaining the consequent 
improvement, neglecting the most trivial precautions relative to the 
light and to the duration of the work, real diseases were brought on 
that at times became irreparable. Ocular hygiene, like a beneficent 
providence, has liberated many pupils from these fearful accidents by 
permitting them to complete their studies under favorable conditions 
or preventing their continuation, when on account of important ocular 
defects they could not do so without great sacrifices. 

A knowledge of the state of the refraction in the eyes of every 
pupil is a first necessity. Observation teaches us that the different kinds 
of ametropia are unequally distributed in every country, both as regards 
the total number, as well as the relative proportion of each class. In 
Mexico, the relative frequency of defective refraction differs greatly 
from that which is observed in other countries. I have studied this 
point and in an international congress I have presented some statistics 
on the subject. In this I was greatly assisted by Drs. Uribe Troncoso 
and Montaiio. In a subsequent important work, the first reached simi- 
lar conclusions, adding a considerable number of cases to those which 
appeared in the first statistics. My subsequent practice has led me ta 
confirm my ideas, especially through what I have observed in an 
important school which has hundreds of pupils and in which I have for 
many years held the office of oculist. My private clientele has since 
that date furnished me opportunities to observe thousands of ametropes, 
not only in children but also in adults, who come from this city 
and from different states of the Republic, and through whom I have 
obtained new and abundant data, all of which corroborate my opinions. 

Hypermetropia, in its different varieties, is comparatively commoner 
in Mexico than in any other countries, whilst myopia is cwnparatively 
rarer. This undoubtedly depends on ethnic influences, as amongst three 
hundred pupils of the pure Indian race I only found one near-sighted, 
having found amongst them two hypermetropes. Amongst the half 
breeds, myopia shows a tendency to become more frequent, but with- 
out reaching the high figure that is found in European countries and 
more especially in Germany. 

Amongst the two thousand pupils of the primary and secondary 
schools, who belonged to the half breed race, my statistics show a pro- 



AMETROPIA IN ITS RELATIONS TO OCULAR HYGIENE. 225 

portion of 4.4 per 100 of myopes and three per hundred of hyper- 
metropes, with 0.50 per hundred of cases of astigmatics. 

In the pupils of the upper school the figures are very different, as 
out of 500 whom I examined, there were nineteen per cent, of myopes, 
six per cent, of hypermetropes, and 3.2% of astigmatics. These num- 
bers very clearly demonstrate that in proportion as the studies are 
deeper and require a more sustained exercise of the visual organs, the 
proportion of myopes increases in a very appreciable manner. The 
statistics presented by Cahn relative to the pupils of Breslau in Ger- 
many, show much higher figures as regards myopia, seeing that amongst 
the children of the elementary schools he found a proportion of 7 
myopes per 100; of 10 amongst the pupils of the middle class, and 
of 26 amongst the students in the upper schools. 

Even though the figures presented by Dr. Uribe Troncoso in his 
last work do not entirely agree with those of my first statistics, to which 
he efficiently contributed, it is to be noted that the conclusions are 
similar. Tn the students of the normal school he found up to 10% of 
myopes, a proportion similar to that which I found amongst the pupils 
of the superior schools. 

It will be noted in both tables that this ametropia is less frequent 
amongst us than in other countries; that the hypermetropia is com- 
paratively more common, and that it progressively decreases from the 
pupils of the elementary schools to those of the upper schools, and that 
myopia increases in inverse proportion. 

A great deal has been done of late years to place pupils under the 
most favorable hygienic conditions so as to prevent the development 
and progress of ametropia, which is undoubtedly brought on by the 
continuous use of the eyes in the course of their studies. 

Both in Europe and America great improvements have been made 
in everything relating to the lighting and furniture of schools as well 
<is to the form of the letters, or in one word, in everything that could 
save the overwork of the eyes on the part of the students, and in these 
points the progress made is a real triumph, and really leaves nothing 
to be desired. Nevertheless, the ametropes not only continue to appear, 
but even tend to increase with the progress of civilization. 

As regards the students of the upper classes, the evil is not remedied 
except to a slight degree, however good may be the conditions of the 
schools, as after the school hours are over, the pupils continue their 
studies at night in their own houses, and very often to excess, especially 
as the time approaches for the examinations. Some of them make use 
of very poor light and also adopt the bad custom of studying in bed. 
The rules of individual hygiene are neglected, and sooner or later this 
15 



226 AMETROPIA IN ITS RELATIONS TO OCULAR HYGIENE. 

also produces unfavorable results. It is necessary to warn the pupils 
that if they continue these undesirable practices, they expose them- 
selves to serious danger, which later on may be difficult to avoid. It is 
not sufficient to improve the conditions of the schools; all hygienists 
have studied the matter, and as far as this goes, they have reached 
really satisfactory results. 

It is necessary to give attention to another problem of an essential 

character, and which requires the best possible solution ; I refer to the 

dioptrical correction of the ametropia from the moment it is discov- 

, ered, and to the fact that the discovery should be made in due time and 

not left to chance. 

In dealing with the high degrees of ametropia this discovery is of 
great importance, as when a boy is too short sighted, the parents and 
the masters at once can see that his vision is imperfect; that he is 
unable to read the blackboard and requires to approach very closely m 
order to distinguish objects with clearness, and this entirely anomalous 
condition requires consultation with a competent oculist so as to at 
once remedy the evil. 
{^ The same thing does not happen with slight ametropies, which do 
not show themselves at once, but on the contrary may pass unper- 
ceived by persons who are not observant. 

A difficulty in defining objects, vague pains in the head, occasional 
running at the eyes or slight conjunctiva injections which appear peri- 
odically ; a holding of the head in a vicious position at times in read- 
ing or writing, and at others an involuntary and instinctive aversion to 
study on account of that uneasy feeling, which gives the student a bad 
character for laziness. I have known several students under such 
circumstances, who after having continued their studies with slight 
advantage, have shown when their eyes were inspected, symptoms of 
ametropia (h)rpernietropia or astigmatism), which once corrected al- 
lowed tiie pupil to continue his studies without any sacrifice and to his 
great advantage. 

From this it results that a conscientious examination of the state 
of the refraction is indispensable with each pupil, when he matricu- 
lates in the schools. This should also be done in private schools and 
not limited to those which are maintained by the nation. 

Our progressive and liberal government has medical inspectors who 
are charged with the physical selection of those who desire to enter the 
national schools. It would be desirable that a similar examination 
could be made of the pupils in private schools, and that the state should 
also supervise the matter in which instruction is given, taking care that 



AMETROPIA IN ITS RELATIONS TO OCULAR HYGIENE. 227 

the programs and methods of teaching are in accordance with the same, 
even in private institutions. In this manner, the officially appointed in- 
spectors would attend the examinations of those institutions, in order 
to ascertain the results of the scholastic year, and to obtain a certainty 
that the laws were complied with, whilst in the same manner, a cer- 
tainty ought to be obtained that the laws of general hygiene are also 
carefully observed in every school. 

As in order to keep a proper watch over the organs of sight, it is 
indispensably necessary to possess an extensive practical knowledge of 
the subject, it would be desirable that this delicate office should not 
be entrusted to persons who have only a general knowledge of medi- 
cine, but to specialists who have a familiar knowledge of this branch. 

The diagnosis of the existence, nature and degree of a case of ame- 
tropia is not always a very easy matter, even to one who is accustomed 
to that study, and the practical prescription of correcting lenses is often 
still more difficult, and very often requires a long series of observa- 
tions. There are many ametropes who require lenses of two classes, 
dome for distance and some for close sight. It often happens that 
the two eyes are entirely unequal from the point of view of refraction, 
and this makes the prescription still more difficult. 

All of these difficulties are greatly increased when any ocular com- 
plication exists, and in such cases the analysis must be made of what 
the latter consists of, and of what is due to ametropia. 

It is true that there are professors and parents who are extremely 
careful and at once consult the specialist whenever they think they have 
found anything abnormal in the eyes of their pupils or children, but 
I have already stated that the defects of refraction do not always pre- 
sent themselves in an appreciable form, but on the contrary, are in- 
sidious and resemble a very different condition. 

Besides these we find other persons who are highly apathetic, and 
can witness an abnormal condition of the eyes of the children without 
taking any particular notice. 

I must speak of another circumstance, which was lately referred to 
in the Mexican Opthalmological Society, even though it is from an- 
other point of view. I refer to some opticians who do not confine them- 
selves, as they ought, to the making and sale of lenses in accordance 
with the prescriptions given, but claim to make inspections for them- 
selves and to correct ametropia as may appear to them best. Many 
persons find it more convenient to apply to an optician who makes 
an examination, than to consult an oculist who may at times require 
several examinations and observations in order to give a conscientious 



228 AMETROPIA IN ITS RELATIONS TO OCULAR HYGIENE. 

prescription. There can be no doubt that the option sometimes gives 
relief, at least apparently ; in a case of compotmd myopic astigmatism^ 
for example, they may correct as far as regards the myopic, leaving 
the astigmatism unrelieved, and this undoubtedly somewhat increases 
the clearness of the vision, although without making a complete cor- 
rection. On the other hand no opinion of the eye can be formed which 
is trusted to the care of these men, as a live organ, and possibly 
afflicted, seeing that the necessary knowledge is not obtained. It may 
be looked upon at the utmost as common optical device which in 
many ways differs from others of the same kind. Certain agents can- 
not be employed, such as the cycloplegies, by these persons, the previous 
use of which is necessary in certain cases; and in one word, they act 
like persons who are more or less instructed in optics, but not in the 
science of the sight. In the United States, the opticians applied to the 
state legislature of New York to authorize them to exercise their 
profession under the title of '^Optometry." They did not gain their 
object and very justly so for the reasons that I have above stated, and 
they were shown that even though they might understand optics, they 
have no knowledge of ocular anatomy, physiology, and neither do they 
know how to employ certain drugs which might be required in order 
to diagnose and properly correct certain defects of refraction. 

We have no law whatever that would prohibit the opticians from 
making ocular inspections or prescribing lenses, and it would not be 
easy to convince the public of the evils of such a practice, as the 
opticians freely advertise themselves and promise great advantages. 
The warnings would be little studied, and it might even happen that 
they would be thought inspired by ideas by no means scientific or 
humanitarian. 

If we cannot obtain for the public in general the benefits of such a 
law, it is possible to obtain them for the students. These as well as 
the other advantages that I have referred to can be obtained by means 
of a medical inspection, carried out by competent specialists, and 
would have the power to stop the matriculation in superior schools, of 
those who combine with the ametropia other serious disorders of the 
eyes, such as the so-called progressive myopia, complications of the 
retina, or of the chorioid, or others of the same character. 

fti view of the above, I think it right to propose that attention should 
be called to the propriety of appointing eye inspectors in sufficient 
number to watch over the ocular hygiene of the schools. The special- 
ists who might be designated would occupy themselves amongst other 
matters, with the diagnosis and correction of the ametropia which is so 
common amongst students, keeping careful statistics, and extending- 



AMETROPIA IN ITS RELATIONS TO OCULAR HYGIENE. 229 

their jurisdiction, not only to the national institutions, but also to the 
private colleges, and doing their best to bring about an agreement 
between the respective regulations and the liberal spirit of our laws. 

In this way we would avoid the danger of the culture of the people 
being counteracted by the injuries received through the organs of 
vision. 



TRACHOMA IN MEXICO. 
DR. LORENZO CHAVEZ, Mexico, D. R, Mexico. 

There is no subject in ophthalmology which has given rise to so 
much discussion and study as trachoma. 

Although it has been very raf e in Mexico and therefore little known, 
since the last meeting in this capital of the Second Pan-American Med- 
ical Congress held in November, 1S96, opinions have been divided. 
Some think that trachoma does not exist in Mexico except among the 
few foreigners who bring it in from abroad ; that it is not contagious 
because the pathogenic agent, similarly to that of yellow fever, com- 
pletely loses its contagiousness at a height like ours of 2,340 meters 
above sea level, and that it has never appeared among the indigenous 
races of this coimtry. 

Others, like ourselves, have maintained the contrary opinion, namely 
that trachoma does exist in Mexico, and also that it is contagious. 

For my part, I have founded my opinion, not only on the cases which 
I have assisted, but on the statistics carefully registered in the Oph- 
thalmological Hospital since its foundation in the year 1876, and which 
give a cipher of 44,200 patients. The eminent masters who have pre- 
ceded me as directors of this hospital and my fellow physicians who 
have substituted me several times while absent in Europe, have all diag- 
nosed granulations or trachoma and in many cases have noted down 
complications of pannus, ulcers, entropion, synoblepharon, etc., which 
irrefutably prove the existence of trachoma in Mexico. 

Contagion has been very much discussed everywhere, but it is today 
imiversally accepted, based on the following facts; 

1st. Experiment: Sattler inoculated a man with the contents of a 
granulation entirely foreign to suppurative complication and produced 
granulated conjunctivitis. Hess presented, last year, to the Ophthal- 
mological Society of Heidelberg, a monkey (Papion) in which through 
the inoculation of trachoma, granulations of the conjunctiva had been 
produced. 

2nd. Cases of professional contagion, valuable as being Sattler's 
experience : The eminent German oculists Manz and Homer received 
contagion from their patients. Quaglino, the celebrated Italian oculisti 
received some of the secretion from granulation on his ccmjunctiva ; he 
was attacked with trachoma and it lasted until his death. Dr. Cuignct, 
of Paris, who discovered skiascopy, lost his eye in this way. Dr. Santos 
Fernandez refers the following case: "A practitioner of the Charity 

230 



TRACHOMA IN MEXICO, 231 

Hospital in Havana took to the hospital a young woman, who mis- 
takenly, he thought was granulated, and turned up her upper eye-lid 
to cure it. Finding her perfectly healthy, on discovering his mistake, 
he allowed her to go, but the simple contact of his fingers was enough 
to develop the granulated conjunctivitis which happily was afterwards 
cured." 

3rd. The clinical observations that have been published of con- 
tagion in families, schools, etc., are numerous. 

Now, does contagion occur in all altitudes and among all races ? In 
the Tenth International Congress of Medicine, Chibret declared that 
the countries situated more than 200 meters above sea level, and some 
races like the Celts, were immune from trachoma. S. Burnett made 
the same statement with regard to the black race. 

Subsequent researches have come to prove the falsity of these as- 
sertions, but perhaps on account of their not being sufficiently known, 
it has happened, as we have already seen, that some of our esteemed 
colleagues regard Mexico as a country endowed with immunity on ac- 
count of its altitude, and therefore I shall speak at some length on 
this point. 

The country which has served as a basis for the error regarding im- 
munity in certain altitudes is Switzerland. Now, the roost remarkable 
study known on trachoma in Switzerland is Dr. Bauer's, published in 
1900, in which we read the following conclusions: "Switzerland, a 
privileged country, a model of immunity against trachoma, situated 
more than 400 meters above sea level, has seen its children suffer from 
trachoma contagion; and if this contagion is infrequent, and if tra- 
choma has not been propagated, it is due not to its altitude, but to the 
good, healthy conditions of the country and to the fact that the Swiss 
do not mix up intimately with those attacked with trachoma, who 
immigrate principally from Italy, but this trachoma-immigration is a 
very great peril which authorities and physicians ought to take into 
account. 

Let us also see what happens in other countries of greater altitude. 

In the mountainous districts of Hungary Dr. Simon PoUacsck pub- 
lished the following observation in December, 1900: "As was the 
case in the greater part of the heights and mountainous districts, the 
county of Trencsen did not suffer the great trachoma invasion which 
took place in Hungary and in all Europe with the return of Napoleon's 
armies from Egypt in 1802. Still, since the year 1870, a number of 
the inhabitants began to descend from the heights, engaging themselves 
as farm hands during the spring, in the valleys and plains situated 
towards the south, and which were infested with trachoma. Then this 



232 TRACHOMA IN MEXICO, 

extraordinary fact began little by little to make itself evident: The 
poorer people of the mountains, who were the principal source of this 
periodical immigration, were invaded by trachoma, while the richer 
ones, situated at lower altitudes, and therefore nearer to the infested 
plains, remained immune or almost so. The northern elevated dis- 
trict of Zolna number 32 villages attacked by trachoma, whilst the 
southern, lower district of Trencsen is completely free from the disease. 
Out of the 258,769 inhabitants of the county, according to official sta- 
tistics, 4,000 are trachomatous, but without any doubt the real num- 
ber is much greater, almost double this figure, which increases remark- 
ably every year in spite of all the measures that have been taken." 

Something similar has happened in the Tyrolese Mountains. Dr. 
Emil Bock has stated : "Trachoma exists in the sporadic and endemic 
form in Carniola. In the city of Laybach, it is in the sporadic form, 
with the exception of epidemics in two orphan asylums and in the 
house of correction. Upper Carniola traversed by high mountains is 
not free from it. Contagion is proved by transmission of trachoma to 
localities where it does not exist by persons coming from places where 
the disease does exist. Example ; At Gottschee by traveling merchants, 
who leave Gottschee, and after wandering about the world, return with 
trachoma and communicate it to their relatives. In southern Carniola 
trachoma has been imported in part by miners who have returned from 
America, where they have worked, or by carpenters returning from 
Egypt. In the eastern part of Upper Carniola it comes probably from 
Lower Syria (the disease is endemic at Leutsch). The western side 
of Upper Carniola has been probably contaminated from the coast." 

Van Milligan has stated: "The opinion of some authors that tra- 
choma is not propagated in countries of a higher altitude than 200 
meters seems to me to be erroneous. The frequency of trachoma in the 
high plateaus of Asia Minor (Erzeroum, Armenia, Van, etc.), of Per- 
sia and of Central Asia, of Algeria, of Libia, indicate that this disease 
may be propagated in localities situated from 1,500 to 5,000 meters 
above sea level. Dr. Treacher Collins, who lately traveled through 
Persia, assured me verbally that trachoma was very common in all of 
Yran, and especially so in the little villages situated on the highest 
mountains of Persia. It was while crossing the chain of Koich-i-Kena, 
between Chiraz and Yspahan (in Faharistan) that he observed the great 
frequency of trachoma. The poverty and uncleanliness of the inhabit- 
ants of these villages are beyond all description, and it is in just such 
countries that trachoma spreads with the greatest facility. These are 
trachomatous countries." 

At the International Congress of Medicine assembled in Paris in 



TRACHOMA IN MEXICO. 233 

igoo, Prof. Ed. Brusch expresses himself as follows in the second 
conclusion of his study : "Trachoma attacks ali races and all nationali- 
ties. Its development is in proportion to the anti-hygiene in each case, 
without giving preference to any ethnographic group. The altitude 
above sea level of itself exerts no influence, as trachoma exists in 
Algeria as high as 1,200 metres and more above sea level." In our 
neighboring republic to the north, as may be seen in Norris and Oliver's 
System of Eye Diseases, published in 1900, trachoma exists in Denver 
at an altitude of 5,000 feet, and in Colorado Springs at that of 10,000 
above sea level. Lastly, in our own country, a patient who was pre- 
sented by one of our colleagues in the session held by the First Pan- 
American Congress on the 19th of November, 1896, had contracted the 
disease at Toluca, that is 2,630 meters above sea level. 

The above facts seem to be sufiicient to demonstrate that trachoma 
can develop in altitudes much higher than that of our capital. 

Let us now go into the influence that it has on races. 

It has been asserted that the Celtic (Chibret) and the black (S. Bur- 
nett) races are immune. 

Prof. Hischberg, of Berlin, states the following: "There is no im- 
munity against trachoma. Race has no influence upon it. It has been 
stated that Celts are immune, but the purest Celts, who are the Irish, 
are attacked equally in their old and in their new country, the United 
States of America. The Norwegians similarly contracted the disease in 
America. The blacks in their birthplaces do not suffer trachoma, 
as is proved by examining those recently arrived from the Soudan. 
Among the blacks in the United States trachoma almost does not exist, 
but that is due to the fact that they live separated from the whites. 
Among the blacks in Brazil, in Turkey and in other countries that pro- 
fess the religion of Mahoma, the proportion of trachoma cases is very 
great. (700 per 1,000, according to V. MulHngen.)" 

This opinion of Hirschberg's is today almost universally accepted. 

Some physicians have tried to explain the so-called immunity of the 
blacks. Stevens, by saying that they are cataphoic, Fukala by saying 
that their lachrymal canal is much larger than other people's, and 
others attributing it to their extraordinary cleanliness. The truth of 
the matter is that such immunity does not exist. 

Does trachoma exist among the indigenous classes of the Republic of 
Mexico? 

While dealing with this subject at the Ophthalmological Society in 
October, 1903, I stated that I had treated several pure bred Mexican 
Indians attacked by trachoma, and at the time had one in actual treat- 
ment. Since that time I have come across more such cases, the greater 



234 TRACHOMA IN MEXICO, 

part of which have come from Texcoco. Almost all have presented 
more or less advanced affections of the cornea, entropion, blepharifi- 
mosis or other complications which indicate the length of time they 
have been suffering and which leave no room for doubt as to the 
diagnosis. They only come for consultation once or twice, returning 
home the same day. Owing to their natural indolence or their poverty^ 
they do not present themselves at the proper time nor as opportunely 
and as frequently as they should in order thus to obtain a radical cure. 
Naturally it is among these people that we have had occamn to ob- 
serve the greatest number of complications. 

As we have already observed that trachoma may be contracted at any 
altitude above sea level and by all races, let us now study the influence 
of the known causes of its propagation. 

It is universally acknowledged that the want of personal cleanliness, 
the want of hygiene, and the crowded gathering of a great number of 
individuals in reduced dwellings favor the development of this dis- 
ease. These factors are indisputable, but in order to exert their influ- 
ence, the primum novens must naturally exist, that is the agent of con- 
tagion, or be it the trachomatous individual, who must come into inti- 
mate contact with the healthy ones, in order that he may communicate 
his disease, making use of the same article of personal use or of the 
tools which he handles ; in one word, he must mix up intimately with 
others. 

In relation to other countries foreign immigration to Mexico has 
been small. As regards the nationality of the trachomatous patients 
that come to us, we may say that the greater part of them have been 
Spaniards, and that in few numbers, because Spain is not a country 
eminently trachomatous as is shown by its statistics (io% suffer from 
eye diseases), and by the observation made in Cuba by Dr. Santos Fer- 
nandez to the effect that the inflow of immigrants into Havana proceeds 
mostly from Spain and Palestine and in spite of the Turks not immi- 
grating in large numbers, among them there have appeared more 
affected by it than among the Spaniards. That scarcity of tracho- 
matous immigrants and their not heaping up together in large masses, 
their not having mixed up intimately with the dirty, anti-hygienic lower 
classes, are the real causes of our having been freed from the propaga- 
tion of trachoma. 

The following have been stated to be efficient or at least favorable 
causes for the development of trachoma: 

1st. The increase in the density of population. 

2nd. The felling of woods which has occasioned the remarkable 
increase of dust in some countries of Southern Africa, in Syria, Pales- 



TRACHOMA IN MEXICO. 236. 

tine, Persia, Hungary and others. The dust inflames the conjunctiva, 
making it smart and itch, causing the patient to rub his eyes with his 
hands ; his fingers become infected and infect all the object with which 
they come in contact. (Zien Zulzer.) 

3rd. The scarcity of water in the town. Dr. Alamino in the De- 
partment of Girgenti has been able to demonstrate that trachoma does 
the most havoc in those places where water is most scarce. All these 
causes have existed in Mexico for some years back, and although the 
one last named will shortly disappear, at present we are still suffering 
from it. 

Summing up: Neither the altitude nor the race can free Mexico 
from an epidemic of granulations. On the other hand there exist here 
the conditions which I have just mentioned, favorable to its develop- 
ment, and therefore it is to be feared, as I had occasion to announce 
three years ago in the Ophthalmological Society, that if the ordinary 
circumstances in which epidemics appear should present themselves in 
Mexico, such as war, famine, etc., which produce the heaping up of the 
masses, the intimate mixing of the sick with the healthy and the want 
of hygiene, we would soon see that the former, in spite of their small 
number would soon infect the latter. 

Although fortunately we have had neither war nor famine, my 
fears have been realized. 

In the month of July of the current year, a young man with tra- 
choma came to me for consultation at the Ophthalmological Hospital. 
In the following month of September the same young man returned, 
bringing with him two of his schoolmates afflicted with the same dis- 
ease ; and during that same month and the following one, new cases 
of the same kind and from the same source, came under by notice. 
Investigating into the conditions in which those youths lived, we were 
able to ascertain the fact that over 400 slept in only four dormitories, 
in each of which the beds were almost touching each other, owing to 
the space being very much reduced ; that, after washing they all made 
use of one big single towel, and not infrequently the ones availed 
themselves of the books belonging to the others. 

All the patients presented pure or dry granulations, as they have 
been called, with their typical characteristics, and their essentially 
chronic progress, and therefore all doubt as to the existence of 
trachoma was dissipated. Nevertheless, in order to prove the diagnosis, 
I had recourse to the aid of bacteriology and pathological anatomy* 
Six of the boys were sent to the bacteriological laboratory of the Su- 
perior Board of Health. Dr. Gonzalez Fabela took g^nulations from 
them and the littk secretions that they had, sowed it in different me- 



536 TRACHOMA IN MEXICO. 

diums of cultivation and in none did he obtain colcmies, nor find 
microbes. This negative characterstic, pointed out by Morax and 
recommended by Wecker and others, as marking the absence of patho- 
genic microbes perceivable in other classes and kinds of conjunctivitis, 
and in the doubtful cases of granulation, making it possible to affirm 
the existence of the real trachoma, as perfectly well demonstrated. 

From these same patients I took granulations from the cartilages 
and from the bottom of the superior sack of the conjunctivas and, plac- 
ing them in adequate liquid, I sent them to Dr. M. Toussant. The 
preparations which this skilled histologist obtained are marvelously 
precious and indicate the existence in those patients of real trachoma. 

Now, to what is due the development of this small epidemic which 
now presents itself in Mexico for the first time? In the first place it 
is due to the immigration which has recently been effected from Syria, 
a country eminently trachomatous. I have treated four cases among 
these immigrants. In the second place, it is due to the remarkable 
increase in the density of the population; house rent has risen since 
the beginning of the year, thus the poor families, who before lived 
ivith certain amplitude in houses of more or less dimensions, are today 
obliged to rent small rooms, and the result is agglomeration and heap- 
ing up of individuals. . In short : On the one side we have foreign 
importations of the contagious agent,' and on the other agglomeration 
and heaping up of filthy people in tenement houses, the hygienic con- 
ditions of which still leave much room for improvement: These con- 
ditions being filled and being universally accepted, the development 
of the disease is a necessary and natural consequence. 

Having shown and proved the existence of the disease, it is our duty 
to investigate what measures have been taken in other countries and 
what results have been thereby obtained. 

In Hungary every trachomatous immigrant is allowed to enter the 
country, but is obliged to undergo treatment. This measure which 
necessitates a special service of hospitals and consultories, devoted to 
trachoma cases exclusively, is not feasible amongst us, as it requires 
a vigilance which it would be impossible to exert here efficaciously in 
order to attain success. 

The United States of America, since the year 1897, have put in prac- 
tice the law of exclusion, by virtue of which a strict ocular examination 
is made of all the third class immigrants and the trachomatous ones 
are sent back to their country at the expense of the navigating com- 
panies who transported them. This law which was certainly odious 
during the first years in which it was applied, owing to the number of 
the rejected, is no longer so today, because by obliging the companies 



TRACHOMA IN MEXICO, 237 

to defray expenses of a useless voyage, the ocular examination is 
most scrupulously carried out at the starting point and there, those 
attacked with the disease are at once rejected. The result of this law 
has been marvelous. The United States have freed themselves from 
some thousands of trachoma cases and the disease has diminished not- 
ably as may be seen by the statistics published by E. Davis. (The Post 
Graduate, May, 1902.) 

The Argentine Republic, which in South America receives the im- 
mense majority of the European immigrants, and has placed no barrier 
to the immigration of the trachomatous, presents exactly the contrary 
example: trachoma has spread in the most alarming manner accord- 
ing to Wernicke and other oculists. 

With such examples before us we have to confess the benefits that 
result to a country that adopts the law of exclusion. 

As local measures of prophylaxis the following may be put into 
practice : First : To state in the certificate exacted from boys for ad- 
mission into schools, besides the requisite that he should be vaccinated 
and that he does not suffer from any contagious disease, that his eye- 
Kds be examined carefully and that they be free from granulation. 
Second : That the inspectors in charge of examining the ocular refrac- 
tion should at the same time examihe the eye-lids to see if granulations 
exist. Third : The isolation of those who should be found affected 
with the disease, inasmuch as their personal property and belongings 
must never come in contact with that of the other boys. Fourth : To 
provide the schools with water in abundance and to oblige the diseased 
beyond the natural cleanliness ordained by the school, to wash their 
hands several times a day. Fifth : To establish in the ophthalmological 
clinic of the Faculty of Medicine a special service for the treatment 
of the trachomatous ; to instruct these and their families as to the pre- 
cautions they should take in order to avoid contagion. To give period- 
ical conferences in order that the sanitary physicians who are not spe- 
cialists and those about to practice out of the capital may acquire 
knowledge and practice in diagnosing and treating the granulation in 
order to be able to give certificates and to assist those afflicted by the 
disease, in the absence of an oculist. 

With these measures it will be possible to check the epidemic which 
is now beginning, and we shall be freed from the propagation of that 
dreadful ophthalmic scourge as most justly has been called the disease 
of which we are speaking. 



A CASE OF RECURRENT FEVER OBSERVED IN HAVANA. 

Dr. MARIO G. LEBREDO, 

Vice-Director of "Las Animas" Hospital, Havana, Cuba. 

Tfie important role played by the spirochetes as etiological factors 
in many human diseases, give true worth and opportunity to the 
description of the following case of recurrent fever, which we have 
recently observed in Havana. Its appearance in this city compells us 
to make certain hygienic considerations before the American Pubhc 
Health Association. 

The clinical picture of this disease, formerly called "bilious tyj^oid 
fever," has a characteristic feature, a constant symptomatic identity. 
In regard to the temperature curve, due to the paroxysms it is really 
a cut difficult to be confounded with that of other diseases, provided 
we have before us the complete curve. But the diagnosis may lead 
to mistakes if we only examine the febrile paroxysms, without mak- 
ing an hematological examination. 

Besides, the spirochete discovered by Obermeier, in 1873, in the 
blood of patients suffering from recurrent fever, is still considered as 
the only indisputable patfiogenic organism of this disease. 

While it is true that so far as the clinical aspect and the etiology 
of recurrent fever, it has not changed any, yet the place which belongs 
to the Spirochete Obermeieri among the organic beings is a subject 
of important discussion since Schaudinn showed that certain 
spirochetes were only evolutionary forms of animal parasites (leuco- 
ytozoons, trypanosomes). 

The clinical history of the case is as follows : 

Henry Mason, a mulatto, 34 years of age, native of Chicago, U. S. 
A. Entered "Las Animas" Hospital on February 22d, 1906, sent by 
the sanitary authorities of the port of Havana. The case was sent 
because the patient was not an immune to yellow fever, had- fever, 
and came from an infected port. 

On admission he tells us "he had never been in Cuba except for a 
few hours; that he comes from Colon (Panama) where he remained 
three weeks ; that he embarked on the steamer "Miramar" on February 
7th and arrived at Havana on the 22A of the same month (the day 
he was achnitted to the hospital)." 

288 



A CASE OF RECURRENT FEVER OBSERVED IN HAVANA. 239 

First paroxysm — 

On the 1 8th and 19th he fell sick, with pains all over his body, 
but he was able to work; he believes he had fever; that on 
the afternoon of the 20th he had a chill. 

His temperature on admission was 38.6** C, and his pulse 100 per 
minute. Severe headache, and epigastric pain radiating to- 
ward the left hypochondrium. 

Examination of the blood showed: Sp. Gr. 1050. Haemoglobin 
(Talquist's Scale) 80%. No malarial parasites. Obermeier^s 
Spirochetes present. 

The diagnosis is, of course, settled, — recurrent fever. 

The t)rpical temperature curve became evident in the course of a 
few days, as can be seen in the chart herein shown. 

Feb. 23d. Was awake all night. During the day-time he vomited 
— greenish fluid. Urine examination : slight traces of albu- 
men, Erlich's diazo-reaction, negative. 

Feb. 24th. Had a fairly good night. At 9:15 A. M. perspires 
freely; at 11:30 A. M. perspiration continues very freely. 
Coincidently with the profuse sweating the temperature fell 
below normal. Blood examined at 3 :oo P. M., that is, dur- 
ing the descent of the temperature (37.1** C.) revealed no 
spirochetes. General condition is improved. Urine has albu- 
men in quantity sufficient to precipitate. 

Feb. 25th, 26th, 27th, 28th and March ist (5 days). Feels well 
and afebrile except a degree for half an hour on the 25th. 

Second paroxysm — 

March 2d. Previous night had slight malaise. Examination of 
the blood in the morning shows the reappearance of the spiro- 
chetes. 12 M., rise of temperature: 5 P. M., severe head- 
ache. 6 P. M., refuses to drink milk. No albumen. Erlich- 
reaction negative. 

March 3d. Vomited large quantity of greenish fluid at 6 and at 
8:30 P. M. 

March 4th. He refuses to take milk during the night. At 8 A. 
M., has a bad headache and besides, pains in both limbs from 
the knees down and in the right shoulder. Feels bad, worse 
than ever, and has great tendency to vomit, and therefore 
refuses the nourishment. Marked icterus in the sclerotic 
coat. The examination of the blood still shows Obermeier's 
spirochetes. 10 P. M., vomited a large quantity of white 
fluid. 10:30 P. M., perspires freely. 

March 5th. Interesting point; the temperature reaches the nor- 
mal at 6 A. M., but again rises immediately, recording at 9 
A. M., severe chill. 12 M., an examination of the blood does 
not show the spirochetes (temperature being 38.6** C.) 9 
P. M., profuse perspiration. Apyrexia. 

March 6th, 7th, 8th, 9th and loth (5 days). Feels well and with- 
out fever. 



240 A CASE OF RECURRENT FEVER OBSERVED IN HAVANA, 




A CASE OF RECURRENT FEVER OBSERVED IN HAVANA, 241 

Third paroxysm — 

March ii. Sleeps well. 8. A. M., slight headache and chill. 

The pulse begins to rise, although the temperature is 36.7® C. 

Painful sensation in the splenic region. The examination of 

the blood shows again the spirochetes. 

March 12th. Chills. Feels very bad. 3 P. M., vomited greenish 

fluid. 
March 13th. Since midnight the fever descends, and at 3 A. M. 
there is no fever. The spirochetes disappear from the blood, 
and the patient is free from his troublesome symptoms. 
From that date on, the febrile paroxysms cease and the patient con- 
valesces rapidly. 

Studying and grouping the most prominent symptoms of this 
• clinical Eiistory, we can maJce the following summary which shows, 
after comparing one paroxysm with another, that there exists an 
interesting symptomatic uniformity, except in regard to the duration 
of each individual paroxysm, because each succeeding one was 
shorter than the previous one. 

The length of the sickness, from the first paroxysm (February 17th) 
to the last fall of the temperature"^ March 12th) was twenty-three 
days 

The length of each individual paroxysm, was as follows: 

1st paroxysm 6J days. 

2d paroxysm 4 days. 

3d paroxysm 2 days. 

The length off each afebrile period, was as follows: 

from the ist to the 2d paroxysm 5 days. 

from the 2d to the 3d paroxysm 5 days. 

The headache and slight chills, always preceded the elevation in the 

temperature of each paroxysm. 
The appearance in the blood of the spirochetes also preceded by a few 

hours, the elevation of the temperature. 
Vomiting never appeared in the first day of the fever, but always on 

the second, coinciding with the pains and the general malaise. 
The disappearance of the spirochetes in all three paroxysms occurred 

always before the complete defervescence. 
The defenfescence was always accompanied in each paroxysm by a 

prolonged and profuse perspiration. 

The general condition of the patient during the febrile periods 
was relatively excellent. 

16 



242 A CASE OF RECURRENT FEVER OBSERVED IN HAVANA. 
PARASITOLOGICAL STUDY. 

The parasite observed by us in this case was unquestionably the 
Spirochete Obermeieri. 

We studied it only in stained preparations. Its appearance was 
thread-like, serpentine, rather wavy more than spirally. 

The dimensions were very variable, depending on the larger or 
smaller inflection of the spirals or ondulations; these apparent 
diversities in the forms of the organism, from the spiral form, to the 
ondulating and the slightly straight ones, are perhaps due to the technic 
employed in preparing the smear of blood, or to the method ot fixa- 
tion. 

Generally we notice two sizes of spirochetes, one rather small, 
the other a large one. The length of the longer was usually twice the 
size of the small one, and some times in exceptional instances was 
thrice as long. 

The small spfrochetes averages 7-5 /* 

, The large spirochetes averages 16.5 /& 

We have failed to find the maximum sizes described by Kolle and 
Heltsch,^ who claim for the spirochets 10, 20 and 30 fi in length. 

Most of the larger specimens have in the middle of each a sort of 
thinning process which refuses to stain, and so simulate two small 
organisms joined together end to end. (This corresponds probably to 
some advanced stage of transverse division.) 

Again, in other long varieties we have been able to observe a true 
cut across the thickest portion of the spirochetes; this cut is sharply 
defined because the two opposing surfaces of the two fragments of 
the divided spirochetes are plainly seen. (This probably corresponds 
to a somewhat recent stage of transverse division.) 

The stains usually employed were Giemsa's and a ten per cent 
saturated aqueous solution of gentian violet. The latter preparation 
is especially useful in the smears where few spirochetes arc present, 
because a thick smear may be obtained and decolorizing the red cells 
with an acetic acid solution, the spirochetes will show to advahtage. 
Stain for five or ten minutes, warming the flooded preparation from 
time to time, but never to boiling. Wash and examine. 

None of the staining methods revealed to us any ondulating mem- 
brane, nor evidences of longitudinal division, nuclei, nor spores in the 
spirochetes. 

* Kale and Dr. H. Heltsch. 



A CASE OF RECURRENT FEVER OBSERVED IN HAVANA, 24S 

Unsuccessful attempts were made to cultivate the organi^n in 
medium made up of agar-agar and defibrinated rabbit's blood; in the 
preparation of the agar, Liebig's meat extract was employed. TKe 
cultures were made on the condensation fluid. 

Negative results were also obtained with the common bed-bug in 
experiments similar to those of Tictin.* We could not coax the bugs 
to suck blood from the patient in spite of the fact that we chose for 
the experiment those that were completely free of nourishment. 

Until very recently it was believed, that experimentally Obermeier's 
spirochetes could only be inoculated successfully to apes and men, 
and that all other animals were fully resistant against the disease. 

It has been conclusively shown that man acquires recurrent fever 
by direct inoculation of blood containing the spirochetes. An investi- 
gator experimenting with monkeys infected with spirochetes from a 
recurrent fever case of Dr. R. J. Carlisle,* inoculated himself acci- 
dentally. The monkey during a febrile period, during which there 
was an abundance of spirochetes in the blood, was bleeding from the 
gums, and biting the investigator really made a direct inoculation of 
spirochetes. 

The same result is obtained in the monkey by the simple subcu- 
taneous injection, — a classical experiment — personally known to us, 
because in this hospital a monkey was successfully inoculated with 
blood from a case of recurrent fever (Dr. Biada's case*) which came 
to Havana in 1902. 

What really is an event worthy of notice, is the fact shown by 
Norris, Pappenheimer and Floumoy,' that white mice and rats may 
be inoculated successfully with blood containing Obermeier's 
spirochetes, employing for that purpose from a few drops up to 1.5 
c c. with the addition of sodium citrate. They observed that the 
spirochetes multiplied themselves while in the animal's body, demon- 
strating their presence in the peripheral circulation during two or 
three days. By subsequent passages from animal to animal, they 
succeeded in having the spirochetes alive for months. 

Inoculated men and monkeys suffer evident disturbances in their 
general state of health, they apparently become ill and may even die, 
but inoculated mice and rats do not seem to suffer in the least. Does 
the above faqts prove that the spirochetes of Obermeier are only 

'J. Tictin. — Centralblatt fur Bakt. 1897, 21. 
•R. J. Carlisle, Journ. of Inf. Diseases, Chicago, 1906. 

*Dr. Biada M., Ua case de fiebre securecute, Revista de Medicina y Cinijia 
'de la Habana, 1902. 

• Norris Pappenheimer and Floumoy, Journ. of Inf. Diseases, Chicago, 1906. 



244 A CASE OF RECURRENT FEVER OBSERVED IN HAVANA. 

pathogenic for men and monkeys, and that in white mice's blood they 
only find an appropriate medium in which to thrive and multiply 
temporarily? — No. — This erroneous conclusion can be upset by an 
irrefutable proof, to wit: that the spirochetes cause intimate bio- 
chemical modifications in the white mouse, for the latter acquires an 
immunity equally as great as man and monkey, against a new attack of 
the disease. 

How long the inmunity lasts has not been definitely settled as yet. 

f 

UNITY OR DUAUTY OF HUMAN RECURRENT FEVER. 

In East Africa there is a disease which has great clinical and 
parasitic similarit}' to the European recurrent fever. 

That is today one of the most important questions for investiga- 
tion, — whether we are dealing with one, or two diseases. 

African recurrens or tick fever has for its pathogenic organism, a 
spirochete. 

Koch,* who has had the opportunity to study numberless cases of 
African recurrens, in the German Protectorate of East Africa, gives 
the following two important clinical differences: 

1st. Short duration (two days at the utmost) of each febrile 
paroxysm; total number of paroxysms, four. 

2nd. Scanty number of spirochetes in the blood of patients, eve» 
during the period of highest elevation of temperature. 

In spite of these differences, Koch thinks that as the complica- 
tions and sequelae in both fevers (European and African) are so 
similar, it is not worth while to consider African recurrens a new 
disease, but he grants that it may be thought of as an African variety 
of recurrent fever. 

Button and Todd, investigators of human tick fever in the 
eastern part of the Congo Free State are equally inclined. 

Searching for further proofs in order to know if they are one or 
two diseases, the comparative study of the spirochetes has been re- 
sorted to, testing the virulence and infectiousness of each in various 
animals. 

