mosquito that was applied to him four days before became fixed
upon our minds, we decided to test it upon the first non-immune
person who should offer himself to be bitten; this was of
common occurrence and taken much as a joke among the soldiers
about the military hospital. Barely fifteen minutes may have
elapsed since we had come to this decision when, as Lazear
stood at the door of the laboratory trying to "coax" a mosquito
to pass from one test-tube into another, a soldier came walking
by towards the hospital buildings; he saluted, as it is
customary in the army upon meeting an officer, but, as Lazear
had both hands engaged, he answered with a rather pleasant
"Good morning." The man stopped upon coming abreast, curious no
doubt to see the performance with the tubes, and after gazing
for a minute or two at the insects he said: "You still fooling
with mosquitoes, Doctor?" "Yes," returned Lazear, "will you
take a bite?" "Sure I ain't scared of 'em," responded the man.
When I heard this, I left the microscope and stepped to the
door, where the short conversation had taken place; Lazear
looked at me as though in consultation; I nodded assent, then
turned to the soldier and asked him to come inside and bare his
forearm. Upon a slip of paper I wrote his name while several
mosquitoes took their fill; William E. Dean, American by birth,
belonging to Troop B, Seventh Cavalry; he said that he had
never been in the tropics before and had not left the military
reservation for nearly two months. The conditions for a test
case were quite ideal.
I must say we were in great trepidation at the time; and well
might we have been, for Dean's was the first indubitable case
of yellow fever about to be produced experimentally by the bite
of purposely infected mosquitoes. Five days afterwards, when he
came down with yellow fever and the diagnosis of his case was
corroborated by Dr. Roger P. Ames, U. S. Army, then on duty at
the hospital, we sent a cablegram to Major Walter Reed,
chairman of the board, who a month before had been called to
Washington upon another duty, apprising him of the fact that
the theory of the transmission of yellow fever by mosquitoes,
which at first was doubted so much and the transcendental
importance of which we could then barely appreciate, had indeed
been confirmed.
STATE OF THINGS BEFORE THE DISCOVERY OF MOSQUITO TRANSMISSION
Other infectious diseases, tuberculosis, for instance, may
cause a greater death-rate and bring about more misery and
distress, even to-day, than yellow fever has produced at any
one time; but no disease, except possibly cholera or the
plague, is so tragic in its development, so appalling in its
action, so devastating in its results, nor does any other make
greater havoc than yellow fever when it invades non-immune or
susceptible communities.
For two centuries, at least, the disease has been known to
exist endemically, that is, more or less continuously, in most
of the Mexican Gulf ports, extending its ravages along the West
India Islands and the cities of the Central and the South
American coast.
In the United States it has made its appearance in epidemic
form as far north as Portsmouth, N. H. At Philadelphia in 1793,
more than ten per cent. of the entire population died of yellow
fever. Other cities, like Charleston, S. C., suffered more than
twenty epidemics in as many summers, during the eighteenth
century. In the city of New Orleans, the epidemic which
developed in the summer of 1853 caused more than 7,000 deaths.
Later, in 1878, yellow fever invaded 132 towns in the United
States, producing a loss of 15,932 lives out of a total number
of cases which reached to more than 74,000: New Orleans alone
suffered a mortality of 4,600 at that time. Recently (1905),
this city withstood what is to be hoped shall prove its last
invasion, which, thanks to the modern methods employed in its
suppression, based upon the new mosquito doctrine, only
destroyed about 3,000 lives.
It is by contemplating this awful record, and much more there
is which for the sake of brevity I leave unstated, that one
realizes the boon to mankind which the successful researches of
the Army Board have proved. The work of prevention, the only
one that may be considered effective when dealing with the
epidemic diseases, was entirely misguided with regard to yellow
fever until 1901: the sick were surrounded by precautions which
were believed most useful in other infectious diseases, the
attendants were often looked upon as pestilential, and so
treated, in spite of the fact that evidence from the early
history of the disease clearly pointed to the apparent
harmlessness even of the patients themselves. All this
notwithstanding, cases continued to develop, in the face of
shotgun quarantine even, until the last non-immune inhabitant
of the locality had been either cured or buried.
