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ottlte

xnniveraiti^ ot Mieconsin

of the

TKnivcrsiti? of Mieconeitt

Proceedings of

The Second Pan American

Scientific Congress

WASHINGTON, U. S. A.

Monday, Decemb^ 27, 1915
to Saturday, January 8, 1916

ad wlltod aBdw the dlwcdwi af
GIm L»Tta Swigg0tt, iiriitmf Secrtty G«Mnl

SECTION vm

(IN TWO PABT8)

PART 1
PUBUC HEALTH AND MEDICINE

WILUAM C GOBGAS, SOBOKON OBNBBAI. U. & A^ CHAIBMAN

VOL. K

WASHINGTON

GOVERNMENT PBINTING OmCB

1917

21 i903

^EC 10 i9i7

/^/4 CONTENTS.

fnST PART. pj^gg^

Letten of tiuttinittal ▼"

Foreword ^^

Executiye committee ^

Organizatioii oflBcers ^

Committees of Section VIII ^

Aims and purposes of the congress 5

Program statement of Section VIII 5

Adopted resolutions and recommendations of Section VIII &

M/tODhig wearion of December 28, 1915 t

Yellow fever and its eradication, by Gen. William C. Goigas T

S^ifermedades transmitidas por insectos en Pan AmMca, by Juan Guiteras — d'

Immunity to yellow fever, by H. R. Carter 4>

Filaiiads in the Americas, by Allen J. Smith -.. 48>

Afternoon session of December 28, 1915 77

The ei»demic of typhus ezantiiematicus in the Balkans and in tiie prison

camps of Europe, by Bert W. Caldwell 77

Present views in respect to modes and periods of infection in tuberculosis, by

llasyck P. Ravenel 86

The perasitic diseases in the American tropical countries and their effect upon the

progress of civilisation among the Latin-American people, by D&maso Rivas. 95

A review of the present yellow-fever situation, by Arlstides Agramonte 100

liceaga and yellow fever, by Maj. T. C. Lyster 106

Gttlos Finlay on the house mosquitoes of Habana, by Frederick Kuab 107

CoDsiddrations sur bt fi^vre dite "fi^vre de firuits," by C. Matiion and L.Audain. 110
La profilaxia de la fiebre tifoidea pot medio de la vacunaci6n, by Justo F.

QoosfleB 115

La bubs (Leishmanioris americana), by Luis £. Migone 117

Nota sobre a extinct completa da febre amaiella no Estado de S. Paulo

(&«flil), by Emilio Ribas 12a

La ll^vrety^de en Bolivie, by Nestor Morales Villaa6n 126^

Homing 1888100 of December 29, 1915 14^

The alcohd and drug habit and its prophylaxis, by Harvey W. Wiley 146'

Ob fumadofes de maconha; effeitos e males do vido, by Jo86 Roddgues da

Costa Doria 161

Lodia contia el alcohdismo, by Ricardo Sanniento Laspiur 1(12'

El ptoblema del alcobolismo y su posible soluci6n, by Luis L6pes de Mesa. ... 166

An inquiry into the causes of crime, by R. B. von KleinSmid 181

Ptaporism: An analysis, by Edwatd T. Devine 187

AftenuKm aeaaion of Decenaber 29, 1915 195<

Mechanical appliances in the treatment of pyotihea alveolaris, by Felipe

QaU^gos '. 195-

Beb^Higiene del embaiaso y de la primera infancia, by AtiUo Naranelo 196 -

Poffieultnra, by P. Raeda. 288

La novocaina gtfcsfo-yodada, by Juan D . Susini 285*

IV CONTENTS.

rage.
Los diapensarios para lactantes (gotas de leche), como medio para disminuir la

mortalidad infantil, by Julio A. Bauz4 242

O erro esencial de peasda na lei brazileira do casamento civil, by Jos^ Rodrigues

da Coflta Doria 247

M^todos modemos para la prevencidn de la mortalidad instil, by Artuio L.

Guerra 254

Frophylaxia do ophldumo na America, by Vital Brazil 258

2^ota sobre tratamiento de la infecci6n puerpeiml por los bafios tabios prolongados,

^ by Arfstidee Fiallo Cabral 261

A.cci6ii respiratoria del depressor cordis, by Teodoro Muhm 262

Lepra y autosangioterapia— Necesidad de una liga panamericana antileprosa,

by Luis Zanotti Cavazzoni 274

Joint sesaion of Subsection C of Section Vm and the American Aasooia-

tion for Labor Legialation 276

Child labor and public health, by Owen R. Lovejoy 276

Legal protection of female wage earners, by John B. Andrews 280

El trabajo de la mujer embarazada, by Augusto Turenne 283

Factory sanitation, by E. R. Hayhurst 288

Morning seaaion of December 80, 1915 299

The etiology and prevention of tuberculosis from the sociological points of view,

b y William Charles White 300

Tratamiento de la tuberculosis por el pneumo-t6rax artificial, by Joaquim de

Oliveira Botelho 305

Housing of wage earners, by Lawrence VeiUer 314

La influencia de la habitaci6n en la lucha contra la tuberctilosis, by Juan

Monteverde 322

La inspecci6n m^ica en las escuelas pdblicas de Centro America-— Necesidad y

X>osibilidad de establecerla en vista de las condiciones existentes en Costa

Rica, by Louis Schapiro 330

Joint session of Subsection B of Section vm and the American Sta-
tistical Association 335

The nature and significance of the dianges in the birth and death rates in recent

yeaiB, by Walter P. Willcox 336

The potential influence of vital statistics on the conservation of human life, by

W.S.Rankin 344

The relation of sickness reports to health administration, by John W. Trask. . . 347
Informes referentes a la morbosidad infecto-contagiosa-— Disposidones y pro-

cedimientos adoptados por la administmci^n sanitaria para su obtenddn, by

Julio Etchepare 352

Vital statistics in relation to Ufe insurance, by Louis I. Bublin 355

Infant mortality statistics, by Lewis Meriam 365

Cooperation by the Bureau of the Census with State authorities in securing the

enactment of adequate laws for the registration of births and deaths, by

Richard C. Lappin 374

Joint session of Subseetion D of Seotlon Vm and the American Ohrlc

Association 377

Town and dty planning, by F. L. Olmsted 377

The human side of dty planning, by J. Horace McFarland 385

The effect of land subdivision upon housing and public health, by John Nolen . 387

Rural hygiene, by J. N. Hurty 393

Joint sssslou of Subsection B of Section Vm and the American Sta^

tistical Association 400

The Federal registratbn service of the United States; its devdopment, prob-
lems, and defects, by Creesy L. Wilbur 400

CONTENTS. V

Ihe incidence of the different causes of mortality in Providence during 65 years,

1856 to 1910, by Charles V. Chapin 403

Vital statistics in cities, by \^illiain H. Guilfoy 411

Desarrollo de la estadistica demogr&fica en la Isla de Cuba, by Jorge Le-Roy y

Cassi 415

Cinco alios de demograffa uruguaya, by Joaquin de Salterain 456

The accuracy and completeness of compiled vital statistics in the United

States, by John S. Pulton 464

Afternoon sesaioii of December 80, 1015 477

Ph)phylaxis of venereal diBeases, by Edward L. Keyes, jr 477

Educaci6n sexual de los ]6venes como medio profiL&ctico de las enfermedades

ven^reas, by Alfredo P^rsico 483

Public health measures in relation to venereal diseases, by William F. Snow. . 486
International agreements in relation to the suppression of vice, by James

Bronson Reynolds 49^

Proyecto de la ordenanza reglamentaria de la prostituci6n, by Silvestre Oliva. . 518
Joint session of Subsection C of Section viii and the American Socio-
logical Association , 526

Ways and means of bringing matters of public health to social usefulness, by

Wlliam C. Woodward 526

What can unofficial effort do for public health? by Irving Fisher 529

What can unofficial effort do for public health? by Hoyt £. Dearholt 533

La medicina social y los problemas del trabajo en la Repdblica Aigentina, by

Eniique Feinmann 540

La inflnenda de la ankylostomiasis sobre la prospeiidad de la agricultura y

sobre la mortalidad in&mtil, by Louis Schapiio and Mauro Fem&ndez 587

Afternoon session of December 81, 1015 590

Medical preparedness for campaign, by Edward L. Munson 590

A contributiom to the study of artificial illumination, by James D. Gatewood. 599

Thesanitation of the Panama Canal, by D. F. Reeder 610

£1 pabell6n modelo de cllnica m^dica del Hospital Rawson, by Tom^ S. Varela 612

Climate and hygiene of Rio de Janeiro, by Joaquim de Oliveira Botelho 613

Buildings for human occupancy, by Robert W. de Forest 615

The means by iddcb. infectious diseases are transmitted and their extermina-
tion, by Alvah H. Doty 623

Joint session of Subsection C of Section viii and the American Psycho-
logical Association 628

The defective child and the prevention of feeble-mindedness, by Henry H.

Goddard 628

The training of defectives, by E. R. Johnstone 631

Youthful offenders— A comparative study of two groups each of 1,000 young

lecidivistB, by William Healy and Augusta F. Bronner 636

Mental hygiene — ^Tlie etiology and i^evention of insanity from the sociological

point of view, by William A. White 645

Educaci6n de los nifios nerviosos, by Bernardo Etchepare 651

Regimen de convalecenda en los alienados, by Santin Carlos Rossi 667

La equivalencia mental entre el hombre y la mujer, mirada del punto de vista

psU^ddgico, by A. Moiaga Porras 674

lEL ejercido muscular de la respiraci^n, sistema sueco, es fisiol6gico? by A.

Moraga Porras 688

Autofrasias mentalee, by Fernando Gorriti 696

Higiene mental en sua relaciones con el desarrollo y conservacidn de la energfa
psfquica y de la &tiga producida por la ensefianza escolar, by A. Moraga

Ponas 698

Letters of Transmittal*

Washington, D. C, May Si, 1917.

Snt: Punaant to the lecommendatiQn of the e^Focutive committee of the Second
IVm American Scientific Oongren, which was held in Washington December 27, 191&-
January 8, 1916, and by the cooperation of the United States Congress (uigent defi-
ciency bill, Sept. 8, 1916), the papers and discussions of that great intwnational
scientific gathering have been compiled and edited for publication under the able
direction of the Assistant Secretary General, Dr. Glen Levin Swiggett. In this
volume is contained the report of Section VIII, of which General W. C. GorgM, of
the executive committee, was chairman.

In my formal report, which has already been submitted, I enlarged upon the
importajuce of the Second Pan American Scientific Congress, its laige attendance, and
the high quality of its papers and discussions. I will, therefore, in this letter, which,
in sli^tly varied form, introduces each volume, make only a few general references.

All of the 21 Republics of the Western Hemisphere were represented by official
delegates at the Congress. Unofficial delegates, moreover, from the leading scientific
associations and educational institutions of these Republics presented papers and
took part in its deliberations. The papers and discussions may be considered, there-
fore, aa an expression of comprehensive Pan American scientific efifort and possess^
in consequence, inestimable vahie.

The Congress was divided into nine main sections, which, with their chairmen,
were aa follows:

I. Anthbopoloot. W. H. Holmes.

II. AsTsoNOMT, Mktboboloot, AND Sbismoloot. Robert S. Woodward.

III. CoNsxBVATioN ov Natitral Rbsourobs, AgricultuTs, Irrigation, and Forestry.

George M. Rommel.

IV. Education. P. P. Claxton.
V. Enqinbbbino. W. H. Bixby.

VI. IntbbnaxionalLaw, PiTBUoLAW,ANDJuBisPBimBNOB. Jsmss Browu Scott.
VII. MnnNO, Mbtallubot, Eoonomio Gboloot, and Afpubd Chbmistbt. Hen-

nen Jennings.
VIII. Pubuo Hbaiah and Mbdioal Soibncb. William C. Qorgas.

IX. Tbanspobtation, Commbbob, Pinanob, and Taxation. L. S. Rows.

These sectkms, in turn, were further subdivided into 45 subsections.

Over 200 delegates were in attendance from the Latin American Republics, while
over a thousand from the United States participated in its meetings. The discussions
and proceedings of the Congress attracted wiurld-wide attention, and it was undoubt-
«lly the greatest international scientific meeting that has assembled anywhere in the
history of the Western Hemisphere and possibly of the world. It was, therefore, a
fitting snccossMT to the first Pan American Scientific Congress, which assembled in
Santiago, the capital of Chile, in 1908, and to its predecessors, confined to Latin
American representation, which in former years met, respectively, in Rfo de JaneirOy
Montevideo, and Buenos Aires. Its success was a logical result of these preceding
gatherings in Latin America and of the hearty cooperation of the Latin American
Governments and scientists.

To those who may have their attention brought only to the individual volumes
covering the papers and discussions and who wish to know more of the proceedings o f
the Congress and the results accompUshed by it, it is recommended that they should

Vni LETTERS OF TRANSMITTAL.

also read ''The Final Act— An Interpretative Commentary Thereon/' prepared under
the direction of Dr. James Brown Scott, reporter general of the Congrefls, and the report
of the secretary general, prepared by the latter and the assistant secretary general,
Dr. Glen Levin Swiggett. In these will be found not only the final act and the
illuminating comment thereon but lists of del^;ates, participating Governments,
societies, educational institutions, and other organizations, together with a careful
story and history of the Ccmgrese. They can be obtained by addressing the Director
General of the Pan American Union, Washingttm, D. C.

In conclusion, I want to briefly repeat, as secretary general of the Congress, my
apinreciation, already expressed in my formal repent, of the hearty cooperation in
making the Congress a success given by everyone concerned from the President of
the United States, yourself as Secretary of State, and the del^iates of Latin America
and the United States, down to the office employees. The great interest manifested
by the i>ermanent executive committee, headed by Mr. William Phillips, then Third
Assistant Secretary of State, the Carnegie Endowment for International Peace through
its secretary. Dr. James Brown Scott, and the executive aid of Dr. Oleai Levin Swig-
gett, as assistant secretary general, were vitally instrumental in making the gathering
memorable. The Pan American Union, the official international organization of all
the American Republics, and whose governing board is made up of the Latin American
diplomats in Washington and the Secretary of State of the United States, lent the
fav<»rable influence of that powerful organization to the success of the Congress and
authorized me as the director general of the Union to also take up the duties of secretary
general of the Congress.
Yours, very truly,

(Signed) John Babrbtt,

The Honorable The Sbcrbtart op State,

WashmgUm, D, C.

Secretary General.

Washinoton, D. C, si de mmo de 1917.

ExMO. Snb.: Em cumprimento de uma recommendagfto emanada da Oommissfto
Executiva do Segundo Congresso Scientifico Pan Americano, que teve lugar em
Wadiington, de 27 de dezembvo de 1915 a 8 de }an«iro de 1916, e, devido ao auxilio do
Congresso dos Estados Unidos (Lei para Or^amentos extnordinarios de 8 de setembro,
1916) as memorias e as discussdes deesa assemblda scientifica intemacional, foiam
colligidas e preparadas para publicaySo sob a proficiente direc9So do Secretario Geral
Adjuncto, Dr. Glen Levin Swiggett. Este volume comprehende o relatorio da secgfio
VIII que foi presidida pelo General W. C. Gorgas, da Gommiaafto Executiva.

No meu relatorio official, que j& tive a honra de apreeentar, me detive sobre a impor-
tanda do Segundo Congresso Scientifico Pan Americano, da sua grande concorrencia
e da alta importanda das theses e das discussOes. Na presente nota, portaato, de uma
maneira muito ligeira, destinada a apresentar cada um doe volumes, eu farei apenas
algumas referendas muito geraes.

Todas as Republicas do Hemispherio Occidental, vinte e uma em numero, se
achavam repreeentadas por delegados officiaes ao Congresso. Delegados sem nomea-
^ dos GovonoB, mas repreeentando as mais notaveis sodedadee sdentificas e
institcd^Oes de ensino dessai republicas apreeentaram theses e tomaram parte nas
deliberagOee. As memorias e discussdes devem ser conaderadas portanto, como a
expresBfto de um justificavel trabalho sdentifico Pan Americano e poesoe, por esse
motive, um valor sem egual.

O CongreoK) foi dividido em nove secedes prindpaes, que a segoir enum^ro, com
OS nomee dos sens presidentee:

I. Anthropolooia. W. H. Holmes.
II. AsTRONOMiA, Mbtbreolooia b Sismolooia. Robert S. Woodward.

LBTTBBS OF TBANBMITTAL. IX

111. CONSEBVA^jIO da RiQUBZA NaCIONAL, AoRIGULTUBA, iRRIOAglO B SiLVI-

cuLTURA. George M. Rommel,
rv. Is&TRvoglo. P. P. Claxton.
V. Engbkhabia. W. H. Bixby.
VI. DiBBiTO Intbbnacional, DntETro Publico b Jubibpbuobncia. James

Brown Scott.
VII. MiNAs, Mbtallurgu, Gbolooia pRAcncA E Chimica Industrial. Eennen

Jemungs.
VIII. Saude Publica b Sciencias Mboicas. William C. Gorgas.

IX. VtAS DE COMMUNICApIO, COMMERCIO, FlNAN^AS B ImPOSTOS. L. S. RoWC.

Estas secgdes, por seu lado, eram subdivididas em 45 subeecyOes.

Mais de 200 delegadoe das Republicas da America Latina frequentaram as seeeOes
emquanto os Ebtados Unidos se achavam representados por mais de mil pessoas. As
disciissdee e os relatorios do Congresso attrahiram a attend de todo o mundo e foi
sem duvida a maior aasemblea scientifica que se realizou no Hemispherio Occidental
e talvez em todo o mundo. Foi sem duvida um idoneo continuador do Primeiro Con-
gresso Scientifico Pan-Americano, que se celebrou em Santiago, capital da Republica
Chilena em 1908 e das anteriores assembleas que previamente se tinham realizado,
apenas com delegados da America Latina e que se reuniram em annos anteriores no
Rio de Janeiro, Montevideu e Buenos Aires. 0 seu successo foi um resultado logico
das reunites previas na America Latina e do cordial concurso dos Govemos da America
latina e dos sens homens de sciencia.

A aquelles que nSo quizerem limitar-se a consultar os volumes que cont^ as
memorias e as discussOes e que desejarem conhecer alguma cousa mais dos trabalhos
do Congresso e dos resultados por elle alcan^do se Dies recommenda a leitura da
Acta Final — a expoeiy^o geral concemente & mesma— publicada sob a direcgSo do
8r. Dr. James Brown Scott, Relator Geral do Congresso, e o relatorio do Secretario
Geral, preparado pelo abaixo assignado e pelo Secretario Geral Adjuncto 8r. Dr.
Glen Levin Swiggett. Nestes trabalhos encontrar-se-hSo nSo s6mente a acta final
mas tambem um magnifico commentario, a llsta dos delegados dos Govemos que
adheriram, sodedades, institui9des de ensino e outras corporayOes, seguidas de uma
cuidadosa historia do Congresso. Estes volumes continuam d disposigfto dos que os
pedirem ao Director Geral da Unifio Pan-Americana, Washington, D. C.

Em conclusfto, eu desejo repetir, em duas palavras, como Secretario Geral do Con*
gresBo, o meu apre^ e reconhedmento, que jd tive occasifio de exprimlr no men
relatorio official, pela cordial coopera^ que por todos me foi prestada para levar
a bom ezito este congresso, desde o Preeidente dos Estados Unidos, V. Exa., coma
Secretario d'Estado, os Senhores Delegados da America Latina e dos Estados Unidos
at^ OS diversos funccionarios do Congresso. 0 grande intereese manifestado pela
CommisB&o Permanente Executiva presidida pelo Sr. William Phillips, ao tempo
terceiro Sub-secretario d'Estado, pelo Institute de Carnegie pan a Paz Intemacional
na pessoa do Sr. Dr. James Brown Scott, assim como a coUaborag&o prestada pela Sr. Dr.
Glen Levin Swiggett, como Secretario Geral Adjimcto, constituiram obras basilares
para o successo desta reunifio.

A UniSo Pto-Americana, instituiydo intemaclonal sustentada por todas as Repu-
blicas Americanas e cujo Conselho de Administra^ 6 constituido pelos represen-
tantes diplomaticos em Washington e pelo Secretario d'Estado dos Estados Unidos,
conlribuiu com a sua poderosa influencia para o bom exito do Congresso e me aucto-
lizou a servir de Secretario Geral do Congresso.

Com a mai<»r con8iderac2o, subscrevo-me

De V. Exa.,
Vor. Mto. Atto.,

John Barrett,

Seeretatio OfTtU.

Exmo. Snr. Sborbtario db Ebtapo,

WoMhingUm, 2>. C.

X LETTEES OF TRANSMITTAL.

Washington, D. C, 31 de tnayo de 1917,
Se^or:

En cumplimiento de una recomendaci6n emanada de la Comisidn Ejecutiva del
S^:undo Congreeo Ciendfico Fanamericano que se ieuni6 en Washington deede el
27 de didembie de 1915 hasta el 8 de enero de 1916 y gracias a la cooperaci6n id efecto
prestada por el Congreeo de Ice Estados Unidoe mediante su ley eobre rectificaci6n del
presupuesto dictada el 8 de setiembie de 1916, h^oise recopilado y preparado pan
sa publicaci6n, bajo la hibil direccidn del Sr. Dr. Glen Levin Swiggett, Subeecretaiio
General, las memorias presentadas a dicho Congreso y los debates a que dieron lugar.
£1 presente volumen contiene el informe relativo a la Secci6n VIII, de la cual fu6
presidente el General W. C. Ckirgas, miembro de la Gomidi6n Ejecutiva.

En el informe general que ya tuve el honor de presentarle, me fu^ dable considerar
detenidamemte la importanda del S^:undo Congreso Cientffico Fanamericano, la
numeroea concurrencia que al mismo asbti6 y el elevado m^to de las memorias
presentadas y de los debates que en aquel se susdtaron. Por consiguiente, he de
limitarme en la presente, destinada a servirle de mera introducci6n a cads imo de los
voldmenes, a algunas consideraciones de car^ter general.

En el Congreso estuvieron representadas por medio de delegaciones ofidalee las
veinte y una repdblicas del Hemisferio Occidental. Tambi6n asistieron al mismo,
tomando participaci6n en bus debates y presentando trabajos personales, delogados
particulares de los prindpales cuerpos cientfficos y de los institutes docentes de esas
mismas repdblicas. En tal virtud, las memorias y los debates mencionados deben ser
considerados como la expresiiSn de un amplio esfuerso denttfico panamericano,
encenando, por lo tanto, un valor inestimable.

El Congreso estuvo dividido en nueve secciones prindpales que en seguida paso a
enumerar junto con el nombre de sus presidentes. Fueron las siguientes:

I. AMTEOPOiiOoiA. W. H. Holmes.

II. AsTEONOidA, MsTBOROLOOiA T SisMooEAiiA. Robert S. Woodward.

III. CONSKRVAadN DB IA8 FUSNTBS NaTUBALBS DB RiQUBSA, AoBIOULTUBA,

iBBiGACiiN T Sblvicui/tuba. Geofgo M. Rommel.

IV. iNSTBUOoidN. p. p. Clazton.

V. iNOBNiBRiA. W. H. Bizby.

yi. DbBBCHO iMTBBNAaONAL, DbBBCHO Ft^UOO T JURISPRUDBNCIA. JamOS

Ikoini Scott.

Vn. MnrBRiA, Mbtaluboia, GbolooIa EooNdmcA t QubnoA Afucada. Hen-
nen Jeimings.

YHI. Salubridad FtBUOA T CiBNCiA MioioA. William C. Gorgas.

IX. Traspobtb, CoMBBao, FiNANZAS B Impubstos. L. S. Rowe.

Estas secciones estuvieron dividas, a su vez, en cuarenta y dnco subsecdones.

De las repdblicas latino-americanas asistieron m^ de doscientoe del^ados; en
tanto que las sesiones del Congreso concurrieron m^ de mil personas de los Estados
XJnidos. Los trabajos y debates del cuerpo despertaron ludversal inters, pues indu-
dablemente fu6 aquel la asamblea dentffica m^ grande que registra la historia del
Hemisferio Occidental y probablemente la del mundo. 1^ fu^, en consecuencia, digno
continuador del Primer Congreso Cientifico Fanamericano que en 1910 se reuni6 en
la capital de Chile y de los que previamente y con iina asistenda exdusivamente
latino-americana se habfan congregado en Rfo de Janeiro, Montevideo y Buenos
Aires. Su ^to fu^ consecuenda Idgica de las asambleas que anteriormente se habfan
teunido en la Am6ncA latina y del cordial concurso que recibid de los gobi^nos y
de los hombres de denda de esa misma parte de Am^ca.

A cuantos no quisieren limitane a consultar los voMmenes que contienen las
memorias y los debates y desearen conocer algo mis de las labores del Congreso y de
ios resultados por 61 alcansados, se les recomienda la lectura del Acta Final y de la
Kxpoaid6n General concremiente a la misma que escribio el Dr. James Brown Scott,
Informante General del Congreso, asf como el Informe del Secretario General, prepa-

LBTTBBS OF TRANSMITTAL. XI

mdo por el suacrito y por el Dr. Glen Levin Swig^ett, Subsecretario Gena»l del
mismo. En estoe documentos podr&n hallar no 86I0 el Acta Final 7 luminoeas consi-
detadonee acerea de la mieana, sine tambi^n la n6mina de I08 delegados y de los
gobiernofl, Bociedadee e institatoa docentee que tuvieron repreeentacidn en la Asamblea,
juntamente con una relaci6n puntualizada de \bb labores de la miama. Loe que deseen
obtener eatoe voldmenes pueden aollcitarloa del Director General de la Uni6n Pan-
amerirana en W^bhington, D. C.

Como Secretario General del Congreeo deeeo hacer constar una ves m^, antes de
concluir, el agradecimiento que en mi inlurme general express por el cordial concurso
que de todos redbf para aaegurar el 6xito del Gongreao, deede el Preaidente de loa
Eatadoe Unidoa y usted miamo como Secretario de Eatado y deede loa delegadoa de
la America Latina y de loa Eatadoa Unidoa haata loa diveraoa funcionarioa del Congreao.
El gran inter^ deapl^gado por la Gomiai6n Permanente Ejecutiva, que preaidid el
Sr. William Phillipe^ a la aasdn Tercor Subaocretaiio de Eatado; por la Fundaci6n
Gamegie para la Paz Intemacional, por el drgano de au Secretario, Dr. Jamea Brown
Scott; aai como la colaboraddn del Dr. Glen Levin Swiggett, Subaecretario General,
contribuyeron poderoaamente a hacer memorable la aaamblea. Ja Uni6n Pan-
amerirana, inadtucidn intemacional aoatenida por todaa laa reptiblicaa de America y
cuyo Oonaejo Directive eatd formado por loa repreeentantea diplom&ticoa latino-
americanoa reaidentea en Wdushington y por el Secretario de Eatado de loa Eatadoa
Unidoa, contribuy6 con au poderoaa influenda al 6xito del Congreao y me autorizd
para que deaempefiara laa funcionea de Secretario General de aqu^.

Con aentimientoa de la m^ alta consideracidn me aubacribo
De uated muy atento aervidor,

John B^rbett,
Secretario General.

Al Honorable Skcrbtario db Estado,

Wdshington, D. C.

Washington, D. C, Le 31 max 1917,

Monsibur: Conform^ment i la recommandation du Comity Ex6cutif du Second
Congrte Scientifique Panam^cain qui a eu lieu i Waahii^ton du 27 d6cembre 1915
au 8 Janvier 1916, et par la cooperation du Congrte dea Etats-Unia (loi du budget
extraordinaire, 8 aeptembre 1916), lea m^moirea et diacuaaiona de cette grande rdunlon
adentifique intemationale ont ^t^ recueillis et ^t^ pour dtre public aoua Thabile
direction du docteur Glen Levin Swiggett aoua-aecr^taire g^n^ral . Ce volume contient
le rappOTt de la aection VIII, dont M. le g^n^ral W. C. Gorgas du Comity Ex^cutif
etait prMdent.

Dana mon rapport offidel qui a ^t^ d^jli aoumis, je me suia ^tendu sur Timportance
du Second Congr^ Sdentifique Panam^ricain, sur le grand nombre de personnea qui
y etaient pr^aentea et sur Texcellence de sea m^moires et de ses discussions. C'est
pourquoi, dans cette lettre qui, apr^ avoir subi quelques changementssans, impor-
tance, sort d 'introduction i chaque volume, je n'en parlerai que d'une mani^
gtedrale.

Toutea lea r^publiquea de rn^misph^re Ocddental au nombre de vingt-et-une
^taient repr^sent^ au Congrte. De plus, dea d^l^gu^ ^ titre officieux envoy^
par lea associations sdentifiquea et lea institutions 6ducativea lea plus en vue de cea
r6publiquea ont aoumis dea m^moirea et ont pris part aux d^b'b^rations. On pent
done consider lea m^moires et lea discussions comme Texpression d'un grand effort
sdentifique panam^ricain, poss^dant en consequence une valeur inestimable.

Le Congr^ etait divisd en neuf sections principales que nous enum^rons d-dessous,
eo donnant le nom de leura pr^aidenta.

I. Antbopolooib. W. H. Holmes.

n. AaTRONOMiB, MtrioBOLOOiB BT SisifOLOQiB. Robert S. Woodward.

XI [ LETTEB8 OF XBANSMITTAL.

III. Ck>N8BRyATI0N DBS RbSBOUROBS NaTURBLLBS, AORIOULTURB, iRRIGAnOK

BT FoRftrs. George M. Rommel.

IV. iNSTRUOnON PUBUQUB. P. P. ClftXtOIl.

V. GiNiB Civil. W. H. Bixby.

VI. DROir Intfrnatiokal, Droit Public ft Juivi8PRxn>BNCX. Jame^ Brown
Scott.

VII. MlNKA, M^ALLURQIE, GAOLOGIR PRATIQT7B, CT OhIMIB ApPLIQiriB*

Hennen Jeiinings.

VIII. Santb Pubuqub et Soibncb M^icalb. William G. Gorgas.

IX. TRAN9POPT, COMMBROE, FiNANCM BT ImpOt. L. S. Rowe.

A leur tour cca sections 6taieDt subdivis^ en quarante cinq eoup-sectione.

On y comptait plus de deux cents d^^^ de<9 r^publiques latino-amdricaines, et
plus de mille 64A6ga6a des EtatR-Unis ont assists aux reunions. Les discussioM et
len proc^verbaux du Congr^ ont attir^ I'attention du monde entier, et Q a ^t6 sans
le moindre doute la plus grande assemble scieniifique interna tionale de I'histoire
de 'H^misph^re Occidental et peut-^tre mdme da monde entier, qui se soit r6unie jus-
qu'ici. Venant apr^ le Premier Congr^ Scicntifique Panamdricain qui s'est r6uni k
Santiago, capitale du Chili, en 1908, ev apr^ ceux qni ont eu lieu pr^cMemment, respec-
tivement k Rio de Janeiro, k Montevideo et k Buenos-Ayres, ces demieis n'ayant que
des repr^eentantB de P Am^que Latine, il e'est montr6 leur digne succeoseiur. Sa r^us-
site a 6t4t un logique r^sultat de cee pr^o^dents conckuis dans PAm^que Latine et de
la sinc^ et cordiaie cooptotion des gouvemements et des hommes de science de
PAm^rique Latine.

Pour ceux qui u'ont port6 leur attention que sur les volumes renfermant les m^moires
et les discijstdons, et qui d^reraient connattre d*une mani^ plus approfondie lee
actes et proc^-verbaux du Congr^, ainsi que les r^ltats qui s'en sent snivis, je leur
conseillerai de lire "L'acte Final, Commentaire explicatif,'' r6dig^ bous la direction
du docteur James Brown Scott, rapporteur g6n^ral du Congr^, et le rapport du Secre-
taire Gen6ral r^ig^ par ce dernier et le docteur Glen Levin Swi^cgett. En les lisant
on n'y tiouvera pas seulement TActe Final et le commentaire explicatif, mais encore
les listes des d6l^^, dee gouvcmemento qui ont particip6 au Congr^, dea sod^t^
des institutions ^ducatives et autres, en m^mo temps qu*un compte rendu soign^
ainsi que I'histoire du Congr^. On pent se les procurer en faisant unu demande par
4crit au Directeur G^n^ral de TUnion Panam^ricalDe k Washington, D C.

En terminant, je vais en quality de Secretaire General du Congr^ exprimer de
nouveau en peu de mots mee remerctments, ce que j'ai d^j^ fait dans mon rapport
officiel pour la part que chacun a eue dans la reussite du Congr^ depuis le President
dee £tat8-Unis, vous comme Secretaire d'etat, les dei^gu^s de PAmdrique Latine et
ceux dee £tats-Unis jusqu'aux employes de biireau. Le haut inter^t manifeste par
le Comite Ex^cutif permanent preside par M. William Phillips, qui etait alors troisi^me
Sous-Secretaire d'Etat, par la Fondation Carnegie pour la Paix Internationale, par
Pentremise de son secretaire le docteur James Brown Scott, et I'aide prdte dans Pexe-
cution par le docteur Glen Levin Swiggett, comme sous-secretaire general, ont puissam-
ment contribue k hire de ce Congr^ un evenement memorable. L'Union Panameri-
caine, administration officielle intemationale de toutes les republiquee americaines,
et dont le Comite d'Admimstration est compose des diplomates latino-americains k
Washington et du Secretaire d'etat des £tat8-Unis, a use de sa favorable influence pour
assurer le succ^ du Congr^ et m'a autorise, en qualite de Directeiur General de
PUnion, k prendre en mains les responsabilites de Secretaire General du Congr^.

Veuillez agreer, M. le Secretaire d'l^tat, en m^me temps que mes respectueux
hommages Tassurance de mon entier devo(kment,

John Barrett,
Secretaire GSrUral.

Monsieur le Segr^airb d'^at,

Washington, 7). C.

FIRST PAKT. j^^

Agramonte, Aristidee 100

AndrewB , John B 280

Audain, L UO

Bauzi, Julio A 242

Brazil, Vital 258

Bronner, Augusta F 636

CaldweU, Bert W 77

Carter, H.R 41

Chapin, Charlee V 403

Dearholt, Hoyt E 633

Devine, Edwaid T 187

Doty, AlvahH 623

Dublin, Louis 1 356

Btchepare, Bernardo 651

Etchepare, Julio 352

Feinmann, Enrique 640

Femtodez, Mauro 687

Fiallo Cabral, Aristidee 261

Flaher, Irving 529

Forest, Bobert W. de 616

Fulton, John S 464

Gallegoe, Felipe 196

Gatewood, James D 599

Goddard, Henry H 628

Gons^ez, Justo F 115

Goigae, Gen. TVilliam G 7

Gorriti, Fernando 696

Guena, ArturoL * 264

Guilfoy, William H 411

Gmteras, Juan 9

HayhuTBt, E. R 288

Healy, William 636

Hurty, J. N 398

Johnstone, E. R 631

Keyes, Edward L., ]r 477

KleinSmid, R.B.von 181

Enab , Frederick 107

Lappin, Richard C 374

Le-Roy y Cassi, Jorge 416

L6pez de Mesa, Luis 166

Lovejoy, Owen R 276

Lyster, Major T. C 106

Mathon, C 110

McFarland, J. Horace 385

XIV RE0I8TEB OF WBITEBS OF PAPEBS.

Page.

Meriam, Lewin 365

Migone, Luis E 117

Montev^de, Juan 322

Moraga, PonrM, A 674,688,698

Morales Villaz6n , N ^stor : 126

Muhm, Teodoro 262

Munson, Edward L 590

Narancio, Atilio 196

Nolen, John 387

Oliva, Silvestre 518

Oliveira Botelho, Joaquim de 305,613

Olmsted, P. L 377

P^raico, Alfredo 483

Rankin, W.S 344

Ravenel, Mazyck P 85

Reeder, D. F 610

Re}mold8, James Bronaon 496

Ribas, Emilio 123

Rivas, Ddmaso 95

Rodrigues da Costa Dorla, Joe6 151,247

Rossi, Santin Carlos 667

Ruoda, P 233

Salterain, Joaquin de 456

Sarmiento Laspiur, Ricaido 162

Schapiro, Louis 330,587

Smith, Allen J 49

Snow, William F 486

Susini, JuanD 236

Trask,JohnW 347

Turenne, Augusto 283

Varela, Tomis S 612

Veiller, Lawrence 314

White, William A...., \. 645

White, William Charles 300

Wilbur, Cressy L 400

Wilcox, Walter F 336

Wiley, Harvey W 146

Woodward, William C 526

Zanotti Cavazzoni, Luis 274

FOREWORD.

The work of the hygienic section has been most valuable. It has
already produced excellent results in causing the Rockefeller Foun-
dation to undertake the work of exteraiinating yellow fever. All
the South American countries affected by this disease have agreed
to cooperate, and if it had not been for the European war the work
would have now been well under way.

(Signed) W. C. Goegas,

Chairmofln,.

SECOND PAN AMERICAN SCIENTD1C CONGBESS.

KlfiCUTIVK COfiiMrnBB.

WiLUAM Phillips, Aasistaiit Secretary €i State, Chairmaii ex officio.

Jamxs Bbown Soott, Secretary, Carnegie Endowment for International Peace, Vice

Chairman.
William H. Wblch, President, National Academy of Sciences, Honorary Vice

Chairman.
John Babrbtt, Director General, Pan American Union.
W. H. BiZBT, Brigadier General, U. S. A., retired.
Philandbr p. Claxton, Commismoner of Education.
WiLUAM C. GoBQAS, Suigoon General, U. 8. A.
William H. Holmbs, Head Curator, Smithsonian Institution.
Hbnnbn Jbnnikos, fonner President, London Institution Mining and Metalluigy.
Gbobqb M. Rommbl, Chief, Animal Hushandry Division, Bureau of Animal Industry,

Department of Agriculture.
L. S. RowB, President, American Academy of Political and Social Science.
Robbbt S. Woodwabd, President, Carnegie Institution ai Washington.

ORGAraZATION OPnCBBB.

John Babbbtt, Secretary General.

Glbn Lbvin Swioonr, Assistant Secretary General.

684»e— 17— VOL IX 2

SECTION Vin.— PUBLIC HEALTH AND MEDICAL SCIENCE.

William G. Goroas, Surgeon General, United States Army, Chairman.
John Van R. Hofp, colonel, United States Army, retired. Vice Chairman.
Eugene R. WHrrMORS, major, Medical Corps, United States Army, Secretary.

COMBOTTBES.

SuBSBCTiON A.— Public Health.
Rupert Blue, Surgeon General Public Health Service, Chairman.

Subsection B.— Vital Statistics.

Samuel L. Rogers, Director of the United States Census, Chairman.

Subsection C. — Sociological Medicine.

Gborob M. Kodkr, President National Aflsodation iar the Study and F^vention of
Tuberculosis, Chairman.

Subsection D. — Sanitalion.

WnjJAM C. Braistbd, Surgeon General United States Navy, Chairman.

Subsection E. — Laboratory Conferences.

Eugene R. Whttmorb, majw, Medical Corps, United States Army, professor o£
pathology and tropical medicine, Army Medical School, Chairman.

SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

AIMS AND PURPOSES.

The congress, in accordance with its high aims and purposes,
namely, to increase the knowledge of things American, to dissem-^
inate and to make the culture of each American coxmtry the heritage
of all American Republics, to further the advancement of science by
disinterested cooperation, to promote industry, inter-American trade
and commerce; and to devise the ways and means of mutual help-
fulness in these and in other respects considered the following general
program of subjects, divided into appropriate sections and subsec-
tions.

SECTION Vm.— PUBLIC HEALTH AND MEDICAL SCIENCE.
PUBLIC HEALTH.

Infectious diseases — the bearing of their modes of infection on
methods of control; nutritional diseases — their pubUc health bearing,
with special reference to beriberi and pellagra; reduction of infant
mortality.

VITAL STATISTICS.

Sickness (morbidity) reports; birth and death registration.

SOCIOLOGICAL MEDIOINE.

Relation of the individual to the community; ways and means of
bringing matters of public health to social usefulness; public health
measures — ^industrial hygiene and sanitation; venereal prophylaxis,
alcohol and drug prophylaxis; tuberculosis; mental hygiene.

SANITATION.

Town and city planning; buildings for human occupancy; food
and water supply; ventilation; disposal of refuse.

LABORATORY CONFERENCES.

SympK>sia on anaphylaxis, Ufe histories of protozoa , and cancer
research.

£ PBOGBBDINQS SECOND PAN AMBBICAN SOIEKTIFIO C0K0BB8S.

RESOLUTIONS AND RECOMMENDATIONa

The Second Pan American Scientific Congress considered and dis*
cussed the subjects set forth in its program in the light of an inteU
lectual Pan Americanism in a series of meetings from December 27,
1915, to January 8, 1916, and adopted resolutions and recommenda-
tions pertinent to the work of the nine main sections of the congress.
The following recommendations refer to Section VIII:

Article 39.

The Second Pan American Scientific Congress, recognizing that the
education of the pubUc in the elementary facts of malaria is of the
utmost importance, requests that the American Republics inaugurate
a well-considered plan of malaria eradication, based upon the recog-
nition of the principle that the disease is preventable to a much
larger degree than has thus far been achieved.

Article 40.

The Second Pan American Scientific Congress urges that the Amer-
ican BepubUcB in which yellow fever prevails or is suspected of pre-
vailing enact such laws for its eradication as will best accomplish that
result; inasmuch as yellow fever exists in some of the European col-
onies in America, they be invited to adopt measures for its elimina-
tion.

Article 41.

The Second Pan American Scientific Congress recommends that
such of the American Republics as have not already done so should
justify the international conventions concerning the white-slave
trade.

GENERAL SESSION OF SECTION VIIL

New Ebbitt Hotbl,
Tuesday morning, December £8, 1916.

Chairman, William C. Gorgas.

The session was caUed to order at 9 o'clock by the chairman.

YELLOW FEVER AND ITS ERADICATION.

By WILLIAM C. GORGAS,
Surgeon General^ United States Army.

I should like to diacuss before you to-day yellow fever, and more particularly td
discuss its sanitary side. Yellow fever is one of the diseases that America has inflicted
upon the human race and I hope before many more years shall have passed that we
shall be able to say that Americans have freed the human race from this fell destroyer.
When the Europeans first came to America, in the latter part of the sixteenth century,
they found yellow fever on the Mexican littoral of the Gulf of Mexico. Fevers at this
time were not differentiated so that they did not recognize it as a distinct disease.
The vastly increased travel caused by the coming of the whites gradually spread
yellow fever far beyond its original bounds. About the beginning of the nineteenth
century it bad spread through all the American tropics, the American Temperate
Stoes, had ravaged Spain and had spread down the West Coast of Africa. At this
time it looked very much as if yellow fever was about to become one of the great
world-plagues, as had cholera and plague. It takes no very vivid imagination to pic-
ture what tlie conditions would be when this disease had spread around the Mediter-
ranean Sea, through India and into China. If the ravages in these regions were as
great as had been the ravages in Spain, the gloom of the picture could hardly be over-
drawn. In the year 1800 it looked as if yellow fever had entirely conquered America,
was firmly established in Europe and Africa, and as if it were weU on its way to an
equally firm footing in Asia. About this time steam navigation was introduced and
sailing vessels began to be displaced as a means of sea travel. The sailing vessel was
peculiarly adapted for carrying yellow fever from one port to another. The sailing
vessel has to carry a large supply of fresh water for the use of its crew. This tank of
fresh water was well adapted to breeding the st^gomyia mosquito, and the sailing ship
in wann climates always had on board a plentiful supply of these mosquitos. The
sailing ship upon coming into a port and tying up to a dock where st^gomyiaprevaUed
at once had stegomyia come aboard, lay eggs in the water tank and from that time
forward carried with her a plentiful supply of stegomyia. While in this condition
whenever a human being came aboard in the early stage of yellow fever he was bitten
by scnne of these mosquitos and the ship at once became infected . By means of these
sailing ships yellow fever was transmitted and epidemics started far beyond the north-
em habitat of the stegomyia mosquito. In Boston, for instance, the epidemic would

8 PBOCEEDINGS SECOND PAN AMERICAN SCIENTIPIC C0N0BE8S.

be started in this way: A ship supplied with stegcnnyia would come into the harbor
and tie up to the dock early in the summer. The stegomyia would escape from
the ship and begin to breed in the neighboring cisterns, wells, and other fresh-
water deposits. Later in the summer an infected ship would come into the port.
A man in the early stage of the disease would sleep ashore and infect the stegomyia
ashore. This would start the epidemic which would continue imtil the cold weather
came on and killed all the stegomyia. The introduction of steam vessels changed con-
ditions so that they were very much less favorable to breeding stegomyia aboard
ships.

Steamships, when they carry fresh water, carry it in tanks located in parts of the
ship not accessible to mosquitos, and gradually steam vessels have ceased to carry
any considerable supply of fresh water, but distil it from time to time as needed . With
the introduction of steam vessels the area affected by yeUow fever was slowly con-
tracted till by 1900 the disease was confined to tropical and subtropical countries. In
1901 Reed and his co-workers annoimced to the world their great discovery that yellow
fever was conveyed from man to man by the bite of the female stegomyia mosquito
and in nature in no other way. The sanitary authorities of Havana with the knowledge
of this means of transmission wero enabled to entirely eradicate yellow fever from the
city of Havana. For 150 years Havana had never been free from yellow fever and
had been the endemic focus from which yellow fever had spread to all the Northern
Hemisphere which had been infected by yellow fever. Within 10 years after the
eradication of yellow fever from Havana the disease had practically disappeared from
the Northern Hemisphere. The yellow fever sanitary measures worked out at Havana
have since been adopted at Panama, Rio de Janeiro, and other places in the tropics.

Yellow fever since 1901 has been driven from stronghold after stronghold till it is now
endemic in only three or four communities, and there is no reason why these com-
munities, in which yeUow fever is still endemic, if they adopted the sanitary meas-
ures now well known as applicable to yellow fever, should not themselves become free.
As we look back over the history of animal life as revealed to us by geology, for the
past two or three million years we can see that thousands of different species of animals
have been slowly brought to perfection through untold eons of time. For various
causes many species have become extinct. Where the last animal of a species had
died there is no possibility of again restoring this species. As far as we can tell from
our geological record a species once extinct has never been redeveloped. The titano-
saurus, for instance, which became extract many thousand years ago, we know has
never been redeveloped from any remaining animal, and we all of us know that it is
impossible for the titanosaurus to be redeveloped from any animal at present on the
earth during any length of future time. Now the same is true of the yellow fever
parasite.

While we do not know the yellow fever germ from its analogy to malaria, we know
that it must be a parasite very similar to malaria. If we can once get rid of yellow
fever in the two or three places in the world where it is at present endemic the yellow
fever parasite will be in exactly the same condition that the titanosaurus now ia.
No environment or no length of time could ever redevelop this parasite, and man for
the first time in his history would have completely conquered a disease. He will
not only have conquered it, but he would have placed it in such condition that no
faults or errors on his part would ever cause him to be again scourged by this fell
destroyer.

There is no doubt in anybody's mind that if the buffalo were a hurtful animal and
the United States wished to deliver the world from the buffalo they could issue orders
today which would cause the buffalo to become entirely extinct by the first of next
February. Now, the yeUow-fever paiasite is in a much more precarious condition
than the buffalo. There are many more herds of buffalo in the United States than
there are endemic foci of yellow fev^ left in the world, and the countries in which

PUBLIC HBALTH AND MEDICINE. 9

theae foci exist could iamie sanitary orders which would cause the extinction of yellow
fever by December 31, 1916, just as certainly as could the extinction of bu^o be
brought about.

The countries rejnresented in this congress are the ones principfdly concerned with
yellow fever. This section of the congress is the section concerned with hygiene and
sanitation. I therefcwe uige upon the section that they appoint a committee who
shall draft resolutions urging the countries concerned to adopt the measures, in the
two or three places where jrellow fever Ib still endemic, which have been so successful
in driving yellow fever from the rest of the world.

Dr. Juan Guiteras. Mr. Chairman, I would move you that a com-
mittee be appointed by the chair to prepare a form of resolution to
be presented to the general congress for action, tending to take up
the question of the complete eradication of yellow fever from the
Western Continent.

The motion was seconded and unanimously approved.

