The Making of Arguments

of the fact that this case occurred in the city of Havana, where yellow fever is endemic, and of the eighty-six negative results from similar inoculations, the inference seemed justified that in this case the disease was contracted in some other way than as a result of the so-called "mosquito inoculation." The thirteen cases in which only "acclimation fevers" occurred "within a term of days varying between five and twenty-five after the inoculation" appeared to me to have no value as giving support to Finlay's theory; first, because these "acclimation fevers" could not be identified as mild cases of yellow fever; second, because the ordinary method of incubation in yellow fever, is less than five days; and, third, because these individuals, having recently arrived in Havana, were liable to attacks of yellow fever, or of "acclimation fever" as a result of their residence in this city and quite independently of Dr. Finlay's mosquito inoculations. For these reasons Dr. Finlay's experiments failed to convince the medical profession generally of the truth of his theory relating to the transmission of yellow fever, and this important question remained in doubt and a subject of controversy. One party regarded the disease as personally contagious and supposed it to be communicated directly from the sick to the well, as in the case of other contagious diseases, such as smallpox, scarlet fever, etc. Opposed to this theory was the fact that in innumerable instances nonimmune persons had been known to care for yellow-fever patients as nurses, or physicians, without contracting the disease; also the fact that the epidemic extension of the disease depends upon external conditions relating to temperature, altitude, rainfall, etc. It was a well-established fact that the disease is arrested by cold weather and does not prevail in northern latitudes or at considerable altitudes. But diseases which are directly transmitted from man to man by personal contact have no such limitations. The alternate theory took account of the above-mentioned facts and assumed that the disease was indirectly transmitted from sick to well, as is the case in typhoid fever and cholera, and that its germ was capable of development external to the human body when conditions were favorable. These conditions were believed to be a certain elevation of the temperature, the presence of moisture and suitable; organic pabulum (filth) for the development of the germ. The two first-mentioned conditions were known to be essential, the third was a subject of controversy. Yellow fever epidemics do not occur in the winter months in the temperate zone and they do not occur in arid regions. As epidemics have frequently prevailed in seacoast cities known to be in an insanitary condition, it has been generally assumed that the presence of decomposing organic material is favorable for the development of an epidemic and that, like typhoid fever and cholera, yellow fever is a "filth disease." Opposed to this view, however, is the fact that epidemics have frequently occurred in localities (e.g. at military posts) where no local insanitary conditions were to be found. Moreover, there are marked differences in regard to the transmission of the recognized filth diseases—typhoid fever and cholera—and yellow fever. The first-mentioned diseases are largely propagated by means of a contaminated water supply, whereas there is no evidence that yellow fever is ever communicated in this way. Typhoid fever and cholera prevail in all parts of the world and may prevail at any season of the year, although cholera, as a rule, is a disease of the summer months. On the other hand, yellow fever has a very restricted area of prevalence and is essentially a disease of seaboard cities and of warm climates. Evidently neither of the theories referred to accounts for all of the observed facts with reference to the endemic prevalence and epidemic extension of the disease under consideration. Having for years given much thought to this subject, I became some time since impressed with the view that probably in yellow fever, as in the malarial fevers, there is an "intermediate host." I therefore suggested to Dr. Reed, president of the board appointed upon my recommendation for the study of this disease in the island of Cuba, that he should give special attention to the possibility of transmission by some insect, although the experiments of Finlay seemed to show that this insect was not a mosquito of the genus Culex, such as he had used in his inoculation experiments. I also urged that efforts should be made to ascertain definitely whether the disease can be communicated from man to man by blood inoculations. Evidently if this is the case the blood must contain the living infectious agent upon which the propagation of the disease depends, notwithstanding the fact that all attempts to demonstrate the presence of such a germ in the blood, by means of microscope and culture methods, have proved unavailing. I had previously demonstrated by repeated experiments that inoculations of yellow fever blood into lower animals—dogs, rabbits, guinea pigs—give a negative result, but this negative result might well be because these animals were not susceptible to the disease and could not be accepted as showing that the germ of yellow fever was not present in the blood. A single inoculation experiment on man had been made in my presence in the city of Vera Cruz, in 1887, by Dr. Daniel Ruiz, who was in charge of the civil hospital in that city. But this experiment was inconclusive for the reason that the patient from whom the blood was obtained was in the eighth day of the disease, and it was quite possible that the specific germ might have been present at an earlier period and that after a certain number of days the natural resources of the body are sufficient to effect its destruction, or in some way to cause its disappearance from the circulation. This was the status of the question of yellow fever etiology when Dr. Reed and his associates commenced their investigations in Cuba