University of Virginia Library

20. CHAPTER XX

On May 23rd, the same day that the Surgeon General put in
his request for the formation of the yellow fever board, Dr. Lazear
was called to 20 General Lee Street, Quemados.

“He's been complaining of headache all day, doctor,” Mrs.
Sherwood told him.

“We'll take a good look at him and see what the trouble
is,” Lazear said reassuringly.

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Sherwood was a stout, short, strong-looking man who worked
in Havana. His head ached, he said, and he felt howt all over -
he supposed he'd picked up a cold someplace. Lazear examined him,
carefully, found his temperature was over a hundred degrees, and
took a sample of his blood to examine in his laboratory. A mos-
quito, buzzing viciously in the doctor's ear, made him shake his
head vigorously.

“They don't give a man any peace,” Sherwood complained.
“They get to be an awful pest about this time of year.”

“I'll catch a few of these fellows,” Lazear remarked, “and
take them along with me. They're wonderful things under a micro-
scope.” He rose and clapped the open end of a test tube over one
sitting on the wall, tapped till it flew down into it, and corked it.

Sherwood was not greatly interested. “Do you think I can
get back to work tomorrow, doctor? I'm soo busy to be sick.” He
smiled feebly at his pleasantry.

“No!” Lazear's tone was positive. “You must stay in bed -
no moving around whatever, and nothing at all to eat. Just plenty
of cold water. I'll be out and see you again in the morning.”

Back in his laboratory, he took off his uniform coat, lay-
ing it on the table with special care for the five mosquitoes, cap-
tive in test tubes, that he had brought from Sherwood's room.
Quickly preparing a blood smear, he put the slide under the micro-
scope and examined it searchingly. His handsome, bearded face be-
came grave: there were no malaria parasites in it.

“But there's a chance it isn't yellow fever,” he muttered
out loud. “The Widal test may show typhoid.”

The Widal, too, was negative. In the morning Sherwood
ached all over and his temperature was higher. Lazear had him
moved to the isolation ward of the post hospital. Yellow fever
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was loose again.

The plague picked its vicitms with its usual eccentricity.
From 20 General Lee Street it hopped around the corener to 102 Cal-
zada Real, where no one from Sherwood's house had entered or was
even acquainted. Then it struck again in General Lee Street,
skipping, in its passage, over a house inhabited by two non-immunes.
A few days later it came back to attack them. It progressed in er-
ratic jumps through the clean, pleasant little suburban town.
Sherwood died, more people got sick. The officers of his mess com-
plained to General Lee that Kean shouldn't be allowed to visit yel-
low fever cases -he might bring it back and distribute it among
them. Kean, ordered to keep away from the fever, obeyed -and came
down with it himself on the 21st of June.

Havana was having an epidemic too, and the officers of Gen-
eral Lee Wood's staff were falling before it like bowling pins. In
the officers' mess they drank their red wine, supposed to have a
preventive effect, with the grim toast, “ThHere's to the ones who
have gone. Here's to nethe next one to go.” People were getting fright-
ened. Rigorous sanitary measure, carried out with all the thorough-
ness of which Major William Crawford Gorgas, the Havana sanitary
officer, was capable, failed to check the pest. It's rapid spread
made mock of the health officers.

Lazear and Agramonte were kept busy examining blood,
and mmaterial from autopsies. Lazear, in addition, studied his mos-
quitoes in the minutest detail, and found nothing. He did not dis-
cuss this phase of his work with anyone, but he persisted in it.
The authorities could ridicule the mosquito theory all they wanted
to -he had a hunch there was something in it.

* * *

Reed and Carroll landed on the morning of June 25th in
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Havana harbor. Carroll had never been in Cuba before, and Reed as
they rode through pointed out the sights to him -the long, low
Governor's Palace where General Wood now had his headquarters, the
nearby cathedral which had once held the bones of Columbus, the
forts, the leper hospital and the parks. The massive architecture
of the buildings; the flat, tiled roofs; the ornate balconies and
facades; the narrow streets; the shrubs and palm trees; the heat
and the brilliance of the tropical coloring -all made Carroll
feel as if he were in another world. But the doherty wagon and the
lively mules, switching their tails impatiently at the flies, those
belonged to the familiar, unchanging world of the United States
Army.

