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Cholera.-A very extensive epidemic of cholera ravaged Japan in the fall of 1916, and assumed such proportions that bacteriological examination for cholera carriers was enforced at the Pacific coast and the insular quarantine stations against passengers from the At Port Townsend, San Francisco, Honolulu, and Manila 13,327 bacteriological examinations were performed. Át Manila 21 carriers were discovered among those examined and were denied passage.

A disease in epidemic proportions clinically simulating cholera was reported as prevalent in eastern Mexico and on the Isthmus of Tehuantepec. Investigation by service officers made it apparent, however, that the suspected cases were the algid form of malarial infection.

Although cholera was reported as present in several of the belligerent countries of continental Europe, it did not actively menace trans-Atlantic commerce, chiefly because of the restricted maritime traffic with the infected countries.

Plague.-Plague was reported as present in every section of the globe. The infection continues to prevail in epidemic form on the west coast of South America, particularly in the city of Guayaquil. In Brazil plague was reported in several widely separated States of that Republic. Reports were likewise received of its prevalence in South Africa, Egypt, and various ports on the Mediterranean, India, the entire China coast, Japan, and the Malay Archipelago.

Rodent plague from time to time was reported at Liverpool, London, Hull, and Bristol. Apparently at these English ports the infection never effected a secure hold, and probably the infection reported was introduced from vessels from the Orient. On several occasions plague, both in man and in rodents, was reported in ships en route from India to European ports.

Plague infection was reported during the year from the island of Hawaii, and probably was an exacerbation from a residual focus. Rodent plague was discovered as the result of the fumigation of a vessel at New Orleans quarantine. The source of the infection remains a matter of speculation, since within the preceding 12 months the vessel had not been to any known plague-infected port, but had plied between ports of the United States, more particularly New York and the continental ports of Europe and England.

To prevent the introduction of the infection into the United States all vessels from plague-infected ports were fumigated for the destruction of rodents. At Hongkong rodent infection was demonstrated on a vessel about to sail for an American port. The vessel was fumigated under the supervision of the service officer on duty in the American consulate at Hongkong. As a result two infected rats were found among those destroyed. The referred-to vessel, however, had not had any infection amongst the personnel. Rodent plague prevails so extensively and so insidiously that with the world-wide journeying of cargo carriers it is almost impossible to decide what ships have been exposed to the infection. The only solution of this problem appears to be a periodic fumigation of all vessels from foreign ports for the purpose of making them as nearly rat free as possible.

Yellow fever.-Yellow-fever infection was reported during the year from Mexico, Guayaquil, and the west coast of South America,

from Brazil, and from Barbados and Martinique, in the West Indies. The disease reported as yellow fever in Barbados was subsequently determined by Asst. Surg. Gen. H. R. Carter and Dr. Juan Guiteras, after an investigation, to be some other infection. The endemicity of yellow fever in Maracaibo, Venezuela, still continues to be a moot question, mild cases being reported from time to time by the local profession. Acting Asst. Surg. Stewart reports from La Guaira that while the form of fever in Maracaibo is more or less atypical and mild, the general trend of medical opinion, nevertheless, both at Maracaibo and Caracas, is that occasional cases of yellow fever do occur at Maracaibo and in the vicinity.

Two cases of yellow fever were discovered in the fall of 1916 on a ship from Progreso. The vessel was detained by the quarantine officer at New Orleans quarantine station. The ship was appropriately treated and, no other cases developing, was released after six days' detention.

Yellow fever was reported in epidemic proportions from the Provinces of Yucatan and Campeche during the summer of 1916 and in June, 1917, the infection was again reported in Yucatan, the first case being in the person of a nonimmune from Mexico City. This circumstance merely emphasizes the endemicity of yellow-fever infection in the Province of Yucatan.