The mystery which accompanied the usual course of an epidemic,
the poison creeping from house to house, along one side of a
street, seldom, crossing the road, spreading sometimes around
the whole block of houses before appearing in another
neighborhood, unless distinctly carried there by a visitor to
the infected zone who himself became stricken, all this series
of peculiar circumstances was a never-ending source of
discussion and investigation.
In the year 1900, Surgeon H. R. Carter, of the then Marine
Hospital Service, published a very interesting paper calling
attention to the interval of time which regularly occurred
between the first case of yellow fever in a given community and
those that subsequently followed; this was never less than two
weeks, a period of incubation extending beyond that usually
accorded to other acute infectious diseases. The accuracy of
these observations has later been confirmed by the mosquito
experiments hereinafter outlined.
FACTORS WHICH LED TO THE APPOINTMENT OF THE BOARD
One may well believe that such a scourge as yellow fever could
not have been long neglected by medical investigators, and so
we find that from the earliest days, when the germ-theory of
disease took its proper place in modern science, a search for
the causative agent of this infection was more or less actively
instituted.
Men of the highest attainments in bacteriology engaged in
numerous attempts to isolate the yellow fever microbe:
unfortunately not a few charlatans took advantage of the dread
and terror which the disease inspires, to proclaim their
discoveries and their specific CURES; one of these obtained
wealth and honor in one of the South American republics for
presumably having discovered the "germ" and prepared a
so-called vaccination which was expected to eradicate the
disease from that country, but for many years after the foreign
population continued to suffer as before and the intensity and
the spread of yellow fever remained unabated, although
thousands of "preventive inoculations" were made every month.
Geo. M. Sternberg in 1880, then an army surgeon, was directly
instrumental in exposing the swindle that was being
perpetrated, putting an end, after the most painstaking
investigation, to all the claims to discovery of the "germ" of
yellow fever that had been made by several medical men in
Spanish America. The experience which he obtained during a
scientific excursion through Mexico, Cuba and South America
gave him a wonderful insight as to the difficulties one has to
contend with in such work and made him realize the importance
of special laboratory training for such undertaking. It is
interesting to note that, as surgeon general of the U. S. Army,
twenty years after, General Sternberg chose and appointed the
men who constituted the yellow fever board, in Cuba.
The year before the Spanish-American war, an Italian savant,
who had obtained a well-deserved reputation as bacteriologist
while working in the Institute Pasteur of Paris, came out with
the announcement from Montevideo, Uruguay, that he had actually
discovered the much-sought-for cause of yellow fever; his
descriptions of the methods employed, though not materially
different from those followed by Sternberg many years before,
bore the imprint of truth and his experimental inoculations had
apparently been successful. Sanarelli--that is his name--for
about two years was the "hero of the hour," yet his claims have
been proved absolutely false.
The question of the identity of his "germ" was first taken up
by the writer under instructions from General Sternberg: during
the Santiago campaign I had opportunity to autopsy a
considerable number of yellow fever cases and, following
closely upon Sanarelli's directions, only three times out of
ten could his bacillus be demonstrated; at almost the same
time, Drs. Reed and Carroll, in Washington, were carrying out
experiments which showed that Sanarelli's bacillus belonged to
the hog-cholera group of bacteria and thus when found in yellow
fever cadavers could play there only a secondary role as far as
the infection is concerned.
Unfortunately, two investigators belonging to the U. S. Marine
Hospital Service, Drs. Wasdin and Gleddings, were, according to
their claims, corroborating Sanarelli's findings: there was
nothing to do but that the investigation should continue, and
so I was sent by General Sternberg to Havana in December, 1898,
with instructions and power to do all that might be necessary
to clear up the matter. Wasdin and Geddings had preceded me;
the work carried us through the summer of 1899; we frequently
investigated the same cases; I often autopsied bodies from
which we took the same specimens and made the same cultures, in
generally the same kind of media, and finally we rendered our
reports to our respective departments, Wasdin and Geddings
affirming that Sanarelli's bacillus was present in almost all
the cases, while I denied that it had such specific character
and showed its occurrence in cases not yellow fever. A virulent
epidemic which raged in the city of Santiago and vicinity
during 1899 afforded me abundant material for research.