The wagon turned off the Calzada Real into the road to the
hospital grounds and drew up in front of the officers' quarters.
The porch was crowded with doctors waiting to welcome them. Cap-
tain Alexander Stark, the chief surgeon of the post, Agramonte, La-
zear, Truby, Pinto and Ames gathered enthusiastically around Reed.
Carroll, lingering at the edge of the group, watched Reed's re-
ception with almost personal pride, until Reed, taking him by the
arm, introduced him to the men he did not already know. Glancing
around as though looking for someone, Reed finally asked,

“Where's Kean? Busy?”

“Major Kean's got it, sir,” Ames told him. “Yellow jack.”

“No! How is he?”

“Not bad. Would you like to see him? He's been looking
forward to your coming. It would do him no end of good.”

“By all means, doctor. Right away, if you please.”

Roger Post Ames, a contract doctor who was unusually suc-
cessful in the treatment of yellow fever, always attended the
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cases that occurred in the camp. He and Reed walked through the
hospital grounds and across the foot bridge over the railroad cut
to the group of small buildings composing the isolation ward.

Reed was startled by Kean's yellow and shrunken appearance.
He stayed with him only a few minutes, long enough to twit him
affectionately about taking the trouble to demonstrate in person
the first case of yellow fever he, Reed, had ever seen.

“Has he had a very severe attack, doctor?” Reed asked Ames
when they left. “I'm not able to judge, never having seen it before.”

“It was bad enough to worry us,” Ames admitted. “Some
bleeding from the gums, but he's over the worst now. He's going
to be all right.”

“Thank heaven! You've cheated yellow jack; notw it's up to
us to eliminate him.”

The same afternoon, June 25th, the Yellow Fever Commission,
as it came to be known, met for the first time as a body on the
veranda of the bachelor officers' quarters. The wind swept in cool
from the sea, and they could look across the grounds to the frame
shacks, picked out clearly in the brilliant tropical light, in
which Kean and other yellow fever victims were lying.

It was a serious meeting, but it is hardly likely that any
of the doctors realized that it was a historic one. Their first
decision was undramatic. They agreed to start by looking for the
germ of yellow fever; then they would try to discover how it got
from person to person. First they would work again on bacillus-Rom
Rom/-icteroides, to check their previous conclusions about it. Agra-
monte would continue to work in his laboratory at Military Hospital
Number One in Havana, and the rest of them would work at Lazear's
laboratory on the post hospital grounds.

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“I think we're going to solve it, gentlemen,” Reed told them
confidently. “Everything is in our favor: we're well equipped,
well trained and a congenial working unit. And our accomplish-
ments whatever they may be, will be the result of cooperative ef-
fort; the credit for them will belong to the entire board.”

* * *

The epidemic was rampant both in both Quemados and Havana.
Reed and Carroll, who had never before seen yellow fever cases, had
a full opportunity to study them at the Camp Columbia hospital and
at Las Animas, the Havana hospital under the direction of Dr. Juan
Guiteras, an authority on tropical diseases.

So completely had the experience of the first half of the
century been forgotten, that Reed learned with surprise, for the
first time, that non-immune nurses who came in closest contact
with patients in all stages of the disease seemed to be in
no more danger of catching it than anybody else. It made him won-
der if fomites were as dangerous as they were generally thought to be.

Concentrating on its efforts to find bacillus icteroides, the
board examined the blood of eighteen people sick with yellow fever
in every phase of its progress. No bacillus icteroides. As the
epidemic progressed, more people died. The board autopsied
eleven cases, and examined the organs with the utmost care. Still
no icteroides.

Rom
Rom/

Lazear was not greatly interested in the search for Sanar-
elli's germ. He had found an exciting new clue that supported the
mosquito theory. It was in a paper by Dr. Henry R. Carter, of the
Marine Hospital Service, who was then stationed in Cuba. Dr. Carter,
during a recent yellow fever epidemic in Mississippi, had observed
that it took two or three weeks for the first case of yellow fever
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in a community to produce the next case. After that, non-immunes
would fall victim within one week of visiting the infected region.
The thing that struck Lazear was the two or three weeks that elapsed
between the initial case, and the first one to develop from it.
Apparently during this period the original case was powerless to
spread the infection. His suspicion was strengthened that an in-
sect might be involved in the spread of yellow fever, an insect
called, in scientific terms, an intermediate host.