The Chaismak. I will appoint on the committee Dr. Vital Brazil,
of Brazil, Dr. Juan Guiteras, of Cuba, and Dr. Henry Carter, of the
United States, the committee to elect their own chairman. It would
be desirable, if possible, for the committee to bring in this resolution
for the afternoon meeting. The sooner it is adopted, the sooner we
can get it to the general meeting of the executive conmiittee.

I shall now call for the first paper on the program, ''Problems of
insect-borne diseases in Pan America," by Dr. Juan Guiteras, of
Habana, Cuba.

ENFERMEDADES TRANSMITIDAS FOR INSBCTOS EN PAN-AMfiRICA.

Pot JUAN GUITERAS,
ProftiCT de Patologia Otmral y de Bnfermedadea Tropicales en la Univenidad de la

Habana.

El Presidente de la Secci6n m^ca del Gongreso ha tenido la bondad de sefialarme
el tema de eete trabajo para su desarrollo y, dentro de los llmites de tiempo que se me
ha concedido para la preparaci6n, me esforzar6 por llenar mi cometido de la mejor
manera posible, atendiendo mis espedalmente a aquellos foctores del problema que
puedan afectar o iuteresar las relaciones intemacionales de los palses que estin aqui
representados.

En la doctiina de las enfermedades transmitidas por insectos se revive de una
manera singular y bajo los auepicios de la ciencia, el pensamiento sendllo y directo
del pueblo desde tiempos muy remotos. La opini6n popular acogla f&cilmente la
idea de la penetraci6n de las enfermedades por la superficie externa del cuerpo,
s^tin se desprendd del concepto expresado por la palabra contagio. Asi vemos a
Apolo en la leyenda hom6rica, lanzando a lo lejos sus dardos sobre los griegos para
henries con terrible pestilencia, y asi tambi^n, mds tarde, en la Edad Media, encon-
tramos la leyenda de los imtos como causa efectiva de la propagacidn de la Peste.
Los recientes deecubrimientos de diversas infeccionea transmitidas por insectos, han
confirmado estas opiniones, estableciendo un grupo notablHsimo de enfermedades
introducidas "pot la niel: FilariasiH. Fiohre Amarilla, Paludismo, Peste, Tripanoso-

10 PBOOEEDINOS SECOND PAN AMBBIOAN SCIENTIFIC CONOBESS.

miaais, Espiioquetoaui, Undnariasis, LeLBhmaiuasu, y otras. Incluye el grupo
algnnas de las inf ecciones de mim grave importanda para la rasa humana.

En la mente popular, la piel, la parte m^ expuesta del cuerpo, se presenta como
la m^ vulnerable, y acept&base naturalmente esta via como la m&B directa y sendlla
para las infecdonee. Pero de tal modo estaba imbulda en los hombres de dencia la
idea de medios de traniimiai6n mim rec6ndito8 y complicados, que, aun deepu^s de
aeomar los primeros albores en estos campos de investigad6n, el gran inidador miono,
el Dr. Patrick Manson no supo llegar a la vordad completa de la inoculad6n directa
de la filaria por el n^osquito, sine que bubo de inventar la via tortuosa que suponfa la
muerte del mosquito filari^lco en el agua, y la ingestidn del par&aito con aquel Ifquido
por la via g^strica. Y mis redentemente aun, cuando bacfa ya ados que Finlay
predicaba la transmiaibilidad de la Fiebre Amarilla de bombre a hombre por el
mosquito, directamente a trav^ de la piel, Manson todavla indicaba la misma via
torcida, por el mosquito y el agua al estdmago del bombre, para la propagad6n del
Paludismo.

Es de sentirse que drcunstancias, entre las cuales cuento el haber sido escogido yo
como ponente, impidan el desarrollo de este tema en forma que mejor se ajuste con la
ocaai6n preeente; porque en v^dad que nunca bubiera podido escogerse tema alguno
que mds digno fuera de un Congreeo de esta indole. El tema es eminentemente un
tema americano, del cual puede decirse, que ha derramado m^ gloria sobre la dencia
americana que acaso los temas todos juntos que pudieran presentarse ante un Con-
greso Pan-Americano.

Americano fu6 el que, en el afio 1881, de una manera precisa y con acopio de dates
Men fundamentados, declai6 por primera ves que se transmitla de bombre a bombre,
por la picada de un Insecto, una inlecci6n de caiicter general.

Que infecdones de esta naturaleza se relacionaban de algtin modo con las picadas
de insectos, que parecfan inocular algtin veneno, producto de descomposidones de
substancias animales o vege tales en el ambiente, la tierra, los pantanos, el aire; era
una nod6n entrevista desde tiempos atr&s por pueblos salvajes, o poco menos, en
diversas regiones y propuesta como solud6n dentifica por pensadores originales como
Beaupertliuy (3), Nott (38), y, ya deerpu^ de la declarad6n terminante del Dr. Finlay,
tambi^n por Eing (31). Extensas dtas de estos tiabajos, con observadones, se
encontrar&n en la Bibliograffa que acompafia este escrito.

Pero la declaraddn precisa de que el microbio de la fiebre amarilla se transmits
de bombre a bombre por la picada de un insecto, y que este insecto no podfa ser otio
que el mosquito que boy Uamamos Aedes calopuSf eea declaiad6n la bizo el ado 1881
el Dr. Carlos J. Finlay, como consecuencia de genial razonamiento que se fundaba en
una serie de profundas observadones y originales experiencias sobre la bionomfa de
aquel dfptero. De esta manera se presenta el Dr. Finlay como fundador de la doctrina
de enfermedades de tranamisidn insectil. No s61o fu4 el primero en mantener que se
transmitfa una enfermedad del enfermo al sano por mediad6n de un insecto, sino
que previ6 tambi^n que se bacfa mis virulenta la picada al transcurrir algtin tiempo
deefpu6s de cbupada por el insecto la sangre del enfermo.

Y fu4 tambi^ €1 el primero en aplicar un insecto bemat6fe^ a un enfermo y despu^
a un bombre sano con el objeto de tiansmitur un virus. Nos ensefi6 de esta manera el
Dr. Finlay el m6todo de experimentad6n, con todos sus procedimientos de t6cnica,
sobre el cual se fundan los grandes adelantos de la Medicina. Tropical. Invents
tambl^n y public6, con todos los detaUes necesarios, el sistema que debfa seguirse
para la extind6n de la Fiebre Amarilla.

El Dr. Finlay falled6 el 20 de agoeto del ado en curso. Propongo a la Asamblea
que se ponga en pi6 en reverenda a la memoria de aquel grande bombre.

81 no fuesen sufidentee los anteriores triunfos para darle al Continente Americano
la prioridad en este camix) de investigadones, podemos presentar la serie magistral de

PUBLIO HEALTH AND MEDIOINE.

expeiimentoe que condujo a la comprobaddii por Smith y Kilbome de la tnui8mui6n
de la fiebre tejana del guiado por la garrapata, el Margaropui annulatus, (50)

Las inveBtigaciones de Smith y Kilbome y los resultados que obtavieron, consti-
toyen la primera comprobaci6ii completa de la doctrina de Finlay, de la traiiflmiflidii
de enfermedades por inaectos sanguisugos; y constLtuyen tambi^n la primera apli-
cacidn can dxito de sa m^todo, ee a nber: la preparaci6ii de insectoe, con conodmiento
completo de ea bionomk, para la vida de laboratorio y para obtenm*, a volnntad, picadas
socesivas sobre animales enfermos y sanoe, en condiciones que se aproximasen lo
m&s poable a las condiciones natorales.*

Finalmente, si todo eeto no faese bastante a establecer sobre base finne la prioridad
americana, podemos sefialar a la cdpula que corona el edificio, la obra de la GomisI6n
del Ej^rcito de los Estados Unidos de Norte America, con la demostraci6n concluyente
de la tnnfimisi6n por el mosquito de la Fiebre Amarilla, enfermedad epid^mica
dotada de extraordinarias fuerzas de resistencia y de expanfli6n. (107), (108)

Gomo resultado prictico del aistema de profilazis fundado en estas doctrinas, hemes
eliminado del Gontiente, casi totalmente y en el transcurso de pocos afios, una de las
pestilencias mis tembles que jam^ azotaron a la humanidad.

y^ase Bibliograffa de (1) a (53).

Pasarmnos a estudiar sucesivamente las enfermedades transmitidas por insectos
que m&B impcvtanda tengan en Pan-Am6rica.

Paludimo^—Entre estas enfermedades nos parece que el primer lugar le corres-
ponde sin duda alguna al Paludismo. Es verdad que a primera vista la enfermedad
no parece presentar ningtin grave problema intemacional, ni siquiera manifestaciones
que pudi^ramos llamar de Inter^ general. Quiero dedr que el problema no se
preeenta en forma alarmante a la opini6n pdblica. Podemos decir del Paludismo
que es una enfermedad local y que, si su ^ea de distribuci6n es grande, est& com-
iraesta de innumerables focos de cai^ter local. Son ^stos, sin embargo, tan numeroeos
y ponstentes, que su caiicter fraccional no impide que, sumados los focos, constituyan
la fuente m^ poderosa de destrucci6n de vidas y de eneiglas en la raza humana,
exceptuando tan s61o la Tuberculosis.

En ciertas regiones de los trdpicos, tan extensas algunas que llegan a formar nacionee
de importancia, la mortalidad por el Paludismo puede superar a la de cualquiera
otra enfermedad. Tal era la atuaci6n en Cuba en el ado 1900, que fu6 el primero en
que contamos con dates del territorio todo de la Isla. Tal fu6 tambi6n la situacidn en
Venezuela en el a£Lo 1910 y probablemente tambi^n en los afios anteriores, contando
desde el 1905. (1)

Nihruro de D^nciona por Paluditmo en Venezuela^ en lo$ afloe que $e espec^fican.

Moertes

Allot.

por

Paludinno.

190B....

O.Olfi

1906.-..

8,644

1907....

7,006

1908....

8,441

1900....

10,268

1910....

8,488

El Annaiio de Venezuela que se cita, s61o da el ntbnero total de defuncionee por
todas las catms paza el alio 1910. Pero las cifras del Paludismo se mantienen a tan
elevado nivel, que no cabe dudar que en todos los alios mendonados la Malaria debe
de ocupar el primer lugar, como ^n el afio 1910. Los infonnes de la India, de Italia,

I Lm Ttrdadaros preomaorea de Tinlay y Ifanaon se eoeoentnm entre lot iiiTettigtdoret del Ctibundo,
Dvftim, O. Etodet tar Is oontagton da diarbon ehet let animtoz domettiiiaet. Balletin de TAotd. dt
lfid.4aPafit,18T0. VoL XXXV, pi». 216 y 471.

PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONGRESS.

de Panami, del Braail, de la Isla Mauricio y otros, nos muestran iguales resultadoe
para regiones determinadas, con exacerbaciones notables a vecee. Pueden ^etas
alcanzar proporciones tales que Uegue a pioducirse un electo visible sobre la mor-
talidad general. En estas condiciones decimos que existe un eetado de Paludismo
epid6mico.

En alios redentes nos vamos acostumbrando tambl^n a encontrar reducciones
igualmente notables en la mortalidad por el Paludismo, como resultado de en^igicas
medidas profiUcticas.

Ejemplo muy notable de tales reducciones encontramos en las cifras demogr^cas
de Cuba, segtin aparece en la gr&fica y cuadros adjuntos.

Como antes dije, en el afio 1900, el Paludismo lleg6 a ocupar el primer puesto como
mayor causante de las defunciones en Cuba. De entonces ac& ha descendido al
vlg^sLmo lugar. Es este un resultado muy satisfactorio y Men vale la pena de estudiar
las cifras en detalle.

CuADRO I. — Ndmerode Defunciones por Falicdumo y Mortalidad por la misma causa por
lOfOOO habitantes en los afios que se especijican. Repdblica de Cuba.

Afios.

Nrtmero
de De-
funciones.

MortaU-
dad.

: Afios.

NAmero
de De-
funciones.

Mortali-
dad.

3.43
3.38
2.80
2.25
2.16
1.87
1.83

1900
1901
1902
1903
1904
1905
1906
1907

4,107
3,286
1,546
1,204
1,079
1,100
1,147
925

25.16
19.42
8.79
6.06
5.79
5.69
5.77
4.51

1908
1900
1910
1911
1912
1913
1914

730
746
622
497
493
446
453

CuADRO II. — Defunciones por Paludismo y Mortalidad por la misma causa^ por 10,000
habitantes en la Habcma en los afios que se especifican.

Afios.

Ntimero
de De-

Mortali-
dad.

' Afios.

NtSmero
deDe-

Mortali-
dad.

funciones.

fondoDes.

1871

262

13.01

1803

246

11.21

1872

316

15.72

1894

201

9.00

1873

829

16.41

1895

206

9.00

1874

288

14.39

1896

450

19.50

1876

284

14.22 1

1807

811

34.58

1876

334

16.77 1

1896

1,907

80.03

1877

422

21.23 1

1809

'900

37.35

1878

453

22.77 t

1900

335

13.02

1879

343

17.23

151

6.87

1880

384

19.27

1902

2.90

1881

251

12.59

1903

1.87

1882

223

11.77

1904

1.50

1883

183

0.16

190S

1.11

1884

196

0.80

1906

a88

1885

101 '

5.05

1907

a 76

1886

135

6.71

1906

0.60

1887

269

12.43

1900

0.18

1888

206

10.37

1910

0.46

1880

228

11.16

1911

0.30

1890

256

13.30

1912

0.12

1891

292

13.78

1918

a 16

1802

286

13.26

1914

0.11

Como que el 6xito que exponen los anteriores cuadros se dehe principalmente a
obra emprendida contra la Fiebra Amarilla, dejaremos para cuando se trate de dicha
enfermedad el explicar c6mo se ha hecho esto y lo que ha costado.

Dudoso es en \erdad que se pueda duplicar este ejemplo si tenemos en cuenta que
la Hahana es una ciudad tropical de gran importancia comercial, centro de gran
movimiento penonal y centro, por consiguiente, de grandes hospitales pdblicos y parti-
culares; de loe cuales estos dltimos, por su organisaci6n especial, atraen un gran con-

Ill-iSi^;

srrr = :T = r« IS HIISI I S Mi 1 1 i 1 1 1 f H H • SH i ^ ; 2

PUBLIC HEALTH AND MEDIOIKB. 13

tiDgente del interior de la Reptiblica. Ck>n respecto a las eetadlsticas de esta dltima,
conviene tambi^n recofdar que en todo el territorio no exiate lugar alguno donde las
condiciones de temperatuza sean obst&culo a la e v oluci6n de las anofelinas.

Refiri^ndome bievemente al quebranto econdmico que para una comunidad signi-
fica el Paludiamo podemos decir, que el Director del Departamento de Entomologfa
en Wasbington, L. O. Howard (24) eetima que las p^rdidas que el Paludismo le ocaai-
ona a lod Estadoe Unidos pueden c&lcularse en 100 millones de pesos annates; y Angelo
Oelli, deepu^ de entrar en detalles sobre el mismo asunto con respecto a Italia, y sin
olvidar la influencia que sobre la emigraci6n sin duda ejerce el paludismo, concluye
<*on estas palabres: ''Riassumendo, si pu6 dunque con certezza as8e\erare che la
malaria casta annttalmenU aW Italia incalcoktlnli tesari,** (55)

La campafia contra el Paludismo debe naturalmente de participar del miamo
<:ardcter local que hemes sefialado con respecto a la distribuci6n y otras manifestaciones
de la enfermedad. La obra, por consiguieDte, deberd subdividirse grandemente con
el fin de cubrir las numerosas y desemejantes secciones del pals afectado. Las varias
campafias que se proponen, y loe numerosos informes que se encuentran en la publi-
caci6n que, bajo el titulo de ''Paludismo " edita el Comit^ para el estudio del Paludismo
en la India, son muy caracterfsticos de esta clase de trabajos, s^n se descubre por
la divisidn en comisiones y subcomisionee que con frecuencla dlfieren entre si en
cuanto a oplniones y m^todoe. El Presidente del Comity Central se quejaba de estas
divergencias y discusiones que no son sine resultados de la naturaleza misma del
problema. (64)

Ross (65) en su ezcelente monografla, reconoce la importancia de las opiniones
locales y da mayor realce a su libro introduciendo en ^1 "contribuciones especiales"
por autores que se ban labrado renombre intemacional por su labor en estoe proble-
mas, en di'.ersas partes del mundo.

Como era de suponer las campaiias antlpalddicas ban recibido mayor impulse, y
han alcanzado sua mejores 6xitos en tomo de grandes centros de poblaci6n, o aquellos
que por alguna causa especial se distinguen. Tales son las campafias de los ferro-
carnles de Italia, de la Habana, de lamailia, de Panamd, de Mauricio, de Rio, Nueva
Orleans, Bombay y otras.

Encontiadas son las opiniones con respecto a los m^todos profil&cticos mia prove-
choeoB en diversas localidades. Los campos contendientes pueden reducirse a doe
grupoe, a saber: loe que ponen su esfuerzo principal en la campafta anticulicida, y
los que se proponen Uegar a la inmunizaci6n del hombre por la administraci6n de la
quinina en dosis profil&cticas.

Tales discusiones me parece que pueden ser de inters en loe palsee donde no reina
la Fiebre Amarilla; pero donde quiera que coexistan ambas infecciones, parece que
debiera aceptaise como sistema fundamental de la profilaxis, la lucha contra el mos-
quito que combate a la vez el Paludismo y la Fiebre Amaiilla.

Los ^xitos que antes vimos patentizados en las eetadlsticas de Cuba, per obra anti-
culicida ezcluaivamente se obtu\ieion. Con respecto a la quinina podr& dedrse que
la droga se emplea hoy m&B eficazmente que antes; por lo menos no se gasta intitilmente
en el tratamiento de estados que no son paltidicos; pero el uso profiUctico de la qui-
nina no se ha empleado en Cuba, sino es individualmente.

La inmunizacidn est4 muy claramente indicada en las enfermedades estrictamente
humanas; pero, en aquellas infecciones que se mantienen en formas mis o menos
larvadas en algtin animal intermediario, debemos sefialar los petigros de la seguridad
falsa que se produce, de la creaci6n de razas de par&dtos resistentes a la quinina, y de
favorecer formas peraistentes de la infeccidn himiana.

No puede negarse, sin embargo, que en palses donde no exists la Fiebre Amarilla,
el uso profiUictico de la quinina ha sido tan efectivo, y probablemente miB pr^tico y
econ6mico, que cualquier otro m^todo. Vdanse, por ejemplo, las campafias anti-
pal(idicas de Italia y de las colonias alemanas.

14 PB00EEDIK08 BBGOKD PAK AlCBBICAN SOUmTUflO 00KGBE8GL

En loe pttes de Fiebre Amarilla, nnestia seguridad depende de la eficada de nuesCxft
labor anticaUcida. A este fin debemos siempre mantener escuela de prepaacidn
para estas funciones que combinan a la vez las del entom^ogo, el ingeniero y el sani-
tario. LaanadoiieBqaeiioest&npiepaiadasporeiiflefianzasiMictic^
debieian enviar hombres que se adieetreu en centros de rec<mocida expenencia como
son, Nue . a Orleana, Habana, Flanam4 o Rfo de Janeiio.

Pues no debemoe olvidar que hasta la existencia nacional entra en juego con la
reflolucidn de estoe problemas. El vigor, la vida mimna de loe puebloe se gastan y
rebijase el caricter a niveles inferiores bajo la influencia del Fbludismo, quedando la
defenaa nacional reducida a la misma endemia inho^italaria que ahuyenta al extran-
jero de las costas. Tal fu6 probablemente la decadencia de los imperios del Mediterri-
neo que nos representa una de las eetrofas finales del Gbilde Harold:

Thy shores are empires, changed in all save thee

their decay

Has dried up realms to deserts.

He dicho que el Paludismo no presentaba ningtin problema intemacional grave,
y, sin embargo, hay un aspecto de esta cuesti6n que no hemoe discutido adn, y que
debe connderarse desde el mismo punto de vista que los problemas sanitarios inter-
nacionales, ee decir, el de las cuarontenas. Desde luego que no voy a proponer que se
incluya el Paludismo entre las enfeimedades cuarontenables. Como procedimiento
intemacional no serla eso practicable. No debemos pasar por alto, sin embargo, el
hecho de que nuestros medicos de puertos detienen, en la inspeccidn de barcos pro-
cedentes de pafses sospechosos de peste o de fiebre amarilla, a muchos individuoe
febriles que son enviadoe al Hospital cuarontenario. Resulta con frecuencia que
se establece el diagn^tico de Paludismo, y estos individuos son debidamente tratadoe
antes de entrar en el pais.

Pero era mi objeto roferirme mis particularmente a lo que pudi6ramo6 llamar
cuarontena interior de una parte de la poblaci6n contra otra; procedimiento que he
recomendado en rolaci6n con las grandes industrias azucareras y otras empresas que
atraen gran ndmero de jomaleros.

Al hablar de cuarontena, en este case, me rofiero al examen de individuos que
acuden a buscar trabajo en grandes centros industriales y que debieran ser en^rgi-
camente tratados, si presentan infecciones paltidicas, hasta que dejen de ser una
amenaza para la comunidad .

Olvldase amenudo tener en cuenta la influencia de las congr^aciones humanas y
de his corrientes migratorias sobre el Paludismo; influencia que se manifiesta tan
claramente como en otras enfermedades transmisibles. Tal parece que todavfa tro-
pezamos con diflcultades en la aplicaci6n prictica de la doctrina de la tranamisibilidad
del Paludismo que fundaron Gerhardt, La^ eran, Ross y Grassi.

Las notables recrudescencias del Paludismo, particulannente akededor de centroe
de desmonte y otras empresas fezro^ iarias, hidr^ulicas o agricolas, no se explican gene-
ralmente de manera satisfactona. Estos brotes, que pudi^ramos llamar de Paludismo
epid^mico, obedecen principalmente a movimientos migratorios. Aquellas giandea
empresas pagan buenos jomales y acuden a ellos hombres de todas clases, amenudo con
8US tamilias. Suelen ser estos hombres predsamente de aquellos que no han prospe-
rado en otras partes donde son conocidos por trabajadores indtiles, sujetos a los trastor-
nos agudos y cr6nicos que ocasiona el Paludismo; individuos que acaso por esa misma
causa buscan tierras mis salubree. Jomaleros de esta clase, y aun m&s probablemente
sus familias, importan el Paludismo de la misma manera que pudiera importarse la
Fiebre Amarilla.

Resultarla econdmico para las referidas empresas el establecer laboratorios y pagar
la direccidn de peritos para obras de saneamiento, y para descubrir y tratar debida-
mente los casos de Paludismo que se presenten. Todo trabajador, antes de ingresar

PUBLIC HEALTH AND MEDICINE. 16

«n el campamento, debiera ser examinado para detenninar el aumento del bazo o la
presenda de paiisitos en la sangre (60).

Un eetadio cuidadoeo de los cuadros de la mortalidad en la Habana, que mia arriba
insertamos, nos hari ver la influencia de los movimientos migratorioB sobre el Pa-
ludiono. £1 incremento en IO0 afioe 1877-78 se debe a la terminaci6n de la guena de
dies af&os, y la vuelta de las tiopas del campo a la Habana. En el atio 1895 empieza la
aegunda gaena de independenda; iniciase en 1896 el ascenso de la mortalidad por Pa-
ludiono, la que llega a la espantosa cifra de 80 por 10,000 habitantes cuando la recon-
€entraci6n de la poblaci6n campesina en las ciudades por la orden tristemente memo-
rable del General Weyler.

Hace algunos afios que hlce un viaje de exploraci6n en la Gi^naga de Zapata que se
extiende por la costa sur de las provincias de la Habana, Matanzas y Santa Clara.
Es la Ci^naga un enorme dep<3sito de aguas dulces que no encuentran suficiente salida
al marftel Sur, y que constituyen, como era de suponerse, un gran criadero de an6fele8
y otroe moequitos. En la parte sur de la Ci^naga la poblaci6n consiBte principalmente
de lefiadores y carbonoros. En la ocasL6n de mi visita la lormaban antiguos residentes,
alguna gente de mar y reci^n Uegadoe de Espafia. No habfa Paludismo, y las condi.
cionee de salubridad eran excelentes aunque se estaba trabajando en canalissaciones
para el desagtte y el trilfico.

En la orilla Norte de la Ci^naga se encuentran terrenos de grandee centrales para la
plantaci6n de cafia. Uno de ellos, el central ''Constancia/' se proponia darie nuevo
impulso a BUS operacionee y habfa importado de la provinda Occidental de la Ida,
empobrecida par la decadenda del cultivo del tabaco, un ntbneio considerable de
trabajadores con sus famllias. Se les habian construldo casas higi^nicas en un lugar
Uamado ' ' la Horquita, ' ' junto a la Ci^naga. La r^6n de donde venlan estas famllias
era de ligera endemiddad paltidica. Pronto deepu6s de su llegada eetall6 entre elloa
un brote epid^mico de tal intensidad que amenasd seriamente el ^to de aquella
cdonizaci6n, si no hubierasido por el en^rgico tratamiento qulnico estableddopor el
Dr. J. M. P(»rtuondo que afortnnadamente estaba bien prei>arado para esta clase de
emeigencia.

£1 foco mayor de Paludismo en Cuba se encuentra hoy en la r^dn Oriental donde
ae fomentan nuevos centrales de azticar y a donde acude la corriente migratoria del
resto de la Reptiblica, de Espafia y de Jamaica. La mortalidad mis alta se preeenta
en Guantinamo, con 19.62 por 10,000 habitantes, y le sigue Palma Soriano con 15.29.
Por otra parte, en mudios t^rminos munidpalee ha deeapareddo el Pftludismo en
estoe (Utimoe afios.

Sigue una lista de las Anofelinas encontiadas en este Continente, y se marcan con
bastardilla aquellas que han side sefialadas como transmlsoras del paludismo.

Anaphela fnaeuUpenmt, Estados Unidos y Canad4; Anopheles emeiam, Estadoa
Unidos y Cuba; Anophelee punctipmmis, Estados Unidos, Jamaica; Anophdee peeudo^
punetipennU, Panami, Antillas, Mexico; Anophelee punctimaculata, Panami;
Anopheles apicmacula, Panamd; Anopheles malefactor, Panamd; Anopheles eisemi,
Fuiain4; Anopheles annuUventris, Chile; Anopheles annulipalpii, Argentina; Anopho^
loBigoti, Chile; Anopheles Cruzeij Braeil, Panamd; Anopheles Lutsi, Braeil; Anoph0'
les pseudonuicuHpes, Braeil; Anopheles franciscanus, Estados Unidos, Panami;
Anopheles Gorgasi, Panami; Anopheles nigripee, Estados Unidos; Anopheles tarsima^
eukOaf Panami.

Chagasia Fajardoi^ Brasil.

ArnhdUagaia maeuUpes, Braeil; Arribalzagaia pseudomaculipes, Brasil.

UangninhoiBa Lutzi, Braeil.

Steihom^ niniba, Brasil, Guayana.

Mysomyia Lutxi^ Braeil, Guayana.

Cydolepteron Qrabhami, Jamaica, Cuba; Clyclolepteron mediopunetatum, Braail;
Cydolepteron intermedium, Brasil.

Myzonhynchella Lutzi, Braeil; Myzonhynchella nigrUttrsis, Braeil; Myzonhyn-
chella parva, Brasil; Myzorrfaynchella dbiamactdata, Brasil; Myzorrhyndiella Oilesi^
BrasO.

16 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

NyssoniiyncuB albimanus, BrasU, Venezuela, Guayana, AntiUas, Argentina.

Cellia albimana, Antillae, Panamd, Guayana; Cellia argyrotarsis Estadoe Unidoe,
Guayana, Braall, Argentina; Cellia Brazilensis, Braail.

Kerteszia Boliviensis, Boli^'ia.

V^ase Bibliografia de (45 a (67).

Peste, — ^Le corresponde, sin duda, a la Peste el segundo lugar en el estudio que
venimos haciendo. Es en la ^poca actual la enfennedad transmitida per insectos que
mifl seriamente parece amenazamos; enfermedad nueva en nuestro Continente, donde
fu6 introducida por primera vez en el (Utimo aflo del siglo pasado.

Existen vaiios focos end6mico8 de Peste en el Viejo Continente. Con excepcidn
del de Yunnan, todos los dem^ pennanecieron inactivos en el aflo 1893. En eete alia
el mencionado f oco manife8t6 una gran ac tividad . Es el Yunnan una de las provincial
meridionales de la China, limltrofe con la Birmania y el Tonkin. En el cursctodel a£Lo>
1894 se extendi6 la epidemia por las vias de comunicaci6n, a trav^ de las provincias
de Ewang-si y Kwang-tung hasta U^ar a la costa por Cant6n y Hong-kong. Este
puerto fu6 el centre de distribucidn pura el mundo entero: Oporto en 1899, Brasil, la
Argentina, Paraguay y Hawaii en el mismo afio; California y Glasgow en 1900; Cons
tantinopla, Ndpoles, Liverpool en 1901; Odessa en 1902; Chile y Perti en 1903;.
Panamd en 1905; la Isla de Trinidad en 1907; Venezuela en 1908; Nueva Orleans y
la Habana en 1912.

En nuestro continente se diagnosticaron los primeros cases humanos en Santos, en^
1899, y por el mismo tiempo, en la Asunci6n, Paraguay. Es muy posible que haya
existido la Peste murina con anterioridad a esta fecha. Se presentan dudas con
respecto al origen de la infecci6n en las costas del Brasil y del Plata, y se discute si
fu6 importada de Mozambique o de Oporto. Sea cual fuere su punto de origen, la
enfermedad nunca ha desaparecido de aquel litoral.

La misma confusi6n existe con respecto a la importaci6n de la Peste en los Ekrtados
Unidoe. La enfermedad apareci6 en Hawaii en diciembre de 1899. Prevaleci6
de^graciadamente por aquel entonces la tendencia a la ocultaci6n. El caddver de un
chino encontrado en San Francisco en marzo de 1900, y reconocido por las autoridadee
f ederales como cad&ver de Peste, fu4 la primera intimaci6n de la presenda del mal en.
los Estados del Paclfico.

Extendidse la infecci6n por aquella costa, Uegando a MazatUox en M6jico por el Sur
y a Seattle i>or el Norte, estableci6ndoee finalmente entre las marmotas (Citellua
beecheyi) de California y entre las ratas de dLudades de importancia comercial, par-
ticularmente en las que son centres de distribucidn de granos y de vfveres. En centres
de esta clase parece que no e^posible, con los medios de que hoy* disponemos, lograi:
la extinci6n de la Peste entre los roedores. Testigos son: Londres, Liverpool, Rfo de
la Plata, Rio de Janeiro, California, y, mis recientemente, acaso tambi^n, la Habana
y Nueva Orleans.

Dije antes que la Peste era una enfennedad nueva en America, y esto es precise-
mente lo que le da una potencialidad amenazadora para noeotros. En la India ha
estado sujeta la enfermedad a flujos y reflujos tan inesperados como inexplicables.
Cabe pensar que lo mismo pudiera suceder en este continente, aunque, por la expe-
riencia hasta ahora adquirida, tenemos alguna base para la esperanza de que la actitud
de los pueblos americanos ante la enfennedad ha de aseguramoe siempre el pronto
dominio sobre ella. 7

Por el contrario, se me figura que, entre los pueblos orientales, existe una actitud
pasiva, algo semejante al fotaliemo que en la America Tropical predominaba con
respecto a la Fiebre Amarilla. En eea misma actitud pudiera quiz^ encontrarse una
explicaci6n de la mortalidad mia baja que en America parece presentar el mal . Quiero
decir que en Oriente hay mis probabilidades de que pasen inadvertidos los casos ligeros
y que la alta mortalidad represente una espede de selecci6n de casos graves.

Loe foctores del ^xito en las campafias antipestosas son principalmente dos: d
reconocimiento y pronta declaraci6n de la existencia de casos de Peste, ya sean hu-

PITBUO HEALTH AND MEDICINE. 17

manoB o muiinoe, y el mantenimiento de una bien organizada per8ecuci6n de latas,
particulannente en Iob lugares donde liaya razones i>ara aospechar la existencia de
ratas infectadas.

Lo6 reeultadoe obtenidos en la Habana ban aido muy satisfactorios. Es esta dudad
un impartante puerto de mar y nn gran centre de distribuci^ de vlveres. Las paredes
de loe edificioe en la Habana vieja y barrio comerdal son mny gmeeas y eet&a cons-
truf das de nn mortero que excavan f&cilmente los roedores, i^riendo cuevas y galerias
que ascienden en complicada red hasta dos metros por endma del nivel del suelo.
D^beee probablemente a estas condidones que hayamos tenido en la Habana predi-
lecddn por el Bistema de fumigadones como uno de los medios para la defiratizad6n.

En breve resumen los resultadoe obtenidos en la Habana son los siguientes: en el
primer afio (1912) bubo tres caaos; en el segundo afio (1914) bubo 25 casos y 17 en el
tercer afio (1915) . Durante el primer afio no bubo ningtin brote secundario. Durante
el segundo afio tuvimos un caso en cada uno de dos pueblos del interior en iicil comu-
nicacidn con la Habana por ferrocarril y carretera; una rata infectada en otro pueblo
en las minmas condidones y 16 casos en Santiago de Cuba. En el tercer afio tuvimos
dos casos en la capital de la Provinda Occidental que se comunica con la Habana por
ferrocarril, y dos casos en un suburbio de la Habana al otro lado de la babfa. Un total
de 57 casos en cuatro temporadas de Peste. Nuestra estaci6n de Peste ocurre en la
primera mitad del afio.

Nuestro ^to en la dominaddn de brotes de Peste es evidente; pero en la Habana
lo mismo que en otras partes, existe la misma persistente tendenda a la reapaiid6n en
afios sucesivos. Nos parece comparativamente f^Unl extinguir los brotes de Peste
humana, o reducirlos a pequefias proporciones; pero es muy dificil extinguir por
completo la Peste murina, por lo menos en grandes centres de distribud^n de granos
y de vlveres. La causa se encuentra, sin duda, en las dificultades con que se tropieza
pwa poner la poblad6n a prueba de ratas.

En la Habana le damos mucba importancia al empleo del &ddo danbldrico en
fumigadones extensas y en inyecdones parciales del mismo gas en las cuevas y ttineles
de las ratas. Tiene la ventaja el gas danbldrico de ser r&pido en su acd6n, y de no
ahuyentar las ratas por el olor picante. Destruye adem^ las pulgas al mismo tiempo
que las ratas, e impide que se infecten nuevoe roedores que acudan a ocupar las ma-
drigueras abandonadas. A las fumigadones muriddas se une una campafia activa de
desratiaacidn por medio de trampas, la que se reconcentra en loe lugares donde se
snpone que pueda baber ratas infectadas.

Deseo aprovechar esta oportunidad i>ara insistir, como en otras ocasiones, en que se
ciimpla estrictamente el Artlculo Primero de las Gonvendones Sanitarias Intemado*
nales — la pronta declarad6n de casos de enfermedades cuarentenables. Losprimeros
paaos de la Peste en este Oontinente se caracterizaron a vecee por deegradadas vadla-
dones en la comprobacidn y declarad6n de los casos. Es bastante general la tendenda
a condonar estas infracdones y aun se tiene a mal que de ellas se hable ptiblicamente.
No me conformo con este sistema. Preferirfa que se sefialasen los infractores y se
encontraae el modo de castigarloe.

Debemos insistir, no s61o en la declarad6n inmedlata de los primoos casos de Peste
humana o murina, sine en el envlo continuado de informes sobre las operaciones de la
cami>afia antimurina. Si no se envlan informes de esta class, me permito sugerir que
est& justificado el mantenimiento de medidas defensivas, aunque se declare que la.
infe<xddn ha ceaado.

Presento adjunto la forma en que se rinde en la Habana informe decenal de las
operadonee del servido de desratizacidn.

Deseo tambi^n recomendar insistentemente el uso del dddo danbldrico para la
desratizacidn de naves que proredan de puertos infectados. lios gases que se
ohtienen por la combustion del car))ono, al matar un ntimero de ratas sin destruir

FB00BBDIKG8 BEOOHD PAIT AMBBIOAN SOISJmFIO 00KGBB88.

Uf pulgM]^qae ftlbeigan, dejan en libertad pulgM infectadiB que pueden atacar al
hombre oja nuevas latas que lleguen a bordo. El monoxide de carbono parece ester
tndicado para la deflratizaci^n de naves que no procedan de puertoe Infectedos.
Estd per inventer nn apaiato genecador y propulsor de ^do cianhldrico para

inyecter el gas, bajo presI6n y r&pidamente, en cloacas, cafios, cuevas de rates y
eqMcios mayares. Acompafio la figura que represente el aparato generador, ideado
por el Dr. Hugo Roberto, y que empleamos en la Habana para la inyecci6n del gas
cianhfdrico en cuevas de rates.

PtJBtIO HBALTH AND MEDIODnB.

No 86 ai hay en esta aaamblea algdn repreeentante de la "United Fruit Company''
que exponga el plan que ha ideado el Dr. Deeks, medico jefe del departamento de
aanidad de dkha compafiia, para poner las navee a prueba de ratae. Di.ide el
Dr. Deekfl bob barcoe en compartimientos o unidades, cada una de las cuales estd
perfectamente alslada de las otras, de manera que se imposibilita el movimiento de
una rata de una parte a otra. Conviene estudiar este plan por si fuese conveniente
bacer obligatoria eeta construcci6n, o, por lo menos, elconcederprivilegiosBanitarioB
a laB compafifas que la adopten.

y^ase la BibUografia de (68) a (94).

Fitbre amarUla. — No hace mucho que hubiera llamado la atencidn el ver postponer
a un segundo tdrmina la endemia de tan tenribles manifeetadones epid^micas. Fiebro
ameiicana, Pestilenda americana, Tifus americano, fueron tftulos con quie se indi*
caba el origen americano de la infecci6n. Ya la enfeimedad habfa rendido sus
bandens cuando se inidaron estas conferendas o acaso tambi^n hubiera recibido
algdn tftulo pan-americano.

KBPUBUCAD* CUBA

SECRCTAUA DE SANIDAD T BENEFHXNOA

JWATDSA lOCAt, im LA BABAWA

DIRECCION PS SANIPAD
PESTE BUBONICA

SSKVKIO OS DHSRATBACIOXr

Retumen de lo$ $ervieios pre$tado$ por egta Ofieina durante el transcuno de la deeena que
termina eldiaSdel me$ de dieiembre de 1915,

Tbabajos.

Dfaa.

TotaL

1»

Batooowen aso diario

600

eoD

1,613

600
1,612

600

1,612

600
1,612

5,400
1,613

*****

• ..

* *

■

1
157

6
158

2
126

3
179

12
212

6
145

5
146

125

4
169

Rates eoD tmnpM ... .

1,^

Total deratas

168

16S

128

182

224

150

120

168

.1,447

Dalas868nitMexaiiil-
oadatenel Labora-
torio de In^wttga-
aioiiea, aa l&s ho^o la

IfftiB A ^TATulrlnnfl

Mnt MrfOMiVf

lis

113

155

101

868

MnflC Poeii

Mas Alezandriniis.
MnsDMumainis...

MnsMuaculos

MnsRattiis

MnaaPoeU

tiiiwiaitan.rnsiTiln,
aslkMy easas da

osis&jaajr::

Oueras obtonMlas....
iBspaeeido noetmna

debaUaaadapisos.

todas por Infrao*
alooaa dadrdenes
dal sarTido da
dwraUsaolrtn

Ninf

90
90
90

35
15

una.

'•"lis*

115
115

42
17

1
110
110
110

23
16

96
96
96

22
80

68
63
68

41
44

3
56
55
55

62
53

27
27
27

37
63

60
60
60

2
70

72
73
72

32
43

609
699

609

327
318

1
52 1

115

100

drdewa

6tf

68486— 17— TOL EC-

20 PB0CEEDIKG6 SECOND PAN AKEBICAK 8CISKTIFIG cbKOBBSS.

Raiumen de lot $ervicio$ vre$iado9j>or e$ta Ofidna durante d troMcurso de la decena que
termina udiaS dHmee de dteiembre de 19 IS — Contintia.

DIM.

TotaL

Beeord de A§enie9

Btptehies tu Caia,

DUMt»^Raitt9 Bm-

tnfadtu.

1
9

4
4

trito.

Nombnt.

J. Roane

A.Orfeg»

80
81

J. Lkxeft

B.Cttitel

J.Herreim

CBm.

R-Tnero

RegU.

F.deV Otrate.

Agente qae ha tenido meior record, BmiUo Cantel, d«l Dtotitto No. 4.

Lt^&ret enpufuenm
hMia$latrM7ratM.

Diitrltondmerol

104

Distritoodmero3

140

DistritoodmeroS

881

Distritoodmero4

425

Dlstrito otkmero 5

800

MneltodeCaballeffa...

Mnelto de San Fran-

1
1

4
1

1
2

Mnelle de Pania

MoeUef Hayana Cen-

tral

2
8

1
2

1
4

1
5

MoeUeeSanJoatf

MoeUeeTaUapledra....

DlstritodeCaMiBlanca.

DistritodeRegla

Total derates

158

103

128

182

224

150

129

168

1»447

Record batido por el Distrlto No. 4 a cargo del Inspector Sr. Eogenlo OarraUo.

Reetanen general de raUu habidoM dt9de el6 de marzo de 1914.

I^timadeoena 90,617

Esta decena 1,447

Total general 92,064

AivrrtenekLt,—^ oremaron 276 guayabitosL y de las mil ooatrodentoe ooarenta y aiete ratas captoiadas
281 se atraparon en Km reglstros del alcantarluado.

El tUtimo oaao de peste hnmana ooorrid el dla 4 de JnUo, y el tUtimo case de peete murina ooorrld el dfa
12 de mayo del aflo actuaL

Habana, 3 de dioiembre de 1915.

Vto. bno.:

Dr. F. RoDBlouss Aloitso,
J^t del Negoelado de DesraHmeUm.

ABMAMDO DSL VALLB,

StgundoJ^e,

Lleg6 la enfeimedad a adquirir a veces tal fuerza de expanai6ii que amenazaba
tomar el car&cter de pandemia. Afortunadamente se le han cortado las alas y ya hoy
muy remotas son las probabilidades de que se cumpla la profecfa de la inva8i6n de la
India por la Fiebre Amarilla siguiendo la abreviada nita del Canal de Panamd. La
Fiebre Amarilla ha desaparecido de Panami, de las Repdblicas de Centaro Am^iica,
de las Antillas y de Vera Cruz. Casi puede decirse que est4 extinguida en las costas
del Atldntico de Sur Arnica. Si el gran foco de endemiddad amarilla en el Africa
Occidental no estuviese en vlas de recibir la atenci6n que reclama, (110), (111), (112),

PXJBLIO HBALTH AND MEDIOIHB.

podiera suceder qne el amnento de las comunicadones tiaiiscontinentales y marf timas
U^gaoe a ser mia amenazadora para la India que el Canal de Panamd. Es de recoidar
que la Paste no lleg6 a nueetro Continente por la que parecfa la via mia directa, el
Facifico, flino que anibd primero a las costas del Atlintico. Desde luego^que, eecep-
toando acddentes, la rata serd aiempre la del mayor ti^co.

£1 HJgniente cuadro expone el descenso de la Fiebre Amarilla en Cuba hasta su
total extincldn:

CuAOBO III. — MortaHdad por Fidnt AmarxUa en Cuba, par 10,000 habitanUs en Jot

cttloB que ee eepeeifiectn.

Afios.

Mortatt-
dad.

1900

3.35

1901

a3i

1902

0L006

1903

1904

1905

ail

1906

a 16

1907

a27

1906

ao7

1900

1910

1911

1912

1913

1914

No tenemoB en forma utiUzable los dates anteri(»es a la Intervenci6n Americana,
pero 68 pxobable que los que de la Habana poseemos, representenlbastante aproxi-
Biadamente el movimiento de Fiebre Amarilla en toda la Reptiblica, puesto que la
H^Vna. hM ado aiempre centre distributive, no solo de mercancias ytdejinmigiantea,
amrt tambi^ de enfermedades.

CuADBO jy^.—Fiebre Amarilla. Ciudad de la Habana. NUmaro de dduneionee u
martalidad por lOfiOO habitanUe en loe afloe que ee etpec^iean.

AfiOi.

Ntawro
de

MortaU-
dad.

AiUw.

NOmero
d«

^S2^

Obitoi.

Obitoa.

dad.

1854

1,043

49.18

1886

166

8.35

1865

660

31.73

1886

167

8.84

1866

1,808

62.81

1887

683

3a 66

1867

^'068

96.88

1888

468

38.84

1868

1,896

67.01

1889

308

14.88

1860

1,198

67.61

1890

308

14.80

1860

439

31.35

1891

356

ia80

1861

1,080

49.60

1893

857

ia66

1801

1,888

67.58

1808

496

33.61

1863

660

36.86

1804

383

17.11

1864

6,665

37.15

1896

568

34.86

1866

388

11.67

1896

1,383

55.56

1866

3.50

1807

858

8a60

>2E

601

39.10

1898

186

6.70

1868

390

14.81

1899

108

4.35

1860

1,000

49.45

1900

810

13.41

1870

573

38.84

1901

a 09

18n

991

49.32

1902

1872

616

26.63

1908

1878

1,344

62.06

1904

1874

1,426

71.34

1905

a76

1876

1,101

5a 16

1906

a40

1870

1,619

81.30

1907

a 16

MSI

1,374

6a 14

1908

ao8

1878

1,669

78.38

1900

1870

1,444

73.65

1910

1880

646

83.38

1911

1881

486

34.33

1913

1888

729

36.54

1918

1888

840

43.63

1914

1884

611

35.67

PBOCBEDnrOB SEOOKD PAK AMBBIOAK SOIBinmO 00KQBB88.

Al tratar del Paludiamo en otra parte de este trabajo hube de introdudr mi cuadro
semejante a ^ste, y dije entonces que el descenflo de la mortalidad por el Paludlsmd
en la Habana y Cuba era resultado de medidas tomadas especialmente contra la
Fiebre Amarilla; y que dichas medidas conmwtfan, prindpalmente, en operadonee
contra el mosquito. Ofrecf entonces que al llegar a esta parte del trabajo, por ser
donde correefponde, presentarfa un resuznen de dichas operaciones, con relaci^ de los
gastos.

£mpezar6 dtando la f6rmula que debe servir de base en las campafias contra la
Fiebre Amarilla. Las palabras fueron escritas por el PresLdente de esta Secddn,
Dr. Gorgas, en el afio 1908: "Me inclino a creer que para la propagad^ de la Fiebre
Amarilla es necesaria la presenda de derto n6mero de mosquitos y que, genoslmente^
en los pafses de Fiebre Amarilla existe dicho ndmero con gran exceso. La campafia
contra el mosquito contin^ pues por algt&n tiempo redudendo el n6mero sin obtener
resultados apredables sobre la enfermedad; pero que, llegado a derto punto se reduce
el ntlmero por debajo del nivel neceeario, y la Hebre Amarilla cesa abruptsmente.
Mant^ngase, pues, la poblaci6n de e8t^;oinias por debajo de 6se nivel que llamar^mos el
nivel de Fiebre Amarilla y , por grande que sea el ntlmero de no inmunes o el de casos de
Fiebre Amarrilla que se introduzcan, la enfermedad no puede piopagarse." Senci*
llamente ezpuesto asf el problema es como un gran programa reduddo a una simple
cartilla.

Ezceptuando el uso de telas de alambre en los hoepitales y en lugares improvisados
de aislamiento, nuestros esfuerzos se ban dirigido casi ezdusivamente contra las
larvas de mosquitos. Me inclino a creer que los m^todos redentemente introduddos
para atacar tambi^n la forma alada del insecto merecen tomarse en consideiacidiu
Naturalmente que en presenda de un brote de Fiel^e Amarilla se impone la fond-
gad6n culicida de los lugares donde ocurren casos.

La campafia contra las larvas incluye el chapeo y limpieza de sanjas, drenaje,
eliminad6n de dep6sitos de agua, introducci6n de peces larvlfogos y el uso de larvi-
ddas (petrdleo, preparadones de fenol). Entre los peces larviddas debemos mencuH
nar los que en Oul^ llamamos guajacones. Son camivoras y abundan m^ espedid-
mente en nuestros rfos las espedes Oambusia punctata y O, puncHeulata, Poey.