A severe epidemic of unknown infection but suspiciously like yellow fever was reported as prevalent in Tampico, Vera Cruz, and the Isthmus of Tehuantepec during September and October, 1916. In Tampico, with an estimated population of 45,000 persons, there were in the month of September some 616 deaths, or an annual death rate for that period exceeding 160 per 1,000. The State of Nuevo Leon, Mexico, instituted quarantine measures against persons coming from Tampico on the assumption that the epidemic in Tampico was yellow fever. Investigation by service officers, Surgs. Guiteras and Francis and Passed Asst. Surg. Ridlon, and also a representative of the Cuban sanitation department, demonstrated that the chief cause of the high mortality rate was malarial fever, both the pernicious and benign form. There were many cases of the algide and hemorrhagic malarial type of infection, which, accompanied by dysenteric infection and the lowered vitality of the poorer class, inability to secure proper medication and even sufficient nourishment, caused a very high death rate. Passed Asst. Surg. Ridlon reported that in a personnel of 180 men on the U. S. S. Nashville, lying in the Panuco River off Tampico, 122 had been down with malaria, the cases, however, being reported by the ship's surgeon as the benign type of the infection. The anopheles albimanus seems to have been the chief malarial carrier in the vicinity of Tampico. Yellow fever was excluded as a factor in the morbidity of Tampico and Vera Cruz, but considering the endemicity of the infection in Yucatan and Campeche there is grave apprehension that the disease may at any time be imported to Vera Cruz and Tampico, at both of which places conditions are most favorable for an epidemic once the infection is introduced.

"Acting Asst. Surg. Gimler stationed at Progreso reported the occurrence of 31 cases in Progreso and Merida during the summer of 1916. It is thought, however, that the disease was probably more

extensively present in those Provinces than the cases actually reported would indicate.

Smallpox.-Smallpox continued to be prevalent at most of the world ports having commercial relations with the United States, but the chief source of concern in this connection was the prevention of the introduction of the infection from Mexico, in which country the disease prevails very extensively, and is of a specially malignant type of infection. Vaccination was performed at the various border quarantine stations against all persons coming from Mexico who did not present evidence of immunity, either through a recent attack or recent successful vaccination. This practice of vaccinating incoming travelers was also extended where necessary to the purely local traffic. At the various national quarantine stations on the Texas-Mexican border there were vaccinated 110,073 persons.

Typhus fever.-While typhus continued to be reported from the various European countries in particular, its prevalence in Mexico constituted the chief menace of the introduction of the disease into the United States. It is especially to be noted that in carrying out preventive measures along the border Inspector David M. White, contracted the infection and died. Dr. W. C. Kluttz, city health officer at El Paso, likewise contracted the infection in the line of duty with a fatal issue. The chief measures taken to prevent the introduction of typhus infection on the border are described under the heading "Quarantine Operations Along the Mexican Border."

QUARANTINE OPERATIONS ALONG THE MEXICAN BORDER..

Typhus fever continued to be as serious a menace along the Mexican border during the fiscal year 1917 as it was in the preceding year. No official reports were received from Mexican officials, either local or federal, as to the prevalence of this disease, but from authoritative sources and statements in various Mexican papers, it was evident that typhus prevailed in Mexico on an unprecedented scale, thousands dying of the disease. These reports indicated that the morbidity and mortality of typhus in Mexico during the fiscal year 1917 were greater than in the preceding year. In the city of Zacatecas, capital of that Province, the local aid society reported 2,000 deaths from typhus in the four months preceding September, 1917, the population of that city being approximately 60,000.

Increased facilities for the application of effective preventive measures were secured, however, at the various ports of entry along the Texas-Mexican border in the way of adequately equipped buildings for disinfection purposes under the control of the service. The policy of the service, as in the previous year, contemplated only the treatment of incoming travelers for the purpose of rendering them and their personal effects vermin free. No attempt was made to establish a 12 days' detention for the detection of cases in the incubative period on account of practical reasons set forth in the annual report of last year. In brief, the treatment at the border quarantine stations accorded to travelers from Mexico who were considered as likely to be vermin infested was as follows:

The men and women were separated, males entering one side of the building, women and small children on the other. In suitable rooms

all clothing was removed, made into a bundle, and put through an opening in the wall into the central portion of the building, where steam disinfection was accomplished. Shoes, hats, belts, and other articles which might be injured by steam were placed in a large laundry basket, and when necessary were exposed to hydrocyanic-acid gas in a specially designed chamber. A small waterproof bag was given to all persons, so that they could place therein their money or valuables and retain them in their possession. After the clothing had been removed and passed into the disinfecting room the nude person was next inspected by a male or female attendant, as the case required, for vermin infestation. If head lice were found the hair of the men and boys was clipped, the hair dropped on newspaper, and this burned. The heads of women infested with head lice were treated with a mixture of equal parts of kerosene and vinegar, applied to the hair for one-half hour. The dilute acetic acid loosens the eggs from the hair, and the kerosene kills or stupefies the adult lice, which are thereafter removed by washing the head and hair with warm water and soap. After this treatment liquid soap is sprayed upon the body from an elevated reservoir, and the person passed on to the shower baths. The soap container is a 5-gallon can with a spout in the bottom to which a rubber tube is attached, the method of handling being similar to that of a fountain syringe with clip attached. The soap is made by boiling 1 part of soap chips in 4 parts of water and then adding 2 parts of kerosene oil. When used, 1 part of this product is added to 4 parts of warm water, this making a good liquid soap at a small cost.