In the meantime the city of Havana was being rendered sanitary
in a way which experience had taught would have overcome any
bacterial infection, and, in fact, the diseases of filth, such
as dysentery, tuberculosis, children's complaints and others,
decreased in a surprising manner, while yellow fever seemed to
have been little affected if at all.
Evidently, a more thorough overhauling of the matter was
necessary to arrive at the truth, and while the question of
Sanarelli and his claims was practically put aside,
Surgeon-General Sternberg, recognizing the importance of the
work before us and that its proportions were such as to render
the outcome more satisfactory by the cooperation of several
investigators in the same direction, wisely decided to create a
board for the purpose and so caused the following to be issued:
Special Orders No. 122
HEADQUARTERS OF THE ARMY,
ADJUTANT GENERAL'S OFFICE,
WASHINGTON, May 24, 1900
Extract
34. By direction of the Secretary of War, a board of medical
officers is appointed to meet at Camp Columbia, Quemados, Cuba,
for the purpose of pursuing scientific investigations with
reference to the infectious diseases prevalent on the Island of
Cuba. Detail for the board:
Major Walter Reed, surgeon, U. S. Army;
Acting Assistant Surgeon James Carroll, U. S. Army;
Acting Assistant Surgeon Aristides Agramonte, U. S. Army;
Acting Assistant Surgeon Jesse W. Lazear, U. S. Army.
The board will act under general instructions to be
communicated to Major Reed by the Surgeon General of the Army.
By command of MAJOR GENERAL MILES,
H. C. CORBIN,
Adjutant General
It may be of interest to the reader to learn who these men were
and the reasons why they were probably selected for the work.
Major Reed, the first member in the order of appointment, was
the ranking officer and therefore the chairman of the board. He
was a regular army officer, at the time curator of the Army
Medical Museum in Washington and a bacteriologist of some
repute. He deservedly enjoyed the full confidence of the
surgeon general, besides his personal friendship and regard.
Reed was a man of charming personality, honest and above board.
Every one who knew him loved him and confided in him. A
polished gentleman and a scientist of the highest order, he was
peculiarly fitted for the work before him.
Dr. James Carroll, the second member of the board, was a
self-made man, having risen from the ranks through his own
efforts: while a member of the Army Hospital Corps he studied
medicine and subsequently took several courses at Johns Hopkins
University in the laboratory branches. At the time of his
appointment to the board he had been for several years an able
assistant to Major Reed. Personally, Carroll was industrious
and of a retiring disposition.
Dr. Jesse W. Lazear was the fourth member of the board. He had
graduated from the College of Physicians and Surgeons (Columbia
University) in the same class as the writer, in 1892, and had
afterwards studied abroad and at Johns Hopkins. Lazear had
received special training in the investigation of mosquitoes
with reference to malaria and other diseases. Stationed at
Columbia Barracks, he had been in Cuba several months before
the board was convened, in charge of the hospital laboratory at
the camp. A thorough university man, he was the type of the old
southern gentleman, kind, affectionate, dignified, with a high
sense of honor, a staunch friend and a faithful soldier.
The writer was the third member of the Army Board. Born in Cuba
during the ten years' war, while still a child, my father
having been killed in battle against the Spanish, I was taken
to the United States and educated in the public schools and in
the College of the City of New York, graduating from the
College of Physicians and Surgeons in 1892. At the breaking out
of the war I was assistant bacteriologist in the New York
Health Department. The subject of yellow fever research was my
chief object from the outset, and, at the time the board was
appointed, I was in charge of the laboratory of the Division of
Cuba, in Havana.
It may be readily seen from the brief sketch regarding the
several members that the components of the yellow-fever board
really constituted a perfectly consistent body, for the reason,
mainly, that they were all men trained in the special field
wherein their labors were to be so fruitful and that before
their appointment to the board they had been more or less
associated in scientific work.