El siguiente cuadro presenta el resumen del trabajo de un afio en la persecudte
de larvas. Para obtener el cuadro se ha sacado el promedio de varios afios de loa
inf ormes decenales que envfan las Jefaturas de Sanidad de toda la Repfiblica.

CuADBo y. — Ndmero de Inspeceiones por larvae y ndmero de eriaderoe que ee eneuentron^
con el tanto por ciento de eeioe.

Mmm.

Ndmero
deinspee-

dOOM.

CrfaMlerat
deltfTM.

TMDtO

dSto.

iKoero

246,846
286,808
260!804
248,006
261,701
2a, 683
268,646
244,068
287,484
248,212
244,828
281,442

282
207
268
828
880
686
678
648
028
826
878
278

0.11

fahnro

aot

fiSSS?:..... I . . .. ;

0.10

AbriJ.:::::::;::::::::;::::::::::::::!::;:":;:::::::;!:::;:::.;::;;.."..

0.U

lltyO r.r-.

0.1S

jaiUo!

0.28

Julio

0.28

Afosto

0.28

86ptleiiibn •

a28

OotubrB ... .....••••.....•......••..•...••.•.•••...•«.••.••••.••«.•.

0.21

NovtombfB

ais

DifilAmbra

0.1S

Total

2,842,462

8,108

0.17

El presupuesto para este servicio en toda la Reptiblica, en el afio de 1914, ae com*
pendia en la forma siguiente:

Personal |82&,720

Petedleo 44,732

Total 270.452

FUBUO HBALIH AND UXDlCimL 23

Otios d^ftulos del Ptesapuesto Nacional de Sanidad que asdende a $2,616,770, y
BO dedicadoe expreeamente a obras de petiolizaci6n y zanjeo, contribuyen tambi^,
de manera indirecta a la campafia contia el mosquito.

Ki colega el Dr. Agramonte ha de tratar del eetado actual del problema de la Fiebre
jmarilla deede el punto de vista epidemioldgico y etiol6gico. Sigulendo el programa
que me he trazado tzatar6 brevemente las cuestiones cuarentenarias que se reladonaa
con Fiebre Amarilla.

No ha de taidar mucho en reunirse en Montevideo la Conferencia Sanitaria de las
Keptiblicas Americanas y parece el presente Congreso lugar indicado para presentar
pnqpoeiciones de enmiendas a la Convenci6n Sanitana de Wdahlngton de 1905.

Me prqpongo, pues, discutir dicha Convenci6n en lo que se relaciona con enferme-
dades transmitidaB por insectos, y asuntos generales que con ellas se relacionan.

£1 Artfculo I de la Convenci6n se refiere a la obligaci6n que contiae todo Gobiemo
de notificar a los dem^ de la apaiici6n de un caso de Peste, C61era o Fiebre Amarilla
en 0u territorio.

En este Artlculo debiera ezigirse tambi^ la notificaci6n de la presenda de Peste
inurina, y convendrla agregar un ptoaf o por el cual se facultase a los palses a mantener
medidas especiales de defensa contra el que no cumplieee con el Articulo Primero.

£1 Articulo VII dispone que la presenda de un solo caso de Peste, C61era o Fiebre
Amarilla no impone necesariamente la aplicad6n contra un pais de las medidas
indicadas en el Capftulo II de la Convenddn.

Yo propondrla que se eliminase a la Fiebre Amarilla de esta exenci6n o piivil^o.
£n la ^poca actual, con el aumento progresivo de la poblad6n no inmune en los que
fueron focos end^micos, la presenda de un solo caso aut6ctono de Fiebre Amarilla,
descubierto probablemente despu^s del tercer dla de la enfermedad, es asunto m^
grave, a mi juido, que la presenda de un caso de las otras dos enfermedades, particu-
lannente si consideramos que pueden pasar 18 dias antes que obtengamos pruebas de
que se hayan infectado mosquitos.

Articulo VIII . Dispone que las medidas restric tlvas que contra un pais se impongan,
debedm limitarse al distrito que estd actualmente infectado.

En este articulo propondria yo que se agregase al primer pdirafo, lo siguiente:

"Podri hacerse excepcidn, en el caso de paises donde han existido, o se supone que
existen, focos end^micos de Fiebre Amarilla en medio de una poblad6n escasa y
diseminada, y donde la existencia de habitantes inmunes puede ser causa de que no
•e manifieste la presenda de mosquitos infectados."

En el tercer p&rrafo de este articulo se expresan las condidones que deben cmnplirse
para que las restricdones se limiten al distrito infectado. Aq\ii agregaria yo otra
condid6n en esta forma: ''y con la condid6n, adem£s, de que el Gobiemo afectado
dicte las medidas conducentes a obtener informes y hacer declarad6n de nuevos
casos que en otros distritos se presenton. "

Articulo IX. Expone las condidones que deberin cimiplirse antes que se declare
on distrito libre de una infecci6n, y expresa el periodo de tiempo que deberd trans-
cmrir sin que se presente caso alguno de la infecd6n. Con respecto a la Fiebre Ama-
liUa el articulo autoriza a los Gobiemos para extender este periodo. Esta autorizacidn
ha flido muy criticada, y, a mi juicio, debe mantenerse, por la misma raz6n que aduje
al analif.ar el Articulo VIII, es dedr: por el cardcter larvado o latente que puede
•■amir la Fiebre Amarilla en medio de una poblaci6n inmune. Los mejores esfuerzoe
de las autoiidades sanitarias se estrellan ante la imposibilidad de s^uir las huellas
de casos diseminados, de car^ter benigno, y que ocuiren prindpalmente entre nifios,
pero que sirven de eslabones ignorados que unen un brote epid^mico con otro.

£1 dltimo ptoafo de este Articulo, que indica las medidas que deben dictarse para
impedir la propagaci6n de la enfermedad, debiera redactarse en la forma siguiente:
"S^gundo, que todas las medidas preventivas de la propagad6n de la enfermedad
han aido aplicadas, y han aide continuadas i>or un tiempo razonable, hasta que se

24 PBOOBEDINQS SEOOND PAK AMEBIOAK BCIEKTIFIO COKGBBSS.

eetablezca satisfactofriamente que no ha habido propagaddn fueia del distiito
infectado."

ArticuloXX. 01a«iflcaci6n de navea. Elsegundopfoafodice: ''SeconaLdeiacomo
iospeekom la nave a boido de la cual ha habido caaoe de Peste o de O^eia «& el momento
de la partida o durante la travesfa, pero en el cual no ae ha declarado ningdn case
nuevo deede hace slete dias. Ser^ tambi^n Bospechoeoey tratAndose de Fiebre Anu^
rilla, Ice buquee que hayan pennaneddo en tal proximidad a las costas infectadai^
que haya hecho podble la entrada de mosquitoe en ellos."

He de proponer que el pdrrafo quede redactado en la forma mguiente:

"Se conaideraii como Bospechoso el buque a bordo del cual ha ocunido un case o
casos de Peete o de Gdlera, en el momento de la partida o durante el viaje; pero en
el cual no ha ocunido ningdn case en loe siete dlas anteriorea al de la arribada. Con
reapecto a la Fiebre Amaiilla, el barco que, habiendo eatado expueato a la introduc-
cidn del mosquito calopus de cualquier procedenda, embarca paaajeroa en puerto
infectado y llega sin fiebre amarilla a boido. Con reapecto a la Peate, tambi^ el
barco en que ha ocurrido una mortandad ins61ita de ratas."

£1 tercer pdrrafo dice: "Se considera como ind^nne, aun cuando llegue de puerto
contaminado, una nave que no ha tenido ni defundonea, ni caaoa de Peate, de O^era
o de Fiebre Amarilla a bordo, aea antes de la partida, aea durante la traveala o en el
momento de la llegada, y que, en el case de Fiebre Amarilla, no ae haya aproximado
a la coata infestada a una distancia aufidento, a juido de las autrndadea sanitariaa^
para redbir mosquitos."

Propondrfa que se modificase la ^tima parte del p^orafo que se refiere a Fiebre
Amarilla, en la forma aiguiente: "con la condid6n, ai ae tiata de Fiebre Amarilla,
de que la travesla haya durado m^ de seis dias, y que se pueda excluir la presenda
de estegomias a bordo."

ArticTilo XXI. En el pteafo 6, con referenda a la desratizadiki de baicos infectados
de Peste, propongo que se introduzca una clausula que eapecifique que la operaddn
debe hacerse con gas sulfuroso o icido cianhldrico, para obtener al mismo tiempo la
destrucddn de las pulgas y evitar la infecd6n de nuevas ratas que puedan introdudrae,
o de personas.

Artfculo XXIY . Se refiere al barco clasificado como indemne, en que aparecen rata«
infectadas, o en que se presenta una mortandad insdlita de roedores. Aqul tambi^n
debe inaistirse en el uso de gas sulfuroso o cianhldrico para la desratizad6n.

Los artfculos referentes a la Fiebre Amarilla que en la Convenci6n de Wddiington
colocamos al final con el Ntim. XLVI, para conservar el mismo orden de artfciilos que
tenia la Convend6n de Paris de 1903, deben colocarse en su lugar y recibir el Ntim.
XXIX.

El Artfculo XLVII de la Convend6n de W&ahington que, segthi lo que acabamos
de decir, debe llevar el Ntlm. XXX dice: "Los barcos sospechosos de Fiebre Amarilla
deber^ someterse a las medidas indicadas en los ntimeros 1, 3 y 5 del Artfculo anterior;
y, 81 no se fumigan, se descargar&n segta dicfpone el sub-pdrrafo (a) 6 (b) del mismo
AxtfcTilo. "Yo agregarfa, adenUb, "Con respecto al pdrrafo 3 del Artfciilo anterior,
el perfodo de observad6n deber6 contarse desde el momento de la tiltima exposici6n
al contagio."

Otro asunto que habr& de discutirse desde el punto de vista intemacional, es la
8ignificad6n de la palabra "inmune " en relad6n con la Fiebre Amarilla. Desde que
empez6 a legislarse para impedir la propagad6n de eata enfermedad, hubo que tomar
en conBideraci6n la existenda de un grupo considerable de personas que eran inmunes.
Primero se consideraron como tales a los negros y a los natives de pa^ donde reinaba
la Fiebre Amarilla. Despu^s se acept6 como base, que la inmunidad dependfa de
un ataque previo de la enfermedad. En los reglamentos de cuarentenas s61o se con-
aideraban como inmunes a aquelloa que preaentaban certificad6n aatiafactoria de

PUBLIO HEALTH AND MSDICINE. 25

haber pasado la Fiebre Amarilla, o de haber residido en un loco end^mico el tiemiK>
necesario para juatificar la supoeicidn de que ya habfan adquirido la inmunidad.

El ntfmero de mmunes a la Fiebre Amarilla disminuye progreaivamente y parece
ya llegado el tiempo de que no ae tomen en conaideraci6n al redactar reglamentoe de
cuarentenafly o, si se conaidera demaaiado radical eete acuerdo, definase, por lo menos,
k) que, en lenguaje cuarentenario, debemos entender por ''inmune."

Gomo que el ndmero de focos end^micoB viene diaminuyendo deade hace afioa,
creo que debemoe aceptar actualmente como "inmunee" a^o a aquellaa peraonaa que
ban residido en un loco reconocido como end^ico, durante diez afioe conaecutivoe
anteriores al de 19Q2.

y^aae la BibUograffa de (95) a (112).

Las FUarioM, — ^Faaamoa ahora a la conflideraci6n de laa enfermedadea filari^caa.
Fneron ^staa laa primeraa que acept^ definitivamente la cienda como enfermedadea
tnmamitidaa pcnr insectoa. En la conBidefaci6n de eate aaunto encontramoa un nuevo
i^Myo para la opinio antee expreeada en favor de la campafia contra el moaquito
como principal factor en la profilaxia del Paludiamo; pueato que dicha campafia ea
efectiva a la vez contra el Paludiamo, la Fiebre Amarilla y la Filariaaia.

Mucbo fliento no poder preaentar datoa eatadfaticoa confirmatiyoa; pero ee general
la opinidn entre loa m^dicoa de la Habana que laa manifeatacionee filarifaicaa ban
diflminuido en eata capital con laa campafiaa anticulicidaa.

Cuatro eapeciee defildridas ban aido reconocidaa en America como parasitariaa del
hombre, a aaber: Filaria Bancro/H, FUaria Demarquayif AcarUhocheUonema pentOTis y
Dirofilaria MagaJhaen. De 6ataa la MagaUiaesi, encontrada en Braail, ea muy poco
conocidsi; la Demarquayi eat4 limitada a algunaa de las Antillaa Menorea y laa Guay«
anaa, y la pentaru al Africa Tropical y la Guayana Ingleaa. La diatribucidn de eataa
fiUridas en Am^ca ea, por conaiguiente, muy reatringida. No aaf la FUcaria Banr
crofti que tiene una diatribuci6n mundial en laa tierraa bajaa y en laa cuencaa de loe
rlba, en laa zonaa tropicalea y aubtropicalea. En el Continente Americano au ^ea de
diatribxicidn abarca deade 31^ de latitud Norte baata 23^ de latitud Sur.

Laa aiguientea eapeciea de moaqultoa ban aido aefialadaa como transmiaoraa de la
Banearofti en America: en primer lugar y aobre todaa laa dem^ la CuUx /atigam,
Mia dudoeamente la Aedes (Stegomyia) calopiu y CelUa aUnmana, Al Dr. Lebredo
(117) debemoe una deecripci6n muy completa del mecanismo de la inoculaci6n de
la filaria en el memento de picar el moaquito.

Hay razonea para creer que la Bcmcrofti y la pentaru ban aido introducidaa en eete
Continente en ^poca relativamente reciente. La importaci6n de eeclavoe de la coata
Occidental de Africa debe de baber aido el medio de introducci6n de ambaa; aunque
la BoTiero/H pudiera tambi^n baber aido importada de Asia por loa cidla.

Ea intereeante obaervar que algunaa formaa de filiridaa y el Dracunculus, que deben
haber sido importadoe frecuentemente con loa negroa de Africa (del Dractinculua ae
aabe poeitivamente) nunca lograron naturalizarae en America, evldentemente porque
no exiate el hu^ed intermediaiio. En Cuba a61o logr6 domiciliarae la Bancroft!,
aunque eete pafa redbid, proporcionalmente a au poblaci6n, m^ negroa que ninguno
olio, y continu6 recibi^ndoloe baata una fecba m^ reciente.

y^ase la BibUograffa de (113) a (121).

lyits eJkmtemdtico.'-EstBk enfermedad nunca ha llegado a tomar, en America, laa
grandee propordonea que en el Viejo Continente. Exiaten aquf, ain embargo, focoa
end^micoe, de loe cualea el m^ importante por au peniatencia, gravedad y extenaidn,
ea el que deade bace mucboe afioe exiate en la meaeta central de M^jico donde ae le
conoce con el nombre de ''tabardillo." Otro foco, deaconoddo baata ^poca muy
reciente, exiate en laa dudadea importantea dd Nordeate de loe Eatadoa Unidoe
donde ae preeenta la enfermedad en forma baatante atenuada y con poca tenden-
da a la propagad6n. En eata forma hi6 deacrita como nueva entidad noaol6gica por
Bxill, y ae llam6 BriU'a Diaeaae. (124.)

26 PBOCEEDINGS SECOND PAN AMEBICAK 8CIENTIFI0 00NGBES8.

No 86 presenta el Tifos Ezantem^tico en las Antillaa. La clase de poblaci6n que
padece el Tifus, que ee la clase pobre, no emigra en America, por lo menos, en grandes
grupos como en Europa. Deede el afio 1900 861o he viflto en Cuba un case de Tifus
Exantemdtico, que fu^ importado de la capital de M^jico. Ni ee probable que esta
infecci6n se naturalice en las taeiras calientes. El calor es poco favorable al desa-
iToUo del Fedieulus vestimenU, ya por la acci6n directa de la temperatura, como
perecen indicar los experimentoe de Anderson y Goldberger, o por la clase de ropa
que el clima requiere.

El descubrimiento de la transmisidn del Tifus Exantem&tico por el piojo de la ropa
se hizo en 1909 por NicoUe, y en el mismo afio, independientemente, por Anderson
y Goldberger (122) que estudiaban el Tifus en la meseta de M^jico. Todos estos
observadores hideron sus experiencias en monos que resultaron ser muy susceptiblee.
Nicolle experiment6 con el chinpancd y Anderson y (roldberger con el MacacuM
rhesiu.

La identidad de la enfermedad de Brill con el Tifus mejicano o Tabardillo, y con
el Tifus europeo parece estar bien establecida.

En mayo de 1914 Plotz (125) da cuenta de haber encontrado en la sangre de enfermos
de Tifus un badlo pequefio que se obtiene en culdvoe aner6bicos.

y^ase la Bibliografla de (122) a (126).

Fiebre de Uu MontafUu Rocalloioa. — ^Es esta una enfermedad humana transmitida
por garrapatas y que estd limitada a los Estados de la Uni6n Americana en la secci6n
de los Rocallosos, partlcularmente los Estados de Idaho y Montana. El foco mi»
intense se encuentra en el Valle de Bitter Root en este ^timo Estado.

Los Doctoree Wilson y Chowning de la Univeraidad de Minnesota, el Dr. H. T.
Bickets que muri6 martir de sus estudios de esta infecci6n, y oficiales medicos del
Servicio de Salud Pdblica y del Ej^rcito, han contribuldo a la elucidaddn de este
interesante problema. La Bibliografia se encuentra en un trabajo resumen de W. C.
Bucker en "Public Health Reports" de septiembre 6 de 1912.

Estos inveetigadores han demostrado que la Fiebre de los Rocallosos o Fiebre de
manchas (spotted fever) es una infecci6n transmitida por la garrapata Dermacentor
ventutus. Se han encontrado garrapatas de esta especie infectadas naturalmente y
se sospecha que la cabra (Oreamnos montanos) y la marmota {CiUlltu columbianus)
de los Rocallosos son los depositaries habituales de la infecci6n. El 4rea de distribu-
ci6n de la cabra corresponde con la de la enfermedad en el valle de Bitter Root, y
McClintic encontr6 ima garrapata infectada sobre uno de estos animales. Son suscep-
tibles a la infecci6n los siguientes mamiferoe de aquel distrito: la marmota, el topo
de aquella regi6n, la ardilla de rocas (Callospermophilus lateralis) ^ los chipmunks
(EtUamias luteiventris y E. qtuidriviUatus) y la rata de montafias (Neotoma cinerea).

No se ha descubierto el ageute inf eccioeo de esta enfermedad . Los primeros trabajos
de laboratorio parecieron indicar la presencia de un piroplasma en la sangre, pero esta
obser aci6Q no ha side confirmada por Stiles. Lo mismo puede decirse del bacilo
deecrito por Rickets.

V^ase la BihUografla de (127) a (131).

Existe tambidn en los Andes una Fiebre de las Montaflas que se presenta en algunos
valles de la Cordillera. Se ha descrito la enfermedad con los nombres de Verruga
peruana f Fiebre de Oroya, Enfemudad de Carridn, El informe preliminar de la Comlsidn
de la Escuela de Medicina Tropical de Han ard, bajo la direcci6n del Dr. Sfiong (140)
mantiene que la Verruga y la Fiebre de Oroya son dos enfermedades distintas; una
afecci6n local aquella, y una infecci6n general y gra^ e ^ta. En junio de 1913 el Dr.
Townsend, entom61ogo del Gobiemo peruano, public6 (142) la relaci6n de im experi-
mento de transmisidn de la Verruga a un perro chino, por inoculaci6n en la piel, de
unoe insectos recogidos en la zona infectada. El intedo es un Phlebotomu$ y la especie
ha side designada Verrucarum por Townsend. Segdn se informa en esta experienda
la sangre del perro preeentaba los cuerpoe endoglobulares deecubiertos por Barton, y

PUBUO HBALTH AND M8DIGIKB. 27

que han recibido el nombre de Bartania baciUifarmit. La GomiaidD de Harvaid
confinna la presencia de eetoe cuerpos en la Bangre de loe enfennos de Fiebre de Oroya.

V^a^ la BibUogiafia de (132) a (143).

La$ Espiroqtieto9e8. — De macho menos importancia que las eufermedades hasta ahora
mencionadas tenemos en Arnica ^ureas de infecci6n por las espiroqu^tidas. El g^nero
de esta familia que presenta especies paiasitariaa en el hombre, y causantes de fiebres
del tipo recunente, es el g^nero Spiro9(Aaudinn%a,

Mucho se ha diecutido sobre ai las espiroqu^tidas debeo claaificaree entre las bacterlas
o entre loe protozoarioe, sin que, hasta ahora, se haya resuelto definitivamente el
problema.

Se han descrito varias especies de Spiroschaudinnia, cada una de las cuales produce
una enfermedad especifica, distinta de las otras; pero todas bastante parecidas entre
sf, aunque se presentan en regiones del globo muy apartadas unas de otras.

Las especies son: Spiro9chaudinnia reewrrentUf descubierta por Obermeier en 1868,
en casos de Fiebre Recunente europea. Fu6 ^ste el primer microorganiamo descu-
bierto y comprobado como agente de una enfermedad en el hombre. Transmftese
esta eq>ecie por la chinche, Clinoeorii leetulariui y por los piojos.

8. DoUoni, es el microbio de la Fiebre Recurrente del Africa Occidental y de
Colombia, infecci6n transmltida por especies de la ^unilia de las ArgdsidaM: el OmithO'
doftu mouhata en el Africa Occidental y el Argaa Americanus en Colombia. Algunos
autores no admiten la identidad de estas doe formas de Spiroschaudinnia.

S. Novyi, agente infecti . o de la Fiebre Recurrente de Norte America; 8, Carteri de
la Recurrente de la India y S, Berbere de la del Africa Septentrional. Estas dos
dltimas son tiunsmitidas por piojos.

V^ase Bibliografla de (144) a (149).

La Tripanoiomiasu humana de Amhica, — Como era de esperarse, la gran ciudad
tropical de Rio de Janeiro ha llegado a ser centio importante de investigaciones en
lledicina Tropical. En tomo del '' Institute OswaJdo Cruz" y de la distinguida
pecBonalidad cuyo nombre Ueva, se ha formado una escuela notable a la vez por los
brillantes resultados practices obtenidos en la Medicina preventiva, y por las contri-
buciones a las dencias m^dicas.

La entomologfa, la helmintologia, la protozoolbgia de aquella regi6n son hoy objetos
de investigaciones y publicaciones admirables; de manera que no es poaible hacer
estudioe de caricter general sobre aquellas ramas de la ciencia sin referirse uno a la
llteratuza braailefia.

En la segunda parte del Vol. 1 de las **Memorias do Institute Oswaldo Cruz " aparece
tin trabajo (160) en que el Dr. Carlos Chagas da cuenta de una nueva Tripanosomiasis
por €i descubierta en la Proainda de Minas Geraes. Encargado de ima campafia
antipalddica en la linea de construcci6n del Ferrocarril Central, llam6 su atend6n
on hemfptero, de considerable tamafio, chupador de sangre que con el nombre de
Barbeiro era conoddo en aquella comarca e infestaba las chozas de los pobres, donde
se ocultaba de dla en grietas y rendijas de techos y paredes, para caer de noche sobre
los habitantes dormidos. El insecto es igualmente vordz en los tres perfodos de su
e\ olud6n, lar\ a, ninfa y adulto.

Un estudio cuidadoso del hemfptero revel6 al Dr. Chagas la presencia de formas
critideas en el intestine posterior. La inoculacidn de animales de laboratorio y de
monos demostr6 que las critideas eran formas evolutivas de un tripanosoma de maml-
leroe, para el cual el insecto era un hu^sped intermediario perfecto. Pudo seguir
Chagas el dclo complete de la evoluci6n. El descubrimiento de peculiares procesos
endoc^ulazes de esquizogonia di6 lugar a que se creyese necesaria la creaci6n de un
nuevo g^iero de Trypanosomidas, al que se di6 el nombre de Schizotrypanum. Mis
tarde, Chagas ysua colegas, al encontrar procesos esquizog6nicos semejantes en otras
Tiipanosomidas, han propuesto que se abandone el nuevo g^nero.

Desfgnase, pues, el pahbito, Trypano9(nna enui, y el insecto transmisor, Lamoi
mtffitHuMf de la familia B^duviidMy aerie Oymnoeerata, suborden HeUrdptera^ ocden

28 PB0GEEDING8 BEOOND PAN AMEBIOAK BCIEKTIFIO C0KGBE8S.

Eemiptera, Ptoece que el ^ero Conorrhintu, pr6xiino al Lamut, y algunas Glino-
c6ridas {Uchdarius) pueden tambi^n hacer el papel de hu^sped intermediaiio.

Es evidente que el par^to se adapta f^ilmente a variadas condidones natumlea
7 experimentales (ciiltivoa, etc.). Recieutemeute sugiere Chinas que el annadillo,
Jkayput navemeinetui, puede aer el depositario natural del par&aito.

Dada la adaptabilidad del oiganumo no debe mara illamos que la infecci6n ae haya
generaliaado en la comarca y que constltuya un gra :iiiimo tdtctor de destruccidn y
degeneiaci6n en las claaes pobres. En loe perfodoe de su desarrollo adiptase tambi^n
el par&aito a variadas localizacionee endocelulaies que producen, en la esquizogonia,
miUtiples lesiones de di ersos diganos, como el tiroidee, el aistema ner /ioeo y el muscu-
lar, incluyendo el coras6n. La gametogonia se produce en las c^lulas endoteliales
de los capilares del pulm6n. Tambi^n los eritrocitos albergan por algdn tiempo a
los merossoitos en su crecimiento. Esta mdltiple exuberancia da lugar a la mia
extraordinaria combinaci6n de sfntomas, desde ed case agudo de 10 a 30 dlas de dura-
ci6n, hasta las variadas manifestaciones cr6nicas que constituyen diveraas formas de
la enfeimedad: la peeudomixedematosa, la mixedematosa, la cardiaca, la nerviosa y
la fonna cr6nica con exacerbacionee agudas.

Las formas agudas ocurren generalmente en la primera infancia, de manera que las
formas cr6nicas que se presentan en nifios que sobreviven al ataque agudo, tienen la
duraci6n toda de la vida para extender su miserable carrera de infortunios.

La enfennedad se caracteriza siempre por una hiperplasia del tiroides con dismlnu-
cl6n de su acti idad funcional, por lo que se le ha dado el nombre de tyraiditU para"
titaria. Presenta, miB o menos intensamente, los fen6meno6 del hipotiroidismo, as(
como tambi^n los de la insuliclencia suprarenal. SI consideramos por un memento
los efectos de estas insuficiencias glandulares y los que ban de producir mdltiples
lesiones del sistema ner ioeo, formas difusas de meningo-ence&ilitis, lesiones mlocardf-
ticas mds o menos extensas, no deber&n de aorprendemos las aiguieDtea palabraa del
Dr. Ghagaa: ''Melhor fdra, no ponto de ^ ista social, viesse aempre a morte elimlnar
da comunhSo himiana esses especimes de degenera^fto esqulzotripaaoaica, evitando
asdm a continuag&o de uma vidaimproducente." Mejor fuera, dice, desde el punto
de - ista social, que ^ iniese siempre la^ muerte a eliminar de la comuni6n himiana esas
muestras de d^;eneraci6n esquizotripandsica, evitando de eate mode la continuaci6n
de vidas improducti as.

La naturaleza de este trabajo no me permite entrar en deacripciones m^ completas
de tan singular enfermedad y debo ahora poner tannine a esta aerie de ligeros bosquejos.
Permftaseme, sin embargo, que al concluir insista por un memento sobre el punto
mds saliente de esta nue a doctrina de enfermedades transmitidas por insectos, punto
que no * acilo en declarar, es el beneficio inmenso que le ha reportado a la humanidad.

Podemos predecir con satis&u:ci6n los reaultadoe del deacubrimiento del Dr. Chagas
sobre aquella poblaci6n degenerada, cretina, paralitica, de las comarcas del orte de
Minas Geraes. Podemos predecir c6mo se eliminard allf otra de las r6moras que
imped fan la marcha de los pueblos tropicales. La mayor parte de las enfermedades
que hemes bosquejado en eate trabajo afectan eapecialmente al hombre de loa tr6picos,
y algunas han despoblado extensas regiones de aquella zona.

Desde el comienzo de estos estudios he crefdo, y asf ha pensado tambi^n nueatro
Preddente, que la nueva luz aer& punto de atracci6n para loa fundadorea de imperios,
y que un gran por\ enir le eapera a laa razaa que han venido luchando contra inniune-
rables obstdculos para reno% ar las grandes civilizaciones del pasado en las tierras
del Sol.

Y pensar, Sefiores, que un hombre clamaba por largos afios en el desierto, clamaba
en A ano para que el mundo \iese la nueva luz. A 61 dedicamos las palabras de Garlyle :
"Cuintas -v eces hemes visto algtin explorador aventurero que, entre las censuras de la
mdltitud, penetra por regi6n ohidada y distante, pero de importancla vital, cuyos
teaoros escondidos bi6 61 el primero en descubrir y proclamar persistentemente, hasta

PUBLIO HEALTH AKD MSDIOINB. 29

<liie la fttenci^ii van enal y el etfaeno alH ae fijaion, y el triunfo tti6 complete. De
ial mode, en aqoellM sua excuraioneB, al parecer ain nimbo, abre nuevas orientaciones
y foada cobniaa habitablee en la vasta extenaidn ambiente de la Sombra y de la
Nada." (Sartor Renrtus. Chapter I.)

BIBUOO&AViA.

1. Annario estadistico de Venesnela y docnmentoB de 1911 y 1912. Caracas, 1913.

2. AiribUzaga, F^lix Lynch. Dipterologla Argentina. Revista del Mtueo de la
Plata, 1891.

8. Beanperthuy, Lonls-Daniel, Travaux scientifiquesde, docteur en m^ecine dee
heukt6B de Paris et de Caracas. Naturaliste fran^ais et mirmgiaphe. Bordeaux,
1891.

En tfto afio pabUod kM mamiaoritof QD hennano del Doctor. ]fcste lUjeeKS en el tfio 1871. Be dice quo
mnidtm etttfn ineorpondas eo oomnnieadoiwe dirlgidM a Is Academla de Parfs entre los alios de 1888
J 18B. XI eaiiltalo aobn flebie amariUa del libro que antes ae dta, le publied en "La Oaceta Ofldal da
Cnmaoi'' de mayo 38 de 1864. Dedlohocai^ttilohacolaBeltatqiieaoontintiaoidnapareoen.

DaapuN de deeir que habla sido nombrado mMloo municipal de Comani durante la epidemia de flebre
amarflla de 1868, contlnda:

"Dans la mission que j'a-* ais k remplir, j'apportais le fruit de quatorze ann^
d'obser. ations tidtes au microscope sur les alterations du sang et des autres fluidee
de r^conomie animale dans les fi^vres de tons les types."

Despu^ de algiinas declaraciones may terminantes con respecto al tratamiento,
abotda el tema de la etiologla en los aiguientes t^nninos:

L'affectioa connue sous le nom de typhus amaril, de vomissement noir, etc., est
produite par la mdme cause qui produit les fi^vree r^mittentes et intermittentes,
C'est par suite d'une distraction bien grande qu'on a fait de la fi^ re jaune une maladie
inflammatoire. L'examen microacopique dea mati^res noirea rejet^ea par les indi-
vidua atteints de la fi^\ re jaune montre qu'elles sent de la m^me nature que cellea
obaer 6ea dana lea fi^vrea irtermittentea, rdmittentea et pemicieuaea. L'analogie eat
complete; c'eat la mdme aubatance, k la couleur pr^ qui eat jaune, verd&tre ou o1 acure
dana lea autrea fl^vrea. II n'y a de diff^nce que dana le degr^ d'intenait^ de la
maladie. Sana la preoccupation de vouloir faire de la fie\ re jaune une affection dia-
tincte dea autrea fi^vrea, on eut tenu compte da antage que ce mal reconnatt pour
cauae lea mdmes foyera de putr^factioo produite par la decompoaitlon dea aul atancea
animalea et v^tal^a qui occaaionnent lea fid rea que Ton nomme miaamatiquea de
toua lea types; et que cea fi^ rea coexiatent constamment a ec lea epid^miea de typhus
amaril. Som ent, du reate, la lid re jaune re% ^t une forme normale qui n'eat pas
one complication (comme on Ta donn^ k entendre) et pr^aente lea typea remittent et
intermittent, et dana ce caa toua lea auteura aont d'accord aur Tefficacite dea anti-
periodiquea pour enrayer la marche de cette affection. Noua ne pou ona partager
Topi^on dea auteura qui attribuent lea aympt^knea obser ^a dana la premiere p^riode
de la fi^re jaune k une gaatrite. L'autopeie ne confrme paa cette manidre de oir,
puisque dana le plua grand nombre de caa la muqueuae inteatinale eat intacte, et lea
ecchymoaea qu'on obaer . e quelquefoia k aa aurface ne doi ent paa 6tre plua attrit u^ea
k un etat inflammatoire que lea peteduea et ecchymoaea de la p>eau ne procMent de
rinflammation de cette membrane. Cea epanchementa aont dua k la grande lique-
faction du aang qui auinte en quelque aorte k la surface dea muqueuaea, comme cela
arri e dana le acorbut, la fidvre typh<Ade, dana lea caa de mort due k la moraure dea
serpents ^ enimeux, etc.

Le friaaon, la c^phalalgie, lea naua^ea, lea etourdiaaementa, la conrbature, etc., qni
s'obeervent an debut du typhua amaril, aont lea mdmea aymptdmea qu'on obaerve, k
on mcandre degre, il eat vrai, dana I'invaaion dea fievrea remittentea et intermittentea;
et penonne ne a'eat aviae, dana cea demidrea maladiea, de lea attribuer k rinflammation
de la membrane gaatro-inteatinale; et jamaia cea aymptdmea n'ont ete regardea comme
one centre-indication k I'emploi dea antiperiodiquea.

so PB00EEDING8 8B00ND PAN AMEBIOAN 8GIBHIIFI0 C0KGBE88.

Le typhus amaril est une fi^vre de type axumnal, qu'on doit attaquer nns attendre
la r^miflBion dee symptdmefl, et 11 hnt adminiatrer les neatralisuitB dee influenoea
r^ut^ miaamatiquee, dans le fort mdme de la fi^vre, comme cela ae pratique dans lea
premiers acc^ des fi^vree pemideusee: m^thode qui est constamment suivie dee plus
heureux succ^.

Qu'il me salt permis, en terminant ce court expos6, de dire quelques mots des
traitements pr^conis^ dans le but de ranger la fi^vre jaune sous Tempire de certaines
doctrines.

La saign^e est constamment nuisible. Elle a deux graves inconv^nients: celui
d'activer Tabsorption de la mati^ alt6r6e et qui constitue k un degr^ avanc6 la
substance noire des dejections, et de preparer une convalescence tx^B longue. Lea
saign^es locales sont ^galement nuisibles pour lee mdmes raisons, bien qu'k un moindre
degr6.

Lea vomitifs sont, pour le moins, inutiles. lis fatiguent les malades, et n'ont paa
la puissance de d^truire Tagent morbide.

Lea puigadfa ne aont indiqu^s que lorsque les antipModiques ont neutraUs^ Taction
d^l^t^e de Tagent r^put^ miaematique.

On ne pent conaid^er la fi^vre jaune comme une a£fection contagieuse. Les causes
de cette maladie ae d^veloppent dana des conditiona climat^riquea leur permettant
de a'^tendre k la foia ou aucceaaivement aur pluaieura locality. Gee conditiona aont:
rei^vation de la temperature, I'humidite, le voiainage des cours d'eau, les lagunee,
le peu d'ei6vation du sol au-dessus du niveau de la mer. Ges conditions sont cellee
qui favorisent le d6veloppement des insectes tipulaires.

La fi^vre jaune n'^tend jamais see ravages dana lea terraina mar^cageux de Tinterieur
de la province de Cuman^. Elle eat inconnue dana lea belles et fertiles valines de
Cumanacoa, de San Antonio, de San Francisco, Guanaguana et de Caripe, vall6es
deatin^ea k devenir avec le tempa de granda centarea de population, et dont Taltitude
varie de 200 2i 800 m^trea.

La fi^vre jaune ne diff^ dee fi^vres putrides, remittentes et intermittentes, que
par rintensite dea symptdmea. Comme cee maladiea, elle se d^veloppe apr^ une
p^riode plus ou moina longue d'incubation, p^riode pendant laquelle lea fluidea
lymphatiquea et sanguina aont alt^r^a profond^ment, avant m^me qu'aucun aymiH
t6me faaae entendre son cri d'alarme.

Lea tipulea introdulsent dana la peau leur su^oir, compost d'un aiguillon canalia6
piquant et de deux acies lat^rales; ils instillent dana la plaie une liqueur venimeuae
qui a dea propri^t^s identiquea k cellea du venin dea aerpenta k crocheta. II ramoUit
lea globulea du aang, determine la rupture de leiira membranes tegumentairee, diaaout
la partie parenchymateuae, facilite le melange de la mati^ colorante avec le a6rum.
Cette action eat en quelque aorte inatantan^e, comme le d^montre Texamen microa-
copique, puiaque le sang abaorb^ par cee inaectea, au moment mtoe de la succion,
ne pr^aente paa de globulea. Cette action diaaolvante paratt faciliter le paaaage du
fluide aanguin dana le conduit capillaire du su^oir. Si Tinsecte eat interrompu dans
Poperation de la auccion, tout le venin reste dans la pMe et prodult une plus vlve
d^mangeaiaon que loraqu'une grande partie du fluide venimeux est repomp^e avec
le sang. On attribue sans motif le prurit k la rupture de TaiguiUon; cet aiguiUon est
une substance cohi6e eiastique, dont je n'ai jamais observe la rupture dans mee
nombreuaea observations.

Lea agents de cette infection presentent un grand nombre de variet^s qui ne sont
paa toutes nulaibles au m^me degr^. La variety zancudo bobo^ k pattes ray^es de blanc,
est en quelque sorte Tesp^e domestique. Elle est la plus commune et sa piqilre est
inoffensive comparativement k celle des autres eep^ces. Le pt^on est le plus grot
et le plus venimeux; il produit une gale;^ son aiguillon est bifurque k son extremity;
sa piqiire, dans les cas plus favorables, otTle venin n'eet pas absori>e dans reconomie,
determine une irritation locale qui presente la forme d'un bouton prurigineux sem-

PX7BLI0 HEALTH AND MEDICINE. 31

blable an scabies pornlent, maia nullement contagieux. O'est Burtout lea enfonta
qn'il attaqne. L'^tendue da foyer de sappuration rend diffidles lea recherchea qui
tendent k d^couvrir Texiatence du aarcopte dana cea vMculea.

L'adde carboniqne aaUor^ et lliydrog^ne phoephor^, gaz d6gag^ dana la d^compo-
stum dea matidfee ammalea et v^talea en putrefaction, peuvent bien, k un certain
degr^ de concentration, d^tarminer Paflphyxie; maia jamais produire un malaiae
conpaimble aux cymptdmes des typhus ou des fi^vres d'acc^.

Lee plagea des r^giona ^quatorialea et intertaropicales sent couvertes de d^biis de
plantea marinea, de poiaBons, de crustac6s, de moUusques, etc., dont Taccumulation
pfoduit une fennentation trte active, surtout k I'dpoque de lliivemage, quand lea
pMea et lliumidit6 de la saison ferment de nouveaux elements ajout^ k la putrefac-
tion. Lee radnee et lea tronca des paietuviers (rbizophora) et autres arbres p^lagiquea
se couvrent k mar6e haute de couches de mati^res animalee, de mucosites et de myria-
des de zooph3rtee geiatineux, dont lea vastes bancs, s'etendant pendant certainea
auaona de I'annee k pluMeura millea de longueur sur la surface dea flots, sont generale-
ment connua aoua le nom de agiui mala. A la mar^e basse, toutes ces substances
ghitineuses appliqueee confxe r6corce dea arbrea se dess^chent et ferment un enduit
qui ne taide paa k ae coirompre. Lea insectes tipulaires que frequentent les sombrea
letraites formeee par lea mangliers, maintiennent leur existence en absorbant ces
ihiidea d6c<NSipoeee. G'est acddentellement, on pent le dire, qu'ila font servir le sang
de lliomme k leur nourriture, et dana ce caa, la puissance dissolvante des sues contenus
dana le tube intestinal de cea inaectea eat telle, que les globules du sang sont ramollia
€t hquefiee d'une mani^ preaque instantanee, comme j'ai eu occasion d'en faire I'ob-
aervadon au moyen du microscope. Que sont ces mati^rea p^lagiquea dont lee tripu-
lairea ae nounriaaait, ainon des substances animalee phosj^orescentes comme la chair
dee poiasona? Qu'y a-t-il d'etrange que I'lnatillation dana le corps de lliomme de
ces substances k I'^tat putride produiae des d^sordrea trte graves? M. Magendie
n'l^t-il paa pionve que quelques gouttes d'eau de poisson pourri, introduites dans le
Mag de0 animaux, determinaient en peu dlieures des symptdmes analogues k ceux
du typhus et de la fi^vre jaune? N'est-ce pas, en effet, une instillation de poisson
en putr^&Mstiim que versent ces insectes sous la peau et dans le tissu cellulaire de
lliQmine 7

n n'eat plus necessaire de chercher pourquoi le typhus icterode, si commun au
voianage de la mer, est si rare dana Tinterieor des terres et sur les lieux peu fr^quentes
par lea insectes tipulaires. On a observe k la Basse-Terre, capitale de Tune de nos
Antilles, que les epidemies de fi^vre jaune n'etendent pas leur influence pemicieuse
jusqu'au quartier du Matouba, localite aituee k une distance k peine d'une lieue de
cette yille. n faut convoiir que cette diatance eat bien rapprochee pour preserver
le Matouba des effluves pretendus nuiaibles exhales sur le littoral, et que les courants
aeriens qui leur aervent de vehiciiles peuvent y transporter en peu de minutes quand
le vent souffle dans la direction de Touest; tandis que cet eioignement du livage de
la mer, c'est^rdire dee localitea habiteea par les insectes tipulaires, eet plus que
sdBaaat pour preaerver de leur action et des gravee inconvenienta qu'elle produit.
D'ailleura la diimie n'a-t-elle paa examine lee gaz des marecagea et dee mati^ea
animales en putrefaction? Sea moyena parfoits d'analyae lui out permis de recon-
nattre que les produits volatils de ces decompositions ne sont que des addes carb-
ooique, hydrogteie sulfure et hydrog^e phosphore. II est parfadtement reconnu que
ces gas peuvent k un certain degre de concentration determiner raaphyxie, mais
jamais produire aucune maladie comparable aux sympt(knes des fi^vres d'acc^.

Non aeulement le vima des insectes tipulaires varie aelon leura esp^cea et les localitea
qn'ils habitent, mais auasi selon les saisons de Tannee.

Cast aprte les gxandes inondationa et k repoque de Tabaissement des eaux qui les
anoaent que lea aUuviona deposees sur les bonis des fleuves sont reputees malsaines.
La retndte dea eaux abandonne lea mati^rea animalee et vegetales emp&tees dans ces

32 PBOGEEDIKOS SECOND PAN AMEBIOAN 80IENTIFI0 C0NGBE8S.

teirains ^uigeux aux aideora du soleil qui Active puinwunment leur putr^foction. G'est
alors que les piqiires des insectee tipulaires qui s'alimentent de cee subfltances d^com-
poshes cauBent plus d'irritation et Bont pluB dangereusee. C'est une vMt6 reconnue
8ur lee bords de Urns lee grande fleuvee dee pays chaude, que lee fi^vree eeeentidles
diminuent et eont plue b^nignee pendant la crae dee eaux. Cee faita e'appliqaeiit
k TAmazone aued bien qu'au Magdalena. On eait que la peete dieparalt en Egsrpte
k r^poque du d^boidement du Nil.

On a dit que lee effluvee d^gag^e dee mar6cagee exeicent eur T^concnnie animale
une influence plue nuieible pendant la nuit que pendant le jour. Pour quelle raieon
en eerait-il ainai? Cee effluvee ne eont-ile pae au contraire beaucoup plue abondanta
pendant le e^jour du eoleil our Thorizon? La chaleur n'eet pae I'agent le plue actil
de la d6compoaition dee matinee v^talee et animalee, et de la f<»mation dee gas qui
e'en 6chappent7 C'eet une explication peu eatiefaieante que la euppoeition de Tinno-
cuit^ dee effluvee, pr6ciedment dane le m<Hnent de la joum^ oil ile eont plue abondante.
On a admie que cee effluvee, apr^ avoir mont^ dane Tatmoii^^ durant le jour,
retombaient pendant la nuit comme une roe6e malfaieante au voieinage dee mar^cagee.
Pour que cette explication f dt exacte, il faudiait admettre Timmobilit^ de Pair au*
deeeue dee endioitB mar^cageux. L'atmoq>h^ de cee locality n'eet-elle done pas
aoumiee k cee giande courants a^ena qui bailaient avec une viteaee de pluaieura lieues
par heure la euperficie de la terre? Que deviennent lee effluvee au milieu de cea
giande mouvemente de ventilation? Dane lee i^one ^uatorialee et tropicalee, c'eet
pr^de^ment pendant le jour que le eoleil, ce puieeant ventilateur, donne impuloon
aux courante a^ene, et c'eet au contraire pendant la nuit que Tatznoflph^ reete en
calme.

AnimakuUs de laJUvre jaune; Vermiateaux lymphaiiques.—CeB animalcules se meu-
vent dane toutee lee directione, remontant le courant, et eont dou6e d'un mouvement
de giration de drdte k gauche et de gauche k droite.

Une trte petite quantity de eulfate de quinine m^lang6e avec le liquide, paralyse
inetantantoent Taction dee animalcules. lis eont entratn^ par le cours du liquide
sane manifeeter aucun mouvement.

Nota. — Cet article a 6t6 public dane la Gazette offidelle de Cumani, le 23 mai 1854,
num. 57.

Algonos han erefdo Ter en la dta anterior donde dJee: "uneudo hobo, a pattee ray^ea de blane" qua
Beaaperthuy sefialaba eete moaquito de patas rayadas de bianco oomo el oaniante de la llebre amarina.
La Terdad es que el mendonado aator dice piedsamente lo oontrario. 81 le lee ooidadoaamonte todo a|
pasale en que ooorre la fraae antes oitada, le observaiA que Beanperthny eYldentemente conftinde doa
clases oomunes de moeqnltos rayados, a saber, a AtdeM (Steffomfia) ealoput, y el Culex toUeitaut, Este
dltimo merece ▼erdaderamente el nombre de bobo. Es muy Mdl matar este mosquito coando se posa
sobialapleL Lo oontrario suoedeoon el colofwt que eeunodelosmosqaitos mis viyos, todo lo oontrario de
bobo, £1 tolicUaut invade las habitadones hnmanas en grandee nt!meros y, sin la preeisldn de nnestroa
oonocimientos actoales, se le tomaria por una eepede domdstioa. £1 hecbo de oonsiderar Beanperthny
eete taneudo bobo como espede dom^stloa le Induce a sefialaro como el menos peligroso de los mosqultoa
porque tiene, supone #1, menos oportonidad de aUmentarse de las sabstandas anlmales y vegetales en
desoomposlddn, lasooaleSfSegto lacreendade Beauperthuy oontienen losanimAleolosde laflebie ftwiftHf^.

4. Berkely, William E. Laboratory work with moequitoes. New York, 1902.

5. Boyce, Robert W. Moequito or man? The conquest of the tropical world.
London, 1909.

6. British Museum. How to collect moequitoes, 1899.

7. Carter, H. R. Notee on the sanitation of yellow fever and malaria from isthmian
experience. Reprint from New York Med. Record, July 10, 1909.

8. Castellani and Chalmers. Manual of Tropical Medicine, 1913.

9. Chantemesse et Mosny. Traits d'Higi^ne, Vol. XVII, Etiologie et prophylaxie.
Maladies transmissiblee par la p>eau, 1911.