Knowledge that insects were the intermediate hosts of cer-
tain disease germs was twenty years old. In 1880 Dr. Patrick Man-
son had established that a certain kind of mosquito spread elephan-
tiasis. First it fed on the blood of a person with the disease,
taking the germs into its own body, where they developed for a time
then it deposited them in the blood stream of a well person by bit-
ing him, thus giving him the matured germs -and the disease. Thir-
teen years later Dr. Theobald Smith of the Department
of Agriculture's Bureau of Animal Industry had demonstrated how a
particular kind of tick, by a like process, spread Texas cattle
fever. In 1898 Dr. Ronald Ross had shown how the anopheles mosqui-
to similarly spreads malaria. In each of these three cases the in-
sect host, even after biting the sick individual, remained harmless
for a definite length of time, while the germs it had swallowed
ripened, so to speak, inside it. Only when the germs reached a
certain stage of development could the insect convey the in-
fection by its bite.

The insect host theory, Lazear realized, might account for
the time that elapsed between the first yellow fever case in a com-
munity, and the next: maybe the mosquito bit the first case, re-
mained harmless for a couple of weeks while the germs it had swal-
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lowed ripened, and, once they were ripe, gave the pest to everyone
it bit. It was just a guess, just a possibility, but what an ex-
citing one!'

He told Reed about Carter's paper and the train of thought
it had suggested to him. Frowning with interest, the older man
listened attentively.

“That does seem to lend color to your favorite theory, La-
zear,” he admitted. “But if an insect host spreads yellow jack,
then fomites probably don't -and that fomites do spread it is the
one thing that practically every expert agrees on.”

“Everybody agreed that contaminated water was the only cause
of typhoid, sir,” Lazear pointed out, “until your board proved
otherwise.”

“You're right, of course,” Reed agreed. “Popular beliefs
aren't necessarily Gospel, even when they're held by scientific
men. I'll have a talk with Carter.”

Hadn't
Carter
left Cuba?

Reed was a good scientist, a man who could change his mind
when he had reasons. His talk with Carter was one reason. Then
something happened which provided another.

There had been an extraordinary increase in sickness among
the soldiers stationed at Pinar del Rio, the capital of the west-
ernmost privince of Cuba. The death rate from “pernicious malar-
ia,” as the doctor in charge called it, was remarkably high. Sus-
piciously high, it seemed to Captain Stark, acting as chief sur-
geon of the district now that Kean had gone home to recuperate.
After consulting Reed, Startk ordered Agramonte to Pinar del Rio
to investigate.

Traveling by the narrow gauge railroad across the tropical
interior of the island, Agramonte arrived on July 19th and im-
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mediately did an autopsy on a “malaria” victim who had just died.
Stark's suspicions were woefully confirmed. The “malaria” was
yellow fever. The post medical officer was hopelessly incom-
petent, and the Commanding Officer refused to believe that he had
yellow jack at his camp. Agramonte, a contract doctor without
authority, wired Stark for official support, and Stark promptly
saw to it that he had full authority to enforce precautions. By
the time Reed arrived on the 21st, Agramonte had established a tent
hospital for yellow fever and put it under quarantine.

The two doctors together questioned everyone who might
throw light on the source of the epidemic and examined the sick
reports for two months back in an effort to identify the first
cases. There had been thirty-five, altogether, with eleven
deaths, and the original infection had apparently come from the
town of Pinar del Rio.

“Now here's the interesting thing,” Reed pointed out to
his colleague as they sat in their tent working over the records,
“none of the usual precautions of disinfecting bedding and clothes
were taken here, since yellow fever wasn't suspected. Yet you'll
notice that the nurses, and the other patients in the wards, and
the three men who do the hospital laundry all escaped infection.
Some of them, at least, must have been exposed to fomites.”

“That, of course, confirms what we've already observed
in Havana and Camp Columbia. It's certainly mystifying.” Agra-
monte, puzzled, twisted the upturned end of his long mustache
and ran an agitated hand through his dark pompadour. “And then
the guardhouse case, too.”

“That one, I think,” Reed spoke slowly and carefully,
“presents our problem very nicely. Here we have a soldier,” he
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placed a penny on the table, “under close guard for six days with
eight other men.” He arranged eight coins around the penny and
traced an imaginary line around them with his finger. “Neither
he, nor any of them, has been in contact with a case of yellow
fever, or with fomites. Our soldier, and he alone, gets yellow
jack; he dies, poor fellow,” Reed flipped the penny back in his
pocket, “after six more days, and his eight cell mates remain in
perfect health. Now, how did the infection get to this one man,
and how did it happen to spare the rest?”