FIRST PART OF THE WORK OF THE BOARD
My first knowledge of the existence of the board was had
through the following letter from my friend Major Reed:
WAR DEPARTMENT,
SURGEON GENERAL'S OFFICE,
WASHINGTON, May 25, 1900
DR. A. AGRAMONTE,
Act'g Asst. Surgeon U. S. A.,
Military Hospital No. 1,
Havana, Cuba
My dear Doctor: An order issued yesterday from the War
Department calls for a board of medical officers for the
investigation of acute infectious diseases occurring on the
Island of Cuba. The board consists of Carroll, yourself, Lazear
and the writer. It will be our duty, under verbal instructions
from the Surgeon General, to continue the investigation of the
causation of yellow fever. The Surgeon General expects us to
make use of your laboratory at Military Hospital No. 1 and
Lazear's laboratory at Camp Columbia.
According to the present plan, Carroll and I will be quartered
at Camp Columbia. We propose to bring with us our microscopes
and such other apparatus as may be necessary for the
bacteriological and pathological work. If, therefore, you will
promptly send me a list of the apparatus on hand in your
laboratory, it will serve as a very great help in enabling us
to decide as to what we should include in our equipment. Any
suggestions that you may have to make will be much appreciated.
Carroll and I expect to leave New York, on transport, between
the 15th and 20th of June and are looking forward, with much
pleasure, to our association with you and Lazear in this
interesting work. As far as I can see we have a year or two of
work before us.
Trusting you will let me hear from you promptly, and with best
wishes,
Sincerely yours,
(Signed)
WALTER REED
On the afternoon of June 25, 1900, the four officers met for
the first time in their new capacity, on the veranda of the
officers' quarters at Columbia Barracks Hospital. We were fully
appreciative of the trust and aware of the responsibility
placed upon us and with a feeling akin to reverence heard the
instructions which Major Reed had brought from the surgeon
general; they comprised the investigation also of malaria,
leprosy and unclassified febrile conditions, and were given
with such detail and precision as only a man of General
Sternberg's experience and knowledge in such matters could have
prepared. After deciding upon the first steps to be taken, it
was unanimously agreed that whatever the result of our
investigation should turn out to be, it was to be considered as
the work of the board as a body, and never as the outcome of
any individual effort; that each one of us was to work in
harmony with a general plan, though at liberty to carry out his
individual methods of research. We were to meet whenever
necessary, Drs. Reed, Carroll and Lazear to remain at the
Barracks Hospital and I to stay in charge of the laboratory in
Havana, at the Military Hospital, where I also had a ward into
which yellow-fever cases from the city were often admitted.
Work was begun at once. Fortunately for our purpose, an
epidemic of yellow fever existed in the town of Quemados, in
close proximity to the military reservation of Camp Columbia.
Even before the arrival of Reed and Carroll, Lazear and I had
been studying its spread, following the cases very closely;
subsequently a few autopsies were made by me, Carroll making
cultures from the various tissues and Lazear securing fragments
for microscopical examination; a careful record was kept and
the results noted; cases gradually became less in number as the
epidemic slowly died out, about the middle of August.
In the meantime a rather severe outbreak of yellow fever had
occurred in Santa Clara, a city in the interior of the island,
having invaded the garrison and caused the death of several
soldiers; as the origin of the infection was shrouded in
mystery, and cases continued to appear among the troops even
after they had moved out of the town, it was agreed that I
should endeavor to trace the source of the epidemic and aid the
medical authorities in establishing whatever preventive
measures might seem proper. This service is here recorded
because in the general discussion of the start and course of
the epidemic with Dr. J. Hamilton Stone, the officer in charge
of the military hospital, we incidentally spoke of the possible
agency of insects in spreading the disease, pointing
particularly in this direction the fact of the infection of a
trooper who, suffering from another complaint, occupied a bed
in a ward across the yard from where a yellow fever case had
developed two weeks before.
The infection of the city of Santa Clara had evidently taken
place from Havana, distant only one night's journey by train.
Captain Stone, a particularly able officer, had already
instituted effective quarantine measures before my arrival, so
that I only remained there a few days.
But as to the actual cause of the disease we were still
entirely at sea; it helped us little to know that a man could
be infected in Havana, take the train for a town in the
interior and start an outbreak there in the course of time.