10. Clement, A. L. Deetruction dee insects et autree animaux nuieiblee.

11. Doty, A. H. On the extermination of the moequito. Am. Journal of the Med.
Sciences, February, 1906.

FUBUO HBALTH AND MEDIOD^ 88

12. Doty, A. H. The Mosquito: Its relation to disease and its extermination.
New York State Journal of Med., May, 1908.

13. Finlay, Carlos J. Trabajos selectoe. Selected papers. Publicaci6n del
Gobiemo de Cuba, Habana, 1912. The first publications of Finlay on the trans-
mission of disease by mosquitoes may be found also in ''Transactions of the Interna-
tional Sanitary Conference of Washington." Protocol Ntim. 7» session of Feb., 1881,
p. 34, and in the An. de la Real Acad, de Sciencias M6d. Fis. y Natur. de la Habana,
Vol. XVIII, p. 147, session of Aug. 14, 1881.

See also, ''Method of Stamping out Yellow Fever suggested since 1899 " in ''Selected
Papers" above mentioned, or Transactions of the Conference of State and Provincial
Boards of Health of North America, Oct., 1902, or New York Med. Record, May 27,
1899.

14. GaUi-Valerio, B., y Rochaz, J. Manuel pour la lutte contreles moustiques, 1906.

15. Geriiardt, C. Ueber Intermittensimpfungen. 2Seitschr. f. klin. Med., VII,
S. 373. 1884.

16. Giles, G. M. A. Handbook of the gnats or mosquitoes. London, 1902.

17. GMdi, Emil A. Die sanit&risch-pathologische Bedeutung der Insekten.
Berlin, 1913.

18. Goigas, W. 0. Sanitary Work on the Isthmus of Panama during the last three
years: Reprint frcnn the New York Med. Rec., May 19, 1907.

19. Goigas, W. C. Sanitation of the Tropics with special reference to malaria and
yellow fever. Reprint from the Journal of the Am. Med. Asso., April 3, 1909.

20. Goigas, W. 0. Sanitation of the Canal Zone. Address delivered at the Com«
mencement Exercises of Johns Hopkins Univ., June 11, 1912.

21. Grail, Ch, et Clarac, T. Traits de pathologie exotique. Vols. I and III, 1910
and 1912.

22. Grubbs, S. B. Vessels as carriers of mosquitoes. Yellow Fever Institute,
U. S. Mar. Hosp. Serv., 1903.

23. Grunbeig, Kari. Die blutsaugenden Dipteren. Jena, 1907.

24. Howard, L. O. Economic loss to the people of the United States throu|^
insects that cany disease. U. S. Dept. of Agric., Bureau of Entomology, B\il. Nthn.
78.

25. Howard, L. O., Dyar, H. G., and Knab, F. The Mosquitoes of North and
Central America and the West Indies, 3 vols., published 1912, 1915.

26. Howard, L. O. Mosquitoes. How they live, etc.. New York, 1901.

27. Howard, L. O., and Marlat, C. L. The principal household insects of the
United States. U. S. Dept. of Agric, 1902.

28. Howard, L. O. Remedies and preventives against mosquitoes. U. S. Dept.
of Agric., Ftoners' Bui., 1911. _

29. Howard, L. O. The mosquitoes of the United States. Dept. of Agric, 1900.

30. Kendall, A. I. Experiments in practical culicidal fumigation. Bui. Nthn. 2,
Board of Health, Isthmian Canal Com.

81. King, A. F. A. "Insects and disease, mosquitoes and malaria." Abstract of
a paper on "The pre\'ention of malarial disease, illustrating, inter alia, the consen a-
tive function of ague/' read before the Philosophical Society of Washington, Feb. 10,
1882. Popular Science Monthly, New York, Sept., 1883, pp. 644-658.

Aonqoe h«el« mtfs de on afto que Laveno luibla deeoublerto e] Plasmodiiim coando el Dr. King eeorlbld
sa tnba^o, no ae refleie Me a aqoel detoabrlmiento. El Dr. King diee: " Bt mt prindpal objeto presentar
eneitetrabi^Ioebediosqnepviedaeiidefeiisadel origen oollddodelasflebresmaUileas." Pareoepenaar
el Dr. King, lo miono que el Dr. Nott oon respeeto a la ilebre amarlUa, que el moequito ee en oierto mode
el agente morblfleo. Poreeoemplesasutrabajodelaiigulentenianera: "ElorlgenanlmaoularoiDseotll
de lai enfermedadee no es una nuera idea." Como qniera que tea, el Dr. King, que eseribid un afio despu^
que el Dr. Finlay luil>la heoiio bob deelaradonee oon reepecto a la tranamisldn de la flebre amarilla por el
BMaqofto, no ae refleie en manera alguna a la transmiatbilidad del paludismo de bombre a hombre, ni por

84 PBOOEEDINOS SECOND PAK AMEfilOAN SCESKTOIO 00NGBE88.

•I mosquito nl por nlngto otro medio. Oonttene, sfai embaiso, sa tnbi^ jxdm aerie de infenioeot argo*
inentot qiw pniebcm que Is praeenoift del pahidismo ae lelaoioiia de algte

toe. BreTemente ezpreaedoe los argomentoe eon: Cotocideiida de oondidonee teltiricae y cMm<ttcae que
feToreoen a los moequitos y a la enfenneded; semejama de oondioioDee que protejen al hombie contra la
flebreyoontrainseetos; la aciomeracidndeeasasseoponealdesanollodemoequitosyde la malaria. De
la mlsma mauera estodia la aeddn de la Interposieite de boeques, del enlttro del toneno, de la fanrndacidtt
de las tlerras, de la ezposiof^n duraate la noobe, del use de fuegos, de la Influenola de las ocnpadopea, da
la eleyaddn sobre el nlrel del mar j, finatanente, la ooinddeDCia del pahidismo y de los moequitos.

Es esto, sin duda, un Ingenloeo rasonamiento; pero no alcanxo a descubrlr que dlfleraeeencialmente del
que, en Ibrma m48 omda, Herd a pueblos ignoranteo en difersos pafses a las miamas eonelustonee qua ez«
ponen Beauperthuy, NoCt y King, es deeir, que los mosquitos tonlan algo que ver oon la pgodncddn del
paludlsmo.

32. Knab, Frederick. Unconsidered tacton in diaease tranflmiaaion by blood-
sucking insects. Journal of Economic Entomology, Vol. V, No. 2, 1912.

33. La eran, A. Note sur un nouveau parasite trou. 6 dans le sang de plusieurs
maladee atteinto de fi^vre palustre. Acad, de M^., Paris, 23 Nov., 1880.

34. Manson, Patrick. Tropical medicine. London, 1903.

85. Mense, Karl. Handbuch der Tropenkrankheiten. Zweite Aufl., 1913.

36. Bfitchell, Evelyn Q. Mosquito life. New York, 1907.

87. Mosquitoes or Gulicidae of New York State. New York State Museum, 1914.

88. lie propongo reproduolr fragmentos del trabalo del Dr. Nott, porque entiendo que no ae le ba com-
prsndldo y basta ae olta endneamente el tftulo de su publloaddn, que es oomo slgue:

Nott^ Joslab a, M. D., Mobile, Alabama. "Yellow Vtvti oootrMted wlfh BUious Few. Reaaoos
tar beBertng It a disease wrfftiKfto. Its mode of propagation. Bemoleoanse. Probable inseet or anlmal-
onlar origin, ete." New Orleans Medical and Burgieal Journal, VoL IV, No. 6, March, 1848.

Rs el trabajo del Dr. Nott, oonalderando la 4poea en que ae eseribld, un hibU argumento en pro de la
teoria microblana de las enfcrmedades. Lafreeuenoiaconqueemplealapalabra"inseoto"oomosindnimo
da "animilonlo'' o germen o miorobio, oomo dMamos abora, y el nso que fkconenlemente haee de aecaa
mis elerados en la esoala animal, verdaderos Inseotos, para sus ezpUcadones, ban eonduddo al esior da
erser que 41 defendla la idea de la transmisldn de la flebre amarllla por el mosquito.

Biguen los fragmentos del trabalo dtado:

I now propose to give the results of mv observations on the peculiar habits, or what
may be called the natural history of this disease, and my reasons for supposing its
q>ecific cause to exist in some form of insect life.

I propose now to show, from facts presented during the various epidemics in Mobile,
that the morbific cause of yellow f e er is not amenable to any of the laws of gases,
vapors, emanations, etc., but has an inherent power of propagatbn, independent of
the motions of the atmosphere, and which accords in many respects with the peculiar
habits and instincts of insects.

Before entering on the "Insect Hypothesis" in detail, it may be well to give a
familiar illustration of it, based on (acts well known to all classes in the cotton region.
The perfect analogy between the habits of certain insects and yellow fever will thus
be made apparent at once.

It is a law of nature that eiery plant affords sustenance to several parasitic insects.
The cotton plant, like others, is attacked by its parasites, ha- ing their peculiar habits
and instincts. One or se.eral of these insects may appear the same season, and, true
to their instincts, each attack, different parts or oigans of the plant, as the leaves,
burk, woody fiber, roots, pods or bolls, flowers, etc. Some years there may be an
entire exemption nom one of these insects, or, to use a medical phrase, there may be
a few sporadic cases. At another time a wonn may appear at a single point, and
from this focus will spread slowly o- er a portion of a field (as did the yellow fever in
1842 and 43), leaving the other portbn almost untouched. In another year a worm
comes like a great epidemic, apnearin^ at many points in rapid succession or simul-
taneously, and ravaging not only a single pUmtation but laying waste the cotton
region for several hundied miles.

All the attempts heretofore made to account for the greater activity of the morbific
cause of yellow lever at nig^t have fadled, and in my humble opinion the fact may be
much better explained by a reference to habits of insect life. Many of the Infusoria,
as wdl as insects prc^r, are rendered inactive by too much light, heat, or dryness.
They remain quiet through the day^ and do their work at nif ht.

It was not my plan to argue the insect origin of periodic tevers in this paper, but
the morbific causes of fevers have been so long and so inseparably united in the
minds of the profession that it is almost impossible to tear them asunder now.

PUBUO HEALTH AKD MEDIdNB. 35

All writefB aie a<p»ed on the foct that a very imperfect barrier will obstruct the
progresB id marsh miasmata— row of houses or of trees, etc., will often effectually
protect dwellings from the access of this faital poiaon. It is moreo>'er asserted that
these miasma are not only impeded but attracted by trees.

I ha e been a^ le in my researches, to disco ea no facts of this kind in ccmnection
with yellow fe rer, and my personal obser atbn repudiates them in toto. We ne er
find vellow fe er as the sportsmen say ''up a tree " but on the contrary, the materies
morbi, whate er it may be, creeps along the ground, regardless of winds, passing
under and throu^ houses, trees, etc., and knowing no impediment but a sheet dl
water.'

^ Contagion. If by this term we undontand that a morbid poison generated in one
li ing body may by contact, either mediate or immediate, reproduce an identical
disease in another, Uien are we justified in denying that jrellow te\ex is a contagious
disease. But while without hesitation I take this position, I am equally strong in
the con iction that there exists no concliud e e iaence that the germ or materies
morbi may not be tran^Mrted from one locality to another. There are many curious
fscts connected with this question which require a passing notice.

The insect theory here again comes to our aid, and may explain difficulties which
ha e much perplexed writers on contagion. The early history of ^rellow fe er
Is in ol ed in great obscurity, and many of the highest European authorities belie e
that this disease was imported originally into the Old World, and that it may still
be transported from one country into another. There is no time here for discussing
this point, and I will only say that the mass of authority in h or of this opinion is
such as to challenge our full respect; no reasonable man, in the present state of facts,
can assert positi ely that yellow fe. er may not, under peculiar circumstances, be
transported.

I have shown that yellow fever often commences in a point from which it gradually
extends from house to house for several weeks. Now it is clear that in this case there
must be a local, though in iaible. cause; it can not exist in the atmosphere, as it could
not, if thus diffused, be confined to a point. Suppose the infected point and a few
surrounding acres of ground were taken up in August and put down m the center of
\ew York or Philadelphia, is it not probable that the disease would spread from that
point as in Mo^ -He? If so, why may not the morbific cause 1)e carried and thrown out
of a vessel with a caigo of damaged coffee, potatoes, grain, sugar, meat, etc.? The
fferm might here 6nd a hiding place, though I ha e no idea that the gaseous emanations
from these potable or animal substances could produce yellow fe er. We ha e
no reason to belie e that such emanations, differing so widely in themsel es, can
produce one specific disease.

We ha e e idence around us almost constantlv that the germs of insects lie dormant
for indefinite periods and are then suddenly called into acti ity and propagated with
inconcei a^ le rapidity. By what physical causes these sleeping and waking states
are go emed, human sagacity can not yet di ine.

It Is proVaHe that yellow fe er is caused by an insect or animalcule bred on the
ground, and in what manner it makes its impression on the system, is but surmise —
unless the animalcule is, like that of psora, bred in the system, we could no more ex-
pect it to be contagious than the bite of a serpent. We may therefore easily under-
stand that it can at the same time be transportable in the form of germ ana yet not
contagious.

As according to the theory we are discussing, the natural history of yellow fe- er
is closely allied to the natural history of insects, it is proper that I shomd say a few
words more on the latter. The infusoria or microscopic animalcules particularly
demand a passing notice, as few of our readers ha e access to original sources on this
curious subject. It has, I think, been pretty clearly shown that the propagation of
yellow fe er can not he explained by tne malarial theory, and it must remain with
the reader to determine whether the chain of analogies offered render the insect theory
more pro> able.

The habits and instincts of larger Insects are obscured by numerous impediments,
but how much more perplexing must be the natural history of those whicn can only
be reached by powerful microsc<^Ms? We ha e learned much about the infusoria
proper, but myriads of minute beings might inhabit the air and e . en congregate in
sucn numbers as to dim the light of the sun without our being able to seize and obser . e
them. Denying animalcules the power of flight, which would be absurd, there are
•till ample pro isions of their transportation long distances, whether in the form of egg
or perfect animal.

I It if a oarkfOM tect tint from 1821^ to 1837 tbone wai no epktanio of yallow fever tn Mobile, tnd dartng
tail time tbe iteaats wen beeutltally sheUed; slnoe ISrr we have had it Ove times, and the shelling was
Bot cootlnoad. H the Imect theory be oorreot, could the lime be an impediment to their progrMs aoroet
ttneta?

684Se— 17— VOL IX— 4

86 PBOOBEDIKQS SECOND PAK AMEBIOAK BCIENTIFIO C0KGBS8B.

The narcotic poisons, for example, though deii^ ed from different plants and differing
in their analysis, will often produce symptoms so alike as to render it impossible for
us to decide under which a mitient is laboring. The same confusion will be found in
the poisonous effects of different snakes, spiders, etc. In like manner fevers, if
arising from insects of the same genus, might present some genial characteristics in
common and yet preser e specific differences.

The history of those great epidemics which sweep over the surface of the globe affords
very strong support to the insect theory.

" Whatever is true as to the habits of insects obvious to our senses is likely to be more
especially so in those whose minuteness removes them further from observation.
Their generation may be presumed to be more dependent on casualties of season and
place* their movements determined by causes of which we have less cognizance;
and their power of affecting the human body to be in some ratio to their multitude
and minuteness." This last paragraph is quoted from Sir Henry Holland.

39. Nuttall, George H. F. On the rdle of insects arachnids and myriapods, as
carriers in the spread of bacterial and parasitic diseases of man and animids. Re-
print from the Johns Hopkins Hospital reports, Vol. VIII, 1899.

40. Osbom, Herbert. Insects affecting domestic animals. XT. S. Dept. of Agri-
culture, 1896.

41. Pasos, Jos6 H. Gontribuci6n al eetudio de los mosquitos de Cuba. Bdetin de
Sanidad y beneficencia, julio-diciembre, 1909.

42. PeryasB6, Antonio Gon^alves. Os culicideos do Brazil. Trabalho do Insti-
tute de Manguinhos. Rio de Janeiro, 1908.

43. Proceedings of the Medical Asso. of the Isthmian Oanal Zone. Half-yearly,
1910-1913.

44. Rosenau, M. J. Disinfectbn against mosquitos. Bulletin No. 6. Hygienic
laboratory, U. 8. Marine Hosp. Service.

45. Revista de Medicina Tropical, Vols. I-VII, 1900-1905.

46. Rubner, Gruber u. Ficker. Handbuch der hygiene, Vol. Ill, 1913.

47. Scheube, B. Die krankheiten der warmen l&nder. Jena, 1910.

48. Sergent, Edmond. Determination des insects piqueurs et suceurs de sang.
P&ris, 1909.

49. Sergent, Ed. et Er. Moustiques et maladies infectieuses.

50. Smith, Theobald, and Eilbome, F. L. Investigations into the nature, causa-
tion, and prevention of Texas southern cattle fever. Bulletin No. 1, Bureau of Animal
Industry, U. S. Department of Agriculture, Washington, 1893.

51. Surcouf, J. M. R., et Gonzalez Rincones, R. Essai sur les dipt^res vuln^rants
du Venezuela. Paris, 1911.

52. Theobald, Fred. V. A. Monograph of the culicidae or mosquitos. 4 yds. snd
Atlas, 1901-1907.

53. Vermoret, V. Les pli^ges lumineux et la destruction des insects, 1902.

Malaria,

54. Bertrand et Ellynens. La malaria, 1903.

55. Celli, Angelo. La malaria secondo le nuove ricerche. Roma, 1899.

56. Darling, S. T. Transmiasion of malarial fe\ er in the Oanal Zone by anopheles
mosquitos. Journal of the Am. Med. Asso., Dec. 18, 1909.

57. Same. Factors in the transmiasion and prevention of malaria in the Pftnama
Canal Zone. Annals of Tropical Med. and Parasitology, July, 1910.

58. Gorgas, W. 0. The sanitary organization of the Isthmian Canal Zone as it bears
upon antimalarial work.

59. Grassi, Battista. Studi di uno zoologo sulla malaria. lUmia, 1900.

60. Guiteras, Juan. Malaria, in Manual de PWbctica Sanitaria. Issued by the
Health Department of Cuba, 1905.

61. Laveran, A. Du paludisme et de son hdmatozoaire. Ptaris, 1891.

62. Mannabeig, J. Die malaria-krankheiten in NothnagePs Specialle Fathologie
u. Therapie. Vol. II, 1899.

PUBUO HEALTH AND MBDICnnS. 37

(S3. Orenstein, A. J. Moequlto catching in dwellings In the prophylaxis of malaria.
Amoican Jour, of Pub. Health, February, 1913.

64. " Palludiflm " being the Transactions of the Committee for the Study of Malaria
in India. Simla, Noe. 1-5, 1910-12. Also Proceedings of the Third Meeting of the
General Malaria Committee, 1913.

65. Rofls, Ronald. The pre^ ention of malaria. London, 1910.

66. Stephens and Christophers. The practical study of malaria, 1908.

67. Sternberg, G. M. Malaria and malarial diseases, 1884.

Plague.

68. Agramonte, A. The late outbreak of plague in Havana. Reprint from Amer-
ican Journal of Trop. Diseases, July, 1914.

69. Agramonte, A. Plan de campafla sanitaria contra la peste bub^nica. Secre-
larfa de Sanidad y Beneficencla, 1915.

70. Agramonte, L6pez del Valle, Guiteras. Discusi<Sn sobre peste bub6nica.
Acad, de Ciencias Med. Fisicas Natur, febrero 26, 1915.

71. Baker, Carl F. The classification of American Siphonaptera. U. S. National
Museum, 1905.

72. Bamet, E. B. La peste bub^nica. Junta Sup. de Sanidad, Cuba, 1903.

73. Boelter, W. R. The rat problem. London, 1909.

74. demow, A. G. Plague in Siberia and Mongolia and the Tarbagan. The Jour-
nal of Tropical Med., Feb., 1900.

75. The same. Hie endemic centers of plague. Journal of Tropical Med., March,
April, May, 1900.

76. Creel, R. H. Epidemiology of plague in New Orleans. Am. Journal of Trop.
Die. and Prev. Med., Sept., 1915.

77. Chrux, Oswaldo Gongalvez. Peste. Instituto de Mangguinhos, 1906.

78. Eager, J. M. Hie present xMtndemic of plague. U. S. Pub. Health and Mar.
Hosp. Service, 1906.

79. Giemsa, G. Ueber die vemichtung von ratten, etc. durch kohlenozid.
Arch. f. Schififs-u. Tropen-Hygiene. Band XV, 1911.

80. Guiteras, Juan. La pulez cheopis, transmlsora de la peste bub6nica entre las
nUas de la India e& la pulga corriente en las ratas de la Habana. Comunicaci6n v erbal
COQ presentaci6n de specimens. Anales de la Acad, de Ciencias Med. Fis. y Nat. , 1908.

81. Guiteras, Juan. Three cases of bubonic plague in Habana. Journal of the
Am. Med. Asso., Nov. 16, 1912.

82. Guiteras, Juan, and Recio, A. Bubonic plague in Cuba. Reprint from Boletfn
de Sanidad y Beneficencia, 1915.

83. Hart, Merriam C. California ground squirrels. U. S. Ptih. Health Reports,
Dec. 25, 1908.

84. Journal of Hygiene. Plague numbers and papers. Vol. VI, No. 4, Sept., 1906
VoL VII, No. 3, July, 1907; Vol. VII, No. 6, Dec., 1907; Vol. VIII, No. 2, May, 1908
Yok, X, No. 2, Aug., 1910; Vol. X. No. 3, Nov., 1910; Vol. XII, No. 1, May, 1912
Voi. XII, No. 3, Oct., 1913; Vol. XIV, No. 3, Nov., 1914; Plague supplements I and
n, 1912; III, 1914; IV, 1913.

85. KoUe, W., u. Wassermann, A. Handbuch der pathogenen Mikroorganismen.
Pest. IV, Bd., p. 165, 1912.

86. Lebredo, Mario G. Plan de campafia contra la peste bubdnica. Secretarla de
Sanidad y Beneficencla, 1915.

87. Liston, W. Gl^i. The cause and prevention of the cfpread of plague in India.
Dec. 11, 1907.

88. The rat and its relation to public health. Publication of the U. S. Pub. Health
and Mar. Hoap. Service, 1910.

88 PBOCEEDIKGS SBOOKD PAK AMBBIOAK 8CIBNTIFI0 OOKOBE88.

89. Boflenau, M. J. An investigation of a pathogenic microbe applied to die
destruction of rats. Hygienic Laborat<»ry Report No. 5, U. S. Mar. Hosp. Servicf^
1901.

90. Arehivf. SMffB- u. TropenrHygiene, The first volumes from 1897 follow very
closely the march of the plague pandemic. See also the Weekly Reports at th«
U. S. Public Health Service.

91. Simpson, W. J. Recrudescence of plague in die East and its relations to
Europe. The Journal of Tropical Med., Sept., 1899.

92. Simpson, W. J. The Groonian lectures on plague. Journal of Trop. Med. and
Eyg., July-Sept., 1907.

93. SweUengrebel, N. H., u. Otten, L. Ueber "mitiglerte'' Pest Infektionbei
Ratten, etc. Arch,/, Sekiffe- u. TfoppenrHyg., Bd. XVIII, No. 6, 1914.

94. Wyman, Walter. The bubonic plague. Publication of the U. S. Mar. Hoip.
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Yellow/ever,

95. Agustin, Geoige. History of yellow fever. New Orleans, 1909.

96. Boyce, Rubert. Yellow fever and its prevention, 1911.

97. Garter, H. R. The period of incubation of yellow fever. New York Med. Ba^
March 9, 1901.

98. Same. The methods of the conveyance of yellow fever infection. Yellow
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99. Same. A note on the spread of yellow fever in houses.

100. Finlay, Carlos J. Trabajos selectos. Selected papers. Publicaci6n del
Gobiemo de Cuba. Habana, 1912. The first publications of Dr. Finlay on the
transmission of disease by mosquitoes may be found also in ''Transactions of the
International Sanitary Conference of Washington,'' Protocol No. 7, Session of Febru-
ary 18, 1881, p. 34, and in the Anales de la Real Academia de Ciencias M^cas,
Flsicas y Naturales de la Habana, Vol. XVIII, p. 147, Session of August 14, 1881.

See iJso Method of Stamping out Yellow Fever suggested since 1899, in Selected
Papers above mentioned, or Transactions of the Conference of State and Provincial
Boards of Health of North America, October, 1902, ot New York Medical Record, May
27, 1899.

101. Quiteras, Juan. Experimental yellow fever at the inoculation station, with
a view to producing immunization. Amer. Medicine, Phila., Nov. 23, 1901. Pub-
lished in Spanish in Revista de Medicina Tropical, Habana, Oct., 1901.

102. Guiteras, Juan. The natural history of epidemics of yellow fever. Annual
Report of the Supervising Suigeon General of the U. S. Mar. Hosp. Service, 1888.
Republished with notes on endemicity and infantile yellow fever, in BoMn d$
Sanxdad y Bencficeneia, Dec., 1912.

103. The same. La fiebre amarrilla infantil. Revieta de Med, Trop,^ Habana,
abril, 1902.

104. Marchoux, Salimbeni et Simond. Raport de la Mission Fran^aise. Arm,
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105. Otto, M., Neumann, E. 0. Studien tkber das Gelbe Fieber in Braailiem.
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106. Parker, H. B., Beyer, G. E., Pothier, 0. L. A study of the etiology of yeUow
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107. Reed, Walter, Carrol, James, Agramonte, A., Lazear, J. W. The etiology of
yellow fever. A preliminary note. Read at the meeting of the American Pul^
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Med. Journal, Oct. 27, 1900.

106. Reed, Walter, Carrol, James, Agramonte, A. The etiology of yellow fever.
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1901. Published in Spanish in Revista de Medicina Tropical, Habana, Feb., 1901.

PXJBUO HEALTH AND MEDIGINB. 39

109. Ribas, Emilio, Lntz, A., Pereiia, Baireto, Barroe, A., Silva, Rodrlgaes. Ex-
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110. West Africa, Disciission on the distribution and prevalence of yellow fever
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FUaria,

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114. FOllebom, Uebertiagung von Filarienkrankheiten durch MQcken. Anh, /.
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115. FOlleb<m, Beihefte. Vol. XII, 1908.

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118. Manson, Patrick. The filaria sanguinis hominis. London, 1883.

119. Mastin, W. M. History of filaria sanguinis hominis, 1888.

120. Ndfies, Enrique. La drugla de las manifestaciones filarii^sicas. Premio de
la Academia, 1905.

121. Wucherer. OauUa Med, da Bahia, Dec., 1868.

Tjfphutfi

122. Anderson, John F., and Gddbeiger, Joseph. A note on the etiology of "Tabar-
dillo," the typhus fever of Mexico. Public Health Reports, Dec. 24, 1909.

123. Andcmn, J. F. Tyjdius fever, its etiology and methods of its prevention.
U. 8. Pvbl. Health Reports, Apr. 30, 1915.

124. Brill, Nathan £. An acute infections disease of unknown origin. A clinical
■tody based on 221 cases. Am, Journal of the Med. Sdmiices, Apr., 1910.

125. Plots, Henry. The etiology of typhus fever (and of Brill's disease). PreHm-
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126. NiccoUe, Gh. Beptoduction exp^rimentale de typhus exanthdmathique dies
le rioge. Compt. Rend. Acad, de SeUnaes, juillet 12, 1909.

Rocky Mountain fever.

127. Andsfson, J. F. Spotted fever (tick fever) of the Rocky Mountains. A new-
disease. Hygienic Lab. Bulletin No. 14, U. 8. Pub. Health and Mar. Hosp. Service,
1903.

128. Aihbum, P. M., and Craig, Ghas. F. A comparative study <^ tsutsugamushi
disease and spotted fever or tick fever of Montana. Manila, 1908.

129. McOlintic, T. B. Rocky Mountain spotted fever, being the last season's notes
(1912) before he died of the disease he was studying. Public Health Reports, Apr.
24,1914.

130. Reed, R. Harvey. A contribution to the study <^ mountain fever. Journal
Am, Mad. Asso,, April 20, 1908.

131. Stiles, Ch. Wardell. A zoological investigation into the cause, tzansnussbn,
and source of Rocky Mountain "spotted fever." Hygienic Laboratory Bulletin* No
20, 1915. Public Health and Mar. Hosp. Service.

40 PBOGEEDINGS SECOND PAN AKBBIOAK 80IBNTIFI0 OOKOBB88.

Oroiyajtver.

132. BaasetrSmith, P. W. The pathology ctf the blood in Verruga. Brit, Med.
Jaum., 1909, Sept. 16, p. 783.

133. Biffi, Ugo. Sobre las h^noaglutinas de la aangre humana y hematologfa de
la ''enfermedad de Oarridn." Bol de la Aead. NaeUm. de med. de Lima, III, 1903,
No. 2.

134. Biffi y Carbajal, G. Sobre un caso de "enfermedad de CtmGia" con vernico-
mas 8upurado6. Cr6niea midica, XXI, 15 de Oct. de 1914.

135. Hiisch. Handb. d. hist.-geogr. Path.- 2. Anfl. II, 1883, p. 78.

136. Odiiosola, Ernesto. Estado actual de nuestroe conodmientos acerca de.Ia
enfermedad de Ganidn o verruga peruana. lima-Perd, 1908.

137. Odiiozola. Gac, med. de Lima, 1858, abril; Med, Tim. and Oaz., 1858, Sept.,
p. 280.

138. Ruge, R. Zur geographischen Pathologie der WestikOste Siklamerikas. Beri.
tlin, Woeh,, 1897, No. 46, p. 1005.

139. Salasar. Oae, med, de Lima, 1860.

140. Strong, Richard P., Tyzs^, £. E., Brues, Charles T., Sellards, A. W., Gasti*-
bum, J. C. Verruga Peruviana, Oroya Fever and Uta. Preliminary report of tlie
first expedition to South America hem. the department of tropical medicine of
Harvard University. Jour, of the Am, Med, Aseo,, Nov. 8, 1913, Vol. LXI, p. 1718.

141. Tamayo, M. 0. Apuntee sobre la bacteriologia de la enfermedad de Carridn.
Cr6n. Mid, Lima, jtmio, 1913.

142. Townsend, C. H. T. La Zitira es traamisora de la Verruga Peruana. Cr&mea
Med,, junio, 1913.

143. Townsend, Charles H. T. The Transmission of Verruga by PhlebotomiiB.
Jour, of the Am. Med. Auo., Nov. 8, 1913, Vol. LXI, p. 1717.

Spiro€haetoiii,

144. Balfour, Andrew. The q[>irochaetae of Egyptian reli^MUig fever. Fourth
Report of the WeUcome Tropical Reeeanh Laboratoriee, 1911.

145. Breinl, A., Kingdom, A. Observations on the animal reactions of the spiro-
chaetae of the African tick fever. Lancet, March, 1906.

146. Same. Studies on q[>irillum Obermeieri and related organisms. Jour, qf
In/, Die,, Chicago, May, 1906.

147. MtUilens, P. Ruckfallfieber. Spiroch&ten. Handbudi der path, mikroofg.
Eolle u. Wassermann, Bd. VII, p. 864, 1913.

148. Novy, F. G., Enapp, R. £. Spirochaetae Obermeieri. Jour. Am. Med.
Am$o., Jan. 13, 1906.

149. Sergent, Edm., Foley, H. Recherches sur la fi^vre recurrente. Ann, d$
rinetitut Poiteur, May, 1910.

TrypanoeomiUmt.

150. Chagas, Carlos. Nova tripanozomiaze humana. Estudios sobre a morfoloji*
e o ciclo evolutive do Schizotrypanum cnud n. gen. n. ep. ajente etiolojico de novm
entidade morbida do homem. Memoriae do Inetituto Otwaldo Cruz, agosto, 1909.

151. Chagas, Carlos. Nova entidade morbida do homem (Resume geral de estudos
etiolojicos e clinicos). Memoriae do InetUuto Otwaldo Cruz, Tomo III, Fadculo
II, 1911.

152. Diaz, Ezequiel. Molestia de Carlos Chagas. Estudios hematologicos. Memo-
riae do Inetituto Oewaldo Cruz, Tomo IV, Facfculo 1, 1912.

153. Guerreiro, Cezar. Observa^oee urolojicas na molestia de Carlos Chagas.
Memoriae do Inetiiuto Oewaldo Cruz, Tomo IV, Facfculo 1, 1912.

154. Hartmann. Notiz liber eine weitere AH der Schizogonie von Schizotrypanum
cruzi. Arch,/, Protietenkunde, 1910, Vol. 10, p. 361.

PUBLIO HEALTH AND MBDIOINB. 41

155. Mayer, Martin, a. da Bocha-Iimai H. Zum Vedialten von Schizotrypanum
cniii in WarmblHtem und AiQacfpoden, ArMvf. Sehift u. Trop.-Eyg., Beihefte,
VoL XVIII, 1914.

156. Viann% Gaqiar. Gontiibu9ao para o eatado de anatomia patolojica de "Mo-
leetia de Oarloa Ghagas " (Eaquizotiipanoae humana ou tireoidite parazitaria). Menuh
fiat do ImtUuto Otwaldo Cna, Tomo III, Fadcolo II, 1911.

Dr. AfifsTiDES Agbamonte. Before begiiming the discussion of
this interesting paper of Dr. Guiteras, I b^ to move you, sir, that
the suggestions which Dr. Guiteras has made toward modifying the
articles adopted by the last Pan American conference be referred to
a committee for action, report, and recommendation; and, further^
more, that the chairman be authorized to appoint this committee.

The motion was seconded and unanimously approved.

The Chairman. Since this subject is somewhat aUied, I will refer
it to the committee just appointed, consisting of Dr. Guiteras, Dr.
Carter, and Dr. Vital Brasil.

CoL John Van R. Hoff. It has been suggested that Section VHI
of this congress consider most praiseworthy the work done in Cuba by
the various organizers of the health organization there, and pass a
resolution of thanks and applause to said organizers. I wish to
make this motion.

The motion was seconded and unanimously approved.

The CH/vraMAN, As Dr. Carter's paper wlQ be upon much the same
subject as that of Dr. Guiteras, the chair will rule that further dis-
cussion be postponed until the conclusion of Dr. Carter's paper.

Hereupon, Dr. Agramonte, of Habana, Cuba, took the chair.

IMMUNITT TO YELLOW FEVER.

By H. R. carter,
AtsisUmi Surgeon Oeneralf United States Public Health Service,

Whether the Immunity pvoduced by an attack of yellow fever ia permanent or
tttnpofary ia a disputed point among modem epidemiologista. NaturaUy, a diaeaae
pfodoced by rnkfoorganiama and which recovers apontaneonaly mnat produce im«
mnnity, local or general, tonpoiary or pennanent, else one would not recover. That
U ia permanent haa been, and ia now, the opinion of American epidemiologistB and
of the older generation of the French and English writers, who added so much to our
knowledge of thia disease by their observations in the West Indies and in Africa.

There was, however, a very common belief among the laity of localities in which
yellow fever was endemic that leaving such focus of endemidty for a sufficient time
would reetare the susceptibility to the disease. This belief is alluded to by many
writers. It was, I think, universally r^arded as erroneous by those not living in
endemic arttm, bat given more consideration and sometimes, I think not generally,
affirmed by writefs who live in such endemic areas.

On the other hand, a commission of the Pasteur Institute (Marchoux, Salimbeni,
and Simimd), working at Rio Janeiro in 1903 to 1905 state categorically that the im*

42 PB00EEDIKG8 8B00KD PAK AMEBICAK BGIBKTIFIO COKOBESS.

immunity i»oduced by an attack of yellow fev^ gives temporary immunity only
and that the inf ecti<m is kept up in endemic centers by recurrent attacks among
the indigines. This view is reiterated by other recent French observers and, so
far as recurrent attacks being common, is accepted by Seidelin, Bubert Boyce, and
others. Indeed, it is fair to say that this view, that recurrent attacks of yellow fever
are common, is held by nearly all of the writers recently engaged in investigating
the epidemiology of yellow fever. Seidelin seems to base his belief mainly on the
occurrence of sickness in men who have had yellow fever before, which attacks he
pronounces to be also yellow fever on account of finding in the blood of these patients
the organism, Paraplasma flavigenum, he believes to be the cause of yellow fever.

When the statement above quoted was first made by Mardioux and Simond no
evidence therefor was, I think, given. A large amount is given, however, by Simond
and his collaborators in the report on the epidemic at Martinique in 1908 and 1909.
This report is far stronger in its implication of recurrent attacks than it is in assa-
tions of definite recurrences in individual cases and it is a strong report. Without
cnticiaing it— this would require a greats knowledge ol the nosology and epidemi-
ology of Martinique than I possess— it is so at variance with what I have seen in the
United States, in Cuba, and in Panama that it seems advisable to give such reasons
as I have for the opposite view. Especially as one would suppose that in the United
States where greats intervals occur between epidemics of yellow fever, which have
also been apparently both more extensive and more severe than those in Martinique,
one would be more apt to find recurrent attacks than in that island.

In speaking of the immunity given by an attack of yellow fever being permanent —
generally permanent only is meant. Absolute immunity given by one attack is
not predicated of any disease.

Obviously, the natural method of testing this question is by observation of the
exposure of men who have had yellow fever to the infection of that disease and deter-
mining if they contract it again. The existence of the infection and degree of ex-
posure would be judged of by the proportion of cases contracted by those who had not
had yellow fever similarly exposed to infection as contrds. If a negative result is
reported the observation would be convincing in proportion to the number of sup-
posedly immune men thus exposed, the intervals from their last attacks, the degree
of exposure, and the certainty that secondary attacks did not occur among them.

Such observations are not rare. For instance, at the end of 1879, there must have
been a very small proportion of the population of New Orleans, Mobile, and the coast
towns between them who had not suffered an attack of yellow fever in that or in
previous years. They were free from yellow fever until 1897. In that year and 1898
there were widespread epidemics. Yet recurrent attacks were reported in extremely
few cases in these towns in 1897 and 1898, 18 years lat^. Certainly no considerable
number of well-marked cases could have occurred in those years. The same is true
of many other epidemics and many other towns in the United States. We can readily
present then a large number of people having had one attack of yellow fever exposed
alter sufficiently long intervals to infections very prevalent among those who had
not had yellow fever with report of no, or extremely few, cases of yellow fever among
them.

Ou^t not this to be convincing of the permanency—the general permanency— of
the immunity? Put yourself on the other side. The first three factors in the evi-
dence: The number of people exposed, the lengths of the intervals and the prev-
alence of the infection— you will readily grant us; but I fear that a question will be
raised on the last condition— the certainty that secondary cases did not occur. The
question will be asked: Is it certain that yellow fever did not occur, and quite gen-
erally, among these people? It would be held that on account of b^eving that <me
attadc gives permanent protection we would not recognize yellow tevet occurring
among them.

^PXTBIIO HEALTH AND MEDICINE. 43

There is truth in thifl contention. We of my generation have accepted previous
opinion on this matter and, not having found it contradicted by obvious facts, have
not examined into the matter critically. We assumed that one attack gave perma-
nent protection. We would then have been little apt to consider an attack of sick-
ness occurring in one who had previously had yellow fever as yellow fever unless it
was either (1) well marked or (2) gave rise to yellow fever in others. The first might
not be the case with lig^t — certainly not wit^ ephemeral — attacks, the kind which
woidd naturally occur as second attacks. The second we will consider presently.

Even if a second attack were clearly yellow fever one with our belief would, in the
absence of good evidence to the contrary, question the diagnosis of the previously
reported attack. This it is natural to do because we know how many cases of other
diseases are diagnosticated as yellow fever during an epidemic. I did this in the
case of an officer in my service, who died of yellow fever under my care at Chande-
leur in 1890. He was reported to have had yellow fever in 1878. For the acceptance
of a second attack then it might require that a well marked case of yellow fever
occur twice in the same person. Now, even under the doctrine of temporary immu-
nity, this would be rare, as those who hold it also hold that there would be a lowered
susceptibility from the first attack and that if the attacks were not very far apart
the second one would be mild— or very mild — and that is reasonable. You can see
then that we have not been in a proper state of mind to examine this part of the ques*
tion critically, and indeed I at least have not done so. Even allowing for this, the
number of second attacks reported in places in which yellow fever occurs only in
epidemics — the places in which we would be most apt to expect them — are exceed-
ingly rare. They are reputed, however, and the recognition of such cases is proof
that our eyes are not so blinded by our belief that we can not recognize second attacks
of yellow fever, if they be plain enough. I have seen three cases of yellow fever in
people who were said to have had a previous attack. In two of them the evidence
for the first attack seemed to me to be slight; the third I could not inquire into.

When we come to individual cases, the men we knew who had yellow fever at one
epidemic and were exposed to it a second time after a considerable interval — and I
have seen many such— the most I can say is that in my acquaintance I have not
known a second attack to be reported. Drs. P. and W. had yellow fever in Memphis,
Tenn., in 1878 and 1870, respectively, and were not exposed again until 1897 at Ed-
wards, Miss., after intervals of 18 and 19 yean. P. was not reported to have yellow
fever at Edwards, but he woi sick there with a diagnosis of malarial fever, which was
also prevalent and to which he was subject. W. was not sick at all. Lieut. G. had
yellow fever in Brownsville, Tex., in 1882. No exposure untO 1898 at Siboney, 16
years later. He was sick at, or after leaving, Siboney with a diagnosis of malarial
fever, which was extremely prevalent. He did have malaria; plasmodia demon-
strated and recurrent attacks for about a year; but that by no means excludes the pos-
sibility of yellow fever. Dr. P., of my service, had yellow fever at Chattanooga, Tenn. ,
in 1878. Next exposure was at Panama in 1903 — ^26 years interval. He was, after
nearly a year's residence in good health at Panama City, sick at Ancon Hospital in
October, 1904, with what I myself thought was going to develop into a severe attack
of yellow fever until the second day, when the case showed itself to be clearly dengue^
I am satisfied that this case was dengue— although it was before we knew the diag-
nostic value of the blood-picture— for it was a severe case, and such are well marked.
The terminal eruption, too, was typical. Yet you see that one believing that secondary
cases are common might find fault with the diagnoses of all of the above. Icouldadd
ol my own knowledge I think from 25 to 50 cases to the above, but they would be
more or less similar. Some did not get sick on the second or subsequent exposure»
yet that is not convincing. Some people who have never had yellow fever go through
an eiademie unscathed. Also, light attacks might well escape any notice.

44 PBOOEEDIKGS 8B00KD PAK AKBBIOAK SOIBNTIFIO 00K0BE88.

The difltodty is that we recognize no sign %a pathognomonic for all caaes of yellow
fever, the mild and ephemeral as well as the severe. It is true that Seidelin claims
to have such a sign in his Paraplasma flavigenum, and also to have demonstrated it
in a secondary (ephemeral) case of yeUow fever in himself and in others, some of
whom showed no signs of illness— i. e. were "carriers.'' Without in any way pro-
nouncing on the validity of his claims, yet until his primary contention is con-
firmed—the transferrence to guinea pigs is certainly discredited— we can not accept
the existence of his bodies as pathognomonic of yellow fever and hence as proving
a second attack.

The second test, that yellow fever was communicated to others from cases of sick-
ness of men who had previously had yellow fever, Ib again hard for us to apply.

When you consider how freely men '* protected by a previous attack of yellow
fever" have been allowed to move from places virulently affected with that disease
into susceptible communities in the United States, and how many hundreds of times
this has occurred during epidemics, you would think we should have satisfactory
data on this subject, positive or negative. If not immune to yellow fever, some of
these men should have contracted it and developed it in an infectable but not
infected place, and even if not diagnosticated it should have infected mosquitoes
and spread to others in whom the diagnosis would be easy. An epidemic can not
be hidden.

I know of no evidence that this has occurred, yet the evidence to the contrary
has not been scrutinized critically. Since we did not believe that secondary cases
of yellow fever occurred— or occurred very rarely— if an outbreak occurred we would
be little apt to impute conveyance of yellow fever to any sickness of indeterminate
nature occurring among people who were "protected by a previous attack of yellow
fever.'' Almost any other hypothesis would be accepted to explain it, or it would
be left unexplained. Indeed, in times of epidemics there are so many ways in which
infection can be introduced that an outbreak of which we are not able to explain
the introduction is not to be wondered at.

To use this test, then, we must depend upon the scrutiny of exposures of susceptible
communities to cases of sickness of such "protected" men who had themselves been
exposed to yellow fever and under such conditions that other sources of exposure of
the community are excluded. Opportunity for tlus would rarely occur during an
epidemic.

As evidence that attacks of yellow fever do not recur among such "protected"
people, these observations to be convincing must be on a laige scale; there must be
many failures of susceptible communities thus to receive infection. Tlus would
be negative testimony and convincing only in proportion to its mass. I know of
no positive observations on this subject. It seems useless to relate the twenty-five
or thirty-^naybe fifty— negative observations I could give you. They are not
enou^ to be convindng.

Possibly, however, we have in the passenger traffic of the Plant Steamship line
data of sufficient mass to be worth considering. From 1889 to 1800, inclusive (9 years)
there was no bar to the transit on these vessels from Habana to Key West and Tampa
of passengers "protected against yellow fever by a ptewioua attack or 10' years resi-
dence in an endemic focus," and a great many of them came— Cubans on their 10
years' residence and Americans on certificates of a previous attack. There were
dgar Victories in Key West, Tampa, and Jacksonville, all manned by Cuban em-
ployees. There were generally two vessels per week; part of the time three vessels.
Habana was about 6 hours from Key West and 24 frc»n Tampa. I am unable to get
the exact numbers of these passengers on account of the destruction of the records
of the State Board of Health of Florida by fire. Such reports of this board as are
available to me give the number of such passengers as follows:

PUBUO HEALTH AND MBDIOIKB. 45

Tampa Bay quarantiiie —

1891, May 1 to October 31 2,620

1892, May 1 to October 31 2,684

1893, May 1 to October 31 2,449

1894, May 1 to October 31 3,681

PoupyeM* 11,434

Key West—

1893, Aogiist, September, and October 3,134

1894, May 1 to October 31 7,656

One and a half years 10, 690

In addition we have a Habana record showing that about 3,420 passengers were
co-tified fen- Tampa in 1895 (2,850 from May to October 1). At the above rate the
entries at Tampa would, for 9 years, be 25,726. Call them 20,000, to be conserva-
tive. For the short time of which we have record, Key West had^ double as many
entries as Tampa, and this is in accord with my observation at the time in 1899. It
will be very conservative, then, to put the number of these so-called ''immune pas-
■eaigera" at 30,000 for the 9 years-^it was more likely 50,000 or 60,000. Many entries
naturally were of the same people going backward and forward between Habana and
Florida ports. Now, remember that this very considerable number of people— and I
have given you minimal figures — came from a city where yellow fever was epidemic;
that they came in hot weather; to towns where Aides calopus (Stegomyia) were abun-
dant and active and where people susceptible to yellow fever were also abundant.
If, then, any considerable propc^on of them after arrival had been infective to
Aides eaiopue (Stegomyia) I can not but think that there would have been at least
one outbreak of yellow fever in Florida during these 9 years. There was none.

Were these people so exposed in Habana that any considerable number of them
would certainly hare contracted yellow fever if they were susceptible to that disease?
Let us see. That those who had not had yellow fever were liable, and very liable, to
oontzact that disease from exposure in Habana at this time was evidenced by the his-
tory d vessels from that pert whose personnel had not had yellow fever. They fre-
quently brou^ cases of yellow fever to our quarantine stations. In 1895 at the Dry
Toftugas I had 13 cases of yellow fever on Habana vessels out of a crew list of less than
450 men. Indeed the crew list of men exposed to infection in Habana was not over
hall of 450 as the steamers lay in a safe part of the harbor— Triscofia— and allowed only
a Tery few men ashore and were practically free from fever. It occurred (with one
exception) on vessels which had lain on the Habana side of the harbor. Unqueetion-
My then, those susceptible to yellow fever could contract it in Habana during this
time.

Compare these observations:

(1) Four-hundred and fifty people who had not had yellow fever, from Habana,
gave 13 cases of yellow fever, every one of which should have been infective to Aidee
ealajme (Stegomifia).

(2) Thirty thousand people from the same place during a period covering the same
time give no evidence of infecting .£det calopus (Stegomyia): certainly gave rise to no
outbreak in the susceptible communities to which they moved.

