4TI0NAL LIBRARY OF MEDICINE NLH DD12mM2 7 U.S. NATIONAL LIBRARY OF MEDICINE NLM001241427 YELLOW EEVER: (fe ft ITS NATURE, DIAGNOSIS, TREATMENT, Jf AND PROPHYLAXIS, ^'JS ^ 0° o QUARANTINE REGULATIONS RELATING THERETO, OFFICERS OF THE U. S. MARINE-HOSPITAL SERVICE (From Aunual Report Marine-Hospital Service, 1898.) TOGETHER WITH AN ABSTRACT OF THE REPORT OF THE MEDICAL OFFICERS DETAILED AS A COMMISSION TO INVESTIGATE THE CAUSE OF YELLOW FEVER. PREPARED UNDER DIRECTION OF THE SUPERVISING SURGEON-GENERAL. WASHINGTON: GOVERNMENT PRINTING OFFICE. 1899. LTD V V* n CONTENT S. 'J^y- -•■A- \ * ... ' /y4?J ^age. Lettkr to the Secretary of the Treasury.....Y?. A.l'1-..-i-ri.' ./cJ-- 287 diagnosis of yellow fever. s Circular letter, by Surg. R. D. Murray....................................xt>.. 289 Diagnosis of yellow fever, by Acting Asst. Surg. John Guiteras............... 296 TREATMENT of yellow fever. The treatment of yellow fever, by Surg. R. D. Murray........................ 301 Therapeutic treatment of yellow fever, by P. A. Surg. H. D. Geddings......... 313 HYGIENIC MEASURES TO BE ADOPTED BY PERSONS LIVING WITHIN AN AREA OF YELLOW-FEVER INFECTION. By Surg. H.R.Carter........................................................ 319 By P. A. Surg. Eugene Wnsdin............................................... 330 By P. A. Surg. H. D. Geddings................................................ 333 By Sanitary Inspector W. F. Brunner........................................ 335 PREVENTION OF THE SPREAD OF YELLOW FEVER. Measures to be adopted in towns infected with yellow fever, by Surg. H. R. Carter........................................."...............*............ 339 Measures to be adopted in a district threatened by yellow fever, by Surg. H. R. Carter........................................................'............ 358 Measures to be adopted in infected and uouinl'ected towns, by P. A Surg. A. H. Glennan.................................................................. 361 Measures to prevent the propagation of yellow fever from an infected to a non- infected locality, by Asst. Surg. Scaton Xorman............................ 367 Regulation of traffic to, from, and through infected towns, by P. A. Surg. J. IT. White.................................................................... 370 Communication with an infected town, by Surg. H. R. Carter................. 373 Detention camps and camps of observation, by P. A. Surg. J. H. White........ 378 ^Train-inspection service, by P. A. Surg. George B. Young...................... 389 Synopsis of interstate quarantine regulations, by P. A. Surg. J. H. White..... 412 MARITIME QUARANTINE AGAINST YELLOW FEVER. Precis of United States quarantine regulations to prevent introduction of yel- low fever, by Surg. Preston H. Bailhache................................... 415 A concise explanation of the maritime quarantine regulations of the Treasury Department, by P. A. Surg. J. H.White.................................... 421 POST-EPIDEMIC DISINFECTION. Circular letters issued by the Marine-Hospital Bureau relating thereto....... 425 THE BACTERIOLOGY OP YELLOW FEVER. Present status of, by P. A. Surg. E. K. Sprague................................ 428 AUTOPSIC FINDINGS. Value of, in cases dead of suspected yellow fever, by P. A. Surg. Wasdin...... 432 TRAIN INSPECTION. In yellow-fever epidemics, by Surg. H. R. Carter.............................. 441 THE ETIOLOGY OF YELLOW FEVER. Abstract of report of the commission of medical officers, Marine-Hospital Serv- ice, detailed to investigate the cause of yellow fever..................... Ill Conclusions of the commission............................................. VIII ADDENDUM. Shipment of merchandise from a town infected with yellow fever, by Surg. H. K. Carter............................................................... 5-15 ARTICLES ON YELLOW FEVER: ITS NATURE, DIAGNOSIS, TREATMENT, AND PROPHYLAXIS, AND UUARANTINE REGULATIONS RELATING THERETO. 285 YELLOW FEVER, ITS NATURE, DIAGNOSIS, TREAT- MENT, AND PROPHYLAXIS, AND QUARANTINE REGULATIONS RELATING THERETO. The following articles and letter of transmittal were published and transmitted in book form to quarantine and health officers, and others: LETTER OF TRANSMITTAL. Treasury Department, Office of the Supervising Surgeon-General, Marine-Hospital Service, Washington, JD. C, June 15,1898. To the Honorable The Secretary of the Treasury. Sir : I transmit herewith, arranged for publication with your approval, a number of articles by officers of the Marine-Hospital Service relating to yellow fever. These articles have been prepared by my direction by the officers of the service, whose valuable work in connection with yellow-fever epidemics has made them particularly well qualified for conveying the information herein contained. No similar work has ever been published, and while it is to be hoped that with the advancement of scientific medicine a positive knowledge of the true nature of yellow fever will before long be acquired, and that the measures for its prevention will be more accurate and certain through this acquired knowledge, yet the information herein given is at the present time pertinent and necessary. It is proposed to transmit this volume not only to the medical officers of the Marine-Hospital Service, but to State and local quarantine officers and to others to whom a plain statement of the method of diag- nosis of yellow fever, its treatment, and the measures for the preven- tion of its introduction into the United States, and for its suppression when it has passed the boundaries of this country, will be of immediate value. I have the honor to remain, respectfully, yours, Walter Wyman, Supervising Surgeon-General, Marine-Hospital Service. Approved: L. J. Gage, Secretary. 287 CIRCULAR LETTER ON DIAGNOSIS OF YELLOW FEVER ADDRESSED TO CERTAIN PHYSICIANS ON THE GULF COAST. By Surg. R. D. Murray. Mobile, Ala., May 28, 1898. Dear Doctor : I have prepared a short letter on the importance of early diagnosis of cases of yellow fever, which I have arranged to send to every physician on the coast. As you are associated with me officially I will repeat to you what I have written them and add some arguments to increase your usual interest and perhaps give you some extra aids in prompt diagnosis. ******* DISCOVERY OF FIRST CASES ENABLES SUPPRESSION OF EPIDEMICS. It is well known that first cases can be prevented from spread of dis „ , ease can be pre- conveying the disease. Every prevalence for years lias vented. shown this, and the results of prompt and proper action at rerkinston, Miss., and Franklin, La., and in other towns during the past season should stimulate every physician to "catch on" to the first cases. A man is not a scoundrel because he suspects a case, nor a fiend because he finds a first case. But a doctor is culpable if he slurs over a case and hopes against his judgment in order to save his precious record with a vacillating public. I can not quite agree with Dr. Guiteras that we can inure our people to prompt announcements of suspicion and actual cases, but I know the people will fully trust us if our words and conduct are apparently in behalf of their final interest. It is easy to call every illness "yellow" a month after other towns have quarantined, but it is not easy to decide on an individual case when no warning has been given and no source of infection is read about every morning. 289 290 MARINE-HOSPITAL SERVICE. DO NOT BE DILATORY IN REPORTING FIRST CASES. It will not do to advocate the notion that any place is free from the chance of infection, nor to insist that all the old-time symptoms must be present, with a death or two added, before one suffers with a twinge of honesty and risks his present prosperity by doing what should be done with a first case. False alarms Scares and false alarms are hurtful, but they do not "Jcted caseas8.neg usually kill. I would as little trust an alarmist as one who "would die before he would report a suspicious case." Duty to one's self, to one's family, and to all communities demand careful observation of every fever case, with proper action in case there is reason to suspect yellow fever. A lot of "rejected" cases have spread the infection. It is established that only yellow fever makes yellow fever, but it is not so well known that a mild case of yellow fever is as dangerous as a case that ends fatally in sixty hours. I think the mild case much more dangerous than a " genuine" one. "MILD CASES" ARE DANGEROUS DISEASE SPREADERS. Mild cases most Now, to quicken your senses, to increase your usefulness, saniury^st'and- and to assist you in giving your best efforts to your people p,"nt" I presume to give you some hints as to discovery of first cases. I do not claim to be expert, but I have a long record of lucky decisions which warrant me in speaking freely to those who have been so fortunate as to have an abiding place or a place called "home." I am not infallible, bnt I am in earnest in my desire to do good to others and to save my people from the horrors of an epidemic and the provo cations of quarantine. Mild cases of yellow fever are the mildest cases of disease that can be seen. Walking cases, nursing cases, and transient cases are more common than doctors realize. Mild cases transmit infection as easily and effectually as bad cases, and thus make "genuine" cases in the proper persons. Mild cases are not so quickly apprehended as severe ones, but they can be isolated more easily and at less expense thau bad ones. Mild cases are the cases to look out for. It is not true that a prevalence of the disease must be Don't wait for begun by a death or black vomiting. It is true that a foreaunouncing. walking case introduced the disease into a village last year where the earmarks of yellow fever were shown the best, and the results were worst in comparison with all other infected towns of which there is a record. Hibernation. I do not believe in recrudescence or hibernation of the fever in small towns or in the country, but many health MARINE-HOSPITAL SERVICE. 2ulse, temperature, and nausea was of same sort—his patient died. Third. If called to any person who sickened in the night or early morning and complains of headache and malaise or body and leg ache with some stomach distress, suspect the case and make inquiry as to where he got it. A chill initial chin. is called for in the books, but one sufficiently severe to be told of to you is rare; there will be a story of chilliness or waking up in discomfort. Distress in the early morning is a rule; a failure to eat a good breakfast is a bad omen, but hints at a mild case. Fever of 101 to 103 with pulse of 110 to 120; cutting pain through the forehead, with aching eyes; fullness of eyes with some pain and suffusion, gener- ally with injection are probable signs. The back and thighs will be sore in a severe case; there is some soreness in the mildest cases. Severer cases will have pain in Duodenal x pain. back of neck and in calves. Ask few questions. Press firmly and deeply over where you think the gall bladder lies and you will generally elicit a squeak—don't men- tion it! The face will be full and less mobile than in health with a fullness of the upper lip rendering a smile less swollen lip. gracious.* These signs depend somewhat on an acquaint- ance with the person. The cheeks will be of a dusky red color—more or less—and depending on the patient's color; "Passed Assistant Surgeon White reports that he made two diag- noses with the swolleu upper lip as the first noticeable symptom. 292 MARINE-HOSPITAL SERVICE. sometimes faintly purplish. Sweating will diminish these face signs in a few hours. The injection of the sclerotics will increase until after thirty-six hours some yellowing may be observed; in children, the eyes will remain pearly excepting the suffusion and the red streaks; some excep- tions. Frequently pressure on the eye balls will cause complaint—sure to do so in bad cases. Primary complete Constipation 0r semi constipation is always present. I never heard of a diarrhoeic person being attacked. The cases you hear of will bear explanation or further inquiry. sluggishcimi- The circulation in the skin will be faulty; the skin may be streaked by the passing finger or paled for a quarter of a minute by pinching; this is a good sign, and best after thirty-six hours. The skin will be moist, as a rule, and will keep moist to the end, whether medicine is given or not. In diagnosis early or for first cases don't look for yel- low skin. The pain of back and legs will be in the muscles and not in the bones and joints; you can make this point by care; squeeze the thighs or calves. Note that unless there is nausea or headache the person lies quiet. (Vide Pnise rate. dengue.) There will be less rapidity of the pulse than the height of fever warrants, judging from lung disorders and enteric fever. Do not blunder over one who smokes too much, for his pulse will count less when he reduces his daily quantity or has to quit smoking. Also, consider the effect of your presence on your patient's excitability. The pulse should be counted without the patient's knowledge. After two and a half or three days the pulse will fall below 70 and later on lower yet; fright and irritations will pre- vent the slow beating from being observed. The above signs are sufficient to warrant isolation and disinfection of all discharges, clothing and discarded bed- ding, even if there is no known fever within a thousand miles. Also, warrant for sending for me if you need me. Please note that these signs may be in minimum—any old nurse can comprehend the maximums. After sixty hours there should be some albumen in the urine—it is possible urine. for no urine to be procured and that no albumen is found. In women urine is not reliable; in children it is difficult to get. But it must be obtained. Do not confound albumen with mucin and do not treat other symptoms lightly because you do not get albumen. stools. At this stage some brown mucus, or black discharges, or "bismuth" stools maybe looked for rather early in mild cases—may be late in severe ones. This is only confirma- tory; rather late for diagnosis. So with nausea and vomit ing. Mild cases suffer with distaste for usual food only. MARINE-HOSPITAL SERVICE. 293 Of course there is anorexia from the beginning; usually Anorexia. vomiting of the last food taken; bile will be vomited early if the early nausea is not checked; no bile will be vomited after about thirty-six hours if the patient has had proper bowel actions. After vomiting of last food taken and a little bile the^gJuJ' reglir vomit will usually be white, and will remain so until blood oozes into the duodenum or stomach. As to black vomit- ing, do not be hypercritical, the chances are vastly in favor of yellow fever. Please notice the hiccough and retching, and listen to the black fluid regurgitating through the pylorus into the stomach. But this is rather late for diagnosis of a first case, and is not applicable in mild cases. Mild cases demand examination of the feces. Always con- sider the chances of infection to and from your patient. DIFFERENTIAL DIAGNOSIS. Yellow fever is like a language; you should know some- Differentiation thing of others. Differentially considered, dengue has afrom deng116- demonstrable rash in the fauces always, between the shoulder blades, generally, and often over the big joints and on the trunk. The pains of dengue are in the bones and joints. A dengue patient is in pain and can not lie still— he don't want to get up. Yellow fever pains, except the head, are in the muscles, and the patient after four or five days is comfortable in bed, but wants to get up and do a lot of work. He gets up only to faint and return to bed. The dengue patient gets up, but keeps on growling about his pains. This is a late distinction, but it is valuable. Malaria is usually prodromed for some days by malaise, From malaria. loss of appetite, discontent, and a general tired feeling. It nearly always attacks in the daytime or when the victim is at his work, and is ushered in with a positive chill. Consti- pation is the rule, but not so marked a feature as in yellow fever. The malarial tongue is full—swelled—too big for the mouth—tooth marked and heavy coated, with white edge and yellow or dirty top area. A yellow-fever tongue is rarely indented—if it is, there is malaria in the patient; it soon shrinks and gets a red edge and red tip; the red tip is diamond-shaped, the front of the diamond being made by the edges. I do not know about the congestion of the ves- sels under the tongue in yellow fever and the paleness of same in malaria. You, maybe, will have a chance to make observations. Malarial vomiting is attended with more bile than is usual in yellow fever; this is a guess-point in diagnosis, but 294 MARINE-HOSPITAL SERVICE. the statement is true. Malarial attacks generally permit the fever to decline without medicine and the fever will not cease unless medicine is given. Another good point in differentiation is the presence or absence of labial herpes in convalescents, particularly in young persons; herpes does not occur in yellow fever cases; it is common in mala- ria. Of course, this is a late sign so far as the individual is concerned, but it has aided me much in giving a hint as to what the other sick one suffers with. Malaria and As a hint for you to consider in deciding on the first case permit me to say that the yellow fever patient gets up "all knocked out; was never so weak in my life after so short a sickness;" the dengue patient gets up "sore and tired; ache all over yet;" the malarial patient is able to work every other day. Another hint, but late for diagnosis: the yellow fever patient is mentally alert; the dengue patient complains much; the malarial don't care much. These points do not apply to individual cases, but are valuable if you have a number of patients to visit. I have given you sufficient reasons, symptoms, and signs to either put you on your guard or to permit you to act for the benefit of all. Yellow fever is not a "bogey," neither is it uncontrollable. I hope you will duly consider the possibility of cases occurring in your rounds and also the importance of early action in first cases. I am at liberty to visit you on call by letter or telegram at any time at no expense to you or your clients, and to the best of my ability and the limit of my time I will be glad to serve you. Please notice that rumors of fever are plenty here and there, and consider that a prompt denial will oftentimes prevent a panic; also a prompt notice will save lives by permitting orderly exit from danger centers. blood™"1**101101 ^ne serv*ce bas arranged to have samples of suspected blood examined by the new agglutinative test by Dr. Archi- nard, of New Orleans. Samples of malarial blood can be examined in the hospital at Mobile. If you wish special instructions please make request of me. In return for what I hope to do for you I request that you send me, at least, a weekly report of health conditions in your region and that you inform me in detail of all rumors and suspected cases. As I am pretty well ac- quainted with the town and people it is needful that I get names and addresses. Sometimes it may be advisable for me to go in person, and if 1 know the residence can save MARINE-HOSPITAL SERVICE. 295 much time by going direct from depots. Again, if I have names I can from time to time refute the secondary rumor without doubt as to persons and places. I fear I have tired you, but I am so desirous of enlisting your aid and arousing your interest in this very important matter that 1 am willing to be blamed for prolixity. Command me in any way, personal or professional. Yours, sincerely, R. D. Murray, Surgeon, Marine-Hospital Service. DIAGNOSIS OF YELLOW FEVER. By Acting Asst. Surg. John Guiteeas.* When ordered by the Government to inspect points in the South as a yellow fever expert, I have assumed it to be my duty, not solely to report upon the diagnosis of individual cases, but to form an opinion as to the actual state of the outbreak, whether it be possible to localize it and stamp it out; or, on the other hand, whether the outbreak is beyond the control of our means of sanitation. I have even deemed it possible, when yellow fever was not found in one of the Southern States, to predict whether it was likely to break out or not during the summer. The diagnosis, then, from my point of view, is of two kinds, namely, as to the epidemic status of the locality, and as to the individual cases. A careful study of the conditions existing in Cuba during the earlier part of the present summer made it very probable that yellow fever would extend from that island to this country. There probably has never been so much yellow fever in Cuba as there has been during the present season. DETERMINATION OF EPIDEMIC STATUS. First, as to the epidemic status: There are several features charac- teristic of the community where yellow fever is prevailing that make the fact known to an experienced observer, even when willfully or other- wise its presence is denied by the physicians and local authorities. Without seeing a single case of the disease I have often made up my mind as to the existence of yellow fever from the reports of prevailing sickness given by the physicians. In the first place, many cases of acute febrile attacks of mild charac- ter are reported and an attempt is made to show why they can not be cases of yellow fever. They are usually ascribed to an epidemic of dengue or to a prevailing malarial infection. The report that some of these cases have.shown albumin in the urine becomes extremely suspi- cious. Fatal cases are reported, but some intercurrent disease or pre- viously existing condition is supposed to be the cause of the fatal ter- mination. On investigation it is found that most of these cases are of * Acting assistant surgeon Marine-Hospital Service during the yellow fever epi- demic of 1897. 296 MARINE-HOSPITAL SERVICE. 297 young people. Very often one or two physicians are found in a locality who positively declare that they have seen extremely suspicious cases or positively diagnosed such cases yellow fever. These physicians are generally younger members of the profession who have never seen the disease. It is a matter of experience that usually the older physi- cians acquainted with the disease in former epidemics fail to recognize these early cases and are the last to become convinced of the existence of the disease. Convalescents from yellow fever may be discovered also on the streets. An icteroid hue of the eye persists usually for some time after recovery, and I believe not rarely shows itself also as a premonitory symptom of an attack. Another aid toward forming an opinion is found in the study of the mortuary records. A comparison should be made between the present time and the preceding year. Sometimes this investigation is in itself enough to give strong presumptive evidence one way or the other. The characteristic feature of the mortuary records is the increase in the number of deaths among the white population. The class of the white population especially affected varies according to the manner of intro- duction of the disease. It may affect especially the sailors, or children, or railroad people. Even when there is no marked increase of the death rate of white people we may find causes of death that are suspicious. For instance, young adults dying of congestion of the stomach, con- gestion of the brain, purpura hemorrhagica, meningitis, Bright's disease, bilious remittent fevers. DIAGNOSIS OF INDIVIDUAL CASES. The diagnosis of individual cases of yellow fever is, in my opinion, very easy. There is no acute febrile disease in which there are as many signs that may be called pathognomonic. The diagnosis of the disease rests upon three such symptoms; namely, the facies, the albuminuria, and the want of correlation between the pulse and temperature. I rely mainly for my diagnosis upon the facies, which I consider extremely characteristic. However, as I consider it my duty to convince the local practitioners of the existence of the disease, I make it a rule not to announce officially the existence of yellow fever until I have been able to show the presence of albumin in the urine. My own mind, however, is generally made up by the simple inspection of the patient, and I almost invariably find my opinion confirmed on the second, third, or fourth day by the appearance of the albuminuria. FACIAL APPEARANCES. The appearance of the face is that of typhus fever during the first forty-eight hours of this disease or like that of measles before the eruption breaks out, with a more or less pronounced icteroid hue. It 3934----2 298 MARINE-HOSPITAL SERVICE. is the latter feature, I believe, which gives the face its characteristic appearance. In the first twenty-four or forty-eight hours it is by no means a distinct jaundice. The physician to whom I am showing the signs of the disease usually expresses surprise when I state that jaun- dice is present. It is, of course, best noted in the sclerotics. It is hidden, however, by the marked injection of the smaller vessels. The icteroid hue is often better seen at some distance from the patient than when the eye is closely inspected. It seems to show itself in waves with the different movements of the eye. Possibly this is the result of transient contraction of the vessels of the conjunctiva or of the different angles of reflection of the light upon the eyeball. In severe cases, and on the secoud and third day of the disease, the jaundice becomes more prominent. It will show itself in distinct waves as the capillaries of the skin contract with the movements of the facial muscles or it may be brought out by taking up a fold of the skin between the fingers, when the contrast between the yellowish, anaemic skin and the surrounding congested areas will become well marked. Later on there may be well marked jaundice. By this time usually the florid color of the face has been replaced by a more dusky hue. In the later stages of the disease there are also characteristic features of the facies in grave cases. The mind is usually clear, and there is a peculiar alertness and watchfulness that is not seen in other acute febrile diseases. The physicians who have not seen yellow fever for many years seem to have this peculiar phase of the later stages of yellow fever impressed upon their minds. This, however, is too late a diagnostic sign for my purposes, and besides it does not appear in mild cases of disease. ALBUMIN. The albumin appears in the urine usually on the third or fourth day of the desease. It may be very transient albuminuria. In many mild cases the albumin is present only in the urine passed in the even- ing of the third or fourth day. In many cases it is only a trace, but even then by a careful centrifugation granular casts may be found in the urine. lu severe cases the quantity of albumin may be very great and the different forms of casts characteristic of acute paren- chymatous nephritis are found in abundance in the urine. Now, there are many acute febrile diseases in which albumin may be found in the urine, but in none of them so constantly nor so early when in connec- tion with such mild manifestation of the toxaemia. In all such diseases the albuminuria will be found at the end of the first week or during the second week, and as an evidence of persistent high temperature and intense toxaemia. Cases of yellow fever corresponding in intensity with these present at the same time such characteristic features, that it is impossible to mistake them. The difficulty of diagnosis can only be met with in connection with mild cases. MARINE-HOSPITAL SERVICE. 299 PULSE AND TEMPERATURE. The third characteristic symptom of this disease is the want of cor- relation between the pulse and the temperature. This may be a rather late manifestation and may be absent, especially in children. It should be remembered that the characteristic feature of yellow fever in this connection is not a slow pulse during the convalescence or even during the defervescence of the fever. The characteristic features is that quite often we find that at the same time that the temperature may be rising the pulse will be falling. On the third or the fourth day of the disease, for instance, with an evening exacerbation of half a degree or 1° of temperature, we may find that the pulse is perhaps 10 beats slower than in the morning. I have seen, however, the same discrepancy in cases of true dengue, and in the Tropics also, in connection with other febrile diseases. Still, this is exceptional. In dengue the excessive fall of the pulse presents itself with a distinct defervescence of the tempera- ture, and 1 suspect that many cases that are reported from Cuba of slow pulse in typhoid and malarial fevers may have been cases of yellow fever. USE OF THE MICROSCOPE. An erroneous belief has prevailed throughout the South, especially among physicians who were not practical microscopists, that the micro- scope should be an important aid in the diagnosis of yellow fever. It appears that poorly prepared abstracts from the work of Sanarelli have led many to believe that a characteristic feature; the bacillus of Sanarelli itself, was found on examination of the blood. Now the truth is, that even with the assistance of post-mortem examinations, Sanarelli was able to discover his bacillus in 50 per cent only of the cases of yellow fever. He would be a poor clinician, indeed, who could only diagnose about one half of the cases. The truth is, however, that during life the microscope could not establish a positive diagnosis. As far as our present methods go, it would be impossible to distinguish between a drop of yellow-fever blood and blood from a healthy man. Negative evidence may be presented by the microscope. The pres- ence of the Plasmodium malarias, for instance, would prove that a case was suffering with malarial poisoning, and presumably not with yel- low fever. But the differential diagnosis between these two diseases is usually easy. The bilious remittent fever, that in our old text-books of medicine occupied a conspicuous place in tables of differential diagnosis with yellow fever, has practically disappeared from the Southern sea border since yellow fever ceased to be an endemic there. It was, in fact, the yellow fever of the natives and of places in the interior. The former were supposed to possess in a certain degree immunity against yellow fever, and the disease was believed to be restricted almost to the littoral. The Plasmodium has been found in the blood in cases of yellow fever. 300 MARINE-HOSPITAL SERVICE. The mistake made by the board of experts of New Orleans, when they failed to recognize the existence of yellow fever at Ocean Springs, was due to the finding of the Plasmodium in at least two of the cases. DENGUE AND YELLOW FEVER. The prevalence of a widespread, mild, epidemic fever during the present outbreak of yellow fever has been undoubtedly a source of doubts and difficulties in connection with the diagnosis. Many of these cases were found to exist in houses where cases of yellow fever were present at the time, and I must confess that it was impossible to discover in them any of the characteristic symptoms of yellow fever. Many of these cases had a distinct eruption and must be looked upon as cases of dengue. This fact may bring forward new problems as to the relations between these two diseases. From our present point of view, we can only state that yellow fever appears to spread more easily when there is an epidemic of dengue, prevailing. All evidence goes to show that a previous attack of dengue does not protect against yellow fever, and we must look upon the former as an entirely distinct disease. IMPORTANCE OF DIAGNOSIS OF FIRST CASE. I can not insist too much upon the importance of the diagnosis of the first case of yellow fever in a locality. Undoubtedly the cause of the epi- demic of yellow fever is to be found in the introduction into a commu- nity of cases that are not suspected to be yellow fever. This probably occurs most frequently in connection with individuals of the colored race. The disease in them is usually very mild, and their movements from place to place are less likely to attract the attention of the health authorities. I have no hesitation in saying that if the first case of yel- low fever introduced into a city were always recognized, the spreading of the disease would be invariably prevented. ' I will conclude this report by inviting your attention to the fact that the movements of the yellow-fever expert have been frequently inter- fered with by the fears of the communities that he might convey the disease from place to place. In moving from one locality to another I took all the necessary precautions and felt absolutely sure that I could not be a source of infection. 1 was immune and traveled with very little baggage, which I frequently changed. Yellow fever has never been carried from one locality to another in this manner. This fear of the communities was in part genuine and due to igno- rance, but was also in part a pretended fear of those who knew better. 1 have finally to state that I have received every attention and assistance from the local health authorities in all the cities that I have visited. TREATMENT OF YELLOW FEVER. By Surg. R. D. Murray. I have seen yellow fever in twenty-one summers (including 1870) and in every month except February. The elimina- tion of yellow fever from our nomenclature will follow when there is a proper conception of the influence of clothing, bedding, and unclean bedrooms as transmitters. The dis- ease is air borne for some distance; the infection is stronger at times and places than at others; whether it is intensity or quantity I do not know; it may be diluted, and is trans- mitted by clothing, bedding, and related articles. Hair from the dead has transmitted it; corn sacks, blankets, and old newspapers have carried it; mountains of filth will not produce it; they may give it a new nidus or garden from which it goes out "seeking whom it may devour." The cleanest town in the South may have a severe prevalence if the people insist on disobeying the advice of the health officials. In 1875, as a result of several post-mortems and an attack certain ideas of the disease, I came to the conclusion that yellow fever was as au inflammation of the duodenum, primarily, and wanted to call it epidemic duodenitis. Many post-mortem examina- tions have since convinced me that the primary lesion is in the duodenum, and I insist that the mildest cases have a lesion in the organ referred to that can be demonstrated, if due care is taken. The same after-death examinations, as well as bed side experience, have shown me that the death- dealing process was not the "inflammation" that I was taught thirty years ago to understand as inflammation, i. e., there is no proliferation of cells or tissue and no new growth. There is a primary involvement of the duodenum and .D"°d.nai on the symptoms of the disease follow generally in regular order. The mildest cases have a tender duodenum (if you know how to press) and a little back ache; note how close 301 302 MARINE-HOSPITAL SERVICE. stools to be ex- to the spinal column the duodenum lies. If the stools could be all and carefully examined sometime a mass of white mucus with a black or brownish middle will be found. May- be there will be a stool of black mucus once only. It is fair to say that there is always a clay or bismuth stool with the mucus clot stained with black. The ubloody sweat11 from the duodenum, and in bad cases from upper intestines and stomach, starts in the duodenum. Fulminant Sometimes the symptoms come in such quick succession cases. t^at we tllink the attack is necessarily fatal. Many times in such cases we have no chance to ask the patient how matters fared with him twenty-four or thirty-six hours before, when he was sick, but would not admit the fact. Walking cases are as common in this as in the other bed diseases. I have known a man, suffering with headache for three days on duty, to vomit black on the stairs on the way to his deathbe I. I have given immune certificates to persons who never went to bed. choice of a In ordinary, the patient should like the medical attend- piysician. a^ jf tiie physician is distrusted, he should be called off or feign illness, so that a favored one can be called in. Consultations over the patient are injurious. I would have the doctor do his share in keeping up courage, hope, and life-purpose in his patient; to minimize the aches, distress, and fears, and to carry his patient's mind away from the note with its dreads to to-morrow, with its reward or re- Psychoiogicai venges. Several people are living now because, in their desire to take vengeance on me for what they thought was my indifference, they forgot themselves and their conditions. effects NOT EVERY CASE NEEDS TREATMENT. Mild cases It is fair to say that of one hundred cases seventy-five need only to be let alone by the extra attentive nurse or friend and heroic physician. They will get well under any plan of treatment and under miserable local conditions; notably so with infants, who, if they die, are generally sacrificed by curds or some acrid medication. These seventy-five are "cases" and should be recorded, but only for sake of good records and to establish their immunity. They should receive only what occasion de- mauds and be watched for untoward incidents. Of the twenty-five some will need formal attention and careful procedure; others will die in spite of all reasonable aid. Some vicious habit or chronic disease will add to the trouble, and in some cases uncontrollable fear will insure a fatal result. Age limits My oldest patient to get well was 109 years of age; the MARINE-HOSPITAL SERVICE. 303 youngest was 52 hours old when she threw up black vomit. One of my children had black vomiting five days after she was born. I know of the recovery of a chronic chronic dis Bright's disease sufferer; of a morphiomaniac's recovery, ST&ta£.habit" and last summer gave a diabetic doctor such cheerful council that he had a severe attack without fatal result, and has been in better health since than before. I cite these cases to show the triviality of the disease if " taken right and in time." I have often said " Yellow fever is the Yeiiow fever a most honest, most trivial, and cheapest to treat of all dis f,ankdisease- eases that kill." It is "honest" because it comes with definite signs and leaves no trace, always insuring the afflicted one that he is hereafter immune; it kills, if at all, in a few days, and is merciful in the killing, as the doomed one is usually conscious to the last and does not linger as a consumptive or one afflicted with cancer; "trivial" be- cause 50 per cent of those who suffer with it are scarcely aware of serious illness, and have no sequels to make them miserable the remainder of their lives; also, because it rarely takes off children, and they, by reason of the attack, gain the privilege of living in its habitat; "cheapest to cheapness of ieat" because it is so; the delicacies, liquors, etc., some- times provided are generally consumed by the disbursers and attendants and are not fairly chargeable to the sick; the medicine actually needed costs very little. TREATMENT OF YELLOW FEVER. When called to a man (most of my work has been with Tnji;ial signs v ^ calling tor men) who has had a chill some time during the previous prompt treat- ' x ruent. night, has a pulse of 100 to 112, with temperature of 101.5° to 103°, headache (cutting across the forehead), backache running down into the thighs, sore muscles, skin hot if you hold your hand on it a while (hands and wrist not hot to gentle touch), anorexia, white tongue (may be a yellow cen- ter far back—the red edges and red diamond on tip will not show at once), suffused eyes, and notably or faintly purpled cheek bones with semipuffed upper lip, the hun- dred chances are you have a case of yellow fever.* * Yellow fever usually begins at night when the person is in bed and iu a relaxed conditiou; malarial fever usually attacks when thf person is at work. Regardless of books, I reasoned this point out at a diagnostic fact over twenty years ago, and am flattered that otheri discovered it too. Night watchmen have sickened in daytime. A restless early morning in bed with little desire for breakfast is a fre quent history; everything eaten as breakfast does harm in such casei Dengue pains are worst in joints—yellow fever soreness is betweei the joints. As malaria coincidents there is no rule for differentiatioi excepting perhaps the attack in bed or at work. 304 MARINE-HOSPITAL SERVICE. initial purge Give three or four compound cathartic pills at once and necessary. ag gooi) ag p0Ssii,ie give a hot foot bath (an all-over bath is better, but is not always possible), with or without mustard and salt. Mustard at this time is really a nonessential, but sometimes the patient thinks it is the proper thing; so with the table salt. As to the cathartic: calomel at first is too slow and usually must be sent for, the pills contain enough of it and are in your vest pocket. Every yellow fever doc- carry purga- tor should carry first doses of compound cathartic pills, pocket.in y°ur compound acetanilide tablets, and such other pocket reme- dies as may be needed on emergency. A parade of a small medicine chest is not advised. Do not begin to make a reputation for wonderful medical skill now. Dwell on the dengue symptoms and the signs of malaria, and without great formality convince the patient that "it is not yellow," Don't let the but do not say so. Keep back information about the FsVery in"0' e actual temperature all the way through, but tell them about the height of the fever. No patient should ever hear that his fever went above 102° until after he gets well. (I saved a doctor once by hiding his thermometer and using my French scale, which he could not translate.) coal tar dcriv- Give as soon as convenient, or, if fever is above 102°, at once, any coal-tar derivative in 7£-grain doses, with some bicarbonate of soda and caffeine. The antikamnia com- pound is a good one. If powders or tablets are objection- able to the patient, give autipyrine. I nearly always use acetanilide with soda and caffeine. Have no objection to any, except that I like cheapness and simplicity. After the bath and a good sweating, under blankets, for from four to six hours, rub dry and cover with two blankets. (The clothing should have been hung outside of the house Disposal of or dumped into a tub of water; dispose of the wet sheets ing. and blankets in like manner. When washed they are ready for use again; this hint in regard to prevention of infection.) If a person likes blankets ue^t the skin, so much the better for prevention of skin shock. Quilts and counter- panes are objectionable because of the nasty odors they retain. Repeat the coal tar derivative every three to six hours if fever keeps above 102°; give for effect and not pro forma. Have the face and hands wiped frequently, give orange-leaf Dnnka. tea, Apolliuaris water, lemon grass tea, hot lemonade, gin ger ale, small sij)s of ice water, and other drinks ad libitum, but not ad nauseam. Always start with the quantity you are willing the patient should have, and let him drain the cup; this particularly in the case of water. Try to supply MARINE-HOSPITAL SERVICE. 305 fluid for the three or four days' sweating that will be kept up. Apolliuaris is good on account of the common salt it contains; for some reason common salt is a good thing to Common salt. give and has been grossly neglected. Passed Assistant Surgeon Smith, on duty at Ship Island last year, used it, methodically, about a drachm a day, with excellent results. I have always given much salt in the food, but never gave it dry. No spirits of any combination should be even thought of for the patient. The first bowel actions should be had sitting up for the, Bowels to be . . kept open. first thirty-six hours or so for physical reasons—and for mental reasons, too. If the bowels are not freely and com- fortably relieved within six hours, give a small saline, and let the patient choose the kind. Castor oil is the best thing to give, but many so bitterly object to it that it is not advisable in all cases. Sulphate of soda is the next best. As a rule, the magnesias cause griping and flatulence. Seidlitz powders are good, but cause some gassiness and uneasiness—however, the patient should have his choice, as he feels bad at this time and an insistence on one thing magnifies his dangers, in his own mind. Sometimes an extra pill will do the hoped-for duty. I do not object to sirup of figs, castoria, or other cathartics—only want re- sults. If nausea is present an enema is in order. DIET (OR LACK OF IT) A MATTER OF FIRST IMPORTANCE. Do not deny food but give the milklike water of long- Diet boiled hominy or corn meal, salted and strained through cheese cloth. Keep the pot boiling all the time! Rice water is good. Sago is better, as it is slightly aromatic, but my experience has been with the poor. Mexican atole is excellent—made from crushed lye-hominy. Sometimes it is well to' flavor with a bit of meat juice. Chicken soup, with rice, so thin as to be equal to starch water, is not to be tabooed. The point is to give no food for four or five days, but to appear to give food regularly. Often you must promise food and abuse the nurse in the presence of the patient for the nonfulfillment of your orders, and then apologize to the nurse outside. If the first form of antipyretic tires the patient, or seems Antipyretic*. to him to do no good, change the form; here lactopheuinor amonol or antipyrine will serve as substitutes; may be cap- sules of the same as you were giving will accomplish the object sought. Do not forget the bicarbonate of soda and caffeine. Remember always that the patient is sick; not the doctor. 306 MARINF.-HOSPITAL SERVICE. Conjoint ii.foc- Here I must advise you to carefully consider the question tion malaria and ^ ^ l yellow fever. ()f malaria, for the Laveran organisms can do their work while the yellow-fever germ is also active. In a malarial region it is advisable to give from 40 to 60 grains of a cinchona salt in the first twelve or twenty-four hours, in order to ward off or forefend a malarial chill which may occur during the period that should be yellow-fever con valescence. I lost two patients with malaria when they were convalescing from yellow fever twenty years ago. In nonmalarious regions, or on shipboard, no routine is necessary, but in Mobile, New Orleans, Scranton, or in the back country, care must be exercised. The preliminary cinchonidia or quinine may be given with the compound cathartic pills, and it is believed that early cinchona aids in producing calm in or to the patient. Do not give all at once, and do not expect the cinchona salt to act instead of the coal tar products. Give them together, or nearly so. High enemata. After thirty-six hours or so give an enema every day and try to have a bed pan used. It is impossible for many to use abed pan; then have the patient helped up on a vessel or commode. Instruct the attendant that the patient must be helped, and not use his own strength. The patient's own muscular force must be saved somehow. If the expected action does not occur, give another enema with a long tube. A short catheter of 30 or 32 caliber should be in every yel- low-fever doctor's pocket, which, attached to an ordinary self injecting syringe, makes a "long tube." I and many others have saved lives by use of a large catheter. The catheter may be washed and used again. Do not fear infection. Enemas may be made quickest with soapsuds and mo- lasses; ordinarily soapsuds will suffice, later on not too strong. Consider the stools, and if they are not sufficient in quantity, and you have reason to believe there is a faecal matter high up, think of giving a dose of castor oil 2 drachms and olive (not lard) oil, 6 drachms, more or less as occasion seems to demand. Lemon juice is the best vehicle for the oil. Perhaps it will be better to tell the attendant to give the potion as if you knew nothing about it. Patients like to circumvent the doctor! I believe that oil catharsis, small doses of castor oil and large doses of sweet oil will not produce the frequent contractions of the colon and the common intussusceptions of the small intestines that are found post mortem. Constant peristalsis downward is necessary; harsh purgation is to be avoided. This remark does not refer to the primary emptying of the bowel, but MARINE-HOSPITAL SERVICE. 307 For nausea Cocaine. Keep surround- ings clean and to repeated emptying efforts by calomel or pills or salts to insure a daily bowel movement. Olive oil does not cause the bowel strictures that I dread—I think small doses of castor oil will not. I prefer to mix them, and have saved many lives by this plan. For nausea use ice about the head, face, and neck. A piece of ice, wrapped in a cloth, rubbed rapidly about the lips, temples, and neck will keep down almost any offensive dose. If the nurse can not do it effectively or does it rudely do it yourself. Give cocaine in one-fourth grain tablets floated down the throat, repeating as required: so- lutions do not accomplish the object as well, and as the patients are human beings they might get poisoned. Dr. Thorington, of Colon, introduced cocaine as a remedy in yellow-fever nausea in doses of 2 to 3 grains in solution. I think I first insisted on small doses in tablet form floated into the stomach where it is needed. Bathing the face with vinegar frequently is excellent in subduing nausea. Eau sedatif is praiseworthy for the vinegar it contains. Elegant toilet waters are pleasing to all and possible to some. Mustard to the epigastrium is always to be resorted to, but avoid sickening the patient by putting the pungent mass too close to his nose. Look to the covering, the pil- low, the mattress, the commode, the nurse's breath, or other condition as a cause of nausea. A fresh sheet or pillow case or pillow sometimes makes a "lot of difference" in the matter of comfort. Do not forget the bowel peristalsis; the "duodenal bloody sweat" may be trying to get up through the pylorus and maybe an enema from a long tube is now essential to produce quiet. To relieve restlessness and the aches and "tired feeling" it is well to briskly rub the legs and back with a coarse towel under the cover every three to six hours. Massage through the cover is sometimes grateful. After sixty hours, in ordinary, examine the urine. If Albuminuria albumen appears as a trace give more fluids. If the quan- tity increases to from 5 to 20 per cent give turpentine in 7 or 10 drop doses every four hours. For 5 per cent albumen nothing but more fluid is necessary; if it increases to 75 per cent give more turpentine. Rub the chest and back with turpentine, not so much for absorption, but so as to put your charge in a turpentine atmosphere, to pre- arwi>ed.v vent him from smelling and tasting the medicine. Do not let the patient know you have examined or want to examine the urine; have portions saved without his knowledge. It is amazing what quantities of turpentine can be taken Massages. Turpentine as 308 MARINE-HOSPITAL SERVICE. without harm. There is no danger of strangury. I have given half, sometimes a teaspoonful, to children where there was suppression, and generally with good effect. But it is not advisable to give all that may be considered necessary in a case at one dose. Turpentine is a diffusible stimulant and a good styptic; it is laxative also. I have never seen a particle of benefit follow administration of cool enemata. digitalis. Large enemas of water about the temperature of the air, or cooler, placed high up, do much good if they are retained. Please note that the kidneys are not inflamed, but rather paralyzed. suiionaiforin- For sleeplessness after second night give sulfonal in 15 to 30 grain doses, and repeat if necessary in three or four hours. Bromide and chloral are good, but are often borne badly. I used trional once with good result. Ofttimes sleeplessness is due to the odor from a dirty quilt or pillow; Good beds, sometimes to a lumpy mattress. These may seem trivial, but it is a doctor's business to look out for his patient. In some cases a woolen shirt—a sweater—is necessary, as in restless children and persons who will not keep the arms under cover. Diet in conva As the fever subsides diminish the remedies and increase the food, but it is generally unsafe to give anything like milk or eggs before the fifth or sixth day. Your patient will not starve to death, but if he is fretted by a great lot of rules or unpleasant attendance and surroundings he may not get well. COLLAPSE. Treatment of Collapse is a horror. Generally an enema with a little collapse. whisky and turpentine, given with a long tube, will do good. Hypodermatic strychnia, brisk rubbing of arms and legs and back with mustard is to be adopted. It is always necessary to procure an action from the pylorus downward. If this is not done there will soon be black vomit. A deft administration of olive oil—1 to 3 ounces— cause and pre is a life saver. Collapse is usually caused by an influence lapse.' equivalent to surgical shock, and the organs through which the shock comes are in order of frequency—the stomach, from excess of, or because of faulty, food; the skin, from chilling by getting up or getting uncovered; the brain, from hearing bad or unwelcome news. To avoid collapse it is needful to prevent any shock to the organs mentioned. Whatever the origin of the collapse, the treatment is the same, but in case of mental disturbance some abusive or con- soling talk, as the case requires, must be indulged in also. More people have died in consequence of too early or impru- MARINE-HOSPITAL SERVICE. 309 dent feeding than is generally supposed. I have saved a life by insisting on having a window shut down to prevent Cause and pre <-r,~ „ j. /■ /, .,1 i it t, vention of col tbe entrance of " the lovely breeze." Free ventilation has lapse. caused the death of many; so has the sleepy nurse who let the rolling patient get naked in the chilly hours of the early morning; so has the gossipy neighbor who consoled the convalescent by telling him of the death of a friend or of the outbreak of fever in the town to which the patient's family has fled. There is another source of col- lapse. During early convalescence there is an excessive venereal desire, and under such circumstances conscience is much dulled or dead. It is necessary to warn the part- ner who is not sick or arrange that man and wife shall not be left aloue until convalescence is complete. Thus nurses of the opposite sex are to be doubted and tabooed, if possible. I am confident that collapse, whatever its apparent cause, is generally accompanied with an obstruction in the small intestine and oftener in the upper part. I would like to say that the shock caused the obstruction. Sometimes it is food—then high up; sometimes it is an intussusception— then lower down; sometimes it is due to a contracted colon, but if the patient could have been permitted to lie in quiet there might have been continued peristalsis. There are some who dispute my mechanical theories and the effects of mental conditions. SECONDARY FEVER The secondary fever (that of after five days) is a ptoma- ptomaines. ine poisoning and needs some modifications of the routine. Give antipyretics and high clysters for effect and increase the food. Ice to the head and rubbed down the spine, every half hour rolling the patient from side to side, will do good. Alcohol will do much good at this stage; the stimulants. patient's choice is the form to use; brandy is the worst form, as it produces hiccough. Dry catawba has served me well. Gin is the best form, as it may assist the kidneys. 