Breinl and Kinghom^ succeeded in infecting intraperitoneally, with 
blood containing tick f everts spirochetes, a monkey, a horse, a dog, 
rabbits, guinea-pigs, rats and mice. The disease produced in each of 
those animals was of a grave nature, and the rabbits, rats, mice and 
some of the guinea-pigs succumbed to the infection. 

•Robert Koch, Berliner klinische Wochenschrift, 1906, No. 7. 
^The Lancet, March 10, 1906. 



A CASE OF RECURRENT FEVER OBSERVED IN HAVANA. 246 

It is evident that there exists a great difference for various animals, 
judging from the above experimental proof, between the virulence 
of the European and the African spirochetes. — Norris, Pappenheimer 
and Floumoy, besides successfully inoculating monkeys and white 
mice, as has been mentioned before, also inoculated rabbits and guinea- 
pigs. Two of the inoculated rabbits manifested slight infection; the 
others escape; the guinea-pigs were absolutely resistant against the 
infection. 

Undoubtedly, therefore, the Sp. Obermeieri has for man and 
monkey, slight virulence; the guinea-pig does not acquire the disease; 
nevertheless for all of them the spirochetes of tick fever has an 
extreme virulence. 

The comparative morphological examination of both spirochetes 
according to Novy and Knapp,® proves that there are two distinct 
organisms, evidently shown by structural details, position, ondula- 
tions, and chiefly by the length, being greater in the Sp. of tick fever 
than in the European. 

In short, there are two recurrent fevers, the Alfrican and the Euro- 
pean and Indian fever, which, though having very slight clinical 
differences between them, yet are distinct. For each of them 
there is a separate spirochete: the European, due to Sp. Obermeieri, 
and the African, due to Sp. Duttoni, as has been proposed to call it, 
with all justice by Novy and Knapp in memoriam of the lamented 
Dutton, who died victim of that disease, in the Upper Congo (Africa), 
February 27, 1905. 

Which is the propagating agent of recurrent fevers? — Unquest- 
ionably it must be some blood-sucking insect. 

Dutton and Todd, and Koch, have shown in a most positive man- 
ner, how African recurrens is transmitted by means of a tick, — the 
Omithodorus moubata (Mourray). They have proved furthermore, 
that infected Omithodorus may transmit through the ova the in- 
fection to their offspring, and, therefore, the latter are bom already 
infected and infectant. 

Would the Omithodorus be a good propagator for the Sp. Ober- 
meieri Perhaps. If not, we must take for granted that there is 
some analogus specie of tick, or Argas or bed-bug (this insect has 
been experimented with poor success) as playing the role of propa- 
gating agents. 

That in America must exist an insect, a host, similar to those 
mentioned, can not be doubted — as can be inferred from our own 
case and similar interesting ones already reported. 

'Novy and Knapp, Journal of Inf. Diseases, Chicago, May 1906. 



246 A CASE OF RECURRENT FEVER OBSERVED IN HAVANA. 
IS THERE AN AMERICAN FOCUS OF RECURRENT EFVER? 

The investigation as to the origin of the infection in our case has 
great importance. 

It is a fact, that on the arrival of our patient at Havana, he was 
in the midst of the first febrile paroxysm. Hence, there can be no 
doubt that he acquired the disease either on board, during the voyage 
or else at Colon (Panama) the port of sailing. 

Considering that he went on board at Colon on the 17th of Febru- 
ary, and in the following day while on board the "Miramar" he had 
the first symptoms, we must set aside the possibility of an acquired 
infection in so few hours while on the vessel. 

On the other hand, he had been at Colon (Panama) during three 
consecutive weeks, and therefore the inference may justly be drawn 
that it was there that he got the disease. 

With a positive diagnosis and with the above conviction, the Cuban 
sanitary authorities deemed proper to notify the health officers at 
Panama that the case of recurrent fever, which had come to our port, 
had originated at Colon. 

Indeed, Colonel Gorgas, chief sanitary officer of the Isthmian 
Canal Commission, in a letter replying to the despatch of the chief sani- 
tary officer of Cuba, says, that during the summer of 1905, there had 
been two cases of recurrent fever at Colon. 

It had also been brought out by data, obtained by Dr. Carlisle, 
that besides the two cases at Colon, there had been several others at 
Tuxpam (a sea port between Veracruz and Tampico) during April, 
1905, and "that death occurred from this disease during every month 
throughout the year." 

Besides, the same author has observed, in New York, a case of re- 
current fever, which could only have had, as possible origin of the 
infection. New York, Galveston, or Key West. 

Published reports show that the cases of recurrent fever which 
have presented themselves in the countries represented in the Ameri- 
can Public Health Association, have been relatively numerous. It 
follows, therefore, that those cases must have originated from one 
or more American foci, probably situated in Central America. 

We would like to especially call the attention of this Association 
to this matter, believing that in some locality of easy communication 
there may be a large number of cases of recurrent fever, which pass 
unnoticed, probably, with the diagnosis of malaria, because unfortu- 
nately the blood examination of every febrile individual is not made 
systematically and compulsory in order to make a rapid diagnosis; a 



A CASE OF RECURRENT FEVER OBSERVED IN HAVANA. 247 

doubt is left, therefore, as to the nature of the disease, leading to 
mistakes in therapeutics, and causing serious risks to the public and 
international hygiene. 

The recent reported cases in America, including our own, are un- 
doubtedly cases of recurrent fevers due to Spirochete Obermeieri. 

We believe that the first cases which originated the possible focus 
or foci in America came from Europe. In 1902, Dr. Biada observed 
in Havana another case of recurrent fever traceable to Liverpool, 
which place he considered as the infected origin. 

In Central America the infection, by way of the Pacific, that is, 
through the Western coast, is possible, although difficult, but in this 
instance the introduction of African recurrens would be more feasible. 

Everything connected with recurrent fever makes it a dreaded 
disease if it becomes endemic for the following reasons : 

ist. Because it is easily carried to great distances, owing to the 
nature of the disease itself, which lasts at least twenty days ; the first 
paroxysm being as infectant as the last. 

2d. Because of the resistance of the parasite itself. — Karlinsky 
has found alive spirochetes in bed-bugs thirty days after the latter 
had sucked infected blood. 

3d. Because of the gjeat vitality of the propagating agent (bed- 
bugs or ticks.) 

CONCLUSIONS. 

We can make the following conclusions: 

1st. Recommend to the Association that at the next meeting, 
"Recurrent fever" shall be one of the topics of special interest for 
discussion. 

2d. That the attention of those who are in proper condition to in- 
vestigate as to infected localities which may exist in Central America, 
be enlisted in this work. 

3d. To emphasize the importance of investigations in regard to the 
identity or duality of European and African recurrent fevers. 

4th. To investigate the possible propagating insect, which serves 
as host for the Spirochete Obermeieri in America. 



PROGRAM OF SANITARY HEALTH WORKS IN THE 
VALLEY AND CITY OF MEXICO. 

MIGUEL QUEVEDO. C E., Mexicx), D. F., Mfixica 

The topographical condition of the valley of Mexico, completely 
surrounded by the high ranges that prevent the issue of the waters 
outside of its boundaries, and therefore storing them up in the lower 
{>arts of the plain, in shallow lakes, brought about a difficult problem 
in the existence and development of the populated places which were 
founded in the bottom of the valley. From the first dwellers in that 
valley, who founded the capital of Anahuac, in the same city that is 
now capital of the Mexican nation, the residents of that valley have 
had to struggle against the frequent rise of waters, which inundated 
the Aztec city and other native towns, and tradition as well as history 
have preserved even to this day a more or less exact knowledge of 
those works consisting in piling, dykes or other defense works, in 
the designing of which, the great Netzhualcoyotl distinguished him- 
self, as in other arts. The same solution of the problem by means 
of dykes was for many 3'ears adopted by the Spanish conquerors to 
protect the towns in the valley and principally the capital against 
inundation. The capital city naturally was the most important, and 
at the same time the worst situated, as it occupied the lowest part 
of the valley and close to Lake Texcoco. But the resource of dyke 
building was not entirely satisfactory, and in spite of the important 
works of this character which were built in Zumpango, Xaitocan, San 
Cristobal and other points near the city, the waters continued to rise 
in years of extraordinary rainfall, and either broke through or over- 
flowed the dykes and inundated the capital, which in this way 
suffered loss of life and property on frequent occasions, to such an 
extent that it was thought it would be necessary to abandon the 
plains as insecure, or otherwise undertake works of another character 
which would efficaciously guarantee the existence and development 
of the cities. 

The energetic character of the Hispano-Aztecs of the new nation, 
necessarily overcame this difficult problem, as follows: To the north 
of the valley they commenced the driving of a coUosal tunnel for 
that time, because, as can be easily understood, the timnels driven 
through the Simplon, the San Gothard, the Jungfrau, the Croton, etc., 
have only been possible during the present period through the 
powerful assistance of modern engineering, and consequently, when 

248 



SANITARY WORKS IN VALLEY OF MEXICO, 249 

this tunnel was afterwards converted into an optn cut and denomi- 
nated "Tajo de Nochistongo," it also excited the attention of scientific 
and observing men, amongst whom we may mention Baron Htunboldt, 
who considered it the grandest work of its kind at that period, as 
it was necessary to open a cut with a length of over lo kilometres, 
the greater part of which is more than forty metres deep, and in some 
parts reaches even 75 metres. 

The result of this work was to afford an outlet for the currents of 
water in all the northern part of the valley, and which were of great 
volume, due to the enormous extent of the ranges from which they 
were fed, and which extend to either side of the city on the north- 
west and northeast. These currents were considered the principal 
cause of the great inundations that were commonly seen in the capital 
city. 

The above mentioned works of dykes, tunnel and "Tajo de 
Nochistongo" of the period of Spanish domination, exhausted the 
energy of the inhabitants of the 17th and i8th centuries, the work 
of the open cut being extended into the beginning of the 19th 
century, when it was completed. But this important work was not 
suiSicient to give complete security to the capital and other towns of 
the plain, because as yet there was no canal which would carry the 
waters from the central part of the valley to the cut. The lowest 
part was occupied by Lake Texcoco and the city of Mexico, and in 
view of the high level of the bottom of the cut it was impossible to 
carry the drainage from that lake and from the city to be discharged 
there. • 

If, on the one hand, the risk of inundation was not diminished by 
carrying off the streams from the north of the valley through the 
"Tajo de Nochistongo," on the other hand, that risk was aggravated 
by the rapid filling in of the lakes, principally that of Texcoco, due 
to the cutting down, during those two centuries, of the forests on the 
hills and ranges which formed the watershed round the valley. These 
steep hills were left without any forest protection and the erosion of 
the waters soon carried the vegetable earth to the bottom of the lakes, 
and after that, the salt impregnated earth, which has sterilized the 
low lands of the plain, and converted the northern lakes and that of 
Texcoco into unhealthy swamps, thus modifying not only the hydro- 
graphic conditions of the valley by the formation of torrential streams, 
but also the conditions of the soil as well as of the climate. 

At the period of the conquest, the conquerer himself relates the 
agreeable impression which he received, on seeing the valley of 
Mexico, surrounded with beautiful forests, the greater part of the 



250 SANITARY WORKS IN VALLEY OF MEXICO, 

plain occupied by lakes of crystaline waters, and the rest by diflfercnt 
crops or luxuriant spontaneous vegetation, whilst Lake Texcoco was 
navigable, as we can infer from other data that its depth at that time 
was not less than from three to four metres, whilst a net of navigable 
canals connected it with the capital city. This panorama has been 
entirely changed during the time that elapsed between the conquest 
and the national independence. When this took place in spite of the 
magnificent hydraulic works, the problem of liberating the capital 
and other towns on the plain from inundation still existed, and 
during the political struggles with which our independence was 
initiated and continued, it was impossible to improve the conditions 
of the capital and other inhabited parts of the valley, but on the con- 
trary, these conditions continued to grow worse, so that in the year 
1866, a great inundation which was caused by the heavy rainfall, 
demonstrated the great urgency of undertaking works which would 
save the capital. 

By that time, and even for some years past, a new problem had 
arisen which was connected with that of the inundations; I refer to 
the sanitary problem, as the filling up of Lake Texcoco and the in- 
creasing spread of its waters towards the surrounding plains, whilst 
increasing the dangers of inundation of the capital, rendered it im- 
possible to utilize that lake as the only and therefore necessary point 
for the discharge of the refuse waters of the city through its system 
of sewers, and the great connecting canal of San Lazaro. The con- 
sequence was, that the subsoil of the city became every day more im- 
pregnated with filth and water, through the very impossibility of 
discharging them. But the weak attempts which could be carried out 
in those disturbed times, did not in any way improve the situation^ 
until the present administration, through the general order and pros- 
perity that have been established, was able to lend its powerful as- 
sistance to the beneficent work of the drainage and sanitation of the 
valley and of the capital of the Republic. 

As a matter of fact, it is only of late years that this work has been 
undertaken in the fullest sense of the word, by the successive execu- 
tion of a program of sanitary and public health works. Having now 
combined the problem of the security against inundations with the 
newer one of modern hygiene, of giving an easy outfall to the refuse 
waters of the important agglomeration of people that constituted 
the city of Mexico, it became necessary to design a grand drainage 
canal with sufficient depth to carry off the refuse waters from the 
city by gravity outside of the valley, together with those which might 
possibly inundate the city. It was necessary for that purpose to leave 



SANITARY WORKS IN VALLEY OF MEXICO, 251 

the "Tajo de Nochistongo" on one side and reserve it for only the 
northwest streams, and search for another place to which the waters 
could be directed, because the high level of its bottom required heavy- 
excavations and works to secure the slopes; for which reason it was 
considered preferable to open a new tunnel in the northern part of 
the valley, but further to the east than the "Tajo de Nochistongo."^ 
This tunnel was made to discharge in the ravine of Tequisquiac, with 
a leng^ of 10,021 metres, and through this tunnel the waters of the 
northern lakes, of Lake Texcoco and of the city are carried. In 
order to bring the waters to this tunnel, a g^and canal was dug with 
a length of 47.5 kilometres, and a depth that varies between 5.75 
metres at the commencement on the east side of the city of Mexico, 
till it reaches a depth of over 21 metres at the mouth of the tunnel. 

These drainage works were entirely completed and inaugurated in 
the year 1900 ; but even before their termination, the sanitary problem 
had been attacked, and in the year 1887 a powerful pumping plant 
was erected at the head of the drainage canal in the district called 
San Lazaro, for the purpose of absorbing the waters from the sewers 
and preventing the overflow from Lake Texcoco, which as before 
stated, frequently prevented by raising its level, the discharge of the 
city waters, and even drove them back on to the street pavements and 
lower floors of the buildings. The erection of the San Lazaro pumps 
also facilitated the immediate execution of a good and well designed 
system of sewerage, street pavement and other urbanization and sani- 
tary works, which had become necessary in order that the city might 
be developed and beautified. 

The execution of a new system of sewerage was in every way neces- 
sary for the sanitation of the city, and these works were very properly 
designated under the title of "Sanitation Works." As a matter of fact, 
the old sewers were every way deficient, both as regards their con- 
struction as well as regards their section, location and slight gradient, 
all of which resulted in their silting up, so that the pestiferous waters 
continually impregnated the subsoil of the city, which, being in itself 
water-loaded, made it impossible for the proper laying of any system of 
pavement on the public streets, and thereby kept the dwelling houses 
in an unhealthy condition. 

The consequence of these terrible hygienic conditions of Mexico 
City, showed itself in the heavy rate of mortality, which became equal 
or even superior to those of the deadliest cities of the world. 

The construction of the new sewers in accordance with a carefully 
studied scheme, under which they receive all the refuse and storm 
waters in water proof conduits, which are well ventilated and flushed,. 



252 SANITARY WORKS IN VALLEY OF MEXICO, 

has greatly improved the condition of the surface and subsoil of the 
city. Care is taken in the building of these sewers that the trenches 
will furnish an outlet for the subsoil waters, so that they will be able 
to run oflE into the grand drainage canal. These sewers having 
been commenced in the year 1897, they have been completed over 
two-thirds of the densely populated area, and the pumps for flushing 
them have also been erected together with the greater part of the 
pipes for that service. 

At the same time that the new sewers have been constructed, a 
^eat many of the open ditches which crossed the city, even in well 
populated parts, and were connected with the old system of drainage; 
ditches that were in every way objectionable from a hygienic p(Hnt 
of view as well as unpleasant to sight, have been filled up. 

At the same time the pavements on the streets have been entirely 
relaid after careful grading, with cement and asphalt throughout 
the central zone, which is the most populated and valuable, as well 
as throughout certain arteries that are of most importance to the 
traffic and in the modern suburbs to the southwest of the city. In 
the rest of the city, which is less populated, and less valuable, the 
pavements have been laid with cobble stones, well rammed down on 
a bed of sand, the sidewalks being laid either with stone slabs or 
cement. 

These pavement works in the public roads during the last ten years 
have amounted to 39 kilometres and 805 metres in length of asphalt 
pavement, and 452 kilometres of stone pavement, leaving a length 
of 55 kilometres of street still to be paved. 

As regards works for the carriage of refuse and storm waters, 
about 29 kilometres of main sewers of large diameter have been built 
and 159 kilometres of pipe sewers, together with about 18,800 metres 
of iron pipe for flushing those same sewers. 

The city of Mexico having been founded on a comparatively re- 
duced site, on account of the scarcity of land beyond the reach of 
inundation, which even then had to be defended by pile work and 
filling in, we can well understand that the old part of the city suflFers 
from the defect which is common to all old cities of the world, of 
narrow streets with crooked alignment. 

This has caused serious difficulties in the complete execution of the 
program of sanitary works, because if this defect was to some extent 
corrected in the more central and valuable part, it was not so in the 
older parts, and especially in the eastern and southern zones. These 
difficulties have obliged the government to undertake expropriation 
proceedings, always dilatory and costly, in order to open new streets 



SANITARY WORKS IN VALLEY OF MEXICO. 26a 

and correct others, in order not only to be able to give a proper align- 
ment to the new system of sewers, but still more to avoid and correct 
the anti-hygienic conditions of narrow and tortuous streets. In ac- 
cordance with these principles, the authorities have preferred to delay 
somewhat the execution of the sanitary and urbanization works in the 
southeast zone until the defective alignment I speak of was corrected, 
and this has lately been done all through the south zone, where the 
laying of new sewers and pavements has now been commenced. 

As a consequence of the order and prosperity of the country as well 
as the important improvements in the hygienic conditions of the city, 
there has been a great increase in the population, and a g^eat spread 
of the city during the last twenty years. This extension has been 
almost entirely confined to the western side, which is the healthiest 
and highest of the plain, and throughout this portion of the city, the 
sanitation and urbanization works have been carried out in accord- 
ance with a carefully prepared plan, before the buildings could be 
constructed. If we compare the old area of the city with that which 
it at present occupies, we find that until twenty or twenty-five years 
ago, it had been limited to the boundaries which it had in former 
times, doubtless on account of the bad hygienic conditions, the dangers 
of inundation and the scarcity of means of communication with the 
rest of the country. 

During the last few years, on the contrary, the spread of the city 
has been remarkable, and the authorities have been under the necessity 
of displaying great thought and activity to control that expansion, so 
that it should be carried out in every way in accordance with the 
modem precepts of hygiene and esthetics. This has presented no 
difficulties as regards the western zone, in which the new suburbs have 
been organized by companies of private parties with sufficient capital 
to co-operate in the establishment of the urbanization works; but it 
has been diflferent in the other zones of the city, in which the new 
suburbs have been opened by proprietors with only slight resources, 
in which cases it has been found necessary for the authorities to take 
energetic steps to stop the extension of the city without the previous 
execution of those works, as it has been observed that the focus of 
infectious diseases, especially of typhus, is confined, in part, to the 
extreme east and south-east of the city, to which, for the reasons 
above given, it has not as yet been possible to extend those works. 

In every program of sanitary and urbanization works, it is neces- 
sary to give a preferent attention to a plentiful water supply, so that 
it shall be abundant, good in quality and delivered under pressure. 
The colonial administration had established a water supply from the 



554 SANITARY WORKS IN VALLEY OF MEXICO, 

Chapultepec springs, as well as from El Desierto and Los Leones, in 
the mountains to the southwest of the city. This supply amounted to 
about 200 litres per second per inhabitant. These waters were 
brought in over the last kilometres before reaching the city, by means 
of masonry aqueducts, of which those of Chapultepec and Tlaxpana, 
maintained a certain elevation in order to distribute the water to the 
public fountains and house pipes. 

The national government was anxious to improve and increase this 
indispensable service, but the necessity of taking precautions against 
inundation, and at the same time of affording means of drainage, was 
much more urgent, and therefore it had to concentrate all its efforts 
and resources to the sewerage and drainage works. Nevertheless, it 
substituted the old open aqueducts already mentioned of Chapultepec 
and Tlaxpana, with closed metallic pipes, and erected a pumping 
plant in Chapultepec with steam engines, so as to distribute the water 
with more pressure, and at the same time made some increase in its 
volume, by the utilization of other springs in the mountains, and by a 
considerable extension of the pipe systtm in the city. 

The present water supply system covers 27 kilometres of open 
aqueducts, to carry the water from Los Leones and El Desierto, 45 
kilometres for the waters from Salazar and Rio Hondo, and about 
149 kilometres of pipe of different diameters to bring it into the city 
and to distribute it. 

But with the great increase of population during the last few years, 
and in spite of the many artesian wells that have been opened in 
different parts of the city, the water supply is very short, as it hardly 
reaches to 100 or 150 litres per inhabitant per day. According to the 
season of the year is the volume distributed through the pipes. Be- 
sides this, although the water collected in the mountains is pure, as 
it always is in springs that rise in uninhabited forest lands, the long 
distance that it is carried in open conduits across country that docs 
not afford good ground for ditches and is barren of vegetation, leads 
to a considerable fouling with extraneous substances, mostly of an 
•earthy nature. 

As soon as the necessary drainage and sewerage works were 
<:ompleted in the principal zones of the city, attention could be given 
and the money furnished for the important question of the water 
supply, and after a careful study it was decided to at once commence 
works for the bringing of water from the springs of Xochimilco in 
the southern part of the valley. 

For this purpose it was decided to build a closed aqueduct, of ovoid 
form and with a height of two metres, which we are now building 



SANITARY WORKS IN VALLEY OF MEXICO. 266 

by the system of armed concrete that is perfectly water proof, giving 
this aqueduct a length of 25 kilometres. We are also constructing a 
pumping plant which will be actuated by electric power on the site of 
the springs, and with which the water will be caught up and introduced 
into the aqueduct, another plant being erected at the point where the 
aqueduct reaches the city to the southwest in the Colonia de la Condesa, 
so as to raise it to the storage and distributing tanks, which are now 
being built on the hills near Molino del Rey. 

With these works, which we hope to complete within one or two 
years, there will be a volume of water of 2,300 litres per second from 
the Xochimilco springs, without consuming the entire product of them, 
and for a population of 400,000 inhabitants, which is that of the city 
more or less, this will g^ve about 500 litres per head per day, thus 
raising the city to the category of one of the best supplied in the world. 
This will allow the present water supply to be distributed to the other 
towns in the Federal District, which are in great need of it, and for 
this purpose the necessary works will be undertaken so as to prevent 
the waters being contaminated in the aqueducts. 

If, to the series of works referred to as executed during the last few 
years, we add the improvements introduced in the street sweeping and 
garbage service, the creation or improvement of parks and gardens, 
the new school buildings, the hospitals, penitentiary, poor asylum and 
barracks, as well as all those establishments that are dedicated to the 
food supply, such as the slaughter house and markets ; the strict and 
energetic measures that have been taken to prohibit the sale of food 
products that are injurious to health, as well as those intended to prevent 
the spread of infectious diseases, we must acknowledge that the present 
administration has made great advances from a hygienic point of view, 
and that all the authorities have worked together in this sanitary 
campaign, which has transformed the health of the city during the last 
ten or fifteen years. This is very clearly shown by a comparison of 
the mortality tables of late years, with those of the period previous to 
the execution of these works. 

It is only fair to acknowledge, that if the administration has carried 
out a great work, the private citizen has also contributed his part as far 
as lay in his power, as the transformation of the city has not only been 
carried out in the public services that are more or less connected with 
hygiene, but also in private dwellings and other buildings, and the 
proprietors of real estate have generally observed, not only with docility 
but even with enthusiasm, the regulations issued by the authorities with 
a view to having all the buildings comply with the precepts of sanitary 
science. In this way it has become the rule that all sanitary appliances, 



266 SANITARY WORKS IN VALLEY OF MEXICO. 

piping and other details should be installed in accordance with the 
most advanced principles of modern hygiene, and they are all duly 
registered and carefully inspected. The public zeal has gone further 
yet, as the wealthy classes have taken steps to alter the old dwelling 
houses so that they will not only comply with those sanitary requisites, 
buf even present a more comfortable and pleasanter aspect. The result is 
that a great number of old houses have been reformed or reconstructed, 
and that the city has greatly spread by the construction of a great num- 
ber of new dwelling houses under hygienic and comfortable conditions 
all through the western and southern suburbs of the city, all of which 
form an evidence of culture and welfare. 

Unfortunately as yet, nothing has been done to improve the 
dwellings for the poorer classes, a fact which is principally due to the 
small demands made by these classes and the little ambition they have 
to improve their way of life. It is probably for these reasons that com- 
panies have not been organized, as in other countries, for the erection 
of dwelling houses for poor people, which would be economical, healthy 
and comfortable, and there is all the more reason why the government 
should stimulate the construction of buildings of this class by the grant 
of certain privileges, as this is a problem of the highest importance 
which has not been as yet decided. 

The same difficulty has been encountered in the attempt to correct 
the personal uncleanly and careless habits which characterize the in- 
digenous population of the valley of Mexico and all the poor classes, as 
compared with the rest of the Republic, in which they are in general 
cleaner. It would be undoubtedly necessary to make stringent pro- 
visions on this subject as part of our sanitary legislation; but this will 
have to be left until we have such an abundant water supply that we can 
distribute it throughout the city and the different parts of the valley. 

With the recent spread of the population of the other towns in the 
valley, and especially those of the Federal District, it has been found 
necessary to dedicate some attention to their sanitary conditions, in 
which difficulties have been encountered of the same character as those 
in the capital, especially as regards the question of drainage, as there 
are no currents of water that would carry off the refuse, or land adapted 
to utilize this refuse by means of irrigation. 

In order to overcome this difficulty, studies are being carried on for 
the execution of a system of sewerage in those towns, connected with 
purification works, so that the sewage waters may be brought to such a 
condition that they can be run oiF for purpose of irrigation even on 
lands that will not soak them up, or else into the streams or ditches, 
that during the greater part of the year are all dry. 



SANITARY WORKS IN VALLEY OF MEXICO. 257 

On the other hand, a scheme is under study for the prolongation of 
the grand canal, and of certain affluents so as to carry those sewage 
waters to the canal. The hydrographic office which has charge of these 
studies and works, has for some years past executed a series of in- 
teresting works for the security and health of the valley towns in 
general, as in view of the torrential rains and. the topographical and 
geological configuration of the country, it has been found necessary to 
canalize many streams, and thus build really artificial rivers on the plain, 
by means of extensive dykes or banks, so as to prevent these currents, 
which are very voluminous in the rainy season, from invading the towns 
or forming swamps or lagoons on the plain itself, which would be highly 
dangerous to the public health. In this way, we have seen the capital city 
and several other towns delivered from the frequent partial inundations 
of those torrential streams, and in this way it has been found possible 
to protect a number of properties on the plain, several of which, like the 
modem suburbs of the capital, are not completely urbajiized. 

These works are necessarily connected with those which are about to 
be commenced to improve the health conditions of the valley, and in 
connection with Lake Texcoco, and the others to the north, because 
as already stated, these old lakes have no longer any depth, having 
been partly filled in and are only provisionally maintained to regulate 
the discharge of water through the grand drainage canal and tunnel, 
which are not of sufficient capacity to receive the enormous quantities 
of storm waters that flow into those lakes. It has also been considered 
desirable on behalf of public health, to keep some water on these ex- 
tensive plains and not to keep them dry, so as not to diminish the 
hygrometric conditions of the atmosphere, and also because, as the pre- 
vailing winds come from that direction, they would, carry a great 
quantity of dust to the city (iuring the long months when it does not 
rain. But the existence of those swampy lagoons is not satisfactory 
from a sanitary point of view, it is greatly to be desired that the surface 
they occupy should be converted into arable land and covered with vege- 
tation, because the evaporation from irrigated and cultivated land is 
equal or greater than that from the same area of water, and such 
evaporation is not unhealthy, like that of the swamps, whilst it avoids 
the objections to the latter from a hygienic point of view. 

In order to realize this important complement of the sanitary program 
of the valley of Mexico, it will be necessary to store the waters on the 
uplands which drain into those lagoons, as well as the reforesting of the 
watersheds, the first in order to obtain water with which to irrigate the 
plains that are drained and so control the flow of those waters in ac- 
cordance with the capacity of the drainage works, and the latter, that is 
17 



258 SANITARY WORKS IN VALLEY OF MEXICO. 

to say, the reforestation of the watersheds, so as to regulate as far as 
possible the torrential flow of those waters, and prevent their carrying 
down such a large quantity of sterile material into the valley. 

Surveys are now being carried out for the erection of tlie necessary 
dams on the uplands round the valley of Mexico, and as regards the 
reforestation, it has already been commenced, not only for the exclusive 
object above indicated, but on all the surrounding hills and part of the 
plain, as a hygienic step which is intended to improve the conditions 
of the soil and of the climate, which have suffered so much through the 
cutting down of the forests. These works will require energetic efforts 
and perseverance, but will form a worthy termination to the sanitary 
and public health program, the greater part of which has t)een so suc- 
cessfully carried out. 



EVOLUTION OF THE HYGIENIC CONDITIONS OF THE 
CITY OF MEXICO DURING THE LAST FIFTEEN YEARS. 

ROBERTO GAYOL> C. E., Mexico, D. F., Mexico. 

Built at the bottom of a basin without outlet, the city of Mexico 
was under the worst natural conditions for giving shelter without 
danger to health, to the ntunerous population that has collected there 
during the lapse of several centuries, on account of its water-logged 
soil, formed of recent alluvial earth which was continually impreg- 
nated by solid and liquid organic matter, which could not circulate 
because they were already in the lowest point, the only one which 
they could reach under the impulse of gravitation. 

This gradual and continuous accumulation of refuse of all kinds, 
both within the city and in the adjacent land, rendered it not only filthy 
and pestilent, disagreeable to sight and smell, but also unhealthy, be- 
cause even in the dwellings of the richest persons, the house drains 
as well as the sewers in the streets, were simply deposits of infected 
mud, in which the liquids passed with great difficulty or remained 
stagnant, filtering into the adjacent soil in such abundance, that be- 
neath the wooden floors of the lowest rooms, there was a species of 
tank full of these liquids; the moisture in the walls rose up to a 
height of two or three metres, and in any part of the city in which 
excavations were made the foul waters were found at a depth of 70 
or 80 centimetres, or even less. 

These fatal conditions which were the ordinary ones of the public 
and private drains, and which had been created for the want of a fall 
that would maintain the liquids in movement, were specially aggra- 
vated whenever the level of Lake Texcoco rose through an abundant 
rainfall, as then the waters from the lake itself invaded the streets and 
houses of the city, and there remained until the waters again fell 
through evaporation, the only means by which the lake suffered any 
fall. Naturally, the waters thus caused serious injiiry to property and 
very much greater to the public health, and history has given us a 
description of these periodical inundations, that, like a plague, scourged 
the city of Mexico to such an extent that it was even considered unin- 
habitable, and the colonial government several times attempted to re- 
move the public offices to another site, but was always detained by the 
consideration of the value which city property had already reached. 

Besides these periodical inundations, which generally took place 

269 



2eo HYGIENIC CONDITIONS OF THE CITY OF MEXICO, 

every ten years, there were other partial inundations of many low 
lying streets, whenever a rainfall was precipitated of two centimetres 
or more, and as these storms were very frequent during the rainy 
seasons, /the city suffered ten, twelve or more partial inundations in 
the season from May to October; inundations which greatly injured 
the dwellers of low built rooms and especially the stores, or store- 
keepers, who were surprised by the invasion of the waters, whilst 
they had goods deposited in their yards or warehouses. 

Whenever these partial inundations took place, the water, instead 
of being drawn off through the sewers, came up through them in the 
low lying streets, bringing with them the infected mud of which 
they were full, so that when the liquid retired, the pavement was left 
covered by a thick layer of that sewer mud, which presented the 
most repugnant appearance. 

The fact that the people were bom and brought up in the midst 
of this filth, and every day witnessed the most unclean spectacles, 
conduced to a loss of the most elemental notion of cleanliness, and 
as a result of this general bad education, even those persons who 
enjoyed a good social position tolerated the gravest defects in all 
their sanitary installation, without the house proprietors making the 
slightest effort to improve the conditions by which they were sur- 
rounded. These conditions were not neglected for reasons of econ- 
omy or in order to avoid trouble, but simply because they found it 
only natural and in no way disagreeable to support the sight and 
faetig emanations that under other circumstances they would have 
found entirely unsupportable. 

As regards the dwellings of the poorer classes, there were many 
that did not look as if they were intended to give shelter to human 
beings, but nevertheless thousands of men, women and children in- 
habited them under conditions of perfect familiarity with all kinds 
of objects that should have been repugnant to them through their 
great filth, and it was therefore impossible to expect that those chil- 
dren, brought up rolling in mud, should later on become men and 
women with the first notions of their own value, or any idea of per- 
sonal cleanliness. 

It is difficult to understand how these conditions whiqh produced 
so many physical and moral evils, could have subsisted for nearly 
four hundred years, but nevertheless, although the city was founded 
in 1 52 1, it was not until 1886 that any serious work was undertaken 
in the sense of a general drainage of the valley, such as that which 
now furnishes an outlet to the waters that formerly were accummu- 



HYGIENIC CONDITIONS OF THE CITY OF MEXICO, 261 

lated at the bottom of the basin that forms the site of the city of 
Mexico. These works which were officially inaugurated in March, 
1900, have produced a radical change in the appearance of the city, 
because through them it became possible to establish a system of 
sewers that thoroughly drained the soil, and expelled the water from 
the subsoil; sewers that carry outside of the city in a very short 
time, the refuse of the dwellings and permit the cleaning out of 
the houses and the introducing into them of good hygienic conditions. 

The partial and total inundations, with all their evil consequences, 
have now entirely disappeared and the consolidation of the soil leads 
to a better preservation of the pavements, and as the value of the 
real estate has considerably augmented, that increase has been re- 
flected in the city revenues and in an improvement in the municipal 
services. 

As soon as the termination of the general valley drainage was 
assured, on the initiative of Dr. Eduardo Liceaga, the government 
reorganized the Supreme Board of Health, whose services in favor 
of public hygiene in the Federal District are of inestimable value, 
and as valuable as these, or perhaps even more, are those which it 
has rendered to the country in general, through the sanitary service 
in the ports, by which it has prevented the spread of transmissable 
diseases. Amongst these, the most memorable and praiseworthy was 
its struggle against the bubonic plague which four years ago appeared 
in the port of Mazatlan, and which did not spread, thanks to the efforts 
of the government which zealously supported the work of the board, 
ably directed by its president, Dr. Liceaga. 

The labors of this board in the Federal District, and especially m 
the capital of the Republic, have been highly fruitful in practical 
results, and if its advancement was at first slow, it was because there 
was a necessity of educating the masses, inculcating in them the most 
rudimentary principles of public hygiene. During the fifteen years 
that have elapsed since the reorganizatiori^ of that sanitary board, 
these principles have been accepted by the public without discussion, 
without that tenacious struggle with which they were at first re- 
ceived, especially by the house proprietor. All the provisions which 
have emanated from the board of health, which like a new power, 
arose to limit the liberty that every one enjoyed before its appearance, 
to do things as he pleased, without taking the slightest notice of 
the injuries which he might inflict on the rest of the community are 
now accepted as a matter of course. 

This absolute liberty to do things badly no longer exists, as the 



262 HYGIENIC CONDITIONS OF THE CITY OF MEXICO, 

intervention of the board in the preparation of the designs for the 
building of new houses, allows of a timely correction of the defects 
that might work to the injury of the health of the inhabitants, and 
the continuous supervision which the sanitary authorities exercise over 
the defective old buildings, leads to a gradual correction of the objec- 
tionable features in them, that still prevent their reaching an entirely 
healthy condition. 

So great has been the moral and material advancement which tends 
to improve the hygienic conditions o£ the city, that in its moral 
aspect, which refers to the education of the masses, the people show 
themselves with frequency intolerant and do not suffer without pro- 
testing the discomforts, annoyances and injuries which are caused by 
the want of cleanliness and proper sanitary equipment of the houses, 
things that formerly did not attract any notice, because as they had 
never seen anything but defective equipment, they had no means of 
establishing a comparison, and considered it very natural that the 
drains and closets should be dirty and bad smelling, whilst now the 
good plumbing work is increasing in quantity and quality every day, 
so that the objective lessons which the public receives through the 
drains and closets of any well equipped house, have taught them the 
necessity of using the same in their own. 

Even if only this education had been obtained, we could have called 
it a great step in advance; but fortunately, we can report other and 
satisfactory advances in the material part, as out of the 12,000 houses 
more or less which exist in Mexico, the board of health has inspected 
9*307, that is to say, over 77% of the total number, and there can be 
no question that before long each and every one of the houses in this 
city will have its file in the offices of the board in which will be re- 
corded the hygienic conditions of the house, its principal defects and 
the progress made towards their correction, as the proprietors in gen- 
eral have objected to the execution of the works required of them, 
by interposing delays and difficulties, but as the board always insists, 
and in the case of absolute refusal, imposes penalties that are sanc- 
tioned and supported by the law, it has at last been able to convince 
the public, that it is more convenient to accept at cmce the orders of 
the sanitary authorities, seeing that all resistance is fruitless, and that 
sooner or later the proprietors have to execute the works which are 
indispensably necessary to place their houses in good hygienic condi- 
tions. 

This decrease in the resistance which the board has to overcome 
in order to obtain the objects which it pursues on behalf of the public 
health, is another unquestionable sign of progress, as it marks a very 



HYGIENIC CONDITIONS OF THE CITY OF MEXICO. 268 

valuable step in the advancement of popular education, which leads 
the public to give a prompter and better obedience to the mandates 
of the sanitary authorities. 

The conviction has now entered into our customs that it is neces- 
sary to have that authority to watch for the greatest blessing which 
man has, his good health, the fotmtain of progress and welfare, for 
the individual as well as the community, and as the labors of the 
American Public Health Association are dedicated to the same praise- 
worthy end as those of our board of health, the propagation of 
knowledge which is for the benefit of all and the results of which 
we have already felt, that Association, this board, and all who con- 
secrate their active work to a cause of such great benefit to humanity 
in general, merit applause and gratitude, and it is with this senti- 
ment that we welcome the visit with which we are honored by the 
American Public Health Association, and extend to it our most cordial 
welcome. 



THE NEW SCHOOL BUILDINGS IN THE CITY OF MEXICO. 
Dr. M. URIBE Y TRONCOSO, Mexico, D. R. Mexico. 

On the occasion of undertaking a complete reorganization of the 
public education in Mexico, the government began by giving special 
attention to the necessity of installing the schools, and specially the 
primary schools, in buildings which would comply with the requisites 
that are indispensable where childrien are crowded together, who on 
account of their special susceptibility to outside influences, require a 
medium in which their health not only will not suffer through the 
physical conditions which surround them, but rather will receive help 
from them in the development of their health. 

As primary instruction is obligatory in the Federal District, it cer- 
tainly becomes the duty of the government to provide the best means 
of education that are compatible with the physical health of its pujnls, 
who must on no account find in the school, the germs of corporal 
deformations, or of ailments which may diminish his capacity for 
work, precisely at the time when he will have to struggle in a social 
medium which requires of the new generations a full quota of their 
work that can only be given by strong and well endowed systems. 

Immense progress has been realized within the last quarter of a 
century as regards the school hygiene in all countries, and in the 
majority of nations, the new school buildings are real palaces, full 
of light, clean, cheerful and artistic, so that they not only guarantee 
the health of the children, but have become the buildings in which 
hygiene is specially well comprehended and practiced. 

With the diffusion of education and the increase of the school popu- 
lation, the Secretary of Public Education in Mexico found himself 
obliged to face the problem of school premises, that he not only could 
not obtain under good hygienic conditions as the buildings had been 
erected for other purposes, but also could not find any under accept- 
able conditions of rent, which have now been so much enhanced in 
the city. 

The present school attendance in the Federal District, is 51,810 
pupils of both sexes, for whom 363 official schools are provided. 
These figures do not include either the pupils of the private schools, 
whose number amounts to about 10,000, nor those who are educated 
in the orphan asylum, which is under the control of the Department 
of the Interior, and to whose magnificent building I will refer later 

264 



NEIV SCHOOL BUILDINGS IN THE CITY OF MEXICO, 266 

on, nor the pupils of the military, industrial and deaf and dumb 
schools, etc. 

Although the era of construction of new school buildings was in- 
augurated sometime ago by the building of the men's normal school, 
it is only within the last four or five years that this work has been 
commenced in a systematic manner, and the fruitful results, both from 
an educational as well as from a hygienic point of view, will soon be 
felt by the teachers. 

The city of Mexico can boast that it now possesses a number of 
school buildings which are a credit to the culture and broad views of 
the government, and that doubtless are only the nucleus of new 
buildings, seeing that the Department of Public Education has ap- 
pointed a permanent board which is exclusively dedicated to the study 
and practical execution of this idea. 

The object of the present paper is to call attention to this import- 
ant step in advance which has been taken by our public hygiene, and 
to present some considerations with respect to the manner in which 
the problems arising from those buildings have been decided, so that 
after this meeting has fully discussed the subject, with a perfect com- 
prehension of its importance, we may reach the ideal formula of 
hygiene, as applied to this interesting social group. 

Five primary schools are already completed and two more are in 
course of construction. Each of them has cost from one hundred to 
two hundred thousand dollars and they can be looked upon as true 
palaces, in which there has been no sparing of the resources of 
architecture or of artistic decoration. 

The pupils will thus be inspired in a sense of duty and will also 
study under conditions of cleanliness and with a good light. For the 
children of our poorer classes, this will make a special objective 
teaching, which will exercise a powerful influence in their adult habits. 