You may not consider this proof* There may not be enough of it to satisfy you;
bat the mass of this evidence, negative as it is, is sufficient, until the contrary is proven,
to omfirm me in my belief that for sanitary purposes the immunity conferred by one
attack of yellow fever is permanent: that recurrent attacks, infective to Aides ccdopus
(Stegomyia), do not occur and that we are justified in basing our sanitary measures
thereon. It alioald at least prevent your acceptance of the doctrine that the immunity
ooof erred by an attack of yellow fever is quite temporary and that subsequent attacks

46 PBOCBBDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

infeddve to Aides ealoptu {SUgomyis) are common and that sanitary measures based
on the contrary opinion are not justifiable and unsafe. This observation— the passen-
ger traffic of the Plant line— is also inconsistent with the existence of ''Carriers'' as a
common phenomenon capable of infecting JBtfet calopus (Stegamifia) with yellow
fever.

I said " until the contrary is proven," because if it be ever shown that an organism
causative of yellow fever occurs in men who have had previous attacks of this disease,
and is conveyable from them by 2Ede$ ealopui (SUgom^) mosquitoes to other men,
producing yellow fever in them, I will count the contrary proven. I well know how
much more determinative are the results of experimental than of epidemiologicai
investigations. Yet in this disease it was, I believe, the latter that gave the^key to
the problem; which determined the direction of the experimental investigation which
demonstrated the method of conveyance. I do not mean that this is the only mean»
of demonstration. Even if the causative microorganism is not demonstrated, the
frequent recurrence of clinical yellow fever in those who have had one attack, 9m
indicated in the Martinique epidemic sufficiently verified, would be proof.

There are other epidemiological investigations which are at least consistent with a
doctrine of permanent immunity such as the spontaneous disappearance of yellow fe vet
from small and moderately sized towns in the Tropics which received few susceptible
immigrants. I do not mean that this alwa>s occurs, but it is by no means rare in
America. The great decrease of infection in Habana in 1899, due to the falling off of
immigration in the previous years, is also consistent with it. This was shown in the
small number of cases of yellow fever in the spring and summer of that year as com-
pared with normal years, although the town was full of Americans who went everywhere
and of Mdes ecdofms (Stegomffia).

SUHMABT.

Is the immunity conferred by an attack of yellow fever permanent, or are subsequent
attacks common? The first is the view held by observers in countries where yellow
fever prevails epidemically. The second has been the belief of many, especially of
the laity, in endemic foci. It is now held by many eminent investigators who have
worked in endemic foci of yellow fever; by the majority of recent writers, I think.

The evidence for the permanence of this immunity oug^t to be most abundant in
places where yellow fever occurs in epidemics and much is brought fcnward, negative
from the nature of the case. This evidence would rarely be satisfactory to those hold-
ing a contrary view, because the belief of the physicians in such places that this
immtmity is permanent would render them little apt to recognise secondary attack*
unless they were well marked, and they would rarely be well marked.

There are, however, some epidemiological data which, as far as they go, are evidence
against the occurrence of secondary cases infective to AlkUi ealopuM (Stegamyia),

Thus: Between the years 1888 and 1898 there entered Florida ports over 30,0(M>
people certified as ''protected from yellow fever by previous attack, or 10 years'
residence in an infected focus. " They came during the summer, May 1 to October
31 from Habana, where yellow fever prevailed during this time — ^to Key West and
Tampa — towns full of Aides ealopus (Stegamyia) and of people susceptible to yellow
fever. The time of passage was about 8 hours to Key West and 24 to Tampa. As no
yellow fever developed ia Florida during this period there should have been no con*
siderable number of secondary attacks infective to Aides ealopus (Stegamyia) among
these people.

That yellow fever could be readily contracted from Habana by people susceptible
to it is shown by the fact that during this time 450 people from Habana not certified
as immune to yellow fever yielded 13 cases of yellow fevor at a quarantine station.

As 13 cases of yellow fever, any one of which should have been infective to Mlts
ealopus (Stegamyia), occurred among 450 men who had not suffered from one attack

FUBUO HBALTH AND HBDIGIKB. 47

it would seem that, if recurrmt attacks were common, enough cases should have
occurred among the 30,000 to have produced an outbreak in Florida. There was
none.

The abore is also evidence tiiat yellow fever carriers are not as common as allied
by soma modem obeerven.

BIBUOORAFHT.

Marchoox et Simond. Annales de Tlnstitute, 1905

Ifarchoux et Simond. Etudes sur la Fi^vre Jaune. Ann. de Tlnstitute Pasteur.

1906.
Simond, Aubert et Noc. Epidemieologue Amarile. Ann. de Tlnstitute Pasteur.

1909
<9axac et Simond. La Fidvre Jaune. Pathologie Exotique. Vol. 111.
Sddelin Harald. Report of yellow fever expedition to Yucatan. 1911-12.
Seidelin Harald. Nature and Control of Yellow Fever. 1912.
Seidelin Harald. On the Existence of "Pseudo-Carriers" of the Infection of Yellow

Fever. 1914.
Britidi Yellow Fever Commission. Reports 1913 and 1914.
BepcHts State Board of Health of Florida. 1891 to 1896.

The chairman called for a discussion of the papers of Dr. Guiteras
and Dr. Carter. The discussions in Portuguese and Spanish of Dr.
"^tal Brazil of Brazil, Dr. Elias Sag&maga of Bolivia, and Dr. Luis
Ifigone of Paraguay were unfortimately not reported.

Dr. Daicaso Ritas. This subject of tropical diseases is of great
interest, and it has been so wonderfully illuminated by our teacher,
Dr. Guiteras, that there is really nothing to add. Still, there are
some other observations from the standpoint of my own experience
that I would like to speak of.

Emetin, since the subject has been mentioned, is not in my judg-
ment a specific. I have treated cases of ameba dysenterise with
emetin, and I have been able to remove the ameba from the intestines
if I searched long enough, but I never was able to find the occult blood.
I refer to that, because the occidt blood is a test more deUcate than
the microscopical finding of the ameba. The ameba may not be
found in sufficient nimibers so as to be seen imder the microscope,
but the occult blood test I have found more reUable. Emetin has
also been used a great deal in pyorrhea alveolaris. So far as my
experience is concerned, it has no especial value. Of course, I would
not say that emetin in dysentery has no tonic value.

The discussion by Dr. Rafael Gonzalez-Rincones, of Venezuela, in
Spanish was not reported.

Dr. GurrsBAS. Dr. Carter did not use, I think, an argument which
certainly should have some weight, though it is of negative charac-
ter also: It does not seem to me that it would have been possible to
eradicate yellow fever from Habana, the neighboring cities and the
country in Cuba in general, if the recurrence of yellow fever were the
rule as these gentlemen seem to imply. To me that appeals very
strongly. I do not see how yellow fever could have disappeared imder
these circumstances; for instance, if it was being kept up in the interior

48 PB00EEDING8 SECOND PAN AMEBIGAN 8CIBKTIFIC C0KGBB88.

by repeated attacks among the Cuban population. We never should
have seen the end of it, it seems to me.

Dr. Cabteb. When I spoke of the immunity from yellow fever as
being permanent, I meant that it was generally permanent, as per-
manent as that of smallpox, of measles, and of the other zymotic
diseases. Secondary attacks imquestionably occur, but the teaching
at present of certain schools is that secondary attacks are common,
that immunity is not only transitory but very transitory, that it
lasts but a short while. I was led to write this paper because recently
I have been investigating the nature of a disease, trying to determine
whether it was yellow fever or not. I found that it occurred habitu-
ally among people who had been long resident in endemic centers;
and in one case at least had occurred in one who certainly had had
yellow fever. Tlu-ee gentlemen whom I know, one who had worked
with SeideUn in Africa, one who had worked with Simond in Mar-
tinique, and a third, firmly believe that there was no immunity beyond
six months or a year or two years, that secondary attacks of yellow
fever were not only common but the rule. Therefore the conclusion
that I tried to draw from the occurrence of this disease among those
who had had yellow fever fell to the ground. I saw at once that
they were properly unwilling to accept my statement of not having
seen secondary attacks, of not knowing of secondary attacks, at a less
value than I placed on it. It was perfectly true, as they stated, that I
had not been in the proper mental state to fairly evaluate the symp-
toms of obscure diseases or httle ailments, ephemeral diseases occur-
ring in those who had had yellow fever; that I did not expect them to
be yellow fever and therefore might overlook them. Therefore I made
my argument and rested my case upon the broad epidemiological
fact of the immune traffic from Habana to Florida, 30,000 (there
are really about 50,000) people who had had yellow fever coming
from Habana in the summer time into a coimtry where yellow fever
was not prevalent, where stegomyia were present, and that was
full of people who had never had yellow fever. The time of passage
was from 6 to 24 hours. If they had been subject to secondary
attacks or if carriers had been at all common among them, it seemed
to me that they would unquestionably have infected stegomyia in
Florida. Out of this number of people, from 30,000 to 50,000,
some of them would have infected stegomyia and would have pro-
duced an epidemic. Now an epidemic can not be hid. It is upon
that broad epidemiological fact that I rest my thesis that secondary
attacks in yellow fever are rare and from the sanitary standpoint
need not be regarded.

The Chairman. If there is no further discussion I shall announce
that the next paper will be read by title, as the author, Dr. Allen J.
Smith, has just sent a telegram, stating that it will be impossible for
him to be present this morning and read his paper in person.

PUBUO HEALTH AND HBDIOimL 49

FBLARIASIS IN THE AMERICAS.

By ALLEN J. SMITH.
MeManes Laboratofiet of Pathology of the School of Medicme, University of Penn-

sylvania.

In broad wignificance the tenns filariaais, filariosis, and filarial disease have an
inclusive application necessarily beyond the scope of an article intended for current
piesentation; although the writer in the course of literature consultation required
for the preparation of the present pi^>er has been fully persuaded of the desirability
of an inclusive monograph upon the major title, embracing the filarial parasites both
ol man and of the lower animals, with appropriate presentation of their morphology,
life histories, modes of acquirement, and of the pathological consequences of para-
sitism by them, as well as their geographical distribution and histories.

The full subject being of unwieldy proportions the present discussion will be
limited to the geographical distribution and history in the Americas of those species
ol the filarid» which parasitize man, with further restriction, too, to those particular
qpedee alone whose larval or microfilarial stages ^ are met in the blood (for conven-
ience, therefore, to the exclusion of DraeuneuluM medinermi (linn., 1768), the ques-
tionable species FHaria oris hominis Leidy, 1860, and Agamofilaria georgiana Stiles,
1906), and to a few points of particular interest to the writer in the clinical study of
filariaais. Recently Padilla' published his discovery of the presence of a small
aperiodic, actively motUe microfilaria in the blood of persons presenting no symptoms
referable to the parawtes, in the Province of Tucuman in Argentina (in over 25 per
cent of individuals examined in the Galera district, in over 16 per cent of those exam-
ined in Arcadia). This he regards as a new species (F, tvcwnani), in which view he
is not, however, sustained by Neiva, of the Cruz Institute of Rio de Janeiro. The
writer believes he would be acting prematurely in at once accepting the verity ol
Padilla's new species, as in a number of respects (exclusive of its ensheathment, which
Padilla asserts, but which might be a mistake when we remember that Manson himself
at first thought the microfilariae of po'ttoru were ensheathed) it closely resembles the
larval Filana demarquayi. He may perhaps therefore at the present time be pardoned
if no systematic discussion of the proposed species is included in the current paper.
Unquestionably fuller knowledge with confirmation or with correction will shortly
follow.

American Filabiasis.

1. FILARIA BANOROPn (OOBBOLD, Wl),

Synonyms: F. sanguinis hominis Lewis, 1872; F. sanguinis i^gyptioa Sonsino« 1875;
F. damathemiea da Silva Araujo, 1875; F. toUchereri da Silva Lima, 1877; F. noctuma
Hanson, 1891.

Historical. — ^This, the pathologically most important and the most widely distrib-
uted of the restricted group of filarial worms here under consideration, was discovered

> TiMb nme microlUariA, suggested by Le Danteo in 1904 (Malad. des Pays Chaads, Paris, 1010, p. 1000)
M a oonveolent tonn lor th$ vennioular brood met in the blood of the definitive host of whatever species, is
▼arioosly employed as synonymous with the words embryo and larva. The writer believes that a difler-
anttatlon of terms to be applied to the different early stages of tiie parasite is desirable; and he would sog-
gist that the term filarial embryo be applied only to the vermioule within the egg membrane within the
iit«us of the mother; that the term microfilaria or filarial larva be restricted to tiie vsrmicule, whether
shsathed or free, alter its birth and during its presence in the blood or other fiuids of tiie definitive host and
betev tta aoeees to the intermediate insect host; that for tiie stage represented by the further developed
▼wnieale in the mosquito or other intermediate host Uie term prefilaria be employed; and that these
taam be understood as gensral to aU speoMs, to be employed in connection with the spedflo name of the
tdnlt fliaila wbsB refvenee to particular stages of the early lif^ of the parasites is desirable.

■ SaaniM msdioa, BiMOOt AJrss, 1915, Sept S, anno 23, p. 871.

50 PBOOEBDIKGS SEOONP PAIST AMEBICAK SdEKTIFIO C0KGBB88.

in its larval or microfilarial form in 1863 by Demarquay, in Paris, in the fluid with-
drawn from a hydrocele of a patient from Habana.' Demarquay's part in the history
of the parasite attracted little attention and was practically overlooked untU recalled
in 1881 by Dr. Bemhaus de lima.' Three years alter Demarquay's discovery, the
parasite was independently found, again in its microfilarial stage, in the Uoody and
chylous urine of a number of individuals in Bahia, Brazil, by 0. Wtlcherer,* the hosts
being for the most part natives of Brazil. By these first two demonstrations of this,
the first known human hematic microfilaria, America became definitely fixed in the
histcny of our knowledge of this parasite.

,In 1870, Timothy R. Lewis* met the same larval filari« in Galcutta, in the chylous
urine and later in the blood * both of chylurics and of persons apparently in health.
Lewis gave the first descriptbn of the microfilarial sheath, and applied tA these
hematozoa the name Fiiaria mmgxdnis hominis (dropped by rule along with others in
favor of the name first assigned to the later described adult worm of the species).

In 1876, Bancroft, at Brisbane, Australia, after having encountered the larval form
in chylous urine and in the blood, first met with an adult female parasite in a lym-
phatic abscess; and the following year Cobbold, to whom the specimen was sent for
study, described it and gave it the specific name Fiiaria hancrofti* Shortly after
Lewis ' and Garter*, in India, also obtained adult specimens, the former contributing
the first description of the male. Da Silva Araujo* in October, 1877, in Bahia, autf
about a month later dos Santos,** in Rio de Janeiro, first met with the adult parasite
in the Western Hemisphere.

From the time ot their first recognition until 1891 all microfilarise fbund in humaa
blood were r^arded in casual manner as identical and as belonging to the species
here under consideration. Manson," to whom we owe so much of our knowledge of
filariasis in general, in this latter year called attention to the fact that more than one
species, represented by hematic microfilariae, infest man; and separated primarily
those with microfilariae in the peripheral blood stream at night from those whose
larvae are present in the peripheral circulation during the day, and those, the micro-
filariae of which may be found in the peripheral blood both day and night. His
names for these species, Fiiaria noetwma, Fiiaria diuma, and Fiiaria perstans are of
commendable descriptive value; but in accordance with the rules of zoological nomen-
clature the first and second are properly but synonyms for Fiiaria hancrofti Cobbold,
1877, and Loa loa Guyot, 1807.

The rdle of mosquitoes as intermediate hosts of Fiiaria bancrofti was first urged by
Manson,*' his study being taken up from purely theoretical reasouing as to the need
of some bloodsucking agent to free the microfilariae from the original host. The
experimental work was prosecuted in 1877, Manson feeding a number of bloodsucking

1 Oas. mM. de Ptrit, Oct. 11, 1883, p. 686.

• Th«86 inaug., Rio de Janeiro, 1881.

• Oas. med. da Bahia, Dec. 16, 1868, p. 97; fl>id., Sept. 30, 1800, p. 39; of. Unuperger, Zeitsofar. f. Fara-
•Itenk, 1860, t. 1. p. 376; Lenckart, Parasiteii, 1878, Lelpxig and Heidelberg, v. 2, p. 640, et ante.

« Sixth Aon. Rep. Sanit. Comm., Qoyt. India, Appendix A ,p. 196-178, 1870; Brit. Med. Jour., Nov. 19^
1870.

• Rigbth Ann. Rep. Sanit. Oomm., Ooyt. India, Appendix B, p. 9(1, 1879; eee abo Qoain's Diet, of Med.»
arte., Chyloria, Fiiaria saitguinia komhHt.

•London Lancet, July 14, 1877, ▼. 2, p. 70; iWd., Oct. 6, 1877, ▼. 9, p. 496.
f London Lancet, Sept. 99, 1877, t. 9, p. 453.

• Carter undoubtedly early propoeed explanation Ibr the ohylurio fymptoma; but the writer haa tilled
to find reference to the prcoent connection of his name except In Bancroft, and Indudes hie name here
because of the authority of Brumpt, Precis de Parasltologle, 9d ed., 1918, p. 504.

• Oat. mM. da Bahia, Not. 1877; abet. In Arch, de mM. nav., Paris, lUrch, 1878.
■* Progresso mM., Rio de Janeiro, Deo. 15, 1877.

u London Lancet, 1801, t. 1, p. 4; Brtt. Med. Jour. 1897, ▼. 9, p. 1837.

u Cobbold, London Lancet, 1878, ▼. 49, p. 60; Manson In Davidson's Hygiene and Diseases of Warm
Climates, 1803, Edinburgh and London, p. 771; Jour. Lbm. 8oc. London, Aug. 1878, ▼. 14, Zoology, p. 804;
Trans. Linn. Soo., London, 1884, sec ser., t. 9^ Zoology, p. 367.

PUBLIC HEALTH AND MEDIOINB. 51

iBsects upon a filariated individual and examining them at intervalB therealter. In
moflt of the insects the larval filarue were digested or else at least failed to develop;
bnt in a certain mosquito they grew in size and underwent a developmental difiPeren-
tiation. His observations were early and fully corroborated by Lewis,' Sonsino,'
Silva Araujo,* Bancroft,^ and others. At first, while it was appreciated that the
prefilarise underwent a probably necessary development in the mosquito, it was be-
lieved that the latter, dying when ovipositing on water, was responsible in the greatest
sense only for affording access of the parasites to water ; that they became free for a time
in water; and were transferred to the definitive himian host when water containing the
vermicules was swallowed. The real part taken by the mosquito as the direct trans-
mitter as well as an intermediate host came to be accepted only after the studies of
Grassi and No^, and subsequently of Ftkllebom, proving the direct transmission of
Dtrofilaria immxHi Leidy, of the dog, by mosquitoes, and after further studies of Man-
Bdn and Bancroft, and of Low,' James, and 'others, about 1900; but for a considerably
later period the idea of water convection continued to attract adherents (as Audain
and Ricot, in Haiti). ^

From the earliest observations the association of filarial parasitism with hematuria
and chyluria was recognized, although not explained. An influence on the x>art of
FtUma banerofti in the etiology of lymphvarices and elephantiasis was likewise sug-
gested at an early date, as in the experience of Lewis ' and others; but perhaps to
Hanson's studies more than to any preceding influence should be credited our pre-
vailing views aB te the explanation of the relation between the parasite and these
filarial manifestations, with the addendum of the further influence of bacteria (the
dermococcus of Le Dantec) in inducing the recurrent and eventually chronic in-
flamations which lead to the great fibrous overgrowth in the skin in elephantiasis.

OtograpMcal distribtuion in America. — Precise information of the existence of this
type of filariasis is best afforded by examination of blood withdrawn at nighttime by
puncture of the peripheral circulation of the individual under suspicion; and from a
reasonable number of such investigations of different life-residents of a given locality
an acceptable idea of the endemic presence or absence of the affection and of its rate
of incidence in the locality is attained. (It is true that if one will withdraw a larger
amount of blood, hemol3rse it and centrifugate, microfilariae of the species may be
found at almost any time in the 24 hours; but during the day there is a chance that
even by this method the parasites will be missed.) Data based upon such ideal
methods of study are unfortunately obtainable in published form for only a com-
paratively small part of the general American distribution. Hematochyluria, lym-
phedema and elephantiasis are, it is true, comparatively common clinical complica-
tions of filariasis of this type; but it must be kept in mind that other causes of
lymph obstruction than filarial parasites are possible. The endemic prevalence of
such conditions, however, is not likely to be due to such other influences; and in the
absence of better evidence these complications are very commonly accepted as
indicating the presence of this parasite in an area concerned.

Based upon evidence of varying exactness, but in the main quite credible, it is safe
to say, as most writers declare, that Bancroft's filaria is known to-day to be the most
widely distributed species of filaria parasitizing human beings, extending unevenly
throughout the whole tropical belt, and north and south in diminishing rate beyond
the thirtieth degree of latitude.

1 Proc. Asiatlo Soc, B«Dgal, March, 1878, p. 80.
>lCed. Ttmetand Gas., May 37, 1883, p. 654.

* R«f erred to by MiiCft^>**^ in Revlata dos Corios tlMorioaa a prat, da Facnlt. da MM. da Rio de Janairo,
1885, ami. 3, no. 8.
«8dentlflo Lactorae, Brlabane, 1879.
> Brit. Mad. Jour., 1900, v. 1, p. 1466.
« BtH. Mad. Joor., ▼. 3, p. 663.

' Flarraa faitartropicalae, Aodaln, 1909, Porto an Princa, pp. 790-803.
Eighth Aim. Rep. Sanit. Comm., Govt. India, App. B, p. 341, 1873.

e843e— 17— VOL rr 6

52 PBOCEEDINOS SECOND PAN AMEBICAN SCIENTIFIC CONGRESS.

As far at America is concerned, it is very improbable that the worm is indigenous,
although no less acute and erudite clinical reasoner than Carlos Finlay * has raised the
question of its pre-Columbian existence in the Western Hemisphere; suggesting that
possibly the idol Tetzahuitl (meaning ''a horror") may have been intended to repre-
sent filarial disease, being made in the image of a man with a necklace of 10 human
hearts and with a great serp>ent about his body intertwined among a variety of animal
figures. On the contrary, there is a prevalent belief, expressed as early as 1750 for
elephantiasis by Hillary ' and repeated by many others, as in recent years by
Daniels, ' that the species was introduced into America from Africa with the importa-
tion of negro slaves.

There are reasons, suggestive if no more, partly based on the history of human com-
merce and travel in comparison with the grades of infestment of known districts and
the history of ancient prevalence of such manifestations of filariasis as elephantiasis
and chyluria, that would support the conjecture that the original location of the species
was along the southern coast of Asia, and that the parasite spread thence east and west
into Indo-China and Oceania on the one hand and into Africa on the other. In the
latter continent it would appear to have taken a hold first in lower Egypt and the
nearer shores, and to have followed thence along the east coast and to Madagascar, to
have penetrated Africa along the Nile, and to have proceeded along the Mediterranean
coast to and along the west coast of Africa, penetrating thence into the interior along
the Kongo Basin.

The known severity of infestment of some of the Antilles, the fact noted both by
Hillary * and by Hendy ' that elephantiasis is said to have been rare at the beginning
of the eighteenth century in Barbados (although later become so common as to have
acquired the name '* Barbados leg"), and the absence of notice of such a striking
phenomenon as elephantiasis in the detailed records of the discoverers and the con.
querors (as the "Decades" of Peter Martyr, Eden's Translation, 1555) give food for
belief that with the transportation of negroes from the west coast of Africa the parasite
found its first fixed hold in the Western World in the West Indian Islands. From the
frequent infestment of and high grade of prevalence in the Leeward and Windward
Islands one may at least tentatively believe that the parasite found early lodgment
here; although the relative importance of Cuba, Haiti, and Porto Rico make it im-
probable that these large islands failed to be invaded as weU.

The widespread occurrence of filariasis in the West Indies was doubtless largely a
sequence of interinsular communication, with perhaps repeated renewal from Africa.
That the parasite spread from the island foci to the mainland is probable and is
somewhat supported by the popular belief in Dutch Guiana* that elephantiasiB
was brought into that coimtry in 1799 by negro slaves from Barbados. The marked
grade of infestment in Brazil about Bahia and Rio de Janeiro, and the early employ-
ment of negroes in the development of these districts, make it probable that here,
too, direct importation from AMca determined special foci of parasites. The com-
parative freedom of the Pacific coast, even in tropical America, in contrast with the
long range of Atlantic coastal infestment, gives further weight to the general view here
expressed of the origin of American filariasis of the Bancroft type from trans- Atlantic
(presumably African) importation.

As known to-day in America the species has been met in cases indigenous to the
districts for which they were reported as far north as Philadelphia and in South
America as far south as Buenos Aires.

1 Aim. de la real. Acad, de Ciencia8,eto.,de la Habana, 1882, v. 19, p. 40; also Trabs^os select., 1912, p. 611.
> Diseases, acute and ohronio, peculiar to the island of Barbados, I/ondon, 1750; referred to by Castellani
and Chalmers, lianual of Tropical Medicine, 2 ed., 1913, p. 112S.

• Brit. Med. Jour., Sept. 24, 1808, v. 2, p. 879.
« Sup. dt.

• Glandular Disease in Barbadoes, London, 1784; referred to by Castellani and Chalmors, Man. Trop.
Diseases. 2 ed., 1013, p. 1125.

• DaTidsoo's Qeosraphioal Pathology, New Yofk, 1803, r. % p. 9S7.

PUBLIC HEALTH AND MEDIOIKE. 53

United StaUM. — In 1897 Duim ^ published the occurrence of Bancroft's ^ariasis in
a young woman 19 years of age, a native of Philadelphia and resident of this city con-
tinuously, with the exception of a visit in Altoona, Pa. ; somewhat earlier Wyim '
had published a case occurring in a woman of Indiana who, while having visited in
"the West" and in New York City, ''had never resided in nor visited tropical or
subtropical r^ons"; and still earlier Weiss ' had reported a case on about the same
level of latitude in a child who had never been outside of the State of Illinois, John-
stone in 1903 reporting a second case from the same Stated In 1891 Slaughter ^
announced his discovery of two indigenous cases of hematochyluria with micro-
filariss in the urine from the northern part of Virginia, one of his patients residing
within 6 miles of Washington, D. C.

In 1913 Barnes reported a third case of Bancroft's filariasis from the same district
in a Washington negro bom in Maryland and never farther south than Culpeper, Va.*
Nofthingham ^ reports a case of elephantiasis of questionable type, which he regards
as of filarial origin, in a mulatto native of North Carolina, living near Wilmin^n.
Microfilariae were not demonstrated in the case. He quotes Dr. Eoyster, of the same
State, to the effect that filariasis is rare in North Carolina, and Dr. E. J. Wood as
regarding it comparatively common. The first demonstrated cases of indigenous
filariasiB of this type in the United States were reported by John Guit^ras " from Charles-
ton, S. C, along with four other cases from Key West, Fla. These Florida subjects
were natives of Cuba and had probably brought their parasites from their home island;
but Guit^ras expressly stated his belief that the worm existed at the time of his obser-
vations either as '*a permanent resident or a successful colonist in the island of Key
West." His belief has since been confirmed for the State of Florida;* and in South
Carolina, in addition to sporadic cases in the general littoral, Charleston has proved
to be by far the most severely infested focus of filariasis in the United States if not in
the whole world,'^ Johnson " reporting 19.25 per cent of positive findings in 400 hospital
inmates within the past year. A case studied in Philadelphia by F. P. Henry >' is
referable either to South Carolina or Fl<»ida, the subject having lived from birth in
Columbia, S. C, and in Palatka, Fla., imtil shorUy before coming under observation
in Philadelphia, and the writer recalls two South Carolina nergoes infested by FUaria
banarofti, studied in Philadelphia by William Pepper, jr., but not published.

If one may infer from the scattered instances of chyluria and elephantiasis along
the South Atlantic and Gulf coast regions, the affection prevails in sporadic grade
throughout this general district. Mastin " in a comprehensive and analytical article
upon filariasis reported an indigenous case from Mobile, Ala., and in a lecture by
Matas,'^ based upon an imported case of filarial chylocele of the tunica vaginalis, rec-
ognition was expressed of the sporadic occurrence of such filarial manifestations as
chylocele, chyluria, and eleplumtiasis in the Louisiana district. The writer, while
stationed at Galveston, on several occasions met with what he believed to be clinical

1 Tr. CoO. PhyslGteiis, PHila., 18B6» V. ao, 3 aer., p. 80.
a lodkuDs Mad. Jour., 1806^, r. 14, p. 400.

• North AnMriciin Fraot., Oct., ISOO.

« CliiOi«o Med. Beeofder, 1908, T. 35, pp. H 83; Wonien's Med. Joor., lOM, T. 14, pp. 1, 95.
» Med. NewB, Sept. 5, 1801.

• Monthly Cyek^ediA and Med. Ban., Jan., 1013.
' Qiarlotte Med. Jour., 1014, r. 70,p. MO.

> Med. Newa, Apr. 10, 1886.

• CL Smith, Aim. UnlT. Med. SoL, 1803, t. 1, p. L 131; Andnde, Amer. Jour. Med. SoL« 1006, v. 180^
p. 198; Knox, lOttt. Smgeoo, 1011, T. 38, p. 060.

u De SMMore, Med. Newi, Jane 38, 180O; Thompaon, Tnns. So. CaroUna Med« Afl800.» 1888, p. 141;
Andnde, Oa. Praetitiooer, ▼. 8, p. 10.
u Sooth. Med. Jour., July, 1015, t. 8, p. 830.
KMed. News, May 3, 1808.
X Aim. ol 0iix«ery, 1888, T. 8, p. 830.
MKeir OrleaiM Med. and Sng. Jour., June, 1801, t. 18, p. 501.

54 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NQBES8.

expressions of filariasis, a case of chronic lymph fistula and a case of elephantiasis;
but in these, as well as in several series of night-blood preparations from medical
students and hospital inmates, failed to find microfilariss. More systematic studies
would undoubtedly reveal scattered cases through a large part of the southeastern
section of the United States, as suggested by instances of similar clinical manifesta-
tions of filariaais reported from time to time for more than a generation past (as Brigg's
case of elephantiasis at NashviUe, Tenn.*), and corroborated by the occasional demon-
strated cases above mentioned (as those of Weiss and Johnstone in Illinois, and <d
Wynn in Indiana).

Cases of imported filariasis have been recorded from different parts of the United
States, mainly from the West Indian Islands,' and recently on the Pacific coast, from
the Philippine Islands, the Pacific Islands, or from Asia. But as far as the writer is
able to learn at this time, no indigenous cases have been recorded from the Pacific
coast of the United States. Wellman and v. Adelimg ' state that filariasis is con-
stantly present in the cities upon San Francisco Bay, but believe there is no danger
of distribution among the citizens because of the lack of suitable mosquito carriers.
They have studied Culex conaobrinus and Culex tar$ali8t the two most important
mosquitoes of the locality, from this point, and have determined their incapacity to
serve as transmitting agents.

West Indian Islands. — Collectively the West Indian Islands are all open to suspicion
as infested localities. The parasite has been actually demonstrated in most of the
larger islands and in many of the smaller ones; and various clinical featiu^ of filaii*
asis have been recorded for others, lending support to the belief in their infestment as
well.

Discovered first in a Habanese, the parasite to-day constitutes one of the persistent,
if not serious, pathogenic agencies in Cuba, apparently beginning to yield in frequency
of occurrence in response to the vigorous antimosquito campaigns of the past decade
and a half;* and doubtless if one may judge from the early records of filarial clinical
manifestations, the island has been infested in at least a moderate degree for a long
time.'

In reference to the prevalence of the disease the data compiled by Nuilez are of
significance. Out of a total hospital population of Hospital Mercedes, from the estab-
lishment of the institution in March, 1886, to January, 1906, of 62,548 patients, 356
were recorded as proved filarial cases or as exhibiting one or another form of the clini-
cal expressions of filariasis; and in Hospital No. 1, founded in 1900, up to July, 1904.
there had been received 19,586 patients, among whom similar evidences of filariawiB
were recorded in 70 — somewhat less than 0.5 per cent incidence in each institution.

1 Noted in Gross's System of Surgery, 1882, v. 1, 607.

s Otdt^ras, sup. dt.; others mentioned below in asslfnment to plaoes of origin; add here the case of Dela-
field in New York, said to have come "from the West Indies," Med. Oas., 1883, v. 10, p. 210, and case of
Kalisld, Amer. Jour, of Urology, 1911, y. 7, p. 429, in a negro " from the West Indies." KahsU states that
he has met five cases of Bancroft's fllariasjs in New York City in the last five years.

» Jour. Amer. Med. Assoc., July 11, 1910, v. 55, p. 217.

4 Ouit^ras, Insect Borne Diseases, Tr. of II Pan American Congress, Washington, D.C., 1915-16, Scien-
tific section.

» Literature upon Cuban Infestment: Finlay, Ann. real. Acad, dendas med.etc, de la Habana, y. 19,
pp. 40-51, June 15, 1882, and Trabajos Select., 1912, p. 611; Ooit^^fas, Med. News, Apr. 10, 1886, referring
from Key West 4 cases to Cuba; Matas, New Orleans Med. and Surg. Jour., Jan. 1801, v. 18, p. 501, a case of
ohylocele imported into New Orleans from Cuba; Lebredo, Key. de MM. tr(^. Habana, 1904, y. 5, p. 171 ;
Ibid., 1905, V. 6, pp. 117, 141; Jour, of Infect. Dis., 1905, y. 1, supp. 1, p. 3S2, deaUng with mosquito transmis-
tlon; Garcia Rijo, Crdn. m<d.-qutr. de la Habana, 1904, y. 80, p. 119; Garcia Mon y Carballo, Reyista de
mM. y drurg. de la Habana, 1904, v. 9, p. 622; Nuflez, Escuela de Medldna, Mexico, 1906, y. 21, p. 120, and
oontinuationy, dealing with filariasis and its surgical complications; L. Gutierres Lee, Crdn. m6d.-qulr. de
la Habana, 1911, y. 37, p. 550, and Rey. de mM. y churg. de la Habana, 1911, y. 16, p. 406; reference to cases
of elephantiasis in Med. Report of United Fruit Co., New York, 1918, p. 85; Brault, Gas. des Hopit, 1907,
y. 80, p. 155, general artide on geographical distribution of filariasis; etc.

PUBUC HEALTH AND MEDICINE. 55

The Island of Haiti, where the work of Leon Audain and his aseociatee,* has been
notable, is known to be infested and has probably been infested for many years, per-
haps in no higher ratio than Cuba.

Porto Rico at the present time is heavily infested. Ashford ^ after examining a
aeries of civilian and enlisted Porto Ricans, states that in his belief about 10 per cent
of the general population of the island harbor filariae, about 12 per cent of the soldiers
examined and nearly the same proportion of civilians having been found parasitized.
Of somewhat more than a dozen students from Porto Rico examined in the pathological
laboratories of the University of Pennsylvania within the last few years 4 were found
to be hosts of Filaria banerofli* Punk * has reported a similar finding in Philadelphia,
and Marden * in Baltimore, in Porto Ricans. Recently Martinez,* writing from San
Juan, P. R., has discussed a case of filarial lymphangitis simulating bubonic plague.

Young in 1897 ' reported a case from Jamaica; and more recently WanhiU • after
meeting with but a single case in several troops of native soldters«and after inquiring
among local medical officers of experience, states that while occasionally encountered
in Jamaica, filariasLs is almost unknown on that island. He mentions the fact that
Mott failed to find any microfilariae in a series of 400 slides of blood collected by Dr.
Grabham from natives of Jamaica.

Among the Danish West Indies, the islands of St. Thomas • and St. Croix *° are
recorded as infested localities.

It is improbable that the Bahamas are entirely free, but that these islands can have
no more than rare sporadic instances of filariasis is surely indicated by the fact that in
the long list of publications consulted by the writer he has failed to encounter any
record of the affection in these more norUiem islands.

Of the lesser Antilles, in the groups of the Leeward and Windward Islands, stretching
out below Porto Rico toward the South American coast, there is reason to believe
there has been an early and heavy implantation of the parasite, and there is evidence
that it persiBts in some of these islands in high grade up to the present. >>

> Aodain, FoniMs ohir. <to k fllarkne genlt., 1894; Rioot In Audain, Flevns Intertropicales, 1910, p. 777;
cC also Moooarro» in OnndMr and Comby, Traits de UaL de I'Enfuioe, Paris, 1904, y. 2, p. 802.

• Mad. Beoord, Nov. 7, 1908, y. 64, p. 734; Report of Surgeon Oen. U. 8. Army, 1903-04, p. 92.

• Smith and Rivas, Amer. Jour. Trop. Med., Dec, 1914, v. 3, p. 861; 3 cases; 1 unreported.
« Proe. PhUa. Path. Soe., 1914, v. 16, n. s., p. 63.

• Hosp. BolL, Univ. of Maryland, 1913-14, t. 9, p. 60.

• Jour. Amcr. Med. Ajsoe., May 38, 1914, y. 63, p. 1632.
▼ Brit. Med. Jour., 1897, v. 1, p. 1037.

• Jour. Roy. Army Med. Corps, London, 1906, p. 561.

• PoBtopidan, quoted by Blandiard, Traits de ZooioKie MM., Paris 1890, y. 3, p. 637; Opie, Amer. Jour,
of Med. fioL, September, 1901, v. 132, p. 351; and probable case of filariasis, intermittent ohyluria> SoUs-
Ooban, Times and Ragteter, May 18, 1889, Jour. Amer. Med. Assoc., July 3, 1803.

w Abbe, N. Y. Med. Jour., February, 1880; y. 31, p. 139; Lambert, N. Y. Med. Jour., Apr. 30, 1892.

n Literature upon Leeward and Windward Islands: Braolt, sup. dt.; Creyaux, I/Ematmie chylense oa
gyaliwisii des Pays chauds, 1873, raylewed in I/Unkm med. , 1^78, y. 13, p. 795; Leookart, Panwiten, Leipsig
aadHeldeIbiirs,1876,y.3,p.e28; PUnt, N. Y. Med. Jour., June 15, 1895, p. 787, a case in New York from
Barbados; Mansoo, Brit. Med. Jour., 1897, y. 3, p. 1837; Lothrop and Pratt, Amer. Jour. Med. ScL, 1900,
T. 130, p. 535, 3 cases in Boston from Barbados; Qalgey, Select. Colon. Med. Rep. , London, 1004, p. 190, St.
Laeia; Moneonro, in Oruicfaer and Comby, Traits les Mai. de PEnfance, Paris, 1004, y. 3, p. 802; Low,
Jear. Trop. Med. and Hygiene, Feb. 15, 1908, y. 11, p. 59; Orindon, Missouri Med. Jour., 1908-09, y. 5, p.
m^ ease from Ouadaloope; Slmond, Noc and Aubert, BuU. Soo. Path. Ezotique, Paris, 1909, v. 2, p. 319;
CIvac, Leboeuf and Rigollet, Traits de Path. Exotique par OraU et Clarao, y. 6; Mai. Parasit., Peste,
Ftois, 1913, p. 313; HiQary, Diseases peculiar to the Island d Barbados, 1750 and Hendy, Glandular Dis-
mm in Barbados, 1784, both quoted by Castellanl and Chalmers, Man. of Trop. Med., 2 Ed., 1913, p. 1135;
Ljls, Ann. of Sorsery, 1913, y. 56, p. 943, case in New York from St. Kitts; O'Nell, Best. Med. and Surg.
Jbor., 1908, y. 158, p. 117, a ease in Boston from Barbados; Armstrong and Mullally, Surgery, Qyneool.
sad Obstat., 1914, y. 10, p. 699, a case in Montreal from Antigua; Leger et Le Gallen, Bull. Soc Path. Ezo-
tique, Parte, 1914, T. 7, p. 135, Ouadaloupe; Steyenel, ibid., 1913, y. 6, p. 357, Ouadaloupe; Noc et Stevenel,
ML, 1913, T. 6, p. M8, Martinique; for old unedited references see Honllier, De la fllarlose, etc, des Pay
, TbmifUoatpOkt, 1913.

56 PB00EEDIKQ8 SECOND PAN AMEBICAK SGIEKTIFIG C0K6BE88

In Low*8 admirable travel study, he found evidence of heavy infestment (47 <
out of 143 examinations at night) in St. Kitts. Manson found microfilaria in 6
films of blood out of 2B sent him from St. Kitts and Montserrat. In Dominica, Low
examined 144 individuals at night and found that 11 harbored microfilari« in their
blood. In Guadaloupe Leger and Le Gallen, in an examination of 150 Guadaloupiaa
enlisted men in 1914, found 23 infested (15.33 per cent); in 1913 Stevenel found 4
out of 12 individuals examined to harb^ FUaria bancrofti in Guadaloupe. That
Antigua is at least in some measure infested may be inferred from a case reported
from Montreal, Canada, by Armstrong and Mullally in 1914, as originating in Antigua.
Guadaloupe is said by Clarac, Leboeuf , and Rigollet to be seriously involved by filari-
asis,' and Martinique is likewise characterized by these authors. Simond, Noc,
and Aubert state that clinical manifestations of filariasis are common in Martinique;
and Noc and Stevenel in 1913 published data showing that of 4,000 individuals com-
ing to the dispensary of the hygienic institute in Martinique between 1909 and 1913.
88 showed different forms of lymphatic affections (77 endemic lymphangitis, 15
elephantiasis, 25 without microfilarifie).

In St. Lucia, Low examined the blood of 356 persons at night, finding microfilarise
in 27.' In St. Vincent he examined the blood of 100 individuals at night, 6 of these
showing the presence of microfilariae; and Manson found the same number, out of
152 blood preparations sent him from this island, to contain microfilaria. In Bar-
bados, the manifestations of filariasis (as the '* Barbados leg") have been known from
the early part of the eighteenth century; and a serious endemic focus is centered in
this island. Of 600 individuals examined at night by Low, microfilaria were found
in the blood of 76 (12.66 per cent), a proportion comparable to that indicated for
Porto Rico by Aahford. The ishind is particularly named by most writers in sys-
tematic treatises upon parasites and tropical diseases; and a number of Barbadian cases
have been recognized and published from other parts of the world to which they have
gone (as the cases of Lothrop and Pratt, in Boston).

In Grenada, Low found no examples of infestment among 174 individuals examined
at night; and in Oarriacon, a small island of the Grenadine group, out of 28 individuals
he found 1 case of filariasis nt>ut this individual had been bom and lived in St. Kitts
until within a year of the time of Low's examination, and should under the circum-
stances be regarded as belonging rather to the more northern island ).

Trinidad was found by Low to be a decidedly infested Island, 43 individuals out
of 400 examined at night by him showing microfilariae in their blood; Vincent * in
examining 500 individuals in hospital, asylum and private practice found 25 in-
fested (5 per cent) and 33 showing elephantoid complications (6.6 per cent).

While in this hasty review of the West Indian Infestment, the writer has doubt'
less missed nuiny important items, the serious grade of involvement of certain islands
and the widespread diffusion of the parasite is surely shown sufSdently to substan-
tiate the statement that collectively these islands are all to be regarded as open to
the suspicion of being infested . And yet the Bahamas, Jamaica, and Low's experience
in the Grenadines are evidence that such a sweeping statement must not be too seri-
ously accepted for any individual location. There are places in the West Indies
(perhaps, too, limited localities on infested islands), where known and unknown
circumstances have operated to prevent the invasion or the permanent fixation of
the parasite; but whether such circumstances are to be regarded as constant for these
places is quite another matter.

Mexico and Central ^Immoa.— Returning to the mainland of the American Conti-
nent, in Mexico definite records of the discovery of the parasite are singularly lacking
in the literature which the writer has had opportunity to examine, although general
statements of the occurrence of filariasis are now and again to be met in systematie

I See also Leockart, OrerMz, Orindon, Ifonoorro • BilU Med. Jour., 190a; r. 1, p. m.

t Cf, also Galgej.

PUBUO HEALTH AND MEDIOINE. 67

artides upon the affection. Claiac, Leboeuf , and Rigollet ^ state that elephantiasis
18 "comparatively frequent on the coasts of Mexico, becoming more rare as one
proceeds to the north." Newman and Mayer,^ in their cursory statement as to the
distribution of JUaria bancroftif also include Mexico as infested. The writer recalls
to have i>er8onally observed several cases ef elephantiasis in Mexico in the course
of visits in the Republic some years ago.

Nor is the recorded evidence of the prevalence of the parasite in the Central Ameri-
can Republics more satisfactory in the literature available to the writer. Creneral
references to its occurrence in Central America,' in Nicaragua,* and a few specific
records of its clinical manifestations ^ in Costa Rica in the medical reports of the
United Fruit Co. constitute the only items met. The writer's colleague. Dr. Damaso
Rivas, a native of Nicaragua, has personally informed the writer that cases of ele-
phantiasis are not very uncommon in Nicaragua.

In Panama, elephantiasis is noted as "relatively common'' by Clarac, Leboeuf,
and Rigollet,* and examination of the reports of the department of sanitation of the
Isthmian Canal Commission may be regarded as verifjdng this statement. Occasional
cases of elephantiasis, lymphscrotum, and chyluria occur in these monthly reports,
and there are a number of demonstrated cases of filariasis distributed in the various
faoepital records. It is to be recalled that these reports do not deal directly with
the fixed population of the Republic of Panama, but rather with the heterogeneous
group of canal employees who congregated In the Canal Zone during the period of
active canal construction, and that among them many of the laborers came from
known localities of infestment, as from various West Indian islands. Some of these
people, however, doubtless have remained on the Isthmus, and one can not dis-
regard them as having been and even now in some degree being i>otential factors of
maintenance and dissemination of the affection in the district.

The figures collected by the writer from the reports of the department of sanitation
are undoubtedly too low, as they are based upon the hospital records of blood exam-
inations, and for the most part these examinations were made for other diseases than
Bancroft's filariasis, the vast bulk of the blood specimens having been unquestionably
prepared in the daytime. Uncomplicated cases of filariasis, too, are not likely to
have been included in the hospital population; and the tediousness of blood exami-
nations with high objectives, as for malaria, is probably reason to suppose that in
most instances as little as possible of any given blood film would be actually scruti-
nized. The reports for nine years, from 1905 to 1913, inclusive, are best adapted for
analysia, because of the uniformity of the plan of reports of blood examinations and
of report of positive findings of microfilariae. In this period they aggregate a total
of 144,423 microscopic blood examinations in the various hospitals of the Canal Zone;
among which 111 positive instances of demonstration of microfilariae are recorded,
considerably less than 0.1 per cent. By years the distribution of recorded instances is
asfoUows: 1905, 2; 1906. 1; 1907, 3; 1908,3; 1909, 9; 1910, 29; 1911,44; 1912, 13; 1913,
7. The annual report for 1914, which is not included, states that two cases of filariasis
were admitted to the hospitals of the Zone, but does not give the number of blood
examinations made in the hospital laboratories. The cases were distributed over the
entire length of the Zone, being recorded at Ancon, Colon, Miraflores, and Santo
Tomas, indicating, therefore, infestment on the Pacific as well as on the Atlantic
aide. Specific differentiation is not indicated in the reports; but there is one case
(1900, at Colon) reported as "filaria diuma."^

I Sop. dt., L«ewftrd and Wladward Islands, p. 374.

* Atlas and L«hrb. idchtiger tierlseh. Parasit. u. Ihrer Uebertrftg., Mflnchen, 1914, p. 365.
> Castallani and Chalmers, sup. dt. Leeward and Windward Island Literatnre.

« Newman and Mayer, sup. dt.

* As of diyhiria and elephantiasis; Med. ReporU United Fruit Co., New York, 1912, p. 67; 1913, p. 87.

* Sop. dt. I.,eeward and Windward Inlands, p. 374.

' For above dats d. reports of department of sanitation of Isthmian Canal Commission, Waahlnfton,
D. C, tot yean tndleated, condensed in the Annnal Report of the Director, or embodied In the monthly
laboratory reports of the Tarioos hospitals tat the different months of eadi year.

58 PBOCEEDINGS SECOND PAN AMERICAN SCIENTiriC CONGRESS.

South America. — In Colombia Marquez > refers to cases of elephantiasis and chyluria
occurring not infrequently in the Santa Marta district (on the Atlantic side). A case
originating in Colombia, apparentiy near Cartagena, is reported by Cimningham '
in Boston, whither he had come for surgical treatment; and casual mention of Colombia
as infested may be noted in the works of Moncorvo ^ and of Castellani and Chalmers *.
Moncorvo alone, of the writers consulted, lists Ecuador among the coim tries infested;
although it is unlikely to be any more exempt than its neighbors Colombia and Peru,
the latter being incriminated by a number of writers.* Crevaux and Moncorvo place
Chile also among the countries infested by Filaria bancrofli.