1 have never seen any benefit to follow champagne; ginger ale is better. Continue the turpentine if the albumen compels it. I Turpentine- think guaiacol rubbed into the skin of the abdomen would be beneficial, but I never had a chance to try it; if put in the stomach, it is liable to cause nausea and eructations. Chronic vomiting after four or five days may be relieved opium increas- , - , es albumen in by cocaine or one tenth grain doses of calomel with 1 gram urine. soda bicarbonate frequently repeated. One-twelfth grain 310 MARINE-HOSPITAL SERVICE. doses of morphia hypodermically do a lot of good; watch the urine, for opium increases the albumen or the chances of it. Small blisters over the stomach do good service. Sometimes bismuth serves a good purpose; peppermint and soda have served well, but it is necessary to compel a through and through action of the bowels. Avoid milk; For five days give no food but thin starches. Milk kills, as does every sort of food that requires stomach digestion. Limewater alone sometimes gives comfort to the stomach, but mixed with milk it often causes the milk to stay in the stomach to become curds in the half-rotten duodenum. Patent and predigested foods are all right in the ptomaine fever and recuperating stages, but hurtful for first four or five days; so with opium and alcohol. At Flomaton, last summer, over eighty patients were treated with catharsis, tincture aconite, and Warburg pills. They were fed ad libitum on ice cream. Over a hundred gallons of ice cream were used. There were four deaths among the number treated. There are other unique and unusual forms of treatmeut which I could describe, but as I began to tell how to care for worst cases I will omit them for the present. Moral therapy. The physician should remember always that the senses of the yellow fever patient are as acute as those of a puer- peral fever patient and that all necessary subterfuges must appear to be absolute truth. I know of many deaths due to actual truth—brain shock and collapse following. There is no febrile disease in which physic and the mind play such prominent roles. A constipated patient or one who has a dreadful fear of the fever will, as a rule, not recover. THE PHYSICIAN'S DUTY TO PATIENTS. Be confident Primarily it is a physician's duty to be (or appear to be) frank, nonchalant, observant, cheerful, confident, hopeful, and positive; he must convince the patient by word or manner that he for one among the numerous sick is not suf- fering with the " prevailing" fever and is not very sick. Except in disputed cases, a half dozen questions will elicit all the information needful for detailed action for next twenty-four hours. As patients later in the disease are all- embracing in acuteness of senses, it is necessary to be frank (not truthful) and to remember and adhere to whatever has been said before. Many a life has been lost by ill advised sympathy, too much nursing and attention, too frequent dosing, and senseless gossip. MARINE-HOSPITAL SERVICE. NURSES AND THEIR FUNCTIONS. The more ignorant, if obedient, the nurses the better. Nurse All the professional nurses I have seen are at odds with order8' the doctor and continually strive to convince the patient that when all fails he will bring order out of chaos and presto the patient will be cured. The nurse should have only sense enough to obey orders. Dumb nurses would be ideal in all critical or extra critical cases. The doctor should know how to direct the nurse as to his duties and to emergencies and crises and should be careful so that no disputes arise. The sick person must depend on nurse as well as doctor. 1 know of too many preventable, but not prevented, deaths due to strife between physician and nurse; unfortunately in some instances the doctor was to blame in being careless in giving directions. I know of some cases sacrificed to the zeal of a nurse who "knew more than all the doctors." FIRST AID TO SUSPICIOUS CASES. In the Brownsville epidemic I was compelled by the geography of the country to include within the cordon a small region inhabited by nonimmunes. If I had acted in accordance with the law of Texas then in force, I would have exposed many more people nd had an area to care for nearly as big as Rhode Island. To protect the people outside the infected town and inside of the guard line I supplied my guards and patrols with the medicines then iu use, i. e., compound cathartic pills, mustard, and quinine pills, and gave directions for their use. Nearly a hundred cases were treated by the guards, in the country, without a death. Siuce then I have advised interested persons to provide the pills, mustard, and acetanilid in advance. If 1 were to outfit a guard line now I would furnish com- pound cathartic pills, compound acetanilid tablets, and mustard, to be used while the doctor was being sent for. I have suggested to Major O'Reilley, of the Army Medical Corps, that the pills and tablets be added to the first-aid package of the troops who go-into yellow fever regions, with instructions for a man to take a pill at bedtime if his bowels were not freed during the past day; to take more if he had a chill in the night, and to take a tablet if he suf- fered with headache. It takes time to get a physician, and I feel confident that if men are given .. little instruction and the few necessary remedies there will be less suffering 312 MARINE-HOSPITAL SERVICE. and perhaps less mortality. It is well known to Southern physicians that a dose of compound cathartic pills will often stop a malarial attack, particularly in negroes, and it is believed that the use of the coal tar derivatives has lessened the necessity for cinchona in the treatment of malarial diseases. I have tried to tell how to treat the yellow fever with a limited number of remedies. Any person who will care- fully follow directions will succeed in keeping the death rate at about 4 per cent, and counting accidents, ages, habits, and conditions, that is enough to hope for. THERAPEUTIC TREATMENT OF YELLOW FEVER. By P. A. Surg. H. D. Geddings. [From Annual Report of Marine-Hospital Service, 1894.] In discussing the therapeutic treatment of yellow fever, General consid- it is not proposed, indeed it is impossible, to here present any long array of cases, with records of temperai ure and pulse and detailed symptoms of each particular case. It shall be my endeavor to present nothing that has not been of real value in the hands of my colleagues or myself, and anyone taking the trouble to read this and not finding any particular line of treatment laid down will please bear in mind that this is a record, not of what might have been, but of what has been, done. The writer believes that the treatment of yellow fever, like that of other acute specific febrile diseases, should be symptomatic and directed toward meeting plain and specific indications. The symp- toms may be divided, for convenience, into those (a) belonging to the onset of the disease and those (b) which arise during the course of the illness. TREATMENT OF INITIAL STAGE. Under the first head may be included the chill and sub- sequent fever, the distressing headache and pain in the back, loins, and limbs. For the relief of these, as well as for properly initiating a systematic treatment, it is believed that the old plan of administering a hot footbath contain- ing mustard is an eminently proper one. The bath hastens Batha. reaction from the chill, markedly relieves the headache and pains in the back and legs, promotes diaphoresis, in this way accomplishing good, and being perfectly incapa- ble of doing any harm. The patient, being then restored to bed, should be covered warmly but not too heavily, and gradually uncovered as diaphoresis proceeds, in order that too great prostration should not ensue. Care of course 3934----3 313 314 MARINE-HOSPITAL SERVICE. should be exercised to prevent sudden chilling of the sur- face. As soon as the patient is made comfortable in bed the remedial treatment should be begun. At this stage Purgation. this should consist of a sharp purge, preferably mercurial. I have found calomel 0.33 grams, compound powder jalap 0.66 grams, administered in capsules, most efficient. Others prefer the compound cathartic pills (U. S. P.), of which one, two, or three may be administered, according to the age and general condition of the patient. Should either of these remedies fail to move the bowels freely within six or eight hours it may be followed by a moderate dose of castor oil, a seidlitz powder, or a bottle of citrate of magnesia. TREATMENT OF FEBRILE AND NERVOUS CONDITIONS. use of coai-tar Closely following the first purgative should be adminis- tered one of the coal-tar febrifuges, phenacetin 0.50 grams, or antipyrin or antifebrin 0.66 grams, either of which may with advantage be combined with 0.12 grams to 0.18 grams of citrate of caffeine. It will be well to discuss here the effect of the coal-tar series of febrifuges in yellow fever. Possess- ing as they do analgesic properties of the highest order, being second in this respect only to preparations of opium, in addition to their well-known power of reducing tempera- tures, they fill a most important place in the treatment of yellow fever. By their use in moderate doses at the incep- tion of the attack we relieve headache and the racking pain in back and limbs, diminish restlessness, and reduce temperature within twelve hours to a point, not nor- mal, but considerably below that at which it stood when reaction from the chill had fully taken place. Indeed, it has seemed to me that the action of the first dose of the antipyretic furnished, in some sort, an index of the course of the particular case under observation. Given a case in which after the administration of the antipyretic the patient passes into an easy sleep and wakes with diminished head- ache and other pains, a moist skin, and a reduced temper- ture, I feel encouraged to hope, though I do not say that the case will be mild or of moderate severity and will end in recovery. Given, on the contrary, a case in which the antipyretic produces but slight influence on the tempera- ture, where restlessness is not diminished or controlled, where pain persists, and the skin, though moist, has a burning, pungent feeling, I fear the worst and expect trouble to the very end. Repeated doses of the antipyretic are not needed, or indeed indicated. It is my belief that one, two, MARINE-HOSPITAL SERVICE. 315 or at most three, doses in the first twenty-four hours of the disease will accomplish all that is to be gained from this series of remedies. Administered later in the disease, they exercise too depressing an effect on a heart already weakened as a consequence of a toxaemia more or less profound. TREATMENT OF GASTRIC SYMPTOMS. The gastric irritability, which is often extreme at the onset of an attack of yellow fever, may be controlled by sinapisms to the epigastrium, abstention from fluids, and frequent ingestion of small pieces of ice, which not only allay thirst, but also tend in themselves to relieve nausea. Should nausea or vomiting persist, the administration of cocaine hydrochlorate, in doses of 0.015 gram to 0.030 cocaine. gram every hour or two, will often act almost magically. Small quantities of carbonated beverages, as vichy, seltzer, carbonated or appollinaris water, ginger ale, or very dry champagne, beverages- administered ice cold, will often prove of service. Creosote has also been highly recommended, and also a mixture con- taining hydrocyanic acid and morphia. Considerable relief is also derived from the application to the epigastrium of a liniment composed of olive oil and menthol. IMPORTANCE OF RENAL SYMPTOMS. On the afternoon of the second or morning of the third day the presence of albumen in the urine may be noted, unless the case be of the most ephemeral mildness. I believe that no case of yellow fever can occur without presenting albuminuria at some time, though that time be limited to a Albuminuria. few hours, perhaps. It is argued by some that as cases do occur presenting a quantity only recognizable by chemical tests of great delicacy, it is possible that some occur with- out any. On the other hand, it is argued that a disease so terrible when severe must give some sign, even when very mild. The quantity present on first detection, and its in- crease or diminution from day to day, form, perhaps, a fairly good guide to prognosis. If it appears, increases gradually, significance ot and then begins to diminish, prognosis is good. If, on the contrary, it appears at first in large amount, persists or increases abruptly, trouble may be anticipated. "BLACK VOMIT." The fwo gravest symptons that can arise during the course of a case of yellow fever are undoubtedly black 316 MARINE-HOSPITAL SERVICE. Causes. vomit and suppression of urine. Black vomit is caused by rupture of walls of capillaries or venous and arterial radicles, and the discharge of blood into the cavity of the stomach, where, coming into contact with hyperacid gastric juice, it becomes altered into small masses of brownish- black color, somewhat resembling coffee grounds in gross appearance. Its advent may also indicate a general hemor- rhagic diathesis, which maybe manifested by hemorrhages from the nose, gums, fauces, rectum, or by extravasations into the connective tissue of the scrotum. The abrupt appearance of black vomit in large quantities without warn- characteris-ing is unusual. Careful search will often show minute brown or black particles floating in clear fluid, and pre- senting the appearance described by some authors as "bee's or butterfly wings." It is not uncommon, however, that patients just before death should vomit a large quan- tity of black vomit, and that after death the stomach should be found to contain several quarts of the fluid. It would seem probable that in these cases the hemorrhage which produces it was more of an active hemorrhage than a capillary oozing, and that death comes quickly as the result of shock. TREATMENT OF "BLACK VOMIT." Treatment. How shall we best treat the condition resulting in black vomit? The problem being both to arrest vomiting and to treat the condition giving rise to it, it follows that treat- ment should be directed toward the general hemorrhagic diathesis. Probably the most efficient remedy is found in Perchioride of the tincture of the perchioride of iron. That should be given in large doses, 1 to 2 c. c. every hour or two, or, if vomiting is frequent, after each act of emesis. Counter irritation to the epigastrium, the administration of stimu- lants, preferably champagne or good brandy administered Ice- in carbonated water and given cold, swallowing of ice, and cocaine. administration of cocaine, make up about the sum of our remedial agents. While enough has been said to show that black vomit is a most serious symptom, it does not follow that every patient who vomits black matter will necessarily die. A fair proportion of cases recover after the symptom has manifested itself. Still, the ejection of black vomit makes a most profound mental impression on a patient, and for this reason has often hastened a fatal termination in a case which up to the appearance of this accident had done well. MARINE-HOSPITAL SERVICE. 317 TREATMENT OF RENAL SYMPTOMS. Of far graver importance to my mind is the train of symp- toms which leads to uraemia, and which are announced by partial or complete suppression of urine. I believe this to be the gravest accident that can happen in the course of yellow fever. The amount and character of the urinary secretion should be a matter of frequent inquiry in every case, grave or mild, from the inception to convalescence. A sudden and irregular increase in the amount of albumen should put us on our guard against possible urinary sup- pression, and prompt treatment should be instituted and maintained. Counterirritation over the region of the kid- ti Counterhrita- neys with turpentine or mustard, dry cups, the application of hot-water bags, all should be tried. A tisane of water- melon seeds has long enjoyed the reputation of being almost a specific among the Creole population of New Orleans, and I can bear personal testimony to its efficacy alone or given in combination with spirits of nitrous ether. Of almost equal reputation is a tisane of orange leaves, ange8aieaves0or preferably of the bitter variety, given in large quantities8^eldt>ermelon and frequently. A remedy much used in Brunswick in 1893, and vaunted as almost specific by those very success- ful in the management of the disease, was spirits of tur- pentine, which was sometimes given in heroic quantity, as much as a teaspoonful at a dose and repeated. I can not speak of the remedy from personal experience, but the results claimed for it warrant its more extended use. TREATMENT OF BOWEL CONDITIONS. A point in the treatment of yellow fever, with the impor- value of ene- tance of which I am much impressed, is the frequent wash-m' ing out of the lower bowel with enemata of warm water and soap. Constipation is the rule in yellow fever, and no one who has noted the exceedingly fetid, almost putrid, char- acter of the stools of a yellow-fever convalescent can fail to see the wisdom of removing the chances of septic absorp- tion by frequent washing away of this fermenting mass. Pass a well-oiled rectal tube as far up into the bowel as possible, and with a fountain syringe elevated not more than a foot or two force slowly 2 or 3 pints of warm, soapy water into the bowel. The whole operation should be performed with the patient upon a bedpan, not seated upon a vessel or close stool. The effect upon the tempera- ture and general condition of the patient is most marked. MARINE-HOSPITAL SERVICE. USE OF ANTIMALARIAL REMEDIES. As to the use of quinia or allied preparations in yellow fever, I concur in the generally accepted verdict that they are without specific effect. But as yellow fever almost always occurs in regions where malarial diseases are also rife, and as the intercurrence of a malarial paroxysm is one of the most disagreeable incidents that can mar the course of a case of yellow fever, I consider it good practice in such regions to administer 2 to 3 grams of quinine or cinchonidia in the first twenty-four hours, exhibiting the drug per rectum if the stomach is irritable. DIETETIC MANAGEMENT. A most important point in the management of yellow fever is the diet. Many a patient, his crisis past and the borders of convalescence reached, has been hurried into an untimely grave by the misplaced kindness of an appar- ently simple meal. The yellow fever patient should never be starved; on the contrary, he should be well nourished, but the most scrupulous care should be exercised in the selection and administration of his diet. "A little and that often" should be the rule. For the first few days milk with limewater given cold, then animal broths, concen- trated but free of fat, should be the regimen. The fever being reduced, soft-boiled eggs, milk toast, and small bits of the white meat of chicken and tenderest steak may be permitted. Probably at least ten days or two weeks should elapse before the convalescent, by the easiest stages, should be permitted to resume ordinary diet. HYGIENE OF PERSONS LIVING WITHIN AN AREA OF YELLOW FEVER INFECTION. By Surg. H. R. Carter. As I understand the problem the persons with whom we are concerned, living within a radius of yellow fever infec- tion must more or less at intervals or continuously be exposed to yellow fever infection. The measure of no direct communication with infected points will then not be considered, although I think it will frequently be possible to substitute indirect communication for direct. NOT ALL PLACES WITHIN RADIUS ARE INFECTED. All places within a yellow fever infected district, or town itgPr°^^n"^^ even, are not infected or are infected in unequal degrees. ai* to distance. The infection is especially confined to the habitations of men and their environment, and is conveyed a short dis- tance, possibly 220 meters down the wind, from an infected focus. Two hundred and twenty meters is given as the maximum distance this infection can be conveyed, it being the longest distance claimed in any instance in modern times. The general consensus, however, is that this observation (Melier's) is altogether exceptional, and that less than half that distance covers the distance to which the infection is conveyed from a single focus. AERIAL CONVEYANCE GREATER IN LARGE INFECTIONS (PROBABLY). On the other hand, it seems probable that if the focus Foliage ob- . i -I. • « i -i . structs spread. of infection was large, i. e., a .badly mfected camp or part of a town, that the aerial conveyance of infection would be decidedly farther than from a single house or ship. I know of no observations on this matter. The presence of any object—such as a hedge of trees,bushes, etc.—which breaks the wind hinders the conveyance of infection. 319 320 MARINE-HOSPITAL SERVICE. PROBABLE MEDIA OF SPREAD. The microorganism, however, is unquestionably a sapro- phytic facultative parasite, and foci of infection can be established at a distance from the primary focus by the conveyance into suitable culture media of the microorgan- infectionisms—thus, along sewers, about the dumping places of andThaVedspots! refuse, etc., and by fomites. For the same reason the infec- tion spreads slowly along ditches and on damp and shaded grounds to a considerable distance, always to leeward. Taking all these methods of propagation, it may go far from the habitations of men and become general over all parts of a town, yet, in fact, seldom does so. A place which has become infected may remain infected for a considerable period of time, being freed from it by cold weather, ventilation, etc. "CONCENTRATED" AND DIFFUSED INFECTION. We will consider, then, the (1) house infection, and (2) general infection—"out of doors" infection. This is fre- quently called atmospheric infection, but I think the term is liable to mislead. The first is in general far the most apt to infect one exposed to it—"concentrated," "virulent," is usually said of it. The latter, with the exceptions above indicated, is usually confined to the resident part of the town, and especially to the neighborhood of infected houses. INFECTION GREATEST NEAR THE GROUND. The infection is heavy and hangs and spreads near the ground. It is unable to pass a close wall of any consider- able height, although under the shady side of such a wall Actirity at it may spread well when once started. It seems especially active at night, and certainly, out of doors, is less apt to be contracted on clear dry days. It is believed, I think, universally, to be taken into the human system by inhala- tion, although other avenues of entrance (besides the respir- atory tract) are, since the observations of Sanarelli, accused by pathologists—rather from analogy, however, than from clinical observations. RATE OF PROPAGATION OF INFECTION AND EFFECT OF WEATHER. Dust as a prop- The rate of propagation of outdoor infection is increased in cities in dusty weather, apparently being conveyed with the dust. It is temporarily lessened after full rains, to increase more rapidly afterwards. Strong, steady winds in clear weather lessen the infection. MARINE-HOSPITAL SERVICE. 321 MEASURES OF PREVENTION. With this brief resume of well-known facts we can pro- ceed. The measures seem naturally to divide themselves into— (1) Selection and hygiene of the living place; (a) to pre- vent exposure to infection of its residents; (b) to prevent its becoming infected should fever develop among them. (2) Guarding communication between known foci of in- fection. (3) Personal hygiene to prevent the individual from de- Personalhy- veloping yellow fever. (4) Measures to control (limit) infection when introduced in the living place—house, town, camp. I. Selection and Hygiene of Residence. As far as the choice of a living place is possible it must be chosen, itself noninfected, as far from any known focus of infection, or residence portion of the town liable to be or become such a focus, as possible. It should, if sufficient distance be unattainable, be to the windward (prevailing wind) of such portion of the town or separated from it by trees, etc. All this is to prevent exposure to infection. It should be on high, well drained ground, as, if infected, Mevated sites the outdoor infection will be less. As much exposed to wind as possible and not so shady as to be damp—better too much sun than too much shade. I can not find that moderate elevation makes any difference to the house infec- tion of yellow fever. Dryness, sun, and ventilation do. WATER SUPPLY. Parenthetically it may be well to note that there is no Probably not a , ,..,,„„ ,, , , waterborne dis- reason to believe that yellow fever as usually propagated ease. in this country is water-borne—the fresh-water tanks of infected vessels have never been and are not now emptied at our maritime quarantines. Nor am I aware of any facts which accuse this method of propagation in the tropics, and profoundly disbelieve that this is a usual method of propagation. Yet from the analogies of growth of the bacillus icte- roides of Sanarelli, most prominent now as a causative agent, with the colon group, it would seem well to secure a water supply free from possible contamination with this bacillus. The same theoretical reasons exist to suspect food as a means of conveying the fever. There is less evidence of its innocence. 322 MARINE-HOSPITAL SERVICE. PREPARATION OF GROUNDS. This place chosen for residence should be ditched so as to keep dry. Tile draining would be infinitely preferable, d r a i n i n g as the bottom of a ditch is shaded, and therefore damp. It grounds. should be kept very clean, and free from vegetable as well as animal litter, decaying leaves and wood, especially saw- dust, seeming to be as bad as animal refuse. Brush, etc., must be cut out to let the wind freely through, and not too much shade be allowed. CHARACTER OF HOUSES. construction of The houses should be preferably of wood, high above the ground, with free circulation of air under them; very open and light—as little shaded by trees as possible, depending rather on verandas and awnings for comfort. No dark closets—all to have windows, no understairs closets. Light and wind must go everywhere. MOLD FAVORS THE DEVELOPMENT. The writer observed (Annual Report of 1891) "the con- ditions which favor mold favor the spread of yellow fever on wooden ships." He has seen no reason to change his views. Value of sun Dryness of ground and of buildings, with free exposure to wind and as much to the sun as is allowable in a bad climate, with absolute cleanliness, are the conditions aimed at. This is to prevent or limit the extension of infection in this living place (house, town, or camp) if introduced, and if carried out we may hope to have no infection of the locality, even if cases of yellow fever are brought or devel- oped therein. If it be a camp, the people living in tents, it will almost always be practicable to prevent infection. II. Guarding Communication with Known Infected Foci. communication preferably by immunes. Where communication with known infected foci can not be carried on by immunes, if it is practicable to make it indirect, this should be done. The direct intercommunica- tion by immunes (or by nonimmunes not sleeping in the place which we wish to preserve from infection) is practi- cally safe, if any reasonable super vision be given to it. MARINE-HOSPITAL SERVICE. 323 Where direct communication with towns where such foci exist must be practically unlimited, still the safeguard of " daylight communication " may be applicable. DAYLIGHT COMMUNICATION. Under this, nonimmunes are all allowed to go into the infected town during the day, pledged not to enter any residence, and leaving town before evening. The hours in the town are usually from 9 or 10 a. m. to 3 or 4 p. m., and Allowable on what part of the efficiency of this safeguard is due to non- spedLd^ours"* exposure to infection by keeping away from the residence part of the town, what part to the short time spent in it, and what part to the fact of this time being entirely during the bright part of the day is difficult to determine; nor is it necessary. The method is not safe, but it is little dan- gerous, and if carried out in absolute good faith, and only on clear days, would be safe enough for all practical pur- poses—certainly unless the town were very generally infected. DAYLIGHT COMMUNICATION IN CLEAR WEATHER ONLY. The writer knows of two instances of persons who had thus entered and left an infected town a number of times on clear days with impunity, and who, after visiting it on damp, cloudy (muggy) days, developed fever. It would seem, then, that clear weather may be an added protection against outdoor infection. Theoretically it would be. FOMITES. The risk of conveying infection by fomites to our people .Media of infec depends on (a) exposure of articles to infection and (b) capacity to retain infection. For the first, articles stowed away and handled in the nonresident portion (wholesale district) of the town are little liable to be exposed to infec- tion. Of course, we may and do have infected warehouses in this district. The capacity of an article to retain infection depends on the nature of its exposed surfaces. If these be hard, smooth, and nonabsorbent the article will be little likely to convey infection. Household goods are naturally most Household exposed to infection, and of these goods used bedding, upholstered furniture, and clothing are the most certain to retain it. They should be burned. 324 MARINE-HOSPITAL SERVICE. PASSING THROUGH AN INFECTED TOWN. There is, of course, no special reason why articles of freight merely passing through an infected town should become infected in transit. The same applies to such articles stowed in noninfected warehouses. III. Measures of Personal Hygiene to be Adopted by the Individual to Prevent His Developing Fever. the person's surroundings. communica- (l) There are the obvious precautions that he should houses should be not expose himself to infection when practicable to avoid it, i. e., should not enter houses unnecessarily; should not go out of his own (uninfected) quarters at night; should not receive or come in contact with any fabrics or house- hold goods about the exposure of which to infection there is doubt. These precautions, are of decided value, and by them and similar ones a man may live, and many do live, in towns in which yellow fever is endemic for a long time, and escape infection. PERSONAL SUSCEPTIBILITY. (2) Are there personal conditions which affect the sus- ceptibility of an individual to yellow fever; and if so, to what extent are they under our control ? Here I must premise that on not a few points the opin- ions generally current, even among those best entitled to speak authoritatively on this matter, are founded on insuffi- cient data, and are thus shrewd conjectures, based on gen- eral experience rather than scientific deduction from analyzed observations. Still, a consensus of conclusion, independently arrived at by men of wide experience and under varied conditions of observation, has a strong ante- cedent probability of being correct. It is therefore not intended to limit the recommendations on this subject to what is proven of value. A difference will be made, how- ever, between such things as stand on good evidence and such as are merely current belief, confessedly an inconclu- sive data. THE PERSON HIMSELF. There are certain personal factors affecting susceptibility which we can not influence, and yet of which we may avail ourselves advantageously, as— (a) The lessened susceptibility of the negro race. The race. MARINE-HOSPITAL SERVICE. 325 (b) The lessened susceptibility of those living for vears Residence . ' x- ./ o j gives immunilv. (better for generations) under the conditions which obtain in the tropics. ATAVISM. It is this probably that gives the "relative immunity" of those suffering from "tropical anaemia" on which cer- tain French writers insist. What influence ancestral amaryllization has is undetermined—probably consider- able. PHYSIQUE. Thin, spare, vigorous men are less liable to develop the spare men j. , , . , withstand dis- disease, and bear it well; the plethoric and full-blooded ease well. are more liable to develop it and have it severely. But this is nearly the same as saying that those suited by habit of body to the conditions of tropical life have a lessened susceptibility. PHYSICAL STATUS AT TIME EXPOSED. To inquire into the conditions which affect susceptibility which we can influence we must note that there are many observations to show that the time and probably the fact of the development of yellow fever is determined by causes which affect the physical condition of the individual, such causes acting at the time or just preceding the develop- ment of the fever. RESEMBLANCE TO MALARIA. In this respect the disease resembles malarial fever, an attack of which will develop under certain conditions— mainly of failure of elimination of shock or of depression— which otherwise had failed of development altogether. These causes in the main are those which diminish excre- tion and which depress. In the opinion of the writer (the contrary is held by most authorities) the former is the most important factor. Now, these causes we can influence. MOST POTENT AUXILIARIES TO AN INFECTION. To enumerate them about in the order in which they occur in frequence just before the initial attack: (1) A sudden chilling of the surface, especially if wet cmii. with perspiration. This is common in the experience of every one. (2) Excessive exposure to the direct rays of the sun. 8Un.xposure t0 The writer has seen but few cases of this. In all the sun exposure (exhaustion) was associated with a very dry skin. 326 MARINE-HOSPITAL SERVICE. It is much insisted on by Beranger-Feraud and some other French writers. Fatigue. (3) Excessive physical fatigue (in my experience compli- cated with (1) and (4)). (4) Anxiety and mental distress generally, especially fear of the disease. RELATIVE VALUE OF CAUSATIVE INFLUENCES. To estimate the effect, and especially the comparative effect, of these things (many of them frequently acting coincidently)in determining the development of yellow fever is impossible, but that they do influence it is generally cred- ited. There is so frequently a history of sudden chilling (as by a rain squall) of the surface, preceding by a short time the development of the fever, that it seems impossible to ignore its causative influence. The same is true to a less extent of exposure to the direct rays of the sun. The influence of the others rests on much slighter evidence, mainly opinion, and to what extent these opinions are copied by one writer from another, and to what extent arrived at independently, the writer has no means of determining. He has never had any reason to accuse them as etiological factors. DIARRHEA AND CONSTIPATION. Diarrhea, common enough among those exposed to yellow fever, and certainly debilitating, has not seemed to Febrile compii-induce (i. e., precede) an attack. The constipation nearly always associated with the advent of the fever will gener- ally be found to have preceded it some days, and while it may be a prodrome, the writer is of the opinion (on insuffi- cient grounds, he admits) that it has an etiological influence. DIET AS AN ETIOLOGICAL FACTOR. A meat diet is claimed, too, to increase the susceptibility to the disease, as well as to make it more severe, the claim being made that the house servants (negroes) in Martinique and Guadeloupe, who live like their masters, took the fever more readily and had it more severely than the plantation hands, and, indeed, showed nearly the same susceptibility as the whites. The evidence seems insuffi- cient, and certainly is not true to the extent here asserted Meat diet. ofnegroes in the United States. An overfull meat diet, from throwing extra strain on the liver and eliminating organs, would naturally make the attack more severe, and may from the same cause increase susceptibility. MARINE-HOSPITAL SERVICE. 327 ALCOHOLICS. The same is true of alcoholics, and it is well known that having used arlcohol to excess is an element of decided danger to one who has the fever. I know of no evidence that the use of alcohol per se increases susceptibility. The habits of an alcoholic would increase exposure. WATER AND FRUITS. The free use of water and a diet of juicy fruits and fresh vegetables, increasing elimination by skin, kidneys, and bowels, should put a man in a better condition to go through the disease and probably lessen his chance of develop- ing it.* WHAT TO AVOID. To state these conditions and to allege that they favor the development of the disease is to inculcate to their avoidance. The individual must avoid excessive fatigue and undue exposure to the sun. CLOTHING. The use of a sufficient head covering is useful here, and Headcovering nothing is so good as the thick pith white helmet. The white straw hat or duck cap with a handkerchief in it is good, infinitely better than the dark felt hat, or even than the hat or cap without the handkerchief, but nothing that I have seen takes the place with me of the pith helmet. To avoid chilling the surface, flannel should be worn. WOOLEN UNDERWEAR. Indeed, in a tropical clima'te chilling is far more to be avoided than getting too hot. There is no need for two shirts, but let the one worn be flannel. A very thin shirt shirt*. of other material may be worn under it if the skin be tender. The same is true of the leg covering, either flannel drawers or thin drawers and flannel trousers—the former preferably. Drawers. In the opinion of the writer, from considerable personal experience, this rig is also most comfortable. The flannel shirt is more important than the drawers, as the body requires more protection than the legs. He should take *The writer is inclined to believe that a diet with a little meat lessens susceptibility to infection, but the data on which this rests are insufficient to justify any save a "somewhat probable" opinion. A meat diet in the tropics is not wholesome, however. MARINE-HOSPITAL SERVICE. proper precaution—waterproof blanket or coat—to keep dry. Should he go out at night, he should keep warm — take his coat. He should not cool off suddenly when wet with perspiration. He should not drink alcoholics, save when necessary to ward off a chill or avert serious fatigue. There is little risk of eating too much meat; there is little taste for it in the tropics, and it is extremely tough. He must not allow himself to become constipated. This prob- ably is next in importance to the wearing of flannel and proper head gear. MENTAL STATUS. occupation of Keeping the mind occupied and making light of the fever mind during epi- 1.0 j. c 0 demic. is probably the best way to meet the fourth indication, but the evidence that susceptibility is increased by fear of the disease is very slight (or nil). Danger to life after taking fever is markedly increased by it. The most that can be hoped from all these measures is lessened susceptibility, and a considerable proportion of men will develop fever if sufficiently exposed to infection, in spite of them—a less proportion, however, than if no pre- cautions were adopted. Their value is probably not great. SANARELLl'S IMMUNIZATION. The use of the serum of Sanarelli as an immunizing agent is subjudice. From the evidence he has seen, the writer would recommend its use. The use of other immunizing its value. serums is so innocent, causing decidedly less inconvenience than vaccination, that even without pinning one's faith to its efficiency it would seem unwise not to avail ourselves of what is probably a valuable prophylactic, and if so, really the only one worth considering. IY. Measures to Control Infection when Intro- duced into the Living Place. primary cases. Should fever develop among the people the measures used for "first cases in town " are applicable to those that occur in houses, and, should only a moderate number develqp, ought to succeed in averting infection of the locality. In- deed, a very considerable number will not infect the place if properly handled. The principles are well known and discov- set forth at length in another paper. Early discovery of cases, isolation of the same, and immediate disinfection of 328 Coats. Early ery. MARINE-HOSPITAL SERVICE. 329 the premises of the patient are the tripod on which these measures will rest. TREATMENT "AT HOME " POSSIBLE, BUT NOT ADVISABLE. Should removal of the patient be impracticable, rigid asepsis of his environment will frequently, and, under the conditions of life above described, generally, allow us to treat him at home without establishing a focus of infection; but it is less satisfactory and involves greater risk. There should be no question of " suspects," the handling Prompt isoi*. of whom is by far the most difficult question of house quar- tloL*11 *° antine, as the cases among the people we are considering should be discovered early—within twelve, or at most twenty-four hours—moved away, and the place disinfected before it is capable of conveying infection to the other in- mates of the house. REMOVE ALL NONIMMUNES WHEN POSSIBLE. If the patient is treated in his house, it is very advisable, 1 do not say necessary, to move the other nonimmune inmates out of the house. Should the people be in tents the well-known methods of the detention camp apply. Detention These are well known, and if the condition be such thatcamp' they can be used will prevent almost with certainty any infection. The problem here is simpler still, and the same principles apply, only we always move the patient. There are no " suspects." I think we can always prevent the infection " suspect*.- of a well-situated, well-handled camp. Should we fail the camp is to be moved, disinfecting by aeration or otherwise all articles suspected of being infected. HOSPITAL TO BE "CONSIDERED" AN INFECTED PLACE, BUT KEPT FREE IF POSSIBLE. The hospital, regular or improvised, at which these peo- ple are treated must be treated as an infected place, but we can very generally prevent its infection if we have con- trol of it from the beginning. 3934----4 HYGIENE OF PERSONS LIVING WITHIN AN AREA OF YELLOW FEVER INFECTION. By P. A. Surg. Eugene Wasdin. The rules of hygiene necessary to be observed by one exposed to the infection of yellow fever, either in a country to which it is indigenous or in one accidentally infected, are those which apply to the individual and to his environ- ment. AIR-BORNE DISEASE. Yellow fever is essentially an airborne infection, the entrance of which into the system has been supposed to be by way of the alimentary canal; the upper intestine serv- ing the purposes of incubation of the causative germ; the absorption of its poison giving rise to the disease. MODE OF INFECTION. More recently it has been advanced that probably the germ of yellow fever enters the general circulation through the respiratory organs in some obscure manner, and incu- bating in the blood directly poisons this life-giving stream. However, this may prove to be, the present opinion is that one has not to contend with an organism or germ which may be taken into the body with food or drink, but with an almost inexplicable poison, so insidious in its approach and entrance that no trace is left behind. Individual hygiene for one exposed, therefore, is scarcely as important as the Hygiene of hygiene of his surroundings, for if these become infected arroundings. ,, . ' , . there are no known measures for his protection that are in the least specific. AVOIDANCE OF KNOWN INFECTION AND RULES OF PERSONAL CLEANLINESS. The avoidance of localities and material known to be immediately infected is advisable. The observance of the 330 MARINE-HOSPITAL SERVICE. 331 rules for personal cleanliness is imperative. All undue fatigue should be avoided, and the question of suitable clothing carefully considered, for it would be equally wrong to burden oneself with clothing suited to colder climates as clothing. to too suddenly adopt the scantier raiment of a native. Good, warm underwear would prove grateful and prevent too rapid variations of surface temperature. Exposure to the heat of the sun should be as limited as practicable until one becomes accustomed to its influence. Exposure at night is known to be injudicious and should be avoided, avoiled. ir DIET. While we do not know that this infection takes place by way of the intestinal canal, it has become the custom in those localities in which it is endemic to advise all who are first exposed to exercise extreme care in keeping the bowels in good order. It is very necessary that intestinal hygiene intestinal hy- be carefully observed in all hot climates, and there is nogien doubt that the intestines present, in yellow fever, conditions which seem to connect them with the presence of the mor- bific agent. Therefore, the greatest regularity in taking meals should be observed; the taking of well prepared substantial food, such as one has been accustomed to, and in such quantities that there may result no incomplete digestion is advised. A careful discrimination is necessary in partaking of strangely-prepared dishes and of unusual varieties of fruit. DRINK. As to drink, the use of boiled water, so much advised, can scarcely do more than prevent the introduction of agents capable of causing catarrh of the bowels, or fevers other than yellow fever. Still its use is advisable. Alcoholic Boiled water- beverages to one unused to them are harmful; to those' habituated their use in moderation seems necessary in order to avoid that catarrhal condition attendant upon their too sudden withdrawal. Especially should unknown beverages be avoided. PROPHYLACTIC MEDICATION. The use of internal medication to ward off this disease is, I believe, useless, nor is it probable that sachets of cam- phor, or any other deodorant, do more than annoy one. Attention to these simple rules of living and early consul- tation with a physician if needed will serve to maintain the alimentary canal and skin in normal condition, thus 332 MARINE-HOSPITAL SERVICE. directly enabling the system to overcome the morbific agent, or at any rate maintaining it in that condition most favor- able to resist the infection should it occur. Nobody is pre- pared for this better than a normal, healthy one, and it is needless to add that it is wrong to expose oneself to this organic dis-infection if there preexists any organic disease, for the cause extra pre- chances of recovery are in direct proportion to the integrity caution. ... . of the great organs of life—the heart, liver, and kidneys. Any incapacity in these organs must contribute to the mortality in this disease, but scarcely adds to the proba- bility of infection. ENVIRONMENT. The hygiene of environment is the more important. While experience has shown that once introduced into a locality yellow fever may act without marked character- Moisture, heat, istics, yet the presence of dampness, heat, and filth seems to result always in a form of the disease more malignant than when these conditions do not exist. Therefore the selection of habitat is important. DRYNESS AND ELEVATION OF APARTMENTS. One should select a dry, well-drained abode, to which sunlight has free access, and which can be thoroughly Gooddrainage. ventilated. There should be no stagnation of drainage or sewage, nor dampness to result in the growth of moulds; and to this end quarters elevated from the ground present attractions Although it is not known that animal or veg- etable d6bris influences yellow fever infection, yet there is no doubt that their presence induces a lowered vitality, which makes one more liable to the infection. SANITARY POLICING OF ABODES. Therefore, thorough policing of one's habitation must be Disinfectants, rigorously demanded, also the use of disinfectants to insure the destruction of offensive material. Finally, it may be noticed that there can be said, at this time, nothing which is specific. There is nothing which one may do directly to prevent infection after exposure. Many will escape, while others will succumb. A spirit of bravado or nonchalance is equally out of place with one of abject alarm. One should live in such a way that the precau- tions suggested above may be intelligently exercised, and he will have done all that a sound mind within a sound body can do. HYGIENIC MEASURES TO BE ADOPTED BY PERSONS LIVING WITHIN AN AREA OF YELLOW FEVER IN- FECTION. _________ By P. A. Surg. H. D. Geddings. PROCESS OF INFECTION. While yellow fever is a communicable disease, it is not contagious in the ordinary acceptation of the term, but is spread by the infection of places and articles of bedding, clothing, and furniture. This is a process requiring several days (extrinsic infection), and during this period the yellow- fever patient is as harmless as one suffering from a surgical complaint. AVOIDANCE OF INFECTED PREMISES. To my mind the lesson is obvious, viz, that the non- immune should avoid domiciles where yellow fever has prevailed or contact with articles or fabrics exposed dur- ing the course of a case of yellow fever, until disinfected by some approved method. EPIDEMIC INFLUENCE. While yellow fever is generally communicable only under the above conditions, it has been forced upon me that after the existence of yellow fever for some time and in consider- able intensity in a locality the disease may be propagated by what, for lack of a better term, we are forced to denom- inate "epidemic influence." The question has puzzled me greatly, and I can offer no other explanation than that of an "intoxication," caused by the absorption or ingestion of "toxines" liberated by the yellow fever organism in the Toxemia. process of its growth, under favorable conditions, outside of the human body. NIGHT INFECTION. Experience has demonstrated that this infection seems less likely to occur during daylight than at night, conse- quently we can deduce that "exposure by nonimmunes to atmospheric influences at night is to be avoided." 333 334 MARINE-HOSPITAL SERVICE. INFLUENCES TO BE AVOIDED. Experience has demonstrated that during the prevalence of yellow fever in epidemic form, or in an epidemic habitat, Chilling of the anything which causes chilling of the body with conse- xly. quent internal hyperemias or congestions, predisposes to the invasion of the disease. Therefore, wetting by rain or dew is to be avoided, also the sudden chilling of the body when sweating by exposure to drafts or cold bath, when heated by exertion or when fatigued. SLEEPING ON GROUND. For the same reason, sleeping on the ground without the interposition of some impermeable substance is to be avoided, not that the ground is dangerous per se, but that it produces chilling of the body. AS TO WATER SUPPLY. Bad water. While there is no proof that yellow fever is a water-borne disease, it is suggested that as a matter of precaution all drinking water be boiled before use. FOODS. Fruits. While articles of food, especially fruit, can not produce yellow fever themselves, it is perfectly possible that in an epidemic habitat they may serve as vehicles of infection. Therefore they should not be eaten unless sterilized by cooking, preferably by boiling. ALCOHOLICS. Temperance in the use of alcoholics is to be advised, for the reason that the catarrhal conditions caused by their use offer less resistance to the invasion of the specific organism. CATHARSIS. Experience has demonstrated that during the existence of yellow fever in epidemic form, liability to the disease is diminished by keeping the bowels open by mild cholagogue cathartics. Excessive purgation is to be avoided, as tend- ing to impair the force of vital resistance. CLOTHING. To prevent chilling of the surface it is recommended to wear light woolen next to the skin in preference to cotton or linen. The use of hot coffee in the morning before going into the open air is to be recommended. SUGGESTIONS TO PERSONS IN CITIES INFECTED WITH YELLOW FEVER TO PREVENT AN ATTACK OF THE DISEASE. By Sanitary Inspector W. F. Brunner. DEPOPULATION. While the only positively safe measure to prevent the spread is to exhaust the material by depopulation of the infected city, a complete depopulation is impossible. DAYLIGHT COMMUNICATION. In the epidemic of 1876 at Savannah, Ga., it was the habit of several hundred business men to leave the city every afternoon before sunset and spend the night at some of the small towns near by, returning next morning after sunrise to pursue their different callings. But few cases developed among such persons. This plan was suggested after the manner of rice planters and their white managers, who, while daily visiting the rice fields, obtained freedom from attacks of malarial fevers by following this custom. CHOICE OF RESIDENCE—BEST HIGH ABOVE GROUND. There are other persons to be found in infected towns who are unable to leave the city for the night. To this class of persons it is suggested that they occupy living and sleeping apartments as far removed from the ground floor as possible, which should be on the sunny side of the house, and which should be aired daily during the middle hours of the day, and closed during the night as much as would be consistent with comfort. Avoid in every way^™^ exposure to the night air. In a seaport or in a town on a river persons should be prohibited from sleeping near the wharf or river front. Every epidemic has shown that yellow fever attacks more readily persons living in such localities, and the fever 335 336 • MARINE-HOSPITAL SERVICE. assumes a more virulent form. My experience in Savan- nah, 1876, and Vicksburg, 1878, gave positive and prac- tical evidence of this fact. INTEMPERANCE DANGEROUS. The avoidance of all intemperance should be practiced. Alcoholic stimulants are often indulged in, presumably to dull the fear of contracting the disease, but it is known that the highest mortality of yellow fever exists in those persons addicted to the free use of liquor. DIET. Foods should be avoided which are likely to cause irrita- tion of any part of the alimentary tract, and as much care should be taken against the use of drugs so often recom- mended and used by the laity to prevent an attack of the disease. During every epidemic of yellow fever drastic cathartics are daily taken by the advice of druggist and friends. No more unwise course could be pursued. With a suspicious or doubtful water supply, boiled water should always be used for drinking purposes. LAUNDRY. Care should be taken as to disposition of soiled clothes, as they may be taken to infected houses to be washed, and, while returned mechanically clean, may be infected. POLICING PREMISES. The daily removal of household wastes should be care- fully looked after, and all back yards be kept scrupulously clean; great care should be taken not to use one or more of the numerous " so-called disinfectants," used so often to remove offensive odors, it being evident that to remove deodorize?' ° the cause of offensive odors is better sanitation than to stop one odor with another. Too much stress can not be placed on this suggestion. Damp basements and cellars ceuIJs,°etcdamp should be dried and quicklimed at frequent intervals. Privy vaults should be frequently disinfected. The isola- tion of a patient suffering from an attack of yellow fever should be as complete as that of one suffering from diph- theria or scarlet fever. Care should be taken to sterilize penCekroom hy"a11 clothing and material in the infected room and to thoroughly disinfect the room and contents after recovery or death of the patient. It must be said that these sug- Catharsis. Water. MARINE-HOSPITAL SERVICE. 