Nevertheless, over and above the architectural good taste and beauty, 
we must recognize the supremacy of hygienic necessities as the school 
building must above all things be healthy first and handsome after- 
wards. 

I will first study the five buildings that have been completed by 
the Department of Public Education, and afterwards deal with the 
new orphan asylum, which is under the control of the Department of 
the Interior, and in which the two schools fulfill the latest lessons of 
hygiene. The five schools are situated as follows : 

1st: Comer of Aztecas and Carmen. 

2nd : Comer of 2nd Mina and Humboldt. 

3rd: Comer of Limantour Ayenue and Chapultepec Road. 



266 NEIV SCHOOL BUILDINGS IN THE CITY OF MEXICO. 

4th: Comer of 2nd Industria and Calvario. 

5th: 4th Cipres. 

In dealing with city schools, the architects necessarily have found 
themselves obliged to adapt them to the ground given to them for 
the purpose, and which sites were selected in streets of little traflSc 
and noise, generally on corners. 

The situation of the class rooms varies greatly in the new build- 
ings. Those of the Calle de Aztecas have a southern aspect; some 
of those in the Calle de Industria have a southwest aspect, and 
others north and west; those in the Calle de Mina have a northwest 
and west aspect; those of the one on Limantour Ave., open out to 
the north, south and west, whilst those in the Calle Cipres look to 
the east and west As the architects have in general followed the 
advice of Gaval who prefers a bi-lateral light^ their method of lighting' 
has naturally complied with the requirements of this system. 

As we are strongly in favor of the uni-lateral lighting on the left 
side and disapprove of the bi-lateral because it is highly injurious 
to the sight, we consider that the best aspects are to the south, east 
and north. The school on the Calle Aztecas may be considered as a 
model of its class, because the class rooms have a southern aspect 
and therefore enjoy the best light and heat. 

We absolutely disapprove of the western aspect, because it is the 
worst of all, and has been strictly prohibited in the new regulations 
for the construction of rural schools. The north aspect undoubtedly 
gives a more uniform and constant light, as it is not exposed to the 
direct and changing rays of the sun, but it has the disadvantage of 
rendering the class rooms cold during the winter. 

The greatest fault that we can find against the new schools, with 
the exception of that on Aztecas, is that the bi-lateral light has been 
utilized, without making it differential. Seated at one of the school 
desks, I have demonstrated to some of the professors, the play of 
light and shade which is caused by this method of lighting, and 
which is so injurious to the eyes. 

This method has been supported by the necessity of obtaining an 
abundance of light; but happily we can reach the disideratum by 
means of a uni-lateral light with large windows that will occupy the 
entire left side of the class rooms. 

With these the architect, E. Fernandez, has obtained in the school 
on the Calle de Aztecas, a window surface that covers almost one 
half of the ground area, whilst in the school on the Calle de Mina, 
for example, the four doors and four windows of the passage, only 
have an area of about one-third. 



NEW SCHOOL BUILDINGS IN THE CITY OF MEXICO. 267 

In Germany and the United States, the ophthalmologists and hygien- 
ists are almost unanimously in favor of uni-lateral lighting, which is 
the most adapted to give an exact idea of the form of tihe objects, 
and does not produce crossed-rays and the variations of solar light, of 
the lighting by both sides. 

This opinion also finds a great number of supporters in France. 

There is a bi-lateral light in all the class rocmis of the sdiools in 
Mina, Industria and Limantour. In the school on Cipres, the greater 
part of the rooms have a bi-lateral light, and only in that on Aztecas 
do we find an exclusive uni-lateral light. 

In spite of the bi-lateral light, there are some rooms in Mina which 
have dark comers, especially on the ground floor and in the back 
parts. In the school on Cipres, the two courts appear narrow, and 
consequently the ground floor rooms are not well lighted. All the 
others can be considered well supplied as regards the abundance of 
light. In that on Limantour the windows which look to the north 
would almost have been enough, as their area is one-fourth that of 
the ground. 

The capacity of the schools is excellent in all. With the exception 
of that on Cipres, they all have small rooms of 9.50 to 10 metres 
length, by 6.50 to 7 metres width and 4.50 to 5 metres high, and 
with a maximum capacity for 50 pupils. Each of them has over 1.25 
square metres of area available for each pupil. In the school on Cipres, 
the rooms have an unnecessary length of 14 metres and a width of 
7. This great size in the school rooms is contrary to hygiene, as it 
permits the gathering of too many children. Moreover, at a distance 
of 14 metres, the teacher can neither hear nor see the farthest pupils, 
and they in turn cannot clearly distinguish the signs and letters which 
are put on the blackboard. The ventilation has only been arranged 
by natural means, as in Mexico there is never any necessity to use 
stoves or chimneys during winter. 

In those rooms which have a bi-lateral light, it is very easy, by 
only opening the windows on opposite sides, to obtain the necessary 
ventilation, but even in those which have a uni-lateral light such as 
in Aztecas, the air can be conveniently changed by means of ventila- 
tors placed below the windows on the left side and by the window 
sashes which close the windows, and allow the upper part to be left 
open sufficiently to perfectly renew the air. 

In the school rooms in the Calle Cipres, we have noted the absence 
of these window sashes, which are so useful for purposes of ventilation. 

The closets and urinals which have been set up in all of the schools, 



268 NEW SCHOOL BUILDINGS IN THE CITY OF MEXICO. 

fulfill the hygienic requisites, and have been carefully placed far from 
the class rooms. Only in the school at Limantour, can every water 
closet be independently emptied. In all of the others, automatic boxes 
exist which are periodically emptied and wash out the whole of the 
•closets, which consist of a long inclined ovoid tube. 

We would nevertheless observe that want of a sufficient supply of 
water leads to some of them working in an imperfect manner. 

As vestibules to eacji class room, small cabinets have been arranged 
with a profusion of marble washstands, and small lockers in which 
to keep the hats and overcoats of the pupils. This is an excellent 
arrangement which we cannot sufficiently praise, and it would be de- 
sirable that all the teachers should oblige the children of the poorer 
classes to wash their hands and faces on entering the school. This 
would teach them habits of cleanliness, such as they can never acquire 
in their own houses, in which even the commonest kind of washstand 
is often wanting. In the school at Limantour, shower baths and a 
tathing tank have been established. Although we liave no great faith 
in the latter on account of the difficulties of a complete cleansing, 
we again insist on the importance of inculcating habits of cleanliness 
in the school children as in their own homes, they never or hardly 
•ever can acquire this great factor in the teaching of culture. 

The space reserved for free play and gymnastic exercises is, in 
general, sufficient, as the classes alternate in their recreations; but 
those spaces would undoubtedly be insufficient if all the pupils were 
turned out to play at the same time. Thus in the school on the Callc 
de Mina, which has a large central court and another covered one, 
each pupil out of the 300 who attend would not be allowed more 
than 1.5 sq. metres in place of the 3 sq. metres which are prescribed 
by good hygiene. It is true that this school has a small garden in 
front, but this can only be used by the pupils who cultivate orna- 
mental plants for themselves. 

The school at Aztecas contains a lai^e cement paved court and 
that at Limantour has a strip of land which is covered with coarse 
red sand. This kind of pavement is very much superior to cement 
or asphalt, which is used in the central court of the school on In- 
' dustria, because as it is less slippery it does not occasion so many 
falls, the consequences of which might be dangerous. Neither docs 
it present the disadvantage of the dust which is produced in large 
quantities in courts with a rammed earth floor. 

The school furniture is satisfactory in all; double desks are used 
of four different sizes, according to the height of the pupil, and some 



NEIV SCHOOL BUILDINGS IN THE CITY OF MEXICO. 2«» 

teachers take care to measure the height, length of the leg, etc., in 
order to adapt the furniture to the pupils and not the pupils to the 
furniture. 

We must nevertheless call attention to a fault which completely 
counteracts the advantages of modem furniture. It is well known 
, that the negative distance between the edge of the seat which comes 
beneath the edge of the table, is a variable quantity according to 
the height of the pupil, and is the most necessary requisite for a 
good position, especially in writing. For this purpose it is necessary 
that both the desk and the bench should be fastened to the floor in 
relative positions that would be calculated at the time of measuring 
each pupil. In all the schools that we have visited this requisite has 
never been fulfilled, as both the desk and the seat are continually 
moved about fhe floor, thus causing their separation by a positive 
distance, which is very injurious to the child. 

In conclusion, I will speak of the two schools for boys, girls and 
infants, in the new building of the orphan asylum. 

Each one of these occupies a wing of two floors, isolated in the 
midst of gardens, and is composed of double rooms separated by a 
covered passage way, and with a north and south aspect. The rooms 
on the south are dedicated to the general classes, whilst those to the 
north, are principally dedicated to g3mMiastics and the drawing class. 

Each room has a left uni-lateral light, with large windows, whose 
area represents ^.6 of the floor area. In order to divide the room 
from each other, large sliding wooden frames have been used, which 
can be run off so as to convert the rooms into a large hall for lectures 
or other purposes. 

The class rooms at the end of the wings, receive their light on the 
left sides and backs of the pupils, but they are principally dedicated 
to typewriting and singing. Well arranged lavatories are found next 
to the class rooms. 

We may say that these schools are models of their kind as regards 
hygienic conditions, and that their arrangement and situation is per- 
fect. Unfortunately the present necessities of the asylum oblige the 
increase in the number of classes and the estimated capacity, from 
which it results that the management has had to improvise class 
rooms in small halls, in which a great number of children are crowded, 
without the necessary conditions of health. 

This defect can be overcome by either a better distribution of the 
children or by the construction of new rooms, and this is an easy 
thing in view of the design of the schools. 



270 NEW SCHOOL BUILDINGS IN THE CITY OF MEXICO. 

In pointing out the defects of the new school buildings, it has been 
our intention to obtain improvements where necessary in the buildings 
now being erected, as well as to show the unquestionable merits that 
indicate a new stage of progress. Our observations only express the 
desires by which we are animated, for the greatest perfection pos- 
sible in the realization of the hygienic and pedagogic idea, now when 
the era of new school buildings in Mexico is so newly initiated. 



SANITARY INSPECTION OF DWELLING HOUSES IN THE 
CITY OF MEXICO. 

Dr. DOMINGO ORVANANOS, Mexico, D. F., Mexico. 

I believe that some information relative to the manner in which 
the Supreme Board of Health carries out its inspection of dwelling 
houses in the city of Mexico, may be of use to the members of this 
Association ; pointing out the difficulties which have been encountered, 
the manner in which they have been overcome and the practical re- 
sults obtained. Before treating of these points it appears to me de- 
sirable to present a slight sketch of our sanitary legislation as far 
as it relates to dwelling houses. 

* * * 

The Sanitary Code of 1891 imposes on the proprietors the obligaticxi 
to notify the Board whenever they build a new house or reconstruct 
an old one, so that in view of the plans, the Board may make the 
necessary suggestions with respect to the hygiene of the house. This 
provision is followed by a series of articles which set forth the requi- 
sites to be fulfilled in these houses. 

It then proceeds to treat with the existing houses, giving careful 
details of the requisites as regards water pipes and drains, providing 
that the latter must be sufficiently ventilated and fulfill the necessary 
conditions to facilitate the flow of the refuse, prevent the infiltration 
of the walls and floors as well as the escape of gases into the interior 
of the dwellings. 

The law then deals with other causes of insalubrity and especially 
with those which may work to the injury of the whole or greater part 
of the tenants, points out those cases in which the authorities will 
put up on the front of the house a notice in large letters stating that 
such house is dangerous either wholly or in part and in the latter case, 
specifying the apartment or house in question. 

And lastly, it specifies what houses must be ordered disoccupied 
and those in which the work must be carried out by the public works 
office at the expense of the proprietor. 

As it was observed that in spite of the obligations imposed on the 
proprietors to give notice of any new building or reconstruction these 
notices were seldom sent to the Board, the Sanitary Code whidi 
was promulgafed in the year 1894 provides that "the property tax 
office shall not accept the notice given by a proprietor that a new or 

271 



272 SANITARY INSPECTION OF DWELLING HOUSES, 

reconstructed house is oflFered to let, if it is not accompanied by a 
certificate issued by the Board stating that the construction and recon- 
struction of the building has been carried out in accordance with the 
provisions of this code and of the regulations relating to dwelling 
houses." 

In spite of the above provision it was still observed that many new 
buildings were inhabited without the inspection of the Board and there- 
fore the Sanitary Code of 1903, reads as follows in Art. 59: "In 
order that a watch may be maintained over the compliance with this 
article, the public works office shall report monthly to the secretary 
of the Board, all the licenses which it may issue for the building or 
rebuilding of houses." 

"The police inspector shall notify the Board whenever they may 
observe that a building is under construction or reconstruction within 
their respective wards." 

Since the promulgation of 1903, there have not been so many eva- 
sions of the sanitary provisions, although, I regret to state, they have 
not been very rare. 

Another of the important amendments in the Sanitary Code now 
in force as regards dwelling houses, is that which refers to the pro- 
vision to be made for the discharge of the refuse from the "accesorias" 
(one or two roomed houses with door to the street) in order to pre- 
vent people from sleeping in those rooms when they contain a closet 
or are utilized to sell food and beverages. There is also another 
article which authorizes the Board to execute all the works which it 
may consider necessary to ascertain the conditions of the closets and 
drains or of any other part of the building which may be in any way 
injurious to health. 

The present Sanitary Code contains other articles of which we 
will speak further on, and which will contribute in a notable manner 
to the sanitation of the dwelling-houses. 

« ♦ * 

The houses are visited by the sanitary inspectors of whom there is 
one for each of the eight wards into which the city is divided. These 
visits are made whenever a contagious disease makes its appearance 
in any house, when some resident makes a complaint or one is re- 
ceived from any other person which would indicate an unhealthy 
condition, when a second inspection is made to see that the works 
ordered have been properly executed and whenever through any other 
circumstances the Board of Health considers it advisable to order such 
a visit. 



SANITARY INSPECTION OF DWELLING HOUSES, 273 

The report of the inspector goes into full detail, includes fifty-six 
answers to as many questions which relate to the sanitary laws in 
force and besides this, the inspector points out the works which in 
his opinion should be executed besides those which are to be inferred 
from the answers given to the interrogatories. The report of the 
sanitary inspector is on the same day passed over to the member of 
the Board who has under his charge the ward in which the house is 
situated and in view of the answers given by the inspector he decides 
on the fine to be imposed on the proprietor, or through the secretary, 
he orders the execution of the necessary work, for which he allows 
an adequate time. Once this period has elapsed, the house is again 
inspected and if the works have not been executed or only partially 
executed, a fine is levied on the proprietor which may be from $10.00 
to $500.00. 

When dealing with urgent or easily executed works, the sanitary 
inspector himself gives the verbal or written order to the proprietor 
in order that they may be executed and if this is not done the member 
of the Board who has charge of that ward, imposes the respective 
fine. 

Should the interested party desire to appeal from the fine, the case 
is brought before the Board for revision, and will then be decided in 
accordance with Articles 377 and 378 of the Sanitary Code which 
read as follows: 

"Art. 377. Whenever any of the officers or agents referred to in 
the previous article including the committees of the Board should 
impose a penalty and an appeal be taken thereon, as provided in Sec. 
Ill of Art. 30 of the Code of Penal Procedure of the Federal District, 
the minute relating thereto will be referred to the Board which in 
fiill meeting attended by the half and one more of the members will 
confirm, modify or reverse the ruling of the person who imposed it, 
taking into account the arguments presented by the appellant or by 
his representative in writing, and the verbal opinion of the law officer 
of the Board. Should the decision pronounced be entirely in accord- 
ance with that of the officer imposing the fine, there will be no farther 
appeal otherwise the appellant may apply to the Department of the 
Interior within three days asking for a reversal or modification of 
the penalty, in the use of the full powers which that department has 
to amend any ruling pronounced by any sanitary authority which is 
under its control." 

"Art. 378. In the cases of revision which are referred to in the 
preceding article, a stay of execution will be granted until the Board 
or the Department of the Interior has pronounced its ruling if the 
18 



274 SANITARY INSPECTION OF DWELLING HOUSES, 

penalty is imprisonment, or if it is a fine, the appellant shall deposit 
the amount thereof. Should he not make this deposit the fine will be 
enforced as provided by law, on the understanding that it will be re- 
funded if the penalty is modified or remitted by either the Board or 
the Department of the Interior." 

« * :|c 

The practical results which up to the present have been obtained 
through our sanitary laws have been that, as regard new houses all 
that have been constructed from 1891 to date and of which the Board 
has had any knowledge fulfill the necessary hygienic requisites, and 
as regards the old houses, 33% of those that have been inspected within 
the five year period, that is to say over 3,000 have been reformed in 
accordance with the sanitary laws in force. 

The results obtained up to date have not been very great but still 
much greater than those observed in France, where the old buildings 
leave much to be desired in several departments and even in the old 
quarters of Paris itself. In the year 1853 a law was enacted in 
France relative to unhealthy dwellings which was preceded by some 
instructions issued in 183 1, an ordinance issued by the prefect of 
police in the year 1848 and another law in 1850. Nevertheless, it is 
stated in the ministerial circular of the 21st of December, 1858: "that 
with the exception of some honorable cases the greater part of the 
municipalities have shown the greatest indifference towards a bene- 
ficial and moralizing law." This law received a partial application in 
eleven departments, in twenty-six of them very little was done and 
in forty-nine absolutely nothing. 

The expenses caused by the reforms in old houses, for the purpose 
of adapting them to the requirements of modem hygiene on the one 
side, the belief which many proprietors have that such reforms will 
do little or nothing to improve the conditions of their dwellings, which 
they consider healthy, and the indifference and complete apathy 
of the tenants, are all obstacles which oppose the sanitation of the 
dwellings. We have also encountered other difficulties, that for the 
moment have been found insuperable. Our Sanitary Code of 1891, 
in dealing with the existing houses, allowed a term of six months for 
the reform of their closets, drains, etc., and of five years for the ful- 
fillment of the other provisions relative to the dwellings, the proprie- 
tors nevertheless being bound to comply at once with all the sanitary 
provisions whenever the house was reconstructed for any reason. 

The first difficulty which we encountered consisted in the absence 
of sewers in many suburban streets, and besides this the absence o4 
water supply in the greater part of those streets. In some houses, 



SANITARY INSPECTION OF DWELLING HOUSES, 275 

artesian wells have been drilled but the want of a sewer prevented 
the execution of any sanitation works, and in others in which a sewer 
existed they had neither an artesian well nor water from the supply 
pipes and therefore it was impossible for them to comply with the 
law. 

The great rage for building which has invaded the city within the 
last twenty years and which has gone on increasing from day to day, 
gave rise to the creation of new suburbs on the outskirts of the city 
and many of these in the northern, southern and eastern parts of the 
city were filled up with small houses built by the poorer classes of 
the city who had not the least idea of the necessity of complying 
with any municipal regulations. Under these conditions were created 
the so-called "colonies" Dias de Leon, towards the east ; Valle Gomez 
and La Bolsa to the north and northwest respectively and La Viga 
towards the south. All of these colonies abound in apartment houses, 
especially constructed to furnish apartments in common and a par- 
ticular class of dwellings of a most unhealthy character made up of 
sheds; that is to say of rooms badly built up of boards with roofs 
made of mats, rags and rubbish and with the earth for a floor. It 
is in dwellings of this class where the most frequent cases of typhus, 
ftmallpox and other infectious diseases have been observed, and a 
little study of the plans formed by the Supreme Board of Health in 
connection with the epidemics of typhus of 1893 and at the com- 
mencement of the present year, will show that these epidemics have 
been exclusively confined to the eastern part of the city and especially 
in the new "colonies." As regards the western part the isolated 
cases of typhus or smallpox which have been observed were very 
rare. Unfortunately we still have in the central part of our capital 
city large apartment houses that are excessively unclean and of which 
some were old convents or old palaces of the nobility which have sub- 
sequently been adapted as apartments that lodge numerous families. 
In these buildings we have also discovered foci of smallpox as well 
as of typhus. In the new "colonies" to the west of the city the sani- 
tary conditions have always been all that could be desired. 

An attempt has been made to remedy for the future the difficulties 
which are caused by the unhealthy houses in the new "colonies," by 
the following provisions in Art. 328 of the Sanitary Code which reads : 

"The houses which may be erected after the promulgation of this 
Code in 'colonies' in which no municipal sanitary services exist of 
sewers, water supply, pavements, and garbage collection, shall not be 
inhabited as long as such services are not provided. These houses 



276 SANITARY INSPECTION OF DWELLING HOUSES. 

like all others of the city shall fulfill the requisites provided under 
this Code in the chapter which relates to dwelling houses." 

As regards the sheds, the evils to which they may give rise will 
also disappear under the strict compliance with the following articles 
of the Code : 

"Art. 1 08. Every room intended to be used as a dwelling and 
whose walls are not constructed of stone, brick, tepetate or adobe, and 
covered with a lime and sand mortar will be considered sheds. 

"Art. 109. Nevertheless, the provisions of the preceding Article 
will not apply to the wooden buildings which are erected in accord- 
ance with the hygienic precepts of this Code in the opinion of the 
Supreme Board of Health. 

"Art. no. Orders will be issued for the disoccupation, until they 
are placed in good conditions of the dwelling houses which have 
masonry walls but nevertheless suffer from all or any of the follow- 
ing defects: roofs which are not made of bricks and earth or iron 
sheeting under such condition as to prevent the current of air and 
the influence of the changes in the outside temperature from being 
felt, which are not plastered, or have not a wood or brick floor in 

a good state of preservation." 

* * * 

The above remarks show that the laws enacted by the Supreme 
Board of Health of Mexico with respect to dwelling houses are prob- 
ably more severe than those which govern in any other part of the 
world ; that it possesses an authority and the necessary means to exer- 
cise a vigilant oversight; that it has power to punish infractions by 
fine up to a considerable amount and even by imprisonment, and that 
in spite of all these advantages it has been found as yet impossible to 
make any great advances in the sanitation of the dwelling houses. In 
the northern and eastern part of the city we have extensive "colonies" 
with hundreds of houses that are inhabited by the poorest class of 
people; these houses are in close contact with each other; there is no 
drainage of the soil, no water supply, and therefore the subsoil is 
made up of a layer of excrement. As the air can only enter by one 
side of the house, because as a general rule, the door and window are 
opened in the same wall the current which enters through the lower 
part and issues through the upper part of tiie room, describes a 
curve that penetrates only a little way into the interior so that the 
ventilation is very imperfect. In these miserable rooms at least ten 
to twelve human beings are crowded tc^ether of both sexes and all 
ages, dwelling in the most intimate familiarity with dogs, cats and all 
kinds of domestic animals. It is easy to understand that from these 



SANITARY INSPECTION OF DWELLING HOUSES, 277 

conditions follow the physical degeneration, the appearance of dis- 
eases, the social degeneration, and that many of these dwellings be- 
come the starting point on the road to the hospital or the scaflFold. 

The Board has anxiously studied the unhealthy conditions of these 
dwelling houses, and up to the present date has been unable to find 
any solution that could be acceptable and at the same time really 
practicable. In April, 1903, the city council declared that it will 
provide no municipal service for those "colonies" which have not been 
received and accepted by the corporation, but the sanitation of the 
dwellings is impossible if we cannot count on those services. The 
engineer, Miguel Quevedo, a member of the Board, once proposed 
that the proprietors of those "colonies" without sanitation should be 
allowed a certain term within which to furnish all the services of 
urbanization; but the present writer called attention to the fact that 
as the proprietors of the dwelling houses in those "colonies" are all 
very poor men it would be materially impossible however long the 
period allowed them to execute all the urbanization works. As a 
matter of fact the ground on which those dwelling houses are erected, 
originally cost from five to ten cents per metre, so that a lot of three 
hundred square metres cost thirty dollars. The services of urbaniza- 
tion including pavement, sewers, water and light have been estimated 
to amount to somewhere about $3.00 per square metre, that is to say, 
that the same lot would then cost $900.00 a sum entirely beyond the 
means of the greater part of those proprietors. On the other hand 
the city council could hardly come to the determination to undertake 
an expense of some millions of dollars in that part of the city which 
is inhabited by the poorest classes and which therefore would never 
repay the expenditure out of taxes. 

It would be much to be desired that the general government should 
invest a part of the large surplus which is left every year after cover- 
ing all its expenses in the purchase of these foul "colonies" and it 
might even be possible by agreement with some company to build 
healthy and cheap dwellings for the poorer classes either on the same 
lots or on others which might be acquired. 

With a view to reaching a solution of this very complicated problem 
of social hygiene, I invite the co-operation of all who are here present 
and who, from their practice and special conditions may be in a posi- 
tion to give us the assistance 6f their knowledge, talent and experience. 



THE PROBLEMS OF CAR SANITATION. 
THOMAS R. CROWDER, M. D.. Chicago, III. 

The railway had long ago reached such stage of activity in 
America that its sanitary problems became of importance. It was not 
until very recent years, however, that these problemjs were adequately, 
or at all generally, discussed. The rapid development of the means 
of travel gave us a new set of sanitary questions, which have been in 
part answered in the papers dealing with various phases of the subject 
by Bracken,^ Hurty,^ Conn,' Dudley,* Trask,* Rosenau* and others. 

That the problems presented have not yet been solved in all their rela- 
tions, however, is amply proven by the great diversity of opinion still 
held by sanitary experts. Further investigation is needed. It is de- 
sirable to know many facts difficult of determination. But In the work- 
ing out of new sanitary problems, frequent orientation is necessary in 
order to keep them in their right relations, to apply the general princi- 
ples of sanitary science, and to prevent confusion of the major and 
minor questions at issue. I wish to make a brief inquiry mto the 
dangers which railway travel may hold out to the public health, and to 
measure the influence of car hygiene in averting these dangers. 

We may direct this inquiry under three general headings : I. The 
danger arising from mechanical accidents: II. The danger of con- 
tracting infectious diseases : III. The danger incident to a group of 
miscellaneous influences, such as the rapid variable motion, faulty venti- 
lation, heating and lighting of cars, and the breathing of dust, smic^e 
and engine gases. 

^ Bracken, (a) Sanitation in its bearing upon certain Railway Problems. 
The Railway Surgeon, September, 1903. (b) Infection in Transportation. Am. 
Med. August 12, 1905. (c) A Few Points Relating to Car Sanitation. Rep. 
of Am. Pub. Health Ass^n. Vol. XXXI, 1905. 

'Hurty. (a) Passenger Coach Sanitation. The Railway Surgeon, October 
16, 1900. (b) Railway Sanitation. Ohio Sanitary Bulletin, 1906. (c) Inter- 
national Journal of Surgery, May, 1902, page 155. 

• Conn, (a) Report of Com. on Car Sanitation. Reports of Am. Pub. Health 
Ass'n, Vol XXIX, 1903. (b) International Journal of Surgery, May, 1902, 
page 152. 

• Dudley, (a) The Dissemination of Tuberculosis as Affected by Railway 
Travel, Med. News, Dec. 16, 1905. (b) Passenger Car Ventilation Systems of 
the Pennsylvania Railroad. Altoona, 1904. 

• Trask. The Dangers of Unrestricted Traveling of Consumptives. Journal 
of the Ass'n of Military Surgeons, 1905. 

•Rosenau. International Journal of Surgjery, May, 1902, page 157. 

278 



THE PROBLEMS OF CAR SANITATION. 279 

I. Though the first of these items — the danger from mechanical 
accidents — is, in its ultimate analysis, the most important, and in the 
broadest sense, a sanitary problem, we may, for the present purpose 
leave it out of consideration. In the nature of things, the professional 
sanitarian has little to do with the measures taken to prevent such acci- 
dents. They are the special concern of the railway management, and 
require neither the knowledge nor the training of the physician to 
properly interpret and understand. The economic consideration which 
they involve may be trusted almost alone to work out their remedy. 

II. The liability of a passenger to acquire an infectious disease 
during his period of travel, is, however, while a more intangible danger, 
one the protection from which is the sanitarian's special interest; and 
its correct interpretation requires all his technical training and his 
knowledge of technical facts. It covers most of the important prob- 
lems of car sanitation, strictly interpreted. 

We may profitably divide our consideration of this phase of the sub- 
ject also into three parts: i. the danger of infection through associa- 
tion, that is, by direct contagion ; 2, the danger from the use in com- 
mon of the facilities for comfort and convenience ; 3, the danger from 
the infected car. 

I. It must be admitted that the association of any considerable 
number of persons in any confined space renders each one a possible 
victim to the contraction of a contagious disease. This holds true in the 
railway coach, but it differs very slightly, if at all, from the danger 
existent in similar association in the theatre, hotel, store and other 
public places; and we might, perhaps, correctly state that even the 
street and the highway hold out their remote possibility of direct con- 
tagion. Wherever one goes among his fellows, this possibility follows 
him as one of the necessary evils. It is increased by the railways only 
to the extent that they facilitate intermingling. That the average 
danger is in general slight, and is not worthy of exerting any deterrent 
influence upon social intercourse, seems to be a generally accepted 
opinion. It is nevertheless probable that such association Is responsible 
for a very large proportion of the ordinary acute infections and par- 
ticularly of those affecting the air passages. 

It is, of course, desirable that every effort should be made to limit, 
as far as possible, the association of the diseased with the healthy in 
public places. The only obvious way to accomplish this is to deny to 
the sick the right of mingling with the well. In case of smallpox, 
scarlet fever, measles, diphtheria, and a few other manifestly contagious 
diseases, we do this, depriving the affected individual of his liberty if 
necessary to insure his isolation. But a host of other infections, which 



280 THE PROBLEMS OF CAR SANITATION, 

may, under certain circumstances, become directly commimicable, arc 
allowed to associate at will. Consider, for instance, influenza, a disease 
usually prevailing in epidemic form, spreading with such remarkable 
rapidity as to leave no doubt of its extreme contagiousness. Produced 
by a bacillus known to have very little resistence to dessication, sun- 
light and unfavorable temperatures,^ to exist in large numbers in the 
sputum and nasal secretions of the infected, the disease is transmitted 
directly from man to man, and chiefly, it is supposed, by means of in- 
fected droplets expelled in coughing and sneezing. Those afflicted with 
influenza are very often still well enough to go about their business and 
their travels, and thus be spreaders of the infection. Again, it has long" 
been recognized that mild and a typical cases of various ccmtagious 
diseases are by no means rare. That scarlet fever may have no eruption, 
mild sore throat be really diphtheritic, that even smallpox may be mild 
and unrecognized, are facts which have been well established during the 
last decade. Indeed, we know that there is a vast number of un- 
recognized cases of contagious diseases which go about in apparent 
health spreading their infection. Furthermore, it is well known that 
virulent organisms may continue to be produced in the bodies of those 
infected for weeks or months after the disease has been recovered from, 
and that pathogenic organisms are frequently found even in those who 
have never been sick at all. How then is it possible to escape from the 
dangers incident to association? It is not possible to exclude the in- 
fected, but only the sick, and whoever is able to go about with the ap- 
pearance of health will continue to be our fellow traveler. 

How far is the railroad able to aid in preventing contagion from this 
cause by contributing to the desirable segregation of the diseased fr(Mn 
the healthy? Dr. Dudley*, of the Pennsylvania Railroad, has defined 
the situation so clearly that I quote, in part, his words : 

"* * * * It may be urged that the railroads have no right to ex- 
pose their healthy passengers to the dangers of contracting diseases 
from others, and that they should exclude from their cars all people 
affected with communicable diseases. * * * While it is undoubted 
that the railroads have a right to exclude, and, for that matter, do ex- 
clude from their cars people known to have contagious diseases, such, 
for example, as smallpox, it is entirely evident that the exercise of 
this right depends upon correct diagnosis. To refuse transportation 
to a person or persons because they were suspected by the ticket agent 
or conductor of having a communicable disease, might entail serious 
sonsequences. * * * Railroads are common carriers, * * * required 

^Ricketts. Infection and Immunity. Chicago, 1906, page 395. 
• Dudley. The Dissemination of Tuberculosis as Affected by Railway Travel. 
Medical News, December 19, 1905. 



THE PROBLEMS OF CAR SANITATION, 281 

to perform certain public duties, prominent among which are the trans- 
portation of persons and property. It is not possible to refuse trans- 
portation except under certain well defined conditions, and since neither 
ticket agents nor conductors are, or can be from the nature of the 
case, physicians, it is difficult to see how, at least under present legis- 
lation, transportation is to be denied even to those who may be affected 
with communicable diseases. The proper remedy, * * * if any 
remedy is possible, would seem to be in legislation making it a crime 
for those afflicted with certain communicable diseases, to ask for, or 
to accept transportation from common carriers." 

One of the most important of the traveling diseases is tuberculosis. 
While we must look upon this as a disease possible of direct trans- 
mission, and while its prevalence and destructiveness are truly appalling, 
public sentiment, and even the sentiment of the medical profession, ap- 
proves of granting it the right to travel. The railroads cannot refuse its 
victims transportation as dangerous passengers in opposition to the 
public sentiment which permits them the freedom of all other places, 
public and private. While I believe it would be well to restrict the free- 
dom of the tuberculous, still, in recognition of the possible benefit that 
changes of climate may have on the disease, I am not now willing to 
advocate preventing them from taking advantage of such travel as they 
are able to undertake in search of health. We are all, undoubtedly, 
more or less exposed to this widespread infection at some time in our 
lives, and the little more or less exposure involved in the health-seeker's 
travel is probably not of great consequence, the time of association be- 
ing relatively short and not necessarily close. Much may, however, be 
done to limit the danger occasioned by the tuberculous whether in cars 
or elsewhere. Their danger consists in spreading their sputum about 
them, projecting infected droplets into the faces of others or infecting 
the things they use, all of which miay be avoided, at least so nearly 
avoided that the danger practically disappears, by correct personal 
habits. Teach the tuberculous that they are dangerous, and teach them 
personal hygiene ; for so long as they are permitted to associate in free- 
dom with their healthy contemporaries, they probably must also be 
allowed the privilege of traveling by way of the railway coach. The 
sanitarium for the tuberculous is a safe place for the well. It is made 
so by the patients themselves. The railway coach deserves similar 
protection. 

This leads me, naturally, to speak of the often repeated proposal that 
special cars should be furnished for the diseased, more especially for 
the tuberculous. The proposal undoubtedly has excellent virtues, and I 
would say that it should be acted upon forthwith, if there were not 
what seem to me insurmountable obstacles to carrying it into eflfect. 



282 ' THE PROBLEMS OF CAR SANITATION, 

In the first place, there is the eccMiomic consideration. The amount of 
such travel will not justify furnishing special cars. These people are 
often — indeed usually — too poor to pay for the extra expense entailed. 
Railways are economic institutions, and cannot be expected to furnish 
transportation at a loss. The state is not yet sufficiently impressed with 
the desirability of isolation to be )villing to pay the deficit. But of even 
greater practical importance is the great probability that it would be 
impossible to get more than a small proportion of tuberculous patients 
into such special cars. It is not necessarily the bedridden consumptive 
who affords the greater danger of infecting his associates. Far more 
important is the patient, either unsuspected or showing no conclusive 
signs of the disease to the casual observer, who would still insist on 
traveling as a healthy individual would travel. Of this class of patients 
there are vastly more going about the world than of those severely sick. 
Only a law making it a misdemeanor for him' not to declare his disease 
when applying for railway transportation would force him into his 
proper compartment; and even then, perhaps, a large proportion of 
them would either avoid or defy the law and take their places in the 
ordinary coach and sleeping car and escape detection. In its last 
analysis the question would remain not so much of the car as of the 
habits of those who use the car. 

By adopting a pessimistic view, we may theorize the dangers of free 
social intercourse into formidable proportions. The most constant 
optimism' cannot argue it into an entirely negligible quantity. I have 
already expressed the opinion that direct contagion is responsible for 
most of the contagious diseases ; but we must confess that it is a subject 
which it is difficult to materially alter in any other way than by educa- 
tion in personal hygiene which both the sick and the well should apply, 
or by changing public sentiment on the subject of allowing those sick 
of certain diseases the freedom of intercourse and travel. 

2. What are the possibilities of indirect transmission by reason of 
the use in common of a car's facilities for comfort and convenience? 
The answer to this question goes back in great measure to the determi- 
nation of how many travelers are afflicted with transmissable diseases 
or harbor pathogenic organisms — a subject which has been touched 
upon in the above consideration of direct contagion. Statistics are not 
at hand, and are scarcely possible of compilation, showing the proporticMi 
of the infected to the healthy among railway travelers. Yet to de- 
termine, with any degree of accuracy, the possibilities of danger held 
out by them, either from direct or indirect contagion, it would be neces- 
sary to know the proportion of the whole each disease constitutes. I do 
not mean to imply that knowing this would satisfactorily answer the 



THE PROBLEMS OF CAR SANITATION, 288 

inquiry. It would rather furnish premises from which we might hope 
to reason logically upcHi the liability of transmission. It would still be 
necessary to establish, however, the degree to which various utensils 
must be contaminated before they could be said to hold out real danger 
of infecting the user. The contraction of disease by infection is so 
largely a matter of individual resistance and susceptibility that it is 
difficult indeed to draw sharp lines upon its probability. The number 
of organisms which in one person produces disease may be innocuous 
to another. We may compare pathogenic bacteria to poisonous drugs 
and speak of a harmless, toxic and lethal dose. Theoretically I suppose 
it may happen that the smallest dose — a single organism — might be 
capable of producing a disease; but phagocytes, opsonins and other 
protective bodies of the human tissues are generally able to overcome 
considerable numbers of even the most virulent bacteria ; and absolute 
sterility of the things we use, even freedom from pathogenic organisms, 
is not necessary in order for the great majority of us to escape infection. 

The railway should provide facilities in keeping with the state of 
sanitary science and the hygienic habits of the people ; it cannot, how- 
ever, at all times enforce their proper use; and at any stage of per- 
fection in the facilities provided, abuses are liable to occur which 
must be laid at the door of the public which makes use of them. 
The providing of sanitary appliances is the railroad's duty ; the main- 
tenance of sanitary conditions is largely dependent upon the users* 
Before we are through with the crusade against spitting we must 
teach people that it is not sufficient to avoid spitting on the floor or 
the sidewalk, but that a wash basin is not a cuspidor and that drinking 
cups should be held sacred against tooth brushes. Habits leading to 
these abuses are habits formed at home. They do not arise from con- 
ditions existing in cars. It is not difficult to avoid the wash basin in 
brushing the teeth. Most people neither try nor care to do so. They 
need instruction. 

The dangers of indirect infection in railway coaches increase theo-- 
retically, and no doubt practically as well, in proportion to the length 
of time a car is in service on any single trip, a statement which is 
equally applicable to any element of danger shown to actually exist. 
The longer the trip, the longer the personal association of passengers,, 
the greater their necessity of using toilet and other facilities at hand, 
and, consequently, the greater the liability of pollution. Other things 
being equal, the sleeping car would therefore be more liable to con- 
tamination than the day coach. Its average journey is longer. Other 
things are not equal, however, because of the constant supervision 
of the sleeping car en route, more care at its cleaning terminal, its 



2«4 THE PROBLEMS OF CAR SANITATION, 

average higher class of patrons and its carrying fewer persons to the 
car. 

It is in the power of railway passengers largely to annul on the 
one hand the dangers incident to their own intermingling, and on the 
other, whatever measures the railroad may take for their protection. 
They have the right to demand, nevertheless, that the railroad provide 
facilities whereby they may carry out to the utmost their own pro- 
tection. Closets should be well flushed, perfectly emptying, and 
capable of easy cleaning. Lavatories should be supplied with 
abundance of water, well drained, trapped to prevent back flow of 
water and entrance of dust, the surface should be smooth and easily 
cleaned by rinsing and wiping. If each user should rinse and wipe 
out a wash basin after using it, he would do only his hygienic duty, 
and reduce, to the vanishing point, the liability of its conveying in- 
fection, for it is not necessary that a wash basin should be sterile 
in order to be safe. Small towels should be supplied in such abund- 
ance that each needs to be used but once. While the common hand 
towel is perhai>s practically without danger, one should never be 
obliged to use the common face towel. 

The common drinking cup has been much discussed and rigidly 
<:riticized of late, and orders for abolishing its use entirely have 
been considered by the Surgeon General of the United States Public 
Health and Marine Hospital Service. It would be a sweeping reform, 
and the effect of such a move upon the public humor cannot be 
read in advance. For the present the railroad is obliged to furnish 
.something in the way of a drinking cup, however, and the attempt 
should be to provide one with the least liability of conveying infection 
from lip to lip. It should have a perfectly smooth surface outside 
and in, preferably made of glass to better accomplish this result and 
to render immediately visible gross contamination and dirtiness. It 
is through the medium of the common drinking cup that the closest 
indirect relations, from a hygiene viewpoint, are established between 
passengers; and it is here, perhaps, that the greatest danger of the 
indirect transmission of disease arises. There is considerable ex- 
perimental evidence of cup contamination. A. Moeller,' of Berlin, 
has recently found tubercle bacilli, influenza bacilli, staphylococci and 
streptococci on the edges and in the residue remaining in communioo 
cups. Kinyoun*® found pneumococcus, streptococcus, staphylococcus 
aureus and diphtheria bacillus once each in twenty-one drinking cups 

•Moeller. Deutsche Med. Woch. 1905, No. 14. 

"Kinyoun. The Bacterial Content of the Railway Coach. Med. News, 
July 29, 1905. 



THE PROBLEMS OF CAR SANITATION. 285 

from sleeping cars. Probably cups in constant or oft-repeated use are 
very generally infected, since mouths are always so and people 
generally are careless drinkers. For the most part they contain harm- 
less bacteria, (Kinyotm found but one of the organisms isolated to be 
really pathogenic, the diphtheria bacillus, while the pneumococcus was 
very slightly so) ; and the same ntmiber of organisms found in the 
wash basin would, no doubt, be entirely harmless; but the drinking 
glass comes a little too close for comfortable suspicion. Its contents 
gain direct entrance to the body and traverse the whole gastro-in- 
testinal. tract with its vast extent of absorbing surface where some 
point of entrance for organisms may be found. Obviously the danger 
of transmission from this source is greatest in those diseases where 
there are lesions in the mouth, as syphilis, actinomycosis, aphtha and 
tonsilitis; and quite as obviously the simplest way to avoid it is for 
each person to carry his own drinking cup, as many do already. 
The railroads can scarcely be held responsible for a danger to which 
they do not contrilMite more directly than they do to this, and in which 
they follow a custom so generally followed and demanded by the 
public. The common drinking cup is universal. The evil that it 
contains does not exist in its worst form in well regulated cars whefe 
the cups are, or should be, frequently cleaned. There are ways of 
drinking from a cup which render the probability of contamination 
very slight. Most people are careless in this as in other personal 
habits. Rinsing and a clean towel will make almost any cup harm- 
less, however, if the user cares to take so much trouble. 