The parasite is undoubtedly more common and has been better traced in the Atlan-
tic coastal countries of South America. J. Surcouf and R. Gonzales Rincones, in
their paper on the bloodsucking diptera of Venezuela,* state that chyluria and ele-
phantiasis, evincing the presence of Bancroft's filariasis, are very common in Venez-
uela about its important western harbor, Porto Cabello; and the proximity of the
island of Trinidad ^ is strong suggestive evidence that the eastern coasts of Venez-
uela have not failed of infestment. Important texts such as Castellani and Chalmers,
Clarac, Leboeuf, and Kigollet, and Moncorvo,® and Newman and Mayer • mention
Venezuela in their lists of infested countries.

The three Guianas are probably equally and seriously invaded. Speaking of
British Guiana, Daniels ^^ calls attention to the coastal coincidence of Filaria ban-
crofti and elephantiasis in contrast to the absence of elephantiasis in the interior and
to the replacement in the latter district of Filaria bancrofti by another species, F.
demarquayi. Low " found over 16 per cent (25 out of 150) of a series of blood films
collected at night to contain microfilariae in studying the incidence in British Gui-
ana.''

In Brazil, Otto Wticherer,*' at Bahia, was the first in America to observe the larval
stage of the parasite, in 1886, in the prevalent hematochyluria of this district; but
this, as well as other filarial manifestations had been a matter of Interest and anxiety
for years earlier in Brazil. As early as 1835, a conference was held upon the subject
of hematochyluria at Rio de Janeiro, following and probably stimulated by the paper
of Salese upon this condition.'^ Rego '' in 1843 recorded elephantiasis as being com-
mon in Rio de Janeiro, and quoted Souts-Ammarel, of the latter dty, as having dealt
surgically with certain examples of huge elephantiasic growths of the male and female
genitals. Wtlcherer's discovery, not published for several years, was followed in

1 Geograpbia M6dica y Patologfa de Colombia, Bogota y Nueva York, 1916, pp. 140, 219.

• Ann. of Surgery, 1906, y. 44, p. 481.

> Sop. dt., Leeward and Windward Islands, p. 808.
« Sup. dt. Leeward and Windward Islands, p. 1126.

» Castellani and Chalmers, sap. dt.; Creyaux, sup. dt.; Newman and Mayer, sup. dt.; Moocoryo, tup.
dt.;etal.

• Arch, de Parasltologie, 1911-12, y. 16, p. 248.

' Vide supra, Leeward and Windward Islands, Low.

> Sup dt., Leeward and Windward Islands.

• Sup. dt.

M Brit. Med. Jour., Sept. 24, 1898, y. 2, p. 878.

u Sup. dt.. Leeward and Windward Islands.

a Consult also Lodnyood, Maryland Med. Jour., Oct., 1907, y. 46, p. 367, case in Baltimore; Lefeyre,
Tr. N. Y. Path. Soc., 1893 (Noy. 23, 1892), p. 114, case hi New York; Pildier and Pildier, New York Med.
Record, 1911, y. 79, p. 434, a case hi New York; all from British Ouiana. Armstrong and Mullally, Sur-
gery, Qynecol. and Obstet., 1914, y. 19, p. 699, a case in Montreal from British Ouiana; Kingsbury, Jour.
Cut. Med., 1911, y. 29, p. 867, case bom In Venesuela, living from age of 6 to 22 hi British Guiana, one year
later obeenred hi New York; HiUis, London Lancet, 1882, y. 2, p. 669; Manson, Brit. Med. Jour., 1897,
y. 2, p. 1838; Guard, Brit. Guiana Med. Ann., 1897, y. 9, p. 24; Winckel, Arch. f. kUn. Med., Feb. 26, 1876,
y. 17, p. 303; and as noted under Leeward and Windward Islands, Castellani, and Chalmers, Qarac, Leboeof
and RigoUet, Monconro, Creyaux.

u Sup. dt., note 6.

14 Dissertation sur lliomaturie ou pissement du sang. These, Paris, 1834.

» Gas. des Hopltaux, Aug. 31, 1843, p. 412, from Beyista mM. flumenense.

PUBUC HEALTH AND MEDICINE. 59

Brazil by a group of investigators, including at Bahia, J. F. da Silva Lima,' who is
credited with applying the name Filaria wuchereri to the parasite, A. J. da Silva
lima,' da Silva Araujo,' who, in 1S75, met microfilariae in the exudate from lesions
of craw-craw and in this connection applied the name Filaria dermathemica, and who,
in October, 1877, encountered the adult worm in elephantiasis of the scrotum, Pe-
reira,* d*Almeida Couto,' and Paterson,^ and, at Bio de Janeiro, F. dos Santos,^
who was one of the early observers of the microfilariae in the blood in elephantiasis
tnd who obtained the adult worm in a lymphatic abscess only about a month after
de Silva Araujo in Bahia, de Moura,' who obtained the microfilariae in the exudate
from craw-craw lesions, and de Magalhaes.*

As some indication of the incidence of the parasite Paterson at Bahia in 1878 foimd
26 cases of filariasis among 309 individuals examined at random. Moncorvo '° in 1904
stated that the affection was less frequent in Brazil at that date than it once had been.
Oliveira " in 1909 in his thesis presented to the medical faculty of Bahia indicated an
endemic index of 10.5 per cent of filariasis in Brazil."

In 1882 Wernicke " published a case observed by him in Buenos Aires, the most
southern recorded case on the American continent, the solitary case, as far as the
writer knows, referred to in various systematic articles which list Argentine as an
infested district (save the recently reported cases of Padilla in Tucuman).

2. FILARIA DKMABQUATI (HANSON, 1897).

Synonyms: Filaria ozzardi Manson, 1897, pro parte; F. juncea Railliet, 1908.

In 1893 and in 1895, in blood films sent him from St. Vincent by Dr. Newsam, Man-
son " met with a microfilaria which he had not previously encountered, smaller than
the larval Filaria hancrofti, without a sheath, with a finely effilate tail end, and aperi*
odic. Tentatively, at Blanchard's suggestion, he named the parasite in honor of De-
marquay, the original observer of the larva of FUaria bancrofti. And in 1896 and
1897, in a series of blood slides sent him by Dr. Ozzard from Indians of the interior of
British Guiana, Manson again met with a microfilaria of the same morphology (which
he believed might be identical with the St. Vincent specimens) but in association
with it another small aperiodic, nonsheathed microfilaria with a bluntly pointed tail
(which he believed identical with the African perstans). Uncertain of his ground, he
lor a time hesitated to distinguish between the two, giving them jointly the name
Filana oztardi. Ozzard and Daniels >^ shortly after^uds confirmed Manson's discov-
ery, but at the time made no distinction between the two confused larvae.

t Oftt. mM. da Bahia, Sept., 1877, v. 3, 2 aer., p. 387, translated In Arch, de mM. nay., Paris, Dec., 1877,
T. 38, p. 490.

• B«v. iii6d. Rio de Janeiro, July Ifi, 1870, ▼. 1, p. 107.

• llem. Bohre a fiUarose on a molestia por uma nova espede de parasita catanea, Bahia, 1875; Oas. m6d.
de Bahia, Nov.. 1877, t. 2,3 aer., p. 403, translated in Ardi.de mM. nav., Paris, March, 1878, v. 20, pp. 200^
470; Qaz. m6d. da Bahia, 1878, v. 8, 3 ser., p. 40; Oac. mM. da Bahia, Oct., 1870, v. 4, 3 ser., p. 455.

• Hal. parvit. lea plus freqnentes dans les cttmatea intertropioaleB, 1870, Dissert., Bahia.

• Hematuria endemica dos paiaes quMites, Bahia. 1873.

• Has. m6A. da Bahia, Dec., 1878, v. 3, 3 ser., p. 530; translated io London Veterinarian, Jnne 30, 1870,
and to aatveston Med. Jour., Jan., 1880, t. 1, p. 14.

« Gas. ni6d. da Bahia, Marob, 1877, ▼. 3, 3 ser., p. 187; Progresso mM., Rio de Janeiro, 1877-78, t. 3^
p. 95, 100.

• Revista mM. de Rio de Janeiro, Aog. 31, 1875, ▼. 3, p. 315 and continoations; Da Chyluria, These,
Rio de Janeiro, 1877.

• Gas. mt6d. da Bahia, Dec., 1877, t. 3, 3 ser., p. 588; Progresso inM. Rio de Janeiro, Norv. 15, 1877, v.
3, p. SO. ihid., May 15, 1878.

>• Sup. cit.. Leeward and Windward Islands.

u Inaug. Thesis, BahJEft, 1000; quoted by Padilla, Semana mM., Buenos Aires, 1015, anno 23, p. 371.

X For more reoent studies in Brazil cf. Froes, Brazil mM., Rk> de Janeiro, 1000, v. 30, p. 03, 75; Mootolro,
Tribona mM., Rio de Janeiro, 1008, v. 14, p. 00; Ferrari, ibid., y. 14, p. 07.

M Consideraeioose a propodto de un oasode quilnria observado en lapolidtaiioa del oircnlo mM., Argen-
tine, Boenos Aires, 1S83.

■« Brit. MM. Jour., 1807, v. 3, p. 1837.

» QuoCM by Manson, ibid.; see also Ouard, Br. Quiana MM. Ann., 1807, v. 0, p. 24: and Daniels, Br.
GniaiM MM. Ann., 1807, ▼. 0, p. 28; ibid., 1806, v. 10, p. 1; Jour. Trop. MM. and HyK., 1808, v. 1, p. 13; and
Brtt. MM. Jour., 1808, v. 2, p. 878.

60 PBOCEEDINOS SECOND PAN AMERICAN SCIENTIFIC C0N0BE88.

In the same year Daniek ' at a post-m(vtem examination of two Indians, who doff-
ing life had shown both fine-tailed and blunt-tailed larvae in their blood, met with a
number of adult filarise which were identified later with adults of AcanthodieUonema
persUms ' by Manson. As the blunt-tailed larvae were from the first suspected of
being identical with the African perstans lanne, and as such larvae were obtained by
Daniels from the adult females, the one group confused under the name PUcaria oz-
zardi was thus definitely eliminated. Meanwhile Galgey in St. Luda ' had recog-
nized the presence of the Microfilaria demarquayi in St. Luda and in 1899 had ob-
tained a number of adult females from the upper part of the mesentery at autopsy.
One of these he sent to Ozzard for determination and description, but, owing to its
poor state of preservation, little definite could be made out. * In the same year, how-
ever, Daniels * had opportunity to perform a post-mortem section of the body of a
third Indian from the interior of British Guiana and found beneath the peritoneum
of the anterior abdominal wall an entire adult female filaria and the broken caudal
«nd of a male. The Indian in life had shown both fine-tailed and blunt-tailed larvae
in his blood, the former predominating toward the end of life. These adult filarise
differing from the previously separated perstans adults, Daniels published them as
the probable parental forms of the fine-tailed larvae. In form they resembled Filaria
bancro/H rather than AcanthocheiUmema perstans^ were characterized by a smaller head
said thicker body than the latter, and lacked the caudal cuticular processes of the
latter, the tail of the male being more tightly enrolled, terminating abruptly, and
showing no protruded spicules (there are, however, two spicules which were not at
the time recognized). The fine-tailed larvte from St. Vincent, St. Lucia, and from
British Guiana having been identified, these worms (the adult females agreeing with
Gralgey's specimens from St. Luda) have been accepted as Ptlaria demarquayi (the
tentative spedes PiUxria ozzardi thus falling out entirely).

As far as its distribution in America is concerned the study by Low * is the most
complete thus far at hand. In St. Lucia, in an examination of 472 individuals, he
met with the larval demarquayi in 23, and notes the fact that it tends to segregate
itself in special fod, the heaviest infestment of St. Lucia being met in the part known
as Gros Islet. In Dominica he examined 160 persons and found Microfilaria demar-
quayi in but 2. In Barbados he found no instances of the parasite in question in
600 individuals examined (in contrast to the heavy infestment of Barbados by Filaria
hancrofti). In St. Vincent he met it in scattered fod in the country districts, as in
the village of Calliaqua, where 8 out of 30 persons were found to be hosts of the
parasite.

In British Guiana Low examined 163 full-blooded Indians from various parts of the
interior, finding 49 to be hosts of Filaria demarquayi (alone in 11; in association with
Acanthocheilonema perstans in 38).

Vincent,^ in his study oi filariawis among the asylum and hospital populations in
Trinidad, notes the finding of a single instance of panuritism by deTnarquayi,

It ia quite possible that the geographical distribution in America is more extensive
than is here indicated and that Low's suq>idon is correct that it and perstans are
probably scattered all throu^ the deeper forests of not only British Guiana, bat of
the other Guianas as well, and perhaps of Venezuela. One may not improperly
think of it in connection with the diurnal microfilaria reccnded in t^e Colon Hospital
Report for 1906 in the Reports of the Isthmian Canal Conmiission. And the writer

I Drit. Med. Jour., 1898, v. 1, p. 1011; Br. Guiana Med. Ann., 1806. v. 10, p. 1.
s See note to Daniels's paper in Brit. Med. Jour., 1808, t. 1, p. 1011.

* St. Luda, Colon. Reports, 1800; Brit. Med. Jour., 1800, v. 1, p. 146; see also Low, Brit. Med. Jour., 1008,
V. 1, p. 196.

* See Ossard, Jour. Trop. Med. and Hyg., 1902, ▼. 5, p. 250.

• Brit. Med. Jour., 1800, v. 1, p. 1450.

• Brit. Med. Jour., 1002, t. 1, p. lOA.
» Brit. Med. Jour., 1002, v. 1, p. 180.

PUBLIC HEALTH AND MEDICINE. 61

€tn not but ndae the qaestkm whether FUaria tucumani, recently reported from the
district of Tucuman in Argentina, will not be found to be FUaria demarquayi. This
last ii a onall and active microfilaria, without periodicity (but with predilection for
ni^^t as shown by the fact that night blood is apt to contain upward of double the
proportion of microfilarifle seen in day specimens), showing marked variation in size
(but with an average of .0.17 mm. long and 0.005 mm. thick and some as long as 0.252
mm., some not more than 0.087 mm. in length), and provided with a sheath. Varia-
bility in size is well known in case oi the microfilaria of demarquayi.^ If Padilla's
specimens are really ensheathed he is correct in differentiating them from demarquayi,
but the determinaticm of tlus point is not always easy. For example, Manson ' at
first believed that the demarquayi larva was ensheathed, but recognized later that the
^ypearance was due to artefact from the shrinkage of the microfilariae in stained blood
films. Should this surmise be onrect the American limits of distribution will be
materially widened; and there should then be expected more or less infestment in
the deeper Brazilian forests to link up the Guianas with Argentina.

The general impression at first was that FUaria demarquayi is native to America^
the very isolation of its foci of endemicity suggesting this. But the certainty of
such belief is disturbed by the fact that Manson some years ago found a microfilaria
of apparent identity in the blood ol a native of New Guinea, according to Seligman,*
who likewise has met the same microfilaria in the same distant locality.

The importance of the worm is doubtful from a positive standpoint; its presence
being without recognized pathological effects upon the host. But in a negative way
it is of importance that medical men distinguish it and its microfilaria from FUaria
banerofli, lest from omfusion we fail to appreciate in full the serious pathogenic effects
fllth0 latter worm.

Iti intermediate host is unknown. Low, from this standpoint, tested CulexfadganSf
BUgomyia fudata, Culex taeniatua, Anophele$ albipe$, Pulex penetran$f and Pulex
initani witiiout meeting with development of the microfilarise into prefilarial forms.*

8. ACANTHOOHKIIiONBMA P£B8TANS (mANSON, 1891).

Synonyms: FUaria sanguinis hominis var. minor Manson 1891; F. sanguinis hominis
Persians Manson 1891; F. perstans Manson 1891; F. ozmrdi var. truncata Manson 1897.

Hanson, in 1891,^ from the study of blood from negroes from Western and Central
Africa, distinguished microfilarise of essential difference from those of FUaria 6an-
erqfti, which previously were the only known filarial hematozoa of man. Two new
types were met, one of a size comparable to the Bancroft type, ensheathed, but
occurring in the pmpheral blood in day rather than at night, this being subsequently
identified as the larval form of Loa loa (named at this time by Manson FUaria sanguinis
Aofittnu var. major); and a second, smaller, not sheathed, with active progressive
movement, and without either diurnal or nocturnal periodicity in the peripheral blood
but found therein at all hours, to which he gave the name FUaria sanguinis hominis
var. minor (subsequently changing the name to FUaria perstans). In an article pub-
lished in 1897,* inter alia he announced that in blood preparations collected and for-
warded to him by Dr. Ozzard from aborigines living in the interior of British Guiana
he had hiled to find microfilariae of the type of FUaria hancrofti, but had encountered,
sometimes in the same perparation together, sometimes separately, two small non-
sheathed microfilariae, one with a finely drawn point of the tail, resembling the micro-

> CI. Galgey, Brit. Med. Jour., 1399, v. 1, p. I4s!

• Brit. Mad. Jour., 1807, y. 2, p. 1837.

« Joor. of PathoL ftnd Bact., 1901, y. 7, p. 306.
< Brit. Med. Jour., 1902, y. 1, p. 196.

• Loud. LMoet, 1891, y. 1, p. 4, abstncted In C«ntnlbL f. allg. Pathol., 1891, y. 2, p. 298; Trans. Beveotb
Intamat. Congren Hyg. and Demography, 1891, y. 1, aeot. 1, p. 79.

• Brtt. M«l. Jour., 1897, y. 2, p. 1887.

62 PROCEEDINGS SECOND PAN AMERICAN SCIENTIPIO CONGRESS.

filaria of Filaria demarquayi (which he announced in the same paper from the island
of St. Vincent), and the other with a blunter tail, which resembled the African per-
sistent microfilaria. In spite of the recognized morphological differences he for the
time applied to both the name Filaria ozzardi. This finding was shortly afterwards
corroborated by Ozzard and Daniels. *

In December, 1897,^ the latter investigator announced that he had met adult
filarise in the retroperitoneal tissue at the base of the mesentery, about the pancreas
and beneath the pericardium in two autopsies upon Indians from the interior of
British Guiana, who in lifetime had shown in their blood both forms of the so-called
Filaria ozzardi. The females ranged from 70 to 80 mm. in length; the males were 46
mm. long; and in both sexes a small triangular cutiodar process was noted on each
side of the caudal tip. The male tail was curved, and there was noted a single spicide.
Larvae obtained from these adult females corresponded with the blunt-tailed type of
Microfilaria ozzardi. From subsequent comparison with adidts obtained from African
hosts of Microfilaria perstans, come to autox)sy in London, Manson ' identified Daniels's
specimens with the African adult parasites; and subsequently, based upon the cuti-
cular processes at the caudal end they were referred to the genus Acar^thocheilonema
Cobbold by Railliet and Henry.*

In its American distribution AcanthocheUonema perstans (Manson), it is to be noted,
as in Africa, occurs in the hot, heavy and moist climate of tropical forests, rather than
in open districts. In the coast districts of British Guiana neither this nor Filara
demarquayi (the two originally confused under the name Filaria ozzardi) were met in
blood examinations by Daniels and by Ozzard at Georgetown and New Amsterdam.
Filaria bancrofti had been found in 52 out of 348 individuals of the settlements (whites,
negroes, and civilized Indians) by Daniels; and Ozzard had in a like population met
with 24 cases of Bancroft's parasite out of 83 individuals examined. Manson in blood
specimens from 61 natives of Demerara had found 9 instances of Filaria bancrofti^ but
none of the small unsheathed larval worms. But among the aborigines of the interior
Daniels ' found 134 individuals out of 231 examined to harbor the small forms (both
perstans and demarquayi^ confused) which he was at first disposed to accept as varia-
tions of a single species. Low ^ examined 163 full-blooded Indians of different parts
of the interior of British Guiana and found 105 of them to be hosts of the small un-
sheathed microfilariae, with double infestment by Filaria demarquayi and Acantho-
cheUonema perstans in 38, perstans alone in 56 and demarquayi in 11 alone (a total of 94
of the 163 infested with Acanthocheilonema perstans). Apparently this is the only
focus of American endemic occurrence of this parsite, but one which is firmly fixed
among the Indians of the deeper forests of British Guiana, extending, if Low's sus-
picions be correct, into similar parts of both French and Dutch Gulanas and into the
confines of Venezuela. In the upper part of the British Guiana coast it is known to
approach the sea.

The carrier is unknown, investigations thus far made being without positive results;
but it is usually believed to be a bloodsucker of habits requiring the protection of
shade and a constant tropical heat, with moisture. Various mosquitoes have failed
to show development of the larvse ingested from a filariated subject; or at best have
shown only uncertain and partially developed prefilarise. In Africa Brumpt noted
the fact that in spite of high incidence in communities the naked n^joee were by
no means selected; rather those who wore some amount of clothing (but fleas and lice

> Brit. Quiana Med. Ann., 1897, y. 9, pp. 21-28.
» Brit. Med. Jour., 1898, v. 1, p. 1011.

* rroplcal Diseases, ed. 1910, p. M8; see also aonototlon to Daniels, Brit. Med. Jour., 1809, v. 1, p. 1450:
and Low, Brit. Med. Jour., 1902, y. 1, p. 100.

« Ball, de la Soo. PathoL Exotiqu^ 1012, r. 5, p. 895.

> Brit. Med. Jour., 1898, y. 1, p. 1011.

• Brit. Med. Joor.; Jan., 1902, y. 1, p. 196; iUd. 1008, y. 1, p. 722.

PUBUC HEALTH AND MEDICINE. 63

were not found capable transmitters). The writer would reserve until later comments
upon this problem, the solution of which need not necessarily follow absolutely the
proved methods of insect transmission obtaining in case of Filaria bancro/ti and Loa
loa.

The pathogenic influences of the parasite are equally unknown, and apparently
of no great moment. There are apt to be heavy infestments in a single host, the adult
worms ranging from a small number to many. Brumpt,^ in an African subject, met
at autopsy with several hundreds of these parasites.

The species is undoubtedly African, the widespread distribution in western and
central Africa assuring us upon this point. Its American appearance can best be
accounted for by convection through the African slave trade, its definite and limited
distribution here being determined by the conditions of life for its unknown trans-
mitter, clearly favored in districts of little civilization, and therefore determiuing
its marked restriction to the Carib Indians of the dense forests of upper South America,
to whom the improvements of civilization have not yet reached. It seems not impos-
sible that when fuller medical knowledge of the deeper Amazonian forests is attained
the parasite will be encountered in this area as well. The writer would urge for this
parasite not only the chance of an as yet unknown pathogenicity but also the negative
importance, mentioned above in connection with FUcaria demcarquayiy of avoiding
confusion with the microfilaria of Bancroft's parasite.

4. DIROFILARIA MAOALHJBSI (BLANCH ARD, 1896).

SyrwnyfM: F. bancro/H Magalh^es 1892, nee Cobbold 1877; F. magalhassi Blanchard
1895.

The intracwporeal habitat of the microfilariae of this species is unknown, and the
writer is justified in including the parasite in the present article only because of the
probability that, when opportunity is afforded for their observation, they will be
found in the circulating blood (in analogy not only with the other filarise here described,
but more particularly with its closer relative, Dirofilaria immitis Leidy, of the dog).
The parasite has been encountered but a single time. In 1886, J. P. Figueira de
Saboia, at Rio de Janeiro, found at autopsy of a child, in the left ventricle of the heart,
a male and a female adult filaria, which he referred to P. S. de Magalhses for study
and description.' No statement as to the nature of the fatal illness of the child is
given; and the blood is not known to have been examined for larv». The path-
ological role of the parasite is therefore unknown; and this solitary occurrence in a
human being is often held as accidental, with expression that probably it will be found
in more fixed parasitic occurrence in some lower animal. Occasional suspicions of
the possibility of aberrant occurrence of Filaria bancro/H Cobbold in the blood cir-
culatory system in adult stage have been suggested; but even were this true the ana-
tomical characters serve to distinguish these two species and also to distinguish the
specimens of Magalhfies from Dirofilaria immitis Leidy, of the dog (the latter having its
proper habitat in the rightcardiac ventricle) . Magalhaes, at the time of his description,
r^arded his specimens as the adults of Filaria ^7icro/(t Cobbold; and this was accepted
uAtil 1894, when Manson pointed out the mistake and in 1895 Blanchard gave it the
name of its discoverer.* It is distinguished by its size (the female measuring 155 mm.
in length and 0.715 mm. in thickness, the male 83 mm. long and 0.407 nmi. thick); the
female cephalic end is club-shaped, that of the male not swollen; the cuticle is finely
striated circularly; the mouth simple, circular, unarmed, terminal; the tail of the male
has four pairs of preanal and four pairs of post anal papillse of slender shape and villous
surface, two equal spicules, and is slightly incurved. The embryos as obtained from
the adult female measured 0.300 to 0.350 mm. long and 0.006 mm. in thickness.

>C. B. Soc hUA., 1904, v. 51, p. 758.

sMi«alhS3, Oftf. Mad. da Bahla, 1887-88, 3 sw., y. 49, pp. 100, 152, 200; ibid., 1891-93, 4 stf. v. 3, p.
4M; Caotnlbl. t Bakt. a. Parasitenk., 1892, y. 12, p. All.
• Lavtno and Blandiard, Jab hematotoaircs de lliomme et des animaux, Paris, 1895.

64 PBOCEEDINGS SECOND PAN AMEBICAN 8CIENTIFI0 C0NQBB8S.

The desirability of recognition of further instances of this parasite, whether in
man or a lower animal, especially in the Brazilian district where it has been found
in the solitary known case, is of course obvious.

5. LOA LOA (OUTOT, 1806).

SynonyvM: FUaria loa (Guyot, 1805); F, oculi GervaiB and Van Beneden, 1859;
Dracunculvs oculi Diesing, 1860; D. loa Gobbold, 1864; F, tubconjunctivalit Guyon,
1864; F. diuma Manson, 1891; F, sangumit hominit var. major Manson, 1891.

In tracing the American relations connected with this parasite the writer must
primarily express his indebtedness to Ward,' who in his admirable indusive and
analytical study of 1906 has followed the history of this parasite and has, in addition
to a clear discussion of its morphology and life history, arranged a full list of its pub-
lished occurrences with bibliography. From this the writer has cidled the cases
assigned to the Western Henusphere, adding thereto the instances which are recorded
in literature since 1906 for America.

It La to be recalled that Loa loa is within very strict limits a habitant of west Africa,
where doubtless it has existed from time immemorial. Its specific name loa was
the name applied to it by the negroes of Angola, where Guyot, a French naval surgeon,
observed it in 1777, his accotmt not being published until 1805.' Yet before Guyot's
observation of loa reference appeared to certain wanna of the human eye encountered
in the West Indies, which to all appearances must be referred to the parasite here
considered. Thus as early as 1770 Mongin * recorded the extraction of a worm from
beneath the conjunctiva of a negress at Maribarou in the island of Santo Domingo.
Two cases in negroes at Cayenne in French Guiana were reported in 1777 by Bajon,*
in the one case the worm being removed in 1768 from beneath the conjunctiva ci a
negro girl of eight years of age, in the second the worm not extracted but seen to
move across the eye between the conjunctiva and cornea of an older negress (in 1771).
Arrachart published two cases on the authority of Mercier, who in 1771 extracted a
worm from beneath the conjunctiva of a negress in the island of Santo Domingo, and
in 1774 extracted the second from the eye of a negro above the cornea.

Arrachart also states that in 1795 a Creole woman, Mile. Fraise, bom in Santo Domin-
go, assured him that her brother when from three to five years old had had several
worms extracted from his eyes and that young negroes of the island were often attacked.
In Arrachart's publication, appearing in 1805, the accounts of Guyot's observation of
these worms on the coast of Angola and his reasons for differentiation of them from
Dracunculus medinensisy with which doubtless the earlier American cases were con-
fused, were given. Thereafter the American list, following Ward, includes a case in
which De Lassus, an army ofiftcer in Santo Domingo, removed a worm from the eye
of a negro; ^ a case of a worm observed by Clot-Bey * crossing the cornea of an African
slave girl at Monpox, Colombia, in 1828; the removal of two filariee in 1837 from the
eye of a young Guinea negress in Martinique by Blot.^ Two instances of eye filarise
follow from Brazil, in each of which the question of Guinea worm arises, one a case
of extraction of a worm from the eye of a negro in Rio de Janeiro by Lallemont,* the

I Jour, of Infect. Dis., 1900, v. 3, p. 37.

• In Amobart, M^moires, dissertations et obaervations de cblrargie, Ptrls, 1806: M^moire sur 1m vacs det;
yanx, read before the Academy of Surgery in 1778, p. 317.

s Jour, da MM., Paris, 1770, y. 82, p. 888.

« M^miira pour servir a lliistoire da Cayenne et de la Guyana franooise, 2 vols., Paris, 1777, toL 1, p. 826
abitrMtad in Jour de MM., 1778, v. 49, pp. 880, 481; quoted in Arracbart, sup. cit.

• Recorded by Larrey, M^moires de cfairurgie mllitaire et camp., Paris, 1812, 4 vob., toI. I, p. 228.

• Bar. gte. Acad. roy. dee sdeocee, stance dn Dec. 10, 1832. Ardi. gen. da MM., Paris, 1(^ annte., vol.
80, p. 678: tbis by tome aotbors referred rather to BooUn.

' Bsoarded by Ouyon, C. R. Acad. 8cL, Paris, 1838, t. 7, p. 766.

• Caapar's Wocbenschr. f. d. ges. HeUlnmde, 1844, p. 842.

PUBLIC HEALTH AKD MBDICIKB. 65

other the report of a caae obeerved by Siguad ^ of the removal by C. J. doe Santos
oi a worm from the orbit of a negress of the Mina tribe in Brazil, at Rio de Janeiro, in
1833. In 1845 Mitchell ' saw a worm, estimated at about 2 inches in length, in the
sabconjunctiva of a negress in Trinidad who had come from the west coast of Africa
in 1S34. The worm was first noted in 1837, again in 1841 and 1845, and was said to
have grown in the eleven years. (Ward properly questions whether each time the
same parasite was seen.) By Mitchell's account there was a tradition that a similar
worm had been seen in a family in Antigua 60 years before (1799).

With these the published American cases close until the latter end of the past cen-
tury, the usual and probably the correct interpretation of the cessation being that
with the end of slave importation from Africa the source of the parasite was diverted
from the Western Hemisphere. It is to be presumed that the parasite failed of find-
ing a proper insect conveyer in America and that each case therefore died out without
dissemination. The only strong suggestion of endemic fixation concerns Santo
Domingo, where if the statement of Mile Fraise to Arrachart was correct, the worm may
have been locally propagated for a time. It is not stated, but is to be presumed, that
her brother, a child of between three and five years, was born on the island, as she
was, and that he there acquired the infestment she related. The further statement of
the common affection of young negroes on the island and the several recurrences of
case reports from this island bear as evidence in the same line. Whether there was
also some local dissemination in Brazil is also a matter of some possibility, the Mina
negress from whom Dos Santos removed a specimen being presumably a native. It
is to be remembered, however, that there is some uncertainty as to the identification
of all these early American cases; that they were regarded at the time as Guinea
worms (which it is well known acquired at least partial endemic fixation in South
America and the Lower Antilles).

Since the date of Mitchell's observation (1845), alter a lapse of half a century, occa-
sional cases have reappeared in America, but with a change of location to the north,
in the United States and in Canada, and with a change from the uniform infestment
of negroes (except the Creole child related by Mile. Fraise to Arrachart) to infestment
of whites who invariably present the history of sojourn in west Africa (for the most
part in missionaries returned from the latter district).

Ward lists, of the modem American cases, the following: (1) Mrs. M., a missionary
living prior to 1897 for several years at Batanga, 70 miles inland on the Gaboon River,
in west Africa. In 1898, at Toronto, Canada, Dr. Frederick Fenton removed two
q>ecimens from her lids, and in 1899 f otmd a third , but failed in extraction.* (2) About
1896, Dr. F. N. G. Starr, of Toronto, Canada, removed a filarla from the skin of the
chest of a woman who had been a missionary on the west coast of Africa, but had
returned on account of ill health; and demonstrated it before the Toronto Patho-
logical Society.^ (3) In 1902, Milroy, of Omaha, Nebr., removed a loa specimen
from the upper right eyelid of Mr. K., an American who had been living in
Batanga, in German West Africa.' (4) Ward also records a series of cases detailed
to him by Dr. B. C. Loveland, of Clifton Springs, N. Y., later of Syracuse, N. Y.
In 1890, Loveland removed a loa from the skin of the left scapular region of Mrs.
R, who had been a missionary stationed near Batanga; and in 1898 he extracted
a loa from the eye of Mrs. J., also a missionary invalided home from Batanga. Love-
land stated that Mrs. J. informed him that her husband and children have all had

1 Bjgiod, Da CUmat et dfls nnUK) . da BrMl oa itetistique m4d. de cet Empire, Paris, 1844, p. 135.

* Loodon Lancet, 1859, ▼. 3, p. 583.

* Case detaUed in Ward's paper, sap. clt.

* Detailed in Ward's article, sup. dt.; and both this and the previous case recorded by Primrose, Brit.
Mod. Jour., IffB, T. 3, p. 1382.

* Detailed In Ward's paper, sup. dt.

66 PEOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIO CONGRESS.

these parasites. (5) Dr. C. F. Friend, of Chicago, is also quoted by Ward in relation
to a previously unreported case, Mrs. X., formerly a missionary in west Africa, from
whose eye he removed a specimen about four years after her return to America. (6)
Vail, of Cincinnati * presented before the American Academy of Ophthalmology and
Oto-Laryngology in 1905 several specimens of loa he had removed from the eyes of
Mrs. L., the returned wife of a medical missionary at Flat, Ebolowa in central Africa.
To these cases, all from Ward's paper, may be added : (1) McDonald in 1908 ' reported
a case of extraction of a specimen of loa from the eye of an American who for nine
years previously had resided in the Old Calabar reg:ion of west Africa. (2) In 1911 ,
Huffman and Wherry • reported a second case from Cincinnati, Ohio, with description
of the parasites removed from the eyes of Mrs. B., after return from missionary service
at Batanga in the Kameroon district in West Africa.

Smith and Rivas ^ in 1911 presented before the Philadelphia Pathological Society
specimens from two white American missionaries invalided home from the same dis-
trict in west Africa. One of the specimens, from Mr. K., of Philadelphia, was imper-
fect, only the caudal half of the worm, a male, having been obtained. The anatomical
features presented by this led the writers to the query whether it does not represent a
new species of the genus loa. No other species of loa or of other genera of filaridae with
habits like those of Zoa is known; but the question of a possible American species is
raised by Ward to account for the suggestion of endemicity in South America and in
Haiti, as an alternative to acceptance in these localities of a fit insect transmitter.
And such a possibility is by no means to be lightly brushed aside. Can this be the
meaning of the case reported in the Canal Zone at Colon Hospital in 1906. as JUaria
divmaf Or if that case be hunted down, will it turn out to have been an imported
case of Loa loa from Africa (which does not seem probable) or a mistaken diagnoali
of an aberrant day specimen of Bancroft's microfilaria, or the microfilaria of pentans
or demarquayit *

There is no occasion in this article for narration of the identification of loa with
Microfilaria diuma by Manson and others, or of the development of our present views
as to its morphological peculiarities or its pathogenic effects, nor yet to more than
mention that the suspicion held in Africa that the parasite is carried by "mangrove
flies" (Chrysops and tabanv^ species) has been sustained by the success of Leiper *
in obtaining development of the microfilariae into prefilariae in Chrysops dimidiatui
and Chrysops sUacea. Fliee of the same genus and with the same unpleasant habit of
energetically sweeping about the heads of human beings and trying to alight to draw
blood are known in America, as Chrysops vittatia Wiedemann and Chrysops niger
Macquart. Leiper failed to obtain prefilarial development in stomoxys, in various
mosquitoes, and in fleas and bedbugs. It is questionable whether in actual truth the
parasite will be found consistently non transmissible in America; and there may welj
be a suspicion as to whether the uncertain endemicity temporarily apparent in Haiti,
and possibly In South America, was not real, and whether firm fixation was not escai>ed
more by chance than by necessity.

Comments.

Of the main purpose of the current article, that of presentation of the history and
geographical distribution of the group of filarial parasites above considered, the pro-
ceeding pages doubtless cover the principal features; but the writer realizes that much

» See Llppert and also Vafl, Cincinnati Lancot-Clinic, 1905, v. 65, p. 733.

> So. California Practitioner, 1908, v. 23, p. 325.

s Parasitoloi^y, 1911-12, v. 4, p. 7; see also Huffman on the loa larva, ibid., p. 75.

< Proc. Phlla. Path. Sec. 1911, n. s., v. 14, p. 2; and Amer. Jour. Trop. Diseases and Prevent. M*vi.,
1914, V. 2, p. 361.

» See Report of "Dept. of Sanitaticm, Isthmian Canal Commission, laboratory report of Colon Hospital for
June, 1906.

• Proc. Zoolog. Boo. London, 1910.

PUBLIC HEALTH AND MSDIdKB. 67

bfts probably heexk miawd which ahoold have found place therein. SyBtematlcally
ccnnplete knowledge of the geography of the different fiUxndm \b very desirable as a
baaiB for any sound plan for prophylaxis, and for dealing with the larger problems of
eradication of these pests. When we consider that surely three of these five parasites
have been brou^t into the Western Henusph^e, and that of the other two, only one,
the single occurrence of Dtro/Uaria magdUuuif is surely indigenous, and when we recall
how restricted in distribution are AeanthocheUonema perstani and JUaria demarquayif
how Loa loa after seeming to take hold in Haiti and Brazil promptly disappeared when
its importation ceased, and how apparently the mosquito campaign in Cuba gives some
promise of the abatement of JUaria bancrofliy it seems well worth while that we should
look iarwnid to the possibility of eradicating all these parasites from among us. The
problem is surely not greats than that of dealing with the hookworm; for some of the
group probably no more than that of handling yellow fever.

But to establish the fundamental knowledge to be utilized for so laudable a purpose,
we require more definite information as to the precise geographical location and area
of infested districts for each species of filaria. This means concerted work, a combina-
tion of individual and central effort. Where health statistics are maintained by local
or general governments, filariawB (with differentiation of the species for obvious
easons) should be made reportable. Where such plan is impracticable, local medical
organizations should act instead, and ask for voluntary reports from members and other
phyaidans of the district concerned. A central agency for reception, coordination
and publication of such reports could undoubtedly be found in the health department
of some one or other of the American countries, or in such an oiganization as Uie Inter-
national Health Commission, which is doing such admirable work toward reducing
the ravages of the hookwcvm. With the field well mapped out, not only will the
extent of the problem be before us, but at the same time there are sure to be sugges-
tions from that knowledge as to advantageous mode of dealing with the question in its
q>ecific stages.

The pioneer work of Low and others who have been mapping out the infested
areas d the West Indies and of British Guiana is even in its incomplete form suggestive.
The peculiar limitation of demarqiuiyi to country districts and unorganized villages
in St. Vincent, and the restriction of demmquayi and pentans to the forest depths of
inland Guiana, with tendency toward heavy infeetment in these areas, will unques-
tionably be found significant in the matter of the mode of their transmission. And
the promise of effectiveness of mass handling of these affections b to-day in closest
line with prevention of transmission.

1. Problems o/JUarial transmission. — It is probably a general law that transmission
of filarial worms must include opportunity for development of the larval filaria, or
microfilaria, in some intermediate host into an infesting or prefilarial stage. We
know, thanks to the studies of Manson, Bancroft, Lewis, Dutton, Low, James, Lebredo,
Daniels, Leiper, and others that Culexfatigans in the West Indies, Myzomyia rossH in
India, Ppretophorus costaHs in Nigeria, Myzorhynchus sinensis and harHrostris in
India and China, Mansonia uni/ormis in Africa, India, the Philippines, and Australia,
Stsgojn^ pseudoseuUUaris in Fiji (7), and other mosquitoes serve as intermediate
hosts adapted to such development for the larval Filaria banaro/H; that for Loa loa
development of the microfilaria takes place in certain mangrove files, Chrysops dimi-
dialus and silaeea, and that these are i^parently efficient transmitters of the prefilaria;
that Aeanihocheilonema perstans seems to reach at most only partial development in
several types of mosquitoes and possibly, too, in the African tick, Omithodorus mou-
bata, which are therefore only tentatively held as transmitters; and that Filaria
demarquayi may likewise undergo at best only partial development in certain mos-
quitoes, and that these can not be held certainly as transmitting agents. On the
negative side, too, for each of these parasites a liat of bloodsucking arthropods have
been tested and found for the individual species incapable of acting as efficient hosts
and transmitting agents.

68486—17— VOL ix 6

68 PBOOEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NQBE88.

In the early views of mosqiiito transmission, it was not contemplated that the infested
mosquito directly transmitted the prefilaria along the sheath of the proboscis of the
insect to the wound made by the mosquito stilette in the skin of its \dctim. Rather
it was thought that the insect merely provided accommodation for development into a
phase capable of independent life ; that after oviposition on the surface of the water, with
the death of the mosquito, the prefilaria escaped into the water and later gained access to
the human host by being swallowed with the water. The proof of direct transmissdon
of Dirofilaria immitis by Anopheles maculipennis by Grasei and N6e was applied at
once to the conception of the part played by mosquitoes in transmission of human
filariasis; and Manson's theory of partial water convection was abandoned byManson
himself in favor of the theory of direct insect convection. The experience of time
and study have confirmed this latter belief for the mosquito and FUmia hawrofti.
But, on the one hand, does this necessarily disprove the older idea or some possible
adaptation thereof for all species, and on the other hand is the list of insect conveyors
for this one species complete? Are mangrove flies the only transmitters of Loa Uwf
Are we to accept for perstans and for demarqtiayi the imcertain sausage-shaped forms
which have developed in the thoracic muscles of certain mosquitoes as sufficient proof
that these insects are efficient intermediate hosts and capable transmitters of these
parasites in nature?

The relative infrequence with which FUaria bancro/H and Loa loa occur in associa-
tion with other filari^e (more marked for the first than the second) is in consonance
with the mode of transmission by bloodsucking insects specific for each; the frequent
coincidence of Filaria demarquayi and Acanthocheilonenia perstans in British Guiana
is suggestive of a conmion mode of transmission (which may be by some totally differ-
ent type of transmitter, or which may differ itself intrinsically in method). Whatever
the agent or the modo it seems rather fixed in limited areas, not apt to persist in organ-
ized communities, and to he of such a nature as to favor heavy infestments in the local-
ity where it exists. It is qmV« conceivable that such characters may apply to some
bloodsucking insect; but the writer ^'^an not easily rid himself of the thought that the
modus operandi may be quite dififereitb^ and perhaps follow the lines of Manson's
original conception with certain modifications:^

For these latter species may there not be some miStAp of transmission possible which
will not necessitate the supposition of peculiar bloodsucSMC&living only in restricted
and undeveloped districts and in the depths of forests? IBi^B^{t Pp^^*^^® ^ ^^
lack of ensheathment in the blood of the host endows these smal^ltg^®^^*"* *
mode of e cape other than through abstraction by a hematophagoiis inSfi^^^ ^^^
in early comments upon lack of microfilarial sheaths in these blood wornllf^^^te
that perhaps, because of their freedom of movement, these might be able tojE^lTey
through the walls of the blood vessels and escape into the tissue spaces. m5L\i^
not, if they possess such abiUty, succeed by their own efforts in escaping fro3-ni
body of the host to a temporary free existence? Would it be impossible for th%e
without inducing notable symptoms, to escape via the kidneys, the intestine, or ^
lungs to such freedom? > The writer would suggest especially the desirabi ity \
examining the expectoration and the mouth moisture for microfilaria, recalling he>,
the fact that escape through the walls of the pulmonary capillaries is not an unknow)
rtep in the life cycle of certain worms (as in case of larval hookworms and larva-
strongyloides). And as by accident, the larger ensheathed larva of Filaria bancrofi
IS sometimes expectorated with a bit of blood. Dutcher » reports a case of Bancroft'^
filariasis in a Porto Rican soldier, who in a paroxysm of coughing in whooping cougl^
expectorated a small amount of blood between the hours of 9 and 10 in the mornin^,r

« Low (Brit lied. Jour., 1908, v. l, p. 723; Jour, of Trop. Mod., 1808, v. «, p. 130) In Uganda notes \
frequence of large numbers of perttaru mlcroflJariiB in the hincs.
» Joor. Trop. lied, and Hyg., Jane 1, 1M4, v. 17, p. 1«.

PUBLIC HEALTH AND MEDICINE. 69

A number of microfilariae being afterwards found therein. Beukiima, * at Nagasaki;
likewise found microfilariae in the hemoptysis of a case of Bancroft filariasis; a third
case is reported by Yamane,' and Garcia Mon and N. Carballo,' in Habana, met with
a case of repeated hemoptysis at night with microfilariae in the expectorated blood .
(In this last case, because of the time of finding the larvee in the pulmonary area, and
because the blood taken from skin puncture at 9 p. m. failed to exhibit microfilarise,
the query naturally must arise whether possibly there existed here an infestment with
a diurnal filaria.)

We are well aware that the embryonal forms of a related genus, Dracunculus medi-
ntnriSf escape, as the mother worm perforates the skin of the host, from the maternal
body into the water; live independently therein for a number of days, and then
devebp into an infesting prefilarial form in some species of eyclops; and that when
swallowed with the water drunk by a human being they escape into the stomach and
infest the man by penetrating from the alimentary canal into the tissues. This last
is brought out by Leiper's experimental infestment of monkeys by giving them to
drink water containing infested eyclops, and by the fact that in water acidulated with
hydrochloric acid the body of the cyclope is disintegrated, and the contained pre
filarial parasites are set free, apparently not only unharmed by the acid but stimulated
by it into activity of movement.

May it not be possible that some such route of escape is also followed by the small
nnensheathed microfilarise of the perstans and demarquayi species (perhaps to find
their intermediate host in eyclops or an analogous water animalcule)? And is it not
possible that the restriction of locality characterizing these parasites in America (away
from the centers of population, in country villages and in forests), and the high ratio
of incidence in the inhabitants of such places, may be as well explicable on the basis of
contaminated drinking water as upon the local occurrence of a very particular type of
moBquito or other bloodsuckers?

One wiio ia laa from districts where actual investigation is possible on such lines
naturally hesitates to annoy the field worker with such queries; but the points of
analogy seem sufficient to make the thought possible that truth may be near (especially
while we are not assured of success in the mosquito trials thus far made for either
perstons or for demarqvjoyi).

2, Problems of microfilarial peruxiicity. — Clinical diagnosis of filariasis should not
be absolute save after detection of microfilariae in the blood or other fluids of the sub-
ject. Differentiation of the type of fiiariasLs, while possible from gross manifestations
in case of Filaria bancrofU and Loa loa, should rest mainly upon differentiation of
the microfilarial species. This depends principally upon morphological features of
the larval worms; but it is desirable to know whether the subject manifests periodicity
or iqpeiiodicity of microfilarial presence in his peripheral blood, and whether an
Actual periodicity is diurnal or nocturnal, before coming to final conclusion as to the
Bpedes with which he is dealing.

The nocturnal periodicity of the Bancroft type of microfilaria was early a matter
of much speculation and theorization, becoming only the more attractive when a
diwni^l and a persistent species came to be known. Of the older theories in explan-
Mtioa of this phenomenon in case of Filaria hancro/ti that of v. Linstow ^ rests upon
a mechanical basis. Linstow believed that during the active working daylight
houiB of the host the peripheral capillaries are narrowed, or in a state of tonicity,
and that at such times the larvse of Filaria hancro/ti are too large to enter these con-
stricted circulating passages, but that in the relaxation of sleep the peripheral capil-
laries widen sufficiently to allow the vermicules to enter and traverse their lumina

1 Mederl. TtKlaebrin t. geoeesk., Amsterdam, 1884, v. 30, p. 561.

> Csnferalbl. f. UJn. Med., ICar. 24, 1888, p. 221, oondeiMed from article by Kentaro Mnrata in Hit. aos d.
Ifad. Fttcnlt. d. kaiser!. Japanlsoh. Universitftt, Bd. 1, no. 1, Toklo, 1887.
• BoivlrtB med. y. oinuR. da la Habtna, 1004, ▼. 9, p. 088.
4 Oantrttlbl. f. Bakt. u. Parasitenk., 1992, v. 12, p. 90.