337 gestions are applicable only to the intelligent, thinking class of a community; for all others sanitary policing by the controlling authorities is absolutely necessary. TROOPS IN TROPICAL CLIMATES. What has been said in the preceding remarks will apply but little to troops occupying cities and towns in Cuba. Havana, being the largest and most important city in the island, will be the point against which the main body of troops will be thrown, and, after occupation, will require a large force to garrison it. The number of the garrison should be at a minimum compatible with military safety. If possible there should be no men quartered within the city proper. ALTITUDE AND DRYNESS ARE FACTORS IN CAMP SITES. They should be camped on the high hills of the Vidado, lying west of the city. It may be suggested here that the wooden pavilion hospital Alphonso XIII, after disinfec- Aiphonsoxiii tion, could be used as a barracks, care being taken to de- ^spital * good stroy those pavilions which have been used for the care of smallpox and yellow fever. This hospital has a capacity of 3,320 beds. CITY QUARTERS FOR TROOPS IN HAVANA If it is necessary to quarter the men in the city, they should not be housed in any building before complete dis- infection of the same, nor should they occupy any building east of that portion of the city bounded on the north by the Calle Prado. OLD CITY IS VERY BAD. The portion of the town proscribed is the old part of the city, and includes that part bordering on the bay. In my opinion, if it is absolutely necessary to have an armed force of men within the city, they should not be quartered in any building, but should occupy tents placed in the center promenade of the Calle Prado or Prado street. The street Prado a good is the line of demarcation between the old and new sections of the city; it is about 220 feet wide and extends almost due north and south for approximately 1 mile, being inter- sected by what is called the Central Park. The center promenade of the street is raised about 2 feet above the carriage ways on either side, is about 70 feet wide, with 338 MARINE-HOSPITAL SERVICE. two rows of trees on either side furnishing shade during the hottest part of the day without entirely excluding the sun's rays; its surface being elevated above the carriage way, it is free from dampness. RELATIVE SAFETY ON PRADO. There is no question as to the wisdom of quartering the men in tents pitched on this street; many Americans have lived on this street during the writer's residence of one year, and they enjoyed immunity to yellow fever to a marked extent. With the men so quartered all requisites of sanitary policing could be rigidly carried out. Great care should be taken to prevent the men from having the liberty of the city, particularly that part of it near the wharves; night leaves of absence beiug prohibited. This disposition of troops naturally can not be made in reference to other cities beyond the recommendation that if possible the men be quartered outside the different cities. CLOTHING FOR CUBA OUGHT TO BE WOOLEN. One of the principal precautions to be taken is in the matter of clothing. Flannel, light in texture and color, is the best material. Our ration table should be carefully looked after, as the ordinary ration will not answer in Cuba. A PRECIS ON HYGIENIC MEASURES TO BE TAKEN IN A TOWN INFECTED WITH YELLOW FEVER. By Surg. H. R. Carter. WHEN TO ESTABLISH PROVISIONAL QUARANTINE. In general* on the credible report of yellow fever, or suspicious fever, at a place, steps should at once be taken to prevent people and goods from that place leaving it. This should be done pending investigation, which should be immediately made, and the quarantine proclamation should announce that it is temporary and only until investigation is made. For this time, however, the prohibition should be absolute (save possibly for those certainly going to places incapable of infection by yellow fever, and to remain in such places). This is necessary because one case reported may mean a thoroughly infected town, and the exodus, almost certain to take place on the report that an investi- gation is being made, may do irreparable damage. With this had best be also included (in partial quarantine at least) such places as from communication with the quarantined place would naturally share its infection should it be infected. Thus a quarantine (temporary) of Biloxi and other coast towns had been advisable when fever was reported at Ocean Springs. WHEN QUARANTINE IS NOT NEEDED. (1) When the case reported is reported as an "imported case" (i. e., is believed to have contracted infection elsewhere), and is reported early. The presumption then is that there is no focus of infection in town, and if this be true, quarantine is unnecessary. An example is the De Villa case in New Orleans in 1889. This man contracted yellow fever in the tropics (Livingston, I believe) and developed it in New Orleans (or en route) and died in New Orleans on October 3, 1889. It was obviously not contracted in New Orleans; its presence showed no focus of infection there, and quarantine on account of this case was unjustifiable. Similarly the Gelpi case of 1897, obvi- *I say "in general," because there are conditions in which this is inadvisable. 339 340 MARINE-HOSPITAL SERVICE. ously contracted in Ocean Springs, gave no sufficient reason for quar- antining New Orleans, although the known communication of New Orleans with Ocean Springs, I think, did justify partial quarantine independently of the report of any case. An example showing where this rule had led to error, however, is afforded by the Branham case of 1893, at Brunswick, Ga. This case was reported, and believed, to have contracted fever at the quarantine station and was brought to Brunswick. If this were true this sickness was no evidence of focus of infection in Brunswick, and hence no abso- lute quarantine was laid pending investigation; only an inspection quar- antine was put on to prevent persons going by common carriers from Brunswick to infectable towns south, such as Savannah, Jesup, Jack- sonville, etc. On investigation three other cases were found, and on the finding of the second case an absolute quarantine was laid. In the meantime people had driven out from Brunswick to country places near by, and indeed to some distance, and from one of them, Jesup indirectly received its infection. What credence to give to the reported origin of a case of yellow fever reported in a town prior to a full investigation is often a serious prob- lem; but the consequences of delaying action, should immediate action be needed, are so deplorable, that, if doubtful, a temporary quarantine should be laid. (2) When the town is large, There are three reasons for this exemption. (a) The chance of a large town having much infection in it with the report of the first case is minimal, and is not possible if the health officers act in good faith. (6) An exodus from the investigation is little apt to take place from a large town. It is certain to do so from most small towns, and the town being (proportionately) less infected, such exodus as might occur is less dangerous. (c) The loss occasioned by the quarantining of a town is in direct ratio to its size and the length of time it is maintained; and, as the time required to make a satisfactory investigation of a large town is considerable and may vary considerably, the loss from absolute quaran- tine of a large town pending investigation would be very much greater than for a small one (probably about as the squares of their population). It seems, then, that to omit the quarantine of a large town pending investigation is less dangerous and to institute quarantine more injurious than in the case of a small one, and I think in general quar antine should not be imposed on a large town pending investigation. INVESTIGATION OF EXISTING FOCI. Having determined on the diagnosis of the reported case or cases we should, if they be found to be yellow fever, find out— (1) The source of infection. (2) The amount of infection. MARINE-HOSPITAL SERVICE. 341 (3) Who has been exposed to that source or to the foci (presumably) established by the sick in town. I. SOURCE OF INFECTION. The determination of the first may enable us to pronounce the case an imported one, and possibly relieve the town from quarantine. It may enable us to suspect a focus of infection in an unsuspected town, as the case reported by Holloway in Louisville in 1897 led to the inves- tigation of Ocean Springs, Miss. Yellow fever in a resident (as in a new comer from a place where no yellow fever exists) is strong evidence of a focus of infection in town, and hence of other cases. II. AMOUNT OF INFECTION. At the same time, an investigation of other cases of fever in town should be made to determine their nature. A rapid examination of the mortuary reports for the past six or three weeks—a more complete examination may be made later—and such diagnosis investigated as fatal cases of yellow fever are liable to be reported under. This is especially necessary if the source of infection be unknown. Following the preliminary investigation, a careful house-to-house inspection is, for a small town, always to be instituted. III. EXPOSURE TO INFECTION OR TO THE SICK IN TOWN. While investigating the source of infection and determining the existence of other foci or cases in town we must find the location of all who have been exposed to infection, whether from the original source or foci of infection, and to the (possible) infection of the premises of the sick. These are the " suspects." This is a most important and difficult inquiry and the success of the measures, if it be suppressible, depends mainly on its thoroughness.* In this connection it must be remembered that the infection of yellow fever is transmitted a little way aerially, especially down the prevail- ing wind, and there are instances of the measures above described proving futile because the residents of houses adjacent to the infected premises were not counted exposed and therefore kept under observa- tion. It was partly to a careful watch of the houses to the leeward of the infected premises that the suppression of the yellow fever at Franklin, La., in 1897, was due.t How far infection can be conveyed aerially may be a question. Melier's celebrated case at St. Nazaire, in 1861, I think, reported to *The writer has on two occasions found that the laundress, to whom the soiled clothes of the patient had been sent, had not been considered in enumerating those exposed to infection. Inquiry must be made of these and all other articles leaving the house since the sickness began. tin the town of Franklin every physical condition against controlling the fever seemed to exist, and yet it was controlled. 342 MARINE-HOSPITAL SERVICE. have contracted it at a distance of 220 meters, and the writer reported a case in 1891 where the apparent source of infection was a measured 70 fathoms distant. Still, these cases are altogether exceptional, and it is so difficult to eliminate all possible chances of infection that it may be that the apparent source of infection in both of these cases was other than the one considered by the reporter. There is no question, however, that infection i? not infrequently taken from a focus across an ordinary street, and in uy experience this is about as far as it is transmitted. CONDITIONS WHICH DETERMINE QUARANTINE.—PARTIAL QUARANTINE. As soon as the nature and extent of the infection and the measures to prevent transmission of the disease in the town are sufficiently determined, we can determine on the measures of quarantine, if any, which should be adopted against the town. The first question to be determined is, Does the place require quaran- tine, or shall that put on pending investigation be raised? (A) If the disease be certainly confined to a few houses and all who have been exposed to possible infection be known and this house or these houses and all exposed to infection be under guard and sanitary supervision— i. e., "in quarantine," quarantine against the town maybe raised. If in doubt whether all who have been exposed to infection are under observation, it will be necessary to wait some time greater than the maximum period of incubation of the disease before doing this, and if no cases arise in the town we can lift the quarantine. Proper precau- tions to prevent infection from every possible focus having been observed, this, of course, is equivalent to holding the whole town under observation, "in quarantine," and implies a careful and frequent inspection. WHEN DISEASE OCCUPIES RESTRICTED LIMITS. (B) Similarly, if the disease be confined to a portion of the town and this portion can be efficiently isolated from the remainder, this may be done, and this clean part of the town used as a detention camp; and after the period of incubation has passed, there being and having been no fever among the residents, they may be released from quarantine. Since the release of these people from quarantine depends on no fever developing among them, a most careful inquiry for those of them who have been exposed to infection should be made, and these should be removed from this part of the town. FOMITES. Care must be taken with clothing, etc., of these people, not only to prevent them carrying possible fomites out of the quarantine, but to insure that they are not exposed to infection from fomites while MARINE-HOSPITAL SERVICE. 343 they are undergoing their detention. To require the disinfection, when they leave, of the clothing which they take with them is wrong in prin- ciple. If this stuff', or any in the house, be infected, these people are continuously exposed to infection and should not be released. If it be not infected disinfection is not needed. By going through the premises carefully when the isolation is begun we can very generally determine if there be anything in the house which requires disinfection, and if there is it shouM be disinfected then, not later. It was on this principle that in 1897 the camp grounds and Heart- ease Park were isolated from Biloxi, with which they form almost one town, and the residents given pratique after ten days. The same was done in 1893 about Waynesville, Ga., and in both cases a considerable number of people relieved from quarantine restrictions with safety. It is thus seen how the quarantine laid against a town pending investigation will be modified both by the amount of infection and by the sanitary measures taken. The fact that it will be so modified is an added inducement to the town to take proper sanitary measures. COMPLETE QUARANTINE. I do not propose to discuss the methods of putting on a general quarantine against a town, as the problem varies ad infinitum. Whether a cordon forbidding all direct egress of persons, etc., be established; or whether it be limited to guards on the general lines of travel, includ- ing dirt roads ; or simply to railroad and water craft, will depend, as will the degree of communication authorized, on local conditions. The first, of course, should give the most security. For a large place it is generally impracticable, owing mainly to the territory immediately surrounding a large town maintaining direct communication with it, either unlimited or surrounded by certain safeguards, as "daylight communication." This makes the extent of territory exposed to infec- tion too large to be surrounded by a cordon. Whether this direct com- munication should be permitted by the health authorities depends on the risk of spread of infection outside of (and in) this "neutral terri- tory," and must be decided on its own merits for each case. It increases this risk. A word about "daylight communication." Briefly, this is direct communication with an infected town. Persons being allowed to visit it during the daytime—hours generally 10 to 4—under pledge to enter no residence, attend to their business, and return home. People living in the infected town are not allowed to enter the clean one, and certain classes of (or all) merchandise are barred. It depends on two principles: (1) That the infection of yellow fever is mainly confined to the habita- tions of men and their environments. (2) That the disease is not liable to be contracted in the daytime. 344 MARINE-HOSPITAL SERVICE. The first is unquestionably true, and in towns which have a business district distinct and at a considerable distance from the residence portion there is extremely little risk of infection in the business portion of the town night or day, unless the infection of the town be very general. The second is, I think, true to some extent, and if bright, clear day out of doors be substituted for "daytime," probably to a very consider- able extent. Still, most of the evidence brought forward to establish this point involves the first also. The fact remains that people entering a town infected with yellow fever, for business only, coming in after the sun is high and leaving before the late afternoon, rarely contract fever. The instances, how- ever, where communities allowing " daylight" communication have received infection are not rare, and while we (and they) generally explain it by showing that it was some carelessness or bad faith of the person who brought the fever, still, the fact remains, and places holding such communication for a long-continued period will fre- quently become infected. In proportion as this privilege is confined to reliable business men, to short hours, clear days, and rigidly super- vised, it is safe (or rather little dangerous), but women are prone to visit friends. The detail is easily worked out. As a general principle in quarantine operations the guards are most efficient if taken from the country to be protected rather than from the town quarantined, although we always desire to make all possible expenditures among the people of the town, because they need it. WORK IN THE TOWN TO SUPPRESS FEVER. The question here is, Can the fever be suppressed? (A) If there be few foci in town, and they be known, there is good chance of suppressing the fever. If, in addition, all who have been exposed to infection are known and can be properly provided for, this chance is much increased and we can usually attain success. Thus, at Cayuga, Miss., in 1897 Dunn found two foci of infection. Those who had been exposed to infection were in 13 other households. These were kept under observation. In 5 no fever developed in ten days, and they were released. In the remaining 8 fever developed and went more or less through the households. Proper and efficient sanitary measures of isolation and disinfection were taken, and there was no further spread. Similarly, at Franklin, La., although the problem was more difficult, as it was not possible to determine all who had been exposed to infection, yet by similar measures and careful inspection the same result was attained, as also at other places. (B) If the fever be confined to one section of the town, even if pretty general therein, it may be possible to so isolate that part as to preserve the remainder. MARINE-HOSPITAL SERVICE. 345 This was successfully done in 1897 at Clinton, Miss., by Waldauer and Mayor Coleman. A cordon was placed about the infected portion of the town and the disease was confined to 18 houses—about 73 cases— the remainder of the town, about 200 or 300 houses, escaping. This work and at Cayuga, by Dunn, mentioned above, must be characterized as brilliant. DISPOSITION OF PATIENT HIMSELF. The patient should if possible, and it generally will be impossible, be moved to an isolated place or a well-appointed hospital. We can prac- tically always keep such a hospital from becoming infected and the infection of an isolated place, should we fail to prevent it, is little dangerous. How much risk should be borne by the patient and how much by the community is a question which the health officer must consider in advising removal. In general, removal during the first forty-eight or sixty hours prior to the "stage of calm" is not specially injurious. We habitually remove the sick from vessels during this time, and they get well. After that time it is to be deprecated. PREMISES WHERE PATIENT IS TREATED, AND HIS ATTENDANTS. If moved, all possible precautions to prevent infection of his new quarters must be taken, and I believe we can very generally succeed. If he is not moved, precautions to prevent infection of the premises are even more necessary. They will be less often successful. Cleanliness, dryness, good ventilation, sunshine, are all important. No fabrics, carpets, hangings, etc., not absolutely necessary, should be allowed in the room. The clothing, bedding, etc., which go with him if moved must be immediately disinfected. A rubber sheet to protect the mattress must be on the bed. The bed linen and shirt must be changed daily, oftener if soiled; the rubber sheet changed when nec- essary. All fabrics used about the patient should go immediately—in the room—into an antiseptic solutiou. The floor is to be wiped up daily with a similar solution. All excreta* should be disinfected or destroyed, and, in short, every detail to prevent contamination of environment by the patient be carried out. * Observations by Archinard, shortly to be published, gave no cultures of the B. Sanarelli in the urine or black vomit; rarely in the scrapings of the skin (face, throat, and chest); more commonly in the exhalations aud excretions of the mouth. As this bacillus is found in the blood, it may be that the blood from the gums was the source of contamination. That it was not found in the black vomit (blood), may have been due to its acidity. The feces were not examined, but from the similarity of the behavior in cultures of this organism and the bacilli of the colon group and the fact that abrasions of the intestinal mucous membrane, and hence the exuda- tion of blood in the intestine, are universal in yellow fever, it is highly probable (certain?) that the faeces do contain this organism in large number and are thus the main source of its elimination from the patient. One case in Franklin in 1897 is traceable very clearly to faeces or urine of a yellow-fever patient. 3934----5 346 MARINE-HOSPITAL SERVICE. PROPER AND INTELLIGENT ASSISTANCE. The presence of intelligent trained attendants is necessary to carry out these measures, and no consideration of economy can be allowed to come into conflict with this effort to prevent the establishment of a new focus of infection. The above principles are to be observed in the premises in which the patient is treated, whether they be those in which we find him or those to which he is moved. They are to prevent infection or further infec- tion. If he be treated in the house in which we find him—presumably infected before fhe institution of these measures—such measures as are possible to destroy the infection, which already exists, must also be instituted. If possible, prepare a room for the patient on the upper floor, which is sunny and well ventilated, by removing all superfluous fabrics, etc., and scrubbing it out with bichloride solution; then move him into it, and keep it clean. Disinfect as well as can be done without disturbing the patient, and very efficient work can be done. Everything possible must be disinfected—scrubbing all parts of the house, the late sick room especially, with bichloride solution, disinfecting (or destroying) the used bedding, upholstered furniture of the room, etc., and keep the house, the sick room especially, open to sun and wind to the fullest extent as long as it is dry weather. Pay especial attention to the places where the excretions of the patients have been thrown and to any soiled clothing that has been used about him, etc., and, finally, as much cleaning up and disinfection outside the house as can be done and may be needed, should be promptly attended to. The only town in 1897 (until cold weather) which could show a single case of fever without any spread was Perkiuston, Miss., where a very careful disinfection was begun on the third day of the disease and a careful asepsis carried out to the eud. The premises, also, were under guard. The work planned as above was carried out by Dr. Champe, of Perkinston. If the patient be moved, the premises are to be disinfected by immunes, who need only disinfect their clothing, hair, hands, etc.; or, if this be impossible, by nonimmunes, who must disinfect the same way and be treated like the original nonimmune inmates of the house. The house in which the patient is treated (unless a hospital, which we feel sure we can keep free from infection) is to be treated, until it is dis- infected, like an infected place, although we can frequently prevent its becoming so. It is to be put under guard and no ingress avoidable allowed. There is no theoretical reason why egress for short periods (hours) should not be allowed to those feeling perfectly well if sure oi the sterility of their clothing, hair, etc., and it would keep them in better health—hence less susceptible to infection —to takeexercise. Yet, owing MARINE-HOSPITAL SERVICE. 347 to the willingness of people to take risks for their neighbors and the rarity of sustained carefulness in the laity, I would in general not advise this. Hence, no egress. Still, there may be circumstances in which this may be allowed. It can be made free from danger by intel- ligent supervision. PRECAUTIONS TO BE TAKEN BY ATTENDING PHYSICIANS. The physician, if not immune, must take precautions not to establish a new focus should he develop the fever, regulating his disposition of himself on the hypothesis that he will develop it. He should especially not sleep at any house in which it would be objectionable for him to develop fever. It seems to me best that he should stay on the premises with the patient. In any case he should wear clothing little liable to convey infection—linen or other smooth clothing, or change it if he goes out. I know this is very seldom necessary, but sometimes it is, and if the patient be regularly attended through his illness, and much time spent in his room, there is a slight indeed, but real, risk of conveying infec- tion in this way.* These precautions are recommended only when there are very few patients and every real risk, however slight, is to be avoided. PREMISES CONSTANTLY UNDER GUARD. Until these premises are released from observation they must be under guard. This has already been stated. These guards should be immune and precautions taken against the conveyance of possible fomites by them.t If immunes are unattainable, the guards must be under closer supervision, as they will be exposed to possible infection. They must sleep in the guard camp, be inspected twice daily, and other precautions taken, lest they establish new foci, if they develop fever. They should be, of course, as little exposed to infection as possible, and it is, indeed, generally nominal. DISINFECTION OF PREMISES. The premises of the patient and all things in them, including the patient and attendants, must be disinfected as soon as possible on his death or recovery, using the precautions about the disinfectors pre- viously given. *The writer believes (oral communication from Dr. Tarlton, of Patterson, La.) that yellow fever was thus conveyed to Patterson in 1878, and considers it very probable (oral communication of Dr. Folkes, of Biloxi) that it was thus conveyed in one instance to a house near Biloxi, Miss. In both cases the physicians, believed to have conveyed the disease, had been long in the infected rooms (which were badly infected) and in prolonged intimate contact with the sick, his bed, etc., and indeed under the conditions usual with nurses rather than physicians. t Three instances have come to the writer's notice of foci of infection established by guards. 348 MARINE-HOSPITAL SERVICE. WHEN DOES CONVALESCENT BECOME INNOCUOUS? At what time during his sickness or convalescence a patient becomes incapable of infecting his premises I do not know, nor can I find any observations or even opinions on this subject, and yet it is a very practical matter for sanitarians. DISINFECT NEIGHBORING PREMISES. The premises adjacent to those of the patient which from propin- quity, communication, or direction of wind can reasonably be judged to have received infection are also to be disinfected. DEPOPULATION. In addition to these means to prevent infection of premises and, fail- ing this, to isolate them, a most valuable adjunct in suppressing yellow fever, existing under the described conditions, is depopulation of the neighborhood and of the presumptive focus. How far this should be done is implied in the paragraph on aerial transmission of infection; but the wider and more completely (within limits) it is done the better from a sanitary standpoint. Keasonable precautions are to be observed lest new foci be established by some of these people who have been already exposed to infection. (See "Disposition of suspects.") This depopulation, however, is meant to extend well beyond the dis- tance to which fever may be reasonably expected to be aerially trans- mitted from the focus, the intention being to render the focus as isolated as possible from people. Indeed, a general depopulation of the town, safely done, is of much aid in suppressing the fever. In general, how- ever, it is scarcely advisable. DISPOSITION OF SUSPECTS. Now the inmates of the house of the patient (unless immune to yellow fever) should be removed from the house, all clothing, etc., disinfected, and kept under observation, "quarantined," in a place free from infec- tion and so situated that if any of them sickens he may not establish a focus of infection dangerous to the community, i. e., either in locality insusceptible to infection as to northern points, Atlanta (Arbita Springs?), etc., or so isolated by distance and guards that its infection will do no harm to others (Camp of Detention). Indeed it is not gen- erally difficult to prevent such a place from becoming infected with yellow fever, if one has charge from the beginning of a suitable place, even if fever develops among the suspects. These people, if in an infectible locality, should be inspected twice daily until the period of incubation has passed, and if one of them sickens, he must be promptly isolated from the remainder (or better, left where he is and the remainder isolated from him) and measures of disinfection taken. If in noninfectible territory all this is unnecessary. MARINE-HOSPITAL SERVICE. 349 If it be impossible to remove the inmates to a place of safety (it should never be, save by their own will), they must be quarantined in the house. This is bad—bad for them and bad for the community— because there is thus risk of prolonging the existence of the fever in the infected house. Their own risk being optional, they must take it for the safety of the community. Here measures previously inculcated to prevent infection of the house are especially necessary. It is to be noted that if the case be discovered early—time limits not definitely determined—the premises apparently are not yet capable of communicating infections to persons, and the inmates have not, so far, been exposed to chance of infection. This is a reason for their prompt removal, and the statement one so often hears, "I had as well stay, as I have been here ---- days," should never be allowed to weigh with health officers in allowing these people to ignorantly risk their lives. Those who have been exposed to infection—not inmates of the patient's house—must also be provided for. If possible they should be sent to noninfectible territory or to an isolated place (Camp of Detention) and kept there under observation during the period of incubation of the disease, due care being taken that they are not exposed to any infection, as by fomities carried in, while isolated. If neither of these methods are practicable, they must be inspected daily or, if possible, twice daily at their own houses, and measures, as before indicated, taken should they become sick. There is no theoretical reason why these people may not pursue their ordinary avocations while well, as during the stage of incubation the disease is not transmissible, but there is every reason why they should not sleep away from home (fever very generally developing at night), and, unless they be trustworthy, they had best be kept on their own premises. It is to be noted here how rarely people taken from infected premises and placed in camps, or under the conditions of camp life, develop fever. Whether it be the relief from anxiety or the open-air life, the fact remains that the development of fever among suspects in camp is rare. I know of no definite comparative statistics, but the fact has been remarked by all who have had experience and whose attention has been called to it, that development of fever among people in camp is far less common than among an equal number isolated in their own houses. Measures of this kind are taken for the purpose of preventing further development of the fever—"to stamp it out." They certainly give a fair chance of success if the early cases are reported. Failing this, they will greatly retard its rapidity of spread and will have done good in proportion to the lateness of the season. Indeed, if the season be very late, it may be advisable, in spite of what will be said presently, to continue these measures or a modification of them even after we have no hope of suppressing the fever by their means, for the purpose of lessening the rapidity of spread of the fever, which is then extremely desirable, being indeed equivalent to an earlier frost. 350 MARINE-HOSPITAL SERVICE. The stringency with which they should be then administered depends on many conditions, mainly the lateness of the season. A balance is to be struck between the good to be gained and the hardship imposed. HOUSE QUARANTINE OF NO AVAIL IF MANY CASES ARE CONCEALED. And here let me also say that the measures above outlined for use prior to an epidemic are recommended where practicable—i. e., when the authority or influence of the health officer is sufficient to carry them out.* Should the condition be such, however, that the attempted enforcement of these restrictions leads to the successful concealment of cases they must be modified, as successful concealment of cases takes away all chance of suppressing fever. Our reliance is then placed on preventing the infection of his environ- ment by the patient and preventing ingress. Above all, the first is important and is to be depended on. The presence of the sanitary inspector and of the trained nurse necessary to carry this out are such boons to the patient that we may be sure that no cases will be concealed on account of these measures, if reasonable tact be used. Indeed, the aim must be in all cases to make the household with the yellow fever a privileged one, so that it will be to its interest if there be a case among them to have it officially known. To this end physicians and medicines, delicacies for the patient, and even subsistence for his family free, are wise sanitary measures as well as charities. Remember, if cases are concealed to any considerable extent our chance of suppressing the fever is lost. MEASURES NECESSARY WHEN THE FEVER CAN NOT BE SUPPRESSED. The townspeople are always loth to recognize that this condition exists, but when we find cases arising of which we can not trace the source of infection, when we are unable to efficiently carry out the measures here outlined, or when cases are being successfully concealed we may know that the fever will not be suppressed until it has run its course or cold weather supervenes. * Obviously it is implied that the state of feeling in the community is to be taken into consideration also. Measures which will be readily agreed to and carried out in good faith in one community will excite violent and unconquerable opposition in another. The observation of the writer is that, in small towns at least, Americans of Eng- lish descent will willingly bear any reasonable amount of inconvenience and some hardship if convinced that this ia necessary to avert a greater calamity from the rest of the community, whether of their own town or neighboring towns, and if con- vinced of the reasonableness of the measures to be taken will assist in carrying them out. The case of Jesup, Ga., which closely guarded itself, well illustrates this, as does the "house quarantine" in Franklin, Perkinstou, and several towns in north Mississiiqn. It is paralleled by the history of not a few English towns with the plague. The sense of duty to the community seems to be strong. MARINE-HOSPITAL SERVICE. 351 ILLICIT COMMUNICATION. An infected town is a source of danger to its neighbors, no matter what means of quarantine are taken. This is because a certain amount of illicit communication from the town to clean territory will be kept up, no matter what rules and regulations are made. The clanger is almost exclusively due to those who leave the town for infectible terri- tory. It is in proportion to the number who thus leave directly and to the proportion of infection in the town, hence to their product. Thus, 100 persons leaving when there is 1 per cent of the town infected con- veys the same risk as 10 people if 10 per cent of the town be infected. It is our aim, then, to reduce the number who leave directly for infect- ible territory to a minimum (and, if possible, have none to leave). But to take such risk of leaving as must be taken rather in the beginning of the fever, when there is little infection, than later, when there is much more, we first take measures to prevent these people leaving directly without sanitary supervision—i. e., establish quarantine, and, second, arrange for their leaving under such conditions as will not con- vey infection to clean territory. MAKE LEGITIMATE COMMUNICATION EASY, AS BEST PREVENTIVE OF ILLICIT. This allowing some means of egress from the infected town should go hand in hand with the prohibition of unsafe egress, not only on the ground of humanity to the townsfolk but because a legitimate means of egress being provided, the number of attempts to pass the lines in other ways—a certain proportion of such will succeed—is enormously lessened, and the providing of a legitimate means of egress, if safe, is an added safeguard, and an important one, against the infection of clean territory. While it is scarcely necessary to cite instances of this, many can be given; it is self-evident, certainly to all who have had experience of epidemics and seen the imperfection of the best devised prohibitive measures. On the same principle this means of egress should not be made more difficult than is necessary for safety. We wish to encourage its use; to have it, rather than an "underground railroad" selected by those who would leave. Depopulation, then, which has long been recommended as a valuable means of lessening the horrors of an epidemic in the interest of the infected town, is not less valuable as a protective measure to the surrounding infectible territory. EARLY DEPOPULATION SAFER THAN LATE DEPOPULATION. Stress should be laid on early depopulation. There is then not much infection in town, and not only are people who leave escaping risk to themselves by leaving early and lessening the rapidity of the spread of 352 MARINE-HOSPITAL SERVICE. the disease in the town, but the chance of infection of outside places from any mishap which may occur is less than if it should happen later, CLASSES WHO MAY LEAVE. All who have been certainly not exposed to infection, which we would be able to say of few later, should go without let or hindrance. The others may go (1) directly to points incapable of receiving the infection of yellow fever, generally northern points—high altitudes— to remain there indefinitely, or for a time to cover their incubation; (2) to points capable of receiving such infection but through a camp of detention. By a "camp of detention" is meant any place at which these persons stay unexposed to any infection a sufficient time to cover their period of incubation. No infected article going within. PEOPLE LEAVING FOR NONINFECTIBLE TERRITORY—POINTS NORTH. (1) How to get these people through infectible territory to their destination without infecting it is a problem of "traffic," and will be there considered. Before these people are allowed to go north we must be assured that they will remain there to cover the period of incubation of yellow fever, say ten days, or indefinitely, i. e., after frost. TREATMENT OF BAGGAGE. Disinfection of baggage is not necessarj' for such people. If, however, they will return after a time to points South, their baggage must be disinfected on departure. Indeed, if there be any reasonable doubt of their not returning, the burden of proof being on them, disinfection of baggage must be done. The methods by which the train inspector, on whom this work falls, assures himself (1) that a passenger intends and will stay North indefi- iuitely, and (2) that he will stay ten days and not double back, must be worked out for each particular epidemic, and to a certain extent to each particular road and case. A good man will err by over suspicion and hard rulings. TRAIN INSPECTIONS. A person leaving New Orleans in 1897 took an affidavit—the stub of which was preserved by the train inspector—that he " would not return to any place quarantined against New Orleans" or that he would not return to quarantining place " for ten days." In the latter case his baggage was disinfected and a certificate of disinfection given him giving the date of his departure from New Orleans, and of course the same date of disinfection and the number and kind of pieces disin- fected. A label of thin paper was then pasted on each piece of bag- gage. The certificate of date of leaving New Orleans had a personal description, and the baggage label was made of thin paper so it could MARINE-HOSPITAL SERVICE. 353 not well be detached and used over again. It had the name and date on it, and was signed. It seems best to disinfect all baggage going to remain at points like Atlanta, Charlotte, Nashville, etc., which are great distributing points for railroad travel south, and the only baggage ever sent to any such places undisinfected in 1897 was that of some schoolgirls going to Nashville to a seminary the latter part of October. Indeed, Atlanta required this to save herself from quarantine by the coast cities. There seems no reason why baggage going north through these places should be disinfected, any more than Havana baggage going by the Ward Line to the same points. Indeed, there is good sanitary reasons for not doing so. Every obstruction, however slight, put in the way of people leaving an infected town to some extent prevents their leaving and to a disproportionate extent induces them to put off leaving if they do leave. We want them to leave early. Again, as before said, no quarantine is perfect, and in proportion as a safe and legitimate way of exit is obstructed the illegitimate ways are sought, which is (especially if sought after the town is well infected) danger- ous in the extreme to the territory we seek to protect. Unless we have been in an epidemic on the inside we fail to realize what slight obstructions prevent people leaving an infected town by the ways provided and induce them, for the purpose of avoiding moderate inconvenience, to take sanitary risks for others which are simply appall- ing. The rule which should obtain, then, would be to "require every- thing which is necessary for safety and nothing which is not necessary," throwing, of course, the doubt in favor of stringency. Arrangements should be made with sanitary inspectors at places to which most of these people go to return South again—Atlanta, Nash- ville, St. Louis, etc.—so that they can keep some supervision of them and see that they do not leave for the South until their ten days are past. It would not be difficult to arrange for a pretty fair supervision. It will require to be supplemented by a train inspection south from some of these places. This latter has always been put on. (2) Persons leaving for infectible territory through a detention camp. The method of conducting detention camps in detail will not be described. They require much pains and care in their management. I would again call attention to the sanitary protection they afford to the quarantining places as well as advantage to the infected town by letting its people escape. By providing a safe and allowed means by which people who can not go North can leave the infected town, the effort to evade quarantine restrictions is lessened and the seepage, so to speak, through the cordon is minimized. It is extremely difficult to prevent people evading quarantine who have friends willing to receive them outside, and these are the very people who will go through a camp. For the same reasons as given for not disinfecting through baggage, the camp should be made as pleasant as possible, and impose no restric- 354 MARINE-HOSPITAL SERVICE. tions which are not necessary to prevent the conveyance of infection. The writer holds that it should be known that it will not be held open indefinitely, but be closed after a limited time, so that those intending to avail themselves of it should not unduly put off coming to it. The earlier the people come to camp the less fever will develop among them; and while the development of fever at a camp is to be expected, yet it is to be averted as much as possible. It is surprising how little does develop. WORK IN THE TOWN. It is no part of this paper to describe the "relief measures" to be taken in the town for the care of the sick, relief of pecuniary distress, etc., only such as appertain to purely hygienic " quarantine" work. They have, consequently, not been considered. They are not the less important. A modification of the measures of disinfection and isolation hereto- fore outlined may be of use in lessening the rapidity of spread of the fever even when we no longer hope to suppress it, and I quote from the latter part of a paper read by title at the Mobile Conference, on "House quarantine." House quarantine during an epidemic.—Here, it seems to me, no elab- orate or specially restrictive measures are advisable. Certainly in large towns, and with the epidemic well under way, none are practica- ble. To attempt too much is to fail and do less than if less were attempted. The aim should be— (1) To prevent infection of sick premises and to keep the other inmates from developing fever from such infection as we fail to prevent. (2) To prevent unnecessary ingress of people in the sick room, or premises. (3) To prevent conveyance of infection from sick premises to outsiders. (4) To destroy, as far as possible, the focus (presumably) thus estab- lished. Of these, the first, second, and the fourth are now the most important. (1) The removal of unnecessary fabrics from the sick room, cleanli- ness, aeration and destruction or disinfection of the discharges are about all that can be done to prevent infection of premises. The isola- tion of the inmates from the sick room should be advised and the advantage of sleeping in the upper story remembered. (2) The means which will prevent ingress varies with the respect for the law and the good sense of the community. In some places, as at Montgomery, Ala., an official prohibition and placarding is sufficient, and when this is not it is doubted if the measures which would be are advisable. In general, simply designating the houses and prohibiting entrance is all that to me seems advisable. (3) Perfection here would be change of clothing, disinfection of hair, MARINE-HOSPITAL SERVICE. 355 etc., on the part of tliose leaving the house. Free egress would then be harmless. This can not, in general, be enforced, but the change of clothing should be recommended and ordered and will be followed to a considerable extent, and to that extent do good. There is less risk in even free unconditional egress than is generally believed. (4) The premises should be disinfected with as much thoroughness as will not lead to such obstructive measures—concealment of cases— as would defeat our ends. Burning the certainly infected heavy bed- ding (soiled mattresses, etc.) and replacing it by new articles is not only good per se, but does much to make disinfection popular, and hence more general and efficient. It was found last year that the disinfection of the person—required in some towns of all in the house—was more objected to than every- thing else and, save for the patient, I would not require this and would be satisfied with soap and water for him. If an epidemic begins early in the season it may well be a question whether even the method here outlined, which works little inconven- ience and no hardship, is worth attempting. An epidemic of yellow fever well scattered in a town will be apt to go through it. The propositions presented for adoption in the above-quoted paper are also reproduced here for adoption. (1) House quarantine may be an efficient means of suppressing the spread of yellow fever in a city. (2) It may also be an efficient means of retarding its spread. If used for the first purpose there being but few cases of yellow fever in the city, (a) The nonimmune inmates of the patient's house should, if they remain in the city, be moved from that house immediately and kept under observation in an isolated place free from infection. (b) The patient if not in a suitable place, and it be safe to move him, should be moved to one, and the premises disinfected. (c) The premises the patient occupies should be under guard, pro- hibiting ingress and egress of persons, save as absolutely necessary and under sanitary supervision. (d) Every possible precaution must be taken to prevent infection of his environment by the patient. (e) Guards must be under sanitary surveillance. (/) The premises of the patient should be thoroughly disinfected on death or recovery of the patient. (g) That if the conditions be such that successful concealment of cases be caused by the measures adopted they must be so modified as to avoid this and such restrictions removed and privileges added as may be required. If used for the second purpose, during an epidemic, (a) Such precautions as are not too onerous should still be taken to prevent infection of premises of patient and inmates of his home. 356 MARINE-HOSPITAL SERVICE. (b) Ingress into the infected premises should be discouraged and unnecessary ingress forbidden. (c) Egress from the infected premises should be freely allowed, with such precautions, as change of clothing, etc., as can be enforced. (d) The premises should be disinfected on death or recovery of the patient. (e) These measures are advisable in proportion to the lateness of the season. DISINFECTION. It seems better to put these few points on disinfection of premises by themselves. They really belong on page 73, "Premises," but to insert them there would, I think, break the continuity of the sketch. It is not proposed to give a description of the process, only to call attention to a few points not always noted. A. The owner must be insured against any loss from disinfection. We must do no injury, or pay for what we do. If this be not done, it may lead to concealment of cases of fever or else to concealment of fabrics especially valued, which thus escape disinfection. B. Unless the disinfector be experienced, it is well to do as much burning,* wetting and soaking in antiseptic solutions as possible, using gaseous disinfectants as adjuvants. C. For gaseous disinfection the house must be close or must be made so. For thick fabrics—cotton quilts, mattresses, pillows, beds, etc.— gaseous disinfection can not be depended on, if more than their sur- faces be infected. For the disinfection of these articles steam is required, and, indeed, it is advisable to use this agent for all fabrics where attainable. Boil- ing, of course, is equally (absolutely) efficient, as soaking in an effi- cient germicidal solution. The writer would state that his observation leads him to have full faith in the use of sulphur dioxide if properly used; also, it has been his experience that this agent very rarely is properly used outside maritime quarantine stations. He has full faith, also, in the efficiency of the aeration of fabrics. Prolonged exposure to sun and air, reasonably dry air, will disinfect any ordinary fabric from yellow fever as completely as burning, and if the choice be between gaseous disinfection as usually applied and aeration he would, by all odds, prefer the aeration. Of course the location of the premises is frequently such that aeration of infected fabrics is not possible. The house should be kept open, well ventilated, and dry after disinfection. * Not a few cases of development of fever has been ascribed to burning infected articles. Whether the current of air caused by the fire carries the agent of infec- tion through the heat, etc., may be a question. If the surface of the pile be pretty thoroughly wetted with coal oil and this fired first, it would seem impossible that infection would be thus spread. The writer has no personal cognizance of anv spread from burning infected articles. MARINE-HOSPITAL SERVICE. 357 D. The premises outside the houses must be made clear of trash— chips, leaves, pieces of board, etc., rotting wood being believed to be an especially bad nidus of infection. The mere wetting of these things as they lay with bichloride solution is not thorough disinfection, the underside seldom being reached by the solution. It is an injury to wet the leaves of living plants with bichloride of mercury. It kills the leaves, etc., and after a rain has washed the bichloride off, these dead leaves are a good nidus (culture nudium) for any infection not destroyed, as on the underside of the leaf. It is not reasonable to believe that the living leaf would serve such an end. E. -The thorough wetting of the cleaned ground, ditches, etc., with bichloride solution or covering it with chloride of lime is doubtless efficient, but unquestionably the disinfection of the outside premises by fire is the method of election. This is best done by the Barber asphalt furnace as used by Farrar in New Orleans in 1897, which is fairly manageable. If this machine is not available, ordinary fires built and continued for a considerable time, as done by the writer at Conquests Camp and at Brunswick, Ga., in 1893, is absolutely efficient but far less manageable and more apt to set neighboring structures afire. The introduction of the asphalt furnace by Farrar is a distinct and valuable addition to our disinfecting armamentarium, and indeed is equivalent to giving a new and most efficient "method," for it renders quite generally applicable a method which was but rarely used by the crude means used in 1893. By watching the houses to the leeward of the disinfected house one can sometimes form a fairly good idea of the efficiency of the work done about the premises, even if the nonimmunes do not return to those disinfected. F. Disinfection, when we hope to suppress the fever, must be thorough. Everything must yield to this. The evil we seek to avert is too serious to weigh expense, or convenience, or hardship against it. G. When we no longer hope to suppress the fever and use this meas- ure simply to limit or lessen the rapidity of its spread the extent to which it should be carried out depends, as so many other quarantine measures, on the balance between the good to be attained and the cost, including hardship and inconvenience. In general, the fabrics of the sick room and nurses' room and these rooms themselves should at least be disinfected. This, if done by some method not injurious and little annoying—formaldehyde and steam, and scrubbing the floor with bichloride solution—will not make the second factor large, and will, I believe, in a considerable number of instances prevent the further infection of the household. No one who has examined the lists of the sick by houses, as in post-epidemic disinfection, can fail to be impressed with the fact that yellow fever is to a considerable extent a house disease, even during an epidemic. MEASURES TO BE TAKEN IN A DISTRICT THREATENED BY YELLOW FEVER. By Surg. H. R. Carter. The measures to be taken in the district threatened by the yellow fever epidemic depends to a great degree on what is done in the infected district, including its immedi- ate environment. Perfect cordon if a cordon absolutely perfect were around the infected Impossible. " x district and the arrangements for mail, freight, express, and passengers were also perfect, nothing need be done by places in the threatened district any more than by the country at large with a good maritime system on account of an epidemic in Havana. It seldom or never happens that these conditions exist, and precautions to supplement imperfections in our first guard are requisite. It is well at first to determine on the limits (next to the infected town) of certainly clean territory. The district between this and the territory adjudged infected, or probably infected (the Neutral zone. S0-called "neutral zone"), requires special attention. Before a cordon is established there is almost invariably an exodus into the country adjacent to an infected town, and after it is established there is especially at first a cer- tain amount of seepage, so to speak, through the cordon. Also the district adjacent to a large town will probably elect to continue some direct communication with it, choos- ing rather to run a certain risk of infection than to inter- rupt their trade relations entirely. Unless this action unduly risks other communities, I think it is to be allowed. This communication, too, may be so guarded that the risk is minimal ("daylight communications," etc.), and yet these districts should not be considered for quarantine purposes as "certainly clean." This region (neutral zone), of possible contamination, yet which we try to keep clean, is to be held as infected so far as communication with clean places is concerned and as clean with regard to that infected district. It should be 358 MARINE-HOSPITAL SERVICE. 