The drinking water should be the purest locally obtainable; it 
should be cooled by ice from sources of a pure supply, which should 
be well washed before putting into the tanks, and handled only from 
clean receptacles with tongs or clean gloved hands. The water 
coolers should be removable and cleansable and protected from possible 
contamination by car occupants. They should be frequently scoured 
and steamed. These are clear-cut duties of the railroad or car com- 
pany and distinctly apart from the hygienic duties of the traveling 
public. 

3. Hangings, linen and bedding are in general appurtenances of 
sleeping cars only. What part are they likely to play in the indirect 
transmission of disease? Linen may be at once dismissed from con- 
sideration since it is always fresh to the user. So far as any single 
trip is concerned, the hangings and beds belong in lots to single indi- 
viduals, and the consideration of their possible danger to the health 
of the traveler brings us to the discussion of the third element of the 
danger of infection in railway travel, namely, the possibility of the 



286 THE PROBLEMS OF CAR SANITATION. 

car itself being infected in such a way as to transmit disease to its 
occupants. This is dealing simply with a new phase of the question 
of indirect transmission of disease — indirect transmission from 
previous passengers or from extraneous sources. 

Some investigation of this problem has been made in both this 
country and in Europe, though an insufficient amount of evidence 
is now at our command to warrant the drawing of any sweeping con- 
clusions as to the relation between the public health and car infection. 
We might logically apply a form of reasoning, based upon the more 
general investigation of the bacterial content of various other in- 
habited places, the details of which it is not necessary to repeat here, 
and say that railway coaches may be expected to contain many 
microbes, mostly harmless, but now and then pathogenic in their 
nature. The investigations of Kinyoun, above referred to, prove the 
correctness of this interpretation of the general conditions. His re- 
search included : ( i ) The bacterial content of the dust from carpets ; 

(2) the bacteria obtained from the interior furnishing of the coach; 

(3) the bacterial content of the air of the coach, and (4) the 
bacteria of the drinking cup, already referred to. 

It is worth while to review the results of these examinations. 
Dust was obtained from 200 cubic feet of air passing over carpets 
being swept, beaten or blown with compressed air. Seven samples 
so obtained, were investigated. Many varieties of bacteria were 
found, principally those ordinarily found in the air. Microscopic 
search failed to demonstrate the tubercle bacillus among them, and 
animal inoculations proved its absence. The pneumococcus, 
staphylococcus aureus, streptococcus and colon bacillus were the only 
pathogens found ; of these, the author says : "only the pneumococcus 
proved pathogenic, and this but slightly so." Some of the inoculated 
animals, I find from the subsequent text, however, developed ab- 
scesses from staphylococcus infections, a result to be expected no 
matter what the source of the dust. 

Dust was collected from the interior furnishings of 29 sleeping 
cars, 3 day coaches and 2 smoking cars, by rubbing sterile moist swabs 
over not less than 15 square feet of surface. Eleven of these cars 
were running to health resorts during the height of the travel 
Microscopical examination of these samples showed them to contain 
various bacteria, and the ordinary elements of the dust of habitations. 
Numerous samples stained for the tubercle bacillus gave two positive 
tinctorial and morphological results. Sixty-four animal inoculations 
gave one positive tuberculosis, 5 pneumococcus infections, i di[A- 
theria, 2 staphylococcus, 2 streptococcus, 2 colon bacillus, i malignant 



THE PROBLEMS OF CAR SANITATION. 287 

oedema, i streptothrix, and 6 hemorrhagic septicaemias. Forty-three 
animals gave negative results. 

Realizing that the pathogenic bacteria floating in the air are of 
greater relative importance than those with stationary lodgment, spe- 
cial attention was given to their examination. Amounts of air ranging 
from 1500 to 7200 cubic feet were aspirated from 48 occupied coaches, 
27 running to and from health resorts, and its dust filtered out and sub- 
jected to analysis. Numerous yeasts, moulds, sarcinae and bacteria 
were observed. The pathogens isolated were pneumococcus, stajrfiylo- 
coccus aureus, colon bacillus and an organism causing hemorrhagic 
septicaemia. The author says, "The majority of the bacteria found 
in the air [of coaches] evidently had their origin, as would naturally 
be expected, from the outside air." Ninety-six animal inoculations 
were made which resulted as follows: Tuberculosis i, pneunwcoccus 
infection 8, staphylococcus infection 4, general septicaemia 5, malig- 
nant oedema i, negative 76. Pneumococcal infections were obtained 
from the air of smoking cars 'almost entirely. 

Prausnitz** and Petri** were able to demonstrate tubercle bacilli 
in cars carrying many consumptive patients to the health resorts of 
Switzerland and to Berlin during the first activity of Koch's tuber- 
culin treatment. They were found chiefly on the floors as the result 
of spitting, an evil which our widespread crusades has materially less- 
ened in the last few years. 

Every space occupied by human beings is to a certain degree in- 
fected, as are all the individuals themselves. The colon bacillus, for 
instance, is a normal inhabitant of the human body. It appears in the 
intestines soon after birth and is not thereafter absent. Ordinarily it 
is harmless, perhaps even useful to the bodily functions, though under 
certain conditions it may take on virulent activities and give rise to 
pathologic processes. We expect to find it more or less generally dis- 
tributed where human beings exist ; otherwise the child would not be- 
come uniformly infected in the first few days of its life. Its existence 
in the railway coach is scarcely more than normal. "The pneumo- 
coccus is present in the nose, mouth and pharynx of a large percentage 
of individuals. * * * it persists for weeks and months in the 
mouths of convalescents from pneumonia, and it reaches the mouths 
of those who are in the vicinity of pneumonics. It is found frequently 
in the conjunctiva and occasionally in the deeper air passages.** 
Knowing this organism to be fairly constant in the upper respiratory 

"Prausnitz. Munch. Med. Woch. 1892. 
" Petri. Arb. aus d. Kais. Gesundheitsamte 1894. Bd. 1111. 
"Ricketts. 1 c, p. 339. 



288 THE PROBLEMS OF CAR SANITATION. 

passages of normal individuals, we should expect to find it fairly con- 
stant in the places they inhabit. Having but little resistance outside 
the body it soon dies off, but occupied places are being constantly 
reinfected. Concerning the unusual conditions that must arise to pre- 
cipitate infection of the pulmonary tissues we have little but theories. 
Certain it is that attempts should be made to lessen its distribution; 
this can be done only by care on the part of those who harbor it. 

So far as the staphylococcus is concerned, it is widely distributed 
in nature. We all expect to find it on our hands, consequently on 
the things our hands pick up. Almost as much may be said of the 
streptococcus. It can usually be cultivated from the normal mouth 
cavity. Streptothrix is also frequently found in the normal mouth and 
is usually harmless there. The bacillus of malignant oedema is normal 
in garden earth which we handle with impunity. To introduce it 
into the peritoneal cavity is another matter. Hemorrhagic septicaemia 
is produced by various organisms, which are more or less widely 
distributed in nature, and is not ordinarily an infection easily acquired. 

Diphtheria bacilli may persist in the nose and pharynx of conval- 
escents for weeks and months, continuing long after recovery. They 
are frequently found in the upper air passages of healthy persons 
who may never have had diphtheria, but who have been in contact 
with the diseased. Kober^* obtained virulent bacilli from 8% of in- 
dividuals who had been in direct contact with patients, and he states 
that 0.83% of the people at large carry with them virulent organisms. 
Ustvedt" found 4.5% of 4,277 school children to be infected, while 
Geirsvold^*, Graham-Smith^*, Leegard^' and others report percentages 
of infection ranging from 2% to 30% of those examined. It is fur- 
thermore well known that many sore throats of benign type are really 
caused by the diphtheria bacillus. Wassermann*^ has shown that the 
blood of a large proportion of both children and adults contains diph- 
theria antitoxin, even when there is no history of the disease. In 
these facts exists ample explanation for the finding of the organism 
in cars and other places where people congregate and the practical 
impossibility of preventing such findings. The diphtheria badllus is 
an obligate parasite, having no vegetative existence outside the body. 

"Kober. Die Verbreitung des Diphtheriebazillus auf der Mundschleirchaut 
gesunder Menschen. Zeit. f. Hyg. XXXI, S. 433. 

"Ustvedt. Die Diphtherieprophylaxe und die Bedeutung der gesunden Ba- 
zillentrager fiir die Verbreitung der Krankheit Zeit f. Hyg. 1906, LV. S. 147. 

"• Ref . by Ustvedt, loc, cit. 

" Wassermann. Ueber die personliche Disposition und die Prophylaxe ge- 
genuber Diphtherie. Zeit. f. Hyg. 1895, S. 408. 



THE PROBLEMS OF CAR SANITATION, 289 

Infection takes place chiefly by direct contact. It may occur also by 
indirect contact or presumably by the dust from infected fomites, 
since the organism may remain virulent for a considerable period in 
the dried state. But with the vast number of infected throats among 
the general population the inference of indirect contagion is not only 
unnecessary to explain the cases that arise, but without clear and 
direct evidence of such a mode of infection is scarcely a logical sup- 
position. Though I cannot accept Chapin's*® recently expressed view 
that infection by fomites is among the great rarities and that disin- 
fection is unnecessary, still he has sounded a timely sentiment in urg- 
ing the relative infrequence and unimportance of the transmission of 
contagious diseases by inanimate objects, and called attention to more 
fundamental, if not more important, means of control than fumiga- 
tion. He quite correctly looks upon the infected individual as a far 
more dangerous source of transmission than the things this individual 
has used or the place he has occupied. 

In view of the fact that about 15% of all people die of tubercu- 
losis and that 80% or 90% of autopsies show evidence of healed in- 
fections, and that a large proportion of the afflicted associate with 
the healthy and distribute their infected sputum with indiflFerence, it 
is a surprising element of Kinyoun's results that he succeeded in 
producing the disease in only two of 160 animals inoculated. For 
my own part I cannot feel or manifest surprise that car sweepings, 
dust and furnishings are now and then infected with the tubercle 
bacillus. Any public place is likely to be so. Under present conditions 
we must expect it. We all understand the procedure necessary to 
most successfully combat the evil is to prevent spitting any place 
where the sun does not shine. The remedy is personal cleanliness. 

The results obtained in the investigation of railway coach bacteri- 
ology up to this time are in the main what might have been expected. 
It is not possible, however, to draw conclusions from them which will 
finally establish the relations between the railway coach and disease 
without adding vastly to the experimental evidence which they contain. 
It is desirable to know something of the average absolute number of 
pathogenic bacteria and their relation to the whole number present, 
their ratio to the number of passengers and to the length of trips, the 
relation between the internal air and the surrounding air of the mov- 
ing train, and to compare these results with those obtained by investi- 
gating other inhabited places. If the car contains only the organisms, 

"Chapin. The Fetich of Disinfection. Jour, of the A. M. A., Aug. 25, 1906, 
XLVII, No. 8, p. 574. 

19 



290 THE PROBLEMS OF CAR SANITATION. 

absolute and relative, found in other similarly inhabited places, the 
problem then becomes one of altering conditions of infection generally ; 
the car sinks into the insignificance of its smaller proportion of the 
whole and is merged in the general combat. If, on the other hand, 
the car is fouriU to be burdened with pathogenic bacteria in excess of 
other places, it then becomes a problem calling for special methods of 
solution and special care in its handling. The time and labor required 
to determine these things is necessarily great on account of the many 
factors entering into the problem as it concerns the coach in transit. 

It is of course hopeless to attempt to keep cars sterile, or free 
from even pathogenic bacteria ; nor is this necessary in order that they 
may be safe. In order to acquire an infectious disease we must re- 
ceive organisms in sufficient quantity and of a sufficient degree of 
virulence. We must also have a resistance low enough to permit in- 
fection to take place; and having that we may ourselves harbor the 
very germs that await the critical moment. 

Though we must expect most cars to contain pathogenic micro- 
organisms in greater or lesser numbers, it is nevertheless desirable that 
the railroads should take precautions to reduce them to a minimum. 
Good mechanical cleaning is the first element in the combat. Re- 
move dust, and dirt or excreta that may become dust, and most ot 
the bacteria, grossly considered, will be removed with it. Beat or 
blow with the air blast the seats and carpets, outside the car if pos- 
sible. It will not remove the last particle of dust, but if it is well done 
not enough will be raised from them in ordinary use to afford danger 
of infection to the car occupants. Scrub the floors, wash basins and 
closets and disinfect them regularly. Wipe down the woodwork. Ex- 
pose bedding to the disinfecting influence of air and sunlight, and to 
beating and blowing. If the sick have occupied coaches or sleeping 
cars, fumigate them at the end of the run. In addition, regular fumi- 
gation at stated intervals is indicated simply as a prophylactic measure. 
There has been applied to the Pullman service within the past year a 
system embracing all these measures, and one which in my judgment 
meets the more important requirements for the maintenance of sani- 
tary cars. Much labor is expended in removing dust ; much time is given 
to sunning and airing; smoking rooms and closets, basins and cuspi- 
dors are washed daily with disinfectants; cars that have carried the 
sick are fumigated ; all cars are fumigated monthly, and those running 
to health resorts weekly or oftener. The public has a supplementary' 
duty and the members of the medical profession a complementary one ; 
educate the social body to an appreciation of its own power of self 
preservation. 



THE PROBLEMS OF CAR SANITATION. 291 

III The miscellaneous influences constituting the third group of 
the dangers of railway travel, as I have outlined them, aflFect the 
health of car occupants only indirectly as a rule, and tend to reduce 
resistance rather than to produce disease directly. Certain individuals 
have peculiar susceptibilities of the nervous system- rendering them 
liable to the so-called "car sickness" during any long railroad journey. 
I have known people, too, who almost invariably have attacks of 
migraine under similar conditions. It is not possible to entirely pre- 
sent these results of rapid train motion in the predisposed, though 
smooth roadbeds and comfortable cars probably tend to lessen the 
liability of their occurrence. 

The ventilation of cars is a vital problem. That it has not been 
solved long ago is due to its great mechanical difficulties. The car 
contains, and must contain, a minimum of space for a maximum num- 
ber of occupants. The swift and changing motion of the train, its 
constantly changing direction and wind conditions, its rapid transit 
from cold to warm or warm to cold regions, the necessity of changing 
the air frequently, the consequent great liability to draughts, and the 
variable sentiments of the passengers, who must all accept the same 
amount of air, make up a combination of conditions difficult to man- 
age. The real difficulty arises, of course, when the outside temper- 
ature is low. Summer ventilation is scarcely a problem. We all know 
-that cars often seem to be ill ventilated and "stuffy" ; but as a matter 
of fact, we do not know just how good or how poor is the average 
of car air from the chemical standpoint. A series of experiments is 
now under way to determine this. The results of these experiments 
and of the practical test of a new system of ventilation will be made 
the subject of a future communication. 

Remaining long in an atmosphere heavily overladen with the pro- 
ducts of respiration may produce headache, drowsiness, nausea and 
general malaise. Similar results may come from a close, overheated 
moist atmosphere, even though its chemical purity is sufficient for 
every hygienic demand. Indeed, recent experiments by Fliigge^® 
Heymann*®, Paul*^, Ercklentz^^ and others go* to show that high tem- 
perature, much moisture and air stagnation are alone responsible for 
the deleterious influences of faulty ventilation, and that chemical im- 
purity of the air plays no part in them except under the most extra- 

"Flugge. Ueber Luftverunreinigung, Warmestauung und Luftung in ge- 
jfchlossenen Raumen. Zeitschr. f. Hyg., Bd. 49, S. 363. 
•Heymann. Ibid, S. 388. 

"Paul. Die Wirkungen der Luft bewohnter Raumen. Ibid, S. 405. 
^Ercklentz. Ibid, S. 433. 



292 THE PROBLEMS OF CAR SANITATION, 

ordinary conditions. A strong opponent of this view among recent 
writers is Wolpert*', who maintains that the metabolism is hindered 
by a much breathed atmosphere. Whatever the explanation, it seems* 
to be certain, however, that poor ventilation is ordinarily not harm- 
less; and that in addition to the temporary symptoms of discomfort, 
the long occupancy of so-called "stuflFy" rooms so lowers resistance 
as to be conducive to the contraction of colds and perhaps also to the 
more serious infections. But draughts of cold air are equally depress- 
ing, and the problem is, to find the means of introducing enough air 
to maintain comfort and not enough to produce danger from exposure. 

Heating is a problem going hand in hand with ventilation. With the 
present means at our command, it needs but care and intelligent opera- 
tion to maintain a proper temperature in the closed car. With the at- 
tempt to change the air frequently, however, the difficulty is many 
times increased, for the reason that the entering air is so liable to 
great variation in amount and temperature as indicated above. If 
Fliigge and his followers are right in their contention that the relation 
existing between temperature and moisture and the motion of the air 
are responsible for the whole of the bad effects of ill ventilation, then 
the problem of heating becomes relatively more important than it has 
heretofore been considered and ventilation relatively less important. 

A certain amount of dust and smoke and locomotive gases inevitably 
enter the train. These are, of course, liable to great variation; but 
smoke and gases are not really troublesome except in passing tunnels, 
when they produce no more than temporary discomfort. Ordinarily 
only the heavier particles of smoke — the small cinders — enter the 
car, the lighter* solid particles and the gases floating upward and away 
with the wind. If we are forced to breath much smoke for prolonged 
periods it acts as a mechanical irritant and exerts a harmful influence 
upon the respiratory passages: Ascher** of Konigsberg has recently 
published a series of experiments on animals showing that it both 
hastens the fatality of tuberculosis and predisposes to acute infections 
of the lungs ; and he arrives at similar conclusions concerning human 
beings from a study of the vital statistics in relation to smoke produc- 
tion in the manufacturing towns of Prussia. 

Ordinary dust is of more importance because it is more prevalent 
and because it may be infectious. It comes chiefly from the railway 
tracks, and their nearly universal free exposure to the sunlight makci 
is very probable that any pathogens will be rendered innocuous before 

•Wolpert. Zeitschr. f. Hyg. Bd. 50, S. 529, und Bd. 51, S. 175. 
**Ascher. Der Einfluss des Ranches auf die Atmungsorgane. Stuttgart^ 
1905. 



THE PROBLEMS OF CAR SANITATION. 293 

the dust stage of their container is reached. Track contamination is 
probably of greater danger to the consumers of the water of streams 
into which sewage may be washed before it has a chance to dry than 
to the users of cars. The mechanical irritation of dust is, however, 
of some importance. It may produce mild inflammation directly, or it 
may lower the resistance of the mucous membranes of the respiratory 
passages to the point of favoring infections. Certain dusts, as those 
of the alkali deserts, which are soluble in the secretions, may act as 
chemical irritants. Sprinkling of the track with oil, as is practiced by 
some railroads, is therefore a salutary measure from a hygienic stand- 
point. To convert dust into something else than dust removes the 
difficulty in the best way, and is in the end the simplest. Of next 
efficiency would be some air filtering device. 

It need scarcely be said in conclusion that it has been the author's 
purpose rather to define and to estimate the importance of the various 
problems of car sanitation than to detail their solution. That there 
is always a slight danger of acquiring infectious diseases in railway 
coaches cannot be denied. That this danger is chiefly dependent upon 
direct contagion in the close personal association of passengers seems 
probable, while indirect transmission through the common use of facili- 
ties for comfort or by the infected car is of secondary importance 
only. 

An attempt has been made to show why it is that personal hygiene 
is a very important element in the solution of most of the problems 
of car sanitation, and why the co-operation of travelers is necessary to 
an eflFective combat against the contraction of infectious diseases m 
cars. This statement must not be interpreted as a defense of the rail- 
way company which does not take every reasonable precaution to main- 
tain its cars in a sanitary condition, or does not provide facilities 
whereby the liability of the transmission of infectious diseases may be 
reduced to a minimum. The duties of the railway in this regard are 
perfectly clear and their fulfillment is essential to the maintenance 
of the public health. Bad habits in matters of personal hygiene are 
due largely to ignorance of the possible consequences. It is the cor-^^ 
rection of this very general ignorance in the public at large that 
must supplement the best car sanitation in order to bring it to a high 
degree of efficiency in protecting those who travel. 



REPORT ON THE CONDITION AND PROSPECTS OF 
VITAL STATISTICS IN THE UNITED STATES. 

Dr. CRESSY L. WILBUR, Washington, D. C. 

By request of the President of the Association, I have the honor 
to present what may be called a special report on the "Condition and 
Prospects of Vital Statistics in the United States." 

For many years, until the last session of the Association, the subject 
of vital statistics, its needs and tendencies, has been presented by a regu- 
larly constituted committee. For a considerable period Dr. John S- 
Billings was chairman of that committee. In 1897 I succeeded, by his 
special request, the lamented Dr. Samuel W. Abbott, of Massachusetts, 
as chairman, and, after my resignation in 1900, was followed by Dr. 
John S. Fulton, of Maryland (1901), and by the late Mr. William A. 
King, Chief Statistician of the Census, who presented the reports for 
1903 and 1904. No report was made on this subject at Boston last 
year. The subject of vital statistics is of such fundamental importance 
in public health work, that it would seem imperative that proper pro- 
vision be made for it in the regular program of this Association, and 
I shall accordingly submit, as a part of this special report, a recom- 
mendation for the reconstitution of the committee on vital statistics, 
and also urge, on account of the increasing importance of the subject 
and the wider sphere that it should properly occupy in the work of 
this Association, that it be assigned, not only to a committee, but that 
a special section be organized as a part of the Association, to deal 
with vital statistics, very much in the same way that the present 
laboratory section is now constituted. 

DEATH OF MR. KING. 

Before passing on, however, to the subject matter of this special 
report, it becomes my sad duty to refer to tlie death of my predecessor 
in the office of Chief Statistician of the United States Census, which 
occurred on April 2T, 1906. Mr. King was for many years my intimate 
personal and official friend, and the news of his death fell upon me, 
as I presume it fell upon all of you who have been in close relations 
with him, as a profound shock. His character, embracing the highest 
devotion to the important duties of his position, is known to you all, 
and I can place no more fitting memorial of his service upon the 
records of this Association than to quote the official announcement 
made by the Hon. S. N. D. North, Director of the Census : 

294 



VITAL STATISTICS IN THE UNITED STATES. 296 

It is my sad duty to announce that William Alexander King, Chief 
Statistician in charge of vital statistics, in the Bureau of the Census, 
died April 27, 1906. 

Mr. King was born in Utica, Ohio, May 7, 1855. He entered the 
Government service in 1879, at the Tenth Census of the United States, 
as a clerk appointed from Indiana. Subsequently he was promoted to 
the position of Chief of the Division of Vital Statistics. In 1883 he 
was transferred to the Land Office. In 1888 he resigned and removed 
to Pueblo, Colorado, to engage in the practice of law. He returned to 
the Government service in connection with the Eleventh Census, being 
appointed from Colorado, August 3, 1889, as Chief of the Division of 
Vital Statistics, in which position he served until the completion of 
the Eleventh Census in 1897. Mr. King was then honored with 
retention as the sole employe, or clerk, of the Census, in the office 
of the Secretary of the Interior, occupying that position from 1897 to 
1899. At the Twelfth Census he was made Chief Statistician for 
Vital Statistics, which position he retained until his death. 

Mr. King has thus been connected with each census since 1880 and 
enjoyed the distinction of being the only person uninterruptedly em- 
ployed by the Government upon census work from 1889 ^"t^^ the pres- 
ent time. He rendered invaluable assistance to the committees of both 
houses of Congress in drafting legislation for taking the Twelfth 
Census. His work in preparation for and in the compilation of the 
vital statistics of the Twelfth Census was a marvel of thoroughness 
and accuracy. It has not been surpassed by any similar undertaking 
in any country. In his grasp of detail and his comprehension of the 
relation of that detail to the whole field of vital statistics, Mr. King 
was without a superior. He dedicated his life to statistical work, and 
no one has contributed more to bring the science of vital statistics out 
of the chaos and confusion which so long retarded the progress and 
limited the usefulness of this branch of statistical research in the United 
States ; and he may, in truth, be said to be the author of the "Standard 
Death Certificate" which is now in use, or its equivalent, in more than 
one-half of the states of the Union. 

The sense of personal loss and sorrow occasioned by Mr. King's 
death is very keen and is shared with me by all of his late colleagues 
and associates, recognizing as we all do, to the fullest measure, the 
great service which he has rendered to an important branch of science 
throughout the country, and to the census, as well as his many sterling 
qualities as a man and a friend. 

Statistical science, and especially the subject of vital statistics, 
has sustained another profound loss during the Ipresent year in 
addition to the death of Mr. King. This was in the death of Doctor 
Joseph Korosy, of Budapest, who died, June 23, 1906. His loss is 
an irreparable one to vital statistics and to the public health service 
of the world, and it is fitting that this Association should recognize 
the passing of this tireless sanitary worker. 



296 



yiTAL STATISTICS IN THE UNITED STATES, 



COOPERATION OF THE AMERICAN PUBUC HEALTH ASSOCIATION AND 
THE UNITED STATES BUREAU OF THE CENSUS. 

Members of this Association are well aware, and others can 
readily learn by reference to the last published volume of the Bureau 
of the Census relating to vital statistics ("Mortality, 1900-1904"), 
how close have been the relations of this Association and its com- 
mittee on vital statistics with the Bureau of the Census in its official 
work, and what valuable results have been attained thereby. 

I need only refer to three important measures which have been 
more or less completely attained through this co-operation, (i) The 
adoption of a uniform and comparable classification of causes of 
death — the International Classification; (2) the adoption antl gen- 
eral use in this country of a uniform blank for securing the primary 
data relating to births and deaths — the standard certificate; and 
(3) the extension of the registration area by the promotion of the 
passage of proper laws in various states, measures which have al- 
ready resulted in the addition of no less than five states to the regis- 
tration area during the present year, namely, California, Colorado, 
Maryland, Pennsylvania, and South Dakota. 

I can best inform you in regard to the addition of these states by 
exhibiting a tabulated statement of the "Status of EflFective Registra- 
tion of Deaths, 1906," and some extracts from the Report of the 
Director of the Census for the current year, made to the Secretary 
of the Department of Commerce and Labor: 



STATUS 


OF EFFECTIVE REGISTRATION OF DEATHS, I906. 


REGISTRATION STATES, 1900. 


ADDED AS REGISTRA- 


NOT YET ACCEPTED AS 




TION STATES, 1906. 


REGISTRATION STATES. 




Population, 




Popula- 




Popula- 


State. 


1900. 


State. 


tion, 1900. 


State. 


tion, 1900. 










Alabama . 


1,828,697 










Arizona .. 


122.931 










Arkansas . 


1.311,564 






California 


1,486,053 










Colorado . 


539,700 






Connecticut 


908,420 






Delaware . 


184,735 


Dist. of Columbia 


278,718 






Florida . . 
Georgia .. 
Idaho .... 
Illinois . . . 
Ind. Tcr... 


528,542 
2,216.331 

161,772 
4,821.550 

392,060 



VITAL STATISTICS IN THE UNITED STATES. 



297 



STATUS OF 


EFFECTIVE REGISTRATION OF DEATHS, 1906. — CONCLUDED. 


REGISTRATION STATES. 1900. 


ADDED AS REGISTRA- 


NOT YET ACCEPTED AS 






TION STATES, 1906. 


REGISTRATION STATES. 




Population, 




Popula- 




Popula- 


State. 


1900. 


State. 


tion, 1900. 


State. 


tion, 1900. 


Indiana 


2,516,462 
















Iowa 


2,231,853 










Kansas ... 


1,470,496 










Kentucky . 


2,147,174 










Louisiana. 


1,381.625 


Maine 


694,466 














Maryland . 


1,188,044 






Massachusetts ... 


2,805,346 










Michigan 


2,420,982 






Minnesota 
Mississippi 
Missoun .. 
Montana .. 
Nebraska . 
Nevada ... 


1,751,394 
1,551,270 
3,106,665 
243,329 
1,066,300 
42,336 


New Hampshire.. 


411,588 










New Jersey 


1,883,669 






N. Mexico 


195,310 


New York 


7,268,894 


Pcnnsylv. . 


6,302,115 


N. Carolina 
N. DakoU. 

Ohio 

Oklahoma 
Oregon . . 


1,893,810 
319,146 

4,157,546 
398,331 
413.536 


Rhode Island .... 


428,556 


S. Dakota. 


401,570 


S. Carolina 

Tennessee 
Texas .... 
Utah 


1.340,316 

2,020,616 

3,048,710 

270,749 


Vermont 


343,641 






Virginia . . 
Wash'gton 
W. Virg'ia 
Wisconsin 


1,854,184 
518,103 
!^58,80o 

2,069,042 






Total . . 




Wyoming . 
Total .. 


92,531 


Total 


19,960,742 


9,916.482 


46,117,351 



Population, registration states, 1900 19,960,742 

Per cent, of total population 26.8 

Poptdation, registration cities in states added, 1906 3,835,119 

Per cent, of total population - 5.0 

Population of registration cities in non-registration states 6,969,767 

Per cent, of total population 9.2 



298 VITAL STATISTICS IN THE UNITED STATES, 

Population in registration area, 1900 30,7d5,618 

Per cent, of total population 40.5 

Net population added to registration area in 1906 6,081 .363 

Per cent, of total population 8.0 

Population in registration area in 1906 36,846,981 

Per cent, of total population 48.5 

Note. — Nearly all of the states not yet accepted as registration states have 
now, or have at some time possessed, laws intended to secure the complete 
registration of deaths. These laws have usually been defective in principle, 
although in some instances faulty admini^ration may have been responsible 
for failure to secure results. Only three states — Indiana, Maine, and Michi- 
gan — were added to the registration area during the decade 1890 to 1900, 
while one state — Delaware, which was admitted as a registration state in 
1890 — was dropped from the list in 1900. Two states — Nebraska and Utah — 
have adopted legislation in 1905 which requires immediate registration of 
deaths with compulsory burial permits, and it is hoped that the results obtained 
will justify their admission at an early date. In addition to the population 
of the registration states given above, it should be remembered that certain 
oities in states not yet accepted as registration states having an aggregate 
population of 6,969,757 in 1900 are also embraced in the registration area, 
which makes the total population of that area on the basis of the census of 1900 
amount to 36,846,981. 

The Bureau will continue an(I increase its efforts to enlarge the 
registration area by encouraging the enactment of the necessary legis- 
lation in states where it is still lacking and by urging more careful 
registration in other states where the laws exist, but are indifferently 
enforced. In the meanwhile the most encouraging results have already 
followed the efforts of the Bureau in both of these directions. Dr. 
Charles V. Chapin, of Providence, R. I., an eminent authority on vital 
statistics, has recently stated that the year 1905 witnessed a greater 
advance in the enactment of laws for the proper registration of births 
and deaths than any previous year in our history. Nearly all of the 
states have at one time or another enacted registration laws, more or 
less perfect, which are enforced with more or less rigor. Of those 
states, eleven, including the District of Columbia, have heretofore been 
accepted by the Director as affording data which meet the full require- 
ments of the census law. These states contained a population of 
19,960,742 in 1900. In July, 1906, five additional states — California, 
Colorado, Maryland, Pennsylvania, and South Dakota — containing 
a population of 9,916482 in 1900, were added to these registration 
states for census purposes, on the application of their health officials 
and on the presentation of satisfactory evidence that their registra- 
tion laws are fully enforced and the results obtained in harmony with 
those prevailing elsewhere. 

This important step increases by nearly one-fifth the area covered 
by the Census reports, and will add correspondingly to their value. 
In two of the states which are not yet accepted as having reached the 
full standard of the registration area — Nebraska and Utah — laws 



VITAL STATISTICS IN THE UNITED STATES. 2W' 

were enacted in 1905 requiring burial permits, and under which, if 
thoroughly enforced, it seems probable that their admission may be 
recommended at an early date. Among the other non-registration 
states are also six — Florida, Iowa, Minnesota, North Dakota, Oregon, 
and Wisconsin — having laws requiring a census of population in the 
interdecennial year, and it is especially important, therefore, that their 
registration laws be so improved and that they shall be enforced with 
such a degree of efficiency as to permit their inclusion in the area cov- 
ered by the Census reports, as very valuable comparisons of mortality 
and population will thereby be rendered available. 

Whenever it shall appear that adequate laws exist and are so en- 
forced in any states as to secure approximately complete records, the 
proposition to include their returns as a part of the annual Census 
reports will be favorably considered. On the other hand, evidence 
that defective registration is permitted and the laws carelessly en- 
forced in any of the states whose returns are now so included will 
result in their exclusion from the subsequent reports. It is believed 
that the Census Bureau can best establish and encourage accurate and 
careful registration everywhere by an impartial enforcement of this 
general policy. If, in consequence of it, it shall become necessary to 
exclude any state whose returns have previously been accepted, it will 
be made sharply evident to the people of that state that their laws 
either require amendment or are not being properly enforced, and the 
responsibility for the negligence can be located and the necessary 
remedy applied. This is the only way in which the Census Bureau 
can exert any influence to promote accurate registration on the part of 
the states. The same situation exists in the case of the registration 
cities, and the same policy will be adopted by the Office with respect 
to their inclusion or exclusion from the registration areas. 

In the meanwhile it is gratifying to record the evidence of the 
substantial progress in the establishment of effective mortality records 
which has followed so quickly upon the establishment of a permanent 
Census Office; with facilities for the annual compilation and analysis 
of the statistics of the whole country, and their correlation and com- 
parison with each other. Results of the greatest medical, sanitary, and 
scientific value are certain to follow in due course of time. The facts 
above stated regarding the registration states are summarized in tab- 
ular statement on p. — . It will be noted that the states and cities with 
laws contained, on the basis of the census of 1900, nearly one-half of 
the total population of continental United States — a most gratifying 
progress. 

Attention may also be called to the fact that there is no strictly 
Southern state in which efficient state registration laws exist. Because 
of the presence of a large negro population, as well as by reason of 
climatic differences, it is highly important that registration should be 
undertaken in this section of the Union; and attention is here drawn 
to the subject in the hope that the movement for proper legislation, 
now under way in several of the Southern states, may bear fruit before 
the Thirteenth Census. 



.300 VITAL STATISTICS IN THE UNITED STATES, 

OPPORTUNITIES FOR FURTHER COOPERATION. 

Vital Statistics is a progressive and not a stationary science. Wc 
have not yet reached a period of repose, but shall find, and I trust 
It will be our pleasure to find, new fields to conquer as soon as we 
have gained one victory. 

The cooperation of the American Public Health Association and 
of the Bureau of the Census is just as necessary and vital for the 
further development of sanitation and vital statistics in this country 
to-day as it was five years ago when it first took effective form. 
Indeed, we are prepared to cooperate more eflfectively than ever, 
and I am sure that the result which we shall obtain in the next five 
years will far surpass those that have been accomplished in the five 
years just passed. 

TEST FOR ACCURACY OF RETURNS. 

One of the ways in which the American Public Health Association 
can perform valuable service is by aiding in the invention and "try- 
ing out" of an effective method for testing the accuracy and com- 
pleteness of the registration of deaths — perhaps also later of births — 
in the various states. As you know, the so-called "registration states" 
are constituted on the basis of approximately ninety per cent of com- 
pleteness of registration of deaths as compared with the total num- 
ber of deaths that actually occur. This is a low standard, and it is 
to be hoped that all, or nearly all, of the states now included in the 
registration area far surpass this lower limit. 

The determination as to whether a state has approximately ninety 
per cent of completeness in its registration of deaths has been practi- 
-cally made by a comparison of the deaths registered under state laws 
and returned to the Bureau of the Census for the census year and 
deaths enumerated by census enumerators for the same period. 

The system is fully explained and its application shown for the last 
census year, 1899- 1900, in the introductory remarks of Volume III 
(Part I, Vital Statistics), beginning on page xi. This method in- 
volves a duplication of the data for the year compared, is applicable 
only to census years, and, in my experience, is open to very serious 
objections arising partly from the unsatisfactory character of the 
enumerators' returns of deaths, and partly from the great difficulty 
of comparing individual items in. the two sets of returns. Neverthe- 
less, so far no other criterion of the accuracy of the returns has been 
accepted and it is clear that some check must be employed if we arc 



VITAL STATISTICS II{ THE UNITED STATES. 801 

to have any means of vouching for the general excellence of the 
mortality returns from the registration area. 

UNIFORMITY IN ESSENTIAL STATISTICAL TABLES. 

It is evidently very desirable that the official vital statistics pub- 
lished by the Bureau of the Census and by the various state and city 
registration offices should agree in general form and method of 
presentation. It is only thus that the various reports will be com- 
parable, and users of vital statistics will be enabled to make use of 
the data presented with the least expenditure of time and trouble. 

Certainly the most essential data relating to vital statistics should 
be presented in tables of somewhat similar or quite identical form 
in each of the official reports. It is not meant by this that the state 
reports, for example, should not go into greater detail in some re- 
spects than would be justified in the Census mortality report, or 
that a city office should not occasionally find it necessary to amplify 
some of the statistical statements and present figures in greater detail 
than the state registration office would care to do. But it would 
evidently be most useful if such statements could be made in a 
form that would conveniently compare with the tables published 
for larger areas. 

At the present time there is the greatest diversity in the form and 
scope of statistical reports published by the different states and 
cities, so that it is well-nigh impossible in many cases to make satis- 
factory comparisons. A beginning has been made in the work of 
unif)dng these vital statistics by the determination expressed by the 
state registration office of Pennsylvania, now operating under its new 
registration law, to prepare the tables for its first registration re- 
port in close conformity to the general tables that have been pre- 
sented by the Bureau of the Census in its last publication, "Mor- 
tality, 1900-1904/* and which I presume has been carefully examined 
by all of the registration officials of the country. A practical difficulty 
in the way of strict conformity to the Census tables arises from the 
fact that the size of the page employed in the Census reports ("Cen- 
sus quarto") is larger than the octavo page generally employed in 
state and city publications, so that some adjustment will be neces- 
sary in reducing the Census forms to state or city use. It is not 
recommended that the size of the state or city publications be changed, 
as it is probably more convenient than the larger size, and the fact 
that it has been so generally adopted would render any proposed 
change inexpedient. 



^2 VITAL STATISTICS IN THE UNITED STATES, 

AGREEMENT OF TABLES OF CAUSES OF DEATH. 

Another and a very serious difficulty is found in preparing tables 
for causes of death in different offices covering the same area and 
the same period of time in order that the results may be identical, as 
they evidently should be. 

The general adoption and use of the International Classification 
of causes of death in this country was the first and the absolutely 
necessary step for such agreement. But at the present time, and 
until some further advances have been made in regard to the classi- 
fication of causes of death, there is room for considerable di£Eerences 
in the results obtained in diflferent offices. This arises from two 
reasons : ( i ) On account of new terms received by the Bureau of the 
Census and not yet included in the printed Manual of Intemational 
Qassification of Causes of Death, and (2) from varying methods of 
classifying deaths returned as due to two or more causes. 

There is ample reason for marked diversity of judgment in some 
cases as to which term of the two or more causes is preferable for 
assignment, and there has been no means of knowing in a state office 
as to whether the assignment made would agree with the assignment 
given to the same death by the Bureau of the Census. 

PROVISIONAL PLAN PROPOSED. 

As a remedy for this condition, and because it is imperatively 
necessary that official statistics of mortality from all sources should 
agree — there is skepticism enough among the laity in regard to 
statistics generally, without inviting it by presenting radical disagree- 
ments in our results — the Bureau has undertaken a plan which prom- 
ises improvement in this condition. It is attended, it is true, with 
considerable labor, not only in the Office at Washington, but also 
in the state offices as well as in the various city offices wherever the 
system is extended to them, but I am sure that its results will be 
much more satisfactory and the process of making our returns har- 
monize will be worth all that it costs, in coming to a better under- 
standing in regard to the details of classification. 

The method is briefly this : The state registrar, if he has not been 
in the practice of doing so, now enters in pencil upon each original 
certificate of death received by him the classification number accord- 
ing to the International system, or, as in Pennsylvania, the pundi 
number required for use by the mechanical method of tabulation. 
The copyist in preparing the transcripts for this Bureau copies these 



VITAL STATISTICS IN THE UNITED STATES, 



303 



numbers as a part of the return. When the returns reach the Bureau 
of the Census, they are edited in the usual way, referring to the 
Manual, and the card index of diseases for new causes and for joint 
causes, and a comparison is then made of the assignments in this 
Bureau with the assignments made by the state registrar. Where a 
a diflference occurs in assignment, the certificate is listed and when 
a sufficient number have accumulated, a set of sheets is prepared 
and sent to the state registrar, showing the different methods of 
assignment for each individual transcript in which a diflference occurs, 
somewhat in the following form: 

INDIANA. 





Name of dece- 
dent. 


Date of Death, 
1906, 


Cause of death. 


Title 
assigned. 


County or city. 






Richmond city... 
Richmond city... 
Richmond city. . . 


Marion Morgan. 
Edw. Dinkin. . . . 
Freddie Barton. 


April 9 

April 25 

April 30 


La grippe ; acute 
menmgitis . . . 

Pul. tuberculo- 
sis; pneumonia 

Gen. paralysis. . . 


61a 
93 


10 

27 
67 



PENNSYLVANIA. 



1 



Cause of Death. 



Title 
assigned. 






'A 



31528 
31561 
31569 



Pneumonia (catarrhal) 

Pneumonia after childbirth 226 

Inanition ; Prolonged delivery 391 



243 

357 
435 



Note. — An additional column is given for "Remarks," but is not shown 
in the form above. Reference to the certificate is made by the three columns 
showing (1) place of death, (2) name of decedent, and (3) date of death. 



304 VITAL STATISTICS IN THE UNITED STATES, 

as in the examples from Indiana; in Pennsylvania, where each certificate Is 
given a serial number immediately after its receipt at the state office, it U 
only necessary to refer to this number. International numbers are given for 
the Indiana cases, but for Pennsylvania the punch numbers, corresponding 
to certain International titles, are used. 