Agramonte sighed. “It looks as if yellow jack just flew
in the window and tagged him, and flew out again,” he said, discouraged.

“Maybe that's what it did do, doctor,” Reed said thought-
fully, “and maybe a mosquito brought it. Dr. Finlay's theory looks
much less incredible to me today than it did a month ago. We must
see him as soon as we return to Havana.”

On August first, 1st, shortly after the return of Reed and
Agramonte from Pinar del Rio, the board again met on the veranda
of the officers' quarters. Reed described the epidemic they had
just investigated, and told them in full detail of their obser-
vations.

“Now, gentlemen,” he concluded, “we've seen that nurses
and others who come in close contact with fomites are no more like-
ly than anybody else to get yellow jack; and in this guard house
case we've seen that a man who had no contact at all with fomites
somehow picked up a fatal case. These facts suggest that fomites
probably don't spread the fever, and that something else does.
What?” He smiled at Lazear, who was listening eagerly. “Our best
bet, I think, it a mosquito. Dr. Carter's paper suggests an in-
sect host: and all the circumstances surrounding an epidemic -
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low, moist location, warm weather, the way the disease skips around -
suggest that the mosquito may be the carrier. It seems to me now
that we should tackle our problem from a new angle -try to find
out how the germ is spread, rather than what it is. We must prove,
or disprove, an insect host.”

“And to do that,” Lazear interposed quietly, “we will
have to experiment on human beings, as you and the Surgeon General
foresaw. Unless, Agramonte......?” he ended on a question.

Agramonte shook his head. “No. I've been trying them
all -guinea pigs, dogs, cats, rats, even a rhesus monkey I got in
town. I can't infect any of them. My results are all negative,
just like General Sternberg's. I think yellow jack likes only
human beings.”

“So it appears,” Reed agreed. “No one has ever succeeded
in giving it to a laboratory animal. I don't have to point out to
you the dreadful responsibility we all assume in experimenting with
men's lives,” he went on.
“If we lose any cases we'll be ruined, branded as murderers. But
if we find out how yellow fever is spread, the benefit we'll con-
fer on humanity will make the risk, grave as it is, seem trivial.
Hundreds, sometimes thousands, of lives are lost every year, and
a huge amount of valuable property is destroyed. By risking a
dozen lives we may be able to put a stop to that forever. Do you
think we can take such a chance to gain such an end?”

“I don't see how there can be any question about it,” Car-
roll said. “I think, though, that the board members must take
the first risk. We can't expect other men to do it if we don't.
Agramonte, you're immune, I suppose?”

Agramonte sghrugged. “Perhaps. I don't know. Many Cubans
225.

are, from unrecognized light cases in childhood. I wasn't much
more than a baby when we went to the United States, so it's poss-
ible that I've never had it.”

“In any case,” Reed asked them, “we're all agreed to make
the first experiments on ourselves?”

The agreement was unanimous. Carroll smiled.

“Somehow, Major,” he said to Reed, “I can't feel very alarmed
at the prospect. It's going to take a lot of proof to convince
me that fomites aren't responsible. Even the Surgeon General's sure
of it.”

“We'll see,” Lazear grinned happily. He was delighted at
the new turn in the work.

In the end they agreed that and Reed should supervise all
the work; Lazear, because of his experience with malarial mosqui-
toes, should do all the mosquito work; Carroll should continue
the earlier line of bacteriological investigation; and Agramonte,
whose time was already filled by his duties at the Military Hos-
pital in Havana, should do autopsies and pathological study. The
first move would be to call on Finlay and ask him about the mos-
quito.

* * *

Dr. Carlos Finlay, trying to prove that mosquitoes carried
yellow fever, had made about a hundred experimental efforts to in-
oculate human beings. His results had been unconvincing, since he
had not guarded the subjects of his experiments against other
sources of infection. Only his wife and his assistant, Dr. Claudio
Delgado, believed in his theory. Yet, although he had not sup-
ported it by convincing demonstration, he had good reasons, based
on the observation of many epidemics, for holding it. It explained
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the frequently marked remarked presence of mosquitoes during an
epidemic; the fact that the epidemic, along with the mosquitoes,
disappeared with the first cool weather; that the disease existed
only near water and in warm weather; that it moved jumpily, often
skipping over houses occupied by non-immunes and attacking people
who had had no contact with the sick or with fomites; that no
sanitary measures had ever been able to arrest it; and that the
high and breezy sections of a city were not subject to it, even
though it might be flourishing along the waterfront.