359 subjected to frequent inspection, and it frequently happens that a district rendered suspicious by an early exodus of refugees may subsequently be pronounced clean. The local passenger trains running from the direction of Train inspec the infected town should be inspected. This is because a certain number of people may come out even to consider- able distance from the infected town or district in private conveyance and take the train in clean territory at way stations. A proper system of inspection and certificates of residence materially lessens this risk. Inspection must begin at the starting point and go as far as these people are likely to travel by private conveyance. More than this is unnecessary. At some suitable place on each road a place for the temporary detention of suspects is to be established. They should be put off the train at this place and as soon as practicable sent back to the gen- eral camp of detention. It may be advisable, however, to make other disposition of these suspects. There is no need of inspectors meeting the train before coming to each city. A main object of this inspection (of local passenger traffic) is as far as possible to prevent suspects getting on the train—that of the through passenger traffic to prevent them getting off in clean territory. The station agents of the railroads may be our most efficient assistants. Whether it be necessary to inspect trains from the North, No^.th.ins from to prevent the return of those who have gone North and not stayed long enough, may be a question. I think it is generally unnecessary and generally inefficient. On such trains, however, as have inspectors on them going North the inspection on the return trip should be done as an added precaution. There is a section of highland, the southern end of the re^o,nn£outh.ble Appalachian mountain system, which projects into the South, into which refugees may safely be allowed to go, but from which, owing to its proximity and other causes, a train inspection should be maintained. In this district, especially in railroad centers like Atlanta, it is also well to keep as much supervision of the movements of refugees as possible, keeping their addresses, etc., for ten days. The country adjacent to the infected district, having due regard to means of communication as well as distance, should be inspected thoroughly and often, and kept in- spected. This is necessary both for its own safety and that of the country beyond. The inability to do this on account of unwise quarantine restrictions was, I think, one cause of the spread of the recent epidemic. It is also of 360 MARINE-HOSPITAL SERVICE. the greatest commercial advantage in quieting rumors and allowing traffic to go on unimpeded, and if this work be done as a matter of routine the presence of the inspector inspection ofwni cause uo alarm or excitement. This inspection of healthy towns. healthy places may be widely extended in territory having even well-guarded communication with the infected district with the greatest advantage. In towns of considerable size it is well to have an in- Frelght?15011 ofspector of freight and express to see that none is landed without proper certificate. It is a check on the work in the infected district. Towns considered especially threatened by yellow fever Provisional should establish in some safe place a small isolation camp of both tents and buildings, where an important case of fever can be removed, if it be right to move him, and where those presumably exposed to his infection, or rather suspects, may be isolated. Time and risk of infection will be saved by having this ready. A place may be so isolated as to be in extreme danger of infection, generally by proximity, from an infected town. In this case all ingress must be subject to sanitary super- heaithyItownsDp vision and a cordon around the clean town may be required, and practically the same system be adopted as for a be- sieged city. By this method Kenner, La., 11 miles from New Orleans, received no infection in 1897, MEASURES TO BE TAKEN IN AN INFECTED AND NONINFECTED TOWN. By P. A. Surg. A. H. Glennan. The experience of this year has tended to confirm my observations made at Key West, 1 la,, in 1887, where I gained some practical knowl- edge in the early stages of a yellow-fever outbreak. The first case was discovered in a large boarding house in a populous section of the city. Immediately upon the announcement of the disease these unacclimated boarders scattered to different parts of the city, and owing to defective sanitary and police powers they were kept under a desultory surveil- lance only. An immediate exodus of other unacclimated people took place, by every available means, to the neighboring keys and the main- land. This is the inevitable tendency in any community upon the announcement of the first cases of yellow fever, and the immediate steps to be taken are, first, the isolation of the sick, guarding the infected premises and contiguous blocks as well, and second, a sys- tematic supervision over all persons and effects leaving such a city or town, with the least amount of hindrance compatible with safety. ISOLATION OF INFECTED CASES. In incorporated municipalities, infected premises are generally posted with a yellow flag, and a guard stationed at the front door. This is not sufficient. A cordon of guards—immunes if obtainable—should be established around the infected block and contiguous squares as well. These guards, when relieved from duty, should not be allowed to go to and return from different parts of the city, but should be maintained at some near central point. A captain of these guards should inspect the day and night watches at irregular times, prevent persons, vehicles, or street cars entering or departing through the lines, see that supplies and necessary articles are delivered at stated times and places, and also to arrest and return persons escaping through the lines. In addi- tion to this, a house-to-house inspection of the infected area should be made once or twice daily by competent physicians, twice daily being preferable, as it tends to reassure the persons in the restricted district 3934----o 361 362 MARINE-HOSPITAL SERVICE. At the same time a systematic inspection and disinfection of premises, yards, and alleyways should be carried out. This double guarding of first foci of infection is comparatively inex- pensive and worthy of effort, even if unsuccessful by reason of the disease appearing outside of these lines. A result is obtained in a limited time, and the expense can be rapidly discontinued. In Mobile this year yellow fever was confined for some weeks to twelve or fourteen contiguous blocks, belted by a street-car line only, which route it slowly traveled, although no systematic effort was made to restrict it to this belt. Special stress is to be laid upon the fact that guards should not wander about while off' duty. A house guard upon night duty roamed the streets in the daytime, wearing his badge; I afterwards isolated and treated him with a severe case of yellow fever, although he had not entered the infected premises. Interesting points also to be considered, both legal and sanitary, are the removal of the sick, and local depopulation of small infected areas, under proper precautions, to safe points for observation. PASSENGER-TRAIN INSPECTION. The few rudimentary rules laid down in the Eeport of the National Board of Health for 1879 are not adequate for the present rapid transit of passengers and movement of freight. The object to be attained is to ascertain that no person ill or suspected dangerous is allowed to depart from an infected city or town, and also that passengers are under surveillance while en route to destination. I attained the first object this year at Mobile by stationing a compe- tent physician at the union depot in that city, who personally examined all would be departing passengers and obtained a signed declaration of their residence, nonexposure to infection, and number of pieces of bag- gage. To this declaration was attached the inspector's certificate of examination of the bearer and disinfection of baggage. By an arrange- ment with the railroad companies box cars were located near by, for disinfection of baggage, railway mail, express packages, and other matter. Ordinary shipping tags were attached marked "Disinfected," signed, and stamped with the seal of the Marine Hospital Service. This baggage went through to all points without trouble, though I learned that baggage from other points was overhauled along the line. The second object was attained by placing a competent physician upon each departing train, to examine the passengers en route, who were persons from New Orleans and the infected Gulf coast towns as well; memorandum slips were taken up, completed, certificates checked up and passed on at the next relay, the inspector taking the return train at the most convenient point. In this way a double-check service was instituted, and after I assumed direction of affairs not a single passenger developed yellow fever after leaving Mobile. In one instance a passenger purchased a ticket without first obtaining the certificate of MARINE-HOSPITAL SERVICE. 363 inspection. He was detected upon the train and returned to the city by the inspector. The incident was not repeated by the ticket offices. In another case a prominent railroad official with his attending physi- cian departed on passes without certificates and were captured by health authorities in another State and subjected to vexatious delay and disinfection. Pullman sleeping and upholstered cars should be discontinued, except possibly upon through trains for the North. These, together with ordinary cars, should be treated with the steam air blast, disinfected at some central point, and a dated certificate of the fact attached to each car before it is allowed to return. Relays of train crews should be made at not less than five miles from an infected city or town, and another preferably at the State line. It is not necessary to transfer the passengers into new coaches, the expe- rience of this year showing that they are best detained for observation near their point of destination. Train crews, when changed however, should be rigidly kept from mingling, both on freight and passenger trains, as my experience shows that these men, from their environments, offer greater danger along lines of travel than from any other source. FREIGHT DISINFECTION. The disinfection of freight and box cars is best performed outside the city limits, with due regard to its classification. Flat cars are not specially a source of danger, but if their external surfaces are required to be treated it is quickly done with a hand force pump, hose, and spray nozzle, from a barrel of bichloride solution swung upon a light wheel truck, which can be moved along the line of the train; this will also answer for disinfecting the interior of empty box cars. The work is more effective, cheaper, and timesaving, than by fumigation, to say nothing of the absurd method of placing a sulphur pot upon the open traclc beneath a flat car, which I heard of in one or two instances. This may be classed with the exploded theory of refrigerating freight in box cars, as a method of disinfection. The cars should then be lead sealed and a red label pasted (not tacked) to the outside marked "inspected and disinfected," dated, and signed. There is no necessity for transferring freight to new cars at any relay station. Freight upon steamboats is preferably disinfected before being placed upon board, the vessel and the crew being inspected, and disinfection carried out where necessary. Only classified articles should be ac- cepted; household goods, trunks, etc., rigidly excluded. If passengers are accepted at all upon steamers running to interior points, they should be carefully examined and their baggage disinfected, as in the case of passengers departing by train. 364 MARINE-HOSPITAL SERVICE. Highways and other outlets from an infected place should be guarded, possibly by the municipal and county officers, although a great amount of good is not to be expected from these city officers in the way of pre- venting friends and acquaintances from leaving an infected place, while they might be trustworthy in keeping out any threatened danger. DISINFECTION OF THE MAIL. Considerable delay and dissatisfaction was caused during the past season by rural communities refusing to accept mail matter from an infected place under any circumstances. In my opinion, mail bags and mail matter from any infected city or town of considerable size should be disinfected with formaldehyde gas while en route. The mail matter and bags can be scattered and hung upon racks in the mail car, lamps or gas generators used, the car sealed and labeled, and the run made to the next general distributing point, where the matter can be sorted and sent back to points outside of the infected district. This method will effect a great saving of time and an assurance of security. The wooden paddle, studded with nails to perforate letters, is a slow instrument of torture and delay, besides being ineffective, as it plugs the space between the hole of entrance and exit. If necessary, a hopper should be used, but it can probably be proven that the gas is sufficiently penetrating without these punctures. DETENTION CAMPS. While depopulation of an infected city or town is to be encouraged in every way by means of through trains to places not liable to proga- gate yellow fever and willing to receive the refugees under the super- vision as already described, detention camps become necessary as filters of a certain portion of a population who are unable or unwilling to travel considerable distances, but who wish to proceed into the unin- fected surrounding country, and would otherwise do so surreptitiously. The construction and arrangement of these camps is well known. They are here mentioned as a medium of communication between infected and uoninfected places. There are a few points, however, which have developed in the experience of the past season, to which I wish to invite attention. A. The location of a camp should be selected to avoid the possibility of being shut in between infected districts, and preferably near State lines. The distance in the transportation of refugees is of little impor- tance as compared with a safe outlet, for there is no benefit in detaining refugees under observation to afterwards pass them into another infected place, even if it is to return to their homes. B. The expense of wooden buildings can be avoided, dining and kitchen houses can be superseded by medium-sized circus tents, or a MARINE-HOSPITAL SERVICE. 365 number of large wall tents lined together, with central larger tent for kitchen purposes, etc. Light, portable disinfection rooms in sections can form a part of the camp equipage and be rapidly erected for the purposes intended. C. The present heavy tentfloors, in two sections, should be cutthrough into quarter pieces for less expensive handling and quicker transpor- tation. D. In addition to the mattresses furnished a quantity of bedticks should be provided, which can be filled with hay or straw at the camp location, and afterwards destroyed. This is a good idea, suggested to me by Steward Peck of this servi ?.. If these equipments are organized in sections, heavy and bulky material dispensed with where possible, the establishment of a camp will be numbered in days instead of weeks. As soon as they have accomplished their purpose and ceased to be useful they are also more rapidly shifted, in sections, to other fields of usefulness. MEASURES AT NONINFECTED PLACES. The second part of your instructions, to state what precautions should be taken at uninfected places having communication with places which are infected, is complex and difficult. This is due to the fact that in several of the States (Florida excepted) individual counties, villages, and settlements are a law unto themselves as regards sanitary matters. Probate judges, mayors, and self-constituted village authori- ties proclaim a quarantine against the world. Trains are not allowed to pass through their territories under any regulations or at any rate of speed. The roads are tied up. Advantage is taken of the situation to twist commerce for selfish interests. To my knowledge the stock of liquors and provisions became exhausted in one of these places, and an offer was made to raise the quarantine for two days, obtain a fresh liquid supply, and close it down again. Over all this situation the State boards of health have only advisory powers, and their advice is often received with derision. I have observed, however, that where a strict total nonintercourse was proclaimed the object has been signally defeated in time by the entrance of the disease. In some cases where mail was absolutely refused from an infected place it was sent to St. Louis and other points under cover for remailing. Certain general procedures, however, may be outlined, following somewhat the rules laid down for departures from an infected city or town. First. An inspection station should be located not less than 5 miles outside of the corporate limits, where passengers and baggage considered safe can be transferred and admitted Upon a local train, other passengers and train crews being excluded, and to pass through at a speed of not less than 10 miles an hour. 366 MARINE-HOSPITAL SERVICE. Second. A camp of detention is of greater benefit near poiuts of des-; tination than if located just outside an infected district. Diversity of routes and mingling with other travelers are avoided after undergoing the period of observation, and greater confidence is given the pratique. Third. The municipal police and county officers, in a noninfected place, display greater zeal in keeping out irregular communication by road and water ways or other means of entrance by circumvention. Fourth. Mail matter should be received from the first distributing point of the postal service to the northward or outside the infected district with a general authoritative certificate of safety. Fifth. Freight, express matter, and rolling stock if not already cer- tified to as "inspected and disinfected," should be treated at the relay station outside the city limits before being admitted. If a proper surveillance is maintained over the arrivals and the steps taken in a suspicious case, as indicated in the first measures for premises in an infected place, a greater degree of safety will be secured than if total nonintercourse is proclaimed. MEASURES TO BE ADOPTED TO PREVENT THE PROPAGATION OF YELLOW FEVER FROM AN INFECTED TO A NONINFECTED LO- CALITY. By Asst. Surg. Seaton Norman. I. The patient should be isolated immediately and no Disposition of intercourse allowed with healthy individuals. The persons exposed should be removed, if practicable, to a different house, or if the weather permits, to a tent provided for the purpose, and should be kept under observation for ten days. As soon as the patient recovers or dies, the mat- tresses, pillows, comforts, and blankets should be destroyed by fire or be thoroughly disinfected. The house and premises should then be subjected to thorough chemical disinfection and the apartments exposed to sunlight and free currents of air for several days. The attending physician and nurse should, if possible, be immunes. 2. Should more than one case occur, or many foci be when mora discovered, a cordon should be established around the town occurs. or village to control the egress or ingress of the people. The advisability of depopulation will depend upon the size of the town or village, the density of the population, and the number exposed. Where a case has occurred, for instance, in an army post or in a crowded community, an immediate exodus and the subsequent detention of sus- pects will be the best method of exterminating the disease. In cities a cordon would not be considered practicable, and regulations governing the transportation of passengers, baggage, express, freight, and mails must be adopted. 3. The railroads issuing from, and the boats plying on the Supervision of river from, an infected port should be under the strictest med- ical supervision. On the line of each railroad leading from the city there should be established, if practicable, a proba- tion camp at a safe and convenient distance, where persons Detention desiring to leave the infected locality may be detained forcamps' such a time as to insure their freedom from infection. Medical inspectors should be placed on each train, so that 367 368 MARINE-HOSPTTAL SERVICE. should any passenger develop symptoms of suspicious fever he maybe isolated until a station is reached where he may leave the train. The isolation hospital of the probation camp would be the proper refuge for such a passenger. unrestricted persons wi10Se destination is north of the southern bound Drthern exit. ary of Maryland and who do not intend to return within ten days to a point quarantined agaiust the infected terri tory, may be allowed to proceed. Arrangements should bo made for the changing of train crews and railway-mail clerks at stations distant not less than 15 miles from the infected place. Changes should also be required at a point along the route 40 or 50 miles beyond the station where Railroad in- firstchange is made. Railway inspectors should accompany trains for at least 100 miles beyond any infected place. The crews and passengers of steamboats should be inspected immediately before their departure, and if the trips are of less than five days' duration, this inspection should be repeated on their return. Only two cases, I think, developed on the various steamers leaving New Orleans during the fall of 1897, and in both instances the vessels were immediately and thoroughly disinfected. 4. The express companies handled very little matter during the late epidemic, forwarding only such articles as required no disinfection. Regulations of 5. Freight for shipment should be divided into two grand reigiXent °f classes: That requiring no disinfection and that capable of disinfection. A specified list of both classes should be placed in the hands of the freight agents of the various railroads. During the past epidemic in the South such a classifica- tion was made by Surg. H. R. Cartor, United States Marine Hospital Service, and his assistants' certificates were accepted by the entire South. Note.—Free and uninterrupted daylight communication by rail and boat continued between New Orleans and Covington, La., during the past fall. Covington is a small summer resort, situated on Lake Pont- chartrain, directly north of New Orleans, about two hours' journey from New Orleans, and no case of yellow fever was reported there during the late epidemic. If a case did occur there, the conditions favorable to its dissemination did not exist. A similar instance of the capriciousness of yellow fever is recorded by Dr. John P. "Wall in the Annual Report of the Marine-Hospital Service, 1889, where uninter- rupted communication existed between Seflher, Fla., and Tampa, Fla. Although a few persons in the incubative stage at the time of departure from Tampa developed the disease in Seffner, only 12 miles distant, the infection did not spread. Intercourse also existed between Covington and Amite City, La., on the Illinois Central Railroad, although the latter place observed strict quarantine against New Orleans. As far as I know no yellow fever occurred in Amite City. MARINE-HOSPITAL SERVICE. 369 It is barely possible, not probable, that first-class mail]njDj*infection0' matter may convey infection; old and soiled newspapers, coming from an infected house, would undoubtedly be a source of danger. While it maybe considered that the disinfection of mails is generally a useless labor and expense, clamor and fears of the public may render it necessary. In the late epidemic in New Orleans, letters and single- wrapper newspapers were submitted to formaldehyde gas in a closed chamber specially constructed for the purpose, while newspapers were disinfected in a steam chamber designed by the service. Supplementary disinfection was also instituted at points farther north on the Louisville and Nashville and Illinois Central railroads. Refugees should not be permitted to return to the Return of i-efu infected territory until after the second frost or until the fected district. place has been pronounced by the constituted authorities as free from fever. MEASURES NECESSARY AT A HEALTHY LOCALITY TO PREVENT THE INTRODUCTION OF THE DISEASE. No person from an infected territory should be allowed Restriction! .„ ,, , ,-. t -i • i relative to per to enter a nomnfected place unless he has complied with sons. regulations relative to a probation of ten days' supervision and in addition to having his effects amply disinfected by the most approved methods. This rule should not apply to immunes, who should be allowed to proceed, pro- • vided their baggage and other effects have been subjected to thorough disinfection. Places north of the southern boundary of Maryland incur but a minimum risk in re- ceiving refugees, and cities like Atlanta, which are elevated high above the sea level, may receive individuals from the infected district with comparative freedom from danger. In the districts where it is known by experience that the disease if introduced will spread, absolute nonintercourse, if possible, should be observed. Even in such territory, communication, under the proper safeguards (such as de- tention at probation camps, disinfection of effects, etc.), may be permitted with safety. REGULATION OF TRAFFIC TO, FROM, AND THROUGH YELLOW- FEVER-INFECTED TOWNS. By P. A. Surg. J. H. White. A.—Traffic from one clean place to another through an INFECTED TOWN. (1) Freight.—In sealed cars, freight should pass without let or hindrance, but cars should not be allowed to remain in the infected town overnight. (2) Empties.—Empty cars (box) should be passed through sealed, but not allowed stoppage. Flat cars can not become infected, or if so, simple cleaning would remove it, and hence it is a matter of indiffer- ence whether they stop or pass directly through. (3) Passengers and train creics.—Passenger trains should be allowed passage through an infected town in daytime and under observation of inspectors, who should prevent any stoppage or any possible com- munication between any person on the train, crew or passenger, and any other person in the town. Especial care is needed where trains move slowly through a large city, offering opportunity for entry to and exit from them. Special watch must also be kept against tramps boarding trains under these conditions, and, indeed, under any other. Crews may require relay in case of a large city. (4) Mails.—Through mails need no interference. B.—Traffic from infected points to noninfectible points. (1) Disinfection of baggage and freight.—To points North miay be generally assumed to be unnecessary, provided ample assurance is obtained that such will not be returned South. Baggage, if there be any reason to doubt its remaining North, should be disinfected with the same care as that for points South. The freight charges would almost certainly bar any returning of merchandise (new). Household goods (old) should be watched more carefully and should be disinfected even if going North, unless late in autumn. Express matter under same conditions as freight. (2) Empty cars going North.—If going through without stop and left open as freely as possible (end windows as well as doors) to first relay 370 MARINE-HOSPITAL SERVICE. 371 station and then doors closed, no reason for disinfecting, as the aeration so obtained is most thorough and fully as efficient as need be. All cars, however, should be very thoroughly swept before starting. The latter is all that is needed for flat cars. (3) Passengers and train crews originating in an infected totcn and bound North.—Such should from the beginning be under observation, and con- tinue so until they reach a point beyond the infectible zone. Each road should provide a relay for its train crews near to, but out- side, the infected area, where crews should change and the train continue its journey with a crew beyond suspicion. It would be very advisable when possible to have the relay who take the train in hand in clean country to be (at least the conductor and brakeman) immunes. Of course, this may be impossible. A sanitary inspector (a doctor) should be constantly on each passen- ger train and be cognizant of the destination and state of health of each person on the train; should assure himself that they reach that destination, and be aware of their health status when they leave his observation there. On the return trip, he should be empowered to forbid anyone starting who can not prove his recent whereabouts, and so avoid the doubling back of persons recently out of the infected place and trying to reach noninfected but infectible localities. (4) Mails going North, i. e., into noninfectible territory.—Letter mails for points North need no disinfection; neither do newspapers. Parcels will hardly need it, but in view of possible return South would best be either barred or disinfected; this may be modified by location of distributing points • South. Railroad mails should have same supervision as other mail. C. (1) Baggage and freight to points South, i. e., to infectible territory from infected points.—All disinfection of these things may and should be done at point of origin, for same reasons given for mail matter, viz: Economizing officers and avoiding possible infection of the camp or other point selected outside for disinfection. Of course, disinfection outside might be and probably is more certain, but the difficulty and expense incident to the creation and operation of an outside plant would be enormous, and in many cases impossible to overcome. All merchandise should be classified in four separate groups, as fol- lows : (a) Such as may be shipped without any obstruction. (b) Such as requires investigation and may or may not require dis- infection. (c) Such as must be always disinfected. (d) Such as is absolutely barred shipment. (I adopted such a classification in Hamburg in 1893, and found that 372 MARINE-HOSPITAL SERVICE. the volume of actual inspection was much reduced thereby, and also that it did away with much unnecessary disinfection which was already being done, while insuring disinfection of articles needing it.) In railroad work, of course, having no customs manifest as an abso- lute check upon the honest description of goods, we must inspect everything before shipment, but will avoid countless inquiries. Express matter should be governed by same rules as ordinary freight. Household goods should be debarred shipment to points South unless it be possible to disinfect perfectly (generally not the case in the great press of an epidemic). (2) Empty freight cars going South.—These should be swept clean, and if going only a short distance, I would advise an interior surface disinfection with 1-1000 HgCl2, which I did at Avondale, La., and in which manner an energetic crew with proper appliances can treat 200 cars per day at a cost of 25 cents per car. Subsequently all ventilating windows to be left open until destina- tion is reached, be it long or short. Flat cars need no disinfection except such as ordinary sweeping clean will give. (3) Passengers from infected to Southern points.—Passengers origi- nating in infected towns and bound South should invariably (unless well proved immunes) go into a camp of detention for at least eight days before being allowed to proceed. They should be under observa tion, if practicable, while en route to camp and before embarkation. Observation on embarkation has, in my own experience, discovered a few cases of yellow fever, and to that extent relieved the camp of some cases by their being returned to their homes or to hospitals. No health certificates to nonimmunes should under any condition issue from any infected point, and all officers should be forbidden to give any certificate of nonexposure to infection to any person resident in a city or town resting under even a faint suspicion, for the reason that, while theoretically correct, my experience goes to show that one can not definitely determine nonexposure. (4) Mails for points South.—Letters pure and simple need no disin- fection. Newspapers, if originating in a very badly infected quarter, should have the usual manner of steam disinfection; otherwise not disinfected at all. Parcels should be debarred absolutely as possible carriers of disease and involving an amount of labor to disinfect beyond the good derived from same. If disinfection must be done, it can be and should be done in town of origin, because disinfection in town of origin economizes officers and avoids the possible infection of another point, i. e., the mail camp. Puncture of mail should be made with a knife, which should make slits—the nail punctures close up—or, better, have properly punctured envelopes on sale. COMMUNICATION WITH AN INFECTED TOWN. By Surg. H. R. Carter. It must be noted that an infected town is a source of danger to its neighbors, whether communication be allowed with it or not, because a certain amount of illicit and unwatched communication will occur, especially if the season be prolonged, no matter what is allowed. In my experience the rigid nonintercourse rule was, if to be kept up for considerable periods, less safe than carefully regulated commerce. I mean as a general rule. The object then is to formulate general rules under which commerce through and from infected places can be carried on first with the greatest safety to other communities, and second, with the least inconvenience. The measures to be taken to some extent vary from a sanitary standpoint with the degree of infection of the place and from a commercial one with the interests involved and the way these interests are involved. The problem, even considering only the risk of conveying infection, which naturally is the first consideration, is of extreme intricacy, and only a general outline to be varied in par- ticular cases can be given here. A.—Railroad traffic through an infected town. (1) Freight.—Freight traffic in sealed cars passing through such a town needs no regulation; it is safe. (2) Empties.—The same is true of empty freight cars, but care should be taken to see that they do not contain tramps, etc. Neither freight nor empties should stop—i. e., stay in the town. (3) Passengers.—Can pass through such a town by adopting the most obvious precautions—not stopping in town, not communicating with it in any way. Closing the cars is in general unnecessary, but is easy to do and is an added safeguard. (4) Train crews are under the same general rules as passengers. Under some conditions they may require relay. The traffic through such a town must be under the supervision of a sanitary inspector. (5) Mail cars.—To be handled like passenger coaches. 373 374 MARINE-HOSPITAL SERVICE. B.—Railroad traffic from an infected town. Through traffic, i. e., to points incapable of receiving yellow-fever infection, to be designated hereafter as points north, the places capa- ble of receiving infection being designated as points south. (1) Freight.—Freight of any usual kind in sealed cars can go without hindrance through to destination. Freight cars which are ventilated passing to points north were, how- ever, disinfected (bichloride 1-500) at New Orleans to pass through .Southern territory, and I believe this to be advisable. (2) Empties.—Cars, clean, need no disinfection. Box cars, clean and dry and closed, are incapable of conveying infection. If open, the same is, I believe, true, especially if not parked open in a specially infected place. They must be carefully inspected for tramps. (3) Mail.—Is under the same rule as other freight, modified by the location of distributing points. Parcels other than mercantile sample packages shall be barred. It is an easy problem. Railroad mail is also to be attended to. (4) Passengers.—Traffic to points north can be allowed by preventing all chance of such passengers conveying infection en route, either by themselves leaving the train, returning to points south, or by fomites; mainly their clothing. Now, as a rule people travel in clean clothes and are well when they start. The risk from the clothes which they have on, while it exists, is not great. The risk from a case of yellow fever developing en route is practically nil if ordinary precautions be taken, as it takes some days—three is probably the minimum—for such a case to infect his environment. Besides, experience has shown that such cases seldom occur. This traffic should be on a special train, which should not carry other passengers. A sanitary inspector must accompany this train beyond the quarantined territory, under whose absolute sanitary charge the train is, and who will prevent communication by persons or possible fomites with this territory, and carry out other sanitary regulations. It is best that these men, especially the first relay of them, be physi- cians and immunes. The coaches which carry these passengers must be disinfected before they come South again. Unless they stand some time in the infected town, which they should not, there is no need to disinfect them there. Before these people are allowed to go North, we must be assured that they will remain there to cover the period of incubation of yellow fever (say ten days) or indefinitely, i. e., after frost. Disinfection of baggage is not necessary for the latter. If, however, they will return after a time to points South, their baggage must be dis- infected on departure. Indeed, if there be any reasonable doubt of MARINE-HOSPITAL SERVICE. 375 their not returning, the burden of proof being on them, disinfection of baggage must be done. The methods by which the train inspector, on whom this work falls, assures himself (1) that a passenger intends and will stay North indefi- nitely, and (2) that he will stay ten days and not double back, must be worked out for each particular epidemic, and to a certain extent to each particular road and case. A good man will err by oversuspicion and hard rulings. Train inspectors must inspect return trains returning to the infected town for those passengers returning to points South. Train inspectors must be properly relayed and the first tier of them ought to be immune. If they sleep in clean territory, they must be. C.—Local traffic, i. e., traffic to points capable of becoming INFECTED BY YELLOW FEVER, I. E., POINTS SOUTH. (1) Freight.—This traffic must be limited to such articles as will not convey infection, whether by nature, as railroad iron; by origin and history, as original packages in smooth metal containers, put up in clean locality or by disinfection. (It will be further limited by what will be received.) The division of freights promulgated by the Marine-Hospital Service this year in New Orleans, and adopted with slight modification by many State and municipal boards, is not a bad one. It was decidedly incomplete, however, and does not contain all that it could contain, either in the class requiring no disinfection or in that shipable with disinfection. Still, it contained nothing that was not strictly safe if shipped under its provisions and was found practicable and smooth in its operation. A better one can be devised after consultation with merchants, railroad men, and health officers, but it is rather an exten- sive job. Express matter must be counted as freight. It is infinitely more troublesome. Empties.—Under the same rules as in B. Box cars should be opened, not closed. If going a short distance, they may be disinfected; it is very little trouble. If a considerable one this is unnecessary. The chance of conveying infection for even a short way by a clean, dry, empty box car is minimal, if it exists. The time they stay in the town and the locality in which parked, if parked, is to be considered. Mail.—In general, mail can be disinfected as well in town as at a station outside of the infected district. There may possibly be occa- sions, however, when the latter method is preferable. I never saw one, but can conceive of them. Newspapers have little chance to become infected, but if they do 376 MARINE-HOSPITAL SERVICE. might retain and convey it. If in large amount steam is the only prac- ticable method. Packages are best not allowed in the mail. Letters do not require disinfection; the Havana mail has never been and is not now disinfected. On the chance of envelopes containing fomites it may be judged best to disinfect letter mail, but most of such can be discovered in the nec- essary handling, and I believe the added safety does not compensate for the inconvenience. The best way is to have properly perforated envelopes on sale, as at Brunswick, Ga., and to refuse all not in such envelopes, and use formal- dehyde for the disinfecting agent. The ordinary punctured envelope, however, does unquestionably admit gas to its interior, and its use is efficient, though bungling. Steam is not applicable to letters. Railroad mail must be disinfected just as any other. Passenger traffic.—Direct passenger traffic from an infected town to points capable of receiving infection must not be allowed. Those certainly immune may go to such territory without detention after dis- infection of baggage. Personal disinfection, unless in very special cases, as of those recently attending the sick or disinfecting goods or premises, is unnecessary. The others must pass a period sufficient to cover the period of incu- bation of yellow fever, not exposed to any infection during this period, before being allowed to enter this territory. This is the theory of the detention camp. The details of the camp are not to be considered here. People who have gone to points North to spend their period of incu- bation are in the same position as those who have been through a detention camp. The baggage of these people must be disinfected before leaving, and it is best to count the period of detention from arrival at their Northern destination, as there is a possibility (although extremely slight) of contracting fever from possible fomites on the train, just as that in camp counts from disinfection of personal wear- ing apparel. Relays.—All train crews, freight and passenger, in traffic from an infected town, must be changed so as not to go into clean territory. This should be done at a place as isolated as possible, a siding rather than a station, and certainly not in a town. Every man, mail agent, expressman, and train butcher (news agent) must make this relay, unless we know that he is going North not to return to points South, in which case he is like a through passenger. None of the merchandise of the train, butcher, unless disinfected papers be excepted, must pass the relay. No possible fomites must pass the relay to the crew bound North, and as little communication as possible, save what is necessary for the run of the train, is allowed. The relay must be under the supervision of a sanitary officer or officers (two are generally required), whose position is one of great responsibility. MARINE-HOSPITAL SERVICE. 377 The camps for the north and south crews should be at a considerable distance from each other, and the run of trains should be arranged so as to have the crews in camp as little as possible. For passenger trains there need be uo delay; for freight trains generally there must be, and their crews go in camp. There is no necessity of doubling these sta- tions if suitable ones be chosen and they be well conducted, but con- ditions may be such, as on the Illinois Central and Yazoo Valley Rail- road this year, where it is advisable. These stations must be frequently and carefully inspected, and the same is true of the train inspection work. Occasions may arise where it is necessary to guard the southern relay camp by a number of guards, as if it were a camp of detention. It must never be allowed to become infected. 3934----7 A PRECIS OF DETENTION CAMP MANAGEMENT. By P. A. Surg. J. H. White. Although instructed to prepare this syllabus of detention camp man- agement simply with a view to yellow fever, the writer has presumed to so arrange it that with slight changes it may also meet the require- ments of other diseases. Of course it would be possible to go more deeply into details in many directions, but it has been shown by the past experience of this service that competent officers do better work when furnished with outline rules rather than minute instructions. The smaller details will suggest themselves when the outline is given. The mind is able to take a com- prehensive glance of the whole general plan given in outline, while if it be padded with minutiae this desirable result is in a measure prevented. DETENTION CAMPS. To avoid any confusion as to meaning, it may not be amiss to state that this whole article will, in the body thereof, refer entirely to camps for yellow-fever purposes, and that the necessary deviations to meet the requirements of other diseases will be treated in a final chapter. LOCATION OF CAMPS. In the selection of a site for a camp of detention, the general points to be considered are: First. A healthful location, as free from malaria as may be available and a situation which has good natural drainage. The avoidance of any possibility of standing water after heavy rains is essential, because such camps are frequently to be occupied by delicate women and chil- dren, whose health and comfort are both to be watched over. Second. A site so situated as to be easy of access by rail or steam- boat and very preferably the former. Third. One to which good water supply and a good base of food sup- ply is easily accessible. The camp should consist of two distinct portions: (1) main camp and (2) hospital camp. The whole establishment should be, if possible, at a distance of a mile or more from any settlement. The adjunct camp lor yellow fever and intermediate hospital purposes should be at least 378 MARINE-HOSPITAL SERVICE. 379 one fourth mile to leeward or one-half mile to windward of this main camp. The location should be as close to the infected place as clean terri- tory, suitable for the purpose, can be found. It should preferably be upon a line of railway, whose distributing or dividing point outside is a small place rather than a large city. While this matter of small distributing point is not absolutely essential, it is advantageous, as enabling the easy and careful observation of the distributing point, which point is the one most likely to be attacked in the event of any accidental escape of infection from the camp. Camp Perry, located by P. A. Surg. John Guiteras, United States Marine-Hospital Service, in 1888, on St. Marys River, where it is crossed by the Savannah, Florida and Western Railroad, about half- way between Jacksonville, Fla., and Waycross, Ga., on a slightly roll- ing sandy plain, which drained itself rapidly into the river, was an ideal location. It also fulfilled the above-mentioned requirement, Waycross, the distributing point, being only a village of about 3,000 inhabitants. EQUIPMENT. The site having been selected, the ground should be prepared by such slight ditching as may be necessary to prevent any standing water in case of heavy rains. Much ditching should be avoided on account of malaria. It is always advisable to provide the hospital camp com- plete before any other work is done, as it often occurs that the very first admissions bring suspected cases to light. Experience has shown that the general outline of establishment used at Camp Perry, subsequently modified by a board of officers (Surgeon Carter and P. A. Surg. Kinyoun), is the most convenient form. It consists of a hollow square, of which the buildings form one side and tents three. Subjoined are ground plans, which are believed to embody all the needed changes from the plans of Drs. Carter and Kin- youn. An alternative, ground plans of which are also submitted, presents itself here, viz: A double camp, its two parts independent, except for a common executive office and kitchen (although not always feasible), presents the advantage that seldom or never will there be any suspicion attached to Camp No. 2, because, as a rule, nearly all sickness has, in our expe- rience, developed within the first four days, and hence would be devqj- oped in the Camp No. 1. This plan of a double camp would naturally inspire in the people outside more confidence in the safety of camps, and, although not at all a sanitary necessity, may be expedient, for its moral effect alone. Such double camps should be divided, not only by guards, but by a double fence of barbed wire as well. The whole of both camps should be surrounded by a double barbed-wire fence, at least 6 feet in height, each fence to have wires 6 inches apart, from top 380 MARINE-HOSPITAL SERVICE. to bottom, and the two fences set 18 inches apart, so as to render egress in haste a matter of physical impossibility. All refugees in the main camp should be housed in tents, in order that disinfection may be easy after any suspicious case has occurred. Kitchen and dining rooms should be arranged so as to involve a minimum of time and labor in serving meals, and with capacity in the latter for seating the whole number of refugees at one time. For purposes of good disci- pline, there should be provided separate tables for subaltern officers, such as commissary, quartermaster, clerks, et al., in order that they may the better preserve their proper authority over attendants; officers of the guard may be included in the list of such officers, or the whole guard messed together, according to circumstances. It is not at all advisable that the guard, however, should mess with the lower grade of attendants, as the responsible nature of guard duty is prima facie evidence of the necessity for a better class of men for these important posts, and they should therefore be separated when possible. In addition to the privies located on the plans there may be neces- sity for providing a few, more convenient of access, for delicate women, and these should by all means be dry earth closets located in a tent, and daily emptied. The locations indicated in the plan should not be considered as essential, but should be varied to avoid contamination of the water supply or for other sanitary reasons. If not already existent, a sufficient amount of railroad siding should be provided to hold the necessary cars for disinfection and commissary purposes. At a point most convenient for this purpose on this siding there should be built a waiting and dressing pavilion, containing from four to six rooms, to be used for the purpose hereinbefore mentioned, and from four to six tents, end to end, for examination, reception, and registration of applicants for admission. In case it be deemed advisable to use the double camp heretofore recommended, the only necessary change in the plan submitted, and labeled "Exhibit A" will be the placing of the buildings laid down on said plan exactly in the center of the quadrangular open space and the running of a barbed-wire fence through the middle of the camp from side to side, in such manner that the bine occupied by said fence shall bisect the site of the surgeon's office, the telegraph office, the kitchen, and the commissary. It will also be necessary to provide in this case an additional quar- termaster's storeroom unless the existing storeroom is also placed upon the middle line, which can in fact be done by making one building serve for quartermaster's and commissary's work. It is believed that there will be no necessity for changing the entrance to camp in the substitution of a double for a single camp. Should such change, however, be considered necessary, it may be readily accom- plished by leaving out a sufficient number of tents from the camp on the side next to the surgeon's office to provide a 50-foot avenue from the MARINE-HOSPTTAL SERVICE. 381 surgeon's office to the outside and running the wire fence in this case, so far as it concerns that portion fronting the surgeon's office, as two fences, one being on either side of the aforesaid avenue. FOOD AND WATER SUPPLIES. If pure water can be obtained by pumping or carrying from a neigh- boring stream, such supply is preferred, and only when this is unavail able should resort to driven wells be had. In case neither of the above supplies are available, water should be brought in railroad water cars from some reliable source; and in very porous soils, where water is near the surface, the driven-well supply should be a dernier resort, as it is manifest that in a small territory the dejecta from 1,000 persons, no matter how carefully removed, must to some extent poison such water. The food supply should come by preference from a noninfected city or town, but in some cases, as at Camp Fontainbleau, in 1897, it is absolutely impossible to do otherwise than obtain supplies from an infected center. In such cases all containers must be either at once burned or disinfected, preferably burned. Sawdust, paper, cloth, etc., so used should be burned at once. PERSONNEL. In addition to the commanding officer, the medical staff, and the hospital steward, the necessary personnel of a detention camp should be: (A) Guards, who should be placed at intervals, long or short, accord- ing to the topography of the site, and be under officers to be named hereafter. (B) Disinfecting force. (C) Quartermaster, commissary, clerks, bugler, telegraph operator. (D) Cooks, waiters, laundresses, scavengers, teamsters. ROUTINE, DISCIPLINE, ETC. The commandant should make frequent day inspections of camp and guard lines, and occasional night visits to the latter; visit at frequent intervals all parts of the camp, and in general so inform himself as to be capable of deciding, in large measure from his own knowledge, the complaints brought before him. He should see without exception all cases of sickness, however trivial, reported by the inspectors, and him- self decide whether suspicious or not. He should not confine himself, however, to routine inspections, but leave such to his assistants. He should keep careful watch against possible bad food or polluted water as tending to create sickness which may simulate yellow fever and con- fuse diaguosis. The assistant medical staff, consisting of one or more inspectors, in proportion to the size of camp, one resident physician for the hospital, and one doctor or chemist as chief disinfector, should each and all report directly to the commanding officer. A double daily 382 MARINE-HOSPITAL SERVICE. inspection at 9 a. m. and 4.30 p. m. is absolutely essential for the dis- covery in their incipieucy of suspicious cases and should include each and every soul in camp—guests, officers, and employees—and in the event of there being any resident population near the camp, even though a quarter mile distant, these also should be inspected at inter- vals of a few days. The duties of the steward should consist in the supervision of the classes stated in article on personnel, sections C and D, the buying of rations, supervision of accounts, and other such duties as by the regulations of the Marine-Hospital Service appertain to his office. SANITARY POLICING OF THE CAMP. All refuse should be removed each day from all streets and tents, and promptly burned. All privies should be daily scrubbed clean, and the dejecta covered thickly with a mixture of copperas and lime, which is an excellent deodorant. Dejecta should be carted away and buried every week. Kitchen garbage, very apt to accumulate, can best be disposed of to pigs outside the camp, or failing this, be buried also out- side the camp. A special force of one or more scavengers, in propor- tion to size of camp, must be detailed for this work of cleansing camp, and the steward should exercise most careful supervision over their work. Especial care should be used to detect and prevent the commission of nuisances in the camp streets at night, a thing which is extremely difficult to compass, on account of the hoodlum element often present. A liberal use of the guardhouse with a diet of bread and water is the best remedy, but even this is not absolutely effective. As an adjuvant to the thorough cleansing of camps and the disinfec- tion of grounds, it is advisable to provide one or more of the furnaces used by the paving companies in melting asphaltum. These furnaces may be used to sear the ground under and around a tent, which has become infected, and even for destruction of dejecta removed from privies. HOSPITAL. The hospital camp, as before stated, should be at a distance from the main camp and under the same isolation from outside communication. It should consist of, preferably, 8 small wooden buildings and about 12 tents, namely, 4 hospitals capable of containing 2 patients each, 1 kitchen and storeroom, 1 small house for resident physician, and 2 small privies, G tents for suspects at a distance of 100 yards to wind- ward of the hospital tents, and from 4 to 6 tents for guards and attend- ants. The whole camp should be surrounded by a double barbed-wire fence, as in the main camp, and under guard night and day. Commu- nication should be carried on with the main camp by only two means: (1) A telephone, when obtainable; (2) a wagon for supplies and for ambulance purposes, which wagon should be driven by an immune and sprayed with bichloride of mercury solution (1-2,000) whenever used for MARINE-HOSPITAL SERVICE. 