It is evident that in some cases where the diflference of assignment 
may be due to error or oversight, that the state assignment will be 
readily corrected so that the state compilation will agree with the 
Census compilation. In other cases the state registrar may insist oo 
the propriety of his assignment, in which case he will return the list 
to the Bureau with his explanations or reasons. These will be con- 
sidered, and if the Census desires to retain its present assignment, the 
list will be returned to him with reasons for such retention. If, 
after full consideration of the facts, the state registrar still insists 
that a particular death shall be classified under a certain title of the 
International system, then his authority should properly be followed, 
as he is presumably in closer relation to the original source of infor- 
mation, is more fully acquainted with local usage as to reporting 
causes of death, and, in short, is the primary source of the statistical 
data. 

This plan has already been cordially adopted by many offices, among 
them the state registration offices of Colorado, Indiana, Maryland, 
Michigan, Pennsylvania, and Rhode Island. It can evidently be ex- 
tended through the state offices to city offices publishing monthly or 
annual reports, and will result in a closer agreement between state 
and city registrars than has heretofore existed. 

PREPARATION FOR APPROACHING REVISION OF INTERNATIONAL 

CLASSIFICATION. 

The method of comparing results with state registrars will also be 
of great service in bringing out important suggestions for the next 
decennial revision of the International Qassification. 

I am in hopes, indeed, that the date of the next revision may be 
set for the year 1909 instead of 1910, so that its results will be 
available for use beginning with the census year 1910, and state and 
city registrars will be able to employ the new system for the first 
month of that year. I have already suggested this danger to Doctor 
Bertillon, Secretary of the International Commission, and at his 
suggestion have addressed letters to members of the Commission in 
other countries, and trust that the action suggested will meet with 
the general approval of American registrars. There is no reason why 



riTAL STATISTICS IN THE UNITED STATES. 306 

the regular decennial revisions should not be made in the years 1909, 
1919, etc., as well as in the years 1910, 1920, etc., once the change 
has been made. 

The American Public Health Association has performed such a 
signal service in securing the adoption of the International Qassifi- 
cation of Causes of Death in this country and thereby giving the 
movement for uniformity an impetus which has contributed greatly 
to its general adoption throughout the world, that I feel that this 
part of its history should be well understood by every member. As 
Doctor Bertillon wrote me, in a letter printed in the Reports and 
Papers of the American Public Health Association, 1898, page 179, — 

The American Public Health Association, in adopting a uniform 
nomenclature of diseases, realizes a considerable statistical advance, 
which the statisticians of Europe have sought, without being able to 
attain, since 1853, the date of the first International Congress of Sta- 
tistics at Brussels. The question was there presented, but it is only 
in 1898, at Ottawa, that it could be solved. 

Indeed, the plan for the decennial revision was first suggested by 
the American Public Health Association and accepted by the Inter- 
national Statistical Institute. The general principles which should 
govern such a revision were laid down in the report of the Committee 
on Demography and Statistics in their Sanitary Relations as approved 
by the Association in 1898, and whatever degree of imperfection may 
now exist in the present form of the classification and its practical 
employment in the registration offices of different countries may, to a 
considerable extent, be traced to the disregard, due partially to lack 
of available time, of certain of these requirements. 

The matter is so important, and becomes of so much interest while 
we are considering the preparations for the next decennial revision, 
that I shall quote in full the recommendations of the Committee as 
approved by the Association in 1898. 

GENERAL PRINCIPLES. 

1. A regular periodical revision is necessary for every classifica- 
tion of causes of death, in order to keep it abreast of scientific advance- 
ment in the knowledge of diseases. 

2. It is desirable that as many countries as possible signify their 
adhesion to this system and take part in its revision, which should be 
completed by 1900, in order that the international mortality statistics 
of the twentieth century be compiled on a uniform and strictly com- 
parable basis. 

3. All countries adopting this system and taking part in its re- 
20 



306 VITAL STATISTICS IN THE UNITED STATES. 

vision should honorably conform their statistics to the resulting code 
of statistical procedure. 

4. It is right that the wishes of the countries making the largest 
practical use of this system should have the most weight in its revisiwi. 
Therefore, as the registration of deaths is sometimes imperfect or may 
not extend over the entire extent of a country, the basis of representa- 
tion (voting weight) of a statistical office should depend upon the 
number of deaths registered, compiled, and published by it in a year, 
and not upon the population represented. 

.5-. Suggestions for changes are desirable from all demographers, 
clinicians, pathologists, statisticians, sanitarians, and, in general, from 
all persons making use of mortality statistics. The decision as to the 
advisability of proposed changes should remain with the registration 
offices practically engaged in the preparation of mortality reports. 

6. Continuity is very important in statistics, for which reason no 
change should be made unless imperatively demanded. Therefore, for 
the sake of greater conservatism, it would seem advisable that no 
change be made from the methods now in use unless demanded by at 
least two-thirds of all the ballots cast. 

7. While no changes or modifications should be introduced into 
the mortality tables during the period between the periodical revis- 
ions, the commissions charged with the work of revision should remairi 
in office until their successors are appointed for the next revision, so 
that any new questions of classification, or disputed points of classifi- 
cation, arising in the meantime, may be referred to them for decision. 

8. This revision is purely a statistical matter, and will be best con- 
ducted by purely statistical methods. 

I would call attention especially to the third principle. No country 
has more fully accepted and put into practical operation the revised 
form of the International Classification than the United States. There 
has, in fact, been a double, and in some cases a triple, ratification of the 
system. As is necessary in our form of government, the Bureau of 
the Census, the registration offices of the constituent registration 
states, and also the municipal offices of cities within the states have 
each individually adopted the uniform system and cooperated in its 
employment. On the other hand, it appears that certain countries 
nominally represented in the International Commission of Revision at 
Paris in 1900 have not yet adopted, and perhaps never will adopt, the 
classification as there reported and recommended. Either such repre- 
sentation was not fully authorized or else the countries represented 
did not, in good faith, abide by the conclusions of the Commission of 
Revision. This certainly must be guarded against at the next decen- 
nial revision and care be taken that the representation of each country 
is in full official form and empowered to promise compliance with the 
recommendations of the Commission in which it participates; other- 
wise such representation degenerates into a mere farce. 



VITAL STATISTICS IN THE UNITED STATES. 307 

It is also important (and I feel that the leading registration offices 
employing this classification should insist upon it) that full regard 
should be paid to the fourth principle enunciated. The shortness of 
time allowable in making preparations for the first revision perhaps 
rendered compliance with this requirement difficult or impossible in 
1900, but we have now ample time, and it is absolutely necessary for 
a satisfactory result that the amount of statistical work to be affected 
by the conclusions of the Commission, shall be considered in framing 
them. 

TREATMENT OF JOINTLY REPORTED CAUSES OF DEATH. 

It is just as necessary that the manner of assigning the preference 
as to one of several causes reported upon a certificate of death should 
be considered by the International Commission and an authoritative 
code of procedure fromed, as that the order of titles and the inclusion 
of terms under each title should be settled. 

The method of dealing with this question which accompanied the 
report of the International Commission has not been generally accepted 
in this country in all of its details. In fact, it does not go sufficiently 
into detail, and it is perhaps impossible for it to do so in the form 
selected, to meet many practical questions arising in the daily work of 
registration offices. Besides this method there is the plan of record- 
ing decisions in specific cases and using such a record as a guide for 
future decisions — a method which has long been employed in the 
Bureau of the Census, and which is in use in some state and city 
offices. Another method, or perhaps a variation of the preceding one, 
is that by which the registrar, who is a qualified physician and hearth 
officer, passes upon each individual certificate coming before him, 
or at least upon all of the more difficult ones, and gives his decision 
in each case according to his best judgment at the time and without 
reference to preceding decisions or precedents. Probably a consider- 
able degree of uniformity may be attained by an expert statistician 
working in this manner in his own office, but it is evident that his 
results would not agree, with those obtained elsewhere. I do not 
mention as a method the expedient whereby this important work is 
intrusted to careless or ignorant clerks, entirely without medical train- 
ing, and refer to it only to condemn it. 

Lastly I have suggested in a paper on Co-operative Methods for 
Improving the Usefulness of Statistical Classifications of Census of 
Death, read by me in the Section on Hygiene and Sanitary Science 
of the American Medical Association at New Orleans in 1903, and 
reprinted in Census pamphlet No. 105, Statistical Treatment of Causes 



308 VITAL STATISTICS IN THE UNITED STATES. 

of Death; Cooperative Work Relative to Treatment of Jointly Re- 
turned Causes and the Revision of the International Classification, a 
method which seems to me to oflFer the true solution of this problem 
and the only one in which the conclusions may readily be used in 
practical registration work. This is the plan of rating the importance 
of the titles of the classification and of the individual terms under each 
title according to a certain scale, so that the product of the numbers 
will represent the relative importance of the terms occurring upon 
certificates of deaths for the purposes of statistical classification. 

The method was carefully studied by my predecessor, Mr. William 
A. King, who fully approved of its general principles, and it has also 
been studied by other competent statisticians and sanitarians in this 
country, who have contributed sets of ratings which have been em- 
ployed for the purpose of making a practical test of the method. 

It did not seem expedient, however, to "swap horses in the middle of 
the stream" and to introduce any change in the methods of compila- 
tion of joint causes during the present decade. It seemed preferable 
to bring the subject up before the next decennial Commission, not 
only because it is of first importance as providing a proper method 
of assigning jointly returned causes, but also because the conclusions 
reached by means of this method have a most important bearing on 
the revision itself, as fully explained in the paper and Census pam- 
phlet referred to. 

PREPARATION OF REVISED EDITION OF MANUAL OF INTERNATIONAL 
CLASSIFICATION OF CAUSES OF DEATH. 

The Manual of the International Qassification of Causes of 
Death, published in 1902 by the Bureau of the Census, has been highly 
appreciated by registration ofiicials throughout the country as afford- 
ing an indispensable guide in the practical work* of compilation. 

Since 1902 many new terms have been received and assigned by the 
Bureau of the Census, and a new edition is demanded. I hope that 
this may be prepared next year and in connection with the index of 
causes of death a provisional set of rating numbers can be given with- 
out in any way increasing the size of the Manual. This will enable 
registration ofiicials to become fully familiar with the system, although, 
as stated, it is not recommended for actual adoption until it has been 
sanctioned by the International Commission. 

In the new edition some additional matter may also be presented 
in regard to the preparation for the next revision and it may be well 
for me here, at this time, to request all registration officials in the 



VITAL STATISTICS IN THE UNITED STATES. 309 

United States to make notes of all changes in the classification which 
they desire and of all imperfections which they wish to see removed, 
so that they may be duly considered in the next revision. 

PROPOSED ORGANIZATION OF A SECTION ON VITAL STATISTICS AS A PART 
OF THE AMERICAN PUBUC HEALTH ASSOCIATION. 

So many advantages have resulted from the action of the American 
Public Health Association on vital statistics in the past, and such ex- 
cellent opportunities are opened to it for further cooperation with the 
Bureau of the Census and other official agencies in the future, that 
it is eminently proper that we should here consider what are the ways 
in which such work may best be accomplished. 

I was at first inclined to suggest the restoration of the Committee 
on Vital Statistics, but after a full survey of the situation and corres- 
pondence with the officers of the Association and registration officials 
of all of the states and larger cities, I am sure that the preferable 
way is to provide for the establishment of a Section on Vital Statistics 
very much in the same way that the Laboratory Section is now con- 
stituted, and which shall deal with this subject in a similar way. 
This view was sanctic«ied by a letter from Professor Franklin C. 
Robinson, President of the Association, under date of October ii, 
1906, in which he says : 

I am in entire sympathy with your idea of a Section on Vital Sta- 
tistics, and while perhaps I have no power to appoint a committee to 
report in Mexico, still the program was left largely in my hands, and I 
feel sure that I can find a place on it for a paper or report on the 
subject by you or some one you designate. The subjects for the meet- 
ing as selected did not include vital statistics, but it has not been pos- 
sible to get enough papers to fill out a session on some of the topics, 
and I anticipate that the Cuban trouble will seriously interfere with 
others. Hence I feel sure that you can have plenty of time. But 
don't neglect to get your matter ready so that an abstract at least can 
be in our hands as near November first as possible, in order that it 
may be printed in English and Spanish and all may know of it. The 
abstract may be sent to Doctor Probst or myself, preferably to him. 

In order to obtain an expression of opinion from the registration 
officials of the countries represented in the Association, I prepared 
the following circular letter: 

I am preparing a report to the American Public Health Association 
and wish to suggest the advisability of organizing a "National Asso- 
ciation of Registration Officials" as a section of that Association. 

Vital statistics is a necessary part of an efficient public health ser- 



310 VITAL STATISTICS IN THE UNITED STATES. 

vice, whether national, state, or municipal. It requires special tech- 
nical qualifications, and the importance of approved and uniform 
methods for the collection, indexing, and preservation of returns, the 
preparation of statistical tables, classificaticHi of causes of death, and 
other important matters is yearly becoming more apparent in con- 
nection with the work of this Bureau. 

Much may be accomplished by a national union of registration offi- 
cials, and by organizing it in connection with the American Public 
Health Association, which has already done so much for the improve- 
ment of vital statistics, there will be no waste of eflfort and effective 
work can be performed from the start. 

Please let me know your views on the subject, and favor me with 
any suggestions which I may incorporate in my report. 

The responses have been most enthusiastic and gratifying. With- 
out a single exception all of the registration officials endorsed the 
movement. There is only some little difference of opinion, which is 
quite to be expected, as to the best form of organization and the 
details of its connection with the Association. 

RECOM MENDATIONS. 

After reading over the correspondence, there can be no question 
as to the feasibility and advisability of the new organization. It is my 
personal impression that it would be well to appoint a CcMnmittee 
on Vital Statistics at the present session of the Association to look 
after, the details of such organization, to arrange for attendance of 
registrars at the next meeting of the Association, and to draft a con- 
stitution for the Vital Statistics Section of the American Public Healdi 
Association, which shall be adopted at the meeting in 1907. 

The form of constitution now existing for the Laboratory Section 
would seem to provide a suitable outline, and I therefore oflFer the 
following resolution : 

Resolved, That a committee of five be appointed by the President 
of the American Public Health Association to report on the organiza- 
tion of a Section on Vital Statistics at the next meeting of the Asso- 
ciation, and that it be authorized to notify registration officials in the 
countries represented in the Association, particularly inviting their 
attendance at the next meeting, and to prepare a constituticm for 
approval by the Association and adoption by the Section at that time. 



OBSERVATIONS ON THE CENSUS AND MORTAUTY 
TABLES OF THE CITY OF MEXICO. 

Dr. J. MILLAN PONCE, Mexico, D. R, Mexico. 

It has often been stated and repeated with insistence that the city 
of Mexico is highly unhealthy because the mortality returns when 
compared with the census, show a proportion that at first sight ap- 
pears greater than that shown by the statistics of civilized nations 
under good hygienic rules. 

But if we will seriously reflect on this matter and consider the 
inexactitude of many factors that have entered into its statistics we 
will necessarily come to a conclusion which will be very near the 
truth and a great comfort to all who desire to preserve the good 
name of their country. 

What first strikes the imagination is the very small number given 
as the existing population of our metropolis. 

The last census which was taken in the year 1900 shows a popula- 
tion of 368,898 inhabitants. 

It is a well known fact that nothing is so difficult as the taking of 
an exact census. 

There is no nation which can boast of a perfectly exact census, and 
those which come nearest the truth are taken in England, the United 
States, Germany, France and Italy, that is to say in those nations 
which have enjoyed several centuries of progress, which have notably 
decreased the number of their ignorant classes ; which can also count 
on the civic education of their masses, and in one word, who have 
taken many previous census and therefore have experience. 

Our census is certainly inexact, not only absolutely so but even 
relatively or approximately, in spite of powerful and constant efforts 
of the government, who in certain progressive works encounters ob- 
stacles that for the present appear insuperable, but which will gradu- 
ally disappear as our masses increase in civilization and culture. 

One of these difficulties is caused by the fact that our lower classes 
refuse to give information to the census takers for fear that by giving 
their names and the number of males which form part of their fami- 
lies the information may be used for forming lists which will be utilized 
in the levying of a head tax which like all other direct taxes is dis- 
liked by the people, and although it at one time existed in the greater 
part of the state has now disappeared leaving us the unavoidable 
legacy of the memory of the fears which it so justly inspired, and 

Sll 



312 CENSUS AND MORTALITY TABLES. 

which are still exaggerated by our lower classes as soon as they see 
a census taker. 

And this is not the only reason why many individuals refuse to 
give information for the purposes of the census. They still are afraid 
of being forcibly recruited into the army, as used to be done in that 
disastrous period of our political revolution which was happily termi- 
nated by the well established peace that we have enjoyed during the 
last thirty years. 

Tliere is yet another difficulty: when orders were issued for the 
taking of the last, census, a rumor was current amongst the ignorant 
classes that there was an intention to establish conscription in the 
Mexican Republic similar to that which exists in France and Spain, 
and this was another reason why the people of the middle and lower' 
classes and even some of the wealthy classes took great pains to keep 
their names out of the census. This fear was entirely unfounded, as 
in the United Mexican States the army is recruited by voluntary 
contract. 

I will mention two other causes for hiding information which re- 
late to the women and children. 

A great part of the women amongst the lower classes and even 
amongst the middle class avoid entering their names in the census 
because they fear that the authorities will then fine them for not 
registering their children or for not making them attend the school, 
as required by law. As the fathers are generally at work, it is the 
mothers who hide in the house. The children are hidden, both for the 
reasons above given as well as for fear of vaccination, which is also 
obligatory in this country although it is only fair to state, that there 
are comparatively few mothers who hide their children for this reason. 

Lastly there is another reason that can be brought forward against 
the inexact character of the census; I refer to the negligence of the 
census-takers. In taking this census our government was anxious 
to make it as correct as possible, and therefore even high public 
officers personally showed the example to the honorable and enthu- 
siastic persons, who, for the sake of the national advancement accepted 
the commission to collect the census returns that would show the 
numbers of each family. It cannot be denied that the majority fulfill 
their office in a satisfactory manner, but many, for one cause or an- 
other transferred their commissions to mercenary individuals amongst 
whom some worked faithfully but not a few carried out their work in 
such a deficient manner that in many cases the blank forms for the 
returns were not received. 



CENSUS AND MORTALITY TABLES. 313 

If we take into account that the ignorant classes and the middle 
class form the majority of the inhabitants of the Republic in general 
as well as of the capital city, and also bear in mind that for the reasons 
above given a large proportion of both classes hide from the census 
takers, it is only reasonable to assume that the number of 368,898 
which is shown by the last census is very far from approaching the 
real population. 

It will therefore not appear an exaggeration, to estimate an increase 
of fifty per cent which would give us in round numbers, 553,347 
inhabiants for the city of Mexico. 

This is the figure that I will make use of in the considerations I 
now desire to lay before you: 

Having now brought the census returns to a reasonable figure, if 
we look at the number of births we will find that the children who 
were registered during October 1905 to September 1906 were 6,508 
so that this factor of increase which is placed against the mortality, 
added to the immigration is very small and this is only natural if we 
bear in mind that the records of the registry office are entirely inexact. 

It is well known that the immense majority of the inhabitants of 
our capital city belong to the Roman Catholic Church and that in 
obedience with its precepts they baptize the children a few days or at 
the utmost a few months after birth. 

I have applied to this source in order to ascertain as nearly as pos- 
sible the birth-rate and found that during the year 1905- 1906 there 
were 18,270 children baptized in the parish churches of this city. As 
can be seen the difference is very appreciable as follows: 

Births entered in the registry offices during the year 1905-1906 8,508 

Births entered in the parish churches during the same period of time. . 18,270 
Difference in favor of the increase of population 9,762 

To these figures we have still to add the number of children bom 
to parents who do not profess any known religion, those whom we 
might call indiflferent on the subject, and who do not take any notice 
of the legal requirements and do not register their children, either in 
the registry office or in the parish churches for the purpose of baptism. 

The mortality tables constitute the only factor that gives exact 
figures because every death is recorded in the civil registry without 
which requisite no dead person can be buried. 

Within the period 1905 to September 1906 this mortality reached 
19,966 which given a. proportion on the number which I have care- 
fully calculated of 38.6 per thousand. 

If this figure appears alarminie:, I must dissipate that alarm by 



314 CENSUS AND MORTALITY TABLES. 

stating, that with the full knowledge I selected for my studies a 
period of time during which the epidemic of exanthematic typhus 
prevailed which happily only visits us at long periods in a serious 
epidemic form. And I selected a year of epidemic for my calculations 
with the object of proving to this learned Association that not even 
in a period of full epidemic as serious and desolating as that of ex- 
anthematic typhus in our country, does the mortality rise to that 
exaggerated and almost inconceivable form that would result if we 
took it in combination with the incorrect census of 1900. 

I have called that proportion exaggerated and inconceivable for 
Mexico because the nations which place our rate of mortality at 49^ 
51, 52 and 62 per thousand as shown in our statistical returns for the 
years 1900, 1899, ^898 and 1893 "^^st be in a lamentably backward 
condition and you will see, gentlemen, that Mexico progresses, that 
it considerably increases the number of dwellings in extensive sub- 
urbs that run in different directions; that a great number of houses 
which a few years ago had only one or two stories have now received 
two and even three more; that our numerous and ample squares 
preserve and have even improved their gardens, that the conuner- 
cial houses have notably increased in number, the magnificent sani- 
tation works of the city are almost completed; that the immigration 
has increased; that the movement and animation of our streets is 
more active; that within a few months the city will be connected by 
streets with several suburban towns such as Tacubaya and Tacuba, 
which even now may be considered as forming part of the city and 
contain immense groves of trees, pure water, and hygienic houses. 

Those of you who visited us on the last occasion when our Asso- 
sociation met in this city will be able to form an idea of our progress ; 
you will see how our city has advanced, how many educational in- 
stitutions, thoroughly adapted to their purpose we can show as well 
as our hospital, new means of urban communication and in one word 
ever)rthing that has been completed and has been c(Mnmenced. 

Our government spends considerable sums in the improvement 
of the hygienic conditions of the capital as well as in all other branches 
of administration; the confidence which leads to the investment of 
foreign capital is now increasing, and in truth these advances, these 
efforts, this growth and these impulses toward progress are not found 
in those nations whose rate of mortality is six per cent per annum 
as has been believed. If this were correct, we would either have 
gone back or have remained stationary in the conditions in which 
you left us at the time of your last visit, when you brought your 
scientific knowledge to bear on our discussion. 



CENSUS AND MORTAUTY TABLES. 316 

There can be no doubt that our sanitary conditions will improve 
when the new generation which is now rising and which is learning 
the A, By Q of private hygiene will bring into practice its learned 
and beneficent laws for the preservation of health. 

In the official schools, one of the preferred subjects of study is 
individual hygiene, and our lower classes who through their igno- 
rance of this very important subject give the largest contingent to the 
mortality returns, will save themselves from the death which severely 
and blindly seizes all those who sin against the precepts of private 
hygiene. 

It is only necessary gentlemen, for you to take a glance at the 
plan of the city of Mexico which I now bring before you. In that 
you will see shown in red ink the new streets and blocks with which 
the area of the city has been increased; and which covers an area,, 
about equal to that of the city thirty years ago. The immense ma- 
jority of those new houses are inhabited, but nevertheless the old 
houses also have their tenants. It is at times difficult to find houses 
to let and for that reason several companies have already com- 
menced to construct cheap dwellings for the working classes who* 
also find it difficult to pay the rents which have risen with the value 
of the property through the immigration that is every day more ap- 
preciable. 

In bringing to a close these pages, I desire to establish the relations 
between the mortality and the climate of the city and setting aside 
the diseases which do not depend on it come to conclusion which 
although already known to you I desire to repeat here even if only 
as a tribute to scientific truth. 

If we set aside the death caused by violence, those of childrcn^ 
under two years of age, which almost always arise from the igno- 
rance of hygienic feeding on the part of the mothers or on the alco- 
holic or S3rphilitic inheritance which terminates their lives soon after 
birth; the fatty degeneration of the liver and other internal diseases 
that are produced by the abuse of pulque and alcohol; the diseases 
of the nervous system, of the genital organs or in child birth, those 
of the organs of locomotion, senility and others we come to the con- 
clusion that the climate of Mexico City is the cause of very few 
deaths as the greater part of them are due to alcoholism which causes 
great ravages amongst the lower classes, to the carelessness and 
ignorance of the mothers in the bringing up of their children and ta 
other preventable diseases. 

The meteorological observatory of the city of Mexico, through 
its former director, the engineer Mariano Barcena (who unfortu- 



516 CENSUS AND MORTALITY TABLES. 

nately died a few years ago, made the following observations with 
respect to the climate of the capital city; words that were the result 
of daily observations for sixteen years: 

"The climate of Mexico City is temperate and agreeable; its av- 
erage annual temperature is 154°. The highest and lowest temper- 
atures are only felt during a few hours of the day and the rest of the 
same day is almost always uniform and average. Although on ac- 
count of its elevation of 2,265 meters above sea level, the city should 
continually suffer from the inclemency or the cold and other incon- 
veniences of high elevation, on account of its latitude of 19® it could 
also be subject to the rigors of tropical climates; but the cwnbina- 
tion of the two geographical elements produces an annual average 
temperature of 15.4*'." 

I believe, gentlemen, that I have now demonstrated that the figures 
ought to be raised to 553,347 inhabitants, because the number of 
individuals who hide when the census is taken is enormous. 

That the births and immigration are sufficient to compensate the 
mortality rates and still leave a constant factor of increase in the 
population. 

That the mortality rates shown for the year I have studied for 
the purposes of this paper ap^pear exaggerated because during that 
year we had a strong epidemic of typhus. 

. That not even with a strong epidemic did the mortality of Mexico 
reach 49.40 per thousand as shown in the mortality returns for the 
year 1900. (i) 

That these errors will disappear as the teachings of civilization 
penetrate the lower classes of our citizens. 

That even this mortality is diminishing and will progressively 
diminish as our lower classes who furnish seventy-five per cent of 
the total number of deaths learn and practice private hygiene. 

That of the diseases which cause those deaths many are prevent- 
able, and there are well grounded reasons to hope that they will con- 
tinue diminishing and disappear in the course of time. 

And lastly, that the city of Mexico is not unhealthy as regards 
its climate but will bear comparison with any of the European cap- 
itals and even with several of the United States of America. 



* Paper by Dr. Jos6 Ramirez, entitled "Mortality of the City of Mexico for 
the year 1900," read in the National Academy of Medicine in July, 1902. 



NOTES ON PREVENTIVE MEASURES AGAINST HYDRO- 
PHOBIA. 

Dr. M. GODOY ALVAREZ, Mexico, D. R, Mexico. 

It is very commonly believed by a certain section of the public, and 
even by some physicians, that the Pasteur antirabic injections, con- 
stitute an infalliblle resource to prevent the appearance of this terrible 
disease, and I believe it is for this reason, that little by little it has 
become the custom to neglect certain precautions, which, as proved by 
experience of many years, are of unquestionable value for preventing 
the development of the disease in persons who have been bitten by 
rabid animals. 

Without ignoring, but entirely otherwise, holding in high esteem 
the immense services that have been rendered humanity by the 
very ingenious and admirable discovery of the immortal Pasteur, it 
is a fact that, either because the patients come from long distances 
and do not receive the treatment in time, or because even if the 
injections are commenced in time, the incubation of the disease is 
shortened and it initiates its course before immunity has been ob- 
tained ; it is a fact, I repeat, that hydrophobia causes some mortality, 
even though it is not very great. 

On the other hand, it is a disease that produces so painful a death, 
as to justify the horror with which it is looked on by the public, and 
it would be an unquestionably great and legitimate glory for hygiene, 
if it obtained the entire suppression of this mortality. 

For this purpose it is necessary to enforce every kind of precaution 
to avoid the multiplication of the cases of hydrophobia, as well as to 
prevent its development in each individual case. 

It has for some time past been thoroughly established, that hydro- 
phobia is not spontaneously developed in man, but proceeds from the 
inoculation through a bite, mostly by a dog, but sometimes by a cat, 
fox, wolf, etc. 

Unfortunately we have not as yet obtained any knowledge as to 
the conditions under which the disease is developed in the dog, the 
animal that generally transmits it to man, and therefore each indi- 
vidual of that species, constitutes a potential danger. It is neverthe- 
less evident, that the stray dog in the street is the most dangerous, 
whilst the dogs which are private property, especially of the well-to-do 
classes, are very much less dangerous, because it is possible to keep a 

317 



^18 PREVENTIVE MEASURES AGAINST HYDROPHOBIA, 

continuous watch over them and to isolate them in due time, if they 
present suspicious symptoms. 

This is the reason why the ownerless dog is persecuted everywhere, 
and even amongst us there are police regulations which are intended 
to procure their extinction. But the fact is, that up to the present 
date these regulations have not produced any positive results, prob- 
ably because the persons who are charged with the execution, da 
not give it the attention it deserves, and thus the bites of dogs are 
very frequent in our cities. 

The Antirabic Institute of this city, daily serves injections, to 30 
and up to 60 persons, the greater part of whom are residents of the 
same city. 

The cases attended in the Institute for preventive treatment, are 
divided into three classes. The first is formed of those individuals 
who have been bitten by animals, and in whom die rabies have been 
proved. The second class is composed of those cases in which the 
bite was given by dogs suspected of rabies, and finally, the third 
class covers those cases of bites in which the patients procured the 
injection by way of precaution. 

The confirmed cases of bites by rabid animals, form the minority 
and can be estimated at 100 per year; but this figure is high if we 
compare it with the results obtained in other parts, where preventive 
measures are enforced with due energy. 

We thus find that two or three cases of rabies in dogs which may 
be observed within a short space of time, cause a general alarm and 
prevent the taking of severe sanitary measures. It is in this way that 
rabies have almost entirely disappeared in Berlin. 

From reports that I have been able to collect in the office dedicated 
to the administration of antirabic injections, the greater part of the 
persons who come there after being bitten, have been already cauter- 
ized, even if it is only with an antiseptic bandage. 

Such conduct on the part of the physicians who have given the 
first aid, must be considered praiseworthy, and it appears necessary 
to remind them, that the bites of rabid animals have a very different 
prognostic, according to whether they have been cauterized or not, 
setting aside for the moment the Pasteur method. We know that in 
the former case the proportion of deaths is only 31 per cent, whilst 
in the second place the proportion is 84 per cent. 

It is evident that these figures are not to be taken into account 
since the advent of the Pasteur inoculations, and if I have mentioned 
them, it is only to show the influence exercised by the cauterization in 
the cases of rabid bites. 



PREVENTIVE MEASURES AGAINST HYDROPHOBIA, 319 

It is much to be desired that the cauterization should be practiced 
as soon as possible after the bite, but if 24 or 48 hours have elapsed 
after the bite and up to the moment when the patient comes into the 
hands of the physician, even then this precaution should not be neg- 
lected, as it appears, that in spite of the delay, it may probably be of 
use. This appears to be the inference in a case of which I have certain 
knowledge. 

A rabid dog bit several individuals, all of them field laborers who 
for the moment took.no notice of the matter; but instigated by the 
manager of the farm, some of them proceeded to the nearest city in 
search of medical assistance. Although two days had already elapsed, 
the physician thermo-cauterized the wounds in the fullest measure, 
and it was noticed that whilst the men who had been treated suffered 
no ulterior consequences, those who had not received any attendance 
succumbed to hydrophobia. It is only fair to state, that in this case 
the Pasteur antirabic treatment was not applied. 

In closing I beg to present the following propositions: ist. That 
the stray, ownerless dogs should be exterminated, giving this task, 
not to the ordinary police force but to employes of a special office 
organized for the purpose. 

2d. That dogs belonging to private owners should be registered in 
the office above mentioned and pay a tax. 

3d. That private dogs should always be obliged to carry the mask 
which was adopted in Germany, and which efficaciously defends them 
against bites, whenever they go out into the street instead of a 
simple muzzle. 

4th. That when in the opinion of the board of health it should be 
necessary to strengthen the precautions, the dogs should not only 
carry the protecting mask, but also be led by a chain. 

5th. That pamphlets should be distributed in the above named 
office with clear instructions to enable the public to recognize when 
a dog should be suspected of rabies, and therefore be kept isolated, 

6th. The wounds caused by the bites of dogs, should be thermo- 
cauterized as a first precaution, and without prejudice to sending the 
patients to the antirabic institute, in order that they may receive 
proper treatment. 



VETERINARY HYGIENE. 

APPLIED TO THE PROTECTION OF MAN AGAINST ZOONOSIS. 

Dr, SILVIO J. BONANSEA, Mexico, D. R, Mexico. 

I have the honor to present to this learned association, a brief 
paper relative to the establishment of a sanitary service of veterin- 
ary hygiene, which would be adjusted to the last discoveries of 
science, and if wisely applied would undoubtedly be of great benefit 
to public health, 

I refer to a service of sanitary visits to be made for the inspec- 
tion of milch cows, milk and fresh or preserved meats, that on ac- 
count of the present hygienic requirements and the new discoveries 
in science, have greatly increased in number and require to be in- 
spected in order to secure their purity and good qualities from a hy- 
gienic and sanitary point of view. 

I earnestly beg the learned members of this association to fix their 
attention on the many and important benefits which can be derived 
by the public hygiene and health, through the services of a veterin- 
ary and hygienist physician, a specialist in this important branch of 
service, who would contribute greatly to the different ramifications 
of progress that have been made in the field of veterinary hygiene, 
and the application of which exercises a direct influence on the hy- 
giene of man. 

The establishment of a sanitary and hygienic service, such as I 
refer to, is of the greatest importance to public health, if we reflect 
on the many and serious diseases which are daily communicated 
to man through the direct or indirect channel of animals, of milk, 
of fresh or preserved meats, which are used as human food. 

We all know that milk and meat are the fundamental elements of 
good food. Meat occupies the first place, because it is an azoade 
matter, nourishing and easily digested, and which on account of the 
conformation of the human system which adapts it to this food, 
has become an absolute necessity for his maintenance, provided that 
it is good and sound. 

Unfortunately, milk and meat are substances that easily undergo 
alteration, and as they may proceed from sick animals, they are fre- 
quently improper for use as food, and highly dangerous to public 
health. 

Unfortunately, it is only too true that milk, besides the common 

3?0 



VETERINARY HYGIENE. 321 

and inoffensive bacilli, of lactic acid, of coli, etc., of the residues of 
aniii;al and vegetable substances, only too frequently contain the 
specific agencies of tuberculosis and typhus. The struggle against 
bovine and aviary tuberculosis, should be undertaken to protect the 
public health which is threatened by the enormous and increasing dif- 
fusion of the Koch bacillus. 

Civilized nations felt the supreme necessity of protecting them- 
selves against the serious injuries which are suffered by towns, when 
they are fed with infected or decomposing meats and milk, and 
hence the establishment of veterinary and sanitary inspection. 

I would call special attention to the very important work of the 
veterinarion, and also to the fact that his chief duty does not consist 
in the cure of animals, but in the prevention of disease. The veterinarian 
should be considered rather as a hygienist than as a therapeutic, be- 
cause as adviser of the cattle breeding establishments, and in view 
of the advantages of public and private hygiene to the public 
welfare, by giving warning of and stamping out enzootic, epizootic, 
contagious or infecto-contagious diseases that are transmissible from 
animals to man, he becomes an important factor in public hygiene 
and a protector of the public health. 

The veterinary hygienist can no longer be looked upon as a simple 
doctor, because if as a hygienist and bacteriologist he must be learned 
and foresighted, seeing that as sanitary inspector he holds the lives 
of the people in his hands, he is also under the great responsibility 
of preventing the transmission of infectious diseases to man. 

The indisputable utility of the veterinary inspector is always 
proven, more by the sequestrations that he every day makes in the 
great cities, in the sanitary inspections of meat, in the slaughter 
houses and butcher shops, of the milk, fish and preserved or salted 
meats, packing houses, etc. 

It is useless to say that up to the present date there is no class of 
the community which can secure its health against the serious dangers 
of infectious diseases, as no one can live apart in such a manner as to 
escape from the infections that directly or indirectly may reach him 
from the domestic animals unless he exercises the strictest vigilance 
on those animals, as well as on the milk and meat which he con- 
sumes. 

Hygiene charges itself with combatting the causes of the disease, 
not only some but all the causes of disease, and it will not give up 
its task until it has realized that noble purpose, or until men die a 
physiological death. It is evident that this purpose can be reached 
and that it must not only form the sublime aspiration of medical 
21 



322 VETERINARY HYGIENE, 

science on the part of physicians and veterinarians, but also of all 
sociologists, as all other social prosperity is useless^ when the object 
of all is wanting, that is to say, health and life. 

It is now the general conviction that amongst all the adulteraUe 
food, the action of animal food is that which most frequently exer- 
cises a fatal influence. 

There are innumerable cases of malignant pustule that have been 
observed in men through having handled carcasses or simply skins of 
animals that have died of anthrax. 

How many cases of tuberculosis have been caused in man through 
the consumption of meat and milk from tuberculous animals? 

We also frequently see cases of transmission to man of actino- 
mycosis, smallpox, pyaemic affections, septicemia, etc. The cases of 
rabies are too well known for me to make any reference to them here. 
Only too frequently do we read of cases of infection of men 
through the eating of diseased meats. How often do we see in the 
butcher shops, meats which present signs of incipient putrefaction, 
and that nevertheless are sold to the public. I would remind my 
hearers that there is great danger in eating putrid meat, which is 
liable to cause poisoning, because such meats contain ptomaines, toxic 
alkaloids, etc., in a high degree. It has been proved that acute dis- 
eases render meat dangerous as food, because in those diseases fever 
supervenes and we know that during a fever, besides the products of 
progressive metamorphosis which accumulate in the tissues, products 
such as creatine, acetinine, uric acid, hyoxantine, etc., alkaloids or 
leucomaines, are formed, which can poison a system whose renal and 
hypatic functions are defective. 

We thus see that a strict hygiene should exclude from human 
food all meats which proceed from animals that have died of any 
disease, even though it may not be either infectious or contagious. 
There are many cases of poisoning amongst men, which are due to 
the consumption of meats proceeding from animals that have been 
attacked by different diseases, such as sero-fibrinous, peritonitis, 
(Rost.) ; puerpural fevers, (Hartenstein), epizootic afta (Strose), 
infectious pneumoenteritis in hogs, (Ponchet, Strobel), diarrhoea in 
calves, (Krueger), mastoids (Gerla) and other traumatic inflamma- 
tions in which the exudations become septic. 

Special note should also be taken of those meats, which although 
cooked do not lose their infectious quality, such as the meats which 
are infected by the spores of the anthrax, of tetanus, of bovine septi- 
cemia, of the tuberculous bacillus, as according to the last studies of 
Dr. Calmette, it apypears proved that even sterilized milk is capable of 



VETERINARY HYGIENE, 828 

transmitting tuberculosis. Those germs have been found in a state 
of perfect activity, in pieces of a kilo weight which had been in- 
fected after boiling for an hour and a half. 

I make no mention of the many parasitic infections, such as trichin- 
osis, cistercosis, equinocosis, psoriasis, exanthemic disorders, which 
frequently and easily affect the man who eats insufficientiy cooked 
food. 

In his analysis, Petri found the germs of hog cholera alive in hams 
that had been salted for a month and in the smoked meats after they 
had been prepared for three to five months. 

We must also take into account the fraudulent sophistications and 
alterations that are made by butchers, packing houses, and milkmen, 
who care little for the public health. 

It has been demonstrated that in order to remedy these evident 
and serious evils, and to prevent serious infections in the community, 
it is urgently necessary to institute a veterinary bacteriological and 
sanitary inspection of meat and milk which are sold to the public, 
as well as for the sanitary inspection of milch cows. 

The veterinary inspection is necessary in modem communities, see- 
ing that the veterinarian who is charged with the inspection of the 
animals and of the meats in slaughter houses and butcher shops, 
studying the origin, and propogation of such animal diseases as are 
transmissible to them, examining the original causes, will be in a 
position to propose to the superior authorities, the reasonable sanitary 
measures which ought to be taken for the prophylaxis of such diseases, 
for attenuating their ravages, limiting their diffusion and preventing 
their reappearance. 

A true prophylaxis of transmissible disease cannot be obtained 
without the full scientific knowledge which is furnished to us by the 
general etiology of those diseases. For this reason it is necessary 
that the slaughter house inspection should be intrusted to a compet- 
tent and well trained specialist, because the execution of the measures 
which relate to public hygiene, require a special study, and a tech- 
nical ability which cannot be reduced to a simple bureaucratic visit. 

In the field of veterinary and sanitary police, as well as in that of 
the inspection of milk, fresh and preserved meats, will be included 
all the parasitic, contagious, infectious, zymotic, bacterial or micro- 
bial diseases, against which public hygiene should warn mankind. 

The medical veterinary sanitarian, by virtue of his special acquire- 
ments is under special obligations, either through his technical knowl- 
edge, or as the delegate of the administrative authorities, and also as 
the adviser of private people and cattle breeders. He occupies an 



324 VETERINARY HYGIENE. 

important position^ even in the political and national economy, seeing 
that the scarcity of cattle implies an increase in the price of milk 
and meats, ^ question that now greatly occupies the Mexican market 

In view of the many causes which may deteriorate, poison or infect 
milk and meat; of the trade which is carried on in sick animals; of 
the imperfect sanitary inspection of the slaughter houses, butcher 
shops, dairies, packing houses, and other similar establishments; of 
the continuous and serious danger which threatens the community, of 
contracting serious diseases through the direct or indirect contact 
with animals, I ask this learned and humanitarian Public Health As- 
sociation, to encourage the following enactments: 

1st. International laws of veterinary sanitary police. 

2d. That the national veterinay sanitary police should at once 
commence a campaign against the principal infecto-contagious dis- 
eases of an endemic character, which can be transmitted from animals 
toman. 

3d. That steps be taken for the establishment of sanitary stations 
in which to isolate sick or suspected animals, which present S)rmptoms 
of infecto-contagious diseases. 

4th. That technical, competent and trustworthy persons be charged 
with the inspection of the slaughter houses, butcher shops, dairies, and 
other establishments for the sale of animal food. 

5th. That a special laboratory of veterinary sanitary bacteriology 
as applied to hygiene, should test the purity and condition of meat 
and milk. 

6th. That a strict watch be kept over the milk, because it is the 
most appropriate vehicle for the transmission of many and serious 
diseases to man. 