70 PBOCEEDINGS SECOND PAN AMEBIOAN SOIENTinO C0NQBE88.

and that therefore at nighttime alone (ordinarily, for Mackenzie ' had shown that
the phenomenon was connected with sleep rather than with darkness, and could be
reversed by reversal of the sleeping habit of the subject) these parasites are demon-
strable in the blood withdrawn by skin puncture. While attaining for a time wide
credence, this explanation rapidly declined in popularity when its inconsistency
for the diurnal periodicity of Loa loa became appreciated. The suggestion of Myers *
that each periodic appearance of the microfilarise represents a fresh quotidian brood,
and that each interval is due to the death of the last brood, never attained any wide
acceptance; and was thoroughly discredited by the proof that these filarial larve are
possessed of much greater duration of life than a single day, and that in reality the
phenomenon of periodicity is rather bound up intimately with cyclic change of
location of the vermicules in the blood circulatory area. Manson, who first established
the last fact, conceived that theae changes of position of the microfilaria en maose
from the peripheral to the pulmonary area, and thence to the periphery again, can be
explained as a chemotropic phenomenon.' No chemotropic agent, whether positive or
negative in its influence upon the microfilarise, has ever been demonstrated (although
theoretically demonstrable); and we may seriously question the verity of the con-
ception in that it has been shown that periodicity is not absolute for any periodic
species, but that for any nocturnal or diurnal type it is possible at any and all hours
to demonstrate microfilariae of the species in question in at least small numbers in
the blood of the periphery. If chemotactically influenced, all microfilariae in every
part of the circulation should be influenced equally and at the same time. It can not
but appear singular, too, that if there be chemotactic influences regulatory in case of
PUaria bancrofti and Loa loa some evidence of like phenomena can not be witnessed
in case of all hematic microfilariae. The adaptation theory of Bahr * may likewise
be held in question. This conception would presuppose some unformulated natural
law of adaptation of the habits of parasites to the habits of their necessary transmitting
hosts (that, applied to Pilaria bancrofti^ its microfilariae appear noctumally in the
peripheral blood of man to insure their acquirement by a night feeding mosquito;
that, in case of Loa loa^ its larvae are diurnal in order to facilitate their withdrawal
by some day biting bloodsucker, as chrysops). Why should adaptation demand an
ingenious arrangement when mere persistence of the species in the peripheral blood
for the whole 24 hours could not fail to accomplish the same end? Can it be
consistently supposed that Bancroft's microfilaria would change its habit of peri-
odicity to become a persistent parasite in the peripheral blood in order to adi^t
itself to the day-feeding Stegomyia pBeudoBcutellaris in the Pacific islands when,
among others, the efficient intermediary, Culex fatxgans^ prevails in the same lands
as a dusk and night attacking pest? The writer would prefer to accept the indi-
viduality of Filaria philippinerm$ Ashbum and Craig, rather than be compeUed to
the idea that it is a Filaria bancrofti changing its habits to accommodate itself to an
unnecessary intermediate host.

In a recent article the writer, with Dr. Rivas,* detailed a scries of studies made upon
several cases of loa and of bancrofti infestment, in which we felt that we found evidence
against phototropic and thermotropic influences in relation to the phenomenon of
periodicity, and, on the other hand, suggestions that mechanical factors (such as
increase of the circulatory flow from exercise and from alcoholic stimulation, and
variation of compression of the tissues) are operative in determining the number of
microfilaria to be found at a given* time in measured specimens of the peripheral

i Londan Lancet. 1881, v. 1, p. 707.

s Med. Report China Imp. Customs, Shanghai, 1886; abst. in Brit. Med. Jour., 1887, v. 1, p. 783, and edi-
torial, ibid., p. 1394.
a Brit. Med. Jour., 1899, Sept. 9, ▼. 2, p. 044.
4 Jour.'of London School of Trop. Med., 1912, Supplement 1.
* Smith and Rivas, Amer. Jour. Inf. Dis. and Rov. Med., 1914, ▼. 2, p. 361.

FUBUO HEALTH AND MSDIOINB. 71

blood.^ Comparatiye counts of the number of microfilarue (in a Bancroft case) in
measured amounts of blood from the peripheral capillaries (skin prick) and from a
Tcin (by syringe directly from vein) at time of maximum showed a marked excess
of midofilarisd in the former; which was taken to mean that the microfilarue are
accumulated in the perii>heral capillaries at time of presence of the period, probably
because they aro too large to pass through at that time (not merely because they are
too large to get into the capillaries in the interval, as Linstow supposed). We believe
that the maximftl presence thus represents a concentration of the parasite by, as it
were, the sievelike function which the capillary networks serve, a sieve fine enou^
to retard the progress of the vermicules, but not to completely prevent their passage.
This alone can not, of course, explain the clinical peculiarities of periodicity,. but we
bebeve it to be basic. Oonsidering in illustration the microfilaria of FiUxria ban-
cro/H and of Loa loa, this would not explain why the first are nocturnal and the second
diurnal; the two species would present practical identity and probably aperiodicity
were it otherwise. The writers would believe, with v. linstow, that there does
occur a diurnal tonus or constriction of the peripheral capillaries and at night (from
the fatigue of the day and the relaxation of sleep) a slight widening. The proof is
perii^M not complete, but {physiologists believe that such variations of caliber of the
pedi^ieral capillaries is compensated for in the splanchnic area, dilatation of the skin
capillariee bdng accompanied by contraction of the splanchnic capillaries, and vice
versa. However, a second capillary barrier to the free circulation of the microfilaria
in the blood stream, that of the pulmonary capillaries, must be kept in mind, a series
d capillariee the lumen of which is believed to be fairly constant and independent
d at least ordinary variations of the perii>heral circulation.

From histologic studies one may be fairly assured that the caliber of the fine pul-
monary capillary network is much the same as the average caliber of the fine peripheral
capillaiiee, permitting a free progress of the red-blood cells '4n Indian file,'' but not
hufge enough to allow progression of more than a single cell side by side. This should
mean no inconsiderable difficulty for an object of the size and shape of either ban-
etofli or loa microfilaria to pass through the pulmonary area (probably hours, if one
may compare the time of presence of the parasites in the cutaneous capillariee).
The intervention of these two capillary barriers in the circle, one at the cutaneous
periphery of the general circulation (with an appreciated diurnal contraction and
nocturnal dilatation) and one in the lesser circulatory area (this one relatively fixed at
a caliber just permitting single red cells to move easily), may be believed to complete
conditions making for an intermittent retardation of convection of any passive objects
near the size of red cells and not quite as adaptable as are red cells, because of greater
long measurements and unfovorable curves. Caught in the skin capillary network
in the period of diurnal constriction, even those somewhat lees than 0.007 nuUimeter
in diameter would be enmeshed, only to escape in large number as the tonicity of day
gives way to the widening of night (those which pass the pulmonary area at night
and are swept to the skin would at once pass through and back to the lungs);
passed to the lungs, they are again held until the force of the stream washes them
through. Those which more closely approximate the red-cell measurements are
held even better in the relatively unvarying lung plexus of capillaries and are there
enmerfied even when the skin capillariee are dilated in sleep (this probably accounting
for the perfect periodicity of l^eroJUoKna banero/H in comparison with the greater
tendency in case of MieroJUaria 2oa to be found occasionally in the peripheral blood
in the interval). Those that are materially sQudler than red cells are retarded in
neidier set of cafHllaries and are persistently to be found in the peripheral blood as
weQ as in the pulmonary blood. From the standpoint of size the microfilaria of
Bancroft's species is the largest, measuring usually nearly or quite 0.300 millimeter

> Compare GnnvUle^ old theory of the influence of modification of rate of blood flow and blood pressure
bj ileep in explanation of mlgretloB of microfilaria to surface at night, London Lancet, 1S83, Feb. SO.

72 PBOCEEDINQS SECOND PAN AMEBICAN SCIENTIFIC CONGBESS.

in length and 0.0075 to 0.008 millimeterB in thickness; the larval Loa loa is' from 0.200
to 0.250 millimeter long and from 0.006 to 0.007 millimeter in thickness; the larval
form found in the blood of the type described from Japan by Taniguchi is described
as 0.164 millimeter in length and 0.008 millimeter in thickness; the larval demar-
gtutpTineaauiea 0.200 millimeter long and 0.005 millimeter thick; the perstans larva
is nearly of the same size, possibly a shade thinner.

The bancrofti and Umiguckii larvse are both periodic at night in the peripheral
blood, and they are the Uiickest; loa microfilaria ranks less in thickness and is peri-
odic in the diumally constricted skin capillaries; perstans and demarquayi both have
materially smaller diameters and are not restricted at all, that is, are aperiodic.
From the standpoint of size, therefore, there is a basis for belief that the two barriers
of capillary network to be passed determine the fact of periodicity for microfilariae of
approximately the thickness of the diameter of a red blood cell, and offer explana-
tion of the aperiodidty of those of materially smaller diameter. In the diurnal con-
traction and nocturnal dilatation of the skin capillaries (with the relative fixation of
the pulmonary capillary mesh) there is basis for explaining the nocturnal entangle-
ment of the laiger forms at night, and of Loa loa by day.

But size can not be the sole factor to be appealed to. In some sense any ensheathed
microfilaria may be thought of as a relatively passive object, swept by the current of
the blood and unable to accomplish much active progression of its own initiative;
but unsheathed microfilarise can readily dart at will in the fluid in which they live.
To observe the ineffectual wriggling of a larval bancrofti in the field of the microscope,
and to note the swift darting movement of the same larva if in some way it escapes
from its sheath, is to recognize at once the difference referred to. The writer is confi-
dent that even were perstans and demarquayi larvse ensheathed, their small size would
insure their passage through the capillary barriers and their aperiodidty; but their
freedom of movement in the blood, because they lack the embryonic sheath, in addi-
tion assures them ability to force their way along (and probably would, even were
they laiger than they are). With the ensheathed types this advantage does not ob-
tain. The writer knows of no unsheathed periodic microfilarise. Only one aperiodic
sheathed hematic microfilaria of man has been described, the contested Filaria pkUip-
pinensis of Ashbum and Craig, of the Pacific islands. Its microfilaria! measurements
are identical with those of the larva Filaria bancrofti, with which many would identify
it. Its sheath is described as closely fitting, in contrast with the loose saccular en-
sheathment one notes in case of Filaria bancrofti and Loa loa. This surely means as
much in the matter of the effectiveness of its motor efforts, as to a human being it
matters for his ability to run whether he be ensheathed in a closely fitting garment
adapted to his Umbs, or completely enveloped within a loose sac. The writer is dis-
posed to regard the aperiodidty of this exceptional type as due to its ability to move
in free progression in spite of its relative size, because its sheath does not hamper its
movements.

To carry this idea still further, one may well believe that between ha and bancrofti
forms of larvse the more twisted appearance of the former in permanent microscopic
preparations means that in life loa is the more vigorous. Some progression is possible
for each, in spite of the sheath, little though it be for either; but it should be greater
in case of loa, other things bdng equal, and this should mean for loa more fadlity in
passing capillary networks (that is, avoiding concentration of numbers, save in the
fullness of diurnal tonidty).

One can readily apply the explanation to the fact of reversibility of bancrofti peri-
odicity by changing the period of sleep from night to day, and to the loss of periodi-
dty in general disturbances of the circulation from fever, anesthesia, etc. (de Saus-
sure reports a case at Charleston in which during labor a negross lost the periodidty
of her microfilariae, although later the periodicity was regained).* The writer must

1 Med. News, 1890, June 28, v. 56, p. 704.

PUBUO HEALTH Ain> MEDICVSTR. 73

oonf esB that he can not see its applicability to the reported failure to cauBe change
of penodicity in loa infestments by changing the hours of sleep to day, unless the
observers tailed to recognize that there reaUy occurs apeiiodidty (as mig^t be ex-
pected) rather than reversal of periodicity to night. Loa loa is naturally less definitely
' penodic than banerofti (that is in the inteiVal one is surer of finding a few microfilariae
in the peripheral blood) ; in reversal of sleep to-day a failure to get full capillary tonus
would merely cause loss of the required accumulation, that is, would only make the
p^ods less distinct.

In capitulation of tiiis attempt to explain the phenomenon of filarial periodicity,
the writer would hold in theory: (a) That no microfilaria which is without a sheath
in the circulating blood or is closely sheathed and which in size is materially less
than the diameter of a red blood corpuscle or at least not distinctly thicker ,'^ can accu-
mulate under ordinary conditions of circulation in any part of the circulatory cycle,
and can not for that reason present the phenomenon of pmodicity; (b) but that any
microfilaria which, because of size or looseness of ensheathment, along with no great
vigor of motor activity, is likely to be caught in the mediwork of the peripheral and
pnfanonary S3r8tem8, is sure to exhibit this phenomenon; (e) that of this latter group,
the larger the parasite, the looser the sheath and the less vigorous the motor activity,
the more likely is the periodicity to be nocturnal, and conversely the smaller and
more active are likely to be diurnal in their peripheral periodic presences; (d) changes
of marked d^ree in the vascular tone of the host, whether iiom. disease, drugs, or
habit, may induce loss of periodicity.

If Filaria phUippinensis really is Filaria bancro/ti, the writer suspects its aperiodi-
city is rather due to climatic influences upon the vascular tone of the host than to
any change of habit of the parasite itself (aside from the peculiarity of its closely
adapted sheath). Such an explanation should be open to verification or to disproof
experimentally as weU as clinically. In fact Rivas and the writer have sought in a
dog infested by the aperiodic Dirofilaria immitU, kindly sent us from New Orleans
by Dr. C. G. Bass, to induce in mimicry of periodicity an accumulation of microfi-
huw in skin areas by constriction of capillaries in the areas in question from cold
and by compression. Our results have been irregular, variations both in excess and
in deficiency and sometimes no variations at all being recorded in comparison with
the numbers taken from uninfluenced surfaces. That a disturbing influence was
exerted can be said definitely; that the results were not uniform can only be attrib-
uted to failure of imiformity of adjustment of conditions. The writer for the present
can cmly exj^ress hope that fiurther experimentation will lead to more uniform results
80 that reliable statements may be made pro and con in relation to the explanation
we have proposed.

3. Problem a» to the longevity of filarial paratitei, — No less to the general public
than to the infested individual does the problem of prognosis of filariasis appeal. We
have no reliable remedy for the destruction of the parasites; and we can not, save by
extraction of the parent w(»ms (as in loa and in occasional cases of Bancroft 's filariasis) ,
put a stop to the infestment and to the chance of dissemination, or to the danger of
untoward complications to the individual himself. In such a position, what do w#
know of the length of time during which adult filaris remain alive, and for what
period of the lifetime oi the female does she give birth to microfilaria? How long
after entrance into man before they reach maturity? If fertilized, how long will that
state of fertilization continue without renewal? Is infestment in any way preventive
of reinfeetment, or may hyperfilariasis occur if chance permit? How long are the
microfilaria visible in the blood and what comes of the millions which must surely
escape abstraction by mosquitoes? If there be a free stage in any of these species, as
suggested above, what is its length? How long may the prefilaria continue to live in
the intermediate host? It is far more easy to propoimd such problems than to even
suggest the mode of their solution; and yet there is need of exact information in this
genera] connection on mwe points than here brought forward.

74 PBOGEEDIKGS SBOOKD PAN AMEBIOAK SCIENTIFIC COKGBESS.

Adult filaiise sometimes die within the lifetime of the human host, and of neceesity
die at least shortly after the death of the human being who harbors them. They have
been foimd calcified and encapsulated in the tissues. But why they die, whether
from filarial senility or special and unknown cause, we are igncnrant.

To the clinical article by Matas,^ of New Orleans, McShane adds a section dealing
with biological questions concerning FUaria bancro/tif wherein he refers to observa-
tions by da Silva Araujo of individuals who had suffered with chyluria for 14 and 22
years, in whose chylous urine he found microfilaria; of a like observation by Sonsino
of a woman similarly affected for over 20 years, with microfilaria in her urine; and
of a statement by Lanceraux of an old Creole woman of over 80 years of age who had
had chyluria for more than 60 years, in whose urine he found microfilariae. These are
ominous data, but there is no assurance that the last instance (or any of them for that
matter) does not include reinfestment. The duration of complications such as ele-
phantiasis (Mr chyluria without the demonstration of coincidence of microfilaiise in the
blood or urine is not significant of the length of life of the original parasites, obeenra-
tions of cases of such condition without microfilariasis being regarded rather as evi-
dence that the parent worms have died, leaving the complication as a sequel. The
certain knowledge we possess of the life of FUaria baneri/ti within the body is meager;
but from the time of infestment to maturity surely several months must elapse and
possibly more; and the duration of life in maturity probably ranges from 1 or 2 to 15
or 20 years. Longer periods of microfilariasis are probably explicable on the baais ol
reinfestment. The small number of adult parasites usually found and the lack of
clear evidence of reinfestment have opened the question whether an immunity is
gained against ready reinfestment or whether, on the other hand, a condition of
hyperfilariasis is possible.

In case of Loa loa^ the frequent finding of immature worms and the failure to find
microfilaria in children, and the more common finding of mature specimens in adults
have led some to believe the develc^mental period of the parasite in the host is a pro-
longed one, although,' judging from the appearance of its ' ' Calabar swellings, ' ' clinical
effects may appear within one or two months. Its adult life is surely capable of
extending over a number of years (one of the cases reported by Smith and Rivas *
was of at least 10 to 11 years and possibly 18 years in duration); and in this species
the large number of parasites which may be found in one individual (34 found by
Penel in one individual)^ is probably significant of more frequent reinfestment than
in case of FUaria bancrofii,

Kdlz,^ who was himself parasited by AoanthocheiUmema perstoM, first found larval
filari® in his blood four years after the supposed time of infestment. Others reduce
this period of development in the host to within one and a half years; its full life
period doubtless may range up to a number of years, although Uttle is definitely
known of this point. There may be large numbers found in one individual.

The period of development and duration of life of FUaria demarquayi are probably
flindlar to those of the already mentioned parasites, but certain information is lacking.
The number infesting one individual is not apt to be large, but commonly more than
a single pair.

Known instances in Africa of the coincident infestment of one host by Loa loa and
AcanthocheUonema perstarUy and in British Guiana of the coincidence of the latter and
FUaria demarquayi are by no means infreqiient. But thus far it is rare to find coinci-
dence of FUcffia banercfH with other filarial parasites; whether from the special pecu-
liarity of the transmitting agents, peculiarity of conditions of infestment, or any par-
ticular resistance offered by FUaria bancro/H to secondary infestments, is unknown.

1 New Orknns Med. and Snrg. Jour., 1891, ▼. 18, p. 501.

• Leber and Prowasek, Betbeft s. Arch. f. Schiffs- u. Tropenhyg., 1902, v. 16, p. 441.

• Sap.dt.

« Aitdi. de Pansttol., 1906, ▼. 9, p. IM.

• Arch. f. Sohilb- a. Tropenbys., 19U; ▼. 16, p. SU.

PUBUC HEALTH AND MEDIOIKB. 75

Infonnatioii upon the normal periods of development, duration of the period of
sexual reproduction during maturity, the time of senescence, and the full limit of life
of each of these parasites would be of decided interest, and useful from a standpoint
of prognosis, if not for other points as well.

How long is the life of the microfiliaria in the blood of the definitive host? Cer-
tainly more than 24 hours, as Myen once suggested in attempting to explain the
periodicity of FUaria banero/H. The writer has seen one out of a number of larval
FUarim hanero/H living in a thick blood film, isolated on a glass slide, after eight days
bad lapsed; other writers have maintained th^n extracorporeaily even longer. In
cases where fortunate removal of parent filarift by operations has been accomplished
(wh«i chyloceles and similar surgical complications have been treated) the microfi-
laria disappeared from the blood in the course of a few weeks. But this need not
of necessity follow in so short a time, if one may appeal to the analogy of experi-
ments with other filariee. Gruby and Delafond injected microfilariae <d Dirofilaria
immUU into other dogs than the host from which they obtained them, and could find
them for as long a period as three yean thereafter in the blood of the redpients;
and in a rabbit they lived at least 89 days.

We have little knowledge of the fote of the larvae which faH to be taken out of the
drcnlation by the intermediate host. Of course, where such condition as chyluria
exists, many pass to the exterior of the body in the urine. Whether there Ib another
easy path of loss has not'been sufficiently studied. As above indicated, the writer
feels that time and effort should be applied to determine whether they are not fre-
quently to be found in sputum and in the moisture of the mouth and respiratory
passages. Occasional remnants, at times encapsulated and calcified, have been
observed in the capillary areas of the lungs, liver, spleen, and kidneys; but no suffi-
cient trace of the great numbers which presumably die in the host has ever been
realized.

4. Problem of dieTnotherapy offilariagis, — ^The therapy of filariasis, aside from that of
its complications and the surgical indications, involves two possible purposes, the
destruction of the parent filaria (with the consequent destruction of their microfilariae
as well) and the destruction of the microfilarise sdone. Of these the former is of course
the more desirable; but success in the second line may at least prevent serious com-
plications for the individual host and will for the time set aside x>06sibility of dis-
semination of the parasites to new hosts. Neither empirically nor from exx>erimental
studies are we in possession of an agent which can be relied upon to accomplish the
destruction of either the parent worms or their broods of microfilaria; nor is it to be
surely expected that the precise remedy in the same dosage will, if ever discovered,
necessarily be equally lethal for all species of filarise. Numerous drugs which might
be found lethal to microfilariae can not with certainty be expected even in higher
dosage or more persistent administration to kill the fully developed parental forms.
It seems not improbable, too, that the ensheathed microfijariae would manifest a
better protection against destructive agencies than the free microfilariae because of
the ensheathment itself.

But one who has access to fresh blood preparations from filariated human beings
or for that matter anyone who can command similar material from cases of animal
filariasis, as that of the dog, will do well to systematically study in such preparations
(with and without citration of the blood) the possibility of destroying the microfilariae
with certainty and promptness by such drugs and in such dosage as might be permis-
sible in human medication. Accomplishment of even thia limited purpose will mark
a long step in advance; and possibly may suggest further method of eradication of
the parent worms and thus definitely curing the affection. Perhaps adjustment of
dosage or chemical variation of the basic remedy might succeed with the adults
when once a reliable microfilaria! lethal agent or method is realized. The writer is
disposed to believe that investigations prosecuted along one or other of these theo-
retical lines in careful systematic fashion with view of destroying microfilariae will

76 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

eventually be found successful, in each case founding the crucial experiments in
man upon preliminary observations upon living microfilaria on the microecopic
slide and then upon those in circulation in some filariated animal, as a dog. The three
lines of study in mind include the employment of (a) exogenous agents likely to be
immediately toxic to the microfilariae, (6) of means of cutting down or off the food
supply of microfilarise, and (c) of generating within the host of substances toxic to
microfilariae (in each case within range of toleration of the host). Of these of course
the first must appeal the most strongly. Four remedies, administered empirically,
have seemed to have influence in case of Microfilaria hancrofii: thymol, methylene
blue, quinine, and arsenic. Each, urged as curative at first by its advocates, has fallen
into disrepute because of failures in the hands of most of those employing it. Occa-
sional experimental study of such agents ^ may be met with, but little has been done
toward a consistent and systematic trial in vitro and in vivo of the filariacidal influ-
ences of all of the suggested remedies and others which might appropriately be
considered. When one remembers the thorough and long-c<mtinued studies of
E3irlich in ferreting out salvarsan for the destruction or the syphilitic treponema,
the insignificance of our searches for filariacides is obvious.

As far as the second measure is concerned there is of course little actual fundamental
knowledge. There is a slight increase in size of the microfilariae from the measure-
ments of those in the maternal uterus and those of the microfilariae in the circulating
blood (thought by some to be due merely to inhibition of fluid), but the variability
noted in the size of Microfilaria denwrquayi as seen in any blood preparation bespeaks
some degree of growth in the microfilaria! stage of the parasite. It seems unlikely
that the nutrient material basic to such growth was derived solely from the maternal
worm before the birth of the microfilaria. Much of the substance of these as of other
parasitic worms is of carbohydrate nature, largely glycogen; and it is at least worth
consideriog whether by restricting in the diet of the host elements which make readily
for the formation of glucose and glycogen in metabolism (the application of Allen's
diabetic regime, for example) may not influence both the parent and the microfilaria!
parasites in harmful fashion without injury to the host. Suggestions bearing on the
linQ of the third idea, that of inducing harmful changes in the host with the purpose
of interfering with the well being of the filariae naturally first are offered by the
well-known fact that in acute infectious diseases the hosts of intestinal parasites are
often spontaneously relieved of their parasites. The writer knows of no instance of
the cure of filariasis by an intercurrent infectious fever, and has no data that the num-
ber of microfilariae in the blood is influenced under the same circumstances. But
there can be little doubt of the reality of the principle that the toxemias of acute
infections are apt to work harmfully upon coinciding animal parasites. Bahr'
studied the effect of a staphylococcus vaccine upon one of his filariasis subjects,
with negative results. There may naturally be considered in this same connection
the factor of increased body temperature of the host; and undoubtedly the possi-
bility of thermotherapy^presents a field open to research (as by the induction of
febrile temperature by some such definite chemical as /S-tetrahydronaphthylamine).
Reasoning by analogy it is possible, too, that exaggeration of substances identical
or similar to excretory or waste material from the parasites within the host may
be of harmful influence to the parasites. Most of these low animal parasites pro-
duce among their waste products fatty acids, thought to include in important propor-
tion valerianic acid. Is it possible in vitro to find that substances of such a type,
valerianic acid, butyric, oleic, acetic, or lactic acid, in proportions tolerable to the
host, can have lethal effect?

The field is almost entirely unworked, and the writer has said more than enough
to suggest lines of work, which are open at every point in fact.

Hereupon the session adjourned at 12.15 o'clock.

I Bahr, Filariasis in Fiji, Jour, of London School of Trop. Med., snpplement 1, 1913, p. 78.
«Ibld.,p.70.

SESSION OF SECTION Vm.

New Ebbitt Hotel,
Tuesday afternoon, December 28, 1916.

Chairman, Col. John Van R. Hoff.

The session was called to order at 2 o'clock by the chairman.
The Chairman. The first paper on our program is by Dr. B. W.
CaldwcD, of the American Red Cross.

THE EProBMIC OF TYPHUS EXANTHEMATICUS IN THE BALKANS AND
IN THE PRISON CAMPS OP EUROPE.

By BERT W. CALDWELL,
Superintendent Allegheny General Hospital ^ Pittsbxirgh, Pa.

The epidemic of typhus exanthematicus which spread over Serbia from December,
1914, to the end of July of tlie present year, was in proportion to the territory involved
and the population affected, the most severe that Europe has ever experienced. The
spread of this epidemic from the Danube to the Grecian boimdary, involving every
hospital, prison camp, soldiers' barracks, and almost every home, was due entirely
to preventable causes, to inexcusable indifference on the part of the Serbian civil
and military authorities, and to carelessness which amounted to crime.

It is impossible to tell how many were afflicted with this disease, as there are no
reliable statistics available. The military reports do not include the civil popula-
tion and those who were ill and died of this disease unattended by physicians, where
no diagnoses were made. Conservatively, one out of every five of the two and a
half million population was attacked by typhus, and 135,000, including 30,000 Austrian
prisoners, died of typhus during this epidemic. The hospital mortality ranged from
19 per cent to 65 per cent. No part of the country escaped, and every city, town,
and village in Serbia contributed to the morbidity and to the consequent mortality.

The unreliability of the estimates in this epidemic is further increased by the fact
that the Serbian physicians classified typhoid fever as typhus abdominalis, relapsing
fever as typhus recurrens, and typhus fever as typhus exanthematicus, and they used
the term ''typhus*' vicariously to indicate any one of these three diseases. Lack
of physicians in hospitals and among the civil population caused the diagnosis of
tjrphns to be made in almost any case running a temperature, and was given as the
cause of death in many cases where it did not exist.

The word "typhus" covered a multitude of sins in diagnoses, as well as a world of
ignorance and carelessness. This does not apply, however, to the better hospitals
under Serbian control, or to those managed by the American Red Cross units, or
to Red Cross missions sent from other countries.

Typhus is transmitted by the louse. The body louse is completely incriminated;
the bead lo^^ probably so, and the crab louse not at all. While no human experi-
ments were made in Serbia, still the observations made in those cases of typhus oociu>-

78 PBOCEEDIKOS SECOND PAN AMEBIOAK 80IBKTIVI0 OOKQBB80.

ring in hospitals and private homes, gave no evidence that the disease is transmitted
in any other manner than through the hite of the infected louse. Measures looking
to the eradication of lice from people and in their habitations, the improvement of
personal and community cleanliness and hygiene, the isolation of people afflicted
with the disease, within a short time placed the epidemic under complete control.
Like cholera, typhus is one of the easiest infections to prevent, and should it creep
in, it is one of the easiest to eradicate when conditions favor, and when our present
knowledge of the control of the disease is scientifically applied. It is essentially a
disease of winter months, and no sanitary measures at present known are better or
more efficacious than warm weather and sunshine, when the poor can leave their
crowded quarters for the open air, and when bathing can be accomplished frequently,
when clothing can be waited and changed frequently, and when lice leave because
of the heat which they can not endure. As the colder months, with their congested
conditions, immediate want and squalor, are ideal conditions favoring a typhus
epidemic, so warm weather, accompanied by the sunshine, which permits the popu-
lation of homes and communities to seek more hjrgienic living conditions, to take
better care of their clothes and persons, and to destroy the lice with which they
have been infested, are the conditions which favor the control and eradication of
this disease. Want and the overcrowding of people, soldiers, and prisoners, where
the facilities for bodily cleanliness and personal hygiene are denied, where filth
and squalor exist, and is added to by each incoming guest, when the climate is so
severe that heavy clothing with infrequent changing is imperative, afford conditions
for the breeding of lice and the propagation of this dangerous infection which are
ideal.

Typhus has an incubation period of about 14 days; probably a little under 14 days
than a longer period. Eruption follows the onset closely and reaches its maximum
intensity on the fifth day. It is during this five-day eruptive period that the presence
of the infected louse becomes dangerous to the non-immune; after this period of the
disease and during the convalescence, there is little or no danger of the louse becoming^
infected after feeding upon the patient. The disease reaches its climax and if death
does not ensue a long and difficult convalescence is experienced. The mental dis-
tress and disturbance, often serious in character, invariably follows. Gangrene of
the extremities at times necessitating amputation complicates convalescence. Severe
emaciation attends the convalescent stage and a general neuritis is often noticed . The
disease seems to be a general septicemia, but nothing has been discovered at autopsy
to throw any light upon the pathology of this disease, with the exception of the recovery
from cultures taken from the spleen of an organism resembling the Plotz oiganism.

Sex influences the incidence of typhus. Adult males are particularly susceptible;
adult females form a very small percentage of those infected and a still smaller per-
centage of those who die of the disease. Usually the disease when attacking females
is mild in type and the severe sequelae which follow the disease in males is not noticed
among the females who have suffered from this infection. Children of both sexes
are seldom attacked. The greater opportunity which women and children have
and which they exercise for the cleanliness of their clothes and persons and which
men, especiaUy soldiers on campaign and prisoners in barracks are usually deprived
of, undoubtedly affords protection to the weaker sex; so also those who live in sanitary
eurroundings and who have an opportunity to Uve in comparatively good hygiencic
conditions are equally protected.

With proper precautions laige numbers of nonimmimee can Uve in the midst of a
typhus epidemic and escape the disease. In Monastir during the period of the epi-
demic our American missionaries maintained a school and orphanage having an
attendance of 140 pupils. Their school is located in the center of the city and within
a stone's throw of four of the laigest hospitals, accommodating at one time 3,000 typhus
patients. In addition typhus was incident in the homes of many of the immediate

PUBUO HBALTH AND MEDIOINE. 79

ncighbon and the teachers in this school and the senior pupils visited the hospitals
regularly two or three times a week to minister to the sick and yet there was not a
single case of typhus among the pupils or faculty of this school. In Belgrade a found-
lings' home, containing 40 children, is located just across the street from the civil
hospitals and Dr. Ryan's Red Cross Hospital, where thousands of cases were treated
in the course of the epidemic and no case of typhus occurred in this orphanage. The
insane asylum in Belgrade, containing 180 males and 160 females, is located adjacent
to the civil hospital and is separated from it only by a high stone wall. The inmates
of the asylum p^formed manual labor in and about the hospital grounds, yet during
the entire epidemic only four cases of typhus occurred in the asylum and the progress
of the epidemic was immediately checked.

But only where the conditions for hygienic living were provided did the Serbian
peqple escape. All classes and professions were affected. The medical profession
in Serbia suffered more from the disease and consequent mortality than any other
pnrfession in proportion to its number. Overworked and exhausted by the endless
labor of caring for their sick, these civil heroes lost 160 of their number out of a total
of 340 at the beginning of the war. To these self-sacrificing men and women a glory as
great as any gained on the battle field or in fire-shelled trench is due. They spsied
not themselves, they spared no effort and no labor, but worked until exhausted and
the disease attacked them. Among our own American physicians who went to the
aid oi the strickoi people of Serbia five died, two of whom, Drs. Donnelly and Mac-
Grudor, were members of the American Red Cross imits. The nurses did not escape;
they too performed heroic deeds, and in one of our Red Cross imits 11 out of 14 were
strickoi with typhus; happily none of them died. The physicians and nurses which
other countries sent to Serbia suffered as heavily.

The conditions for the spread of the epidemic in Serbia were ideal. During the
Balkan War typhus had invaded Serbia and had never been completely eradicated.
Here and there scattered through the country, especially in the northern districts,
were sporadic cases and from these loci of infection the epidemic had its origin. The
people were exhausted from previous wars; they had been invaded by a large army
and the civil population had retreated as the army fell back. Belgrade in normal
times has 100,000 people— during the war only 30,000 remained. The smaller cities
and villages in central and southern Serbia soon became congested and overcrowded.
The lack of bathing fadlitiee in the homes of the better class of Serbians, their entire
absence in the homes of the middle and poorer classes, the crowded conditions in
which they were forced to live, the cold months of the winter, all favored the intense
spread of the epidemic which had started. Then came their military success. The
Austrian army was thrown back through the invaded territory and across the Save
River and 70,000 Austrian prisoners were taken captive. These prisoners, starved,
exhausted, and vermin infested, were distributed in the little cities and villages oif
central and southern Serbia, thus further increasing the already overcrowded con-
ditions.

In December, 1914, a sick soldier was sent to his home in Belgrade and was confined
to his bed for three days before a physician was called and a diagnosis of his case made.
His home was in one of the thickly populated quarters of Belgrade and many of the
members of his family and his curious but well-meaning neighbors visited him during
this period of illness. When a physician was called the patient was found to be in
the fourth or fifth day of the eruptive period of typhus. No effort was made to isolate
or quarantine this case and people were permitted to visit the patient as before until
he died. Within two weeks in this particular section of the city dozens of cases of
typhus developed and the epidemic spread through all quarters of the city. In
six months it was estimated 7,000 cases of typhus occurred in the city of Belgrade
abme, the civil hospital caring for 1,850 of them, with a mortality of 19 per cent, which
was the lowest hospital mortality of which the writer knows in any hospital in Serbia.

^80 PROCEEDINGS SECOND PAN AMBBIOAN SCIENTIFIC CONGRESS.

At the same time in other cities of Serbia, among soldiers, prisoners, and civil popula-
tion, the epidemic was increising at a fearful rate, and by the middle of January
practically the whole of Serbia was involved.

The overcrowded conditions in the hospitals in northern Serbia led the Serbian
authorities to distribute the surplus sick suffering from t3rphus among the hospitals
in the cities and villages of central Serbia and Macedonia, in many instances infecting
cities wh^e the disease had not existed up to that time. Due to lack of room in ho^
pitals, soldiers and others connected with the army, becoming infected with typhus,
were sent to their homes in whatever part of Serbia they mig^t live, in this manner
carrying the disease broadcast with them. From this time there was no possibility of
controlling the epidemic with such means as the Serbian authorities had at their com-
mand. Such efforts as were made by the medical authorities were feeble and unavail-
ing; indeed , the epidemic had grown to such proportions that the entire time and labor
of the few physicians in Belgrade and throughout Serbia were devoted to waiting upon
those abready infected with the disease. The Serbian authorities lacked oiganization^
capacity, and direction, and the most inexcusable and unexplainable things were per-
mitted to be done by them. Trainloads of typhus patients were sent from northern
Serbia to all parts of the country, even to the extreme southern boundary, in this man-
ner invading many localities with the infection which were comparatively free from
the disease. The cities in which the few cases of typhus had abready made their
appearance might have been protected by prompt isolation, disinfection, and efficient
quarantine. All these measures were entirely neglected. Their hospitalization was
miserable. The regular hospital establishments were too few in niunber and of too
small capacity to accommodate those who had been wounded or taken ill during the
military campaign; and schools, colleges, and public buildings of all kinds were hur-
riedly converted into emergency hospitals to accommodate those who were becoming
infected with typhus. Two beds were placed side by side together and a single mat-
tress placed over them, in this manner affording accommodation for three patients
where only two could have been acconmiodated before. No wards were segregated
for the especial use of treating typhus patients, but the incoming patients were scat-
tered indiscriminately throughout the hospitals in whatever section or ward an empty
place could be found. Often a patient suffering from typhus in the active stage oi
the disease was placed between two patients on the same bed who were not suffering
from the disease, and in the due course of time all became infected. Every hospital
became a hotbed of infection. Few of them had anything like sanitary arrangements^
and in them only military patients were accommodated. The dvil population was
almost entirely neglected; only such attention in a professional way was given to
patients in their homes as could be given by physicians already overworked by their
duties in the military hospitals. In one section of Macedonia, containing a popula-
tion of 250,000 people, there were only 8 physicians, all of whom were attadied to the
military service, and not a single one was left to give any attention to the civil popula-
tion. Hundreds of new cases were reported daily, and the deaths reached an alarming
total. The people, long inured to hardship and misfortune, became disheartened
and discouraged at the fearful danger that was threatening them with extermination.
Starvation and squalor added their terrors to the frightful picture, and the people were
without hope. It was amidst such surroundings and at such a time that the American
Red Cross Sanitary Commission and the commissions sent by the Grovemments of
England, France, and Russia, arrived in Serbia, during the month of April, and began
their energetic campaign to combat and control the disease. There were never more
favorable conditions for the spread of an epidemic than those eaisting in Serbia at this
time. With these commissions came what was far more valuable to the suffering
people and far more effective in the control of the disease — the warmer weather and
the sunshine. With every warm day the disease lessened. The people left their
crowded homes, the prisoners were permitted to leave their congested barracks, and

PUBLIC HEALTH AND MEDICINE. 81

the aoldiera had greater and more opportumties and time for the promotion of personal
and community cleanlinesB. These new conditions, aided effectively by the activi-
ties of the American Red Cross Sanitary Commission, under the energetic, experi-
enced and versatile director, Dr. R. P. Strong, soon placed the infection in that por-
tion of Serbia which was assigned to the American Red Cross Sanitary Com mission
for the field of its labors under good control, and a few weeks later the disease was com-
]detely eradicated. Serbia, for the purposes of controlling the epidemic, was divided
into four sections; the northern and eastern sections, respectively, were assigned to
the Frendi and Russians, the central section was assigned to the English, and the
southern, comprising practically one-half the area of Serbia and many of its laiger and
more important cities, was assigned to the American Red Cross Sanitary Commission.
Immediately after arrival the Americans began their campaign in Uskub, Veles,
Priaien, Pristina, and Monastar, and, while on the 1st day of May there were 3,000
cases in Uskub, 1,500 in Veles, 1,000 in Prizien, 1,000 in Pristina, and 2,000 in Mon-
astir, three months later, on August 1, there were not a dozen active cases in all of
these cities, or in the remaining parts of Macedonia.

The measures taken by the American conmussion consisted in fumigating all hos-
pitals, barracks, schools, and other loci of infection. The patients in the hospitals
were bathed with soap and water and kerosene, and their clothes were disinfected
by steam at a temperature of 115° Cel. for 30 minutes. After this process the patient
was returned to a clean and vermin-free ward. This process was repeated as necessary.
Soldiers and prisoners in barracks were bathed and their clothing disinfected in a like
manner. Houses in which typhus was present were fumigated, and the patients were
quarantined and isolated, or removed to the typhus lazarettos connected with local
hospitals. A general sanitation of towns and cities was instituted, bathhouses were
built, sewers were constructed, and proper disposal of sewage and garbage was insisted
upon. Elmeigency hospitals were abandoned as rapidly as possible, and patients
suffering from typhus were segregated and sent to hospitals or wards especially dedi-
cated to the treatment of these cases. General sanitation and hygiene was insisted
upon throughout the territory, and conditions rapidly improved. With the coming
of the warm months of summer the disease disappeared, and it is worthy of note that
it diflfl^ypeared coordinately in all parts of Serbia, in those districts in which the mis-
sions from other countries were laboring, to the same gratifying degree as in the district
to which the American Sanitary Commission was assigned. Only in the thickly
populated districts of northern Serbia was an isolated case here and there reported, and
it does not seem to have been completely eradicated in this territory. In the event
that conditions such as existed during the past winter repeat themselves during the
coming winter, Serbia will again experience, or at least this northern part of Serbia,
an epidemic of typhus.

Aa magnificent as were the results which attended the labors of the American Red
Cross Sanitary Commission, not less worthy of credit, and certainly more marvelous,
were the accomplishments of the countries bordering on Serbia, in keeping the disease
from getting a foothold within their borders. A nimiber of cases, probably a thousand
or two, w^e reported in those parts of Austria-Hungary adjacent to Serbia, but the
epidemic was not permitted to spread, and after a time was eliminated entirely in
many localities in which it had made its appearance. In Roimiania, which is the
highway of travel between Serbia and the southern part of Europe and Russia, the
energetic measures taken in the quarantine station at the Roimiania-Serbo border
completely prevented the entrance of the disease into this coimtry.

Bulgaria, with its highly developed corps of physicians and sanitarians, which
bounds Serbia for almost its entire lengtii on the east, and which is another hi^way of
oommunicatbn between southern and western Europe, succeeded in preventing any
typhus from crossing its boundary line. But the most creditable of all was that of the

82 PBOGEEDINOS 8BG0KD PAN AMERICAN SCIENTIFIO C0N0BB88.

Greek phymdanB and quarantine officers and sanitarians. (Greece bounds Serbia on
the south, and since the beginning oi the war the only communication which Serbia
had with the rest of western Europe and America, was through the port of Saloniki, a
dty of 200,000 people, with an additional 40,000 refugees of all classes, located within
buildings and barracks within and about the city. Saloniki is connected with Serbia
by two lines of railroads, and the old Via Romana highway affords another means of
conununication between Monaatir and Saloniki. Hundreds of thousands of people
traveled in and out of Serbia through this port, and were exposed constantly to the
disease while in Serbia during the lifetime of this epidemic, yet such were Uie care-
fully executed measures established by the Greek quarantine officers and sanitarians
that lees than 200 cases were reported in Saloniki and in the remaining cities of Greece
while the epidemic in Serbia existed. At each point of entrance into Greece, the
Greek authorities had instituted quarantine stations equipped with disinfecting plants
and isolation wards, and every passenger on every train, and everyone crossing th^
boundary line on foot or by conveyance of any kind, was stopped at these stations,
examined by competent quarantine physicians, their clothing and baggage disin-
fected, and all suspicious cases running a temperature of any Borty or due to any cause,
were held for an incubation period of 14 days before being permitted to continue their
journey into Greece. Upon arrival of any passenger from Serbia to Saloniki, or any
other city in Greece, the traveler was again examined by a physician, who issued him
a card upon which were blanks for the recording of temperature for the five succeeding
days, and under heavy penalty for failure to carry out the instructions, the traveler
was ordered to report daily to the local physicians for the recording of his temperatures

In the city of Saloniki, where a majority of the cases reported made their appear-
ance, the authorities handled the situation in a correct and scientific manner. Every
case which ran a temperature from any cause, in the city, was reported to the health
officer, who held the attending physician to a strict account for the foithful reporting
of progress and diagnosb in the case. In any case of doubtful diagnosis, expert pro-
fessional advice from the health office was tendered without charge to the patient,
and in case a diagnosis of typhus was made, the patient was called for by an ambulance,
taken to a central disinfecting plant, where his clothes were taken from him and disin-
fected in an autoclave, the patient given a hot-water, soap, and kerosene bath, his
hair cut, and new hospital clothes given to him, and in a different ambulance from
that which conveyed him to the disinfecting station, he was removed to a typhus laza-
rett located at the edge of the city, and there remained until his recovery. He was
not permitted to receive any visitor or any article sent from the outside, and was
waited upon during his illness by a competent force of physicians and hospital attend-
ants. The feat which these efficient sanitarians accomplished in preventing the
epidemic from gaining a foothold in their city, which was at that time the greatest and
busiest port in the Levant, is a wonderful demonstration of what proper hygiene and
sanitation will do.

The problems which confront all the countries engaged in this war are the care,
treatment, and preservation of the health of the prisoners which they take captive.
These men, brou^t together from all parts of the world and suffering all the hardships
of long and arduous campaigns, under the most unfavorable living conditions, espe-
cially when engaged in trench wartime, are, when they are taken prisoners, usually in
a state bordering on starvation, exhausted in mind and body, and almost without
exception vermin infested. To the country which takes these men captive comes the
great problem of preventing the bringing in of contagious and infectious diseases,
which not only threaten the health and lives of other prisoners, but their own soldiers
and civil population as well. So far as typhus is concerned, these countries handled
the situation with wonderful success.

In <me of the countries having upward of 2,000,000 prisoners, and in which prison
camps accommodating f<vty <v fifty thousand prisoners are not unusual, with the

FUBUO HBALTH AND UXDiaOTK. 88

exoeptioD of one or two cunps, they hare succeeded in keeping t3rphn8 from coming
in. In these camps in whidi the epidemic has occurred it has been controlled with
t minimnm degree of sickness and loss of life. Their methods for controlling this
disease are simple, but very effective when consistently carried out. Upon the
entmnce of a number of new prisoners into any prison camp they are immediately
isolated in a section of the camp separate from the remaining barracks for a period of
14 days. Upcm admission to these isolation barracks each prisoner has his hair cut,
is taken to a central bathhouse, disinfecting plant, and laundry, located in the center
of the isolation compound, where he is bathed with cresolized aoap and water and
afterwards with kerosene, during which process his clothes are disinfected with live
steam at a temperature of 135^ Cel. for 20 minutes. After his bath his clothes are
retained to him and he departs from the building through an exit in the rear of the
bathhouse. This process is repeated during the 14-day period every 4 or 5 days.
At the end of that time the prisoners are mustered for personal inspection by the
prison physicians, and if they are in condition they are sent to their permanent bar-
neks in the other compounds. In the event that any case of infectious disease occurs
in any part of the prison camp, the case is at once removed to a well-equipped hospital
attached to the prison and is there isolated and quarantined until he is free trom
dangOT to the other prisoners. The American Red Cross Commission, sent to Ger<
many for sanitary work in the prison camps in that country, personally inspected
camps 1b which there were 125,000 prisoners. They mustered for personal inspection
of clothing and persons, hundreds of prisoners of different nationalities in the different
camps: they persoBally inspected hundreds of barracks in which prisoners were
quartered, and thousands of beds and bunks on which the prisoners slept, and not a
single loiaas or bedbug was discovered. This demonstrates the wonderful care and
application whidi the authorities of this Government use in preventing the incidence
of contagions diseases of any sort among its prisoners and illustrates most forcibly
what eneiy<etic and correct measures will accomplish wh^i scientifically applied in
the preventiMi of infectioa.