383 any infectious material. The grounds of this camp should be policed with the same thoroughness as the main camp. An outer guard should patrol this camp and allow no person within 200 yards of the wire fence surrounding it, and especially to leeward of it. An endeavor should be made to prevent the infection of the hospitals themselves or at least to minimize such infection. This end may be best attained by the immediate disinfection of all articles of clothing and bedding as fast as such are removed from the persons of patients, and by the admission of fresh air and sunshine to the hospitals when- ever the weather will permit. All dejecta must be disinfected, as soon as passed. All disinfections to be done as provided in the quarantine regulations of the United States Treasury Department. It is imperatively necessary to prevent the infection of the tents used as an intermediate camp or hospital for merely suspicious cases, and to this end all such tents should, in addition to the precautions named above, be washed down with 1-2000 solution of bichloride of mercury after each occupancy, and the floors removed and ground beneath and around them burned by a Barber asphalt furnace, the floors to be wetted on both sides with 1-1000 solution of bichloride of mercury, If all this is done promptly and thoroughly, this most important part of the camp may be kept free from infection indefinitely. Nurses and other attendants attached to this intermediate hospital should be immune, for it must be borne in mind that these patients are all at least suspicious, and many of them may ultimately find their way into the yellow-fever hospital near by. It goes, therefore, without fur- ther saying, that all officers, guards, nurses, and attendants in hospital or intermediate camp must or should be immune to the disease treated in these camps. There should, however, be no mingling allowed be- tween these two hospitals for fear of infecting some suspect who really has not yellow fever. All cases which have been positively diagnosed should be removed at the earliest possible moment to hospital if yellow fever, or to camp if not. RECEPTION AND TREATMENT OF GUESTS. All persons seeking admission to a camp should be given a permit by some responsible agent in the infected center, and such permits in any one day should in no case equal more than one eighth of the total capacity of the camp. Upon the arrival of a refugee at camp he should be at once examined as to his health by one of the inspecting officers detailed for that purpose, and if found not to be suffering from any sus- picious disease he may be registered. He should then turn in his effects for disinfection and await in a building provided for this pur- pose the return of his disinfected belongings. He should then change his clothing and submit for disinfection the suit worn upon arrival. This being completed, he may finally be admitted to the main camp, and no further disinfection required, unless he subsequently develop 384 MARINE-HOSPITAL SERVICE. disease in his own person. It is advisable that invariable rules should obtain in all camps, and, as nearly as maybe, all persons treated exactly alike and concessions made to none. The hours for rising in the morning, for meals, for inspections, for retiring, and for lights out should be sounded by a bugler at set hours each day. At inspection each and all guests should present themselves at the front of their tents, and be required to remain there until the completion of the inspection, thus avoiding the confusion incident to their being allowed to move about after being themselves inspected, with the consequent result that one man is inspected twice and another not at all. No sickness can be considered too trivial for a careful investigation, and any case presenting symptoms in the faintest degree suspicious should be at once isolated. The attention of the command- ing officer should be called at once to all cases. SUBALTERN OFFICERS AND EMPLOYEES. All employees other than guards and disinfectors should report directly to the steward, if in marine-hospital camp, or to the corre- sponding official in other camps. These should be (1.) a quartermaster, whose duties are to provide outfits for each tent or building, to see to the keeping of the same in repair, and to prevent the abuse or theft of property; (2) a commissary, to receive and issue stores and keep the records appertaining thereto, and to perform such other duties as the steward may direct; (3) a sufficient number of clerks to keep record of entry and discharge of guests and their belongings; (4) a telegraph operator; (5) necessary cooks, laundresses, waiters, and scavengers in proportion to the number of occupants of the camp. The disinfecting force should be under the charge of a competent and experienced man, preferably a physician or chemist, and the num- ber of his assistants sufficient to handle all the effects of guests promptly and carefully. The guard should consist of from 25 to 40 men, who should be selected with the greatest care possible, as on their fidelity and courage depends more than on any other force, the successful issue of the camp. It is advisable to select first two sergeants for night and day duty respec- tively, and ultimately as the men become better known to the command- ing officer, four more, and finally from these six, the captains of the guard, the permanent officers for night and day command can be care- fully selected. The guard should be divided into watches of preferably eight hours' duration, though the length of the watch may well be either four or six hours. They should patrol the outer line of the camps night and day, allowing no one to pass in or out, who can not give the proper countersign. The countersign should each day be provided by the commanding officer. In addition to outside patrol, guards should patrol the avenues, between tents, during the night to prevent noises or nui- sances. All guards should report to the captain of their respective MARINE-HOSPITAL SERVICE. 385 watches, and the captains to the commanding officer, anything unusual occurring under their observation. ADJUSTMENT TO DISEASES OTHER THAN YELLOW FEVER. In the application of the foregoing chapters to the management of a camp for cholera or smallpox, the changes to be made are as follows: For cholera, the food and water supply must without exception come from an absolutely noninfected locality, and no possible variation can be made from this rule. The camp need not be so far from the nearest settlement, and greater pains must be taken to disinfect or destroy dejecta. The period of incubation being short, the detention after last possible infection need be only for five days. For smallpox, the food and water supply demand no greater attention than in yellow fever. The camp need not be at any great distance from the nearest settlement. The dejecta disinfection is of no moment except as to general sanitation. The period of incubation demands at least fourteen days' detention. SUGGESTIONS AS TO BUILDINGS, LIGHTING, AND HEATING. Buildings are most quickly constructed with perpendicular rough planking for weatherboarding, covering cracks with 1 by 3 inch strips and roofed with tarred paper. These buildings are generally for summer use and therefore such construction is ordinarily sufficiently weather- proof. Should heat be necessary, stoves may be used with ease. It is advisable to elevate all buildings on blocks, to a sufficient height to allow free circulation beneath. Wire netting may be stretched around the base of buildings to keep out animals and refuse. Posts should be provided for lamps at regular intervals, to light the camp streets. These lights, preferably regular kerosene-burning street lamps, serve a good purpose in preventing nuisances at night by creating publicity. It sometimes becomes necessary to provide heat, even in a camp for yellow fever, and in such case it is well to build a large shelter with an opening in the center of the roof. Open fires may be lighted under this opening for the comfort of guests. All such fires should be in the central portions of the grounds, and no fire allowed in the camp streets under any conditions, as such fires are very likely to result in destruction of the camp. DISINFECTION (ADOPTED FROM REGULATIONS). The following methods of disinfection are considered efficient: EOR YELLOW FEVER. (1) Apartments or dwellings infected with yellow fever to be disin- fected by one or more of the following methods: (a) By a thorough washing of all surfaces of apartments with an efficient germicidal solution. 386 MARINE-HOSPITAL SERVICE. (b) By sulphur dioxide for twenty-four hours' exposure, 4 pounds of sulphur for each 1,000 cubic feet, plus due allowance made for waste. (c) By formaldehyde gas in not less than a 4 per cent per volume strength, and not less than six hours' exposure. Note.—One liter of 40 per cent solution of formaldehyde gas will evolve about 1,425 liters (50.1 cubic feet) of gas at 20° C. (68 F.). (2) Grounds, outbuildings, etc., deemed to be infected, to be disin- fected with a strong solution of crude carbolic acid (carbolic acid, crude, 2 parts; sulphuric acid, 1 part; water, 25 parts) or an acid solu- tion of bichloride of mercury (1-500); disinfection of ground preferably by fire. (3) Bedding, wearing apparel, carpets, upholstered furniture, and the like to be disinfected by one or more of the following methods: (a) By steam at a temperature of 100° to 102° C, thirty minutes' exposure. (b) By boiling, all parts of the articles to be submerged. (c) By saturation in an efficient germicidal solution. (d) By thoroughly wetting the surfaces of articles with a 40 per cent aqueous solution of formaldehyde, and placing them in a closed space for not less than twelve hours. (e) Where surface disinfection is required, formaldehyde gas of not less than a 4 per cent per volume strength and not less than six hours' exposure, or by sulphur dioxide for not less than twenty-four hours. (4) The dejecta from cases of yellow fever to be disinfected by an efficient germicidal solution. Mails to be disinfected by one of the following methods: (a) By formaldehyde. (6) By sulphur dioxide. (c) By steam. (Newspapers must be made up in such packages as shall be pene- trable to the disinfectant used.) FOR CnOLERA. (1) Dejecta and vomited matters of cholera patients shall be received into vessels containing an acid solution of bichloride of mercury (bichloride of mercury, 1 part; hydrochloric acid, 2 parts; water, 1,000 parts), or other efficient germicidal agents of equal value. (2) Bedding, clothing, and wearing apparel soiled by discharges of cholera patients, or used by them or in their care or treatment, shall be disinfected by one or more of the following methods: (a) By steam at a temperature of 100-102 C, thirty minutes'exposure. (6) By boiling, all parts of the articles to be submerged. (c) By saturation with an efficient germicidal solution. (3) Woodwork or furniture contaminated by cholera discharges shall be disinfected by thorough washing with an efficient germicidal solu- tion. MARINE-HOSPITAL SERVICE. 387 (4) Clothing and personal effects suspected of being infected with cholera shall be disinfected by one or more of the following methods: (a) By steam at 100° to 102° C, thirty minutes' exposure. (b) By boiling, all parts of the articles to be submerged. (c) By saturation with an efficient germicidal solution. (d) By wetting all surfaces of the suspected article with an aqueous solution of formaldehyde gas, and placing it in a closed space for not less than twelve hours. Containers may be disinfected by wetting all surfaces with an efficient germicidal solution and allowing it to dry. Where only surface disinfection is required: (e) By formaldehyde gas in not less than 4 per cent per volume strength and not less than six hours' exposure. (5) Apartments known to be, or suspected of being, infected with cholera shall be disinfected. (a) Washing all surfaces with an efficient germicidal solution. (b) By formaldehyde gas in not less than 4 per cent per volume strength, and for not less than six hours' exposure. FOR SMALLPOX. (1) Apartments infected with smallpox shall be disinfected by one or more of the following methods: (a) By exposure to sulphur dioxide for twenty-four hours, 4 pounds of sulphur for each 1,000 cubic feet, plus due allowance made for waste. (b) By exposure to formaldehyde gas in not less than 4 per cent per volume strength, and for not less than six hours' exposure. (c) Washing all the surfaces of the apartment with a solution of an efficient germicide. (2) Clothing, bedding, carpets, articles of furniture and the like, exposed to the infection of smallpox, to be disinfected by one or more of the following methods: (a) By exposure to steam at a temperature of 100° to 102° C. thirty minutes. (&) By boiling, the articles to be completely submerged. (c) By saturation with an efficient germicidal solution. (d) By thoroughly wetting the surfaces of the article with a 40 per cent aqueous solution of formaldehyde, and confining it in a closed space for not less than twelve hours. (e) By exposure to formaldehyde gas in not less than 4 per cent per volume strength, and not less than six hours' exposure. (/) By exposure to sulphur dioxide for twenty-four hours. MISCELLANEOUS. Articles injured by steam, such as rubber, leather and containers, to which disinfection by steam is inapplicable, to be disinfected: (a) By thoroughly wetting all surfaces with an efficient germicidal solution, the articles being allowed to dry. 388 MARINE-HOSPITAL SERVICE. (&) By exposure to sulphur dioxide. (c) By exposure to formaldehyde gas. The application of gaseous disinfection to these articles should be made in a closed space, air-tight, or as nearly so as possible. The following are considered efficient germicides: (1) Bichloride of mercury acid, 1-1000. (2) Carbolic acid, pure, 5 per cent solution. (3) Trikresol, 2 per cent solution. (4) Solution of formaldehyde, 1-500 (which is 1 part of a 40 per cent solution of formaldehyde to 199 parts of water). (5) Solutions of hypochlorite of calcium (chloride of lime). CAMPS OF OBSERVATION. Inasmuch as it often becomes necessary to remove from trains or other vehicles while still within infectible territory certain persons not properly vouched for, it is probably advisable to establish camps at State lines, on railway routes, or at other strategic points. Such camps are nothing more nor less than small detention camps, with a capacity for 25 to 50 occupants, and should be conducted on the same lines as detention camps. It will not be necessary, as a rule, to establish such camps, and never except at such points as are at too great distance from the regular detention camp for easy access, or too far from noninfectible territory to allow of transportation to such terri- tory of the suspected persons. TRAIN-INSPECTION SERVICE. By P. A. Surg. G. B. Young. PREAMBLE. In conducting a system of train inspection for the purpose of pre- venting the spread of disease and of facilitating intercourse and trade as far as is consistent with safety, it is most important to always keep in mind that the limitation of the spread of the disease should be para- mount to every other consideration, the facilitating of traffic being of only secondary importance. I lay stress upon this because my own experience has taught me that it is often difficult to maintain the proper point of view in the face of the senseless and vexatious oppositions of local origin that often upset one's carefully considered plans. One is apt to become absorbed in the task of opening lines, moving trains, and the like unless careful to remember that such things, while unquestionably of great importance for the public good, are not the most important part of the work. RELATIVE IMPORTANCE OF QUARANTINE AND TRAFFIC. I do not mean to belittle the importance of opening up traffic, how- ever, for the suffering and loss that accompany the interruption of trade and travel during the presence of yellow fever, and the resulting local quarantines, are among the most dreadful consequences of the scourge. Next to preventing the actual spread of the disease the most impor- tant thing to do is to strive to minimize the distress that the fear of its coming brings to all within the threatened territory. In conducting a system of train inspection, then, our first duty is to facilitate in all proper ways the escape from infected places into non- infectible territory of those who desire to go; second, to supervise the movement from place to place in infectible, but clean territory, of those whose necessities compel them to travel; and, finally, to do what we can toward keeping open the channels of trade. Let us consider the principles that should govern our action in secur- ing each of these several ends, and then take up, somewhat in detail, the methods to be followed in maintaining these principles. Under the first head, then, the rule can be laid down that all persons can be permitted to leave infected for noninfectible territory if a rea- 389 390 MARINE-HOSPITAL SERVICE. sonable certainty can be secured that they will not return into infectible territory before the expiration of ten days from the last possible expo- sure to infection, which, however, may be and often is a very different thing from ten days since their departure from an infected place; but that this movement must be so conducted that no danger results to the territory through which they pass en route. ALL PERSONS MUST GIVE SANITARY HISTORY OF THEMSELVES. Under the second head the fundamental principle is that only those should be permitted to travel who can give a good sanitary history; and that while en route they shall be preserved from contact with any infected or suspected person, place, or thing. Given the observance of these principles as to both persons and things and the opening of the channels of trade would seem to follow as a natural corollary, but on account of the peculiar conditions which arise under local quarantines it does not naturally do so. For the proper opening of trade it is necessary, first to secure the confidence of the various local authorities and, second, to maintain san- itary control of the transfer and junction points, the " strategic points" in our sanitary campaign. PORMULATION OF DETAILED RULES AND DESIGNATIONS FOR CLASSES OF PERSONS AND THINGS. An attempt will now be made to formulate somewhat detailed rules for the conduct of a system of train inspection service. For the purpose of brevity the name "suspects" will be applied to persons from infected territory and that of "passengers" to those from uninfected territory. Where mail, freight, or express cars are referred to they will be called "cars," passenger cars being spoken of as "coaches." "Train crew" will refer to all persons employed on the train in any capacity, except that in some instances, to be noted at the time, the Pullman conductor and porter are treated as belonging to a slightly different class. Passenger Traffic from or through Infected Territory. i. the preparation and handling of trains. (a) Where the trains are made up in infected territory and subse- quently run through clean territory. GLASS OF COACHES PREFERRED. Wherever possible, the coaches used in conveying passengers from or through infected territory should be of the kind equipped with cane seats. These are much less apt to become infected and are much easier MARINE-HOSPITAL SERVICE. 391 to clean. No matting should be allowed in the central aisle and, as far as possible, all curtains and hangings should be prohibited. WHERE TO DISINFECT COACHES. Wherever possible, coaches used for carrying suspects should be dis- infected at the ends of their runs, i. e., in clean territory. This disinfection can be done by the employees of the road, but should be under the supervision of a sanitary inspector, who should be informed by wire on the departure of each train from the infected place of the numbers of the suspect coaches, and after disinfection the coaches should be placarded with the date of disinfection and the signature of the inspector. RETURN OF COACHES EMPTY. Where this can not be done the coaches should be locked and returned to the infected place and disinfected there. Indeed, in some cases it will be best to return the coaches empty, even after disinfecting, for if the territory traversed is badly panic- stricken it will greatly help in alleviating the anxiety of the passengers if they know they are in no danger of being put into coaches recently vacated by suspects. In this, as in many other things, it is often advisable to concede something to popular prejudice, so long as efficiency does not suffer thereby, or too great a multiplication of regulations does not result. OBSTACLES TO RETURNING EMPTY NONDISINFECTED COACHES. Theoretically it would be proper to lock these coaches and attach them to the rear of the train while returning them to the infected ter- ritory, so that the train crew could move freely about from car to car of the coaches in use without entering the reserved cars, but practi- cally this presents many difficulties. Railroad men, like other men to whom the established routine has all the force of law, are exceedingly adverse to changing their methods or habits, and while we should, if necessary, utterly disregard their preconceived ideas of what should be done, we should at the same time avoid imposing rules that, while cor- rect in the abstract, do not involve a vital necessity. It is to be understood that I am referring above to lines on which the cars go through to points beyond the danger line, the case of branches and of local lines on which the coaches stand over in the infectible territory is somewhat different. Here, while the danger is very slight, we can not say positively that it does not exist, so it is best to have these cars disinfected at their lay-over places, if it can be done without causing alarm. I think it will be found, however, that the disinfection of cars at a small junction point, or even in a small city, will tend to make people uneasy, and possibly lead to the exclusion of trains. From an administrative point of view it is easier to disinfect 3!>2 MARINE-HOSPITAL SERVICE. at the infected place, because there we will be doing a great deal oi similar work and will have the plant and force for the purpose, and, moreover, the men on the outside would be relieved from keeping up disinfection work at a number of points, the number rapidly increasing as the distance from the infected place becomes greater. PULLMAN SLEEPING CARS. Sleeping cars are in a different class from day coaches and need dif- ferent treatment. In one sense they are more apt to get infected, as they are much harder to clean, contain much more infectible material, and moreover, being occupied at night on at least half the trains, they are very much more apt to have cases of fever develop in them. On the other hand, they are more carefully looked after than the other coaches and are practically always "through" to noninfectible territory. Sleepers are very difficult and troublesome things to dis- infect. The best thing to do with them usually is to require that a sleeper that has made a trip into an infected place shall not be returned into infectible territory until, say, ten days have elapsed—amply sufficient to make them safe. SLEEPING CARS TO BE REGISTERED AND WATCHED. A register should be kept at the infected place of all sleepers leaving it, in order to prevent them being sent out over one line and returned over another. DISINFECTION OF BAGGAGE, MAIL, AND EXPRESS OARS. Baggage, mail, and express cars should be disinfected immediately prior to their departure from the infected place, because, as they are to receive only disinfected baggage, mail, and express, and will be occu- pied after traversing the short distance to the relay station by clean crews, they are not a source of danger to the places at which they may lie over. SOME BAGGAGE TO HAVE CONTAINERS DISINFECTED. The only flaw in this is when undisinfected baggage "for points in noninfectible territory, there to remain," is being handled, and this can be met by disinfecting the outside of the containers. We now come to the consideration of the handling of the trains as a whole. REFUGEE TRAINS BEST RUN THROUGH TO NONINFECTIBLE TERRI- TORY. Unquestionably, where it is possible, and it will seldom be impossi- ble, the trains bearing refugees should run through without making MARINE-HOSPITAL SERVICE. 393 any stops except for coal and water. The refugee train can run as a section of the regular train, and thus disarrange the routine of the road's business as little as possible. In the very few cases where this is impracticable the coaches and baggage cars used for refugees and their baggage should be absolutely reserved from other passengers and baggage. This does not necessar- ily apply to the express and mail cars, since they have been disinfected and receive only disinfected material, whereas the baggage cars may contain baggage "for noninfectible territory, there to remain," that has not been disinfected. TRAIN CREW. The entire train crew should be changed at the relay station to be described hereafter. This applies to conductor, brakemen, engine crew, baggage man, express messengers and mail clerks. As the relay station is only a short distance from the point of depar- ture, this need not seriously interfere with the handling of mail and express. The Pullman crew is best relayed too, but if the terminus of their run is far outside of the danger line they may be treated as indicated for the Pullman coaches—allowed to proceed, but not allowed to come back. This was the method followed to some extent last fall on the New Orleans-Chicago run, and as far as I am aware no trouble arose from it. The train boy must either be suppressed or else made to lie over outside of infected territory, and prohibited from drawing any supplies therefrom. "shuttle" trains. A method which I followed to some extent at Memphis in 1897, and which presents some administrative advantages over the one just out- lined, is to have the refugee train made up at the relay station, and then run a " shuttle train" back and forth between the infected train and the relay station, transferring everything there to clean cars and coaches. This works especially well when the distance between infected and noninfectible territory is short, as was the case between Memphis and middle Tennessee. ADVANTAGES GAINED BY "SHUTTLE" TRAINS. One possible advantage in this method is that the officer in charge of the inspection service can have direct control of all the inspectors and follow their work from the beginning of their runs, while other- wise the first tier of them has of necessity to report to the officer in the infected place, thus increasing his responsibility and labors, and at the same time causing a division of authority that might diminish the effectiveness of the service. 3934----8 394 MARINE-HOSPITAL SERVICE. WHERE SECTIONS ARE TO BE MADE UP. Which ever method is adopted, the section which is to do the local business in neutral or clean territory must be made up either at the relay station or, which is preferable, further out. When separate trains are not used the refugee coaches are handled precisely as if they made up a separate train. (b) When trains originate in infected territory and subsequently run through other infected territory, separated by zones of clean territory. The way to meet this is to have the suspect section make all the infected stops, while the clean section makes the others. Should one of the infected places happen to be an important junction point great difficulties may arise. In such cases, however, it will usually be possi- ble to arrange an immediate transfer, but how this is to be done, as well as the methods to be puisued when only separate coaches are used for suspects, come more directly under the head of actual inspection work and will be treated in that connection. (c) When trains originate in clean territory and pass through infected places. In this case the mechanism is simpler, it being understood, of course, that I am referring to places of too small size to justify the running of refugee trains, or so situated that it is impracticable. This latter con- dition will sometimes occur on account of the difficulty in securing a site for relay stations. TRAIN SHOULD NOT STOP IN THE INFECTED TOWN. The train should not stop at the infected place, but should pick up the refugee coaches at some point outside the town, even if only a few hundred yards, and the necessary couplings and setting of switches must be done by employes other than the train crew. ARRANGEMENTS FOR SMALL PLACES. For the use of small places or of larger places similarly situated, a combination coach and baggage car should be provided, and this coach, as in all "special coach" methods, should be attached to the rear oi the train. ARRANGEMENTS FOR LARGE PLACES. If the place is of considerable size, so that the train has to reduce speed very much in running through it, there is always a danger oi tramps and others boarding the train while in motion; consequently, in such cases, we must have the train stopped at designated points on either side of the town while a search is made for such intruders. - (d) Lines running entirely through clean territory but connecting with lines from or through infected places. MARINE-HOSPITAL SERVICE. 395 A conspicuous instance of this class in the fall of 1897 was the Mem- phis aud Charleston Railroad. Running from Memphis to Chattanooga, it was cut at intervals by all the lines from the South. We accord- ingly had to cover it from end to end to prevent our flanks from being turned. PASSENGERS FROM COLLATERAL AND CROSS LINES. The "side drift" along such lines does not usually amount to very much, and all that is needed is such control that we can be sure that no one actually sick boards the train, and that all the trains are under such supervision as to prevent suspects from disembarking in infect- ible territory. As all the lines from suspected or infected territory are to be under guard, the chances of any harm coming from travel along these cross lines is very slight. REASONS FOR INSPECTING CROSS LINES. The main reason for inspecting these cross lines is that by so doing we can keep all the possible lines of travel under supervision, or at least control the travel, without actually inspecting every train. In the ter- ritory near the Alabama-Mississippi-Tennessee line, for example, there are a number of short branches which connect points in the two former States with points in the latter; but none of them extend south of the Kansas City, Memphis and Birmingham, very few of them south of the Memphis and Charleston. In 1897 we did not patrol these lines because the patrol on the east and west lines made it impossible that anyone could reach the north and south branches. There is nothing particular to be said about the crews of trains of these last two classes, except that of course they should not be changed at an infected place. II. RELAY STATIONS. These are the points at which the crews of trains coming from infected places are changed. This is usually done only when the infected place is the starting point of the train, as in the case of New Orleans or Mobile, or where the infected zone lies along a definite section of road near the starting point, as along the coast of Mississippi Sound. BEST SITUATION FOR RELAY STATIONS. The relay station had best be at an isolated siding—should be there, in fact—but if this is not possible, then the most readily isolated station should be chosen. The distance from the infected place depends upon circumstances. Facility for isolation and control is a more important factor than distance from point of departure. Wherever situated, the relay station must be under absolute control, 396 MARINE-HOSPITAL SERVICE. and an inspector should be on duty night and day, with sufficient guards always at hand to enforce his orders. The ideal condition is to have the relay made at the meeting point of the in and out trains, the crews simply exchanging trains; but this is seldom possible. ALTERNATIVE METHODS. There remain two other methods. In one the crew of the out train lays over at the relay camp to take in the next incoming train; in the other the main train is made up at the relay camp and there is a "shuttle train" that runs back and forth between the infected place and the relay station. As already stated, the latter method is far and away the best. It simplifies the administration of all the work—of trains, crews, and all. The disinfected mail, express, and baggage are transferred to the clean cars and handled by clean crews. All persons are also transferred to clean coaches, and in this way all the difficulty about Pullmans, etc., is avoided. If the trains are disinfected under this method, it can be readily done at the relay station. RELAY CAMPS. At such a relay there should be a camp for the train crews, and the inspector should have absolute control of it. The camp should be arranged in an orderly manner. It should be carefully policed, and all possible pains taken to keep it in good sanitary condition. As this camp must necessarily be in "neutral territory," the greatest care must be taken to prevent any infection of either the camp or the surrounding country. No amount of pains is too great to take to pre- vent the infection of the camp. If the relay is, as it should be, at an isolated siding, it may not be necessary to guard the camp; otherwise it should be closely guarded. Railroad men are especially intolerant of restraint, so there must be a clear understanding with the officials of the road that any disobedience of the inspector's orders means dismissal. This and the exercise of a little judgment at the start will soon get things to running satisfactorily. CIRCUMSTANCES INCREASE DIFFICULTIES. Should the circumstances compel the adoption of the method in which the out crew lays over to take the incoming train back to town, the difficulty will be vastly increased. It will then be best to have two camps, with attendant doubling of the guards, as it is necessary to pre- vent not only communication between the crews but communication between the inner crew and the country. In operating under this method the in crew brings the train to a stop at a point between the two camps and leaves it there and returns to its camp, while the outer crew then boards the train and takes charge of it. For incoming trains the process is reversed. MARINE-HOSPITAL SERVICE. 397 In one case I did about the same thing near Memphis, by station- ing a caboose at a way siding and designating a point some half mile away as the transfer point. A switch engine preceded the train and took siding at the transfer point. When the train came in sight, the "outside" crew walked down to the transfer point and boarded the train, while the inside crew boarded the switch engine and returned to the city. A QUARTERS TRAIN IS ADVANTAGEOUS. If there is sufficient siding room a "quarters train" offers some advantages over a camp, especially in that if it gets infected, or is sus- pected, we can move it bodily to uninfectible territory and get rid of watching a fresh focus, and can then replace it with a clean train and crew and continue business at the old stand. TRANSFERENCE OF FOMITES A GRAVE DANGER. The greatest care must be taken to prevent the transference of pos- sible fomites from the infected place to the relay station, and all trans- fers of passengers and crews should be under the personal supervision of the inspector. HOSPITAL OAR OR ISOLATION TENT. At all relay camps either a hospital car or an isolated tent should be provided for the care of any sick suspects that may turn up. A box car is the best; and another car should be at hand with an auto- clave and supply of formaline for disinfecting purposes; this latter car should be without end windows, should be provided with racks of wire netting, have one door sealed and the other fitted with a canvas or rubber gasket, and have connections fitted through door so as to admit of the use of either formaldehyde or steam from a locomotive. III. MANAGEMENT OF INSPECTIONS. ORGANIZATION AT INSIDE END. Necessarily the inner end of any system of inspection from infected to clean territory must be in different hands from the outer end and the organization of it is embraced in the management of the local work, and as such need not be especially described here beyond what has already been said. How far the jurisdiction of the inside man should extend depends on how far the relay is from the infected place, and more especially on how it is operated. If a " shuttle train " is used the care of the relay should be in the hands of the outside man. If an exchange of trains is made this should also be the case, but if the crews both lay over it is best for the inside man to have charge. If there are two camps the line may be drawn midway between the camps. 398 MARINE-HOSPITAL SERVICE. ORGANIZATION ON THE OUTSIDE. This much being settled, we come to the organization of the outside territory. As the country in which we are to operate is practically confined to the extreme Southern States, with the addition of western Tennessee and Arkansas, it is possible to study it in advance and get a clear idea of the routes of travel, junction points, and the like. The scope of this article does not admit of going into the question of train connections, meeting points, etc. Everyone in charge of such work must work out the details for himself, and he will be apt to find it a troublesome job, but the main points of the work may be glanced at, as they play a considerable part in shaping the plan of organization. STRATEGIC DIVISION OF TERRITORY. Looking at the map, then, it will be seen that the roads in the "infect- ible territory" naturally arrange themselves into three groups. This is exclusive of the roads west of the Mississippi, especially of those in Texas. One group radiates from Memphis and Fulton, Ky., and may be called the western group, another occupies the center of the field with Nashville as a base, and the remaining group is made up of the lines converging on Atlanta and Chattanooga. PROPER DIVISIONS FACILITATE THE WORK. This arrangement facilitates the division of the work, but 1 am strongly of the opinion that the whole territory should be under one man. In no other way can the unity of control be maintained. We have to start off by dividing authority to some extent with the inside man, and further division increases the chance of confusion in a geometrical progression. It is a large territory of course, but I man- aged to cover about three fourths of it fairly well last fall, and if a sufficient number of regular officers were supplied to take the subor- dinate divisions of the territory it would be much easier. TERRITORY WEST OF THE MISSISSIPPL The territory west of the Mississippi should be divided. Arkansas naturally falls into the Memphis district for the most part, but Louisiana and Texas should be separate jurisdictions. The head- quarters for the former should be at Shreveport and for the latter at Houston and Texarkana. TERRITORY EAST OF MISSISSIPPI RIVER. Assuming then that the work east of the Mississippi is to be under one head, he should have an officer to assign to the charge of each of the main divisions, with as many regular officers as possible under them and a sufficient corps of acting assistants and inspectors MARINE-HOSPITAL SERVICE. 399 The Memphis section being the most important, the general head- quarters should be there. Of course these remarks aie based on the supposition that it is the Southwest that is infected. If it is in some other section that the work is to be done the geographical remarks just made will not apply, but the general plan of organization will be applicable anywhere. The headquarters should be adequately provided with clerical and other assistance. It is idle to try to run a large inspection service without adequate office force. I tried to do so on the ground of economy, but it cost more than it came to. Whoever takes charge of such work will find that the impression in the minds of the general public is that " all knowl- edge and all power" have been intrusted to the "marine doctor," and that as a consequence he will be approached by hundreds of people with whose business he has no direct concern, yet whom he must either see or have someone see for him, and whose numberless letters of inquiry most be answered. ARRANGE WITH HEADS OF RAILROADS AT FIRST. Arrangements must be made with all the roads in the territory to furnish transportation for all officers and inspectors, and to issue orders to all employees that the train inspectors are in absolute control of all sanitary matters on trains and that their orders must be obeyed to the letter. Provided one goes to the head officers to make arrangements he will find it a pretty general rule that the larger the corporation the more intelligent will be its cooperation in his work. A clear understanding must be promptly reached with the express companies and with the superintendent of the Railway Mail Service and with the Pullman Company as to just what you want them to do. In all such cases treat only with the man at the top; it will save some trouble and a great deal of time. TIME IS OF PRICELESS VALUE AT BEGINNING. Time is of priceless value at the beginning. If it is a question of losing time or having misunderstandings with local authorities and railroads, act first and straighten things out afterwards; it is sur- prising how much you can do without any real authority if yon insist on having your own way. A competent steward should be in charge of the central office, and, if the territory is a large one, a stenographer and typewriter. DIVISION CHIEFS. The officer in charge should be free to go and come unfettered by office work, vouchers, and correspondence. 400 MARINE-HOSPITAL SERVICE. The chief in each district should have charge of all matters in that territory; receive the reports of inspectors, run over the lines himself pretty frequently, and at the same time cooperate, under the direction of his chief, with those in charge of the other districts. He should report direct to the man in charge of all the work, and take orders from him as far as concerns his immediate sphere of action. OFFICER IN GENERAL CHARGE. The officer in general charge should outline the work for each district chief, leaving the details very largely to them, but holding them to a strict accountability. He should visit all parts of his territory from time to time, investigate all rumors of the presence of disease, and transmit frequent reports of the work to the Surgeon-General, provided he can find the time. He should keep in close and cordial touch with the local health authorities everywhere, and with the heads of the trans- portation companies. The former are often a trifle suspicious at first, but tact and judgment usually overcome this very readily. It is often best to request as a favor what one could demand as a right. The people in the smaller Southern towns can usually be reasoned with— they are rather hard to force. The railroad people are generally eager to give every assistance, and their earnest cooperation is most essen- tial. The discipline of a good road is of the greatest help when enlisted on our side. Generally speaking, the larger the corporation and the higher the rank of the official approached the more intelligent will be the assistance secured. CHIEF OFFICER SHOULD KEEP INFORMED OF ALL WORK. While the details of the work iu each district may be left to the man in charge there, the chief should keep himself intimately informed of everything concerning the work in hand. In this work success depends on the execution of details ; attention to details is really of rather more importance than excellence of general plan. TRAIN INSPECTORS AND WHAT THEY SHOULD BE. The inspectors should always be physicians. They should be fur- nished with plainly written instructions as to their duties, with formal credentials and badges, and if possible should be sworn in as deputy United States marshals. MUCH AUTHORITY NEEDED BY INSPECTORS. It will greatly facilitate the control of the train crews if each in- spector is furnished with a letter from the general superintendent of the road, addressed to all employees of the road, and stating that the inspector is in absolute control of the train. A similar letter from the Pullman authorities should be furnished them, and they should have MARINE-HOSPITAL SERVICE. 401 keys to all cars. They must be instructed that in case they find a case of suspicious illness on their train they will be expected to stay by it and to accompany it to one of the observation camps, mentioned in Section V, Chapter II. CAMPS OF OBSERVATION. These camps should be small, consisting of a couple of tents properly equipped with cots, etc., and in charge of two reliable men, and estab- lished at several points, the location of which can only be determined on the ground. These camps are for the care of cases of suspicious sickness that may be found on the trains. IMMUNITY DESIRABLE IN INSPECTORS. The first tier of inspectors—those under the jurisdiction of the officer inside the infected place—should be immunes. Immunity is desirable but not essential in the others. SCHEDULES OF INSPECTOR'S DUTIES. A schedule must be prepared showing what each man's duties are, what train he takes, where he transfers, etc. At the central office it should be possible, by consulting this table, to tell just where each man is at a given time, as the train dispatcher locates his trains from his "train sheet." Such a schedule may prove a more difficult job than it looks, for suit- able inspectors can not always be found in sufficient numbers, and those found must sometimes sleep and eat; and, moreover, stations, sidiugs, State lines, etc., can not be moved at pleasure, so it may be rather a puzzle to fit the men to the runs. As an illustration of such difficulties and how they are to be met, I give the schedule on the Nashville, Chattanooga and St. Louis Railroad last fall. The trains were worked out of Nashville into the quarantined terri- tory west of the Tennessee River. Some trains ran all the way into Memphis, some part of the way, and some, after entering the quar- antined territory, merged their identity in trains on other roads that entered that territory from other points. On some of the return runs the men could sleep in the Pullmans; on others they had to work both ways. Schedule for Nashville, Chattanooga and St. Louis Railroad between Nashville, Memphis, and McEenzie. Departures. Time. Arrivals. Time. Buns and location of inspectors. Train number. Date. 1st. 2d. 3d. 4th. 5th. 6th. 7th. 8th. 9th. 10th. 11th. 12th. 13th. 14th. 4............... 7.00 a.m.. 2.05 p.m.. 9.40 a.m.. 3.40 p.m.. 9.40 a.m.. 9.30 p.m.. 4.00 p.m.. 3.35 a.m.. 8.45 p.m.. 3.35 a.m.. 9.00 p. m.. 2.15 p.m.. 11.25 a.m. 6.20 p.m. 2.31 p.m. 7.55 p.m. 7.00 p.m. 8. 00 a. m. 8.41 p.m. 8.00 a. m. 1.20 a.m. 8.00 a.m. t: } • } * } • 8 1 2 3 4 5,6 7 8 1 2 3 4,5 6 7 8 1 2 3,4 5 6 7 8 1 2,3 4 5 6 7 8 1,2 3 4 5 6 7 8,1 2 3 4 5 6 7,8 1 2 3 4 5 6,7 8 1 2 3 4 5,6 7 8 1 2 3 4,5 6 7 8 1 2 3,4 5 6 7 8 1 2,3 61.............. 4 60.............. 3............... 5 60-2s........... 101............. 6 62.............. 1-ls............ 7 2-ls............ l-2s............ 8 2-2s............ 63.............. 11 25 p m ' ' 1,2 Each inspector to receive a number from 1 to 8 and take his run in accordance with the positions of said number on this sheet Is means first section; 2s means second section. 4^ O MARINE-HOSPITAL SERVICE. 403 DUTIES OF INSPECTORS. At the beginning it must be explained that the special details of inspection duty will vary very widely on different roads and under different circumstances. In the first place the regulations of the State and local boards will greatly modify the action we must take, and, as a rule, greatly limit our usefulness. I am assuming now that the law under which the work will be done will be as at present. TO KEEP INFORMED OF LOCAL REGULATIONS. The inspectors must keep track of all the changes in the local regu- lations, or at least the officer in charge must; he must also keep track of the way the local authorities construe the State regulations, and if they propose to be bound by them. Very often they do not. TO LEARN STATE LINES AND LOCAL GEOGRAPHY. If the line on which the inspector works runs through more than one State, the inspector must lose no time in learning the location of State lines, otherwise he will have to consult a map or the brakeman before he can answer a passenger's inquiry as to his status, which rather impairs his prestige. THESE RULES ARE ON BASIS OF NATIONAL QUARANTINE REGULATIONS. It being understood then that no hard and fast rule can be laid down as to the action under State rules, I will outline how the inspector should work in order to simply carry out the national regulations, and will begin with the case in which the infected territory surrounds the road's terminus, or at least the place where the trains are made up. INSPECTORS TO BE ON HAND AT DEPARTURE OF EACH TRAIN. An immune inspector, acting under the orders of the officer in local command, will be on hand before the departure of the train to see that all regulations as to the character of coaches, etc., have been complied with. On boarding the train he will carefully inspect everyone, from the engineer down, for even if all hands are relayed at the end of a few miles it is most important that none of the crew be allowed to sicken, lest they infect the transfer station. The sanitary condition of the cars must be looked into, and if the cars on that run are being dis- infected or placarded he must see that the disinfection has been prop- erly certified to and that the placards are in place. Either the inspector himself or another man detailed for that duty must see that no undis- infected baggage or express matter for infectible terrritory is put on board. He will then proceed to make a careful examination of all the 404 MARINE-HOSPTTAL SERVICE. passengers, ascertaining their recent whereabouts and their destina tious. He will enter the names, etc., on the blank here given: Report of United States sanitary inspector. [Train No.---j railroad,-----------.] No. Name. Origin. Destination. Certificate issued at— Date. Eemarks. These forms should be furnished in book form and be used with car- bon paper between the sheets, so as to preserve a record after the original has been torn out and given to the next inspector. TRANSFER OF LISTS AT RELAY STATIONS. On arrival at the relay station he will assist the inspector stationed there to supervise the exchange of crews. He will then examine the new crew and enter their names on his report. If the train is a refugee train and runs straight through, his duties will be confined to seeing that no one either leaves or enters the train at the points where stops have to be made for orders or for water and coal. He will keep the doors locked, allow no passing to and fro between cars, and rigidly restrict the intercourse of the crew with the passengers. When the train stops in a town, or has to run very slowly, he will have all the windows kept closed, not to prevent the convey- ance of infection, but to limit the chance of communication. Should a case of suspicious sickness occur, he must promptly isolate the patient, and his belongings and companions, and wire the facts to his own chief and to the chief of the inspectors into whose district he is running. The ultimate disposition of the patient depends upon the circumstances of the case. Generally speaking it is better to carry him on into non- infectible territory. IN CASE OF REFUGEES IN SEPARATE COACHES. If the run is one upon which the refugees are in separate coaches of a train, doing local work, the inspector must see that there is absolutely no intercourse between the different classes of passengers and thatthe reserved coaches are kept locked at all times and their windows closed while passing through or stopping at all stations. He will carefully exam- ine all persons boarding the train and require them to present satisfactory evidence as to their recent whereabouts. If possible this should be done before the person is admitted to the train; indeed it ought to be MARINE-HOSPITAL SERVJCE. 