I have considered it of great interest to public hygiene, to submit 
the above propositions to this learned association, which if well 
applied, would be of the greatest benefit to humanity. I hope that 
these propositions may be carried out in a practical way, and that a 
public officer be appointed in every town, to protect the public health, 
because 'salus populi suprema lex*. 



OFFICIAL REPORT OF THE PROCEEDINGS OF THE 

THIRTY-FOURTH ANNUAL MEETING OF THE 

AMERICAN PUBLIC HEALTH ASSOCIATION. 

(Note: — No stenographer was provided for the meetings. Mem- 
bers who took part in the discussions were requested to furnish the 
Secretary with their remarks in writing. Many failed to do so. Pa- 
pers in Spanish that were not translated into English were omitted. 
— Ed.) 

MONDAY, DECEMBER 3D, 1906. 

The Laboratory Section held its meeting in the rooms of the Su- 
perior Board of Health imder the chairmanship of Mr. H. W. Clark, 
of Boston, Mass. 

TUESDAY, DECEMBER 4TH, 1906. 
First Day — Morning Session. 

The Association met at the Conservatory of Music and was called 
to order at 9:00 A. M. by the President, Prof. F. C. Robinson, of 
Brunswick, Maine. 

The President called attention to the absence of Dr. S. H. Durgin, 
of Boston, on account of the recent death of his wife. On motion of 
Dr. Hill, of Minneapolis, the Secretary was instructed to telegraph 
Dr. Durgin, expressing the Association's sincere sympathy in his 
affliction. 

The President also reported the illness of Dr. Wm. Bailey, of Ken- 
tucky, who was taken ill soon after his arrival in the city of Mexico 
upon the official train. 

The President then called for the reading of the minutes of the last 
meeting. Dr. Fulton, of Baltimore, moved that the reading of the 
minutes be dispensed with inasmuch as they had been printed and 
distributed to all members. 

Seconded and carried. 

The Secretary reported that a number of applicants for membership 
had been favorably acted upon by the Executive Committee, and that 
the Committee recommended that the applicants be elected to mem- 
bership. A list of the applicants was then read. [See Appendix.] 

On motion of Dr. Wm. C. Chapman, duly seconded, the Secretary 
was instructed to cast the unanimous ballot of the Association for the 
names read, which he did, and they were declared duly elected. 

326 



826 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

Dr. Liceaga then announced the various arrang^ements that had 
been made for facilitating the business of the Association, and pro- 
viding for the pleasure of its visiting members. 

The first paper to be read was by Dr. Peter H. Bryce, of Ottawa, 
Canada, entitled, "Organized Sanitary Work in Dealing with Over- 
crowding." (See page 12.) 

Dr. Oscar J. Mayer, of Mexico City, read a paper entiled, "PuWic 
Health and Prophylaxis of Diseases." (See page 26.) 

Dr. Jose Mesa Guitierrez, of Mexico City, read a paper entitled: 
"Contribution to the Study of the Problems of National and Inter- 
national Sanitary Legislation." (See page 30.) 

DISCUSSION. 

These papers were discussed jointly. The discussion was opened 
by Dr. Josiah Hartzell, of Canton, Ohio, as follows: 

Mr. President — The proposition that has just been presented is 
by no means a new one. In effect Dr. Mayer makes a motion for the 
establishment of a distinctive Government I>epartment of Health. 
Dr. Mesa seconds the motion on the part of the Republic of Mexico. 
In the United States it awakens a responsive second in the hearts of 
all the effective leaders and workers for sanitary reform. 

Because this subject has been before this Association for more 
than twenty years, now and then taking shape in resolutions, it is 
sometimes referred to in a despairing way as a "thrashed out" propo- 
sition. I do not coincide with that view, and never did. The 
need of a comprehensive, well-organized Bureau of Health is as vital 
to-day as ever before — it becomes more so every year. 

The first effort in this field, having National scope, resulted in a 
bill which was introduced in the House of Representatives by the 
Hon. Jonas H. McGowan, of Michigan. It was entitled "A bill for 
the prevention of contagious and infectious diseases and for the 
establishment of a Bureau of Public Health." This bill was passed by 
both houses of Congress, was signed by President Hayes, and became 
a law on March ist, 1879. It was so wisely conceived and drawn that 
it could scarcely be improved upon after the lapse of all these years. 
These facts may have escaped the memory of some of you, which 
might also have been the case with me, but for the fact that the 
member who framed and introduced the bill was a near personal 
friend of mine. 

While this was a valid and most commendable law it remained with- 
out effect for the reason that succeeding congresses took a different 



PROCEEDINGS^ THIRTY-FOURTH ANNUAL MEETING, 327 

^'iew of the subject, or perhaps out of sheer indifference, neglected 
to make the appropriations needed to carry the law into effect. 

The result of the one subsequent effort that was made to erect a 
Bureau of Health is fresh in the memory of all. The aim of this 
new law purported to be some form of a consolidation comprising: a 
National Board of Health and the Marine Hospital Service, a sub- 
department of the government which is under the ccMitrol of the Sec- 
retary of War. Several years have now passed by since this law went 
into effect, if it ever had any effect to speak of. Like all hybrids, 
it has been barren. Not one health ofiker in a thousand is conscious 
of the existence of a National Board of Health. The only result 
worthy of mention is the fact that this semi-political and wholly un- 
warranted expedient really emphasizes our need, as a nation, of a 
National Bureau of Health. 

My view of the subject is that the neglect of Congress to estab- 
lish and maintain this as an executive department of the government 
of the United States is very near being shameful. Congressmen ought 
not to be swayed by side issues and personal politics. Former con- 
gresses have established a Bureau of Commerce and Industry; also 
a Department of Agriculture. Time and again the advocacy of both 
of these was sneered at as "threshed out" propositions, but the advo- 
cates were not deterred. In the end they triumphed, and the people 
approved, as well they may, and as they will again, and with even 
greater unanimity, when the government recognizes that the nK>st 
precious treasure of the people is their health, by placing the same 
under the orderly charge of an independent department. 

While the departments of Commerce and Agriculture were wise ad- 
ditions to the scope of executive attention and authority, how can 
these be compared, in importance to the purposes of a National Bu- 
reau of Health? In contrast with Germany, and her Imperial Board 
i f Health, and corresponding departments in England, France and 
other countries, we cut a sorry figure; one that relegates us to the 
rear in civilization and procession. The United States should have 
such a department, for the collection and dissemination of vitally 
important information ; for the promotion of the public health, which 
is the public's wealth; should provide the same with all needed 
means -and powers, and the same should be presided over by a Secre- 
tary and Cabinet Officer. If it is true, as Lord Beaconsfield once said, 
that "The health of the people is the first duty of statesmanship," 
Congress should see its way clear to the fulfillment of that duty with- 
out any further delay. 



328 PROCEEDINGS^ THIRTY-FOURTH ANNUAL MEETING, 

Dr. C. a. Harper, of Wisconsin, presented the following resc^u- 
tion: 

Recognizing the importance of sanitary control as regards the 
health and prosperity of the Nation, this Association deems it ad- 
vrsable to offer the followmg resolution to the Congress of the United 
States : 

Resolved by this Association, That a department of public health in 
the United States be created by Congress. Be it further 

Resolved, That the head of this department shall be a cabinet officer, 
possessing the powers usually vested in other members of the cabinet 

Dr. Richard H. Lewis, of North Carolina, offered the following 
resolution : 

Whereas, Owing to the rapid development of commerce between the 
nations more perfect machinery for international sanitary relations is 
desirable; therefore, 

Resolved, That a committee of three members from each country rep- 
resented in this Association be appointed by the President before ad- 
journment to secure by such means as they may think best the estab- 
lishment in each country of a Federal Department of Health, the head 
of which shall be a cabinet officer of his respective country. 

Dr. C. H. Irion, of New Orleans, offered the following amend- 
ment to the resolution of Dr. Lewis: 

Be it resolved, That a committee of three be named from each 
State of the United States to memoralize Congress for the establish- 
ment of a department of public health to be presided over by a cabinet 
officer, be appointed by the President of this Association. 

These resolutions and the amendment were referred to the Excu- 
tive Committee without discussion. 

In continuing the discussion Dr. Juan Peon del Valle of Mexico 
said: The Federal constitution of the Mexican Republic provides 
that the Executive Department of the Government shall be ccMistituted 
of a President assisted by as many ministers as may be required for 
dispatching national affairs. We now have two, a minister of Com- 
munications and Public Works and a minister of Public Instruction 
and Fine Arts. Laws relating to public health are of much more 
importance than laws relating to railroads and schools. It would be 
desirable to have a minister of health with executive powers for the 
whole country. 

Dr. J. N. HuRTY, of Indiana said : I am heartily in favor of the creation 
of a National Bureau of Health, the Secretary thereof to be a member 



PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING, 329 

of the President's Cabinet. I presume there is not an opposing voice 
here to the proposition, and the question before us therefore is — 
How may this desirable end be secured? We all well know that the 
subject has been agitated for twenty years at least, and has received 
the support of medical and sanitary associations the country over. 
The line of battle for the cause is a long one and the fight hard 
indeed. The first step is to create a public opinion and then legis- 
lators will listen and not before. Benjamin Franklin said, — "If you 
wish to convince and early carry your point, appeal to personal in- 
terests." It is human nature to be interested in those things which 
help you. Let us then make it known to the people that it is to their 
individual interest to wisely combat disease. Teach them also it is to 
their individual interest not simply to adopt the old adage, "An 
ounce of prevention is worth a pound of cure," but to put the same 
into practical every day operation. A propaganda by this association, 
by all state and other local health associations will eventually produce 
results. If the popular demand is sufficient, then congress will create 
a National Bureau of Health with the secretary a member of the 
presidential cabinet. 

Adjourned until 3:00 P. M. 

FIRST DAY — Afternoon Session. 

The Association re-assembled at 3:00 P. M., and was called to 
order by the President. The following group of papers was read, 
after which discussion followed: 

Yellow Fever, Dr. Eduardo Liceaga, of Mexico City, (see page 38). 

To What Extent are Infected Mosquitoes on Shipboard, Dr. A. 
H. Doty, of New York, (see page 44). 

Sanitary Department Isthmian Canal Commission, Dr. W. C. Gor- 
gas, Ancon C. Z., (see page 52.) 

The Diagnosis and Prevention of Yellow Fever, Dr. Joseph Gold- 
berger, of Washington, D. C, (see page 58.J 

The Yellow Fever Epidemic in New Orleans in 1905, Dr. Quitman 
Kohnke of New Orleans, (see page 89.) 

The Origin of Sporadic Cases of Yellow Fever at Long Periods, 
Dr. Manuel Iglesias, of Veracruz, (see page 83.) 

Notes on Yellow Fever, Dr. M. P. Colemenares, Orizaba, Mexico, 
(see page 95.) 

A paper by Dr. Ernesto Duplan of Puebla, Mexico, on "Brief 
Notes on the Propagation of Yellow Fever was read by title. (See 
page 74.) 



830 PROCEEDINGS -- THIRTY-FOURTH ANNUAL MEETING, 

DISCUSSION. 

Dr. Liceaga said: That in all places where yellow fever is epi- 
demic, there is a federal staff composed of a physician and sanitary 
agents, whose duties are as follows : To make a list of non-immune 
people, to make them a visit every day, in order to know the moment 
in which one of them gets sick, to isolate, as suspicious, any (me of 
the non-immunes as soon as he has fever, to make the necessary dis- 
infections, to spread oil (petroleum) on all deposits of water if they 
cannot be emptied, etc. This service is kept up all year. 

Dr. J. N. Thomas, of Quarantine, La. Mr. President and Gentlemen: 
I have listened with great interest and pleasure to the various papers 
read this afternoon on the subject of yellow fever and quarantine, 
but I wish to reply only to the papers of Dr. Doty of New York, 
and Dr. Goldberger of the United States Public Health and Marine 
Hospital Service. The subject of Dr. Doty's paper is "To What Ex- 
tent Are Infected Mosquitoes on Shipboard?" If this ques- 
tion could be definitely and practically answered, I believe that 95 
per cent of ship fumigation could be done away with, but as it cannot 
be answered, in the light of our knowledge on the subject and in the 
face of facts that we have before us, I cannot see how ship fumiga- 
tion as now practiced at the various Southern seaports of the United 
States, can be greatly restricted without assuming a risk to the public 
health of the country that would be unpardonable. That mosquitoes 
are often present on shipboard is not only well known to quarantine 
officers, but the fact has been abundantly proven by the experiments 
carried on for two or three years by the Louisiana State Board of 
Health. Medical officers on fruit ships and others were instructed to 
carefully watch for mosquitoes on board and were furnished with 
the ordinary test tubes and cotton with which to catch and confine 
them, and they were required to make regular reports on the sub- 
ject to the President of the Louisiana State Board of Health. These 
experiments show that mosquitoes were carried to and fro across the 
gulf without any trouble. If, then, mosquitoes of any kind or variety 
can be imported from tropical ports, it is reasonable to believe that 
infected mosquitoes from infected ports can be easily imported ; and 
there are on record numerous instances to substantiate this belief. 
We are all familiar with the story of the United States sloop-of-war 
Pl)rmouth. After having been pest-ridden with yellow fever, which 
struck down her gallant crew, she was taken to the northern port of 
Portsmouth, N. H., and there put out of commission, dismantled and 
practically scuttled in order to allow the snow and ice of the northern 
winter to kill the supposed yellow fever germs. In the following 



PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING, 381 

summer she was again put into commission, and set sail for southern 
waters, and as soon as she had gotten well within the tropics, without 
ever having touched any seaport whatever, yellow fever again broke 
out among her crew. 

Dr. Henry R. Carter of the United States Public Health and Marine 
Hospital Service, is my authority for the statement that yellow fever 
broke out on one of the Ward Line steamers between New York and 
Havana a few years ago in the person of a Sister of Oiarity, who 
was direct from Paris to New York, and never had any association 
whatever with any one ccwinected with yellow fever. The vessel made 
regular trips between Vera Cruz and New York, calling in at Havana 
only between the hours of sunrise and sunset, and anchoring in the 
open harbor to debark and embark passengers. On the voyage up 
from Vera Cruz to New York no sickness had been reported, no 
fumigation was practiced, and the presumption cannot be otherwise 
than that infected mosquitoes were on board and in the room occu- 
pied by the Sister of Charity, when she boarded the vessel in New 
York. 

Again, the records at the Mississippi River Quarantine Station 
show that there are many instances in which cases of yellow fever 
have broken out on shipboard, which can be ascribed to no other 
cause than that infected mosquitoes were on board. I recall the cases 
on the bark Excelsior, with a cargo of coffee, fifty-two days out from 
Rio de Janeiro. There had been no sickness during the voyage, and 
yet, after arriving at the Mississippi River Quarantine Station, within 
a few days after fumigation, yellow fever appeared among her crew. 
At the time there was no yellow fever at the Station or in the city 
of New Orleans. 

During the summer of 1905 I took a case of yellow fever off a 
Spanish steamer from Vera Cruz that was unmistakably due to the 
bite of an infected mosquito on shipboard. The vessel while at Vera 
Cruz did not lay alongside the wharf, but, instead, anchored in the 
bay, close to shore. The patient, a sailor, had at no time been ashore 
at Vera Cruz, and his statement was verified by the officers and his 
fellows. Upon close inspection mosquitoe bites were found on the 
legs of the patient, and the inmates of the forecastle stated that there 
were mosquitoes present where they slept. The patient was seen by 
the surgeon on board and three quarantine officers, so there was no 
mistake in the diagnosis. These instances, I think, present sufficient 
evidence to prove that infected mosquitoes can be and are carried 
on shipboard. 
I believe, however, that there is a vast difference in the liability 



532 PROCEEDINGS'- THIRTY-FOURTH ANNUAL MEETING, 

to mosquito infection between vessels lying in the open harbors of 
infected ports and those that lie at the wharves of such ports. If such 
vessel lie a mile or so off shore, I think there is little danger of mos- 
quitoes getting aboard^ and if the crew are denied shore leave and 
no passengers from shore taken on board, there is little risk of any 
infection being on board such a ship. If, however, vessels lay at the 
wharves of infected ports, there is good reason to believe that infected 
mosquitoes will get aboard, and, whether the crew go ashore or not, 
there is strong probability that such vessels are infection carriers. 
The latter class of vessels should not be allowed to leave ports of 
departure without a thorough fmnigation to kill any infected mos- 
quitoes aboard. At the ports of arrival the sanitary and quarantine 
treatment of these two classes of vessels should be different. Con- 
sideration as to the time of detention should be given to those vessels 
observing precautionary measures of protection against infection at 
the ports of departure. As to how far a Stegomyia will fly, and at 
what hour of the day or night she will bite, is drawing the point too 
fine — splitting hairs, as it were — and should receive no considera- 
tion whatever from the guardians of public health. 

Quarantine regulation that would apply with reasonable safety at 
the port of New York would not do for the southern ports of the 
United States, and this fact is recognized in the regulations of the 
United States Public Health and Marine Hospital Service, for dif- 
ferent treatment is prescribed for vessels arriving during the quar- 
antine period, from April to November i, from the tropics for ports 
north of the southern boundary of Maryland than those south of 
that line. 

It might be safe to admit a vessel into the port of New York from 
an infected yellow fever port without fumigation, for even if a case 
of fever were introduced it would not spread. It would be criminal 
to knowingly do this in New Orleans, for the introduction of one 
case might be the means of starting an epidemic. Whenever there is 
a doubt public health should receive the benefit of the doubt, and this 
rule should be applied more at the southern maritime quarantine 
than in any other department of sanitary science. 

In this paper Dr. Doty referred to the possibility of New Orleans 
liaving become infected in 1905 from mosquitoes on fruit ships. I 
wish to take strong grounds in opposition to this theory. After a 
most exhaustive investigation into tihis important matter, I am con- 
vinced that the epidemic of yellow fever in New Orleans in 1905 
was due to her open communication with Havana. There was neither 
a national nor a state quarantine against Cuban ports in 1905, yet, 



PROCEEDINGS^ THIRTY-FOURTH ANNUAL MEETING, 388 

as early as May dengue^ pernicious malaria and other fevers were 
officially reported to be there, and these fevers continued to increase 
as the sununer advanced. I saw convalescent patients whose disease 
had been diagnosed as dengue fever in Havana that were distinctly 
jaundiced and whose clinical history bore every evidence that the 
cases were genuine yellow fever. Between the ist day of April and 
the 1st day of August, the weekly passenger steamer was in less than 
forthy-eight hours run from Havana, landed on the wharves at New 
Orleans, opposite the French market, 980 passengers within less than 
1,000 feet of where the first cases of yellow fever were reported. There 
was no fumigation practiced and no restrictions were ever placed 
on the passengers. The vessel laid at the wharf during her days of 
taking on cargo and passengers from Havana, and if mosquitoes 
can fly at all they could easily have covered the distance between 
the ship and the first infected area of New Orleans. I am convinced 
that this was our source of infection. 

In conclusion, I wish to add my endorsement to the able paper 
of Dr. Goldberger, especially so to the point he makes as to the 
probability of a mild or "walking" case of yellow fever escaping de- 
tection in the non-quarantine season, between the first day of No- 
vember and the ist day of April, by the most capable and vigilant 
inspection officer. In the latter part of our non-quarantine season, 
say in the last days of February or March, a case of this kind might 
mean the starting point of an epidemic. 

Dr. Joseph Goldberger, Washington, D. C. I think that most of 
us will agree with Dr. Doty that mosquitoes are very much less 
frequently to be met with on vessels in these days of the steamship 
than in the days of the sailing vessel; but that the Stegomyia mos- 
quito may infest steam vessels is clearly shown by the case of the 
French Sister of Charity, cited by Dr. Thomas. She arrived in 
Havana on the Ward Line steamer "Vigilancia" from New York in 
September, 1899, having been taken sick the day before her arrival, 
with what proved to be a fatal attack of yellow fever. It has been 
the policy of the Public Health and Marine Hospital Service for some 
years now to station officers at foreign ports to observe health con- 
ditions and to report as early as might be the appearance of any 
quarantinable disease. Such officers also supervise the fumigation 
and sanitation of vessels, cargo, crew and passengers at such for- 
eign ports. I myself was on such duty in the summer of 1902, in 
this Republic at Tampico. During that summer I was in the habit 
of going aboard vessels immediately after their arrival at Tampico 
from Havana or Vera Cruz to search for mosquitoes; on one of 



334 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

these» the Italian steamer "II Piemonte", from Vera Cruz, I found 
a female Stegomyia in the captain's quarters. The following day 
one of the crew was taken down with yellow fever. This shows very 
well that the Stegomyia may find its way on board steam vessels where 
if not already infected, it may become infected by a case of yellow 
fever occurring after departure from port. 

Dr. Fred J. Mayer, of Louisiana, followed, and strongly indorsed 
the views of Drs. Thomas and Goldberger, saying that, from per- 
sonal observation, he knew that Stegomyia were conveyed by 
ships, freight cars and passenger coaches; that its name indicated 
it was a house mosquito; that ships and railroad coadies were merely 
floating and moving houses; that one thing should not be lost sight 
of, that the mosquito, like everything in nature, accomodated itself 
to its environments, and hence, when deprived of the house of its 
choice or driven by conditions, it would take up its habitat in ships, 
cars, and even covered wharves ; that while feeble in its wing power 
Dr. Carter had pointed out it could be carried a distance of 1,500 feet 
over water, and doubtless, under favorable conditions, farther, al- 
though its natural habits rarely led it to wander more than forty 
feet from its birthplace, going down one side of a street rather than 
crossing. He accentuated two points: The necessity of reporting 
early cases and the screening of all fever cases, and introduced the 
following resolution, which, under the rules was referred to the Ex- 
ecutive Committee: 

''Resolved, That it is the sense of this Association that early rec- 
ognition of first cases of yellow fever, and the prompt reporting of all 
suspicious cases of fever to the health authorities, is a condition prece- 
dent to the prevention of its spread, and its stamping out before it 
assumes epidemic proportions, and that failure to so report should be 
punished by law. 

''Resolved further, That all fever cases in the yellow fever zone, 
of whatever nature, should be screened in the spring, summer and 
early fall months." 

Dr. Mayer then took up the following points made by Dr. Liceaga, 
President of the Superior Health Board of Mexico : 

"First — The formation of a schedule of immunes. 

Second — House-to-house visits during epidemics, to discover the 
sick. 

Third — The isolation and screening of cases in fumigated apart- 
ments. 

Fourth — In order to determine the efficacy of a given fumigatk», 
the placing of 'witness mosquitoes' under the most unfavorable con- 



PROCEEDINGS" THIRTY-FOURTH ANNUAL MEETING, 836 

ditions in the apartment to see if the insecticide has reached and de- 
stroyed them. 

Fifth — Preventing the escape of infected mosquitoes. 

Sixth — Public instruction in the mosquito doctrine." 

All but article four he asserted had been carried out in New Iberia 
under the personal supervision of Dr. Irion, President of the 
State Board of Health, with the same excellent results that Dr. 
Liceaga declared had followed in the city of Merida. So far as ar- 
ticle six (public instruction) was concerned, Louisiana was the pio- 
neer, and the Louisiana system of hygienic instruction of the masses 
was inaugurated in 1885, successfully passed the experimental stage 
in 1897, when the first popular institute of hygiene ever held took 
place; while now, under Dr. Irion's progressive administration, this 
public instruction was being given by the State, under the auspices 
of the Board of Health. 

As to article four (the "witness mosquitoes"), he believed it a 
wise precaution. Many insecticides, like pyrethrum powder, were 
delusions and snares, and even with sulphur gas, having a higher 
specific gravity than air, it might, if the fumigation was too short, 
or the per cent of gas too weak, settle in a lower strata, and the mos- 
quito, in the struggle for existence, would rise and remain viable in 
the upper strata of air and escape destruction ; hence, this precaution 
should always be taken in order to be assured of their destruction. 

The speaker insisted that in instituting fumigation with SO, gas, 
where a blower to distribute the fumes was unavailable, that sulphur 
pans should be placed at different levels, one near the ceiling, one 
midway between ceiling and floor, and one on the last shelf of a 
ladder like arrangement of shelves, but that in all SO2 fumigation 
in municipal and maritime sanitation, the sulphur engine designed by 
Dr. S. R. Oliphant, of Louisiana, now in use at the Mississippi River 
Quarantine, should be used where saving of time and efficacy was 
an object. 

Dr. Manuel S. Iglesias, of Vera Cruz said that some one had 
stated, that it was impossible to secure isolation of all yellow fever 
patients in a city. This, he said, was an easy matter in Vera Cruz. 
Sanitary officers make daily visits to all non-immunes in Vera Cruz. 
If any such person is found with a fever this is immediately reported 
to the health officer who sees the patient at once. A case of yellow 
fever, or one that is in any way suspicious, is at once isolated, in 
his home in the special wards of the hospital, or in the pest-house. 
In the home it can be done by screening windows and doors. Many 
houses in the city now have a room well fitted for the purpose of iso- 



886 PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 

lation, where a member of the family, a visitor, or relative can be 
immediately isolated if taken ill. When this specially prepared room 
is not available, we make use of a screening chamber constructed 
around the patient's bed. The rooms in which the patient has been 
are disinfected as soon as isolation has been provided for. We aim 
to do this during the period of lethargy of the mosquito which follows 
biting, and when the mosquito seeks some sheltered place to digest 
the blood he has taken. If the patient is not found early all the 
rooms in the house and also houses nearby are disinfected. These 
measures, I believe, have protected Vera Cruz against an epidemic 
of yellow fever, for cases have occurred here and there since they 
were enforced that otherwise would likely have resulted in a great 
spread of the disease. 

Dr. C. H. Irion, President of the Louisiana State Board of Health, 
took up the discussion, saying that no one realized more than he the 
relation of quarantine to commerce, no one more deplored the restric- 
tions necessary to carry on trade with the tropics, and that he was 
determined, in the commercial interest of the Mississippi Valley, so 
far as it was affected by our Louisiana quarantine, to minimize those 
restrictions to the point of safety, but never at the expense of the 
public health, which was of primary importance. He denied that the 
fruit steamers were responsible for the introduction of yellow fever 
into New Orleans; that every indication pointed to Havana as the 
source of infection. He said that only four cases of yellow fever 
had been imported into Louisiana in 1906. All four came from Ha- 
vanna. 

He said that the State Board of Health of Louisana had, at great 
expense, stationed physicians at various tropical ports for the pur- 
pose of reporting on health conditions in those ports, as well as to 
fumigate at the ports of departure such vessels as required it, in 
order to do away with detention at the port of arrival. This was 
done not only in the interest of public health, but to facilitate com- 
merce, and this work will be extended as the demands of commerce 
requires. 

He further said that the undisputed evidence brought out by the 
gentlemen who had preceded him in the discussion of Dr. Doty's 
paper could leave no doubt in the mind of any man at all acquainted 
with conditions on board vessels plying between tropical and American 
ports that both infected and non-infected Stegomyia mosquitoes not 
only could be, but had been carried from infected tropical ports to- 
American ports. Through fumigation at taropical ports on depart- 
ure of vessels had been insisted upon by the Louisiana State Board 



PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 337 

of Health, and vessels undergoing such fumigation had been given 
special consideration at Louisiana ports. He said that Louisana was 
more vitally interested in the traveling habits of these mosquitoes 
than any other State in the Union, and the Louisiana State Board 
of Health had probably given the subject more attention than any 
other body of men concerned in the investigation. New York be- 
ing non-infectable territory, and Louisiana being highly infectable, 
it was manifestly unsafe to apply rules adduced from evidence gath- 
ered at New York to conditions existing at New Orleans. 

Dr. Joseph Girard, of Mexico said: To the two explanations 
made by Dr. Iglesias to explain the etiology of some sporadic cases 
of yellow fever, we can add a third one: and this is the possibility 
of an hereditary transmission of yellow fever virus in the mosquito. In 
support of this theory, Drs. Marchoux and Simond, have demon- 
strated that a mosquito that was bom from an egg that was developed 
in the laboratory of Rio Janeiro, by a female mosquito, that had bitten 
many sick persons, caused a case of typical yellow fever. This was 
an only case, and the same doctors affirm that it was very exceptional. 

FIRST DAY — Evening Session. 

The Association met in the Chamber of Deputies. After music the 
meeting was opened by Dr. Liceaga who delivered and address of wel- 
come on behalf of the Federal District Government and the Local 
Committee of Arrangement as follows : 

Mr. Governor, Ladies and Gentlemen: 

The "American Public Health Association'' which was originally 
formed by hygienists of the United States of America and the Domin- 
ion of Canada, fifteen years ago, invited the Mexican hygienists to 
take part in its organization and had the courtesy to select the City of 
Mexico as the place in which to hold the meeting of 1892. During the 
fourteen years that have elapsed the Mexican physicians have not 
neglected to attend the meetings of the Association in whatever city 
they were held. 

The Association, in selecting Mexico for the second time, as the 
meeting place this year, has given the Mexican nation another proof 
of consideration which we highly appreciate. 

We now have the good fortune to count another nation, the Repub- 
lic of Cuba, amongst those which form the Association. The coasts 
of this Republic, of the southern states of the North American Union 
and the eastern states of the Mexican Republic enclose the Gulf of 
Mexico, so that we may say, that the whole of North America together 
with the Pearl of the Antilles have met here to work for the dearest 
interests of humanity, the preservation of the health, the prolongation 
of life and the physical improvement of the human species. 



388 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

The Mexican nation is grateful to the American Public Health As- 
sociation for having decided to hold its thirty-fourth annual meeting 
in this city. 

Allow me, gentlemen, to look back, even if it is only with a rapid 
glance, and enumerate the culminating discoveries that have been made 
in medical science and utilized in hygiene during the last fifteen years. 

Medical science has utilized the wonderful discoveries of Pasteur, 
and bacteriologists have followed his steps; after Loefler had discov- 
ered the germ of diphtheria, Behring and Roux invented the serum 
which serves both to cure and to prevent that disease; after Yerscn 
and Kitasato discovered the germ of bubonic plague, the same Yersen 
and Bedreska invented the serum for the cure or prevention of this 
disease ; grounded on the discovery of Finlay, Grassi and Manson dis- 
covered that the hematozoon of Laveran completes its evolution in the 
organism of the Anopheles mosquito, thus granting to this insect the 
fatal property of transmitting the malarial fever ; and based on the dis- 
covery of Finlay as well as those made by the English and Italian 
-physicians with respect to the germ of malaria, the American physi- 
cians Reed and Carroll, associated with the Cuban Agramonte, demon- 
strated by means of experiments which form an epoch in medical his- 
tory, that yellow fever is transmitted by the Stegomyna mosquito. 

Enormous is the importance of these laboratory discoveries: Be- 
fore they were made, the measures of prophylaxis had been inferred 
from simple observation; but this, without scientific proof, had no 
compass by which it could be directed. It was thought that, in order 
to take precautions against disease it was necessary to suspend commu- 
nications between the healthy and the sick, and as the former were in 
an immense majority, a nation in order to defend itself from another 
which was invaded by an epidemic would close its ports or, if it allowed 
them to be opened, would detain the vessels in front of them for 
twenty, thirty, forty days, or a longer time, always under the impulse 
of fear and not of cold reasoning. If that nation expected the danger 
to appear on its land frontiers, it closed them by means of sanitary 
cordons of armed forces. What poor resources! Quarantines were 
broken, private interests broke the sanitary cordon, and as these in- 
fringements of the law were naturally clandestine, they were unknown 
until the disease had penetrated the port or had crossed the frontier, 
and the first cases being unknown, the invasion of the territory, up to 
then immune, was certain. 

How different are matters to-day, when we know either the germs 
of certain diseases or the means by which others are transmitted. The 
patient suffering from diphtheria, cholera or plague, is isolated ; the 
articles which might carry the germs of disease are disinfected; the 
passengers who might carry the disease with them, are kept under 
observation and the'others are allowed free passage, that is to say, all 
those who are in good health and who always form the great majority. 

If it is kno^jrn that the plague is a disease which attacks the rats 
and which they transmit to man by means of fleas, the sick rats are 
destroyed, the fleas which are the channels of contagion are destroyed 
the patients are isolated, the healthy people are defended by means of 



PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 339 

the injections of the Yersen and Bedreska serum, the dwellings occu- 
pied by those patients are disinfected, those which cannot be disinfected 
are destroyed by fire and thus the epidemic is first circumscribed and 
afterwards stamped out, as happened three years ago in Mazatlan. 
If the Stegomyia mosquito is the one that transmits the yellow fever, 
the patient is not isolated from other men, but he is simply protected 
by wire gauze which will not allow the mosquito to reach him and suck 
his blood, so as to transmit the disease to a healthy man ; the clothing 
is no longer considered a means of carrying the disease, neither is the 
soil considered the recipient of the germ, nor is the atmosphere con- 
sidered infected, but we persecute the mosquitoes which are already 
infected, they are destroyed and precautions are taken against their 
reproduction by hunting for the larvae in those places in which they 
breed. 

The way is now pointed out ; we must now continue our search for 
the germs of other transmissible diseases, or for the means by which 
they are transmitted, so that within a not distant future, the precepts 
of prophylaxis will be entirely scientific and the sanitary measures will 
be exclusively directed to their object, and will not go beyond it as we 
now have to do with the diseases whose producing agent is ignored. 
In order to reach this desired result it is necessary to encourage asso- 
ciations, such as fhat which meets here, multiplying the number of 
laborers so that, discovering in the laboratories the germs of the dis- 
eases or experimenting on their methods of transmission, we may have 
a safe and certain basis for the true sanitary science and carry into 
the public administration, in all its branches, our scientific knowledge 
in a simple form, and by educating the lower classes by means of sim- 
ple instruction within the reach of their intelligence in the precepts 
of hygiene, so that every citizen, with a full knowledge of the means 
available for his personal defense, may convert himself into an invin- 
cible host against transmissible diseases. 

This is the task which the American Public Health Association has 
imposed on itself ; this is the labor that is already producing its fruits ; 
the hygienists of a nation first meet and afterwards invite their neigh- 
bors of the North and of the South to take part in that task and subse- 
quently call on their colleagues from the other side of the Gulf, and 
in that way form this learned Association. 

But these are the effects which have been made by scientific socie- 
ties who have labored to inculcate the precepts of science on the pub- 
lic administration. Let us now see the interest which the Govern- 
ments have taken to carry into practice the teaching of these societies. 

The nations which formerly worked in .an isolated manner, now 
consider the question of taking joint action in mercantile questions, 
in railroad interests, in the general social problems and dedicate atten- 
tion to the problems that aflfect the health of man. The United States 
of America, convened a great conference of the American Republics 
in Washington which met for the second time in Mexico and for the 
third time in Rio Janeiro, and in these conferences abundant oppor- 
tunity was afforded for the discussion of sanitary problems. We find 
in consequence of the second conference in the Sanitary Convention 



840 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

which for the first time met in Washington, the second time in Ha- 
vana and the third time again in Washington. But this last confer- 
ence did not confine itself to an entirely scientific discussion ; the dele- 
gates of the different nations being duly authorized signed an agree- 
ment ad referendum, which has now been accepted by the United 
States, Mexico, Peru and Costa Rica, whilst the Third Pan-American 
Conference which met in Rio Janeiro, solemnly declared that this San- 
itary Law must be the fundamental law on the subject in all the nations 
of America. 

If the desire expressed in this last Conference is realized, think 
what a grand spectacle will be presented to the world when all the 
nations who inhabit the Western Hemisphere, have only one sanitary 
law, before any such uniformity has been established in the laws which 
are to govern other social interests. 

What an immense advance has been realized in fifteen years ! 

I beg sincerely to congratulate the members of this Association for 
the part which they have taken in this great work, and at the same 
time to thank them for having selected this city in which to renew 
their joint labors. 

Gentlemen of the Association, you are welcome! 

This was responded to on behalf of the United States by Dr. 
Richard H. Lewis, and on behalf of Canada by Dr. Peter H. Bryce. 
Dr. Liceaga then introduced the President, Prof. Franklin C* Rob- 
inson, of Brunswick, Maine, who delievered his address. (See page 

I). 

The Association then adjourned until 9:00 A. M., Wednesday. 



DECEMBER 5TH — SECOND DAY. 
Morning Session. 

The Association met at 9:00 A. M., and was called to order by the 
President. 

The Secretary called the roll of the Advisory Council, and vacancies 
were filled by the President, nominations being made from the &oor. 

The following group of papers on malaria were then presented: 

Geography of Malaria in Mexican Republic, by Dr. Antonio A. 
Loaeza of Mexico City. (See page 98.) 

The Way to Stamp out Malarial Fevers, by Dr. Eduardo Lamicq 
of Mexico City. (See page 102.) 

Something about the Etiology of Malarial Diseases, by Dr. Jesus 
Chico of Guanajuato, Mexico. (See page no.) 

Prophylaxis of Paludic Diseases, by Dr. Juan Brena, of Zacatecas, 
Mexico. (See page 112.) 



PROCEEDINGS^ THIRTY-FOURTH ANNUAL MEETING, »41 
DISCUSSION. 

Dr. Manuel S. Iglesias^ of Vera Cruz said, It would be impos- 
sible to exterminate the mosquito throughout a whole continent, nor 
is it a matter of such great interest, because the entire area is not 
inhabited ; but we should make efforts to do so in the inhabited parts, 
which is entirely feasible, and what has been done in some towns, 
can be done in all. WithiQ a period of two years. Dr. Pressat has 
been able to entirely exterminate the Anopheles mosquito, and conse- 
quently the malarial fever in Ismailia on the Suez Canal, to such a 
degree, that during the first six months of 1904, only two cases of 
this fever were observed in a town that previously reported from 
two thousand five hundred to three thousand cases per annum. 

The salt marshes in the state of New Jersey were at one time un- 
inhabitable on account of the numberless mosquitoes; but, drains 
were run through them and grass sown, so that the region which 
formerly was desolate and abandoned, no longer contains mosquitoes, 
and is now being rapidly settled, and contributing to the national 
wealth. 

Dr. Eduardo Lamicq, in reply said : Dr. Iglesias has not perceived 
that my paper does not refer to the means for diminishing the num- 
ber of cases of malaria; but to the stamping out of this disease 
throughout the American continent, as there is no question, that the 
destruction of all the mosquitoes in any body of water is a very easy 
matter, that it would be more difficult to do so in a house, and still 
more so in a city, whilst I believe that their destruction throughout 
an entire continent would be impossible. For this reason I am of 
opinion that such a method is impracticable as a means for sup- 
pressing malaria on the continent, and also for this reason, I say 
in my paper, that this method is feasible on an island but not on an 
extensive continent, and especially as the mosquito is not the only 
channel for the spread of malaria. 

Dr. a. S. Aguirre, of Huimanguillo, Mexico: I entirely agfree with 
what has been said by Dr. Iglesias, with regard to the destruction 
jof the Anopholes in inhabited places. The sanitation by means of 
drainage of large swampy districts is a difficult problem, and as re- 
gards the state of Tabasco in which I have practiced, such a 
measure would be highly expensive. Amongst the prophylactic 
measures that have been advised, I believe that the preventive ad- 
ministration of quinine and its salts is desirable, as recommended 
by Koch, but in larger doses. In place of thirty to forty centigrammes, 
the doses should go as high as seventy-five to eighty centigrammes. 



»42 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

with intervals, as for example, eight days of quinine and eight 
or fifteen days without. I believe, with Dr. Brena that the quinine 
ought to be administered for some time and not only in the pre-epi- 
demic period. As the price of quinine is beyond the reach of the 
poorer people, it would be desirable that the government should 
undertake to administer gratuitously, as is done by the French Gov- 
ernment in Madagascar. 

Dr. Jesus M. Saldana^ Mexico City: During an epidemic of 
malaria, it is necessary to take steps to prevent the mosquitoes from 
drinking infected blood, and for iJiis purpose I consider the use of 
mosquito netting a primary necessity as in cases of yellow fever. 

Besides this, in order to diminish the number of mosquitoes which 
carry the germs, we should take the necessary measures for their 
extermination, either total or partial, by spreading oil on all stagnant 
waters and wire gauze over the wells which supply drinking water 
to the town, when derived from those sources. 

The mosquito net for each patient is a very simple matter, and 
the government migh even undertake it as regards the poor classes. 
The dwelling should also be frequently fumigated with sulphur. 

A paper by Dr. Everardo Landa, of Mexico City, on "The Jenner 
Vaccine" was read. (See page 196.) Also a paper on "Results of 
Revaccination in Mexico," by Dr. Francisco Bernaldez, of Mexico City. 
(See page 192.) 

DISCUSSION. 

Dr. Alfonso Pruneda, of Mexico City: I consider that the sub- 
ject of revaccination is one of the most interesting which has been 
discussed at this meeting. The American PubHc Health Association 
several times has heard, from the Mexican members, that in Mexico 
the humanized vaccine virus (which is the only one in use here), con- 
fers immunity for all life; and the Association, as I have heard, has 
been surprised at such a statement. Now, gentlemen, there is 
reason for this surprise: there are numerous Mexican physicians 
who do not believe in the permanent immunity caused by humanized 
vaccine virus; unhapily, there are very numerous cases of vaccin- 
ated individuals who have been struck by smallpox, not only in its 
attenuated forms (as it is said by Dr. Bernaldez), but also by the 
terrible forms of hemorrhagic smallpox. It is not true that humanized 
vaccine produces in Mexico immunity for life, and so I declare, 
solemnly, speaking for many Mexican physicians, especially those of 
the "Sociedad de Medicina Interna," who have called attention to this 
interesting point. Then the American Public Health Association 



PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 848 

ought henceforth to consider that there is no truth in the assertion 
made here at former nxeetings, that the immunity conferred by hu- 
manized vaccine in Mexico is permanent. 