Upon rejoining my colleagues (July 2) we resumed our routine
investigations; not only in Quemados, where the disease was
being stamped out, but also in Havana, at "Las Animas" Hospital
and at Military Hospital No. 1, where my laboratory (the
division laboratory) was located. There was no scarcity of
material and the two members who until then had never seen a
case of yellow fever (Reed and Carroll) had ample opportunity,
and took advantage of it, to become acquainted with the many
details of its clinical picture which escape the ordinary
practitioner, the knowledge and the appreciation of which, in
their relative value, give the right to the title of "expert."
Since the later part of June, reports had been coming to
headquarters of an extraordinary increase of sickness among the
soldiers stationed at Pinar del Rio, the capital of the extreme
western province, and very soon the great mortality from
so-called "pernicious malarial fever" attracted the attention
of the chief surgeon, Captain A. N. Stark, who, after
consulting with Major Reed, ordered me to go there and
investigate. A man had died, supposedly from malaria, just
before my arrival on the afternoon of July 19. The autopsy
which I performed at once showed me that yellow fever had been
the cause of his death, and a search through the military
hospital wards revealed the existence of several unrecognized
cases being treated as malaria; a consultation held with the
medical officer in charge showed me his absolute incapacity, as
he was under the influence of opium most of the time (he
committed suicide several months afterwards), and so I
telegraphed the condition of things to headquarters; in answer
I received the following:
CHIEF SURGEON'S OFFICE,
HDQRS. DEPT. HAVANA AND PINAR DEL RIO,
QUEMADOS, CUBA, July 20, 1900
SURGEON AGRAMONTE,
Pinar del Rio Barracks,
Pinar del Rio, Cuba
Report received last night. My thanks are due for your prompt
action and confirmation of my suspicions.
STARK,
Chief Surgeon
Conditions in the hospital were such as to demand immediate
action; the commander of the post refused to believe he had
yellow fever among his 900 men and was loath to abandon his
comfortable quarters for the tent life in the woods that I
earnestly recommended. In answer to my telegram asking for
official support, I received the following:
CHIEF SURGEON'S OFFICE,
HDQRS. DEPT. HAVANA AND PINAR DEL RIO,
QUEMADOS, CUBA, July 21, 1900
SURGEON AGRAMONTE,
Pillar del Rio Barracks,
Pinar del Rio, Cuba
Take charge of cases. Reed goes on morning train. Wire for
anything wanted. Nurses will be sent. Instructions wired
commanding officer. Other doctors should not attend cases.
Establish strict quarantine at hospital. You will be relieved
as soon as an immune can be sent to replace you. Report daily
by wire. STARK,
Chief Surgeon
When Major Reed came to Pinar del Rio (July 21) I had, the day
before, established a separate yellow-fever hospital, under
tents, attended by some of the men who had already passed an
attack and were thus immune. The Major and I went over the
ground very carefully, we studied the sick report for two
months back, fruitlessly trying to place the blame upon the
first case. I well remember how, as we stood in the men's
sleeping quarters, surrounded by a hundred beds, from several
of which fatal cases had been removed, we were struck by the
fact that the later occupants had not developed the disease. In
connection with this, and particularly interesting, was the
case of a soldier prisoner who had been confined to the
guard-house since June 6; he showed the first symptoms of
yellow fever on the twelfth and died on the eighteenth; none of
the other eight prisoners in the same cell caught the
infection, though one of them continued to sleep in the same
bunk previously occupied by his dead comrade. More than this;
the three men who handled the clothing and washed the linen of
those who had died during the last month were still in perfect
health. Here we seemed to be in the presence of the same
phenomenon remarked by Captain Stone in reference to his case
at Santa Clara, and before that by several investigators of
yellow fever epidemics; the infection at a distance, the
harmless condition of bedding and clothing of the sick; the
possibility that some insect might be concerned in spreading
the disease deeply impressed us and Major Reed mentions the
circumstance in his later writings. This was really the first
time that the mosquito transmission theory was seriously
considered by members of the board, and it was decided that,
although discredited by the repeated failure of its most ardent
supporter, Dr. Carlos J. Finlay, of Havana, to demonstrate it,
the matter should be taken up by the board and thoroughly
sifted.