405 always done that way. Persons who can not give a satisfactory account of themselves should not be allowed to board unless holding tickets for points in noninfectible territory. Reaching the point where the in and out bound trains meet, the inspector will transfer to the inbound train, after delivering to the man who has come in on that train a copy of his passenger list, and given him all the necessary information about the train and the passengers. His list should include the crew and every person who has boarded the train up to that time. It will greatly facili- tate the work if the agents are forbidden to sell tickets to those with- out papers. "inside" men and "outside" men. The inspector who comes down on the inbound train, hereafter to be designated the " outside man," will transfer to the outbound train and proceed to check up the passengers with the list furnished him. On the way down he will have made a similar list of his passengers for delivery to the "inside man." He will also have carefully inquired into the recent whereabouts of all who are on board the train. Neither he nor the inside man should allow anyone to leave unless satisfied as to their antecedents. Of course it is not necessary for the doors and windows of the inbound train to be locked, but it is necessary that no one should enter or leave the train except by the permission of the inspector. PURELY REFUGEE TRAINS WITHOUT LOCAL BUSINESS. Of course in the case of a purely refugee train the outside man sim- ply continues the supervision kept up by the inside man, and accom- panies the train back to the starting point of his run. TRANSFERS OF PASSENGERS TO OTHER LINES. The outside man maintains the restrictions then until he reaches the starting point of his run, at which place the passengers are either allowed to proceed without further supervision or are turned over to the next inspector with the list received from the inside man, with the additions made since the transfer. This last list can usually be omitted as far as the purely local passengers are concerned. For instance, there is no use in making a list of the purely local people coming into Memphis over the Illinois Central. The inspector through whose hands the list passes should note on it the disposal of each passenger, whether he went on through, or transferred to another line, etc. All the way along, the inspectors should note on the report if passengers were received from branches or intersecting lines. Where such transfers are made, a list of the names, etc., of those transferred should be furnished the inspector on lines to which they go. 406 MARINE-HOSPITAL SERVICE. ULTIMATE DISPOSITION OF PASSENGER LISTS. At the conclusion of the run the report, bearing the checks and notes of the various men through whose hands it passes, is filed at the central office, and should be preserved there as a means of checking up the movements of individuals whose previous whereabouts may be called in question. The receipt and filing of these reports should not be allowed to become a purely routine matter. EVASION OF RESTRICTIONS BY DETOURS. Of course it is impossible to prevent individual cases of evasion, but the people who take much trouble to evade the restrictions by making detours involving several days' travel are really not a source of much danger. DUTIES OF INSPECTORS ON "SHUTTLE" TRAINS. When a "shuttle train" is used between the infected place and the relay station, the man in charge of it does not have time to list the refugees; he merely has a general supervision of them, sees that none are actually sick, that all are delivered to the inspector who takes out the train from the relay station, and should also see that the coaches of the train are kept in good sanitary condition. LINES RUNNING THROUGH INFECTION BUT CLEAN AT TERMINI. In the case of lines running through an infected place, but with both their termini in clean territory, the control of the entire inspection system should be in the hands of one officer. Here there are no relays to look after, but if the place is of any size there should be designated points on either side of the town at which trains should stop and be searched for tramps and stowaways. The inspectors should, if possible, run from end to end. If the run is a long one they work one way and sleep on the way back. If this is impracticable they exchange at meeting points. If the place is too small to warrant running a regular refugee train, or using refugee coaches attached to regular trains, a way of escape can be arranged by running a special on certain days. In either method an inspector should be assigned to the duty of superintending the embarkation of refugees, giving to such as desire it a descriptive card with the date, to be used by the recipient as a means of identification, should he desire to enter infectible territory after serving out his period of detention elsewhere. In all these methods it is desirable that the refugees be handled on day trains only, for the greater facility in observation and control thus obtained. The method of preparing lists of passengers, reporting, and making transfers being as already described. MARINE-HOSPITAL SERVICE. 407 THE CLASS OF ROADS THAT ARE ONLY COVERED ON ACCOUNT OF THE POSSIBLE LATERAL MOVEMENT OF PASSENGERS FROM OTHER LINES. In some cases this may be very important, as in the work about Brunswick, Ga., where the Savannah, Florida and Western and the Florida Central and Peninsular, while they did not enter the city, were of quite as much importance as the roads that did. Ordinarily, however, this is not the case, and it is not necessary for the inspectors to list their passengers. They should, however, carefully investigate the antecedents of all and allow no one to leave the train in infectible territory whose history is not clear. At junction points, where passengers may be received from lines from infected territory, all passengers boarding the train must be required to present their papers. If the connection is a close one the refugees are received direct from the inspector on the other train, otherwise they should have transfer cards as described below. AS TO THE USE OF SEPARATE CARS. As the number of such persons will usually be very small, often not over one or two, and as they are usually well when received, it will not be necessary to put them in separate cars. Theoretically this is not sound, but practically it is. It must be remembered that much of the isolation to which we subject refugees is for the alleviating of the uneasiness of other passengers and for the restoration of public confidence in the more seriously threatened, and consequently panic-stricken, sections. The inspectors will run straight through, or to meeting points, as is most convenient. NO RESTRICTION TO TRAVEL FROM COLLATERAL POINTS IN CLEAN TERRITORY. No restrictions need be put upon the movements of people boarding the train at points out of reach of the main lines from infected territory, but those received from such lines and those unable to give a satisfac- tory account of themselves must be prevented from leaving the train in infectible territory. If the inspector only goes to the meeting point and has refugees on his train he delivers a list of them to the man he transfers them to. MANAGEMENT OF JUNCTION POINTS. The management of junction poiuts is often very difficult. It is absolutely necessary for their control that we should reach an amicable arrangement with the local authorities, otherwise travel may be utterly 408 MARINE-HOSPITAL SERVICE. and needlessly blocked and great loss and hardship be imposed on innocent people. In two conspicuous cases last fall business was paralyzed and the really necessary work of inspection severely hampered by the unneces- sary obstinacy of the authorities at important junctions. If the train connections are such that a lay over or transfer through town is necessary, these should be in charge of a man stationed per- manently at the junction. Transfers should be made under direction and the travelers be abso- lutely under control of the inspector. The inspector on the train which brings the people should give to each a signed card bearing the date, name, place of origin, destination, and train desired to be taken. The card should state across the face that it is good only on day of issuance. By means of these cards the inspector at the junction can rapidly decide what action is necessary, and when the traveler boards the train the card, previously initialed by the man at the junction, wdl serve as a guide to the inspector thereon. If the junction is a close one the cards are also to be given as a guide to the new inspector. This may seem impracticable, but it is not, and is a help to the inspectors. If the local authorities are competent and willing they can be allowed to handle the transfers. They did so at Memphis in 1897. Such a reciprocity is in many ways most desirable, even at the loss of a certain amount of direct control. A volume might be written on the subject of the possible action of local authorities—how they may aid or hinder the work, and how the conditions thus arising are to be met—but as neither the prophetic vision of Daniel nor the wisdom of Solomon could foretell the occur- rence of or divine the reason for much that they will do, it is useless to discuss the matter here. Through deserving the confidence of the people by conscientious attention to details all will be done that can be done. This, assuming the law to be as at present or as it may be if amended. The wishes of the people will have to be deferred to as long as not inconsistent with safety. OFFICER IN CHARGE SHOULD KNOW ALL LOCAL AUTHORITIES. The officer in charge should visit as many places as possible along his roads and get in personal touch with the authorities, but should avoid "conferences" at any cost. He should see that all local rules not inconsistent with his orders and the regulations are enforced as if they were his own, and should promptly advise his inspectors of any changes in the State or local rules. It may be observed that I have often spoken of "satisfactory evi- dence" as to recent whereabouts. MARINE-HOSPITAL SERVICE. 409 WHAT CONSTITUTES SATISFACTORY EVIDENCE OF HEALTH. It is the custom to speak of "health certificates" in this connection. I have purposely refrained from doing so. The ordinary "health certificate" certifies to nothing at all. The city of New Orleans issued health certificates when the town was full of fever. At Memphis the certificate was merely a statement by the health board that A. B. had appeared and made certain statements which they had not verified. Atlanta had the best form of certificate, but none of them were good for much. The only certificate that is worth much is one in which the physician or other responsible party makes oath before an officer possessing a seal that the facts are so and so, or in which such an officer verifies the signature of the party issu- ing it. This is a hardship on the ignorant and an expense to the needy, and by no means to be always exacted. An intelligent inspector can soon learn to divide the sheep from the goats. The sales books of drummers, telegrams, the postmarks of letters, the dating stamps of the railroad agents at the various places at which the man has been, and many forms of evidence are all worth more than the ordinary cer- tificate. The trafficking in " health certificates " was quite an industry last fall, and the issuing of them at 50 cents or $1 apiece proved better to some people than private practice. Of course immunes and those who hold discharges from service camps may be allowed to go freely to their destinations. For most of the others the sworn health certificates or similar evidence must be required; for wayside stations the identification of the station agent suffices. Probably no one will again be called upon to handle such thousands of people as the Nashville Exposition put in motion throughout the South, so I have said nothing of the special organization in such cases. At best the scope of this article does not admit of much discussion of details. They must be left for their management to individual judgment. WHAT IS TO BE DONE WITH PERSONS WHOSE HISTORY IS IN DOUBT. One part is of interest, however. What is to be done with persons without satisfactory evidence as to their antecedents who are found upon trains bound for infectible territory ? We can't land them. What, then, can we do with them 1 We can compel the roads to return them to the points whence they took them, but if they have not the where- withal to feed themselves en route, and if they come to the line on which we find them from some other line, their condition may be most distressing. I am of the opinion that, if such people are manifestly innocent of intent to evade the inspectors, we should feed them en route, if neces- sary, and use our utmost endeavors to have them returned to their homes. 3934----9 410 MARINE-HOSPITAL SERVICE. For the far larger class of unfortunates, who, while of perfectly acceptable status as far as the national inspector is concerned, are rejected by local authorities, there is very little to be done. They are in the position of an old man on the Illinois Central, whom the road, in trying to deliver at a point in southern Mississippi, had three times in succession transported from Chicago to the South and back. As he began his fourth return trip he lifted up his voice and wept, " The good Lord only knows what will become of me." FREIGHT TRAFFIC. The handling of freight trains presents special difficulties. I am of the opinion that freight trains are a greater menace than passenger trains. They are more numerous, they run at irregular hours, they make longer and more frequent stops, and they are made up of cars from all sorts of localities. So much for the trains themselves. PERSONNEL OF FREIGHT TRAINS PARTICULARLY DANGEROUS. As to their personnel, the crews are less subject to control than pas- senger crews; they are changed more frequently, and the handling of the train at the stops involves more opportunities for contact with the people at those places; then we have to remember that the freight train is the "route of election" chosen by tramps proper and other irregular travelers; of these latter the most dangerous class are the railroad men out of a job, who are smuggled along by their mates in cabooses or box cars, as the discipline maintained on the road may determine. TRAMPS AND RAILROADERS SEEKING WORK. They come from infected places perhaps because work is slack and they go anywhere they choose, inspection or no inspection. The crew will usually promptly eject the tramp, but will harbor the "railroader." All freight crews must be changed at relay stations, as the passen- ger crews are, and when there is much business out of a large and thoroughly infected place there should be inspectors at the next divi- sion points to inspect the crews arriving at the relay stations and to look out for irregulars. WHAT TO DO WITH IRREGULAR TRAVELERS. This brings up the question of what shall we do with the tramps and irregulars found on either freight or passenger trains. Usually the crew promptly ejects them—almost invariably in the case of passenger crews—without the slightest care as to where they come from or how dangerous they may be to the community where "fired." MARINE-HOSPITAL SERVICE. 411 OBSERVATION CAMPS. To meet this difficulty Acting Assistant Surgeon Frick has suggested that at certain designated points there should be small camps of obser- vation, and that the train crews should have positive orders not to eject persons found stealing rides, but to deliver them at said points to the care of an inspector. They can then either be forwarded in batches to noninfectible territory or made to serve out their period of detention. Even where there is a regular detention camp within a few hours' run, it would be much better to deliver the tramps at the certain points as suggested by Dr. Frick, and then transfer them under guard to the regular camps. This duty could be assigned to the men on duty at the freight divis- ion termini. The scope of this article does not admit of treating these questions in fuller detail. It is a knotty problem, and will tax the ingenuity of anyone who has to handle it. UNIFORMITY OF METHOD ESSENTIAL. In conclusion, too much stress can not be laid upon the necessity of securing uniformity of method by putting as much territory as possible under one officer and of supplying as many regular officers as possible as assistants. Under existing laws we can not do so very much toward suppressing the disease when it occurs, but we can do something toward limiting its spread. SYNOPSIS OF THE INTERSTATE QUARANTINE REGULATIONS OF THE TREASURY DEPARTMENT.* By P. A. Surg. J. H. White. In undertaking to prepare a precis of the Interstate Quarantine Reg- ulations, it is apparent at once that such precis will be only a synopsis of the articles preceding this; i. e., Sections D, E, and F. NOTIFICATION. It is imperatively necessary that early notification should be given to the Surgeon-General of the United States Marine-Hospital Service of the existence of the first case of yellow fever in any community if good results are to be attained. It does not follow that this information becomes public property. What is easy if promptly handled becomes a herculean task if allowed to go unheeded for several weeks. Local physicians should notify their local or State health officers and the lat- ter should in turn notify the Surgeon-General of the Marine-Hospital Service, either directly or through the nearest Marine Hospital officer. Telegrams conveying said information can be sent collect. RELATION OF MUNICIPAL TO INTERSTATE EPIDEMIC WORK. It should be borne in mind that the best possible means for preven- tion of interstate spread of any disease is the suppression of the initial case at once. The fundamental principle of sanitary work is, End the disease with the first case. It may be stated as a fact that the risk of spread and the work of suppression increase in geometric progression as the number of infections increase. ISOLATION OF SICK. Upon the discovery of a case of yellow fever, the patient should be promptly isolated and care taken to disinfect all textiles, etc., which may have been infected by the sick. Careful examination should be made of each and every inmate and all healthy persons placed in another house, there to undergo eight days' observation at the hands of a competent physician, and if no case occurs among them they should be released. Before isolation, however, their clothing should be disinfected. The infected house should be rigorously quarantined and no one allowed * The interstate quarantine regulations promulgated by the Secretary of the Treasury are published in full and issued in pamphlet form by the Marine-Hospital Bureau. 412 MARINE-HOSPITAL SERVICE. 413 entry or exit except the physician, who should isolate himself, unless immune, and adopt all proper precautions, arrangements being made for the provisioning of the nurses and the patients in such manner as to avoid any spread of infection. All this is fully stated by Surgeon H. R. Carter in Chapter I, Section D, including the disinfection. DEPOPULATION. Two distinct means offer themselves in the handling of the first cases: I. Removal of the sick and those exposed with them to isolated and separate, and as nearly as may be noninfectible quarters. II. Depopulation of the immediate vicinity within a radius of about 200 yards, and then treating the patient where he sickened, with a sub- sequent disinfection of not only his own but other nearby residences, and especially those to leeward of the sick. A little thought will show that the first is by far the best method of dealing with original cases, as it necessitates less disinfection and tends to remove public disquietude, which in itself is a factor not to be despised. When it is found that we have several cases in a town and the source is not definitely known, it is, I believe, advisable to quarantine with an impassable cordon the whole town, but only until inspection, house to house, shows exactly what section of the town is infected; then release the remainder and cordon that section until it can be depopulated into a camp; treat the sick until well, and disinfect all houses where sick- ness has existed. I am of the opinion this is possible if the presence of yellow fever is discovered before there are more than twenty cases existent; and while it would be difficult of execution, yet it promises such results as to justify the effort; and if successful, it means the extir- pation of an epidemic more promptly than would be otherwise possible Success in this way was attained at Franklin, La., Nittayuma and Cayuga, Miss., and other points. (See Section D, Chapter I, by Surg. H. R. Carter.) HOUSE-TO-HOUSE AND NEIGHBORING VILLAGE INSPECTIONS. Immediately on the discovery of yellow fever inquiry should be made as to the whereabouts of persons who have been exposed. These should be traced to neighboring or even to distant villages or places and kept under observation. In the meantime a careful house-to-house inspection should be made in the infected locality. PASSENGERS LEAVING INFECTED PLACES. Exit should be permitted to all persons from infected towns who desire to go to places beyond the limit of possible epidemic, i. e., such as from New Orleans to Chicago, and in such cases disinfection of effects, while of course salutary, so far as persons themselves are con- cerned, is not necessary if they remain North. 414 MARINE-HOSPITAL SERVICE. All parties, save immunes, going to places inside such lines, i. e., into infectible territory, should go into the detention camps mentioned in this writing. PROVED IMMUNES GOING THROUGH AFTER BAGGAGE DISINFECTION. All persons, wherever going, should be under the eye of train inspect- ors, and this should particularly include railroad employees and offi- cials, as by constantly entering the infected locality they are peculiarly liable to be carriers of infection. All trainmen should be relayed at some convenient point near the infected city, so that no single one of them shall go beyond that relay point, either of the crew belonging at the infected or that belonging at the noninfected end of the line. Coaches should be disinfected at their point of destination (in clean territory), and, in so far as convenient, upholstered coaches should not be used (this simply to minimize the work of cleansing). Train inspectors should also be relayed and an inspector accompany each train until it reaches noninfectible territory. They should also keep watch on return trip against the doubling back of people recently out of infected zone and seeking entry to clean but infectible territory. Exit should be encouraged early in the outbreak, because at that time the amount of possible risk is less than it will be when the town is largely infected. GUARDS, ATTENDANTS, ETC. It is of prime importance that all persons exposed to the sick man or his belongings, in the endeavor to suppress infection, should be immune to yellow fever, and wherever possible all should be so. In the case of the death of a patient the body shall be disposed of under such sani- tary precautions as will prevent the conveyance of infection. WHEN NECESSARY TO PUT ON ABSOLUTE QUARANTINE. When the number of cases becomes so great that it is not possible to exactly trace the origin of each, and it becomes evident that cases are being concealed, a complete quarantine of the whole community becomes necessary. I shall not enter fully into this subject, as it is entirely covered in Section D by several writers, and notably by Dr. Carter. If I have succeeded in impressing upon the reader the imperative necessity of detection and isolation, and proper handling of first cases, I am more than satisfied. This is the very keystone of interstate quar- antine measures. We must treat first cases with such tender consideration—provide such nursing and medical attendance, and at little or no cost to the patient's family—that isolation shall become even attractive, if that be possible, for be it well remembered that concealed cases will spoil the best arrangements. A PRECIS OF THE UNITED STATES QUARANTINE REGULATIONS FOR DOMESTIC PORTS WITH REFERENCE TO PREVENTING THE INTRODUCTION OF YELLOW FEVER IK TO THE UNITED STATES. By Surg. Preston H. Bailhache. As yellow fever is not an endemic disease of this country, regula- tions for the prevention of its introduction from abroad have been prepared by the Surgeon-General of the Marine-Hospital Service, under the direction of the Secretary of the Treasury, and promulgated by the Department under date of April 26, 1894. PRIMARY MEASURES. The primary measure to be adopted to prevent the introduction of this disease into the United States is the establishment at the principal ports of the country of completely equipped quarantine stations for the inspection and treatment of vessels, their passengers, crews, and cargoes. At smaller stations, where it is impracticable to fully equip and maintain a complete establishment, provision should be made for the inspection of such vessels, and these inspections should be main- tained at every port throughout the year. PERSONNEL SHOULD BE IMMUNE. The personnel of Southern quarantine stations should be immune to yellow fever, and all articles liable to convey infection should be handled only by the employees of said station, if practicable. INSPECTION. Vessels arriving at ports of the United States under the following conditions shall be inspected by a quarantine officer prior to entry: A. Any vessel with sickness on board. B. All vessels from foreign ports. C. Vessels from domestic ports where yellow fever prevails. D. Vessels from foreign ports carrying passengers having entered a port of the United States without complete discharge of passengers and cargo. Such vessels shall be subject to a second inspection before 415 416 MARINE-HOSPITAL SERVICE. entering any other port. Vessels from ports suspected of infection with yellow fever, having entered a port north of the southern boundary of Maryland without disinfection, shall be subjected to a second inspec- tion before entering any port south of said latitude during the quaran- tine season of such port. The inspections of vessels shall be made by daylight, except in case of vessels in distress. In making the inspection of a vessel, the bill of health and clinical record of all cases treated during the voyage, crew and passengers' lists and manifests, and, when necessary, the ship's log shall be exam- ined. The crew and passengers shall be mustered and examined and compared with the lists and manifests and any discrepancies investi- gated. No person except the quarantine officer, his employees, United States customs officers, or agents of the vessel, shall be permitted to board any vessel subject to quarantine inspection, until after the vessel has been inspected by the quarantine officer and given its discharge. VESSELS SUBJECT TO QUARANTINE MEASURES. A. Vessels arriving with yellow fever on board. B. Having had such on board during the voyage or within thirty days next preceding arrival, or, if arriving in the quarantine season, having had yellow fever on board after March 1 of the current year, unless satisfactorily disinfected thereafter. C. Vessels from noninfected ports, but bringing persons or cargo from places infected with yellow fever. D. From ports where yellow fever prevails, unless disinfected in accordance with these regulations, and not less than five days have elapsed since such disinfection. Exceptions to C and D.—Vessels arriving during certain seasons of the year, to wit, from November 1 to April 1, may be admitted to entry. Vessels bound for ports in the United States north of the southern boundary of Mary- land, with good sanitary condition and history, having had no sickness on board at ports of departure, en route, or on arrival, provided they have been five days from last infected or suspected port, may be allowed entry at port of destination. But if said vessels carry passengers destined for places south of this latitude the baggage of said passengers shall be disinfected. In making an inspection of a vessel, if from a port where yellow fever prevails, and between April 1 and November 1 of any year, the inspector shall ascertain the destination of each passenger thereon, and if bound for places south of the southern boundary of Maryland, the baggage of such passenger shall be disinfected accord- ing to the rules for such articles infected with yellow fever. Such baggage shall be labeled. Vessels engaged in the fruit trade from ports declared safe for this purpose by the Supervising Surgeon-General Marine-Hospital Service, may be admitted to entry without detention, provided that they carry no passengers and have carried no passengers from one port to another, and have no household effects or personal baggage in cargo, and have complied with the special rules and regulations made by the Secretary of the Treasury with regard to vessels eugaged in said trade. MARINE-HOSPITAL SERVICE. 417 PASSENGER TRAFFIC. Passenger traffic may be allowed during the quarantine season from any port infected with yellow fever to any port of the United States south of the southern boundary of Maryland under the following conditions: (a) Vessels to be of iron, and clean immediately prior to taking on passengers. (6) The vessel must lie at moorings in the open harbor and not approach the wharves, nor must the crew be allowed ashore at the port of departure. (c) AH passengers and crew must be immune to yellow fever, and so certified by the United States medical officer.* (d) All baggage which has not been disinfected at the port of departure by the United States medical officer, or which is not in bond for points north of the south- ern boundary of Maryland, shall be disinfected at the quarantine at the port of arrival; no bedding or household effects to be allowed to enter. GENERAL REQUIREMENTS AT QUARANTINES. Pilots bringing infected vessels will be detained in quarantine a suffi- cient time to cover the period of incubation of the disease for which the vessel is quarantined if, in the opinion of the quarantine officer, such pilots have been exposed to infection. The dunnage of pilots shall be disinfected when necessary. No direct communication shall be allowed between quarantine, or any vessel in quarantine, with any person or place outside, and no indirect communication except under the supervision of the quarantine officer. No ballast shall be allowed to leave the quarantine station unless disinfected. Where it is impossible to disinfect cargo in situ, it shall be removed and disinfected in the manner provided for articles of their class in these regulations; such articles to be unpacked and so arranged as to allow the disinfectant used to reach every part of all surfaces of said articles. Vessels arriving at any port of the United States, having yellow fever aboard during the quarantine season, shall be remanded to an anchorage set apart for infected vessels, and there to remain until after the discharge of the passengers and purification of the vessel. All passenger baggage disinfected under the requirements of these regulations shall be labeled. Vessels detained at any national quarantine will be subject to such additional rules and regulations as may be promulgated from time to time by the Supervising Surgeon-General. The following is the form of certificate which shall be issued to the vessel by the health officer when she is released from quarantine: -----,----------, 189-. I certify that-----, of -----, from-----, has in all respects complied with the quarantine regulations prescribed by the Secretary of the Treasury, and that in my * The evidence of immunity which may be accepted by the sanitary inspector is: First. Proof of continued residence in an endemic focus of yellow fever for ten years. Second. Proof of previous attack of yellow fever. 418 MARINE-HOSPITAL SERVICE. opinion she will not convey quarantinable disease. Said vessel is this day granted free pratique. ---- f Health (Quarantine) Officer, Port of-----. SPECIAL REGULATIONS RELATING TO NAVAL VESSELS. 1. At domestic ports such communication may be allowed with ves- sels of the United States Navy as the certificate of the medical officer of said vessel shows will not be liable to convey infection. 2. The certificates of the medical officers of the United States Navy that the United States quarantine regulations have been complied with may be accepted for naval vessels. 3. Vessels of the United States Navy, having entered the harbors of ports infected with yellow fever, and having held no communication which is liable to convey infection to the vessel or her crew, may be exempted from the quarantine restrictions imposed on merchant vessels from such ports. TREATMENT OF VESSELS INFECTED OR SUSPECTED OF BEING INFECTED WITH YELLOW FEVER. Where practicable, at once remove the sick to hospital; remove and isolate all persons not required for the care of the vessel. If the hold is deemed infected, there shall be a preliminary disinfec- tion as hereinafter provided. The bilge should be cleansed with sea water, if possible, before disin- fection, and the hold rendered mechanically clean. All ballast except close grained hard rock must be discharged. This may be retained aboard if disinfected by immersion in an acid solution of bichloride of mercury, 1 to 800. After discharge or disinfection of ballast the vessel should be disin- fected. If it is so stowed as to admit of disinfection, the cargo and the hold may be disinfected without breaking bulk, except to such a degree as to render disinfection practicable. The personnel of the vessel shall be detained five days from comple- tion of the disinfection, or three days if all baggage, etc., is handled exclusively by quarantine employees. If the vessel has been disinfected under the supervision of an accred- ited medical officer of the United States at the port of departure, the period of quarantine may date from completion of such dininfection, and shall not be less than five days. The following regulations are provided for the disinfection of a vessel infected or suspected of being infected with yellow fever : MARINE-HOSPITAL SERVICE. 419 DISINFECTION BY SULPHUR DIOXIDE. Holds to be treated with sulphur dioxide, 10 per cent strength per volume, forty-eight hours' exposure for iron vessels, and seventy-two hours' for wooden vessels. Empty holds to be disinfected as follows : (a) If of iron, by sulphur dioxide gas, 10 per cent strength per vol- ume, for twelve hours' exposure, followed by washing with an acid solu- tion of bichloride of mercury, 1 to 800, applied under pressure to all surfaces by means of a hose. (b) If of wood, by the same methods as the preceding, save that the exposure to sulphur dioxid gas shall be for forty-eight hours; air streaks to be open. Cabin, forecastle, etc., after mechanical cleaning, to be first treated with sulphur dioxid, not less than 6 per cent strength per volume, twenty-four hours' exposure. Then, after cleansing with water if desired, wash all exposed surfaces with a solution of bichlorid of mercury, 1 to 800, or pure carbolic acid, 3 per cent. DISINFECTION BY STEAM. Clothing, bedding, and all fabrics which can be removed, not injured by steam, shall be disinfected: (a) By exposure to steam at a temperature of 100° to 102° C. for thirty miuutes after such temperature has been reached. (6) By boiling for fifteen minutes; all articles to be submerged. (c) By a thorough saturation in a solution of bichlorid of mercury, 1 to 1,000, and allowed to dry before washing. Articles injured by steam (rubber, leather, etc.), and containers, to the disinfection of which steam is inapplicable, shall be disinfected by (a) thoroughly wetting all surfaces with a solution of bichlorid of mer- cury, 1 to 800, or a 5 per cent solution of pure carbolic acid, and allowed to dry in open air; or (b) by exposure to the sulphur fumigation in cabin, forecastle, or hold. DISINFECTION BY FORMALDEHYD GAS. Since the introduction of formaldehyd gas as a disinfector, additional regulations were promulgated August 5, 1897, as follows: DISINFECTION OF STEERAGE, FORECASTLE, AND CABIN OF VESSELS. After the removal of the bedding, carpets, and furnishings, all aper- tures being tightly closed, the steerage, forecastle, and cabin of a ves- sel may be disinfected by formaldehyd gas in a percentage of not less than 2 per cent per volume strength, the time of exposure to be not less 420 MARINE-HOSPITAL SERVICE than twelve hours. The gas may be generated by one of the following methods: {a) From methyl (wood) alcohol by means of special lamps, using not less than 600 grams (750 cubic centimeters = If pints) of methyl alcohol for each 25.5 cubic meters (1,000 cubic feet) of space, the time of expos- ure to be not less than twelve hours. Lamps used for generating formaldehyd gas from methyl alcohol should change not less than 1 liter (1.01 quarts) of the alcohol within an hour. (b) From an aqueous solution, containing 40 per cent of the gas, known under the names of formalin, formol, or formalose. The gas is best evolved from these solutions by the addition of from 10 to 30 per cent of a neutral salt, preferably calcium chloride or sodium nitrate, and heating the mixture in a special boiler. One liter of a 40 per cent solution of formaldehyd gas will evolve (about 1,425 liters (50.1 cubic feet) of the gas at 20° C. (68° F.), and will be sufficient for 71 cubic meters (2,505.5 cubic feet) of space. (c) From the substance known as trioxymethylene, by means of a special lamp, not less than 2 grams (30 grains) to be used for each cubic meter (35.29 cubic feet) of space. After the disinfection of apartments (steerage, cabin, and forecastle) by formaldehyd gas, the latter should be neutralized by ammonia gas evolved from water of ammonia by heat or by evaporation from water of ammonia sprinkled upon the floor. Note.—The quantity of water of ammonia required for neutralization after each of the above-named methods is as follows: After method (a), 1 liter (1.01 quarts) of water of ammonia for each 1,000 cubic centimeters (1.01 quarts') of wood alcohol used; after method (fc), 1£ liters (1.26 quarts) of water of ammonia for each liter (1.01 quarts) of formalin; after method (c), 1 liter of water of amniouia for each 150 grams (5 ounces) of trioxymethylene. DISINFECTION OF CLOTHING, BEDDING, UPHOLSTERED FURNITURE, ARTICLES OF LEATHER, ETC. These may be disinfected by formaldehyd gas in the ordinary steam disinfecting chamber, the latter to be provided with a vacuum appa- ratus and special apparatus for generating and applying the gas. The gas should be applied in a dry state in not less than 20 per cent per volume strength, the time of exposure to be not less than one hour. Clothing bedding, etc., thus disinfected should be exposed in situ to an equal amount of ammonia gas generated by the special apparatus attached to the chamber, using 1 liter of water of ammonia to each liter of formalin; or compressed ammonia gas may be used. Note.—The special apparatus must consist of a generator, constructed of copper, for evolving formaldehyd gas from its solutions, and a similar one of iron for evolv- ing ammonia gas for neutralization. The principle upon which this apparatus is constructed is described and illustrated in Public Health Reports, Marine-Hospital Service, January 29, 1897, Vol. XII, No. 5. A CONCISE EXPLANATION OF THE MARITIME QUARANTINE REGULATIONS OF THE TREASURY DEPARTMENT RELATING TO YELLOW FEVER. By P. A. Surg. J. H. White. INTRODUCTORY. It is the purpose of this article to convey to masters of vessels and other interested parties a clear idea of the demands put upon them by the United States Quarantine Regulations. REQUIREMENTS AT FOREIGN PORTS INFECTED OR SUSPECTED OF BEING INFECTED WITH YELLOW FEVER. VESSELS AND CARGO. All vessels intending to enter ports of the United States south of Chesapeake entrance should, while lying in yellow-fever ports or ports under suspicion of yellow fever, avoid the wharves and lie at anchor in the open stream or harbor. They should take on board from said ports only such stuff as may be absolutely essential, and all that is taken aboard should be disinfected. This is especially true of clothing. Household goods should be debarred. DISINFECTION. If it be necessary to receive clothing (as of troops returning from war, etc.), and no other means is at hand, a compartment of the ship may be set aside temporarily for the purpose and the clothing disinfected therein by hanging on cords so as to freely expose all surfaces, and then exposing to sulphur dioxid for twenty-four hours, burning 5 pounds of sulphur to each 1,000 cubic feet of space so devoted. The vessel's own steam may be utilized for disinfection in any tight compartment above water line. This will ordinarily accomplish the result desired, or will at least minimize the danger of an outbreak among the crew and passengers. It is safest to disinfect all clothing, though as a matter of fact there is little danger in that actually worn, unless the wearer has been for a long period in direct touch with yellow fever, as in case of doctors and nurses. 421 422 MARINE-HOSPITAL SERVICE. PERSONS TAKEN SICK ABOARD SHIP EN ROUTE TO THE UNITED STATES. Any person taken sick aboard ship bound for the United States from yellow-fever countries should be promptly isolated. A room, well aft in a steamship or forward in a sailing vessel (in order to be to leeward of all healthy persons), should be set apart and kept constantly ready for yellow-fever suspects. The patient and his exposed clothing and bedding should be at once taken to this room. In this connection I would refer to the articles on Diagnosis of Yellow Fever, by Drs. Murray and Guiteras, and to Section D, Chapter I, by Dr. Carter, on measures to prevent the spread of fever. These articles distinctly show the possibility of early diagnosis in the first place and of perfect isolation and noniufection of surroundings in the next. LIMITATION OF INFECTION ON SHIPBOARD. The latter point, i. e., not to allow infection of the hospital room itself, is of manifest importance, and if careful disinfection of all clothing and bedding is done as fast as disused, and if these articles are changed every twenty-four to forty-eight hours and rubber sheet used over mattress, the end is likely to be attained. This protection of the ship, and con- finement of infection to one narrowly limited portion thereof, has been done. I have seen it, and I think Surg. H. R. Carter reports having seen this limitation successfully carried out by ship captains. With a skillful surgeon on board it should be possible to stamp out an infection. TREATMENT UPON ARRIVAL AT PORTS OF THE UNITED STATES. Pilots.—Vessels from ports suspected of or infected with yellow fever should not be boarded by pilots when bound to ports south of Chesa- peake entrance, but should be "conned in" by the pilot to the nearest inspection station. WHEN A VESSEL IS SUBJECT TO QUARANTINE. All such vessels are subject to disinfection and detention between April 1 and November 1 of each year, unless they be vessels of the United States Navy, provided with medical officers of said service, and said medical officers can certify that there has been no communica- tion with the shore at infected points, or only such carefully guarded communication as is free from danger. (See previous chapter, Special Regulations for Naval Vessels.) TREATMENT OF INFECTED OR SUSPECTED VESSELS. Bear in mind that a suspected vessel is to all intents an infected vessel in so far as treatment is concerned and differs therefrom only in that it probably has no sickness aboard. MARINE-HOSPITAL SERVICE. 423 The treatment for such vessels is laid down in full in the precis, Sec- tion H, Chapter I, by Surg. P. H. Bailhache, and I will here only state that subsequent to the completion of the necessary disinfection, a detention of from three to five full days of twenty-four hours each is necessary to the end that we may be reasonably sure that no accidental exposure during the process of disinfection results in an outbreak of yellow fever after discharge of the vessel. Five days' detention is required unless disinfection of all baggage, dunnage, etc., has been performed exclusively by quarantine employes. The details of disinfection are so fully elaborated in Dr. Bailhache's article as to render repetition unnecessary. Should any person aboard be attacked by yellow fever while the vessel is under observation subsequent to her disinfection, it becomes necessary to at once remove the sick person and subject his vacated premises to a rigorous redisinfection; but, unless there has obviously been a fault somewhere in the previous work, it is not necessary to redisinfect the whole ship nor to detain her another full five days. This is generally done, but it is really more a measure to satisfy public anx- iety than a precaution dictated by true hygienic principles. The fact being well established that a yellow-fever patient does not infect his sur- roundings under forty-eight hours at least, or, in better language, that infection resulting from a patient does not become active under forty-eight hours, we should take advantage of this to avoid a spread of the disease and full infection of the ship, and it is plain that removal of patient and disinfection of his quarters does this effectually. Here let me say, however, that it is well to have grave suspicion that the primary disin- fection was not thorough if a case develops after six days have passed subsequent to it, and such late development should justify a full sec- ondary disinfection of the whole ship. QUARANTINE DETENTION AT NORTHERN AND SOUTHERN PORTS. The different rules adopted for Northern and Southern ports, with regard to vessels and persons from yellow-fever infected ports are con- cisely set forth in the following extract from a letter addressed by the Surgeon-General of the Marine-Hospital Service to a quarantine officer in the South: Your third inquiry is as follows: " Whether the rule requiring the detention of vessels three days after being disinfected is a general law, or only applying to southern ports?" In reply to this inquiry I have only to suggest a careful examina- tion of the United States Quarantine Regulations, from which it will be seen that at all ports south of the southern boundary of Maryland, which is an arbitrary line, vessels coming from an infected port, whether the vessel itself gives evidence of yellow fever or not, are subject to disinfection and detention of their personnel. At ports north of the southern boundary of Maryland this regulation does not apply. If the vessel carries no known infection at a northern port it may be admitted without detention, even though it comes from a port which is ordinarily infected with yellow fever, but the passengers on such a vessel must be detained a sufficient length of time to make five days from the infected port. This is done at New York 424 MARINE-HOSPITAL SERVICE. and at our national quarantine stations on the Delaware Bay and River. The Attorney-General has rendered a decision declaring that this regulation is legal. In regard to the change of crew at the quarantine station, you will observe that the quarantine regulations say that the personnel of the vessel shall be detained for three days after disinfection—not the vessel itself. So that if the vessel's crew is taken off immediately on entering quarantine, if the vessel is disinfected by a sta- tion's crew, there would be no objection to the vessel's being brought immediately to the port by another fresh crew which has not been subjected to contact with the vessel or any of its regular crew or engaged in disinfection. In other words, as soon as a vessel has been thoroughly disinfected it is safe, but its regular crew may develop yellow fever even three or four days after completion of disinfection; in fact, they are more likely to, inasmuch as the dunnage of the crew has been opened in the process of disinfection I hope I have made these matters plain, and, if not, I would be pleased to answer any other questions you may ask regarding them. The special regulations relating to passenger traffic, fruit vessels, and vessels of the United States Navy have been mentioned in the preceding article. POST-EPIDEMIC DISINFECTION. circular letter relating to records. Treasury Department, Office of the Supervising Surgeon General marine-hospital service, Washington, D. C, October 11, 1897. To the Medical Officers of the Marine-Hospital Service, Acting Assistant Surgeons, and State and Municipal Health Officers: Anticipating the work of post epidemic disinfection, which will be necessary to prevent the recurrence of yellow fever next season, your attention is called to the importance of keeping a record of each per- son contracting yellow fever, and the street number of each house where the fever occurs. Walter Wyman, Supervising Surgeon- General, Marine-Hospital Service. circular letter relating to post epidemic disinfection and aeration. Treasury Department, Office of the Supervising Surgeon General Marine-Hospital Service, Washington, I). C, December 1, 1897. To Commissioned Officers of the Marine-Hospital Service, Acting Assistant Surgeons, and State and Municipal Health Officers: Referring to circular letter issued by this Bureau October 11, 1897, in which attention was called to the importance of keeping a record of the name of each person contracting yellow fever, and the street and number of each house where yellow fever occurred, I have to state that inasmuch as the fever has disappeared in the South, it is now deemed necessary to begin the work of post epidemic disinfection. In order that the same may be uniform and thorough in .its character the follow- ing plan is recommended: house-to-house inspection. (a) The medical officer in command shall make, or cause to be made, house-to house inspection of all infected localities, and obtain complete 3934----io 425 426 MARINE-HOSPITAL SERVICE. lists (giving number and street when practicable) of all buildings, whether private dwellings, public houses, or hospitals, in which yellow fever occurred or where suspicious disease existed during the past summer and fall—the city or town to be divided into districts. (b) This inspection should be made by competent sanitary officers, under direction of the medical officer in command, and every part of the premises must be carefully inspected, including the rooms, base- ments, cellars, passages, closets, and garrets, the sinks, drains, cess- pools, latrines, privies or water-closets, the stables, sheds, outhouses, pens, etc. (c) The inspection is not only for the purposes of disinfection, but also is intended to place each house and its surroundings in a perfectly sanitary condition, and includes the inspection of all streets, alleys, and byways. (d) The inspection should include an examination into the water supply, and particularly as to the proximity of wells, cisterns, and springs to the privies, stables, pens, and other suspicious surroundings. LIST OF YELLOW FEVER SUFFERERS AND SUSPECTS. Make a complete list of all persons exposed to, or who may have con- tracted the disease, with the result in each case. (a) If death resulted, where buried and under what precautions. (b) If recovered or removed to another domicile in the same city, town, or place (or if departed from the neighborhood), ascertain all facts and make note of the same in order that it may be determined what action shall be taken in each case. GENERAL DISINFECTION. (a) It is recommended that after the inspection above provided for has been made the medical officer shall designate a competent sanitary officer to perform the thorough disinfection and cleansing of all houses and premises which he may have decided require the same, said disin- fection to begin as soon as practicable after the inspection referred to has been made in any locality. (6) It is recommended that the removal of all refuse, garbage, and other deleterious matter be included in the work of disinfection, and that all articles of little value, such as old rags and other accumula- tions of worthless material, be destroyed, whether found in dwellings or "slop-shops." (c) It is recommended that the inspectors inform all parties whose houses are visited that no injury to their houses or contents will result from the disinfection contemplated, that even the most delicate fabrics can now be rendered free from contagion by a harmless process of disinfection, and that it is absolutely necessary for the protection of themselves and the community in which they live. MARINE-HOSPITAL SERVICE. 427 DISINFECTION OF HOUSES. (a) The use of formaldehyd generators or lamps is recommended for the disinfection of houses and their contents. The details of their management for generating and applying formaldehyd gas should be fully understood by the sanitary officers in charge of the work. (&) All the contents of the houses, including wearing apparel of every description, should be spread about the rooms; bedding or mat- tresses not used by the sick should be placed upon the chairs or tables, or, better still, hung up in the yards and beaten; soiled bedding and mattresses used by the sick should be steamed or destroyed; trunks, closets, and bureau drawers, and all closed receptacles should be opened and their contents exposed. AERATION. Both before and after disinfection the houses should be opened and thoroughly aired—"chilled," if the weather is favorable—and later on all the rooms, closets, etc., should be exposed to several hours of airing during freezing weather, and repeated at intervals during the winter. DISINFECTION OF STABLES, PENS, ETC. The use of bichloride of mercury solution, 1:500, or carbolic acid solution, 50 parts to 1,000 parts (applied by means of a spray), is deemed sufficient if all exposed surfaces are completely saturated. Privies may be disinfected by chloride of lime or strong solution of carbolic acid. Walter Wyman, Supervising Surgeoti- General PRESENT STATUS OF THE BACTERIOLOGY OF YELLOW FEVER. By P. A. Surg. E. K. SrRAGUE. Unsatisfactory as bacteriological research thus far has proved in yellow fever, so much labor has been expended in that direction that it can not be passed over in silence. In no other disease have false hopes as to the discovery of the microbic cause been so frequently raised. In 1885 Dr. Domingos Freire* announced the discovery of an organism in the blood of yellow fever patients to which he gave the name cryp- tococcus xanthogenicus. Considerable interest attached itself to this coccus from the fact that it was claimed, and many at the time believed, that inoculations with attenuated cultures would confer immunity to yellow fever. Several thousand submitted themselves to this treatment during 1884, 1885, and 1886, and while I have been able to find only one death, reported by Baron de Ibituruna,t resulting directly from the inoculation, there is not the slightest evidence that immunity to yellow fever followed from its use. When we consider the statement of Stern- berg! that Freire worked with mixed cultures of undetermined organ- isms, it is very remarkable that his inoculations were as harmless as they proved themselves. A flask, supposed to be a pure culture of the cryptococcus, was found not to contain that organism, and an examina- tion of some of the vaccination material gave the same negative result, but in both there were several other distinct microbic species. A cul- ture which Freire brought from Paris proved to be a coccus differing in no essential from staphylococcus pyogenes aureus. Dr. Lacerda, also of Rio de Janeiro, had previously found micro- organisms in the liver and kidneys of yellow fever cadavers, and he sent some of the material to Babes § for examination. This distin- guished observer found bacilli in the given specimens, but in tissues from all other well diagnosticated cases he failed to find Lacerda's bacillus, and he gave no support to the claim that it was the cause of yellow fever. * Freire, Doctrine microbienne de la fievre jaune, Rio de Janeiro, 1885. t Baron de Ibituruna, Annual Report United States Marine-Hospital Service, 1889, p. 187. X Sternberg, Annual Report United States Marine-Hospital Service, 1889, p. 147. $ Babes, Les Bacteries, Paris, 1890, Vol. II, p. 154. 428 MARINE-HOSPITAL SERVICE. 