Dr. Everardo Landa, of Mexico City : I think that now there re- 
mains no reason to affirm hereafter the idea advanced by Dr. Bernaldez 
in his address, that is to say that permanent immunity against smallpox 
is given by the use of humanized vaccine virus. This fact has been 
known a long time, but it has not been diffused in Mexico for rea- 
sons which I forthwith tell. Several dissertations have been read 
before this respectable Association in order to defend the idea again 
discussed to-day, and for the first time two opinions entirely oppo- 
site have appeared in respect to smallpox prophylaxis in Mexico. 
The idea that compulsory re-vaccination must be established here in 
Mexico, reigns, not only among physicians, but also among a great 
part of the public. Many physicians, as Messrs. Terres, Manuell, 
Pruneda, Cosio, Ramos, Bullman, etc., have advocated re-vaccina- 
tion, but as such an idea doesn't come from our sanitary authorities, 
we have attained almost nothing. I do not consider as important, 
the argument that often cicatrices are not those of vaccination: I 
can point to many well attested cases (there are in my statistics 119 
of them), where the characteristic qualities of cicatrices were very 
clear in those that have died from smallpox. I think that one of 
the most important subjects at this meeting is that of compulsory 
revaccination in Mexico. I should be very glad if among the resolu- 
tions of this congress there might be one diffusing the idea I have de- 
veloped in my address, which is the opinion of numerous Mexican 
physicians. 

Adjourned to 9:00 A. M. the following day. 

DECEMBER 6TH — THIRD DAY. . 
Morning Session. 

The Association was called to order at 9 :oo A. M. by the President. 

The Secretary reported for the Executive Committe as follows: 

The Executive Committee recommends that the resolution to ex- 
tend an invitation to the Conference of State and Provincial Boards 
of Health of North America to become affiliated with this Association 
be adopted. 

On motion of Dr. Henry Mitchell, duly seconded, the resolution 
was adopted. 

The Secretary reported that the Executive Committee recom- 



844 PROCEEDINGS'^ THIRTY-FOURTH ANNUAL MEETING. 

mended that a committee be appointed to inquire into the feasibility 
of establishing a section of the Association composed of municipal 
health officers, to outline a scheme for the work of such a section, 
and to report at the next meeting. 

On motion of Dr. Hibbert W. Hill, the recommendation of the Ex- 
ecutive Committee was adopted. 

The Treasurer, Dr. Frank W. Wright, submitted his annual report : 



FRANK W. WRIGHT, TREASURER, IN ACCOUNT WITH THE AMER- 
ICAN PUBLIC HEALTH ASSOCIATION. 

RECEIPTS. 

To cash on hand at last report $1,948 92 

Dues received for 1902 6 00 

Dues received for 1903 30 00 

Dues received for 1904 125 00 

Dues received for 1905 1,840 00 

Dues received for 1906 75 OO 

Sale of transactions 587 73 

Total $4,611 65 



EXPENDITURES. 
1905. 

Oct. 3. By cash paid W. H. Park, (Order No. 186) $12 00 

20. By cash paid F. W. Wright, (Order No. 187) 75 00 

20. By cash paid C. O. Probst, (Order No. 188) 84 90 

20. By cash paid R. S. Weston, (Order No. 189) 12 50 

20. By cash paid Samuel Usher. (Order No. 190) 11 25 

20. By cash paid Adams Ex. Co., (Order No. 191) 24 14 

20. By cash paid Am. Ex. Co., (Order No. 192) 42 69 

20. By cash paid U. S. Ex. Co., (Order No. 193) 85 22 

20. By cash paid Wells, Fargo Ex. Co., (Order No. 194) 19 11 

Nov. 6. By cash paid H. D. Pease, (Order No. 195) 49 94 

20. By cash paid F. F. Wesbrook, (Order No. 196) 36 00 

20. By cash paid Fred J. Heer , (Order No. 197) 515 75 

20. By cash paid Wm. Whitford, (Order No. 198) 200 05 

Dec. 21. By cash paid Wells, Fargo Ex. Co., (Order No. 200). .. . 1 85 

21. By cash paid Am. Ex. Co., (Order No. 201) 1 83 

21. By cash paid B. Login, (Order No. 202) 56 00 

1906. 

Feb. 11. By cash paid B. Login, (Order No. 203) 15 75 

16. By cash paid Underwriters' Agency Co., (Order No. 204) . . 15 00 

16. By cash paid Fred J. Heer , (Order No. 205) 4 25 

16. By cash paid American Ex. Co., (Order No. 206) 3 00 

Mch. 12. By cash paid C. O. Probst, (Order No. 207) 54 25 

12. By cash paid H. M. Bracken, (Order No. 208) 78 50 

12. By cash paid F. C. Robinson, (Order No. 209) 35 75 



PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 846 

April 18. By cash paid B. Login, (Ord^r No. 210) 9 75 

13. By cash paid F. C. McElroy, (Order No. 211) IS 76 

13. By cash paid H. D. Pease (Order No. 212) 22 dO 

June 21. By cash paid Fred J. Hecr , (Order No. 213) 953 32 

21. By cash paid B. Lciin, (Order No. 214) 15 76 

21. By cash paid W. B. Tibby, (Order No 215) 13 50 

21. By cash paid F. C. Robinson, (Order No. 216) 46 50 

21. By cash paid H. W. Clark, (Order No. 217) 4130 

21. By cash paid Engelke & Bigelow, (Order No. 218) 2 45 

21. By cash paid Journal Infect Diseases, (Order No. 219).. 614 97 

21. By cash paid Lutheran Book Concern, (Order No. 220) ... 26 40 

Oct. n. By cash paid U. S. Ex. Co., (Order No. 221) 2 11 

11. By cash paid Wells, Fargo Ex. Co., (Order No. 222) 2 02 

11. By cash paid Adams Ex. Co., (Order No. 223) 6 lU 

11. By cash paid American Ex. Co., (Order No. 224) 11 19 

11. By cash paid Am. Publishing Co., (Order No. 226) 26 50 

11. By cash paid Fred J. Heer, (Order No. 225) 101 35 

24. By cash paid C. O. Probst, (Order No. 227) 335 00 

24. By cash paid H. M. Bracken, (Order No. 228) 5 00 

Nov. 13. By cash paid F. Wright, (Order No. 229) 20 00 

Total $3,659 29 

15. Cash on hand 952 36 

On motion it was voted to refer the report to an auditing com- 
mittee. The President named on this Committee, Dr. P. H. Bryce, 
Dr. Henry Mitchell and Dr. Jesus Monjaras. 

The Secretary presented the report of the committee appointed 
upon the recommendation of the Executive Committee to consider and 
recommend desirable changes in present methods of conducting the 
work of the Association. 

The report wis as follows : 

REPORT OF THE COMMITTEE APPOINTED TO CONSIDER THE 
SUGGESTIONS CITED IN THE ADDRESS OF PRESIDENT WES- 
BROOK AND TO MAKE RECOMMENDATIONS CONCERNING 
THE FUTURE GOVERNMENT OF THE ASSOCIATION. 

To the American Public Health Association: 

The Committee of Six appointed by your President, pursuant to 
your action taken upon the recommendation of the Executive Com- 
mittee at the Boston meeting, held September 29, 1905, and stated 
below, beg to submit the following report : 

Your committee in its deliberations have considered themselves as 
acting under the following resolutions: 

'TDr. Mitchell offered the following: 

'Resolved, That a committee of six, to be composed of the incoming 
president, the secretary, the chairman of the laboratory section, and 



846 PROCEEDINGS — THIRTY-FO URTH ANNUAL MEETING. 

three members of the Association to be selected by the president, shall 
be appointed to consider the suggestions cited in the address of the 
president, and to recommend such changes in the methods at present 
employed in conducting the work of the Association as in the judg- 
ment of the committee will promote the usefulness of the Association. 

''Resolved, That said committee shall constitute the committee on 
program for the coming year. 

''Resolved, That the report of said committee shall be printed and 
distributed to the members of the Association on or before Septem- 
ber I, 1906. 

"On motion, the resolutions were accepted. 

"Prof. Robinson moved that a committee be appointed as indicated 
by the report of Dr. Mitchell, and that the addition to the president's 
recommendations be included and submitted to this committee for 
action. Seconded and carried." 

The committee in its activities have been controlled and guided by 
the above resolutions and by the recommendations of President Wes- 
brook, which were as follows: 

"Appointment of special committee or of sub-committee of the Ex- 
ecutive Committee which shall meet at least once between December, 
1905, and March, 1906, and again, if necessary, one month before the 
date of the next annual meeting, the necessary expenses to be borne 
by the Association. 

The committee shall arrange and cause to be forwarded to each 
member of the Association, the grouping of program material by 
March i, 1906, and shall cause to be forwarded, printed abstracts of 
papers and the final detailed program not later than three weeks 
prior to the date of the next annual meeting, to all members of the 
Association. 

With the final program and the abstracts shall be sent a printed 
draft of the committee's recommendation concerning the mechanism, 
including the exact wording of changes in constitution or by-laws 
which seems necessary or expedient, whereby the following improve- 
ments may be ensured. 

[Words in italics represent additions made after address was read.] 

(a) A board of trustees or small committee representing the vari- 
ous phases of public health work, to conduct the necessary 
business of the Association immediately before and after, and 
also between annual meetings. 

(fe) To increase the revenue of the Association. 

{c) To establish a permanent crffice or headquarters. 

(d) To take charge of, print and distribute program and synop- 
sis of papers at the expense of the Association, so that all 
members may be made familiar with the plans of the Associa- 
tion some u^eeks before the annual meeting, 

(e) To publish the proceedings of the Association and all its sec- 

tions promptly. 
(/) To publish a journal of hygiene and to promote a universal 
use by all state and provincial boards of health of the material 



PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING, 347 

contained therein. This shall be representative of all the in- 
terests of the Association and contain the latest scientific ma* 
terial emd standard methods in relation to practical application, 

(g) To see that all federal, state and provincial boards of health 
and the federal sanitary and medical services are requested 
and do furnish, in writing, proper credentials so that the Ad- 
visory Council may be more definitely and equitably consti- 
stuted. Provision for representation of large cities should be 
considered, 

{h) To arrange for a rigid classification of the membership into 
active and associate members. 

(i) To arrange for a more thorough scrutiny of the qualifications 
of applicants for membership. 

(;) To determine a policy in relation to the examination and 
granting of a diploma of public health by this Association. 

{k) To determine the feasibility and method of incorporating the 
Conference of State and Provincial Boards of Health as a 
section of our Association, 

(/) To provide, if necessary, a municipal health officer section and 
such other sections as seem to be desirable. 

(m) To formulate methods of influencing localities to a greater 
conservation and permanency of organisation in their sanitary 
work and in their representation in our Association." 

Acting upon the above resolutions President Wesbrook appointed 
the following members of the committee: Dr. H. M. Bracken, St. 
Paul, Minnesota, Chairman ; Dr. Henry Mitchell, Trenton, New Jersey, 
and Dr. H. D. Pease, Albany, New York. The ex-officio members are 
Prof. F. C. Robinson, Brunswick, Maine; Dr. C. O. Probst, Colum- 
bus, Ohio, and Mr. H. W. Qark, Boston, Massachusetts. 

Your committee have held in addition to informal meetings of some 
of the members three regular meetings : In New York City, February 
i6th ; Washington, D. C, May 22d ; and New York City, September 
15th, 1906. 

It was deemed advisable to endeavor to bring about as many of the 
changes in the conduct of the work and the government of the Asso- 
ciation suggested by the president, as the committee deemed advisa- 
ble to recommend, by introducing into the constitution and the by- 
laws of the Association such alterations and amendments as would 
tend to operate toward the ends desired. 

The committee, therefore, after prolonged deliberation and frank, 
full and free discussion desire to submit and recommend for adoption 
the amendments to the present constitution and by-laws embodied in 
this report. 

In addition to submitting these amendments, your committee has 
considered as carefully as present conditions in the Association permit 
the question of the establishment of a journal of hygiene, and make 
recommendations as to the character, scope and management of such a 
journal when established. Your committee believe that with the adop- 
tion of a more representative form of government of the Association 



S48 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

through a satisfactorily appointed body of delegates from the various 
sections of the countries represented in the Association, and with the 
business management of the financial and publication affairs of the 
Association in the hands of a small body of long term trustees, that the 
interest of all persons in the work of the Association will be greatly 
stimulated, and that the establishment of a journal of hygiene to be 
the official organ of the Association as outlined, will thereby become a 
possibility. Your committee believe that with this consummated, a 
strong and influential future for the Association will be assured. 



PROPOSED AMENDMENTS TO THE CONSTITUTION OF THE AMER- 
ICAN PUBLIC HEALTH ASSOQATION. 

The following articles are hereby amended to read as follows : 

Article II — Objects. 

The object of this Association shall be the promotion of the science 
and art of public hygiene. 

For the advancement of this object the Association shall endeavor to 
co-ordinate the efforts of the various federal, state, provincial and mun- 
icipal official sanitary organizations, and of educational institutions 
engaged in sanitary instruction of the United States, Dominion of 
Canada, the Republic of Mexico and the Republic of Cuba ; and also of 
all others interested in the objects of this Association, for the purposes 
of fostering the growth and diffusion of knowledge concerning those 
branches of natural science bearing upon the prevention of disease and 
the preservation of health, of developing and directing public opinion 
toward the proper practical application of such knowledge, of securing 
the enactment and enforcement of just and efficient sanitary and hy- 
gienic laws, rules and regulations, of elevating the standard of hygiene 
and sanitary training, of encouraging the appointment of properly 
trained persons to official sanitary positions and their retention in office, 
of promoting friendly intercourse and the free exchange of opinion 
among the workers and teachers of this subject, and of presenting to 
the public practical attainments of scientific public hygiene. 

Article III — Membersihip. 

The membership of this Association shall consist of active, associate 
and honorary members. The active members shall constitute the per- 
manent voting body of the Association, subject to the provisions of the 
by-laws as to continuance in active membership. 

Article IV — Organization. 
There shall be an advisory council constituted as follows : 

Section i. Advisory Council. 

The public health services of the United States, Canada and Mex- 
ico, and of each state and province of said countries, including the 
District of Columbia and the Federal District of Mexico, also of the 



PROCEEDINGS'^ THIRTY-FOURTH ANNUAL MEETING. 349 

Republic of Cuba, the United States army and navy, and each sec- 
tion of the Association, shall be entitled to one representative in the 
advisory council. 

Additional members may be provided for in the by-laws, but such 
additional members from any of the above geographical divisions and 
sections of the Association shall not at any time exceed in number 
the proportion of one additional member to each twenty-five active 
members of the Association of two years' standing, who are offi- 
cers of such services, residents of such geographical divisions, or ac- 
tive members of such sections of the Association. Members of the 
advisory council must present credentials from the bodies they rep- 
resent, which credentials must be granted in accordance with by- 
laws hereinafter provided, but in no case shall credentials be given 
for a period of over one year. 

The past presidents of the American Public Health Association 
the general officers of the Association, and the members of the board 
of trustees, shall be ex-officio members of the advisory council. 

All members of the advisory council must have been active mem- 
bers of the Association for the two immediately preceding years. 

Section 2. Duties of Advisory Council. 

The advisory council shall nominate a board of five trustees, all tlie 
general officers of the Association except the treasurer, all members 
of standing committees, and also authorize the creation and discon- 
tinuance of sections as hereinafter provided. Said council shall also 
recommend to the Association the places of meeting, and shall perform 
such other duties as are stipulated in the by-laws of the Association. 

Section 3. Board of Trustees. 

The board of trustees shall have charge of all property, financial 
affairs, and publications of the Association. During the intervals be- 
tween the annual meetings of the Association, the said board shall take 
action in regard to all matters affecting the interests of the Association 
which cannot in its judgment be delayed until the next annual meeting. 

Upon the adoption of this section of Article IV of the constitution, 
five trustees shall be nominated by the advisory council to serve one, 
two, three, four and five years, respectively. Thereafter one trustee 
shall be nominated annually by the advisory council and elected by 
the Association for a term of five years, at the expiration of which 
period the retiring member shall not be eligible for re-election for an- 
other term, until the expiration of three years, provided that a trustee 
elected for less than a full term of five years shall be eligfible for elec- 
tion for a succeeding full term of five years. The eligibility for mem- 
bership on the board of trustees shall be the same as that required 
for membership in the advisory council. The secretary of the Asso- 
ciation shall be ex-officio the secretary of the board of trustees, but 
shall not be a voting member thereof. 

Section 4. Sections. 

Active members of the Association may be authorized by the ad- 
visory council to form themselves into sections with the consent of 
the Association, to deal with any well recognized department or de- 
partments of the work of public hygiene. 



360 PROCEEDINGS'' THIRTY-FOURTH ANNUAL MEETING. 

Such sections shall have power to elect their own officers, and to 
make such by-laws for their government as are not at variance with 
the constitution and by-laws of the Association. Any section may be 
discontinued by the Association upon the recommendation of the ad- 
visory council. 

Section 5. Officers. 

The general officers of this Association shall be a president, first, 
second and third vice presidents, a secretary and a treasurer. Tliese 
officers shall be nominated by the advisory council, except the treas- 
urer, who shall be nominated by the board of trustees, and all shall be 
elected by the Association by ballot annually. 

Article V — Meetings. 

Section i. Annual Meeting. 

The place of each annual meeting shall be recommended by the ad- 
visory council, but the same may be changed by a unanimous vote of 
the board of trustees for reasons that shall be specified in the an- 
nouncement of the meeting. 

Section 2. Special Meetings. 

Special meetings may be held at any time or place by a call, signed 
by a majority of the board of trustees, providing said board cause to 
be sent to each active member of the Association a written or printed 
notice three weeks prior to date of said meeting of the time and place 
of the meeting and the business to be brought before it ; and no busi- 
ness other than that for which the meeting is called shall be transacted. 

Article VI — Funds. 

Section i. Collection of Funds. 

Funds shall be raised, (a) by the equal assessment of not more than 
ten dollars annually on each of the active and associate members, as 
shall be determined by the board of trustees; (b) from the Associa- 
tion's publications; (c) and in any other manner approved by the 
board of trustees. 

Section 2. Disbursements of Funds. 

Funds may be appropriated by the board of trustees to defray the 
necessary expenses of the Association ; to enable the trustees and offi- 
cers of the Association and the officers of the sections to perform their 
respective duties ; to conduct the publications authorized by the Associ- 
ation, and for any other purpose approved by the board of trustees. 

Article VII — Amendments. 

This constitution may be amended in any particular at any meeting, 
provided that the proposed amendment shall have been submitted in 
writing and read at the previous annual meeting; shall have been pub- 
lished in the announcement of the meeting at which it is to be consid- 
ered, and that two-thirds of the active members of the Association 
present vote in favor of such amendment. 



PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 361 

BY-LAWS OF THE AMERICAN PUBLIC HEALTH ASSOCIATION. 
Chapter I — Membership. 

Section i. Qualifications for Membership. 

Members of the teaching staffs and graduates of departments giving 
advanced courses in any of the branches of public hygiene in recognized 
universities, colleges and schools; members, secretaries, executive offi- 
cers, heads of departments or bureaus, medical officers, statisticians, 
engineers, attorneys, chemists, bacteriologists, pathologists, veterina- 
rians, holding official relations to either national, state, provincial, 
county or municipal boards or departments of health in any of the 
countries represented in the Association ; members of recognized med- 
ical, engineering, chemical, bacteriological and other societies dealing 
with those branches of natural and applied sciences which are allied to 
public health work, and any person who has conducted and published a 
creditable piece of original research in any branch ot public health 
work, and who reside in any of the countries represented in this Asso- 
ciation, shall be eligible for active membership in this Association. 
The board of trustees shall determine the qualification and keep a 
record of the universities, colleges, schools and scientific societies to 
be recognized according to this by-law for the use of the committee 
on membership. 

Any suitable person irrespective of his place of residence, having a 
general interest in the objects of this Association, shall be eligible for 
associate membership. 

Persons who have rendered unusual and highly meritorious services 
in the protection of public health or the development of the science of 
public hygiene, or whose labor or discoveries in any branch of science 
have had a far-reaching influence in stimulating and encouraging the 
development of public hygiene, shall be eligible for honorary mem- 
bership in this Association. 

Section 2. Election of Members. 

Applications of those eligible for active membership in this Associ- 
ation must be made in writing on a prescribed form, which must bear 
the written endorsement of two active members of the Association, and 
contain satisfactory evidence of eligibility, and be presented to the 
secretary of the Association, who shall transmit the same to the chair- 
man of the committee on membership. On recommendation of said 
committee, and on receiving a vote of a majority of the active mem- 
bers of the Association present, the candidate shall become an active 
member of the Association upon the payment of the annual dues for 
that year. 

Those eligible for associate membership shall file with the secretary 
of the Association an application in writing, on a prescribed form, con- 
taining the endorsement of two active members of the Association. 
Such application shall be referred to the committee on membership, 
and upon its approval by the same, and the payment of the annual dues 
for that year, the applicant shall become an associate member of the 
Association. 



362 PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING, 

Honorary members must be nominated by the board of trustees, 
receive the approval of two-thirds of the members of the advisory 
council present, and a two-thirds vote of the active members of the 
Association present when action is taken ; provided, that not more than 
two honorary members shall be elected in any one year. 

Section 3. Forfeiture of Membership. 

Any active or associate member who shall fail to pay his annual 
dues for two years shall be suspended as a member, provided that due 
notice of such intended action shall be given to the member by the 
treasurer. Any member who has been suspended for non-payment 
of dues may be restored upon payment of dues for two years prior to 
year of such restoration. 

Section 4. Registration of Members. 

No member shall take part in the proceedings of the Association or 
any of the sections at the annual meeting until he has registered his 
name and address with the proper oiBcer or committee, and has paid 
his annual dues for the current year. 

Section 5. Quorum. 

Forty active members of the Association shall constitue a quorum 
for the transaction of business. 

Section 6. Classification of Present Membership. 

The membership of the Association at the time these by-laws are 
adopted, shall be classified by the committee on membership in ac- 
cordance with the provisions of Chapter I, Section i, of these by-laws. 

Chapter II — Advisory Council. 

Section i. Qualification for Membership. 

No one shall serve as a member of the advisory council who has 
not been an active member of the American Public Health Association 
for at least the two years immediately preceding. 

Section 2. Term of Membership. 

Members of the advisory council shall be entitled to serve but one 
year without the presentation of further credentials from the bodies 
which they represent. 

Section 3. Bodies Entitled to Representation. 

The credentials of a representative from either the United States 
army, the United States navy, or the United States public health and 
marine hospital service, must be granted by the chief officer of the 
service which he represents. 

Each section of the Association shall be entitled to representation by 
its chairman, vice chairman, and recorder. Should section officers 
bear titles other than those designated, it is to be understood that 
officers holding equivalent positions shall be selected. The credentials 
of such officers shall be given by the section secretary and counter- 
signed by the section chairman. 

The board of trustees shall select all other bodies or organizations 
entitled to representation on the advisory council other than those 
mentioned in the constitution of the Association. (Article 4, Section 
I.) Provided, that the board of trustees shall give the preference in 
such selection to such bodies or organizations in their respective geo- 



PROCEEDINGS-^ THIRTY-FOURTH ANNUAL MEETING. 363 

graphical divisions, having in their membership the largest number 
of active members of this Association. The board of trustees shall 
also determine the ratio of representation in accordance with Article 
IV, Section i, of the constitution of the Association. The board of 
trustees, at least six months before an annual meeting, shall notify the 
proper officers of the bodies, organizations and sections designated or 
selected to send representatives in accordance with the constitution and 
by-laws, of such designation or selection, and shall specify the number 
of such representatives, and request such officers to give proper cre- 
dentials to such representatives. 

Section 4. Registration. 

Every representative must deposit with the secretary his credentials 
from the body or organization he represents. These must be verified 
by the secretary and approved by the committee on membership be- 
fore the member can be permitted to take part in the proceedings of 
the advisory council. 

Section 5. Officers. 

The general officers of the Association shall perform the duties of 
their respective offices for the advisory council. 

Section 6. Quorum. 

Twenty representatives of the advisory council shall constitute a 
quorum for the transaction of business. 

Section 7. Meetings. 

The advisory council shall meet at the call of the president at such 
time as will not conflict with the meetings of the Association or sec- 
tions. 

Chapter III — Duties of Officers. 

Section i. President. 

The president shall preside at the general meetings, and at the 
meetings of advisory council, and shall perform such duties as custom 
and parliamentary usage require. On the evening of the first day of 
the annual session of the Association following his election he shall 
deliver an address not exceeding thirty minutes in length on such mat- 
ters as he may deem of importance to the Association. 

Section 2. Vice Presidents. 

The vice presidents shall assist the president in the performance of 
his duties; during his absence, or at his request, one of them shall 
officiate in his place. In the case of death, resignation or removal of 
the president, the vacancy shall be filled by the first vice president. 

Section 3. Secretary. 

The secretary shall give due notice of the time and place of all 
annual and special meetings of the Association and of the advisory 
council. He shall keep in separate books the minutes of the meetings 
of the Association and of the advisory council. He shall notify mem- 
bers of committees of their appointment and of the duties assigned 
to them. It shall be his duty to verify the credentials of members of 
the advisory council and to provide a registration book for them, in 
which shall be recorded the name of each delegate in attendance at 
each session, together with that of the official service, organization or 
section which he represents. He shall also prepare a roll of the dele- 

23 



354 PROCEEDINGS — THIRTY-FO URTH ANNUAL MEETING. 

gates attending each session to facilitate voting by roll call. He shall 
attend to the publication of the official program of each session, and 
shall perform such other duties as pertain to his office or as may be 
directed by the Association, the advisory council or the board of trus- 
tees. The secretary's salary shall be fixed by the board of trustees. 

Section 4. Treasurer. 

The treasurer shall be the custodian of all moneys, securities and 
deeds belonging to the Association which may come into his possession 
and shall hold the same subject to the direction and disposition of the 
board of trustees. He shall give to the board of trustees a suitable 
bond for the faithful performance of this trust and shall receive for 
his services a salary to be fixed by the board of trustees. 

j- Chapter IV — Board of Trustees. 

The board of trustees shall have charge of all properties and of 
the financial affairs of the Association. At the first meeting of the 
board after the annual session of the Association it shall organize by 
electing a chairman, and the chairman shall appoint such committees 
as may be necessary or desirable. It shall be the duty of this board to 
provide for and superintend the publication of all proceedings, trans- 
actions and memoirs of the Association. It shall have full discretion- 
ary power to omit from the proceedings or transactions, in part or in 
whole, any paper that may be referred to it. Should a journal of the 
Association be provided for, it shall appoint a general manager and 
editor of said journal, which two positions may be held by one person. 
and such assistants as may be necessary, and shall determine their sal- 
aries and the terms and conditions of their employment. All resolu- 
tions or recommendations of the Association, advisory council, any 
committee or officer pertaining to the expenditure of money m'ust be 
approved by the board of trustees before the same shall become eflfec- 
tive. During the annual session of the Association the board shall 
hold meetings as often as may be deemed necessary by the chairman, 
and all matters referred to it by the Association shall be reported on 
within twenty-four hours, if so requested. The board of trustees 
shall have the accounts of the Association audited annually, or oftener, 
if necessary, and shall make an annual report on the same to the Asso- 
ciation, which report shall also specify the character and cost of all 
the publications of the Association during the year and the amount of 
all property belonging to the Association. In case of a vacancy in the 
office of the treasurer or secretary on account of death or otherwise, the 
vacancy shall be filled by the board of trustees until the next annual 
session of the Association. The board of trustees shall fix the salary 
of the secretary and of the treasurer. A regular meeting of the board 
shall be held immediately after the annual session of the Association. 
Special meeting of the board may be called at any time by the chair- 
man, or by three members of the board by mailing a written or printed 
notice to the last known address of each trustees, at least five days be- 
fore such meeting is to be held, in which shall be specified, in general 
terms, the object of such special meeting, and no other business shall 
be transacted thereat; provided, that if at any time a meeting of the 



PROCEEDINGS — THIRTY -FO URTH ANNUAL MEETING. 365 

board be held at which all the trustees are present, or the proceedings 
of which are approved in writing by every member of the board, said 
meeting and proceedings shall be valid, without any previous notice 
having been given. Three members of the board shall constitute a 
quorum. 

Chapter V — Committees. 

Section i. Classification of Conmiittees. 

Committees shall be classified as standing committees and special 
conunittees. 

Section 2. Election of Members. 

Unless otherwise provided the standing committees shall be nom- 
inated by the advisory council and elected by the Association. The 
special committees shall be nom&nated by the president and elected 
by the Association, or in such other manner as the Association may 
direct. The president and secretary shall be ex-officio members of 
all standing committees. 

Section 3. Standing Committees. 

The following standing committees are hereby authorized: 
Committee on resolutions. 
Committee on membership. 
Committee on program. 

Section 4. Committee on Resolutions. 

The committee on resolutions shall consist of six elective members. 
Two members shall be nominated by the advisory council and elected 
by the Association each year. The term of office for elective mem- 
bers shall be three years. Upon the adoption of these by-laws six 
members of this committee shall be chosen, two to serve one year, two 
to serve two years, and two to serve three years, respectively. 

The committee on resolutions shall consider all resolutions offered 
to the Association or to the advisory council, and all resolutions offered 
to either the Association or the advisory council shall be referred 
to the committee on resolutions without debate. After giving proper 
consideration to a resolution received by it, said committee shall 
report the resolution back to the body from whence it originated, with 
the committee's recommendation as to its final disposition. 

Section 5. Committee on Membership. 

The committee on membership shall consist of six elective members. 
Two shall be nominated by the advisory council and elected by the 
Association each year. The term of office of such members shall be 
three years. 

Upon the adoption of these by-laws six members of said committee 
shall be chosen, two to serve one year, two to serve two years, and 
two to serve three years, respectively. During the first year after its 
election the committee on membership shall classify the membership 
of the Association then existing in accordance with the provisions of 
Chapter I, Section i, of these by-laws. 

This committee shall pass upon all applications for membership in 
accordance with the provisions of Chapter I, Sections i and 2, of these 
by-laws. 



866 PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 

This committee shall also consider all questions regarding the reg- 
istration and the credentials of members of the advisory council. 

Section 6. Committee on Program. 

The committee on prc^am shall consist of three appointive mem- 
bers, together with the president and secretary ex-officio. One shall be 
appointed by the incoming president each year. The term of crffice of 
appointive members shall be three years. 

Upon the adoption of these by-laws, three members shall be chosen 
by the incoming president, and their terms of office for one, two and 
three years respectively, shall be determined by casting lots. 

The duties of the committee on program shall be to prepare a pro- 
visional program of the next annual meeting of the Association, con- 
taining a list of the main subjects to be brought before the meeting 
and the relative time to be allotted to each subject. Said provisional 
program, together with a statement of the time and place of meeting, 
railroad rates and other information, shall be forwarded by the secre- 
tary of the Association to each member of the Association, at least 
six weeks prior to the date of said meeting. 

Said committee shall also prepare the final program for the annual 
meetings of the Association. Said program shall include the title of 
each paper to be presented with the name and address of the author, 
together with a statement of the time allotted to the author in which 
he may present the subject and the time to be allowed individual, 
members for its discussion. Said program must be delivered to the 
secretary of the Association at least three weeks in advance of the 
date of said meeting. The secretary shall have the same printed and 
ready for distribution at the opening of said meeting. 

No title of any paper shall be placed upon the final program, nor 
shall any paper be read before the Association, until the same has been 
approved by a majority of the members of the committee, provided 
that immediately before or on the days when the meetings are being 
held a majority of the members of the committee attending the meet- 
ing shall be competent to make such alterations in the final program 
as they may deem necessary for the success of the meetings. 

The final program as prepared by the committee on program shall 
not be otherwise altered, nor an extension of time for presenting a 
subject or its discussion be granted, except upon a two-thirds vote of 
the active members qf the Association present at that meeting. 

The committee on program shall approve all papers and reports 
before the same shall be referred to the board of trustees for their 
approval and publication. 

Section 7. Committee of Arrangements. 

The president shall appoint a comhiittee of arrangements com- 
posed of the president and secretary ex-officio, and one or more active 
members of the Association residing at the place at which the Associ- 
ation is to hold its next annual meeting. This committee shall have 
power to associate with it such persons as it may select for the purpose 
of choosing suitable places of meeting for the Association and its sec- 
tions, and for arranging other matters relating to the satisfactory con- 



PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 867 

duct of the meetings. This committee shall have charge of all the local 
arrangements for the sessions. 

Chapter VI — Papers and Reports. 

Section i. Time of Sending in Titles. 

Titles of papers to be presented to the Association must be in the 
hands of the secretary at least thirty days before the first day of the 
annual session. The title must be accompanied by an abstract of the 
paper, which shall contain not less than 30 or more than 200 words, 
stating the problem attacked and the conclusions reached, and with the 
author's estimate of the time it will take to read his paper. 

Section 2. Papers and Reports Delivered to Secretary. 

Each author shall hand his paper to the secretary of the Associa- 
tion immediately after it is read. Recorders of sections must forward 
the papers presented at the sections' meetings, to the secretary of the 
Association as soon after the close of the meeting as is possible. 

Section 3. Papers and Reports the Property of the Association. 

All papers and reports presented at the meetings of the Association 
when approved by the committee on program, and all papers and 
reports presented at the meetings of any of the sections of the Associa- 
tion when approved by the proper officer or committees of such sec- 
tions, shall, upon their acceptance for publication by the board of 
trustees, becomie the exclusive property of the Association, provided, 
that the board of trustees may permit authors or sections to publish 
their papers in approved journals prior to their publication by the 
Association, under such rules and regulations as they may from time 
to time adopt. 

Chapter VII — Amendments to These By-Laws. 

These by-laws may be amended at any meeting, provided, that the 
proposed amendment shall have been submitted in writing and read at 
a session held on a day prior to the date upon which it is to be con- 
sidered, and that two-thirds of the active members of the Association 
present vote in its favor. 

The by-laws of the executive committee are hereby repealed. 

The following supplemental report by the same committee was pre- 
sented by Dr. Henry Mitchell: 

To the American Public Health Association: 

Your committee, appointed at the annual meeting held in Boston 
in 1905, to consider the advisability of journalizing tfie proceedings of 
this Association, desires to report as follows : 

We recommend the establishment of a monthly journal of public 
hygiene, to be the official organ of the Association, and advise that, in 
the beginning, it shall contain about six hundred pages annually. 

We believe that in its general scope it should not be too technical, 
that not more than two of the complete papers of general interest 
which may be presented at the meetings of the Association should be 



368 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

printed in any one issue; that it should contain abstracts of all other 
papers so presented, giving references to the publicaticms in which said 
papers first appeared in complete form; that it should contain abstracts 
of papers and reports on tc^ics related to public hygiene which may 
appear in publications issued in various parts of the world; that it 
should contain a record of sanitary progress, with items of informa- 
tion relating to the practical application of the art of State and muni- 
cipal hygiene. 

It should contain editorials dealing with current events having rela- 
tion to public hygiene, including scientific and administrative questions. 
It should be a medium for disseminating information relating to the 
enactment and enforcement of laws and ordinances in the various 
states and municipalities of the several countries represented in the 
Association, and for the publication of announcements of the dates 
and places of meetings of other societies and organizations devoted 
to the study of public hygiene or any of its branches or departments. 

We believe that it is advisable that the proposed periodical shall 
be conducted under the direction of a board of trustees, and that upon 
the said board should be placed the sole responsibility for the business 
management, the printing, mailing, advertising, and the editing of the 
journal, and that full authority should be vested in said board to take 
action concerning all questions relating to the fixing of salaries of em- 
ployes and concerning all other disbursements on account of the jour- 
nal, and that an annual financial statemient should be made to this 
Association, showing in detail all receipts and expenditures. 

We further advise that a committee of this Association be appointed 
to report at the next annual meting the cost of printing, mailing and 
editing the proposed journal, and to estimate the amount of the income 
which can be made available for its maintenance, and also show from 
what sources said amounts may be obtained. 

On motion of Dr. Gardner J. Swarts, duly seconded, it was voted 
to accept the reports of the committee and to appoint a committee 
to investigate and report upon the question of establishing a journal. 

A resolution by Dr. Cressy L. Wilbur and Dr. John S. Fulton, rela- 
tive to the date of the next revision of the international classification 
of causes of death was presented by Dr. Fulton and was referred 
to the Executive Committee. 

The following resolution, offered by Dr. J. N. Hurty was referred 
to the Executive Committee: 

Resolved, That a committee of five be appointed by the president of 
the American Public Health Association to report on the organization 
of a section of vital statistics at the next meeting of the Association, 
and that it be authorized to notify registration officials in the coun- 
tries represented in the Association, particularly inviting their attend- 
ance at the next meeting, and to prepare a constitution for approval by 
the Association and adopted by the section at that time. 



PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 369 

A resolution by Dr. John S. Fulton, calling attention to the lack 
of proper registration of vital statistics, was referred to the Execu- 
tive Committee. 

The following papers were then read : 

The Relation of the Physician to the Tuberculosis Problem, by Dr. 
Hugh A. Cowing, of Muncie, Indiana. (See page 136.) 

The Essentials in the Crusade against Tuberculosis, by Dr. Law- 
rence F. Flick, of Philadelphia. (See page 128.) 

Spread of Tuberculosis through Factory Skim Milk, by Dr. H. L. 
Russell, of Madison, Wis. (See page 139.) 

Action of the State against Tuberculosis, by Dr. Jesus E. Monjaras, 
of Mexico City. (See page 119.) 

DISCUSSION. 

Dr. F. J. Mayer of Louisiana asserted that he felt assured all the 
Mexicans would heartily agree that it was an absurdity for people 
to grow hysterical at the appearance of sporadic cases of yellow fever 
on the gulf littoral, with ensuing panics and estoppel to commerce, 
while viewing with perfect indifference 80,000 cases of typhoid in 
Brooklyn and the annual havoc that followed in the wake of tubercu- 
losis everywhere; the relative mortality of which he illustrated by an 
improvised diagram showing that the mortality from consumption in 
one year in the United States, was double that of yellow fever in 100 
years. 

He spoke of the danger of consumptive houses, and cited illustra- 
tions from Louisiana, together with a resume of the work being 
done by Dr. Irion, President of the Louisiana State Board of Health, 
who was deeply interested in the warfare against tuberculosis, and 
was leaving no stone unturned in Louisiana, and that the activities 
of the board during the past year would be quadrupled this year, 
both on educational and statistical lines; that during the past year 
over 100 institutes of hygiene had been held where the mosquito 
doctrine, variola, vaccination, typhoid and tuberculosis had been dis- 
cussed some times in four different languages. 

Dr. Mayer then offered a resolution endorsing the Louisiana plan 
for hygiene education. 

Dr. Richard H. Lewis of North Carolina asked Dr. Mayer what 
the Louisiana system of hygiene education was. Dr. Mayer replied, a 
system which was based on the theory of the university extension, 
applied to hygiene, and on the fact that education in the wisdom of 
the provisions of a sanitary law should precede its enactment; as 



360 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING, 

Otherwise it would be a dead letter on the statute book; that to carry 
this idea into execution and to educate the masses in the fundamental 
principles of hygiene and in the true cause, nature and prevention of 
contagious and infectious diseases in man and the lower animals, it 
was necessary not only to instruct through the secular press, maga- 
zines, by circulars, pamphlets, lectures before colleges and scientific 
bodies, but to hold special institutes of hygiene where all sanitary 
topics would be discussed and practical and illustrated lectures deliv- 
ered. 

Dr. Alfonso Pruneda^ of Mexico City: I must tell the hon- 
orable foreign members of this Association that the compulsory in- 
struction imparted in Mexico includes the teaching of hygiene, and 
consequently the knowledge of the capital ways of transmission for 
infectious diseases, especially tuberculosis. What the last speaker 
wants for our schools is already practiced here. 

Dr. Jesus E. Mon jaras, of Mexico City said : One of the reasons 
for failure in the campaign against tuberculosis in our country and 
in others, is that everything is expected to come by action of the 
State. The fight against tuberculosis is composed of two main points. 

1st. The destruction of the pathogenic agent. 

The removal of the indirect or predisposing causes. 

It is impossible for the State to destroy every bacillus; there is 
no sanitary police service in the world that could be efficient enough 
to do this. 

That must be done by the patients, instructed and persuaded, as 
they have to be, by certain societies, of the harm they do with that 
avoidable practice. 

The disinfection itself, which service depends directly upon the 
State, could not be applied conveniently and with opportunity to the 
public road, the houses and the things polluted by the tuberculosis 
patients ; but something ihai concerned people can do, is not to occupy 
the houses previously inhabited by tuberculosis persons, before they 
have been disinfected. 

As the tuberculous patient is not bedfast before the last period of 
his illness, and as that illness is contagious long before, when the 
patient is constantly in contact with his fellows, isolation can be ac- 
complished only at the end of his disease. 

Before, it is necessary that he be taught what to do to protect others. 

The State should encourage these societies, and compel neces- 
sary repairs in the streets and dark houses, foci where the pathogenic 
agent of tuberculosis is cultivated. 



PROCEEDINGS — THIRTY-FO URTH ANNUAL MEETING, 861 

Dr. Jose Isabel Saloma, of Mexico, then read a paper on, "The Pro- 
phylaxis of Typhus Fever." (See page 205.) 

Dr. Alfonso Pruneda, of Mexico, read a paper on "The Rains and 
T3rphus Fever." (See page 209.) 

Adjourned to 3:00 P. M. 

THIRD DAY — Afternoon Session. 

The Association met and was called to order by the President at 
3:00 P. M. 

A paper by Dr. Charles Harrington, of Boston, Mass., on "The 
Problem of City Milk Supplies" was read by Mr. James O. Jordan. 
(See page 153.) 

Dr. Enriques y Terrazas, of Chihuahua, Mexico, read a paper on 
"The Dairy Industry in Relation to Children's Diseases." (See page 
160.) 

discussion. 

Dr. Everardo Landa, of Mexico, said there should be some way 
of punishing milk adulteration other than by fines. In Mexico some 
milk dealers include expected fines in the cost of production, which 
they have ready when the board of health finds adulteration. 

Dr. Eduardo Liceaga, of Mexico City, said: That in Mexico, ac- 
cording to the regulations of the sanitary code, nothing but entirely 
pure milk should be sold, not allowing, therefore, any adulteration by 
water. That the enforcement of this article of the code is under the 
supervision of the board of health agents and the analyses are made at 
the laboratory of the board of health. 

Mr. James O. Jordan^ of Boston: It may be of interest to know 
something of the fines which may be imposed under the -Massachu- 
setts law. There we have a system whereby. under a complaint for a 
first offence for milk not of good standard quality, an oflfender may be 
punished by a fine of not more than fifty dollars ; for a second offense 
the fine must be from one hundred to two hundred dollars and for a 
later oflfence by a fine of fifty dollars and by imprisonment for not less 
than sixty nor more than ninety days. 