during the summer of 1900. In a "Preliminary Note," read at the meeting of the American Public Health Association, October 22, 1900, the board gave a report of three cases of yellow fever which they believed to be direct results of mosquito inoculations. Two of these were members of the board, viz., Dr. Jesse W. Lazear and Dr. James Carroll, who voluntarily submitted themselves to the experiment. Dr. Carroll suffered a severe attack of the disease and recovered, but Dr. Lazear fell a victim to his enthusiasm and died in the cause of science and humanity. His death occurred on September 25, after an illness of six days' duration. About the same time nine other individuals who volunteered for the experiment were bitten by infected mosquitoes—i.e. by mosquitoes which had previously been allowed to fill themselves with blood from yellow fever cases—and in these cases the result was negative. In considering the experimental evidence thus far obtained, the attention of the members of the board was attracted by the fact that in the nine inoculations with a negative result "the time elapsing between the biting of the mosquito and the inoculation of the healthy subject varied in seven cases from two to eight days, and in the remaining two from ten to thirteen days, whereas in two of the three successful cases the mosquito had been kept for twelve days or longer." In the third case, that of Dr. Lazear, the facts are stated in the report of the board as follows: Case 3. Dr. Jesse W. Lazear, Acting Assistant Surgeon U.S. Army, a member of this board, was bitten on August 16, 1900 (Case 3, Table III) by a mosquito (Culex fasciatus), which ten days previously had been contaminated by biting a very mild case of yellow fever (fifth day). No appreciable disturbance of health followed this inoculation. On September 13, 1900 (forenoon), Dr. Lazear, while on a visit to Las Animas Hospital, and while collecting blood from yellow fever patients for study, was bitten by a Culex mosquito (variety undetermined). As Dr. Lazear had been previously bitten by a contaminated insect without after effects, he deliberately allowed this particular mosquito, which had settled on the back of his hand, to remain until it had satisfied its hunger. On the evening of September 18, five days after the bite, Dr. Lazear complained of feeling "out of sorts," and had a chill at 8 P.M. On September 19, twelve o'clock noon, his temperature was 102.4°, pulse 112; his eyes were injected and his face suffused; at 3 P.M. temperature was 103.4°, pulse 104; 6 P.M., temperature 103.8° and pulse 106; albumin appeared in the urine. Jaundice appeared on the third day. The subsequent history of this case was one of progressive and fatal yellow fever, the death of our much-lamented colleague having occurred on the evening of September 25, 1900. Evidently in this case the evidence is not satisfactory as to the fatal attack being the result of the bite by a mosquito "while on a visit to Las Animas Hospital," although Dr. Lazear himself was thoroughly convinced that this was the direct cause of his attack. The inference by Dr. Reed and his associates, from the experiments thus far made, was that yellow fever may be; transmitted by mosquitoes of the genus Culex, but that in order to convey the infection to a nonimmune individual the insect must be kept for twelve days or longer after it has filled itself with blood from a yellow fever patient in the earlier stages of the disease. In other words, that a certain period of incubation is required in the body of the insect before the germ reaches its salivary glands, and consequently before it is able to inoculate any individual with the germs of yellow fever. This inference, based upon experimental data, received support from other observations, which have been repeatedly made, with reference to the introduction and spread of yellow fever in localities favorable to its propagation. When a case is imported to one of our southern seaport cities, from Havana, Vera Cruz, or some other endemic focus of the disease, an interval of two weeks or more occurs before secondary cases are developed as a result of such importation. In the light of our present knowledge this is readily understood. A certain number of mosquitoes having filled themselves with blood from this first case after an interval of twelve days or more bite nonimmune individuals living in the vicinity, and these individuals after a brief period of incubation fall sick with the disease; being bitten by other mosquitoes they serve to transmit the disease through the "intermediate host" to still others. Thus the epidemic extends, at first slowly from house to house, then more rapidly, as by geometrical progression. It will be seen that the essential difference between the successful experiments of the board of which Dr. Reed is president and the unsuccessful experiments of Finlay consists of the length of time during which the mosquitoes were kept after filling themselves with blood from a yellow fever patient. In Finlay's experiments the interval was usually short,—from two to five or six days,—and it will be noted that in the experiments of Reed and his associates the result was invariably negative when the insect had been kept less than eight days (7 cases). Having obtained what they considered satisfactory evidence that yellow fever is transmitted by mosquitoes, Dr. Reed and his associates proceeded to extend their experiments for the purpose of establishing the fact in such a positive manner that the medical profession and the scientific world generally might be convinced of the reliability of the experimental evidence upon which their conclusions were based. These conclusions, which have been fully justified by their subsequent experiments, were stated in their "Preliminary Note" as follows: 1. Bacillus icteroides (Sanarelli) stands in no causative relation to yellow fever, but, when present, should be considered as a secondary invader in this disease. 2. The mosquito serves as the intermediate host for the parasite of yellow fever. In "An Additional Note"