429 In 1885 the announcement of Dr. Manuel Carmona* y Valle of the discovery of the peronospora lutea and of its etiological relationship with yellow fever was presented for the consideration of the scientific world. He maintained that the spores of this organism gave birth to a muce- dinee, which, entering the human economy, in turn gave rise to the dis- ease, and later was transformed into the peronospora lutea. He prac- ticed preventive inoculations, using the residue, after evaporation, of urine in which the organism was found. The results were what would be expected from such an unscientific procedure as the inoculation of the dried salts and organisms from decomposing urine. In 1887, Gibier.t at Havana, isolated from the contents of stomach and intestines a liquefying bacillus, which, although not constantly present in yellow-fever cadavers, was nevertheless heralded by its dis- coverer as the direct cause of the malady. As an evidence of the causa- tive relation of this microbe to the disease, he stated that there appeared a black sediment in liquid cultures after tweuty-four hours. This pig- ment, he said, gave the characteristic appearance to the contents of the stomach and intestines. None of the subsequent disinterested observers were able to confirm this remarkable peculiarity of the bacillus. It was pathogenic for mice and guinea pigs, but the post-mortem lesions bore little, if any, resemblance to those of yellow fever. That same year Dr. Carlos Finlay i. obtained from the blood and blister serum of yellow-fever patients an organism to which he gave the name micrococcus tetragenus febris flavw, and which he claimed stood in an etiological relation to the disease in question. A few months later lvinyoun§ found this coccus on the skin of those sick with malarial fever, hailing all the way from Portland, Me., to Vera Cruz, Mexico. A little later Finlay abandoned his earlier claims. In a summary of an investigation which included all the previously mentioned organisms, Sternberg|| says: Among the microorganisms encountered there is not one which by its constant presence and special pathogenic power can be shown indisputably to be the specific infectious agent in the disease. About a year ago Havelburg,ff by a method similar to that employed by Gibier, viz, by inoculating guinea pigs with the contents of the stomach or intestines, succeeded in isolating a bacillus for which the usual claims were made. In his description of the organism, although he goes to some length into the differentiation, it is difficult to see why it should not be classed in the colon group, and indeed most bacteri- * Carmona, Lecons sur l'etiologie et la prophylaxie de la fievre jaune, Mexico, 1885. t Gibier, Gaillard's Medical Journal, New York, 1889, Vol. VII, p. 130. t Finlay, Annual Report, United States Marine-Hospital Service, 1889, p. 229. § Kiuyoun, Annual Report, United States Marine-Hospital Service, 1889, p. 105. || Sternberg, Report on the Etiology and Prevention of Yellow Fever, 1890, p. 13. If Havelburg, Public Health Reports, Vol. XII, 1897, p. 795. 430 MARINE-HOSPITAL SERVICE. ologists who have studied this bacillus regard that as the proper classification. In February, 1896, Sanarelli* discovered the "bacillus icteroides,1' and since its announcement to the scientific world the opinions of competent observers have been divided as to the true etiological rdle of this organism. Sanarelli himself is unable to find this bacillus in all of his cases— only in 58 per cent—but an ingenious explanation of this lack of success in constantly finding the bacillus is adduced by Sanarelli, who states that in laboratory experiments icteroides are quickly overrun and killed by the common pus organisms, the colon bacillus, and other bacterial inhabitants of the intestines. He therefore concludes that these last- mentioned organisms, having gained entrance to the circulatiou through the destruction of the natural barrier by degenerative changes wrought by icteroides, proceed at once to kill the first invaders. By inoculations he has produced a disease in animals very closely resembling yellow fever, but the analogy is hardly strong enough, nor do the symptoms and pathological changes differ sufficiently from those produced by other organisms, notably bacillus "X," Sternberg, to war- rant the conclusion that the disease actually has been produced. He further states that serum from convalescents or from yellow-fever cadavers produces only slight agglutination of bacillus icteroides. Other observerst have made much bolder claims for the agglutiuative powers of serum from the above sources. Strange to say, antidiphther- itic serum produces rapid agglutination of the bacillus, which would indicate a close biological relationship between it and the Klebs-Loeffler bacillus. Indeed, there are points of resemblance in the manner in which the infection of yellow fever and diphtheria spread. Typhoid serum also produces this phenomenon but partially, and, as would nat- urally be expected, colon serum and that from normal man and other animals produces no effect. Serum from a convalescent from yellow-fever possesses no curative action when injected into the guinea pig simultaneously with the mini- mum fatal dose of icteroides, but 2 c. c. of the same serum administered twenty-four hours previous to the minimum fatal dose seems to confer immunity; at least, the pig does not die. A horse has been immunized to the bacillus icteroides and 0.5 c. c. of his serum will give to the guinea pig the immunity above mentioned under the same conditions, and even after forty-eight hours have been allowed to elapse 2 c. c. will save the animal. The following is the result of treatment of cases of yellow fever with Sanarelli'sJ autiamarylic serum, conducted by himself. He used tie "Sanarelli, Annales de LTnstitut Pasteur, XI, p. 438, 1897. tArchiuard, New Orleans Med. and Surg. Jour., Vol. L, p. 455, 1898. t Sanarelli: Annales de lTnstitut Pasteur, Vol. XII, p. 348, 1898. MARINE-HOSPITAL SERVICE. 431 serum of a horse inoculated with gradually increasing quantities of the icteroid bacillus for eighteen months. At San Carlos do Pinhal, Brazil, he treated eight cases with subcutaneous injections, the total quantity administered varying from 15 c. c. to 65 c. c, with a mortality of two. Another series of fourteen cases was treated by the "intensive method" or intravenous injections, four of whom died. Dr. Seidl had previously treated eight cases in San Sebastian Hos- pital, Rio de Janeiro, with serum sent him by Sanarelli, with four deaths. During the treatment of the cases at San Carlos, three con- victs were stricken with the fever in the local prison. All the other inmates received prophylactic inoculations of the serum and the threat- ened invasion of the institution was promptly arrested, no more cases appearing. Unfortunately, no mention is made of the number thus protected, nor have weany knowledgeof their previous history, although it is stated that many of them were foreigners; that their physiological condition and the hygiene of the prison left much to be desired, and that they ought to be considered as very susceptible to the disease. The apparent lack of success that has thus far attended the treat- ment of yellow fever with antiamarylic serum constitutes no argu- ment against the bacillus as the cause of the disease, because, as is well known, there are yet many diseases in which the microbic cause is incontestably established, but for which we are still unable to procure a specific curative serum. If all the postulates formulated by Koch as necessary to prove the etiological role of an organism in the production of a disease have not been fulfilled by bacillus icteroides in connection with yellow fever, the demand of one is possibly met in the fact that this organism has not yet been found, save in the bodies of those sick with or dead from the malady. If we are not at all prepared to accept the claims of Sanarelli in their entirety, the future, nevertheless, is bright with hope. Many able and conscientious investigators are working to verify the researches of Sanarelli, and should they not be suceessful in their aim there is every reason to expect that their labors will sooner or later solve the vexed problem. ON THE VALUE OF THE AUT0P3IC FINDINGS IN CASES THAT HAVE DIED OF SUSPECTED fELLOW FEVER By P. A. Surg. Eugene Wasdin. The history of this acute infectious disease establishes clearly the fact that it has been, and continues to be, of absorbing interest to all who have come in contact with it, because of the obscurity which has always enshrouded its etiology, the comparative difficulty in diagnosis, and the varying severity of the disease during different epidemics and in different localities. Naturally the question of its diagnosis, upon which depends very frequently the safety of large communities from its ravages, and, per contra, the integrity of commercial relations between a suspected place and other reactive centers, is a most impor- tant one. For many years the external appearance of the dead body, and that of the internal organs, has been accounted of great value to the diagnostician; and it is of the comparative value of such appear- ances to one called upon to make a decision under such conditions that this paper treats. The yellow-fever cadaver has assuredly a most characteristic appear- ance. All bodies dead of the disease bear a close resemblance to each other; indeed, it would not be difficult to make a diagnosis, other facts being favorable thereto, from the cadaver alone. The body is usually quite rigid, this change in the muscles coming on early and persisting. The color is invariably more or less intensely yellow, and is due to a mixed hepatogenous and hematogenous jaundice. The entire skin is tinted, the scalp usually giving a startling contrast with the parted hair; the whites of the eyes are yellow, the change taking place in the conjunctiva? early in the disease, the scleras becoming tinted later. This yellow tint is always contrasted with the deep purple discolora- tions from hypostasis which quickly appear in the skin of the depend- ent portions of the body after, but which frequently appear before, death. It is at the edges of these hypostatic areas that the mixture of biliary and blood jaundice is particularly noticed, as a muddy, thick, grayish-yellow toue. Hypostasis is common in all cadavers, but par- ticularly is it prominent in this disease. It is not confined to the lower portions of the body, as the buttocks, loins, and shoulders, but invades 432 MARINE-HOSPITAL SERVICE. 433 the neck, chest, ears, and face; the genitals, as a rule, and the finger and toe nails are of a deep purple color. This discoloratiou occurs quickly and is prominent in an hour post-mortem. The pupils are usually dilated; the tongue foul, or, like the gums, bloody; the anterior nares are caked with blood. This is a picture of a typical cadaver, and the appearances may be accentuated or softened, but the characteristic ensemble will be present in all. During my recent stay in the city of Havana, I was called upon by Dr. Curto, of the staff' of the military hospital, Alphonso the XIII, to decide the presence of yellow fever in a cadaver three hours post-mortem. The body was quite yellow and there was hypostasis, but it lacked the characteristic appearance, and section showed indubitable evidence of malarial toxemia of long standing. My experience, from autopsies of cases of malarial fever in the South, teaches that there are externally many points of resemblance in them to the yellow-fever cadaver, and at times I feel assured the decision between them would be very difficult or impossible. Dependence must then be placed upon the conditions found in the internal organs. Sec tion shows deep yellow tintiug of the superficial tissues and the peri toneum; a dryness of these tissues; a glazed appearance of the intestines, which are dry and sticky to the touch, and a deep-tinted peritoneal fluid. The organs are of a yellow tint, ranging from light to deep saffron. The omentum is deeply congested, the dilated, purple veins contrasting with the general tint. The spleen is usually of nor- mal size and appearance; any deviation suggests preceding or compli- cating disease. The kidneys are always congested and swollen;-the stellate veins of the capsule are prominent; the capsule itself is not influenced by the disease; frequently there are extravasations upon the cortical surface. Incision of the organs shows congestion of the renal veins, yet the general appearance is pale; the cortex is swollen, its markings usually obscured, and at the bases of the pyramids of Mal- pighi there are seen pale yellow fatty areas. These are very generally seen, and in cases of* long duration a general fatty appearance is present. I would attract especial attention to these fatty areas about the base of the pyramids withiu the cortex, for they can be seen when the kid- ney otherwise appears free from fatty change. The adrenals are nor- mal. The urinary bladder is usually empty from anuria; its mucosa may present extravasations; in one case only have I known bloody urine from such extravasation. The mesentery is always typically congested, yet I have but rarely seen extravasation in its layers; the congestion is more marked in the reflection upon the duodenum. The liver, long considered the pathognomonic organ, may or may not be normal in size, but any deviation from the normal I consider dependent upon some other cause, for if the histology be considered it will be seen that upon the increased amount of blood in the vessels depends any 434 MARINE-HOSPITAL SERVICE. increase, while the termination of the disease must anticipate noticeable decrease in its size from absorption of the fatty detritus. I have usually found the organ normal in size. The gall bladder is generally empty, owing to intraabdominal pressure from vomiting and decreased secretion, but may contain a normal amount of bile. The color of the organ varies from a light buff or "boxwood" to a dark brown, this seeming to depend upon the amount of congestion, the left lobe and upper portions being as a rule lighter in color than the right and more dependent portions, the posterior surface being a dark blue from stasis.. At times this fatty appearance is diffuse, and again there may be only plaques of yellow upon the surface or throughout the organ. A frequent appearance is that of the so-called "nutmeg" liver, the yellow points contrasting with the red lines about them. Upon section, the liver, if not the subject of preceding disease, presents a normally firm resistance; is of firm consistence; at times friable and dry; of a pale yellow color, and imparts to the blade a greasy stain. The portal vessels are full of dark fluid blood, which quickly changes to carmine on exposure to the air. The venous radicles are distended, the adja- cent parenchyma showing fatty change, and this contrast results in the '•nutmeg" appearance. The smaller bile ducts are empty. The cap- sule is normal. The vessels of the stomach walls are congested, also those of the omental reflections. The stomach may contain more or less blood-stained fluid, which, if exposed to the acid secretion for some time, may have the "coffee grounds" appearance. Frequently the con- tent is a thick, glairy, grayish mucus which clings to the mucosa. The mucosa itself is invariably thickened, swollen, and presents numerous patches of extravasation and shallow erosions. While the entire mem- brane may be affected, the changes are more marked on the anterior surface and near the pylorus, the membrane here presenting a deep port-wine stain from diffuse extravasation, and often evidence of free hemorrhage. If many hours have elapsed between demise and autopsy the mem- brane will be found much softened and with many erosions from post-mortem change. The vessels of the duodenum are engorged; the mucosa is swollen, eroded, and hemorrhagic; in some instances it con- tains black, grumous blood from which the stomach was free. The mucosa of the entire canal may present evidences of ante-mortem con- gestion in the form of minute extravasations. In the female there may be extravasations in the ovaries, or in the mucosa of the tubes and uterus. The vessels are prominent on the surface of the diaphragm. Withiu the thorax the general yellow tint prevails, there being nothing notable about the lungs save congestion; the pleuras frequently present ecchymoses; the pericardium also is frequently ecchymotic both visceral and parietal; the heart is usually iu diastole, or the left ventricle may be rigidly contracted from change in the muscle, the right being always dilated with dark fluid blood. There is always present a very notable MARINE-HOSPITAL SERVICE. 435 congestion of the vasa vasorum of the great vessels at the base of the heart, these minute vessels forming a delicate tracery over their serosa and upon the walls of the auricles, with at times minute ecchymoses. I deem this a very constant and characteristic appearance. The heart muscle docs not show fatty changes very often to the unaided eye. The fluids of pericardium and pleurae are yellow. The changes in the brain and its membranes are those of intense congestion, the fluid of the ven- tricles being yellow, and there may be extravasations. Such are the findings in a typical yellow-fever cadaver. It is sometimes said that a yellow-fever autopsy is a bloodless one, but this expression must have arisen because of the limited scope of many hastily made sections, which consisted in an exposure of the liver and its incision, the extraction of a kidney, and the exploration of the stomach in situ. In reality, the full influence of the toxin is felt upon the vasomotor system, and results in an incomparable congestion of the vessels of the abdomen, and when complete the section presents an appearance quite the reverse. A study of the histopathology of the organs must be limited to the examination of fresh sections from the liver and kidneys, for in these the fatty changes are best seen; the liver cells are more granular, stain more faintly, and contain numerous fat droplets; those of the kidneys lining the tubules, especially of the cor- tex, are also filled with drops of fat. These gross changes are readily detected, and if facilities are at hand they should be sought for. But the importance of an immediate diagnosis will have long passed before the liner histologic changes may be observed. I have said that the above appearances are constant in the cadaver of yellow fever. The question then arises as to their diagnostic value. Is it possible to arrive at definite conclusions from an isolated case presenting all of these signs? Would we be justified in such cases either in withholding quarantine protection from a community or in initiating quarantine to the possible detriment to commerce1? The last phase of the question is a most important one, and at times exercises as much influence as tlie first. From recent observation I feel safe in asserting that it is not possible to diagnose this disease from the appearances and the gross micro- scopic findings alone. I do not undervalue their importance, when taken in due consideration with the history of the case, the clinical charts, and the history of albuminuria, iu assisting to form an opinion, but in the absence of these accompanying facts they are not sufficient to name the disease, although a diagnosis may be safely ventured in the absence of any other known cause of infection. Just here I will venture tentatively upon the question of etiology, as having a direct bearing upon what has been said. All observers in this field have recorded the presence of the bacillus coli communis in its many forms in the blood of patients living, and more freely in the blood and tissues of those dead from yellow fever. Sternberg iu 1889 discovered, among 436 MARINE-HOSPITAL SERVICE. other forms in the tissues of such patients, a bacillus of such peculiar physiologic and vegetative characteristics that he assumed for it a distinctive position among these organisms and, from its influence upon animals, a possible etiologic value in this disease. This was the Bacil- lus "X." In 1897 Sanarelli, of the University of Montevideo, published the discovery of a bacillus supposed to cause the disease—his Bacillus "Icteroides." These organisms present many similar features of growth and chemic reaction, yet there are sufficient distinguishing character- istics to insure them separate places in the group of colon organisms, for, during my observations upon these and other organisms from yellow- fever cases, it became evident that the former belonged to this group aud it appeared probable that the bacillus of Sanarelli was also to be classed among them. On September 28, 1897, it was my privilege to observe a case of yel- low fever at the isolation division of the Marine Hospital Service deten- tion camp at Fontainebleau, Miss., in the person of one Goodrich, and from cultures from his blood, on the fourth day of the disease (which was well marked), to isolate a bacillus, which corresponded to that of Sanarelli, from a contaminating colon bacillus. This was designated Bacillus "Goodrich," aud was esteemed the first organism isolated after Sanarelli in this country. Later, in the city of Havana and in concert with my colleague, P. A. Surg. H. D. Geddings, United States Marine Hospital Service, this bacillus was isolated from a number of cultures taken at autopsy from cases in the isolation hospital in New Orleans during the epidemic of last year. Besides the organisms isolated by us from these native sources, it was our privilege to study a limited number of cases of yellow fever iu the military hospitals of Havana, and in 60 per cent of these we isolated the same bacillus. In all of these instances this organism maintained its distinctive characteristics from the Bacillus "X." Experimental inoculation with these organisms were usually fatal to animals, which exhibited mere or less pronounced, rapid, or prolonged symptoms of intoxication, but necropsy always gave similar appear- ances in the different organs. As an example, I give the notes from an autopsy. "Pig No. 2, white female, weight 525 grams, was injected intraperitoneally with 7 c. c. of a twenty-four hour bouillon culture of Bacillus 'Goodrich,' at 3 p. m. on the 9th of February, 1898. On the morning of the 10th the animal exhibits evidence of distress, does not eat, remains crouched in cage, abdomen tender; temperature, 37.3; respiration, 80. At 3 p. m. the animal is quite ill and has lost 42 grams in weight. At 9 a. m. on the 11th it died. Necropsy immediate. Body still warm; heart first exposed, in diastole and full of dark fluid blood; the vasa vasorum distended over the great vessels at the base; pericar- dium aud fluid slightly tiuted. The liver is congested with numerous plaques of a yellowish-white fatty appearance; when incised this fatty appearance is general. The spleen is slightly increased iu size MA IUNE- HOSPITAL SERVICE. 437 and congested. The kidneys much congested and swollen. The uri- nary bladder contains 6 c. c. of urine which, by the cold nitric acid test, gives a dense 'ring' of albumen, aud which is also shown with heat and nitric acid. Peritoneum not inflamed, some injection at the point of puncture to left of median line; in the left iliac fossa there is a small quantity of cloudy fluid localized. Mesentery normal save an intense engorgement of its vessels, especially in its duodenal reflection. In the stomach the mucosa is congested, thickened, and softened, especially about the pylorus; that of the duodenum much congested with numer- ous small extravasations, but no free hemorrhage. Cultures from blood of organs and from the fluid from the fossa give after twenty-four hours colonies only from the latter. This is a pure culture of the inoculating organism. After forty-eight hours tubes from the left pleural fluid also exhibit colonies of this organism in pure culture, the spleen also giving a colony from contamination. Cover preparations show only a small characteristic rod in pure culture from the fluid in the iliac fossa." In this case there was no free blood in the stomach or bowel, but in the very next of my scries there is this note: "Mucosa (stomach) injected, and near the pylorus there are ecchymoses, and at one point at least there is free hemorrhage, which has stained the food mass a dark or black color; this looks like 'coffee grounds."' This experience has been that of many other observers. These organisms elaborate a toxin which exerts a characteristic and powerful influence upon the vasomotor system, as evidenced in the intense engorgement of the vessels, the gaseous, toneless pulse, and the full diastolic heart, prior to and post-mortem; also in that rapid metamorphosis of the albumi- noids of the highly organized cells of the liver and kidneys. The intention is not to contrast these organisms, but to accentuate the fact that there is no constant sign at these autopsies by which we can name the particular one which has produced the disease. Here I will revert to the subject proper, the value of these post- mortem appearances in the human body. And again I must refer to notes kindly furnished me by Dr. B. E. Baker, of the army general hospital at Key West, Fla., in order to illustrate their value. The U. S. S. Yankee, cruising on the southern coast of Cuba during June, 1898, entered Key West Harbor. She sent to hospital a seaman ill for one week with appendicitis. Her officers later stated that a few Cubans had been entertained on board during this time, aud that several boats' crews had been sent on board of captured vessels for the purpose of destroying them, but that no baggage or effects had been allowed on the vessel excepting four dogs and a few machetes. On the third day after entering hospital and the second after operation for appendicial abscess, the patient developed high fever, became delirious, and died on the fourth, the entire illness being about ten days. Prior to death the acute exacerbation (the temperature having fallen to normal after the operation) aud the mental symptoms attracted attention. The skin 438 MARINE-HOSPITAL SERVICE. was noticed to be jaundiced and suffused, as were the eyes. Urine con- tained no albumen at this time, but found to contain it after death. At autopsy the general appearance of the body impressed the operator, Dr. Baker, with the probability of its being the subject of yellow fever, and I was asked in consultation. After a careful examination of the body and organs I concurred in the diagnosis of yellow fever. Necropsy (made five hours post-mortem): White male adult, poorly nourished; rigor marked; conjunctivae slightly jaundiced; pupils nor- mal; postmortem lividity on back and neck and dependent portions of the body, on scrotum and prepuce; the face, neck, and anterior portions of trunk a bronze-yellow color, not so marked on the legs. On section there is about 12 c. c. of clear bile-stained fluid in the peri- cardial sac; the membrane contains a few ecchymotic spots in its reflec- tion over the diaphragm; the visceral reflection also is ecchymotic, and presents extravasations of blood well marked at the base of ventricles; the vasa vasorum distended; the heart normal in size; the left ventricle contains small amount of soft blood clot; the right auricle and ventri- cle distended with dark fluid blood; valves competent; muscle is pale and yellowish; aorta tinted, some atheroma about valves. The pleura shows old adhesions; the lungs are normal. The abdominal cavity is dry; the intestines sticky; the mesentery and the omentum show ecchymotic patches; the glands are enlarged. The spleen is normal in size and color. The kidneys are slightly increased in size, congested, the stellate veins of the capsule well marked; the inner edges of the cortex, near the bases of the malpighian pyramids, show a yellowish tinge; suprarenal bodies normal. The liver is normal in size, of typical "nutmeg" appearance, with lemon-yellow areas and spots scattered over the surface; the gall bladder contains 45 c. c. of thick greenish-black bile. On section the liver presents a typical " nutmeg" appearance, and much congestion. The stomach is somewhat dilated, iind contains 250 c. c. of brownish-black fluid with brown granules; the mucosa is cougested throughout, but especially on the posterior wall near the cardiac extremity. (When washed there were great plaques of deep wine-colored extravasation and numerous erosions.) The mucosa of the duodenum is ecchymotic and there is free hemorrhage in the form of black vomit. The last inch of the ileum is bound down by adhesions, as are the caput coli and the ccecum. On freeing the gut a small abscess cavity is seen between it and the abdominal wall, in which is the vermiform appendix, with a slough in its distal portion, the upper two-thirds being normal. (This cavity was drained through an incision through the abdominal wall.) In this case there was no doubt in my mind that death had been caused by infection with one of the organisms of the group already named; but with which one? Here there was an acute appendicitis, with localized abscess and perfect drainage. Was it clear that death had taken place froui a general infection from the colon group? Not MARINE-HOSPITAL SERVICE. 439 at all, for this patient had been possibly, or probably, exposed to the infection of yellow fever through the presence on board his ship of persons who may have conveyed infection in their clothing. The time elapsed since such possible exposure was about the incubation period of the disease. If we assume that the fever developed in hospital, it must have been contracted on the ship, since there has been no yellow fever in this city during this season. In this remarkable case, remark- able because of the element in it of serious possibility, amounting to probability, of exposure to the infection of yellow fever, contrasted with the fact of local, if not a general, infection with the bacillus coli communis, I concurred in the diagnosis of death from yellow fever hon- estly, for this was a yellow-fever cadaver, as we know them from external appearance and anatomical facts. However, I am now convinced that it was simply an intoxication from autoinfection with some member of the colon group of organisms. For, notwithstanding the fact that the crew of the Yankee was composed of young Northern men, the New York Naval Reserve, and that the surgeons, nurses, attendants, and neighboring patients were reagents, there has been no sequel to the case, nor is it reasonable to assume that this seaman, ill in his cot from appendicitis, should have been the only one of all the reagents ou this ship to have contracted the possible infection. The city of Key West is the base of naval operations against Spain. Its poor sanitary condition, the presence of a large number of non- immune residents, aud the necessity of keeping the base open, all seemed to me to demand the diagnosis which we made; for under the circumstances the only harm possible would be the restraint placed upon the inmates of the hospital for the prescribed time and extra vigilance upon the part of the medical officer on board the ship. Only a few minutes after the post-mortem one of the medical officers, a reagent, asked me: " How much danger of infection have I risked from my presence at the operation upon this case and my having visited it several times since?" I replied: "None, provided this man has not come into contact with the infecting agent of yellow fever." Moreover, I felt willing to assume the responsibility, provided also all blame, in continuing the routine of the hospital without other restraint than strict vigilance until some sequel demanded its isolation. However, was the autopsy in this case of material assistance of itself? In the absence of any history of possible infection, could anyone familiar with the appear- ances in the organs of animals killed with the organisms mentioned, and comparing these with those found in yellow-fever organs in man, have unhesitatingly decided in this case? Yellow fever clinically studied has impressed many observers, since 1 have heard it frequently expressed among the profession in Southern cities that it is a disease in which probably two etiologic factors are present—the primary, or external agency, giving rise to the initial symptoms of the disease, and a secondary, or internal agent, of autoinfection. 440 MARINE-HOSPITAL SERVICE. Is it not possible, from what has been shown, that the autoinfection may be productive of the autopsic appearances? This view of the dis- ease is reasonable, but not yet proved; nor will it be until the indubi- table cause of yellow fever is discovered; that is, an agent which not only can give rise to the appearances of yellow fever, especially post- mortem, but can, as in the case of bacillus diphtheria1, give rise to an acute dissemination of the disease among those who are reagents. This has not been demonstrated either in the case of the Bacillus " X " or of Bacillus "Icteroides." We should not hastily decide upon the etio- logic value of an organism, so closely allied to the colon group as are the two named, from the influence exercised upon the sick by the exhi- bition of its antiserum, but depend rather upon its power to reproduce the disease, "catching" from person to person and of the antiserum to prevent such infections. Finally, I would suggest that typical autopsic findings should always be regarded with suspicion and demand immediate investigation of their cause. Should there be or not any local center of autoinfection, there should be an investigation of the immediately preceding history of the patient, and should there prove to be evidence of exposure to infection of yellow fever, and should the clinical charts and history present the evidences of the disease which we have learned to recognize, then, and only then, can the information gained post-mortem be of decisive value to the diagnostician. TRAIN INSPECTION. A contributed article by Surg. H. R. Carter, prepared at the close of the epidemic of 1898. COMMUNICATING, NEUTRAL, AND DRIFT TERRITORY. It is not proposed to go into the general question of passenger traffic on railroads from and contiguous to a place infected with yellow fever, but simply to present a few points in train inspection and its necessary adjuncts, which, in spite of the fact that they have been in use more or less completely by this Service since 1893, and, indeed, in principle since 1888, seem to be not thoroughly appreciated. To take the matter generally, let us suppose A to be an infected town,* with lines of railroad A. N. and A. S. running the one through to north- ern points and the other to a southern (infectible) terminal. Let the country around this town as far as X hold direct communication with it after quarantine is laid, and all beyond establish quarantine. Let that district not farther than V have held communication with it under such conditions that it has people in it who have recently been exposed to infection in A, and is suspected of containing foci of infection as yet unknown. The problem is to organize the train inspection on these two roads for passenger traffic, through and local. RELAY. The relay of train crews should take place at R, the last station in the communicating territory. This is not absolutely necessary, as any siding near this limit will do—preferably on the proximal side. If an unoccupied siding be unobtainable, a small place certainly not infected, and kept inspected, will do. If the communication between the city aud the territory between it aud X is unrestricted, there is obviously no need of an inspection on the train up to this place, because an inspector is needed only if there are restrictions to enforce. If this communication be hedged around with certain restrictions, however—"daylight," "disinfection of bag- gage," etc.—this inspection is needed to enforce it. Passenger traffic beyond X must be allowed only under certain restrictions, and hence subject to inspection. * See "Illustrative Diagram," page 442. 441 3934---n 442 MARINE-HOSPITAL SERVICE. N. & ' Reception Camp. Reception Camp. B r+ Territory. Aral Terr/fay. \csting C°r Illustrative Diagram, MARINE-HOSPITAL SERVICE. 443 RESTRICTIONS ON PASSENGER TRAFFIC. This divides itself into permanent and temporary—that is, "pending investigation." From A to X to be determined by the nature of the commuuicatiou agreed. Free communication to be allowed between all places between A and X if under the same rule of communication. (1) No person to be allowed to pass from A north of X save immunes, etc. They would go only into infectible quarantined territory. There is no question, then, of "through passenger traffic" on this road.1 (2) No passengers to be allowed to pass north of Y save immunes, etc., " pending investigation." For this the reason is obvious. (3) No intercommunication to be allowed between places between X and Y "pending investigation." This is because we believe some place in this district is or may be infected, and that all are not. Obviously, then, until we can differentiate the clean from the infectep places communication from the latter to the former may infect a clean place. (2) and (3). Taken together mean that, "pending investigation," no passengers are allowed to board trains between X and Y, and that the north-bound trains go empty into and through this district, unless, indeed, the train for the upper end of the road be made up north of this district. When the investigation has shown, if it does show, that there is no focus of infection beyond X, this neutral territory disappears (or will disappear if sufficient pains are taken with quarantine), and the restric- tions against travel therefrom enumerated above should be removed. The conveyance by rail of infection beyond X is sufficiently pro- vided for by the above rules. Now we believe that there is no infection or persons recently exposed to infection north of Y, yet there is, or at least may be, always a certain number of people who will, by private conveyance or by walking, pass from south of Y to places north of that point. This condition and the danger from it will be considerably increased if by going a moderate distance beyond the quarantine lines at Y they can board the train and proceed to any destination they elect. This, then, is to be guarded against. It is done, so far as the train inspection is concerned, by requiring a "health certificate" of 1 It is a good general rule that people living in communicating territory, if infectible, should not be allowed freedom of travel in clean infectible territory. This is on account of the risk of foci of infection being established in the former and not being immediately recognized. Still, if we know 'that a place is free from infection, the fact of it holding direct communication with an infected place does not of itself render those leaving it liable to convey infection; they could be allowed to travel on a certificate of residence. Residents of Bay St. Louis, which place held direct "daylight" communication with New Orleans (but which was known to be free from infection), were allowed to enter Florida on certificates of residence, and this action was safe. 444 MARINE-HOSPITAL SERVICE. persons boarding trains beyond Y. This "health certificate" is a misnomer and should be a "certificate of residence," because it wit- nesses that the holder has resided iu a locality not quarantined against for not less than----(usually ten) days. Form of Health Certificate. Office of Board of Health, -----, 189—. Health Officer----. To %vhom it may concern: This is to certify that Mr. -----has given satisfactory evidence to me that he has been in-----not less than ten days, and to the best of my knowledge and belief he has not been exposed to the infection of yellow fever, and has not been in any infected or suspected locality for ten days. Description: Age,---- years; weight, ---- pounds; height, ----; v complexion, -----; hair,-----; eyes,-----. > Health Officer. Signature:-----------. Obviously this excludes persons recently from south of Y and gets rid of the transportation by rail of those going by private conveyance from this territory. We can generally depend on the small towns and stations next to Y forbidding people liable to convey infection going to them to remain, while they will frequently make no effort to prevent such people going to them to take the train, and this prohibition to board the trains acts to increase the vigilance of these places against the entrance of sus- pects. Also the knowledge that they can not board the trains even at places north of Y enormously limits the choice of places to which people can go, and is thus very effective in preventing them from attempting to pass the quarantine lines. How to insure that these certificates are true is a problem not to be considered here. Unless much pains be taken they may be very mis- leading ; yet they can be made of great value. From the reasons given for establishing this inspection it is clear it need not extend indefinitely up the road. It must cover the distance to which people south of Y will go by private conveyance; it need not go beyond. Let us suppose Z is beyond (certainly beyond) this distance. Health certificates (certificates of residence), then, will be required of all boarding trains between Y and Z, and the inspector on the train must go so far and need not go beyond that point. This inspection will begin at A or at R, according to whether the communication with A of the " communicating territory " is limited or unlimited. This territory into which people may come by private conveyance from quarantined territory has been called the "drift territory." Of course it may not exist, as there may be no neutral territory; an MARINE-HOSPITAL SERVICE. 445 efficient cordon around the quarantined district does away with it. I have not judged it safe to dispense with it in any epidemic I have seen, although it might have been dispensed with at Franklin and during the latter part of the quarantine at McHenry. (4) Passengers from points between Y and Z shall be allowed to board trains provided they have not been in quarantined territory for----days—i. e., those who can produce proper "health certificates." (5) Beyond Z there should be no restriction in passenger traffic. If this place Y be at the crossing points of the north and south bound trains, it will be very convenient; one tier of inspectors will be enough. The same will be true if it be south of the crossing point, as they can go up on the north-bound train and return on the south bound, simply stepping from one train to another. Notice to the railroad that only those presenting proof (generally specified as "health certificates") that they have not been in any place quarantined for ---- (ten) days are to be allowed to board trains as passengers between Y and Z will result in the ticket agents along the lines demanding health certificates as a prerequisite to the sale of tickets. In general, then, those on board the trains will have the required evidence. If there were time for the train inspector to examine critically into this evidence prior to boarding it would be ideal. In general this causes unjustifiable delay to trains, and the ticket agent, where such exists, has already passed on the matter. A certain number, however, will be found boarding the train between these places who do not present satisfactory evidence on this point, and therefore can not be transported to other clean places. What is to be done with these people? The practice recently—and I think the proper disposition—is to keep them on the train to the end of the inspector's run. If this be the meeting point of the north and south bound trains, he can take them across to the southbound train and carry them back. If the end of the run be not the meeting point of trains, there must be here a building or tents with necessary equipage, under guard—a reception camp or guard tents—where these people can be cared for in isolation and sent south with the inspector on the south-bound train. These people had best, if the inspector believes that they have been exposed to infection, be taken to deten- tion camp. This was done for the few suspects of McHenry, who were very willing to go. Failing this, as was done most generally, they are taken back to the station at which they boarded the train. The health authorities having jurisdiction over this place should be notified in the meantime, and if there is good reason to believe that these people have illegally left the quarantined territory it will be found that they are by these health authorities forbidden to remain at this place and that they either ask to go to a detention camp or to go back to their homes in the quarantined section. It is this bringing back of suspects to the place at which they boarded the train which makes the ticket agent care- 446 MARINE-HOSPITAL SERVICE. fully inspect the evidence (health certificate) which these people pre- sent. After this thing happens more than once, there are very few roads which will retain such an agent without a very satisfactory explanation. I have found that after they come to appreciate this and have had a little experience ticket agents become most valuable allies in train-inspection service. So much for the relays, the restrictions on passenger travel, and the local limits of the work of the officer who inspects the train. INSPECTION OF TERRITORY. It is obvious that when we accept certificates of residence (health certificates) from any place between Y and Z we imply that this place is not infected. Also, that when we require a certificate from such a place we imply that persons capable of conveying infection may be at that place, if only to board the trains. These persons may possibly develop fever at this place and infect it. The country, then, between Y and Z (drift territory) is predicated as clean, but liable to become infected. It is necessary, then, to have at all times authentic informa tion of its sanitary condition, and it should be kept under inspection, to see that no place in it becomes infected without our knowing it. This is absolutely essential; else we will be taking health certificates from infected places and allowing people from such places to travel on them ad libitum, spreading infection. This inspection of territory, then, is as much a part of train inspec- tion, or rather regulation of passenger traffic on the lines from an infected town, as inspection of passengers on the train, which is imper- fect without it. It is obvious that the limits and, indeed existence, of a drift terri- tory depends not on distance, but on the fact that persons from the quarantined territory pass up into it to certain distances unguarded, or insufficiently guarded, lines of communication. If this, by proper quarantine measures, be prevented (by cordon or otherwise), there is of course no drift territory—a condition which sel- dom obtains—and, in proportion as it is rendered difficult, so will this territory become a small factor in our train inspection. It will be seen that in some points this ': drift territory" is the con- verse of the "neutral territory." From the latter we allow no egress until inspection has shown it to be free from infection and from persons liable to develop infection, when it indeed ceases to be neutral terri- tory and inspection for that purpose ceases. For the former we allow egress as long as inspection shows that no place in it becomes infected, and inspection is to continue for this purpose as long as the territory keeps clean. In the one, inspection will remove or confirm suspicion of infection believed to exist. In the other, it is to confirm or deny a belief in the freedom from infection. MARINE-HOSPITAL SERVICE. 447 For the territory inspected, the inspection of neutral territory is fre- quently a great commercial advantage and generally welcomed; it is already in quarantine, and this inspection may relieve it. The inspec- tion of the " drift" is absolutely essential for the sanitary protection of other x>laces, but it may lead to quarantine of places in this territory, and is not generally regarded with special favor by the place inspected. Of the two, it is the more necessary. Obviously it need not extend beyond Z, yet it may be (and usually is) advisable somewhat beyond. The inspector for this work, as for that of neutral territory, must be possessed of certain qualifications. First. Must be skilled in the differential diagnosis of yellow fever, and of such reputation therein that his diagnosis of yellow fever, positive or negative, will be generally accepted, so as to leave as few disputes as possible as to the nature of the disease which he has pronounced on. No one's diagnosis will be universally accepted by the inhabitants of the town in which he declares yellow fever. Yet much opposition can be disarmed by conservatism, carefulness, and absolute good faith. Second. He must be immune to yellow fever. Else should he dis- cover an infected place his usefulness as inspector is destroyed, as he may not go from such a place into clean territory. Should he (non- immune) expose himself to infection and fail to recognize the disease, he becomes a source of danger to the community which he has inspected. For a road of this nature, running only to infectible territory, this system is complete. It requires (1) relay of train crews, (2) inspection of territory, (3) train inspectors, (4) reception camp (guard tents). All of this is necessary for a complete train inspection. Without the relay, crews of trains are liable to convey infection. The inspec- tion of territory is needed to determine from what places people can be allowed passage. The train inspector is needed to prevent other people than those allowed from taking passage. The reception camp is needed to enable the train inspector to carry out his instructions without undue interference with the schedule of trains. For the road A. N. it is obvious for the local passenger traffic that the same conditions exist as for A. S., and we establish our relays at R', mark X', V, and Z' as the limits of the "communicating," "neutral," and "drift" territory, and establish our inspection of territory, recep- tion camps, and train inspectors just as needed before. But as this road runs through to noninfectible territory which is not quarantined, we can allow through passenger traffic ou it from A to Northern points. So far as the origin of passengers is concerned this can take place without any restriction, but we must provide that they do not stop in infectible territory; do not hold contaminating inter- course therein while passing through; do not return thereto until the period of incubation has passed, aud do not then return with 448 MARINE-HOSPITAL SERVICE. fomites. Certain restrictions are necessary, then, affecting the mode of traveling. The two first indications are fulfilled by sending the through passen- ger (refugees), under the care of a train inspector (train guard), who simply sees that they do not leave the train. There is little dan- ger in allowing these people to ride in the same coach with local pas- sengers, because people generally travel in clean clothes.1 But it is customary to give them a train, or at least a coach, to themselves, and this is best; less to obviate the small risk of infection from the clothing of these people to those traveling with them than to enable the inspector to keep them from eluding him.2 Whether the same guard goes through from A to uninfectible ter- ritory or several relays of them operate together is a matter of no importance and is determined by convenience. Whether he is only a train guard having charge of these through passengers or whether to this he adds the duties of the train inspector for local traffic also depends upon the train service of the road. There is no need of shut- ting the windows of the train in passing through places if it be done to prevent them receiving infection from the air of the coach. Whether it is to be done to prevent things being thrown out of the window the guard and local authorities must judge. At times this guard must be a physician, because if the time en route in noninfectable territory is long and the place is badly infected there will very generally be cases of yellow fever occurring en route. At such times it may be necessary to attach an extra coach as "hospital car." I think the latter will be not often needed. It is but seldom that the inspector for local traffic need be a physician. Let us note that the functions of this train inspector (train guard) for through traffic are almost in contrast with those of the train inspector on the lines with only local traffic. The duty of the first is to prevent people from quarantined territory leaving the car in infectable terri- tory; he is a guard, and nothing more. The duty of the latter is to prevent persons from quarantined territory boarding the cars in clean territory. To prevent the return of these people (after we have conducted them north) to noninfectable territory until the period of incubation has passed, and to prevent return at all with fomites, is confessedly difficult; and to do so absolutely is to my mind impossible, while it can be 1 Passengers believed to be especially liable to convey infection are to be eliminated by the inspectors at A, who examine the affidavits. If found on the cars after they leave the relay, they can be either isolated abroad or returned. 2To be consistent, if this separation be required to avoid infection of those trav- eling with them, the train crew who enter the coaches should be required to be immune or isolated. I do not know of any member of a train crew who is suspected of having contracted yellow fever from his passengers. MARINE-HOSPITAL SERVICE. 449 hedged around with safeguards that bring it within the limits of safety given by other quarantine precautions. Of all persons boarding the train to go north affidavits that they " will not return to any place quarantined against A" or " will not return for ten days" is required. These are taken up by the guards or train inspectors. If the second form be the one presented the baggage of the passenger is disinfected and labeled, and a certificate to that effect given him. It is not claimed that an affidavit of this kind gives absolute protection, or even a very high degree of protection. Still, that it does give protection to some degree is shown by the very considerable proportion of those who sub- scribe to the second form, requiring the disinfection of baggage. This was always complained of; much more, it seems to me, than the incon- venience justified, and was submitted to rather than take the first form of affidavit. A list of the passengers (giving date of arrival and if possible address) going to each principal place of reception of refugees, especially if these be distributing points for passenger traffic south, is made out daily from the list of train inspectors. This is to be furnished to the inspector stationed at such a place and by him furnished to the different ticket offices in that town. A supervision of the ticket office at this place and requiring residence certificates of those purchasing tickets south will generally be sufficient to prevent most of this "back" travel. This can be supplemented by inspecting the roads leading south from such places. As stated before, it is not claimed that these methods give absolute protection, but it is believed that this is about all that can be done without unduly inter- fering with traffic, and is within the limits of safety established by other quarantine proceedings. The disinfection of passenger coaches (used for through travel) before coming south again should also be mentioned as a part of this system. For reasons given it is not claimed to be a necessity, but it is advis- able as is, though less so, the disinfection of baggage and mail cars either at the same time or at the infected place.—(Young.) Passenger traffic on lines crossing either of the above lines is obviously to be treated in accordance with the country it runs through and its terminal. If it passes through "drift" territory it will require inspec- tion for local passenger traffic. If it runs to a noninfectable point, receiving refugees, we may allow transfer of refugees to this line if other conditions render it advisable. It is not pretended that these notes cover the whole subject of train inspection, but it is believed that the points on which I have laid stress, while perfectly obvious, have not been brought out systematically by others writing on this subject. 10918----29 450 MARINE-HOSPITAL SERVICE. I Let us illustrate the above principles by some of the quarantine measures of this year. McHenry, Miss.