By methods pursued in Boston it is possible to complete an analysis 
of milk in less than twenty-four hours, the time mentioned by Dr. 
Kohnke. With us the ordinary examination of milk specimens is com- 
pleted in from two to three hours. 

As to the judiciary, we are not troubled by the elective system ; all 
of the Massachusetts judges being appointed by the governor, con- 
sequently it is possible to have decisions in milk cases according to 



862 PROCEEDINGS -- THIRTY-FOURTH ANNUAL MEETING. 

law and evidence without the thought of the possible effect of a finding 
upon future re-elections. 

In addition to the attention given to the purity of Boston's milk 
supply from the chemical standpoint a determined, and I believe a 
successful movement, is being made for improvement in the matter 
of cleanliness. This work is being carried on under the regulations 
of the Boston Board of Health, this board having been the pioneer 
in the establishment of a bacteriological standard by limiting the num- 
ber of bacteria in milk to 500,000 per cubic centimeter. Over 5,000 
samples were last year subjected to bacteriological examination. This 
work, in conjunction with the enforcement of the board's temperature 
standard of not over fifty degrees Fahrenheit, and of the other regu- 
lations in operation cannot fail and is showing marked beneficial re- 
sults. 

At this time Dr. Quitman Kohnke, of New Orleans, by request^ 
gave a repetition of his illustrated address on "The Yellow Fever Epi- 
demic in New Orleans in 1905." 

Dr. Bingham Stone, of Burlington, Vermont, read a paper on "Ty- 
phoid Fever in Rural Districts." (See page 171.) 

Dr. Jose Gayon, of Mexico, read a paper on "Notes on Typhoid 
Fever in Mexico." (See page 189.) 

Dr. Enrique del Bosque, of Mexico, read a paper on "The Water 
Supply of Cities." (See page 164.) 

DISCUSSION. 

Dr. B. R. Rickards, of Boston said: Dr. Stone's paper has been 
of especial interest to me since it shows a state of affairs in rural 
communities which we have long suspected. 

In Boston we have an unimpeachable water supply, and many other 
conditions which usually go to make a high typhoid rate are locally 
absent. Yet every year during the months of August, September and 
October we have a large increase in the number of typhoid cases, — 
during 1905, one-half of the total number of positive results from 
serum test were obtained during these months and the total number 
of Widal examinations during these months was about one-half the 
total for the year. It appears to be a fact that a good many of these 
casese are imported, the organisms being brought back by returning 
vacationists. This appears all the more likely since the heaviest list 
of cases are reported within a comparatively short time, — about the 
average period of incubation, after the two most popular vacation 
weeks of the summer. 

If we look for the cause of this state of affairs we shall find that 



PROCEEDINGS — THIRTY -FO URTH ANNUAL MEETING, 365 

the low-priced summer resort usually is very deficient in sanitary ar- 
rangements. Often times the hotel is the old homestead, perhaps 
enlarged and remodeled but usually having the same old sanitary 
arrangements and drawing its water from the same old well or springs 
the two being often in close proximity. The proprietor may defend 
himself by saying as Dr. Stone has so aptly expressed it that "he is 
drinking the same water his grandfather drank" and that no one was 
ever side from it. 

But this same proprietor does not take into account the fact that 
the area from which the water is drained to supply a few persons is 
much less than that which is drained to supply thirty and that on the 
other hand the sink drain and privy have to take care of a much 
greater amount of waste material, — that, so to speak, the distance 
between the privy and the well decrease in inverse ratio to the num- 
ber of people using them. 

The work which Dr. Stone is doing in investigating this state of 
aflFairs is most valuable and we trust he will be able to carry on the 
work which he has instituted to a most successful conclusion. 

Dr. Edward Bartow^ of Urbana, 111. : In Illinois we receive many 
samples of water from shallow wells. We find it necessary to condemn 
the water from a majority of the dug wells. That from drilled, driven,, 
or bored wells is much better. We therefore, recommend the substi- 
tution of drilled, driven or bored wells, carefully cased to exclude 
surface water, for the dug wells, and believe if this recommendation 
were carried out the suituation would be improved. 

Dr. Jos. Goldberger^ Washington, D. C. : It seems to me that in 
considering the matter of the transmission of typhoid fever, too little 
attention has been given to modes of transmission other than through 
the medium of water and milk. We all recognize the importance of 
isolating convalescents from diphtheria, who may continue to harbor 
the diphtheria bacillus, until the bacilli disappear. Now it has been 
found that some convalescents from typhoid fever continue to harbor 
and excrete typhoid bacilli for as long as 30 to 40 years after an at- 
tack of the disease. It must be obvious that such typhoid bacillus 
carriers are a constant menace to their surroundings and may and 
actually do act as unsuspected foci of the disease. It is such carriers 
that are responsible for some of the "Unexplainable sporadic" cases 
of typhoid fever. I mean to call attention to this point because it 
merits more consideration than it has thus far received from Ameri- 
can sanitarians. 

Dr. F. J. Mayer, of Louisiana, in discussing tyjAoid fever said: 
Its spread in Louisiana is easily understood, when it is remembered 



3M PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

that the Bacillus typhosis had been found not only in the intestines, btft 
in the lymphatics, mesenteric glands, kidneys, liver and spleen, bone 
marrow, rose spots, bile urine and blood, and even on bed sores ; that 
the bacillus had great resisting power, remaining viable for six months 
in upper layers of soil; thriving at room temperature; alternate 
freezing and thawing failing to kill, remaining viable on fomites for 
three months, remaining viable according to some observers in sealed 
bouillon cultures and in vacuum, and in a closet 228 days. The bacillus 
entering the human system through the stomach in water or milk or 
other food contaminated by typhoid laden flies, a bowl of milk into 
which an infected fly had dropped, in a few hours fairly reeked with 
the Bacillus typhosis. In Louisiana the unpaved, unsewered towns, 
filled with dust, the over-ground cisterns and shallow wells, the 
universal drinking source, the unscreened houses present all 
the conditions necessary for a spread of the infection which was sup- 
plied by ignorance throwing typhoid dejecta on the ground without 
disinfection until to-day the State is paying dearly for its sanitary 
laches, every town from the Arkansas line to the gulf having had a 
visitation, the danger growing yearly greater with the increase of 
population, adding to the stun total of excremental filth. 

Dr. Ricardo E. Mannuell, of Mexico City, read a paper on "Anchly- 
lostomasis in Mexico." (See page 201.) 

Adjourned to 8:00 P. M. 

THIRD DAY — Evening Session. 

The Association met at 8 :oo P. M., and was called to order by the 
President. 

The following papers were read: 

New School Buildings in Mexico, by Dr. Manuel Uribe Troncoso, 
of Mexico City. (See page 264.) 

Sanitary Inspection of Dwellings, by Dr. Domingo Orvananos, of 
Mexico City. (See page 271.) 

A paper by Dr. Eduardo Liceaga, of Mexico City, on "The Bu- 
bonic Plague" was read by title. (See page 215.) 

The Problems of Car Sanitation, by Dr. T. R. Crowder, of Chicago, 
Illinois. (See page 278.) 

"Ametropia in its Relation to Ocular Hygiene," by Dr. Jose Ramos, 
of Mexico City. (See page 223.) 

"Trachoma in Mexico, by Dr. Lorenzo Chavez, of Mexico City. 
(See page 23). A paper by Dr. Jesus Gonzalez Uruena, of Mexico 
City, on "Mai Del Pinto" was read by title. (See page 219.) 



PROCEEDINGS — THIRTY -FO URTH ANNUAL MEETING, 866 
DISCUSSION. 

Dr. B. C. Magennis, of Newark, N. J. : I would like to ask Dr. 
Crowder if, in his opinion, he considers it harmful and a menace to 
health for passengers to spit in the wash-bowls, when cleaning their 
teeth. 

My observation has been that most all passengers in cleaning their 
teeth use the wash-bowls as a cuspidor, and I would like to ask Dr. 
Crowder if the Pullman Car Company cannot construct a spittoon 
at the side of the wash-bowls, or in some other part of that com- 
partment which can be used as a cuspidor for passengers to spit in 
when cleaning their teeth. 

It is a custom with myself to use the toilets when cleaning my teeth. 

Dr. Crowder has stated that there can be but little danger in spit- 
ting in the wash-bowl, but it is my opinion that the dangerous ele- 
ment is not what goes in the bowl, but it is what is distributed or spat- 
tered around on the side and top of the bowl. 

Dr. H. W. Hill, Minneapolis: The remarks of Dr. Magenis con- 
demning the use of wash-bowls of Pullman cars for teeth-cleaning 
purposes, appeal, I think more forcefully to the aesthete than to the 
hygienist. So long as we demand that every person shall wash their 
hands in these wash-bowls, after each use of the Pullman closet, so 
long do we countenance the introduction to the washbowl of human 
feces and urine — small in amount it is true, but quite as likely to be 
infective as the saliva thrown into the wash-bowl in the process of 
ordinary tooth cleaning. Persons civilized enough to clean their teeth 
are likely to be modem enough to use some form of disinfectant as a 
tooth paste, powder or wash, and while disinfectants thus used are 
necessarily mild and therefore likely to be rather inefficient, yet they 
probably have some effect. Much more efficient in preventing hy- 
gienic danger is the fact that tooth washings are likely to be pretty 
well flushed out of the washbowl immediately after their deposit 
therein. Finally the splashings from the deposits are not likely to 
be greater in amount than in the case of handwashing after the use 
of the closet. I do not oppose the introduction of a proper hygienic 
device, sparate from the washbowls, for exclusive use in tooth cleaning 
in Pullman cars but I do oppose the advocacy of such a change on 
arguments relating to spread of diseases which cannot stand up under 
critical examination; and especially I am opposed to the illogical posi- 
tion advocating this change, while the more serious, if less obvious, 
practice of washing closet-room-stained hands in the same bowls con- 
tinues. In advocating a separate device for tooth-cleaning, I should ad- 
vocate also a separate bowl for handwashing in the closet itself. I do 



366 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

not believe either form of ablution is a serious factor in the spread of 
infectious diseases, but what little danger exists is more serious in 
the latter than in the former. Hygienists too often "strain out the 
gnat and swallow the camel." (Bible — Revised Version.) Medical 
inspection of sleeping car porters, and dining car waiters and cooks is 
a matter of far more hygienic moment than either of the two so far 
referred to. I personally know, from the man's own statement, that 
the porter of one of the compartment cars of the special on which 
we came down has "a bad case of syphilis." Of course such medical 
inspection should be extended to those performing similar duties in 
hotels, etc., but this discussion is confined to car sanitation. 

Dr. Augustin Chacon, of Mexico City: Hitherto, trachoma had 
been very seldom observed in Mexico. The paper read by Dr. Chavez 
points out the spread of an epidemia of this disease, imported by the 
Syrian immigrants. The immigrants with trachoma are not ac- 
cepted in the United States. 

It is necessary to call the attention of the sanitary authorities to 
this point, and, especially, of the delegate of the Superior Board of 
Health in Vera Cruz. 

Dr. Uribe Troncoso, of Mexico City: The paper of Dr. Chavez 
seems to me interesting, and I agree with the idea he promulgates, 
indeed, they are the same as I set forth some time ago in the National 
Academy of Medicine and the Mexican Ophthalmological Society. 

Trachoma is rare in the Mexican Republic; not only in the central 
tablelands, as has been claimed by those who attribute its rareness to 
the altitude. Oculists in different parts of the country, and doctors 
on the coasts scarcely ever find it among the natives, while oculists 
in the capital who see patients from all over the country, ( for, those 
who suffer from the eyes generally prefer to come to the city to con- 
sult an oculist), very rarely find trachoma. 

On the contrary in regions where immigration is more active, es- 
pecially from countries where trachoma is prevalent, the disease be- 
gins to be frequently seen. Dr. Leal, an oculist residing in Monterey, 
told me that, on account of Asiatic immigration, trachoma is show- 
ing itself in a great number of patients. 

So then, we have little trachoma on the central tableland, not on 
account of the altitude, but of the slight immigration. This does not 
mean, however, that trachoma does not develop with greater mild- 
ness in the highlands; its virulence may be attenuated, as for in- 
stance, in diphtheria, the propagation of which is much less to be 
feared among us. 



PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 867 

I do not believe, however, that at present there is properly speak- 
ing, a trachoma epidemic in the city of Mexico, and our guests might 
carry away a false impression, if such were asserted here. I rather 
think that Dr. Chavez has met with, as sometimes happens, a con- 
tinued series of cases of the infirmity. For my part among about 
3,000 eye patients whom I have seen in the Consultorio Central de la 
Beneficencia Publica up to the present, the usual proportion of two 
or three per thousand has not altered. 

The attitude of the board of health seems to me worthy of all 
praise, because it, as Dr. Inglesias, delegate from Vera Cruz, has just 
assured us, has taken measures to examine all immigrants from coun- 
tries where trachoma is prevalent, and especially Syrians, and to 
have them watched afterwards if they enter the interior of the Re- 
public. 

As immigration to Mexico is still very small, perhaps it would seem 
too radical to have recourse to the measures taken in the United 
States, which systematically exclude all immigrants afflicted with 
trachoma. I believe, however, it is necessary to consider deliberately 
the serious danger of the spread of trachoma among us and to com- 
pare the advantages which the labor of this class of immigrants may 
bring to the country with the great disadvantages which the spread 
of the disease would cause to the working capacity of our industrial 
population, agriculture, etc. 

Dr. Manuel S. Iglesias, of Vera Cruz said that the Superior 
Board of Health had promulgated by-laws for the prevention of the 
introduction of trachoma. All passengers on ships arriving at ports 
are thoroughly examined. If any person is found with this disease 
a report is telegraphed to the Superior Board of Health, giving the 
name, last residence, destination and route of travel, so that he could 
be kept under observation. 

Adjourned to 9:00 A. M. of the following day. 

FOURTH DAY — Last Session. 

The Association met at 9:00 A. M. and was called to order by the 
President. 

The Secretary reported that the Executive Committee recommended 
the adoption of the resolution offered by Dr. Hurty, of Indiana, which 
was as follows: 

Resolved, That a conmiittee of five be appointed by the president of 
the American Public Health Association to report on the organization 
of a section of vital statistics at the next meeting of the Association, 



368 PROCEEDINGS — THIRTY-FO URTH ANNUAL MEETING. 

and that it be authorized to notify registration officials in the countries 
represented in the Association, particularly inviting their attendance 
at the next meeting, and to prepare a constitution for approval by the 
Association and adoption by the section at that time. 

On motion, duly made and seconded, it was voted to adopt the reso- 
lution. 

The Secretary : The Executive Committee reconmiends the adop- 
tion of the following resolution offered by Dr. Wilbur and Dr. Fulton : 

Resolved, That the American Public Health Association recom.- 
mends that the date of the next revision of the international classi- 
fication of causes of death be in the year 1909, instead of 1910, and 
that the regular decennial revisions be held in the years, 1909, 19 19, etc. 

On motion, duly made and seconded, it was voted to adopt the reso- 
lution. 

The Secretary : The Executive Committee recommends the adop- 
tion of the following resolution in lieu of the resolution offered by 
Dr. John S. Fulton, of Baltimore: 

Whereas, A correct registration of births, marriages and deaths is 
necessary to indicate not only the natural increase of population, but 
also the measure of the health conditions and the efficiency of sanitary 
operations in any country. 

Whereas, With the increase in numbers, wealth and age of the 
population of the several states and provinces, the necessity for evi- 
dence of births, marriages and deaths in cases of wills, pensions, in- 
surance, crime, etc., becomes daily of increasing urgency. 

Whereas, Comparison of the health conditions of different countries 
and districts, and climates is only possible through the existence and 
study of such records. 

Whereas, International comity and treaty stipulations not infre- 
quently involve agreements touching the transmission of records relat- 
ing to the birth, marriage, or death of individuals traveling or residing 
in foreign countries. 

And whereas, Such registration is imperfect or wholly wanting in 
some of the states of the countries represented in this Association. 

Therefore be it resolved. That the secretary of the Association be 
instructed to transmit a copy of this resolution to the governors and 
boards of health of such states and provinces urging the desirability 
of efficient legislation on this subject. 

Dr. John S. Fulton presented the report of the Advisory Council 
as follows: 

OMcers: For President, Dr. Domingo Orvananos of Mexico City; 
First Vice-President, Dr. Quitman Kohnke, of Covington, La:; for 
Second Vice-President, Dr. Robert Wiles Simpson, of Winnipeg, Can- 



PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 369 

ada; for Third Vice-President, Dr. Gardner T. Swarts, of Provi- 
dence, R. I. ; for Secretary for three years. Dr. Charles O. Probst, of 
Columbus, Ohio; for Treasurer, Dr. Frank W. Wright, of New 
Haven, Conn. 

Members of the Executive Committee: Dr. Richard H. Lewis of 
Raleigh, N. C., Mr. H. W. Qark, of Boston, Mass., and Dr. Jesus 
Monjaras of Mexico City. Atlantic City was chosen as the place of 
next meeting. 

On motion of Dr. Henry Mitchell, duly seconded, the report of the 
Advisory Council was adopted, and the Secretary was instructed to 
cast the unanimous ballot of the Association for all the officers 
named. This the Secretary did and the officers were declared duly 
elected. 

The committee appointed to audit the accounts of the Treasurer 
reports as follows: 

REPORT OF THE AUDITING COMMITTEE. 

Your committee begs to report that it has examined the books, 
vouchers and receipts of the Treasurer and has found them to be 
correct. 

Your committee begs to direct the attention of the Association to the 
fact that the surplus for the year ending November 15th, 1906, was 
$952.36, while that at the end of Septem&r 20th, 1905, was $1,948.92. 
Your committee finds this diminished balance to be one accrued, 
although the receipts for the year were increased over previous year by 
$351.31, and to have been mainly due to a payment of $614.37 for the 
publication of a portion of the proceedings of the annual report in 
the Journal of Infectious Diseases and to the traveling expenses of the 
members of the committee. 

Signed: P, H. Bryce 

Henry Mitchell 
J. E. Monjaras. 

On motion of Mr. Jordan, duly seconded, the report was accepted 
and approved. 

Dr. Goldberger reported that the Laboratory Section had elected 
the following officers : 

Chairman, H. W. Hill, M. D., Minneapolis, Minn. 

Vice Chairman, James Carroll, M. D., Washington, D. C. 

Secretary, B. R. Rickards, Boston, Mass. 

Recorder^ H. D. Pease, M.D., Albany, N. Y. 

Council, H. W. Qark, Boston, Mass., O. G. Fabela, Mexico City, 
Mex., J. A. Amyot, Toronto, Can., G. C. Whipple, New York, N. Y. 

On motion of Dr. Goldberger, duly seconded, the election of the 
Section's officers as named was approved by the Association. 
24 



370 PROCEEDINGS — THIRTY-FOURTH ANNUAL MEETING. 

The President announced the membership of special committees as 
follows : 

Committee to invite the Conference of State and Provincial Boards 
of Health of North America to affiliate with the American Public 
Health Association: Dr. Gardner T. Swarts of Providence, R. I. 

Committee to investigate and report upon the formation of a Sec- 
tion composed of Municipal Health Officers : Dr. Wm. C. Woodward, 
of Washington, D. C, Dr. Walter D. Greene, of Buffalo, N. Y., and 
Dr. Eugene Buehler, of Indianapolis, Ind. 

Committee to report upon the organization of a Section of Vital 
Statistics : Dr. J. N. Hurty, of Indianapolis, Ind., Dr. Cressy L. Wil- 
bur, of Washington, D. C, Dr. John S. Fulton, of Baltimore, Md., 
Dr. Jesus E. Monjaras of Mexico City, Mexico, and Dr. Chas. A. 
Hodgetts, of Toronto, Ont. 

Conunittee to report upon the establishment of an Association 
journal: Dr. Henry Mitchell, Trenton, N. J., Dr. H. D. Pease, Al- 
bany, N. Y., and Dr. C. O. Probst, Columbus, Ohio. 

Committee on a National Department of Health for the four coun- 
tries represented in the Association, named later, was as follows : ¥a£ 
the United States, Dr. 'John S. Fulton, Dr. Samuel H. Durgin, and 
Dr. C. A. Harper. 

For Canada, Dr. Peter H. Bryce, Dr. E. P. Lachopelle, and Dn 
Robert W. Simpson. 

For Mexico, Dr. Eduardo Liceaga, Dr. Jesus Monjaras and Dr. 
Jose Mesa. 

For Cuba, Dr. Juan Guiteras, Dr. Carlos Juan Finlay and Dr. Aris- 
tides Agramonte. 

A paper on "Conditions and Prospects of Vital Statistics for the 
United States," by Dr. Cressy L. Wilbur, of Wishington, D. C, was 
then read by Dr. John S. Fulton. (See page 294.) 

Dr. J. Millan Ponce, of Mexico City, read a paper on "Vital Sta- 
tistics for the City of Mexico." (See page 311.) 

Dr. Silvio J. Bonansea, of Mexico City, read a paper on "Veterin- 
ary Hygiene." (See page 320.) 

A paper read by Mr. Miguel Quevedo, Civil Engineer, of Mexico 
City, on "Sanitary Work in the Valley and City of Mexico." (See 
page 248.) 

A paper on "Hygienic Conditions in the Qty of Mexico in the past 
Fifteen Years," was read by Roberto Gayol, Civil Engineer, of Mexico 
City. (See page 259.) 



PROCEEDINGS — THIRTY-FO URTH ANNUAL MEETING. 871 

At this time, Dr. Orvananos, the newly elected president, was es- 
corted to the chair, and expressed in most cordial terms his grateful 
appreciation of the honor conferred upon him in selecting him for 
president for the ensuing year. He made special mention of 
the signal courtesy of a member from the United States who had 
declined this honor in order that a representative of his country 
might be selected, which admonished him that this tribute was to his 
country and not to himself personally. 

The following resolutions of thanks were unanimously and enthu- 
siastically adopted: 

Resolved, That the special thanks of this Association are hereby 
extended to the President of the Republic of Mexico, to the Minister 
of Instruction and Fine Arts, and to the other ministers of the gov- 
ernment for the gracious courtesies extended to the members of 
this Association and their friends, and for the generous and splendid 
provisions made for enabling the members of 9ie Association to see 
the wonderful material progress and sanitary development of the great 
Mexican Republic. 

Resolved, That this Association hereby endeavors to express its 
appreciation of the munificent hospitality extended to its members 
by the Governor and his associates representing the city of Mexico, 
and this Association further desires to convey through them its 
thanks, which cannot find adequate expression, to the citizens of the 
city who have overwhelmed its members with public and private at- 
tention and courtesies. 

Resolved, That this Association desires hereby to convey to the 
President of the Superior Board of Health of Mexico, Dr. Liceaga, 
and to its members, an expression of appreciation of the efforts made 
to facilitate in every way the opportunities to observe and study the 
many sanitary works already completed, as well as those which are 
under construction, in the city of Mexico, and also for the elaborate 
provisions made for the convenience of the members of the Associ- 
ation, and for the accommodation furnished for the performance of 
its work. 

Resolved, That the special thanks of the Association are due to the 
committee of Mexican ladies who have been so constant in their 
kindnesses; for the courtesies extended to the members of the Asso- 
ciation, and especially to their lady friends. To them, the visiting 
ladies wish to give voice through the Association of their appreciation 
of the attentions which they have not found words adequate to express. 

Resolved, That the thanks of this Association are hereby extended 
to the municipal authorities, the members of the medical profession, 
and the citizens of Zacatecas, Guanajuato and Vera Cruz, for the 
cordial welcome and generous hospitality shown to the members from 
the United States of America during their visit to said cities. 

Resolved, That the thanks of the Association are hereby extended 



372 PROCEEDINGS— THIRTY-FOURTH ANNUAL MEETING. 

to the Press, both Spanish and English, for the admirable reports of 
the proceedings of the Association and for the facilities given for the 
extension through their columns of sanitary knowledge. 

There being no further business to come before the meeting, the 
President declared the Association adjourned to meet in Atlantic City 
in 1907. 



CONSTITUTION 

OF THE 

AMERICAN PUBLIC HEALTH ASSOCIATION. 



TITLE. 

I. This Association shall be called "The American Public 
Health Association.^' 

objects. 

II. The objects of the Association shall be the advancement of 
sanitary science, and the promotion of organizations and the measures 
for the practical application of public hygiene. 

MEMBERS. 

III. The members of the Association shall be known as Active, 
Associate, and Foreign. 

The Executive Committee shall determine for which class a candi- 
date shall be proposed. The Active members shall constitute the per- 
manent body of the Association, subject to the provision of the 
Constitution as to continuance in membership. They shall be selected 
with special reference to their acknowledged interest in, or devotion to, 
sanitary studies and allied science, and to the practical application of 
the same. The Associate members shall be elected with special refer- 
ence to their general interest only in sanitary science, and shall have 
all the privileges and publications of the Association, but shall not be 
entitled to vote or hold office. Health officials, and other persons 
especially interested in matters relating to the public health of coun-. 
tries not included in the Association, may be elected as Foreign mem- 
bers. They shall have all the privileges and publications of the Asso- 
ciation, but shall not be entitled to vote or hold office. 

Delegates trom national, state, provincial, and municipal boards of 
health, organized sanitary associations, and the army, navy, and pub- 
lic health and marine hospital service, shall be entitled to be enrolled 
as Alctive members upon presentation of their credentials to the Execu- 
tive Committee. Members, not delegates from such bodies, shall be 
elected as follows : 



ii CONSTITUTION. 

Each candidate for admission shall first be proposed to the Ex- 
ecutive Committee, in writing (which may be done at any time), with 
a statement of the business or profession and special qualifications 
of the person so proposed. On recommendation of a majority of 
the committee, and on receiving a vote of two-thirds of the members 
present at the regular meeting, the candidate shall be declared duly 
elected a member of the Association. The annual fee of membership 
in each class shall be $5.00. 

OFFICERS. 

IV. The officers shall be a President, a First and Second Vice- 
President, a Secretary, and a Treasurer, and the officers of the various 
sections. 

All the officers shall be elected by ballot, annually, except the Sec- 
retary, who shall be elected for a term of three years. 

PRESIDING OFFICER. 

V. ' The President, or in his absence one of the Vice-Presidents, or 
in their absence a chairman pro tempore, shall preside at all meetings 
of the Association. He shall preserve order, and shall decide all ques- 
tions of order, subject to appeal to the Association. He shall also 
appoint all committees authorized by the Association, unless otherwise 
specially ordered. 

SECRETARY. 

VI. The Secretary shall have charge of the correspondence and 
records of the Association; and he shall also perform the duties of 
Librarian. He, together with the presiding officer, shall certify all 
acts of the Association. He shall, under the direction of the Execu- 
tive Committee, give due notice of the time and place of all meetings 
of the Association, and attend the same. He shall keep fair and ac- 
curate records of all the proceedings and orders of the Association; 
and shall give notice to the several officers, and to the Executive and 
other committees, of all votes, orders, resolves, and proceedings of 
the Association, affecting them or appertaining to their respective 
duties. 

TREASURER. 

VII. The Treasurer shall collect and take charge of the funds and 
securities of the Association. Out of these funds he shall pay such 
sums only as may be ordered by the Association, or by the Executive 



CONSTITUTION. iii 

Ownmittee. He shall keep a true account of his receipts and pay- 
ments, and at each annual meeting render the same to the Associa- 
tion, when a committee shall be appointed to audit his accounts. If, 
from the annual report of the Treasurer, there shall appear to be a 
balance against the treasury, no appropriation of money shall be made 
for any object but the necessary current expenses of the Association, 
imtil such balance shall be paid. 

STANDING COMMITTEES. 

VIII. There shall be the following standing committees : ( i ) The 
Executive Committee, (2) the Advisory Council, (3) the Committee 
on Publication. 

EXECUTIVE COMMITTEE. 

IX. The Executive Committee shall consist ( i ) of the President, 
First Vice-President, Second Vice-President, Secretary, Treasurer, 
and Chairmen of the various sections; (2) of six active members of 
whom three shall be elected annually by ballot to serve two years, 
and who shall be ineligible to reelection for a second successive term ; 
(3) of the ex-presidents of the Association; and (4) of the Chair- 
man and Secretary of the Laboratory Section and the retiring Chair- 
man of that section. 

It shall be the duty of the Executive Committee to consider and 
recommend plans for promoting the objects of the Ajssociation, to 
authorize the disbursement and expenditure of unappropriated moneys 
in the treasury for the payment of current expenses; to ccMisider all 
applications for membership, and at the regular meetings, report the 
names of such candidates as a majority shall approve ; and, generally, 
to superintend the interests of the Association and execute all such 
duties as may, from time to time, be committed to them by the Asso- 
ciation. At least one month preceding the annual meeting of the 
Association, the Executive Committee shall cause to be issued to mem- 
bers a notice of such meeting, and they are authorized to publish 
the same in medical, scientific, and other periodicals, but without 
expense to the Association; and such notice shall contain the order 
of business to be followed at said meeting, and briefly, the subjects 
to be presented and the special points of discussion. 

ADVISORY COUNCIL. 

X. The Advisory Council shall consist of one member from each 
state, territory, and district, the army, navy, and marine hospital ser- 



iv CONSTITUTION, 

vice, the Dominion of Canada, and each of the provinces, who shall 
be appointed by the President on the last day of each session, and 
who, besides acting as nominating committee of officers for the en- 
suing year, to be announced at such time as the Executive Committee 
may appoint, shall consider such questions and make such recommen- 
dations to the Association as shall best secure the objects of the Asso- 
ciation. They shall at their first meeting elect from their own num- 
ber a secretary, whose record of their proceedings shall be made part 
of the records of the Association. 

COMMITTEE ON PUBLICATION. 

XL The Committee on Publication shall consist of a Chairman, 
the Secretary of the Association, the Treasurer of the Association, 
and a member of each section of the Association, with the President 
of the Association, ex-officio; who shall contract for, arrange and 
publish, under authority of the Executive Committee, the proceedings 
of the Association, including such papers as have been examined and 
approved by the Executive Committee, or which have been submitted 
to them by the latter for their discretionary action. 

REPORTS AND PAPERS. 

XII. All committees preparing reports to be presented to the Asso- 
ciation must submit the same to the Publication Committee not later 
than 30 days before the succeeding annual meeting of the Associa- 
tion ; and all papers other than committee reports shall be in the hands 
of the Secretary not less than 20 days before. 

MEETINGS. 

XIII. The time and place of each annual meeting shall be fixed at 
the preceding annual meeting, but may be changed by the Executive 
Committee for reasons that shall be specified in the announcement of 
the meeting. Special meetings may be called at any time or place, 
by concurrence of two-thirds of the Executive Committee. There 
shall be no election of officers, or change of by-laws, or appropriation 
of money to exceed the amount at that time in the treasury, at such 
special meeting, except by a vote of a majority of all the members of 
the Association. Whenever a special meeting is to be held, at least 
one month's notice shall, if possible, be given by circular to all the 
members, together with the order of business. 



CONSTITUTION. v 

QUORUM. 

XIV. At the annual meeting nine members shall constitute a quo- 
rum for the election of officers, a change of the constitution, the elec- 
tion of members, and the appropriation of moneys. 

ORDER OF BUSINESS. 

XV. The order of business at all meetings of the Association shall 
be fixed by the Executive Committee, and such order must be com- 
pleted before any other business is introduced, except such order of 
business is suspended by a vote of four-fifths present. 

ALTERATION OF CONSTITUTION. 

XVI. No alteration in the constitution of the Association, shall be 
made except at an annual meeting, or unless such alteration shall 
have been proposed at a previous meeting, and entered on the min- 
utes with the name of the member proposing the same, and shall be 
adopted by a vote of two-thirds of the members present. 

SECTIONS. 

XVII. Members of the Association may be authorized to form 
themselves into sections by vote of the Association at any annual 
meeting; such sections shall have power to nominate their officers to 
be elected by the Association, and to make by-laws which shall go into 
effect when approved by the Association. 



BY-LAWS OF THE EXECUTIVE COMMITTEE. 



QUORUM. 

1. Five members shall constitute a quorum for the transaction of 
such business as may come before the committee. 

MEMBERS RESTRICTED. 

2. No elective member of the Executive Committee shall be at the 
same time a member of the Advisory Council, if there is another mem- 
ber of the Association from his state or service. 

PARLIAMENTARY USAGE. 

3. Cushing's Law and Practifce of Legislative Assemblies shall be 
the guide in parliamentary practice until otherwise ordered. 

PAPERS. 

4. Papers to be presented at a general session of the Association 
shall be in the hands of the Secretary of the Association not less 
than twenty days before the coming meeting, and to be printed in 
the transactions in full or in abstract at the discretion of the Publica- 
tion Committee. ♦ 

5. All papers accepted by the Association, whether read in full, by 
abstract, by title, or filed, shall be delivered to the Secretary as soon 
as thus disposed of, as the exclusive property of the Association. 
Any paper presented to this Association and accepted by it shall be 
refused publication in the transactions of the Association, if it be pub- 
lished, in whole or in part, by permission or assent of its author, in 
any manner prior to the publication of the volume of transactions^ 
unless written consent is obtained from the Publication Committee- 

6. Day papers shall be limited to twenty minutes, and evening^ 
papers to thirty minutes each. 

DISCUSSION OF PAPERS. 

7. After the leading papers on each subject, as indicated by the 
Executive Committee, have been read, discussion shall follow, and 
be confined strictly to the subject of these papers; and each speaker 



BY-LAWS. vii 

shall be limited to ten minutes, and shall not speak a second time until 
after every other member who desires to be heard, and then only for 
five minutes, except by unanimous consent. 

8. The Chair shall notify gentlemen who desire to speak to send 
their names, and they shall be called on in the order sent up ; and he 
may, at his discretion, limit the time of speaking to five instead of 
ten minutes, if in his judgment it may become necessary to do so 
in order to allow each one on the list an opportunity to be heard. 

PUBLICATION COMMITTEE. 

9. The Publication Committee shall consist of a Chairman, the 
Secretary of the Association, the Treasurer of the Association, and 
a member of each section of the Association, with the President of 
the Association ex-officio. 

ID. Unless otherwise ordered by the Association, such committee 
is hereby instructed to keep the size of the annual transactions within 
the limits of four hundred pages ; and to this end to conform to the 
several following rules : 

a. Make summaries of such local and other addresses as are not 
of permanent scientific value. 

6. The Chairman of the several Standing Committees shall be 
notified by the Secretary that the reports to be presented by them 
shall include any material prepared by the several members of their 
committees and must be in the hands of the Publication Committee not 
later than thirty days before the succeeding annual meeting for pre- 
liminary printing. 

c. Such reports shall be printed for distribution to the members on 
registering at the coming meeting; but no report shall be printed 
unless in the hands of the Publication Committee, as specified above. 

11. The Publication Committee shall procure a copyright on the 
transactions in the name of the Association, and the committee shall 
have full charge of the publication of the transactions. 

APPLICATION FOR MEMBERSHIP. 

12. All applications for membership must be made upon the appli- 
cation blank of the Association. 

13. Persons not members, having prepared papers to be presented 
at the meetings of the Association, shall be proposed for member- 
ship at the first business meeting of the Association. 



Tiii BY-LAWS, 

EXPENDITURES. 

14. All bills connected with the publication of the transactions shall, 
upon the approval of the chairman of the Publication Committee and 
the Secretary, be signed by the President of the Association, and 
paid by check of the Treasurer directly to the party concerned; and 
the President shall not approve any bill, relating either to publish- 
ing or printing, without the approval first of the chairman of the com- 
mittee in charge thereof. 

15. Bills for current expenses shall be first approved by the Secre- 
tary, then sent to the President, and on his approval they shall be 
paid by check of the Treasurer directly to the parties interested. 

16. The actual and necessary traveling expenses of the Secretary 
and Treasurer to the annual meeting of the Association, and to one 
meeting of the Executive Committee, shall be classed as current ex- 
penses. 

RESOLUTIONS. 

17. All resolutions presented to the Association shall be sent to 
the Chair in writing, and referred to a committee without discussion. 

ARREARAGES. 

18. The arrearages of all members remitting their dues for two 
years shall be cancelled up to the date of the last payment, but they 
shall be entitled to the transactions of the Association only for the 
years for which they have actually paid. 

AUDITING COMMITTTEE. 

19. An Aliditing Ccnnmittee shall be appointed by the Chair to 
audit the accotmts of the Treasurer, and report upon the same. 



OFFICERS AND COMMITTEES 

OF THE 

AMERICAN PUBLIC HEALTH ASSOCIATION. 



OFFICERS. 

President Dr. Domingo Orvananos^ Mexico City, Mexico 

First Vice-President Dr. Qititman Kohnke, Covington, Louisiana, 

Second Vice-President, .DtL Robert W. Simpson, Winnipeg, Manitoba. 
Third Vice-President, ., Dr. Gardner T. Swarts, Providence, Rhode Island, 

Secretary Dr. Charles O. Probst, Columbus, Ohio. 

Treasurer Dr. Frank W. Wright, New Haven, Connecticut 

PRESIDENTS OF THE ASSOQATION. 

Stephen Smith, M. D 1872, 73 74 

♦Joseph M. Toner, M. D 1875 

♦Edwin M. Snow, M. D 1876 

♦John H. Rauch, M. D 1877 

♦ELisha Harris, M. D 1878 

♦James L Cabell, M. D 1879 

John S. Billings, M. D 1880 

♦Charles B. White, M. D 1881 

♦Robert C Kedzie, M. D 1882 

♦Ezra M. Hunt, M. D 1888 

♦Albert L Gihon, M. D 1884 

♦James E. Reeves, M. D 1886 

Henry P. Walcott, M. D 1886 

George M. Sternberg, M. D 1887 

Charles N. Hewitt, M. D 1888 

♦HosMER A. Johnson, M. D 1889 

Henry B. Baker, M. D 1890 

Frederick Montizambert, M. D 1891 

Fttix Formento, M. D 189Sr 

Samuel H. Durgin, M. D 189ft 

Emmanxtel p. Lachafblle, M. D 1894 

William Bailey, M. D 1895 

Eduardo Liceaga, M. D 1896 

♦Henry B. Horlbeck, M. D 1897 

♦Charles A. Lindsley, M. D 1898 

♦George H. Rohe, M. D 1899 

Henry Mitchell, Bl D 1899 

Peter H. Bryce, M. D 1900 

Benjamin Lee, M. D 1901 

Henry D. Holton, M. D 1902 

Walter Wyman, M. D 1908 

Carlos J. Finlay, M. D 1904 

FtJdXK F. Wesbroox, M. D 1905 

Franklin €. Robinson, LL D 1906 

♦ Deceased. ix 



STANDING COMMITTEES. 



EXECUTIVE COMMITTEE. 

[The Officers and Ex-Presidents of the Association and the Chairmas. 
Secretary and retiring Chairman of the Laboratory Section are ex-offido mem- 
bers of the Executive Committee.] 

ELECTED MEMBERS. 

Dr. Juan Guiteras Havana, Cuba. 

Prof. H. L. Russell Madison, Wia. 

Dr. William C Woodward Washington, D. C 

Dr. Richard H. Lewis Raleigh, N. C 

Mr. H. W. CLARK Boston, Mass. 

Dr. Jesus Monjaras Mexico City, Mez. 

PUBUCATION COMMITTEE. 

Dr. Josiah Hartzell Canton, (Miiow 

I^ C O. Probst Cotumboa^ Ohio. 

Dr. Prank W. Wright New Haven, Conn. 

Dr. Herbert D. Pease Albany, N. Y. 

The President ex-offido Member. 

LOCAL COMMITTEE OF ARRANGEMENTS. 

Dr. Edward Guion, Chairman Atlantic City, N. J. 

Mr. W. B. Dill Atlantic City, N. J. 

Dr. a. W. Bailey Atlantic City, N. J. 

Dr. W. Blair Stewart Atlantic Qty, N. J. 

Dr. Emery Marvel Atlantic City, N. J, 

Dr. Theodore Senseman Atlantic City, N. J. 

ADVISORY COUNCIL. 
United States: 

Alabama 

Alaska 

Arkansas 

Arizona 

California Dr. Edward M. Pallbtte, Los Angela. 

Colorado 

Connecticut Dr. Frank W. Wright, New Haven, 

Delaware 

Florida Dr. J. Y. Porter, JacksonviUe. 

Georgia 

Hawaii 

Idaho 



STANDING COMMITTEES, 

Illinois Pkof. Edward Bartow, Urbana, 

Indiana Dr. Eugene Buehuer, Indianapolis. 

Iowa Dr. A. M. Linn, Des Moines. 

Kansas 

Kentucky Dr. William Bailey, Louisville. 

Louisiana Dr. Quitman Kohnke, Covington. 

Maine Henry D. Evans, Augusta 

Maryland Dr. Jno. S. Fulton, Baltimore. 

Massachusetts James O. Jordan, Boston. 

Michigan C. E. Marshall, Agricultural College. 

Minnesota Dr. Henry M. Hutchinson, 5"/. Paul. 

Mississippi Dk. H. McH. Folkes, Biloxi. 

Missouri Dr. H. Wheeler Bond, St. Louis. 

Montana 

Nebraska 

Nevada 

New Hampshire Dr. G. P. Conn, Concord. 

New Jersey Dr. James A. Exton, Arlington. 

New Mexico Prof. John Weinzirl, Albuquerque. 

New York Dr. Chas. F. Roberts, New York. 

North Carolina Dr. R. H. Lewis, Raleigh. 

North Dakota Dr. H. D. Quarry, Grand Forks. 

Ohio Dr. Josiah Hartzell, Canton. 

Oklahoma Territory.... 

Oregon 

Pennsylvania Dr. J. E. Mears, Philadelphia. 

Philippine Islands Dr. Wm. E. Musgrave, Manila. 

Porto Rico 

Rhode Island Dr. G. T. Swarts, Providence. 

South Carolina Dr. Chas. M. Rees, Charleston. 

South Dakota 

Tennessee Dr. Marcus Haase, Memphis. 

Texas Dr. J. H. Smart, Dallas. 

Utah Dr. T. B. Beatty, Salt Lake City. 

Vermont Dr. B. H, Stone, Burlington. 

Virginia Dr. R C. Levy, Richmond. 

Washington Dr. James B. Eagleson, Seattle. 

West Virginia Dr. James H. Brownfield, Fairmont. 

Wisconsin Dk. C. A. H