Finlay had been a middle-aged man when he first advanced
his theory. Now he was sixty-seven, with white side whiskers and
a benevolent face. The son of a French mother and a Scottish
father, he had been born in Cuba, and educated in France, England,
Havana and the United States. As a medical student at Jefferson
College in Philadelphia, he had made a friend of S. Weir Mitchell,
a distinguished doctor noted also as a writer of historical novels.
All through his life he had many friends among the top rank men
of the medical profession doctors in the United States. Although everyone
smiled at his theory, the smile was kindly: his personality was
gentle and endearing, and his professional standing was high.

The board members found the elderly Cuban doctor in the
study of his pleasant home in suburban Vedado. When he heard that
they proposed to test his beloved theory, all the more cherished
for the ridicule it had always drawn, his kindly face lighted
with pleasure.

“I am perfectly sure, gentlemen,” Finlay told them, and
in his delight and earnestness his slight stammer became a shade
more pronounced, “that you will end by convincing yourselves. If
only you can also convince the rest of the profession, and the
world!”

227.

“It's your opinion, isn't it, Dr. Finlay,” Reed asked,
“that only one type of mosquito spreads the malady?”

“Yes. The female of Culex fasciatus. Fasciatus and pungens
are the common mosquitoes down here, and pungens is harmless -in
yellow fever, anyway. Our villainess is an interesting little crea-
ture, with distinctive habits. She's a day timedaytime mosquito and does
not bite after dark. The male doesn't suck blood at all, and the
female does it only after mating -she has to have a meal of blood
before she can lays her eggs. I have some here.” He took a bowl, part-
ly full of water, from the window sill and set it on the table
before them. Leaning over it, the doctors saw a number of tiny,
jet black cylinders clinging to the side of the bowl where e-
vaporation of the water had left them stranded. “If you look at
them under a microscope,” Finlay went on, “you'll see that their
surface is made up of fairly regular six-sided plates, each with
a little round bump in its center.”

Lazear picked one of the tiny eggs up and rolled it between
his fingers thoughtfully.

“Where do they breed, doctor?”

“Oh, rainbarrels, the pan of water you put on the porch for
the dog, a sagging gutter, a vase of flowers that's been standing
in your parlor -any container holding stagnant water.”

“Then she's not a roughneck like anopheles? She's more a
domestic mosquito, and you don't find her in swamps and woods?”

Finlay beamed. “That's right. She's a fragile, domestic
little thing. She sticks close to the house. Her wings are deli-
cate, and she can't stand wind. She's rather striking looking, too,
handsomely striped across the back and legs. You've undoubtedly
noticed plenty of them.”

They all nodded ruefully. It was impossible not to notice
228.

mosquitoes in Cuba unless you were armor-plated.

Finlay was absorbed in his subject, and thrilled to meet,
after almost twenty years, serious attention instead of good-
natured skepticism. He explained how the female lays her eggs, at
night, on the surface of the water; and how the eggs, very resis-
tant to outside influences, can be hatched even after drying for
three months or freezing, when restored to proper conditions of
warmth and moisture. It took them, he told thehis attentive audience,
about three days to hatch; the larva stage lasted about a week;
and the pupa, usually called the “wiggler,” lasted to more days.
Then you had the full grown mosquito, ready to mate, bite, lay, -
and, if it had bitten a yellow fever case, to spread yellow jack.

When they left, Finlay gave them the bowl of mosquito eggs
and promised to help them in any way he could.

Reed had to smile at Lazear's elation. Carrying the little
black bowl as though it held a million dollars, he looked as if
he could hardly keep from skipping. What a dear, enthusiastic
fellow, Reed thought warmly, and what a keen man -here was one who
would make his mark in the scientific world.

“You look as though you'd swallowed the canary, Lazear,”
he teased him. “You know, there may be nothing in it at all.”

Lazear laughed. “We're on the right track, Major, and
I believe you're convinced of it yourself. Cheer up, Carroll,
we've as good as got yellow jack in our pockets already. You won't
be skeptical much longer.”

229.