—Yellow fever: Seven cases were reported here the evening of June 9—the first cases, two of them, occurring May 19. A hasty inquiry showed that there had been such communication between this place and the territory along the Gulf and Ship Island Railroad south of Hattiesburg, and from Lumberton to Gulfport, that (1) there were a number of people in this territory who had been at McHenry within the past ten days, who were thus liable to develop yellow fever, and (2) as the fever had been in McHenry over three weeks there was reason to fear that foci of infection already existed in this territory. Meridian. Perkington. *c±M£ffENRY. •Bree/ancfs. « \Landon. Gu/fport. Mobi/e. 1>A/£W ORLEANS. Map for McHenry. From the fever in McHenry being confined to private houses, none being in hotels or boarding houses, both of these risks were adjudged less than had the public houses been infected. 1. All places were quarantined against the town and a cordon thrown about it. There was thus no "communicating territory." 2. Obviously the district south of Hattiesburg, and from Lumberton to Gulfport, inclusive, was "neutral territory." It was accordingly quar- antined against "pending investigation," and passenger traffic within this district recommended to be discontinued "pending investigation." An inspector of territory, Dr. Perkins, of New Orleans, was taken to Gulfport on the morning of the 10th and stationed there. He was MARINE-HOSPITAL SERVICE. 451 directed to make a house-to-house inspection of that place as often as possible, move all who had been exposed to infection out of town, and see that this place be kept clean. Particular pains were taken with Gulfport because if infected it would be a danger to the line of the Louisville and Nashville Railroad, on which in its immediate vicinity were a number of considerable towns. Three other inspectors of terri- tory, Drs. Stone, Tebo, and Romer, were placed on the line of the Gulf and Ship Island Railroad and directed to inspect this above-defined " neutral territory." 3. The line of the Louisville and Nashville, say, between Scran ton and the Rigolets; the Gulf and Ship Island from Hattiesburg south; and the Queen and Crescent from Hattiesburg to Honey Island were recommended to be considered " drift territory," and no restriction of travel imposed thereon save that certificates of residence be required of those boarding trains in this section. This part of these three roads then was to be covered by train inspection. This division I say was the one recommended. The State boards of Mississippi and Louisiana aud the board of health of Mobile, however, decided to include the line of the Louisville and Nashville, from the Alabama line to the Louisiana line, in as neutral territory in which unknown foci of infection were suspected to exist and quarantined it pending investigation. While the writer thinks, as he then thought and said, that this quarantine of the coast was not necessary, it was not unnatural that different people should differ in judgment about the limits of "neutral territory." He saw, however, and can see now, no sanitary reason for holding this quarantine on, as was done by some boards after inspection had shown that this territory was free from fever, and had sufficient quarantine against McHenry and suspected places. Tents were placed just south of Hattiesburg under guard, to whom any suspects on the traius going north on either road were remanded until the train went south, when they were taken by the inspectors on these roads south to New Orleans or Gulfport, aud sent by the inspector on the Louisville and Nashville to the camp at Fontainebleau, where they were taken in charge by the officer in command of the camp. A small number of people from McHenry, attempting to violate the quarantine, were thus handled. Those picked up on south-bound trains also went to Fontainebleau, without, of course, going into the guard tents. The inspectors of territory soon reported that there were a number of people who had left McHenry within the past ten days at points between McHenry and Gulfport, aud reported suspicious cases of fever at Perkinston, Bond, and at Breelands. In the meantime some of the train crews of the Gulf and Ship Island Railroad which had been exposed to infection in working around McHenry were moved out of Gulfport. Relays were established at 452 MARINE-HOSPITAL SERVICE. Laudon and Maxie, and the investigation of the coast having satisfied the Mississippi board of health that there was no infection there, quar- antine was raised (save by Louisiana) against all save the line of the Gulf and Ship Island between the relays. Later on, this territory showing no yellow fever and the premises where suspicious sickness had occurred being disinfected, it was declared Canton. Asylum Switch. Jackson. Pearson. Meridian. Osyka. Diagram of railroads from Jackson, clean and the relays moved close to McHenry', in which the work was done by a switch engine and special crew. There was then no neutral territory. The work at Jackson illustrates the handling of both kinds of roads, those running to southern terminals and those going north. The fever MARINE-HOSPITAL SERVICE. 453 was announced here September 10. As soon as it was announced and prior to the laying of any quarantine a considerable number of people from Jackson left the town and went into the surrounding country by private conveyances. The counties of Rankin and Hinds, and possibly some others, con- tained then people recently from Jackson, some of whom had possibly been exposed to infection, though there was no reason to believe that any focus of infection already existed outside of Jackson. Quarantine was then laid against the city. There was thus no communicating territory. A glance at the map will show that the Illinois Central runs from Jackson north to noninfectible territory, into which these people could be allowed to go with no restrictions so far as residence is concerned. The Illinois Central Railroad going south; the Alabama and Yicks- burg passing through Jackson, from Yicksburg to Meridian; and the two branches of the Yazoo and Mississippi Yalley, going, respectively, to Yazoo City and Natchez, led only to southern points and are then analogous to the line AS. Inspection was established on all these roads—on the Illinois Central Railroad to extend from Osyka to Canton; on the Alabama and Vicks- burg from Yicksburg to Meridian; on the other two lines from Flora to Yazoo City, and from Raymond to Natchez. Health certificates were required on these lines from all places between the terminals mentioned, and including Flora and Raymond. The distances traversed by the inspectors exceeded what could reasonably be considered " drift terri- tory," but was selected for convenience to get good stopping places; and on the Illinois Central for being a meeting point of trains, and no inconvenience was caused by requiring health certificates from the small amount of territory covered unnecessarily. Health certificates from Yicksburg, Meridian, Yazoo City, and Natchez were not required. Belays.—The lines from Yazoo City to Natchez were not allowed to enter the quarantine limits at all. The Alabama and Yicksburg and the Illinois Central both did their business in the city with switch engines. The Illinois Central furnishing special cars for passengers, express, and mails, and the Alabama and Yicksburg for the mail and express; no passengers leaving by this route. In both cases the trans- fer was made out of town—the one at Asylum Switch, the other at Pearson. No relay camp was required for this work, as the crew of the switch engine remained on their own cars and stayed out of the quar- antined district a very short time, about half au hour per trip. Both relays, however, were under guard. Reception camps were established just south of Canton, at Osyka, just west of Meridian, and at Yicks- burg—at the eastern limit of the town, and at Natchez and Yazoo City. The country covered by this inspection, especially that in which the refugees from Jackson had gone, required inspection; and an inspector of territory, Dr. Waldauer, of Yicksburg, was assigned to this work, although subsequent developments required his services elsewhere. 454 MARINE-HOSPITAL SERVICE. Such people of Jacksou as wished to go north were allowed to go, at first, on separate coaches attached to the day through train of the Illi- nois Central Railroad; and later on, when New Orleans was known to be infected, they went into the same coaches with the New Orleans people, on a special refugee train. A guard was sent with them to north of Carbondale, in Illinois, on the main line, aud north of Padu- cah, Ky., on the branch. These guards were not relayed, making the trip with the refugees to the above destination. The system of relay by switch engine in town is especially applicable to towns which are not terminal for railroads. New Orleans.—The work at New Orleans might be described as illus- trating with small variations all the principles set forth in this preces. We will only mention it with reference to the communicating territory. The fever was declared here in the evening of September 17. The parishes south of the city and Jefferson and St. Charles elected to hold unrestricted communication with the city, as did St. Tammany (this, however, is believed to be uninfectible, or difficultly infectible, ter- ritory). The country along the line of the Louisville and Nashville west of Gulfport elected to hold "daylight communication with disinfection of personal effects of immunes" with the city. The relays were estab- lished at Slidell, Dirt Pits, Laplace, Avondale, and Grand Gulf. No inspection was made for the communicating territory, save along the line of the Louisville and Nashville where the restrictions of "day-light communication" were in force. On the Louisville and Nashville, the Queen and Crescent, and the Illinois Central Railroad, all going to northern points, through pas- senger traffic on special trains under relays of inspectors was allowed. On the other three roads local traffic began after passing the different communicating territory, and went on under inspection, no through traffic being allowed. THE ETIOLOGY OF YELLOW FEVER ABSTRACT OF THE REPORT OF THE COMMISSION OF MEDICAL OFFICERS, MARINE-HOSPITAL SERVICE, DETAILED BY AUTHORITY OF THE SECRETARY OF THE TREASURY AND THE PRESIDENT TO INVESTIGATE THE CAUSE OF YELLOW FEVER. THE ETIOLOGY OF YELLOW FEVER ABSTRACT OF THE REPORT OF THE COMMISSION OF MEDICAL OFFICERS, MARINE- HOSPITAL SERVICE, DETAILED BY AUTHORITY OF THE SECRETARY OF THE TREASURY AND THE PRESIDENT TO INVESTIGATE THE CAUSE OF YELLOW FEVER. Under date of November 8, 1897, P. A. Surg, (now Surg.) Eugene Wasdin and P. A. Surg. H. D. Geddings were detailed by authority of the Secretary of the Treasury and the President as a commission to investigate in Havana the nature of yellow fever. Their full report, dated July 10, 1899, has been received and is printed as a separate publication. The report embodies the work of the commission in fairly testing the claim of Professor Sanarelli, of Bologna, Italy, that the bacillus icteroides is the cause of yellow fever, and the conclusion is drawn that this famous scientist has isolated the true cause of the terrible scourge. This conclusion is based upon a careful bacteriologic study, in the well-equipped laboratory of the Marine-Hospital Service in Havana, Cuba, of 22 cases of disease thought to be yellow fever by the native physicians in attendance. Of these cases all were seen during the progress of the disease, and in 11 of them the commission concurred in the diagnosis. Each case was the subject of careful bacteriologic study, before and, if practicable, after death. This consisted in the abstraction of blood in sterile bulb-tubes from the ear tip under careful asepsis. This blood was then diluted in the bulbs with meat peptone bouillon, and after an incubation of twenty-four hours the growth was transplanted to fresh tubes of bouillon, from which, after twenty-four hours, Petri plates were made in series. From these the organisms present in the blood were isolated in pure cultures and studied. After isolation each organ- ism was subjected to the cultural examination on all media, by means of which those meeting the demands of Sanarelli for the organism he discovered were readily selected and their pathogenicity for animals established. Of the 11 cases diagnosed as yellow fever, the commission isolated the organism of Sanarelli, the bacillus icteroides, from 13, and in the case in which this organism escaped the observation of the commission it was isolated by an independent observer for whom tube cultures had been taken at an autopsy conducted by the commission. 3934----12 in IV MARINE-HOSPITAL SERVICE. Thus the even percentage of isolations has been obtained in these 14 cases, all of which presented prominent symptoms of the disease. In the cases not thus diagnosed the organism of Sanarelli was not obtained. From the living blood in 12 of the 11 cases, abstracted not earlier than the third day of the disease, the organism was isolated, and in the 2 others it was obtained post-mortem. The commission, having preserved a number of cultures made at the isolation hospital in the city of New Orleans from cases seen during the epidemic of 1897, also isolated therefrom the bacillus icteroides in the proportion of 83.33 per cent of the cases examined, the cultures having been made at autopsy. Thus the identity of the bacillus icteroides of our Southern States with that found in Cuba and that sent the commission by Professor Sanarelli, which was obtained in South America, was established. As a control to these examinations the commission made use of a number of cases suffering from diseases other than yellow fever, from which the blood, extracted in the same manner and treated in the same way, failed to yield any organism at all comparable to Sanarelli's. These diseases were representative of those usual to the city of Havana, and were seen during the same period of time in which the cases of yellow fever were under observation. Also there were 31 dead bodies examined, bodies dead from known and unknown diseases, many of them in the city morgue, the most of them in the Spanish military hospitals. In each instance careful sec- tion was made and the blood from the heart, from the liver, the spleen, and the kidneys, and the urine and feces, planted directly into bouillon or agar-agar slant tubes, from which cultures series of plates were made. All bodies thus examined, at times many hours after death, yielded colonies of various organisms, save one, and this at the time of autopsy was diagnosed pathologically as yellow fever and was sterile. In none of these cases of comparative autopsic examination was the bacillus icteroides found—neither in their blood, nor urine, nor feces. Therefore the commission assumes that the organism of Sanarelli is found only in bodies sick with or dead from the disease of yellow fever, at the same time conceding that in many of the sick the blood does not yield the germ, and that in the dead it may prove absent only under certain conditions. Coincident with the above observations the commission carried on the study of the natural history of the organism as to its mode of entering the body, its colonization therein, its toxic possibilities, and its distribution in the organs post-mortem. Numerous and interesting experiments were made with animals, the commission finding all the animals at its command, such as mice, rats, dogs, cats, guinea pigs, rabbits, and monkeys, quite susceptible to the artificial infections produced by inoculating them under the skin, intra- MARINE-HOSPITAL SERVICE. V peritoneally and endo-venously. At the same time it became convinced that the same or very similar results were obtainable by the use of other organisms of different kinds. It found, as had been claimed by Sternberg, that similar clinical and anatomical results could be found after the artificial administration of the bacillus X, as well as that of Havelburg, and of the bacillus coli communis, all of which proved, artificially exhibited, very pathogenic to all animals, and autopsies upon these revealed similar conditions of the organs. Moreover, the toxins elaborated in vitro by the above-named organisms, X, Havel- burg, and coli communis, and icteroides, were precipitated, purified, and tested comparatively upon animals, with the result that the com- mission decided that the mode of death from these toxins, when injected into animals, teas the same in kind, and that the toxins differed only in intensity, and that of these the bacillus icteroides produced the most potent. From these facts the commission, early in its work, became con- vinced that the claim of Professor Sanarelli, of having discovered the germ of yellow fever, was not established by any evidence presented in his published works, and that it was not tenable so long as it could be claimed that the bacillus of Havelburg and the bacillus X of Stern- berg produced the same pathological conditions when artificially inocu- lated, and the commission recognized the validity of this claim, in view of the facts given above, although it had for a long time recognized both of these organisms as belonging to the colon group. At this stage of its work the solution of the problem seemed very remote, but before turning to some other and unknown cause of this disease it was determined to place experimental animals under natural conditions of infection, since it was recognized that all preceding experimental work was so artificial that it was impossible for the com- mission to judge of the pathogenic, or rather specific, merits of the three prominent organisms. From this animal experimentation the commission proves the natural specificity of the organism of Sanarelli; the absolute innocuousness of the bacillus coli communis, of the bacillus X, and of the bacillus Havel- burg to even the most susceptible of animals; and a marked degree of similarity in the reaction of these animals (mice) to the acute infec- tious organisms, such as bacillus typhosus and bacillus cholerse suis, when exhibited to them naturally. The Sanarelli organism is thus eliminated from the colon group and associated with the acute infectious organisms. The commission recognized that Sanarelli's claim was only one of pathogenicity and not of specificity; that until such demonstration of specificity there could be no valid claim for his organism. This validity the commission believes to have established in the conclusion that the bacillus icteroides is "naturally infectious to animals, the degree varying with the species; that in some rodents local infection is VI MARINE-HOSPITAL SERVICE. most quickly followed by blood infection; and, while in rabbits and dogs there is no evidence of this subsequent invasion of the blood, monkeys react to the infection the same as man." The commission has determined "that the infection takes place by way of the respiratory tract,11 and that the primary colonization in the lungs is responsible for the first evidences of absorptive intoxication, such as fever, pains, etc., characteristic of the disease. Also that this primary colonization in the lungs and its poison symptoms may consti- tute the entire attack of the disease in many instances, an attack so light, so ephemeral, that even the most expert diagnosticians may not differentiate them from other ephemera, or poorly marked attacks of allied diseases, as, for instance, the dengue. Moreover, the conclusion has been reached that what is known in the literature of-yellow fever as the "reactionary fever," the "secondary infection" (from germs normal to the body), and the " secondary par- oxysm" is due to the passage of the infecting germ, the bacillus icter- oides, from its primary colony in the lungs into the general circulation, thus producing a "secondary paroxysm" so familiar, clinically, in all marked cases, unless of the siderante type. This "secondary paroxysm" is then a septicemic one, and it depends not upon bacillus coli communis, or bacillus proteus, or upon the micro- cocci, but upon the further colonization of the specific organism in the blood, thus bearing out Faget's observation that the " decline11 of the fever, the true " secondary paroxysm," is as specific as the "rise" or the primary attack. The commission recognizes the- coincident invasion of the blood by the organisms of the respiratory tract, among which are found colon and proteus, as of possible, it may be frequent, occurrence; or these may invade from the alimentary canal "during the last hours of life," when the mucosa becomes impaired from stasis and this invasion becomes possible, such mixed septicemias being of most severe type and frequently fatal. The commission, therefore, differs entirely from Professor Sanarelli in his theory that the disease of yellow fever is primarily a septicaemia. Indeed, it can scarcely be a matter of sur- prise that Sanarelli formulated this opiuion seeing that he always pro- duced, with (as he thought) unimportant exceptions, artificial infec- tions by internal inoculations, which perforce must have produced septicemie. Those cases not open to such explanation, which he observed in man, he explained in a still more unsatisfactory way; in fact, by the assumption that the germ selected to hide away in the spleen in small numbers during the whole course of the disease only to suddenly come forth and produce a septicemia at its termination. The commission, therefore, concludes that the theory of Sanarelli in this regard is not sustained by the facts of these cases, and offers the above solution of probably the most widely and generally observed MARINE-HOSPITAL SERVICE. VII characteristic of yellow fever, the "secondary paroxysm" characterized by a septicemia. The theory formulated and expressed by Dr. Sternberg, United States Army, that the "germinal principle" in yellow fever was to be looked for in the alimentary tract, an opinion evidently dependent upon the well-known influence of the disease upon the organs adjacent and contributive to this tract and portions of the tract itself, as the duo- denum, has been found untenable by the commission, since there is no record of anyone ever having isolated the specific germ from the canal save in the case of its presence there through some capillary hemor- rhage into its lumen. The influence of the various disinfecting agents upon the bacillus icteroides has been studied by the commission with an eye to the prac- tical advantages to be derived from a better acquaintance with the organism, and it is found that the organism is readily influenced by the mechanical and chemical agents in ordinary use. Cold, however, is not a factor in this process, for the organism resists the most extensive refrigeration, and no reliance can be placed on this mode of disinfection. On the other hand, the organism is very susceptible to dehydration and can not withstand artificial drying for more than ten to twelve days, and it is very probable that its susceptibility to frost is due to the lessened humidity of the atmosphere at such seasons rather than to the degree of cold experienced. Sunlight is very fatal to this organism, and no doubt is more so if the organism has lost its vitality through evapora- tion of its fluids, as in a frosty atmosphere. The resemblance between the bacillus icteroides, in its behavior on certain media, and the bacillus of hog cholera, has been brought to the attention of the commission, and it has deemed the observation that there is a possible similarity in the pathogenicity of the two organisms in the domestic hog of great importance, although its experience in the observation of the cultural similarities leads to the conclusion that they are culturally distinct, while the infection of the domestic hog, iu its experience, is impossible by the method pursued of feeding bacillus icteroides to them. However, the question being of too much impor- tance to be determined without full data, the commission placed under treatment a number of domestic hogs in an environment free from sus- picion of the possibility of any contamination with the bacillus cholere suis, with a view to deciding the question of the reaction of these ani- mals to the bacillus icteroides, administered to them in pure cultures in their food. These experiments were conducted at the U. S. quarantine station at Delaware Breakwater, and therefrom it is deduced, first, that the domestic pig is incapable of infection from the bacillus icteroides when introduced through the intestinal or digestive tract; and second, that the bacillus icteroides, when fed to pigs, will not produce any of the lesions or intestinal symptoms of hog cholera. VIII MARINE-HOSPITAL SERVICE. CONCLUSIONS OP THE COMMISSION. i First. That the microorganism discovered by Prof. Guiseppe Sana- relli, of the University of Bologna, Italy, and by him named " bacillus icteroides," is the cause of yellow fever. Second. That yellow fever is naturally infectious to certain animals, the degree varying with the species; that in some rodents local infec- tion is very quickly followed by blood infection, and that, while in dogs and rabbits there is no evidence of this subsequent invasion of the blood, monkeys react to the infection the same as man. Third. That infection takes place by way of the respiratory tract, the primary colonization in this tract giving rise to the earlier mani- festations of the disease. Fourth. That in many cases of the disease, probably a majority, the primary infection or colonization in the lungs is followed by a "secondary infection," or a secondary colonization of this organism in the blood of the patient. This secondary infection may be complicated by the coinstantaneous passage of other organisms into the blood, or this complication may arise during the last hours of life. Fifth. There is no evidence to support the theory advanced by Professor Sanarelli that this disease is primarily septicemia, inas- much as cases do occur in which the bacillus icteroides can not be found in the blood or organs in which it might be deposited therefrom. Sixth. That there exists no causal relationship between the bacillus X of Sternberg and this highly infectious disease; and that this bacil- lus X is frequently found in the intestinal content of normal animals and of man, as well as in the urine and the bronchial secretion. Seventh. That, so far as your commission is aware, the bacillus icter- oides has never been found in any body other than of one infected with yellow fever; and that whatever may be the cultural similarities be- tween this and other microorganisms, it is characterized by a specificity which is distinctive. Eighth. That the bacillus icteroides is very susceptible to the influ- ences injurious to bacterial life, and that its ready control by the pro- cesses of disinfection, chemical and mechanical, is assured. Ninth. That the bacillus icteroides produces in vitro as well as in vita a toxin of the most marked potency; and that, from our present knowledge, there exists a reasonable possibility of the ultimate pro- duction of an antiserum more potent than that of Professor Sanarelli. O MERCHANDISE FROM A TOWN INFECTED WITH YELLOW FEYER. Prior to 1897, when a differentiation of freight into classes was made by the Marine-Hospital Service, it had been the custom in the South for towns quarantining against a town infected with yellow fever to prohibit the shipment of all merchandise from the quarantined town, regardless of the nature or extent of the infection in the latter. There was no attempt made to determine what could be shipped from such towns with safety and what should be barred as liable to carry infection. All classes of freight and baggage were equally and absolutely prohibited. It is not pretended that the classification of freight made in 1897 was the first as regards its disposition from a sanitary standpoint. The first was in the United States Quarantine Regulations of 1893, and under these a classification in detail, quite analogous to the one in 1897, was promulgated the same year by Passed Assistant Surgeon White, of this service, at Hamburg. This, however, was for cholera, and the division for yellow fever, of course, was on a different line. Certain Classes of Freight Shipped from New Orleans in 1897. In 1897 a differentiation of freight into classes which could and could not be shipped was made at New Orleans, La., and some commerce car- ried on from the infected town. This was extended later to Mobile and Memphis. In 1898, having the experience of the past year, this work was taken up at New Orleans on a considerable scale, and to a small extent at Baton Rouge and Alexandria. From the first place a very considerable amount of freight was shipped. The work done on these lines in 1897 was mainly original. It seemed at the time and it seems even now to be imperfectly understood, and it may be that a classification of merchandise on the above lines and a short expose of the principles on which the differentiation rests would be interesting. The classification to be submitted is essentially the same as the "freight rules" agreed to at the Atlanta convention of 1898, and which indeed are the crystallization and development of service methods since 5 6 / 1893, and in the framing of which the writer took some part.l Expla- nation will be given when considered necessary. General Principles. For a proper appreciation of the subject it is well to enunciate clearly in the beginning a principle underlying many quarantine procedures, without which this brochure may be misunderstood. In deciding on the imposition of any quarantine measure a balance should be struck between the risk obviated by its adoption and the loss which the measure entails. We must thus not only consider whether a measure obviates a risk, but whether it entails a loss, and the relation between the two. In measures of quarantine we do not ask for absolute safety.2 It is unattainable, and it will frequently happen that the measures necessary to obviate small risks entail a loss on the communities adopt- ing them greater than the risks thus obviated justify. These restrictions are not in such cases to be imposed. illustrations from maritime quarantine. Illustrations from the maritime quarantine system will explain my meaning. This is selected because its problems are worked out, and we can and do make it so much more safe than land quarantine, and thus can afford to take more stringent precautions. First. It is certain that fomites introduced during the winter into the United States may retain their infection} and, being carried South, produce yellow fever the next summer. To prevent this risk of infection (no matter how small, it is a real risk) it would be necessary to disinfect all possible fomites on all ves- sels from generally infected ports entering any port of the United States, North or South, at all seasons of the year. No sanitarian, as far as I know, has proposed this, nor should it be done. The risk, while a real one, is small and utterly incommensurate with the loss to commerce entailed by such a measure. And even were this done, to give absolute safety from fomites it would require to be supplemented by perpetual inspection and disinfection along the Canadian and Mexican frontiers. 1 Extract from the annual report of the Surgeon-General of the United States Marine-Hospital Service, 1898: "By request experienced officers of the Marine-Hospital Service were detailed to attend this convention, and I authorized them to present to the appropriate com- mittee the regulations which had been prepared by a board of officers of the service called to revise the old regulations. The measures adopted by this convention, which met and adjourned the same day, were practically the same as the regulations pre- pared by this board." 2 Surgeon White expresses this by the epigram. " Quarantine is a sieve, not a dam," and adds, most truly, "to attempt to make it a dam insures its breaking down entirely." It 7 Second. It is known and admitted by the great majority of sanita- rians that the maximum period of incubation of yellow fever is greater than five days. It is also a universally admitted principle that for absolute safety the time of detention in quarantine of persons suscep- tible to infection and exposed to it should cover the period of incuba- tion of the disease dating from last possible exposure. Yet the above time, five days after disinfection, is the maximum imposed at any sta- tion, on the general run of "presumably infected" vessels, i. e., vessels from infected ports without sickness actually aboard. The contention is that on an extremely small proportion of such vessels does fever develop, and that in only a small proportion of cases does the incuba- tion exceed five days, and that thus the risk obviated by requiring more than five days would be small and out of proportion to the loss which would be thus inflicted on commerce. For land quarantine and on vessels coming with yellow fever aboard, however, a larger period is, I think, universally required. This is illogical if we were looking for absolute safety, but is in accordance with the above principle, and to my mind is wise and right. This principle explains many things otherwise incongruous and illog- ical in our maritime quarantine system. For example, the quarantine division into Northern and Southern ports, although it is not held to be impossible that some of the Northern ports may be capable of receiving the infection of yellow fever, if sufficiently introduced; and again, the concessions to the fruit trade from ports where yellow fever exists, and a number of others. In other words, all communities take, and are willing to take, a small risk for a sufficient benefit to their trade. This principle, then, is already recognized and is generally applied in the maritime quarantine system, the most perfect that we have. It is of like applicability to laud quarantine. EFFECT OF OVER STRINGENCY. The statement then, that in our quarantine measures we should "take no risk whatever," is not in accordance with the practice of the best sanitarians. Also it is to be noted that overstringency of quar- antine restriction, especially if continuing for a considerable time and involving much loss and hardship, are apt, certain rather, to involve more risk by the amount of illegitimate communication, " sanitary smuggling," caused by them. This matter has been so thoroughly brought to the notice of sanitarians, and, indeed, to that of the general public the past two years, that it is unnecessary to dwell on it. The object of the sanitarian is to obtain the maximum safety to public health with the minimum loss commercially. RISK. Health, however, must rank first, and only minimum risks may be taken, and in the classification to be presented it is believed that this 8 / is kept well in view, and that when in doubt the decision has always been thrown on the side of safety. It is admitted that any communication with an infected town may involve some risk, from fault of regulation or even of administration, yet it is believed that freight shipped under the provisions to be laid down will scarcely be a factor in increasing the risk; that it is well within the limits of safety given by any quarantine. POSTULATES. The following postulates from a paper read at and accepted by the New Orleans convention of 1899 bear directly on the subject of this paper, and had best be grouped here, to avoid subsequent continual quotation. POSTULATE I. CONVEYANCE OF INFECTION IS GENERALLY BY PERSONS. Yellow fever is usually conveyed from infected places by persons and personal effects, the latter already infected, and the former having the fever in the stage of incubation. The former is by far the most common medium of conveyance. This is borne out by all experience. (Chaille- Sternberg committee of experts, 1879; Toner et al.) In at least four-fifths of the cases in which the origin of the infection of yellow fever in a town is definitely traced it is found to follow the occurrence of a case of that disease in one who has been exposed in another place. There have been many cases of infection where it was stated that the refugee brought no baggage; there have been very many when there was no evidence on this point, but the refugee being almost always the first attacked, and soon after arrival (other cases showing usually after two weeks), is against the theory of fomites, to which others, as well as he, would have been quite frequently exposed. It seems hardly necessary to seriously consider the allegation that the infection is thus carried by the clothing worn at the time the man was taken sick. Considering how very rarely it is carried by the cloth- ing of physicians visiting infected places, and that in many instances the arrival in the place subsequently infected occurs several days after leaving the infected town and after many miles of passage through the open air, it is not within bounds of reason to accuse the clothing worn by those people. Ordinary wearing apparel worn through the sun and air for any considerable time is freed from the infection of yellow fever. There are, however, not a few cases in which packed personal effects have been the agent of conveyance. Other things besides personal effects, such as articles of merchandise, may of course convey infec- tion, but in point of fact seldom do, and the instances in which it has 9 been reasonably ascribed to general freight, not household goods or baggage, are conspicuous by their rarity. The writer knows of but one.1 POSTULATE II. FACTORS OF DANGER IN SHIPMENT OF MERCHANDISE. Merchandise other than personal effects shipped from a place in which foci of infection of yellow fever exist is dangerous in proportion to a combination of three factors: (1) It exposure to infection. (2) Its ability to receive and convey it. (3) The measures adopted to free it from infection if exposed to it. Both of the first two factors must exist to render the merchandise dangerous in the first place, and even then it may be freed from danger by proper measures to free it from infection. The first depends on: (a) The degree of infection in the place; (6) the place of storage and handling of the merchandise. Until the infection of a city becomes general the risk of infection is confined to residences, and places contiguous to them, and in the busi- ness portion of a city is rare, the wholesale business houses being prac- tically free from it. Reference is here had only to a city in which there is such a difference in residence and business portion. Goods from the wholesale district of such a town, unless the infection of the place be very general, are little apt to be exposed to infection. Should the infection become very general, the wholesale district may be invaded. The second depends on the nature of the surface of the merchan- dise. Smooth, clean, dry, nonabsorbing surfaces will scarcely, eveu if exposed to infection, convey it. The third, on the process of disinfection to which the merchandise has been subjected. This requires no explanation.2 Classification of Merchandise not the same for all Towns. Since one element in determining the restrictive measures of quar- antine to be imposed is the loss which accrues from their adoption, we must consider the commercial relations between the infected town and the quarantining district—whether the town naturally supplies this dis- trict or any part of it, and whether its place in so doing can be taken, and at what loss by other towns and other questions of this nature. The merchandise desirable to ship will differ for all these factors, and it is obvious that no classification can apply, at the best, for all differ- ent towns. 1 There is some reason to believe that the fever at Havana was introduced by sec- ond-hand buckets and cans from New Orleans used in Havana for packing oysters. These were collected from residences, groceries in the residence part of the town, were in all states of cleanliness and uncleanliness, and were rather under the condi- tions of "household goods" than general freight. 2Proceedings New Orleans Convention. 1S99, pars. 190 to 199. 10 The one given is adjudged to be generally suited to the distributing centers for an agricultural community, i. e., for the larger cities of the Gulf and South Atlantic States, and we believe gives the minimum of risk with the minimum of loss to the community. advantage of "free list." It is desirable in such a classification to avoid requiring disinfection for merchandise which does not need it, and the aim has been (as was the practice in 1897 and 1898) to pick out the large class which does not need disinfection ("free list") and to disinfect carefully or to prohibit the remainder. To require the disinfection of a large amount of mer- chandise, knowing that 90 per cent of it does not need it, will generally result in not taking the requisite pains with the 10 per cent which does and in which the danger lies. ARTICLES OF MERCHANDISE REQUIRING MORE THAN SUPERFICIAL DISINFECTION SHOULD, AS A RULE, BE PROHIBITED. < Practically only superficial disinfection is undertaken. Articles of mer- chandise requiring more than this should, save in exceptional instances, be prohibited shipment. Not that they are not safe if disinfected, but that it is in general not commercially advisable. GENERAL CONDITIONS. 1. Articles should not be shipped from dwellings, nor from places contiguous to dwellings, nor from any place, believed to be infected. 2. All articles shall be new, clean, and dry. The reason for these conditions are obvious: They insure a minimum chance of exposure to infection of things shipped without disinfection; at the same time they impose a minimum loss because of the shipments prohibited being relatively unimportant. » SPECIAL CONDITIONS OF INFECTION. I.—WHEN FEVER EXISTS IN A SPORADIC FORM. Merchandise under the above conditions can be shipped. The chance of any merchandise, except goods from the few infected residences, conveying infection is nil, and there need be no bar on any kind of merchandise fulfilling the above conditions. II.—WHEN FEVER IS MORE THAN SPORADIC, BUT NOT GENERAL. Merchandise of the above character may be shipped from the whole- sale district of a city, except such as from its liability to infection would be especially apt to conserve it, such as fruit, vegetables in open crates, straw, sawdust, excelsior, and similar articles used for packing. These articles can be shipped only if they have been preserved from possible exposure to infection or have been disinfected. There is still no reasonable risk in merchandise shipped under the above conditions. • 11 REASONS FOR PROHIBITING PACKINGS. The materials excepted against are of such a nature that they are more liable than other merchandise to be exposed to infection, and as they are, or may be, culture media, any exposure to infection, even a slight one, might well make them dangerous out of proportion to other articles of merchandise. It is judged, then, that the risk of passing these excepted articles is in excess of the loss from their exclusion. They are therefore excluded. The special precautions to avoid exposure are to use clean, newly received excelsior, etc., and breaking bulk only when it is to be used in the uninfected packing house. CONTAMINATION BY INFECTED HANDS. As long as the wholesale district is not infected, the risk from ordi- nary freight shipped therefrom is practically nil. The chance of con- tamination of the above classes by the hands of people who have been in infected houses while theoretically possible is not to be considered. Most microorganisms live but a short time on an exposed surface of the body, and ordinary freight is not a culture medium, and even if thus exposed would uot preserve infection. The employees at quar- antine stations do not disinfect their hands to take out the newly steril- ized clothing, although they have just handled that to be disinfected and have done so for twenty years at all stations with no bad results. As long, then, as the wholesale district is not infected there need be no bar to the shipment of any ordinary merchandise, new, clean, and dry, which has been only in this district and is not a culture medium. Even dry goods and woolen goods, from some reason held to be especially dangerous, may pass. GOODS MADE UP IN A CITY. It must be noted, however, that goods (clothings, etc.) made up in a city are frequently made up at residences and others are to certain extent household goods. They are, of course, barred shipment. TO DETERMINE IF HOUSEHOLD DISTRICT IS INFECTED. j To determine just when any part of the wholesale district becomes infected is not always possible; still, as long as the infection is not general in the residence portion of the town, it is fair to assume that the wholesale district is free from infection in the sense of presenting- little chauce of infecting ordinary freight shipped therefrom. If, in addition, a pretty close watch be kept on this district, which is generally easy, from the number of inspectors, one is apt to have work- ing in it, we can be reasonably sure when there is doubt of its cleanli- ness, and when there is doubt it may no longer be counted clean. SURFACES NOT LIABLE TO CONVEY INFECTION. In case there is question as to the wholesale district being free from infection we have a further, and can make a sufficiently safe, guard in 12 confining, and should confine our shipments to such articles as from the nature of their surfaces are not liable to receive or retain infection or to such as have been disinfected. Thus, under ordinary conditions of infection, we would have— Class I.—Articles to be shipped without disinfection. (1) New and dry material, with smooth, nonabsorbing surfaces, shipped unpacked, such as articles of metal and smooth, varnished, or painted wood, leather, etc.; machinery, no part of which is textile. In the original circular of September, 1897, new lumber and new bricks—both with rough surfaces—were included in this list, and there was no reason why they should not have been shipped; but their free- dom from infection was due to the location of the brick and lumber yards in New Orleans, far from any residence—practically in the country, rather than to the nature of their surfaces; aud hence they do not belong to the "free list" under this head. (2) Original packages in clean and smooth wooden or metallic con- tainers not broken or packed in an infected locality. (3) Articles in such containers put up and handled exclusively in the wholesale district, which from their nature or mode of packing are incapable of carrying infection, such as roasted coffee, refined sugar, coal oil, creosote, acids, beans, peas, rice, salted meats, and articles of similar character. The reason for this is, I think, obvious; the chance of surfaces of this nature receiving and retaining infection can scarcely be said to exist. Similarly nil is the chance for beans, pease, etc., with their smooth sur- faces exposed for a few minutes from one container to another. For roasted coffee packed at 250° to 200° F., and refined sugar, also packed hot, there is no question they, like the antiseptics, are then germicidal. Lime, cement, ice, salts, grain, and similar articles, when shipped in bulk, being incapable of receiving and conve'ying infection, together with beer packed in ice or in refrigerator cars, belong to the free list. For coke, coal, gravel, etc., placed by the New Orleans schedule in the "free list," the safety depends on not having been exposed to in- fection. The last, if exposed or mixed with dirt and trash, as is usual, might well convey infection. It is no safer than ballast which is re- jected at maritime quarantine. THROUGH MERCHANDISE TRANSFERRED IN THE TOWN. To the list that may go without disinfection must be added such merchandise as may be transferred through the town under such con- ditions that it is not exposed to infection. First. Merchandise passing through in closed cars. Second. Merchandise directly transferred from car to car at a clean siding, or from vessel to car, or vice versa, at a clean wharf. The point to preserve here is the " direct transfer," making a minimal exposure in event of there being some unknown infection at the siding or wharf. 13 We must on this account except such merchandise as is or may be a culture medium and would be exposed to infection if it existed at the place of transfer; thus cabbage in crates with large exposed surfaces, rotting leaves, stems, etc.; potatoes and other vegetables and fruits in bulk; oranges and lemons that have to be handled and sorted out on the platform are barred. In barrels the same merchandise could pass. Bananas, although imported in bulk, make a direct transfer. They are taken directly from vessel to car without landing on the wharf. They have smooth surfaces, and for commercial reasons no soft bunches or bunches of whose firmness there is any question are shipped. They are allowed shipment. It was required that the cars in which were loaded bananas, the only fruit shipped in bulk through New Orleans, be washed down with bichloride of mercury. This was done because some of the fruit is liable to decay en route, and should there be even the slightest infection in the car the decayed fruit might serve as a culture medium and make a focus of infection. The risk without it was minimal, but it was easy to do and was probably a wise precaution. The rules, then, of the New Orleans convention cover these points very well. (a) Fruits, sound, and taken directly in good condition from clean vessels or cars, which have complied with all quarantine requirements, and transferred at wharfs or railroad depots not infected and in good sanitary condition immediately to the disinfected cars or vessels for shipment. (6) Fruits, vegetables, and Western produce in barrels or boxes directly transferred as above. (c) Freight in good sanitary condition taken directly from clean vessels or cars to cars or vessels at a wharf or railroad siding not infected and in good sanitary condition. New bricks, new lumber, etc., can nearly always be shipped on the " free list" because of the location of the yards where these things are stowed. They need no separate mention. Live stock, too, save for the litter with which they are accompanied, would not convey infection, although the wool of sheep might. They were refused shipment on this account in 1898. Class II.—Articles to be shipped with superficial disinfection. COMPLETE DISINFECTION NOT OENERALLY ADVISABLE. Disinfected, of course any article can be shipped, but the conditions which are obtained iu an infected town during an epidemic are such that it is not generally possible to undertake the disinfection of mer- chandise of which the interior may be infected. In exceptional cases, when it is extremely important to have the merchandise shipped, as for filter press cloths, etc., it can be done, and was done in 1897 and 1898, but it is generally impracticable, and should not be generally under-' taken. 14 SUPERFICIAL DISINFECTION. Fortunately we can differentiate a large class of goods in which the infection, if it exists, can be only superficial, and for which then a super- ficial disinfection is sufficient. The following articles will require only superficial disinfection—i. e., outside of containers: First. All goods in original wooden or metallic packages, not broken or packed in an infected locality, when not included in Class I. These articles may not be included iu Class I (a) on account of the nature of the surface of the container, it being rough, etc., or (&) because we are in more doubt as to its having been exposed to infection in such a way or extent that it may not convey it. Second. Articles which from their nature and mode of packing are incapable of receiving infection, and which sterilize the inside of the con- tainer, such as roasted coffee, refined sugar, molasses, coal oil, creosote, acids, and articles of a similar character, when not included in Glass I. This is not the same as (3) Class I, because if the outside of the con- tainer requires disinfection, it is reasonable that the inside of it does also, and thus only such things as sterilize the inside of the container are advisable. Third. Original packages in textile material, not broken or packed in an infected locality and kept perfectly dry, except sacking, jute bagging, and textiles in loose covers. In the rules as originally issued, in September, 1897, this read, "Original packages in textile containers kept dry and clean require disinfection of the outside of the container only." In that at Atlanta, 1898, this was modified (by Dr. Harralson, of Mississippi, the writer, accepting and advocating the change) to " Original packages other than textile containers," etc. In the New Orleans conference of 1898 this reads, as it did at first with the explanation, "This includes coffee, grain, osnaburgs, and other cotton goods in solid bales with close coverings." The trouble is a practical one, and the merchandise in question is the cotton and cotton bags of jute, of which an immense quantity passes through New Orleans. If the textile container had certainly been kept dry and clean, unquestionably the gaseous disinfection properly applied would pene- trate farther than any infection could; but there were two difficulties: First. It was exceedingly difficult to be assured that the material in question (the bales of jute bagging) had been always kept clean and dry, and so little pains was taken with the storage that the presump- tion that this had been so was not sufficiently strong, and if it had been wet the infection might well be more than superficial. Second. It was difficult to so dispose the bulky, yielding bales as to # get all surfaces exposed to the disinfection. If, then, it had been pre- sumably exposed to infection it was unsafe. Accordingly it was barred 15 (in 1897). The other textiles, osnaburgs, are under different condi- tions, close bailed and of close texture, and for commercial reasons must be kept dry and clean. The bales are small and rigid and easily disinfected on all surfaces. Both Atlanta and New Orleans intend to exclude the jute bagging, and it seems as well to do it in terms. Note.—Any article, of course, can be shipped if entirely disinfected. COMMERCIAL RELIEF AFFORDED BY THIS CLASSIFICATION. An inspection of the classification will show that it allows without disinfection, or with practical—i. e., superficial—disinfection, a consider- able proportion of the merchandise most needed in the agricultural districts of the South, i. e., wholesale groceries, machinery, agricul- tural implements, salt, oil, etc., and thus imposes the least possible loss on the section of country quarantining which can afford to wait for its " piece goods," etc., until frost. Indeed, except for the embargo on cotton bagging (jute), it would give such a district nearly all that it really needs during an epidemic in the city which usually supplies it. It gives also a great relief to the city itself, but by no means so much as to the quarantining district. It is not possible to do this if the dis- ease is fairly general—i. e., is epidemic—as full disinfection (not super- ficial) would be the only way to render many shipments safe, and that is, as I have said, inapplicable. Note.—The New Orleans convention, referred to in the preceding article, was held February 9,1899. The proceedings are published in pamphlet form. The Serv- ice was represented in this convention by Surg. J. H. White, who was appointed chairman of the committee on revision of the Atlanta regulations. Surgeon White, in his report, states: "The one object sought by your representative was the obtaining of a' formal agreement to report first cases, be they either suspicious or positive. This, as may be seen, was fully attained. ''The remaining resolutions are, I believe, in full accord with the regulations of the Marine-Hospital Service, and in many cases they parallel the quarantine regu- lations framed by the board convened in Washington one year ago." o } \ /7-js# * Mfx$W£ »>u IBRARY OF MEDICINE NLn DDiamM2 i #1 NLM001241427