The bathing process is supervised by attendants, and the persons treated thereafter pass into a rear room in which clothing is received through an opening in the wall, after having been disinfected by steam. In the disinfection room bundles of clothing are placed in a steam chamber. When the chamber is full a vacuum of 10 to 15 inches is made, and thereafter steam is introduced until the pressure gauge shows 20 pounds, the temperature being 259° F. The exposure is maintained for 10 minutes, after which a second vacuum is created for the purpose of drying the clothes. The entire procedure requires from 25 to 35 minutes, and although lice are killed by a very short exposure to 212° F., the higher temperature is easily attained and held to insure efficiency. The operator generally controls the maintenance of temperature by wrapping a thermometer in bundles of clothing placed in different parts of the loaded chamber at the top, bottom, and middle and thus secures a fairly satisfactory determination of the efficiency of the sterilization. The water for the shower baths in the plants along the border is heated as the weather may require, some of the stations using coal-burning and others oilburning heaters. The various plants have attached a cyanide-gas room for disinfection of personal effects and baggage when necessary. Sole reliance has been placed on rendering incoming travelers free of lice and excluding those obviously ill. Encouragement and assistance are extended to State and local authorities toward improving the sanitation of those communities in the Southwest where exist Mexican colonies or camps of Mexican laborers. Generally speaking, the living conditions in those quarters differ but little, if at all, from those which obtain in the same class living in Mexico-overcrowded,

indifferent to personal hygiene, and badly vermin infested. A very notable improvement was achieved, especially in El Paso and in the mining and railroad construction camps scattered throughout the Southwest. This latter was accomplished chiefly through the_cooperation of the medical departments of the several railroads. The effectiveness of the service plants, as exemplified by that at El Paso, was attested by Dr. J. G. Cumming, director of the State Bureau of Communicable Diseases of the State of California, who in his report of an inspection of various communities in the State reported:

*

When in view of these control measures instituted at the border of the United States by the Public Health Service the advisability of modifying or abolishing the special regulations (State) was suggested, it became necessary to determine whether or not they had served their purpose, that of minimizing louse infestation * * The construction camps were inspected, and the remarkable cleanliness of some very recent arrivals therein contrasted with those imported prior to January, 1917, and evidenced the value of the efficient delousing work done on the border by the United States Public Health Service. In October, 1916, there was louse infestation to the extent of 35 per cent for body lice and 60 per cent for head lice, while the March 1st inspection showed no body lice and only 1 per cent head lice.

These observations refer to Mexican laborers imported for railroad work.

Altogether there were reported from California, Colorado, and American communities located on the Texas border some 122 cases. It is probable that there were isolated cases at these points which were not reported.

Of the 122 cases, it is estimated that 69 were in the incubative period at the time they entered the United States from Mexico; the symptoms developed thereafter at intervals varying from 24 hours to 18 or 20 days, Thirty-three cases contracted infection from foci established on United States territory, 7 contracted infection from contact with infected cases, no focus being established, and in 8 cases the source of the infection was not determined, either through death of the case before data could be secured, or else because cases had been exposed to infection both in Mexico and in the United States.

As to sex incidence, there were 32 females and 85 males, 5 cases not being reported as to sex. Any conclusion as to sex incidence might be misleading, as most of the ceses were in a migrating class, and were for the most part men going to the United States for the purpose of securing construction work on railroads, farms, or mines. As to race incidence, there were 110 Mexicans, 10 Americans, and 2 Europeans. Here again deductions are difficult because we are not dealing with a fixed population. If two Americans connected with the sanitary force be excluded it can be stated that the typhus cases of El Paso origin were almost all Mexicans. Race mortality shows but little variation, that of American cases being 40 per cent and that of Mexicans being 39 per cent. Sex mortality likewise shows a negligible variation, the death rate among women being 39 per cent and that of men 37 per cent.

As to age incidence, there were 11 cases of 12 years or under and 109 cases over 12 years, the ages of 2 not being given. As to age mortality, in a series of 90 whose age and results were both recorded that of the group of 30 years or younger was 21 per cent, and that of the group of 31 years or over was 60 per cent. Apparently the mortality of typhus increases with the age of the patient.

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