The greatest hotbed of tjrphus and other infections existing in Europe before the
outbreak of the epidsBaic in Serbia was in Galicia and Poland, along the Russian
battle £ront. With the overrunning of these two immense Provinces by the con-
teadins armies the danger from the spread of the disease to the remaining parts of
Europe became greater and more apparent each day. ^lien finally the Russians
were driven back beyond the borders of Galicia and Polwid, and tiie current of travel
between important points of these two Provinces a$;ain began to flow, it became
aecossary for the German and Austrian Governments to make great preparations
and take the most effective measures to prevent the ingress of infection. On this
front ia built what the Germans call a louserin, which was completed at a cost of
6,000,000 marks, and was paid for out of the private fortune of the German Emperor.
To this great establirimient all persons, of wliatever age, nationality, or rank in life,
going from Germany into Poland or Galicia and from those Provinces returning into
Germany or Austria, arc sent and are detained for 5 days, during which period they
are bathed daily and their clothes disinfected in their large autoclaves with each
bath . A t the end of the five-day period each traveler is given a personal examination,
ami upon being found to be free from disease or vermin is given a certificate which
permits him to continue his journey across the frontier. No exception is made in
the case of any traveler, no matter what his rank or station in life may be, the imperial
family being just as amenable to the rules of this great establishment as the poorest
sttl^ject of Poland or Germany.

In Serbia, in addition to typhus, relapsing fever, which is transmitted by the bed-
bug, was prevalent in large numbers. The sanitary methods applied by the American
Red Cross Sanitary Commission in combating the typhus epidemic went very far
toward the elimination of relapsing fever, especially the fumiitation and disinfection
684a&-17— VOL IX 7

84 PBOGBEDIKGB SBCOHD PAN AMBBIOAK 80IBVTIFI0 O0KOBB8S.

of bansckB, hospitali, beds, and clothing. It did not disappear with the approadi oi
■ummer, but decreased to a very great degree. Typhoid fever was constantly present,
not in epidemic form but in sufficient numbers and covering a sufficioitly wide range
of territory to become a serious problem. The cities and viUages of Seibia, without
exception, are built on rapid-running streams, usually on both banks of the river,
which serves the common purpose of sewer and bath, laundry and drinking-water
supply. Only the fact that the water which supplies these streams comes from the
mountains and that generally the streams are rapidly running over gravelly beds,
and the water has a tendoicy to purify itself quickly, is a greater incidence of water-
borne diseases prevented.

The fly problem is always serious, and the natural habits of the peasants and their
living conditions all tend to the increase of fly breeding. Manure of all scurts is care-
fully saved for the fertilisation of the fields and other purposes. Human and animal
feces is carefully conserved, mixed with straw enough to hold it together, made into
large circular cakes, and pasted against the outside walls of the habitations of the
people, there to remain until dry and hard, and in tlus condition to be carefully saved
for fuel purposes during the succeeding winter. Every house, every alley, every
street, every place, was a breeding place for flies, and typhoid fever has probably
be^ one of the current diseases in Serbia and Macedonia for generations.

The country is farmed by irrigation. Every valley has its mains and laterals run-
ning through it, all the ditdies grass-grown and shaded to prevent evapcvation, afford-
ing ideal places for the breeding of mosquitoes. Malaria, during the months of July,
August, September, and October, is prevalent to an unusual degree. It is peculiarly
pernicious in its forms, and the writer knows of more deaths resulting from malaria
infection in Serbia during the six months he was present there than occurred in
Panama during any one of the nine yean of the American occupation.

In addition to all these dinases, Uskub and other cities of Serbia experieoieed epi-
demics of papatacci fever— a three or four day fever, not bital in character, communi-
cated by the papatacci gnat, which is prevalent along the Adriatic shores and in
this section of the Balkans. The patient suffers severely from headaches, back and
body pains, congestion of the conjunctiva, throat and nasal passages, and runs a tem-
perature of 104® F. for two or three days, which then subsides and a rapid c<mvalescence
ensues. The treatment for this fever is purely symptomatic; no measures have been
discovered other than general sanitation and hygiene to combat this disease.

The treatment of typhus fever is unsatisfactory. It is supportive and S3rmptomatic
in character. The use of the serum prepared by Nicolle, or that prepared from the
Plots <»ganism seems to have a tendency to abort the disease, and seems to have
value in its thenqmtics. Plenty of water should be given to the patient, and a
saline infusion should be constantly at hand for use at any period succeeding the
eruptive stage and the climax of the disease. The severe emaciation which attends
all these cases should be carefully managed. The diet should be carefully selected
and carefully administered, and every precaution to support and stimulate the patient
judiciously should be takm . The nervous and mental systems, which are very much
disturbed, should be carefuUy cared for, and this disturbance, often continuing lor
six months following convalescence, should never be neglected.

The prophylactic measures which were employed in Serbia by the American Red
OosB Sanitary OommissioQ, and those idiich are used in the prison camps in Europe
and in the quarantine stations of the countries bordering on S^bia, afford an effective
prophylaxis in this disease. The value of the Plots serum in immuniiing against
tjrphus infection is problmnatical. It probably has a value which will be fully dem-
onstrated before typhus is eliminated from the Balkans. It was very interesting to

ote that out of some two or three hundred people nonimmune to typhus, who found
it necessary to go to this part of Europe during the epidemic, all of whom were inocu-
lated with the Plots vaccine, among whidi numbor were all of the members of the

PUBUO HEALTH AND MEDIOIKB. 86

American Red Gtosb Sanitary Commiasion, with bat one exception, and the memben
ol the mianon which Columbia University aent to Serbia, and many others who were
exposed at some time or another to a greater or less degree to the infection, not one
case developed.

The lesson which this epidemic teaches is particularly valuable to the sanitary
worid, especially to those localities which are from time to time subject to an epi-
demic of typhus fever. It demonstrates beyond any question of a doubt that the
I can be kept out of a country by instituting im>per quarantine and sanitary
s, and by the proper observance of personal and community cleanliness and
hygiene. It has demonstrated with equal certainty that if it should at any time
secure a foothold in any locality, it can be easily limited and eradicated in a short
time. With our present knowledge of the measures which control this disease, we
can take a very optimistic view of the future, and assert with coi^fdence that the
epidemic of typhus which Serbia has so recently experienced is probably the last
eDe which will occur in Europe, unless conditions favoring epidemic are worse than
ever before existed in the history of the continent.

Hie Chaibiian. We shall now listen to a paper on ''Present views
in respect to modes and periods of infection in tuberculosis/' by
Dr. M. P. Ravenel, of the University of Missouri.

ntESENT VIEWS IN RESPECT TO MODES AND PERIODS OF INFECTION

IN TUBERCULOSIS.

By MAZYOK P. RAVENEL,

iVo/ettor i^J Prtventive Medicine and BaeUriology, Dvtetior of PuftKe ITsaUJk Lohor^
torjf, Univenity of Mietourif Columbia, Mo,

In considering the various modes in which infection with the tubercle bacillus can
occur, we may, for the purposes of this paper, leave out of discussion all except inha-
lation and ingestion, because there is practically no difference of opinion concerning
the others. They play a small part in the epidemiology of the disease, and the total
number of cases due to them is insignificant compared to those in which infection
takes place throug}i the respiratory and the digestive tracts. Both routes of infec-
lioo are now universally recognized, and there remains to be determined now only
their relative importance as portals of entry.

Tuberculosis is a disease, the lesions of which are found so preeminently in the lung,
that it is easy to understand how the older physidane considered the respiratory
tmct the route of invasion. The classic work of Arnold gave scientific standing to
tills ?dea, since it proved that the lung could be invaded even by particles of inert
matter, such as lamp-black, introduced by the respiratory tract, and the experiment
of Comet, who exposed guinea pi(pi to the dust produced by breaking up dned tuber-
culous sputum with a broom, resulting in the infecticm of most of the animals, seemed
to settle the question in favor of this method from a practical point of view.

The older 6beervati<ms were apparently lost sig^t of, and did not receive due con-
iideration until after the memorable British Congress on Tuberculosis in 1901, when
the attitude of Koch in regard to the danger of bovine tuberculosis and the all^;ed
larity of primary intestinal tuberculosis brou^t tiiem to the front once more.

RESrUUlTOBT INFaCTION.

Hie work of Arnold and the experiments of Comet have been mentioned as fur-
nishing the basis for the belief that tuberculous infection took place mainly throng

86 PBOGEBDIKOS 8BC01!n> PAN AMEBICAN BCIENTIFIO 00N0BE8S.

the respiratory tract. Further evidence seemed to be at hand in the greater number
of casus in \i hich the supposedly primary lesion was found in the limg and bronchial
l>anph nodes as compared with the intestine and mesenteric glands. The value of
this evidence has been weakened during recent years by the discovery of the fact
(hat in children particularly the bronchial lymph nodes are often tuberculous when
no change can be found in the lung, and the belief is growing that the bronchial
gland:) and nmall lymph nodes are first infected, and the limg tissue becomes in-
volved later. Schroeder and Cotton have demonstrated that infection of the lung
and bronchial glands can result from inoculation into the most distant parts of the
body. A calf inoculated under the skin at the end of the tail died affected with
tuberculosis M the lungs. The bronchial, mediastinal and mesenteric glands were
edematous and contained tubercle bacilli, though not having the histological changes
of tuberculosis. '

Three hogs inoculated in the same way developed progressive tuberculoeis of the
lungs, liver, and inguinal glands, and in one the gastrohepatic and bronchial glands
were involved.

It IS evident that infection of the lung is not the simple process of inhaling bacilli
directly into the alveoli, as was formerly believed, but involves a more complicated
mechanism.

The fixing of the portal of entry by the so-called oldest lesion is also open to serious
question. I have produced fatal pulmonary tuberculosis in monkeys by feeding,
with very insit^iificant intestinal lesions. All the oldest lesions were located in the
lungs and bronchial glands, yet the method of feeding laiT^ly precluded the possi-
bility of the tubercle bacilli reaching the limg except through the digestive tract.
Practically all observers agree that in children there is a marked tendency to rapid
and geneml dissemination of the disease, and many note that it is frequently im-
possible to determine the oldest lesion. As our conclusions have been drawn largely
from post-mortem observations on children these facts are significant.

DUflT AND SPRAT.

In regard to the form in which tubercle bacilli are inhaled, all are agreed that dust
from dried and pulverized sputum, and mouth spray produced in coughing, talking,
needng, etc., both play their part. The relati^e danger of the two methods has not
been determined, some belie\dng that dust is the chief menace, while others follow
Flflgge in holding that the mouth spray produces infection more readily. The bacilli
in the spray are certainly more apt to be alive and virulent. Both must be recog-
nized as capable of producing infection, and droplet infection is probably the more
dangerous.

INFECTION TRBOnOR THB DIOEfrriYB TRACT.

Tbtt fiiit recorded cases of infection through the digestive tract are those of Klenke,
who in 1846 gave the histories of 16 children ^ho have been fed on cow's milk, and
all of whom showed tuberculosis of the intestines, glands, skin, or bones.

Previous to this, however, (^armichael, in 1810, recorded as his observation that
he had frequently seen the mesentmc glands strumous without involvement of the
external glands, and this led him to believe that in scrofula the mesenteric glands
were first involved. He referred to the frequency of a disease similar to scrofula
•een in pigs fed on sour milk, and called attention to the common occurrence of
bowel trouble in children at the time of weaning '*too often followed by di^iease of
mesenteric and lymphatic glands."

Casper. 1882, refers to the extent of tuberculosis ("nodular consumption*') among
the milch cows of Paris, and says: "It is possible that there is a connection between
this phenomenon and the many tuberculous diseases among the children of Paris.'*

Experimental evidence of tuberculous infection in cattle by feeding was given as
early as 1868 by Chauveau, who extended his work with corroborative results in 1872

PUBUO HEALTH AND MEDICINE. 87

and « 1873, and Villemin in 1869 obtained positive results by feeding in rabbits and
guinea pigs. He was the first to employ a tube for the introduction of tuberculous
material into the stomach. Experiments by scientists of every nation have given
positive support to the work of these early observers. It is also a well-known and
widely observed fact that in the spread of tuberculosis of cattle and swine the digestive
tract plays a most important rdle. Swine particularly are infected through the diges-
tive tract in the great majority of cases, and the ingestion of milk from tuberculous
cattle is universally recognized as one of the chief factors in the spread of the disease
amcHig these animals. The first examinaticm made by the officers of the Federal meat
inspection service is based on this fact. In 93.3 per cent of cases tuberculous hogs
show infection of the cervical glands.

As the disease is essentially produced by ingestion the glands and tissues associated
with the digestive tract are the most frequent seats of infection. Indeed, the superior
cervical glands (in almost all cases the submaxillary gland) are nearly always affected,
as at the post-mortem examinations held by bureau inspectors over a consecutive
period on 120,000 tuberculous hog carcasses, 93.3 per cent were found to contain lesions
m these glands. The laige tonsils and the laige number of lymph sinuses in the lymph
glands probably account for this great frequency.

From some records relative to the locations of tuberculous lesions in cattle that were
made at the same time that the figures pertaining to hogs were collected, it appears
that in tuberculous cattle the lesions of tuberculosis were located in the cervical glands
in 66} per cent of the animals, in the bronchial glands in 54^ per cent, and in the medi-
astinal glands in 63.6 per cent.

In 1901, in his London address, while discussing the relation of bovine tuberculosis
to human health, Koch took the ground that infection through food could be assumed
to have taken place with certainty only when the primary tuberculous lesion was
located in the intestines. He claimed that this was rarely found to be the case, and
aigued that the danger of infection through food was slight. The stand taken by Koch
aasomed that the tubercle bacillus was unable to gain entrance to the system through
the intestinal wall without the production of a lesion at the point of entrance.

The question raised by Koch has been thoroughly investigated, and it can be said
with certainty that the tubercle bacillus can penetrate the mucous membrane of the
upper digestive tract as well as that of the intestine readily and quickly, without
producing a tuberculous lesion at the point of entry. It is, however, held by Baum-
gartwi that there is always a focus of infection at the point of entrance sooner or later,
even though it may be microscopic. Against this is the demonstraticm by von Behr-
ing and Roemer of the ready permeability of the intestinal mucosa of young animals
by various bacteria, even the laige anthrax bacillus. In 1 ,000 swine, infected through
food, Ostertag found the glands of the throat, neck, and mesentery tuberculous, while
the mucous membrane of the intestine was always free from disease. Orth, in 1879,
and Comet, in 1880, observed bacilli pass step by step through the fully developed
mucous membrane of the uninjured intestine and reach the lymph channels and mes-
enteric glands, leaving no recognizable trace behind (Furst). Dobroklonski, in 1890,
working under Comil, showed that the tubercle bacdllus would quickly penetrate
the healthy wall of the intestine in guinea pigs. Desoubry and Porcher, students
of Nocard, shofwed in dogs that during the digestion of fats large numbers of bacteria
w«re earned throu^ the intestinal wall and could be detected in the chyle within a
lew hours after the meal was given. If food free from fat was given few or even no
bacteria could be found. Nicolas and Descos, in 1902, found that tubercle badlli
given to dogs in fatty food reached the chyle within three hours. During feeding
experiments conducted at the laboratory of the State Live Stock Sanitary Board of
Pennsylvania, we frequentiy observed extensive tuberculosis of the lungs and thoracic
glands in animals which showed slight or even no involvement of the intestine. In
1902-3 I introduced into the stomachs of a number of dogs tubercle bacilli suspended
in an emulsion of melted butter and warm water, using a tube in order to prevent poe-
•ble inlectioo through the trachea. The dogs were killed alter three and one-hall to

88 PBOCEBDINQE 8EC01!n> PAK AMSBIOAK SCIBNTIFIO 00NOBB8&

four hours, during active digestion, as much chyle as possible was collected, and the
mesenteric glands were removed. Guinea pigs were inoculated with this materiaL
Tubercle bacilli were demonstrated in abundance in 8 of 10 experiments. The dogs
were kept on soft food for some days before the experiments, and were purged with
castor oil, in order to rid the intestine of all foreign matter which might injure the
mucous membrane. Numerous sections of the gut were examined also, but no injury
could be detected.

It b possible here only to mention the work of Oalmette and his students, as a result
of which he reached the conclusion that pulmonary tuberculosis acquired at any age
may be due to recent intestinal infection.

The rapidity with which tubercle bacilli penetrate the intestine and reach the lung
through the thoracic duct is remarkable. Besanti and Panisset found that when fed
to dogs in soup they reached the heart blood within four to five hours. Bartel found
that after a single dose they penetrated the iminjured intestine and reached the
mesenteric glands during the following digestive period. Schlossman and Engel, by
inoculating tubercle bacilli suspended in cream into the stomachs of young guinea
pigs through an incision in the abdominal wall, demonstrated that they reached the
lung within six hours. Their work has been confirmed by Ravenel and Reichel.
Rabinowitsch and Oberwarth established nourishment throu^ a gastric fistula in
swine, and then resected the aesophagus, after which tubercle badUi were introduced
into the stomach. Within 24 hours they were shown to have penetrated to many
organs of the body.

INFECTION BY THE BOVINB TUBERCLE BACILLUS.

The statement of Koch in 1901 that bovine tuberculosis was not a menace to public
health has also led to a vast amount of study which throws light on the portal of entry
of the tubercle bacillus. It is conceded by everyone that bovine tuberculosis is
found almost exclusively in children under the age oi 16 years, and that the suscefH
tibility to this type of infection is greater during the first five years of life than it is
afterwurds. It is perfectly evident that the only exposure that children of this age
can have to the bovine germ is through the food which they eat, and infection there-
fore is invariably through the digestive tract.

The results of the English Royal Commission, the German Imperial Commission,
and numerous private workers have been frequently quoted, and I give here a sum-
mary of cases collected by Dr. Park which indicates fairiy the amount of infection
due to the bovine tubercle bacillus, especially in fatal cases.

Adults, 16 years and over, 955 cases, 940 human, 15 bovine. Children, 5 to 16
years, 177 cases, 131 human, 46 bovine. Children up to 5 years, 368 cases, 292 humaa,
76 bovine.

Many nonfatal cases of tuberculosis are also caused by the bovine germ. These
are found almost exclusively in children and the infection is through the digestive
tract.

Fraser, in 67 cases of bone and joint tuberculosis in children under 12 years of age,
found the bovine germ 41 times, the human 26 times, and both 3 times.

Mitchell examined 72 children under 12 years of age with cervical adenitis and
found the bovine g^m in 65, the human in only 7.

It should be remembered that the human tubercle bacillus is capable also of pto-
dudng infection through the digestive tract and the mistake must not be made ol
considering only those cases in which the bovine genn is found as due to ingestion.

INFECTION THROUGH THI TONSILS.

The frequency of infection through the tonsils has been reoentiy called in question
by von Pirquet, who quotes Albrecht and Ghon to support lus view. The fonner in
1,060 cases found only three instances of primary tonsillar infection and the latter

PUBUO HBALTH AND MBDIOIKB. S9

ill 188 CMM found only one . It is hard to reconcile these findings with those of otiiera
cr with experimentftl work.

Wood has collected from the literature 1 ,671 cases, 88 (5^ per cent) of which showed
primary tuherculosis. These examinations were made by various methods and
probably fall short of the truth. Lartigau and Qoodale have shown that systematic
inoculation of animals gives a higher percentage of tuberculosis. In 75 cases Lartigau
found 12 (or 16 per cent) tuberculous. Dieulafoy by the inoculati<Hi of guinea pigs
found tuberculosis of the tonsils in 15 of 96 cases. His work has been criticized on
the ground that he made no histological examinations and was not careful to exclude
crypts, which may lodge tubercle bacilli. However, Latham, who avoided these
sources of error, in 25 consecutive autopsies on children from 3 months to 13 yean
of age, found seven which were tuberculous— results practically identical with thorn
of Dieulafoy. (Confirmatory reports have been made by a laige number of observenii
many of which are included in the figures quoted from Wood. The susceptibility
of the tonsils to tuberculous infection is shown by the examination of person dead of
phthisis.

Experimentally the tonsils are readily infected by direct application as well as
by feeding tuberculous material. In a series of experiments which I carried out
at the laboratory of the State live Stock Sanitary Board of Pennsylvania swine fed
with tubercle bacilli from man and from cattle developed gviendized tuberculosis
with marked involvement of the tonsils, apparently primary, with necrosis and ulcer-

The experiments on these lines are too numerous to review here. Practically all
experimental observers have noted the susceptibility of the tonsils to tuberculoua
Infection. Wood, of Philadelphia, has carried out a most instructive series of experi-
ments on swine. He found that the application of tubercle bacilli to the back of the
mouth rapidly produced primary tuberculosis of the tonsils, soon followed by involve-
ment of the submaxillary and cervical glands and extensive disease of the lungp.
The mesenteric and bronchial glands were always diseased in about an equal degree.

I have referred above to experiments carried out on monkeys by feeding, in which
the lungs showed extensive and destructive tuberculosiB. In these animals, while
no lesion of the tonsil could be found, caseous lymphatic glands were found in the
neck in the region draining from the throat and there could be no doubt that a part
of the inf ectioQ at least occurred by penetration of the mucous membrane in this
wgioo.

Grober believes that infection through the tonsil is the most frequent origin of
apical tuberculosiB. His experiments have demonstrated that from the cervical
^ands there is a direct route to the pleune and lun^s, and that this leads especially
to that portion of the lung most frequmtly the primary seat of tuberculosia— the apex.

The evidence that the tonsils are frequ^tly the portal of ^try for the tubercle
iMMdllus appears to me very conclusive and it seems equally certain that food is the
bearer of the infection in a laige im>portion of cases.

PERIOD OF INPacnON IN TUBBKOULOSIS.

Few problems offer more inherent difficulties in their solution than the determina-
lioo of the age at which tuberculous Infection cccurs. It is easy to construct tables
showing the age at which the disease becomes manifest clinically, but, except in the
early years of life, these give little clue to the exact time of infection.

There is no doubt of the existence of a widespread opinion that infection takes
place chiefly in inhmcy and childhood and this opinion appears to be growing. It
ssems to have a legitimate basil even if not whdly true. In 1900 Nageli showed by
aalopsiee in Zuridi that by the age of 30, 98 per cent of persons showed tuberculous
Isnoos or scars, results which have been in a measure confirmed in other cities, but
which can not be accepted as correct for the general population.

PB0CBEDIKQ8 SBOOHD PAN AMBBIOAN 8CIENTIFI0 C0KQBE88.

The use of tuberculin by the method of Vod Pirquet or some of its modificatiooB is
even more directly responsible for the belief in early infection. Yom Pirquet himself
obtained positive reactions among children of the poorer class in Vi^ma in a surpris-
ing number of cases— 70 per cent if clinical cases of tuberculosis are excluded and
80 per coit if included, as shown by the following table:

A««(j«w).

Indudlng cases of tubercu-
losis.

~ losls.

Total
number.

Positive
reactions.

Percent
positive.

Total
number.

Positive
reactions.

Percent
positive.

Under 1

410
116
306
264
316
183

21
34
74
127
188
165

6
30
35
48
64
80

888

80
163
180
154
147

lto2

2 to 4

22
63
74
105

4 to 7

7 to 10...

10 to 14

More surprising even are the results of Hamburger and Monti, also on children of
the poorer daas in Vienna:

A«e (years).

Number
obildien.

Positi^e
reaction.

Percent
positive.

rnderl

28
46
56
75
50
68
46
80
85
26
20
19
17
17

lto2

4
11
24
26
82
28
23
25
23
27
18
16
16

2 to 3

8 to 4

4to5

6 to 6

6 to 7

7to8

8 too

9 to 10

10 to 11

11U>12

12 to 13

18 to 14

Based on such findings the belief is widriy hM that over 90 ptf cent of children
are infected with tuberculosis by the 14th year, and statements have been made
that tuberculosis in adult life is only the recrudescence of infection acquired in
early life.

A further study of reports from different parts of the world reveals marked varia-
tions in the percentage of positive reactions, but all show that tuberculous infectloii
in childhood is extremely common, as seen by the following table:

Name.

Overland, Bergen.

Amenta. Palermo

MOIler, Vienna

Caimette, Orvsex and LetuUe, lille.
Stawsky, Odessa

Number
tested.

848
800
949

Age.

12-14
8-13

10-14
5-13

13-16

Positive.

PsresHf.
50.0
88.0
54.0
81.4
60.0

Post-mortem reports by von Pirquet, MQUer, and othem show that the positiva
reactions fall short of diowing the full number of those infected.

Turning to recent work in the United States, we find a somewhat different picture.
Yeeder and Johnston tested 1^1 hospital children in 8t Louis, and obtained a maxi-
mum of positive reactions at the 10 to 14 age peiiod of 48 per cent, including cases ol
clinical tuberculosis, and 38 per cent exduaive of these.

POBUO HBALTH MKD MCDIOIMB.

Tdftd iwMtfonfy ineluiing coMt o/eHmal titherculo9ii.

J^iymmy.

Number

of
ehndren
tested.

positive
reacttoos.

Percent
posltiye.

Under 1

234
187
188
SM
183
157
115
113

35
S4
57
08
74
09
45
54

lto2

Sto4

4to6

• to8

8 to 10

10 to IS

IS to 14

1,831

430

ReaetUmB in thildren without dinieal mantfettatUmt of tuhercidoHs.

Age(yett«).

Number

oC
children
teeted.

Positive
reactions.

Percent
positive.

Under 1

302
100
163
172
153
136
107
94

3
0
83
40
44
88
87
30

1.5

ItoS

5.5

Sto4

19.0

4 too

23.0

0to8

39.0

ttolO

30.0

10 to IS

84.0

IS to 14

38.0

1,135

•

Oattermole, of Colorado, in a seriee of 66 cases from 1 to 14 years of age, found 25
or 38 per cent of positive reactions. Taking the 10 to 14 year age period his positive
reactbns reached 63 per cent.

Cattermole qnotes Manning, of Seattle, as having obtained 58.1 per cent of positive
teactions, at the 10 to 15 age period, in a series of 228 children.

He also quotes Fishberg, of New York, who among 692 children living with tuber*
culous parents in the tenements obtained 67.25 of positive reactions, while among
688 of Uie same dasB, but living with nontuberculous parents, 52.72 per cent gave
positive reactions.

It is impossible to escape the conviction that childhood is preeminently the time
of life when the tubercle bacillus gains a foothold in the body.

These findings are corroborated by post-mortem examinations done on children who
have died from various diseases.

The studies of Harbits throw much light on this question. I give his results, as
well as those of others, most of which are quoted from his monograph.

HarbitE, in 275 autopsies on children under 15 years of age, found 117 (42.5 per
eent) of tuberculosis.

Babes, in 902 autopsies on children under 16, found tuberculosis in 288 (81.9 per
eent).

In 1887, in 93 autopsies, tuberculosis of the branchial and mesenteric glands was
found 66 times. In only 13 was death caused by tuberculosis.

Geilly in 902 autopsies on children under 15, found tuberculosis in 288 (31.9 per
eent). The maximum was reached at the 6 to 9 year pmod, 46.9 per cent.

Mflller, in 500 autopsies on children, found 150 (30 per cent) cases in whidi death
was due to tuberculosis, and 59 (11.8 per cent) of latent tuberculosis.

Hecker, in 700 autopsies on children, found active or latent tuberculosis in 147
(21 per cent).

l^nrad, in 654 autopsies on children, found tuberculosis in 157 (24 p^ cent).

92 PBOOEEDINQS SECOND PAN AMBBIOAN 801ENTIFI0 00N0BE88.

At the Pathological Institate of Kiel, in 2,572 aatopmes on duldien under 15, tu-
berculosis was found in 16.7 per cent

Bolts, in 2,601 autopsies on children under 15, found tuberculosu in 428 (16.1 per
cent). Exclusive of those under 1 year of age, we have 1,171 autopsies witi& tuber-
culosis in 364 (31 per cent).

Heller found latent tuberculosis in 140 (19.6 per cent) among 714 children dead
of diphtheria.

Councilman, Mallory and Pearce, in 220 autopsies on children dead of diphtheria,
found latent tuberculosis in 35 (16 per cent).

Hand, in 332 autopsies on children, found tuberculosis in 115 (34.6 per cent).

Still, in 769 autopsies on children under 12, found tuberculosis in 269 (35 per cent).
In 43 it was latent, and in 117 (43.4 per cent) before the second year.

Many other similar reports could be given, but these have been selected as covering
a laige part of the world, and representing fairly the occurrenqe <^ tuberculosis as
found post-mortem in children.

The difficulty, especially marked in adult life, of connecting the clinical manifes-
tations of tuberculosis with the date of infection, has already been mentioned, but
fairly accurate information on aduk infection can be obtained by the careful study of
groups of individuals of good family history especially exposed to infection for con-
siderable periods, such as physicians and attendants at hospitals and sanatoria for
tuberculosis, and those who marry consumptives. A number of collective investiga-
tions are q^uoted by Cbmet and other writers. Many of these, owing to incomplete
data and other defects, are of little or no value. From the material at hand I have tried
to select those which seem to throw some light on the question.

Saugman states that of 174 sanatorium physicians, whose average term of service
was three years and whose subsequent history was followed for three and one-half
years, only two became tuberculous. Among 64 laryngologists from 8 different
clinics, none contracted tuberculosiB.

Williams has, in two papers, given most interesting facts concerning infection <d
physicians and attendants at Brompton Hospital, founded before the discovery ol
the tubercle bacillus, and before the contagiousness of tuborculosiB was recognised.
His first paper gave the statistics of the hospital staff from its foundation in 1846 to
1882, 36 years. Among four resident medical officers, one of whom held office 25
years, no case of consumption hos developed. Among 150 house physicians, none of
whom held office f<v less than six months, and many much longer, only eight cases
of consumption occurred.

The second paper gives the results from 1882 to 1909. It includes resident and assist-
ant resident medical officers, house physicians, resident and nonresident porters,
pathological assistants and dispensers, in all 369 persons, of whom 12, or 3.2 per cent,
developed phthisis later, two of them through inoculation wounds.

The comments ci (Soring on this report are most interesting. He compares these
results with those obtained by himself in a study of 3,090 individuals of nontub«!CU-
lous parentage, assuming that a person coming of taioted stock would not be likely to
take service in a consumption hospital. Among his 3,090 persons 79, or 2.6 per c^t,
developed tuberculosis. Thus two groups, (me exposed to special risks and <me not,
showed an amount of infection varying only 0.6 per cent. If the two hospital cases
associated with inoculation wounds are left out of consideration, we have fvactically
the same percentage of infection, 2.6 per cent and 2.7 per cent.

At the Adirondack Cottage Sanitarium there has been no case of infection since its
foundation more than 28 years ago among the employees, including waitresses, cham-
bermaids, and laundresses.

Infection through marriage may give some clue to the susceptibility of adults.
Comet says: "The numbor of cases of marriage infection, often of classical simplicity,
runs up into the hundreds." His own study of 594 couples showed that in 23 per

FUBUO HEALTH AND MEDIOIKE. 93

cent both partnen were tub«!cuk>u8. He admits that the findings do not necessadly
imply an etiological relation between the cases. Ck>met believes the actual cases
nin hi^er than the figures given indicate. Other observers place marital infection
at tram 3 to 12 per cent. Recent studies made acc<»nding to modem statistical methods
tend to throw doubt on the earlier work.

The late E. 6. Pope's study of this question failed to show definite proof of infection
between married persons. His work has been reviewed by Karl Pearson, who says:

I may conclude in the slightly modified words of Mr. Pope:

It would seem probable, then, (1) that there is some sensible but slight infection
between married couples, (2) that this is lareely obscured or forestalled by the fact of
infection from outside sources, (3) that the liability to the infection depends on the
presence of the necessary diathesis, (4) that assortative mating lurobably accounts for
at least two-thirds and infective action for not more than one-third of tne whole cor-
felatkm observed in these cases. But the demonstration of this result depends on
the accei>tance of the inherited diathesis to be effective, and the existence of assorta-
tive mating of equal intensitv in the case of want of mental balance must prevent
doamadsm. In all future collection of statistics with regard both to marital uifection
and parental infection, it is most important that the age of husband and wife at mar-
riage and the age at onset and death in both should be recorded. Age at onset and
death of the parent, age of parent at birth of child and age at onset and death of child
ahould also be recorded . It is only by such complete records that we shall ultimately
be able to accurately app(Mtion the action of infection, assortative mating, uid
inheritance.

For real light on the problem of assortative mating of the tuberculous, we must wait
till we have definite knowledge in each case of the family history of botn husband and
wife. If we find (i) that the marriage of two ultimately tuberculous persons took
place before either were suspected of the disease, and (ii) that there is in such cases
a larger percentage of family histories of tuberculosis than in the case of nonmarried
tuberculous individuals, we should have definite evidence of the assortative mating
which seems probable. If, on the other hand, the percentage were smaller, we should
have definite evidence for the infection theory.

The difficulty of determining the date of infection by the appearance of clinical
symptoms has already been mentioned. As our ideas have been in the past largely
drawn from clinical data it is evident that there is need of some revision. How such
data may midead is evidenced by the statement of Goring (Studies in National Dete-
rioration, Y): "The mean age of onset for both sexes taken together is about 27 — ^the
standard deviation is about 9 years. It follows from this that between the ages of 14
and 45 may be looked upon roughly as a danger zone for tuberculous infection. The
modal value of age of onset is about 23, and this is the age when danger of infection
18 most intense; the danger diminishing fairly rapidly to the age of 14, and more grad*
aally to the age of 45."

It aeems certain that the early years of life are those in which tubwculous infec-
tion takes place in the great majority of cases, and primary infection of adults is much
less frequent than formerly believed. Clinical histories can not be relied upon to
determine period of infection. It seems equally certain that infection of adults does
occur, and that no age is exempt.

CONCLUSIONS.

1. The evidence at hand indicates that in the majority of cases the req;>irat(»7 tract
Is the route of infectbn.

2* The alimentary tract is a frequent portal of entry for the tubercle bacillus.

$• The tubercle bacillus is able to pass through the intact mucous membrane of
the alunentary tract without producing a lesion at the point of entrance. This takes
place most retidily during the digestion of fats.

4. The bacilli pass with the chyle through the lacteals and thoracic duct into the
blood, which conveys them to the lungs, where they are retained laigely by the fil-
tering action of the tissues.

5. Infection through the alimentary tract is especially frequent in children*

94 PBOGEEDIKGS 8B00ND PAK AMESIOAN 80IEKTIFI0 C0N0BE88.

6. Infancy and childhood are preeminently the periods of life when the individ*
ual is susceptihle to tuberculous infection, and the majority of cases of infectioD
occur during these early years.

7. Any campaign against tubercnlosb which leaves out of consideration the proteo>
tion of children against infection will fail of success.

8. Tuberculous infection in adult life occurs, but not so frequently or readily a»
genially believed.

9. Tuberculous infection may occur at any age.

Dp. Carter. I am reminded of some data that Dr. Ravenel may
not have seen. I left Habana after the influence of the reconstruc-
tion period had passed. I foimd that the death rate for four or five
years from tuberculosis was four and one-half times that of the aver-
age large American city. I took, for comparison, New York, Chi-
cago, and Philadelphia. It is difficult to state that there should
bo as much infant infection from food in Habana as there should
be in American cities. In the first place, the Cuban mothers in the
beginning nurse their own children; it is rare that the child starts
there bottle fed.

Milk is always boiled before being sold. The people are accus-
tomed only to boiled milk and won't drink raw milk. Their raw
milk will not keep, and so it is boiled from a commercial stand-
point. When I say *'raw milk," I mean raw cow's milk. They do
drink the raw milk from the goat or ass. The little troop of goats
or asses is driven around from door to door and the animal is milked
into the cup or bowl that is brought out from the house. Now, I
think neither goats nor asses are especially liable to tuberculosis,
so one would think that there was little infection from milk in child-
hood in Habana. The foods they got later, it seemed to me, would
be singularly free from conveying tuberculosis. The principal source
of meat was the dried beef from the Argentine cattle, which in
their half-wild state then should have been meas\u*ably free from
tuberculosis; the next was probably codfish; and the third were Amer-
ican hog products. Such beef as they had been getting had come
mainly from the Province of Porto Principe, where the cattle were
wild cattle on the plains. It would seem that the Cuban either in
childhood or in adult life should have been singularly free from in-
gested tubercle bacilli as compared with those in America; and yet,
for the four years I took — ^I forget what they were now, but it was
well after the reconstruction period — ^there were about four and one-
half times as many deaths reported in Habana as from the three
cities I took — Chicago, Philadelphia, and New York. I mention
that not as opposing your view, but because I believe it will give
additional data.

Dr. Ravenel. Not as a reply, but in explanation, I will say that
that same line of argument has been brought up in regard to Japan
and a number of other places. Now, I do not pretend to be able

POBUO HEALTH AND HEDICIKB. 95

to explain eyerything about tuberculosis, but the actual incidence
<rf tuberculosis does not prove the mode of infection one way or the
other. I can only answer by simply saying how much worse it
would have been if exposure through food had been added to expK>sure
through the respiratory tract, how many cases may have been
saved in Habana in spite of there being four times as much as in
diis country, and how much worse it would have been if in addi-
tion to that infection there had been added bovine infection also and
ingestive infection.

The Chairman. The next paper on the program, ''Parasitic dis-
eases in the American tropical countries/' is by Dr. D4maso Rivas,
formerly of Nicaragua, and now of the University of Pennsylvania.
Dr. Guiteras, will you be kind enough to take the chair ?

Thereupon Dr. Juan Guiteras, of Habana, Cuba, took the chair.

THE PARASmC DISEASES IN THE AMERICAN TROPICAL COUNTRIES
AND THEIR EFFECT UPON THE PROGRESS OF CIYIUZATION AMONG
THE LATIN-AMERICAN PEOPLE.

By DAMASO RIVAS,

ProfiM90T Univertity of Penntylvania Mtdieal Sdu)oh

I. iNTRODUCnON.

The term "disease" (dis-ease) implies lack ix absence of ease, uneasiness, pain,
etc. Pathology defines the word "disease" as a morbid !>tate of the body; a deviation
from the health or ncMinal condition of any of the functions of the organism or
tissue of the body, due either to physical, chemical, or biological agencies. By
"biological agencies" is commonly understood that collective ^roup of phenomena
produced by the metabolic activity of certain lower forms of life, either plants or
animals, on the tissues or organs of a higher organsim upon which they live. Since
theee lower forms of life depend for their existence upon the food derived from
the organinn, the name of parasites is given t-hem in contradistinction to the other
organism upon which they live commonly known as ho^t. Biologically, therefore,
disease is a symbiotic phenomenon between the parasite and the host on which the
action of the former is detrimental to the latter.

That these lower fonns of life were the cause of diseases in man was suspected since
the time of the Egyptian and Greek civilization. Not one can fail to recornize the
Importance of the hygienic regulations in the Mosaic period. The writing of Hippo>
cratee, Celsus (25 B. C), AreUeus (3^-00 A. D.), and Galen (131-210 A. D.) are full
of suggestions, and Paulus in 1700 gave an accurate description of the diseases due to
flat and round worms.

Modem medicine began after the Crusades when western Europe was confronted
with new diseases imported from the Orient, and when Fracastori (1483-1553) formu-
lated the theory of contagious and disemination of diseases during his study of syphilis,
but the foundation of parasitology and tropical medicine dates from 1547 when Brie
discovered the liver^uke. and Dubini in 1838 found the hookworm. Demarquay
in- 1863 discovered the microfilaria; Bancroft the adult worm; and Manson demon-
ftrated the lile cycle ol the parasite in the mosquito.

96 PBOOBBDIKOS 8E00KD PAN AMBBICAK BCIENTIFIO C0NOBE8S.

Protoxon were recognised by Lewenhoak siiice 167.5. Obermeyer diecovered the
pararate of relapsing fever, and Loesh the amoeba djrse.iteriae. (H great importance
has been the discovery of the malaiia parasites by Lavaian in 1880, and those of Rosa
and Grassi upon the life cycle of this protosoa in the mosquito. Dutton in 1902 dis-
covered the organism of the sleeping sickness; Schauddinn that of syphilis, and Ghagas
in the last ye^rs the parasite of American trypano^miasis.

A great factor in the develop of tropical medicine and parasitt^ogy in general ha»
been the wonderful progress made in bacteridogy and the name of Pasteur, Koch,
Hansen, Eberth, Nicolaier, Yerson, Kitasato, and others stand preoninently a»
pioneers in this modem science.

II. PAEASmO DI8BA8B8.

Among the parasites in general are included bacteria, protosoa, and metasoa and
they produce bacteria, protoaoan, and metaaoan diseases, respectively, but by common
consent the name of parasitic diseases is commonly implied to those diseases known
to be produced by protosoa and metaaoa parasites in man. Bacterial diseases, as a
rule, are acute, of short duration, and end either m death or complete recovery.
The protosoan and metasoan diseases on the other hand are commonly chronic, of long
duration and of uncertain termination. They are seldom pet h the cause of death,
but they produce in the host a constant impairment of health and a predisposition
to permanent organic disturbances and secondary complications. The parasitic
diseases of man known at the present are numerous and their number are constantly
increasing as the biological cause of these diseases are discovered, but of those only
those due to protosoa and metasoa of a special importance to the tropical countries,
will be here considered.

III. D18BA8B8 DUB TO PARAsmc Protosoa: Malaria, Dtsbntbrt, Trtpano*

SOMIABIS AmBRIOANA.

Of the several protosoan diseases of the Tropics, three particularly deserve q;>edal
consideration, namely malaria, dysentery, and American Trypanosomiasis.

MALARIA.

This disease is especially common on the west coast of Africa from the Senegal ta
Congo, and the whole of Africa except Giqpe Colony. It is also common in India»
Asia, Southern Europe, and all the tropical and subtropical r^ons of America. Of
all the diseases of man, malaria may be said to be the most cosmopolitan disease.
In America it is especially found in the tropical regions along the Atlantic coast of
Mexico, Central, and South America.

The disease is produced by malaria parasite. This protosoon lives in the red
blood cells of man and feeds on the homogjobin of the cell. In a marked infection
the destruction of red-blood cells may be such that a rapid manifestation of anemia
may follow. The parasite is also the source of irritation to such internal organs as
the spleen and liver, which in time gives rise to passive congestion, fibrosis, pigmen*
tation, and other disturbances. The parasite is transmitted by the mosquito —
anopheUi maeuUpene^—yrhich lives in swampy places and bites especially at ni^t.
The malaria parasite on entering the body of the mosquito undergoes sexual devel-
opment and metamorphosis leading to the production of several hundred of minute^
sporelike bodies called $porzoide$ from a single pair of the malaria parasites. The*
mosquito infects man by introducing these qxwsoides during the bite of the insect.

The disease produced by the parasite is known as malarial fever and is manifested
by intermittent attacks of fever, accompanied with chills and sweating. At the*
beginning the disease is characterised by having an acute course lasting from some-
weeks to one or two months, which, if untreated or inq»<^>erly treated, becomes chronic
and incurable. During the chronic stage the malarial parasites may have disappeared

PXJBUO HBALTH AHD MIDIOIHB. 97

from the blood, but it haa left in man a permanent lesion in the intenial organs^
opedally the liver and qpleen, characterixed by torper of these organs, permanent
lesknis in the blood and bloodnnaking organs, manifested by a certain degree of
tecondary anemia, more or less intense. The impairment of function of internal
orgviSy together with this anemia, is the source of general physical and mental lethargy
commonly seen among the people of the tropical countries.

DTSBNTBBT.

By the term ''dysentery" is generally understood a disturbance of the intestines
manifested by dianhea and accompanied with bloody stools. Several may be the
causes for this morbid condition, such as bacterial infection, protosoan, metagoan
infestation, etc. We know at present more than 12 biological agencies as the cause
of dysentory, among which one, BfUamoebakutolytieat is of special interest to the
Amoican tropical countries. These protozoa belong to the ThUapode$. It lives in
the large intestine of man, imbedded in the ulcers of the mucosa and submucosa. As
the organism is the cause of the ulceration, one of the characteristic symptoms of this
disease is hemorrhage from the bowels and the presence of blood in the passage, whidi
in time may gradually give rise to a pernicious type of secondary anemia. In pros-
trated cases the parasite is apt to be carried either by the lymph channels or the
blood stream to the liver, where it produces amoebic abcesses of the liver, commonly
seen in the Tropics. The involvement of the liver is accompanied with torpor <rf this
organ, which is the cause of icterus, gastrointestinal disturbances, and a general
impairment of health. The patient at this stage of the disease commonly presents
a greenish tint of the skin and conjunctiva, his mental and physical power are inw
paired, a general lethargy is common, and a constant desire to sleep prevails. This
condition may be aggravated by a secondary bacterial infection, which not uncom-
monly may cause death.

The parasite is transmitted by ccmtaminated water, food, etc., and probably also
an unhygienic condition of the mouth and teeth are important {H-edisposing factors.
It has been shown lately by Barrett and Smith that in cases ol pyorrhea alveolaris
amoebae are joesent in acortain percentage of the cases in the pus collected from the
teeth. Whether these organisms are the same as those of dysentery has not been
determined as yet, but it is not improbable that the same predisposing fncicn of
pyonhea are those of dysentery. Six cases of dysentery which have come under the
writer's observation, all have shown to bo accompanied with pyorrtiea alveolaris or
to have had the disease for some time previously. Of course pyorrhea alveolaris is a
very conunon disease in man and the above observations may merely be a coincidence,
but thesaprosoitic habit of the amoebesof the mouth leaving, as it does, in the pockets
ol the gums, and that of B. hutoljfttcaf leaving similar pockets in the submucosa of
the intestine, may possibly point to the fact that both organisms, if they are not the
same, at least require the same environments for their existence and that the pre-
dktpooMig causes in both instances are the same, and that pyorrhea alveolaris, if it does
not represent the primary manifestation of dysentery, at least may be regarded as a
prediiposing condition.

TBTPANOeOMIASIS iLMSRICANA.

In 1910 Chagas, in Brazil, discovered a flagellate in the blood of children suffering
with remittent and intermittent fever accompanied with a cortain degree of anemia,
edema, enlargement of the lymphatic glands of the neck, axilla, and the spleen.
This flagellate is known as the trypano$oma crud and is transmitted by eonorkinui '
msgittui, commonly known as ''kining bug.*' This form of disease is of special
in^MTtaiice to the American tropical countries in general, because though it has been
found only in South America, it is not improbable that in the future the dinase will

98 PB0CEEDIKG8 SEOOVD PAN AMEBIOAN 80IBKTIFI0 C0KQBE8S.

be found to be also prevalent in Central America and in the south of Mexico. The
studies made up to the present time on this disease may be said to be incomplete.
They show, however, the interesting fact that the affection is more common among
children; that it produces certain morbid changes dironic in nature which are apt
to leave a permanent impairment of the body, and that, like other chronic parasitic
diseases, it predisposes to secondary infection and complications which not uncom-
monly are fatal, thus bearing an important relation to the infant mortality in the
American tropical countries. In some respects this disease may be compared to the
sleeping sickness of Africa, and {Mrobably it represents a mild character of that disease.

IV. Diseases dub to Parasitic Metazoa: Filabiasis, Anctlostomiasis,

ASCARIASIS.
META20A.

Among the metazoa parasites are included trematodes, cestodes, and nematodes.
The trematodes as a rule are unimportant parasites of man here in America, and with
the exception of schiBtosoma and a few other trematodes common in Asia and Africa^
this group of parasites has only a few parasitic species of man. Among the cestodes,
txnia Bolium, tsenia saginata^ txnia eehinococcus, and dibothrocephaltis latiu are the most
common parasites of man, and though they are indeed of great importance in human
parasitology, they per se are not restricted to tropical countries.

The group of nematodes, however, comprise numerous parasitic species of man,
among which three especially, uBmely JUarix, anqfloitomun, and ascaris are of special
interest to the American tropical countries.

FILARIASIS.

This disease is caused here in America by filaria bancrofti, commonly known at
F, noctuma. The adult parasite lives in the lymphatic of the pelvis and abdomen of
man, where it deposits its embryos or microfilaria, which, carried by the lymphatic
channels and thoracic duct, reach the heart, the blood stream, and are found in the
peripheral blood. The parasite is transmitted to man by several species of mosquito,
and probably by bedbugs and ticks. The microfilaiis enter the body of thes^
insects with the blood. It undergoes development, and after a certain time, about
12 days, it becomes a larva, in which stage it passes to the probosis of the mosquito
and is introduced into man during the bite of the insect.

The presence of the parasite in man may not be accompanied with any appreciable
S3rmptoms, but not uncommonly it mi^ht give rise to a moderate degree of anemia, a
certain degree of eosinophilia and other constitutional disturbances. In marked infec-
tion of long standing, the disease not uncommonly may give rise to a chronic derma-
titis and cellulitis in the dependent parts of the body such as the legs, anna, etc.,
character!/^ by fiborosis of the sucutaneous tissue, hyperplasia of the akin, and
edema of the parts commonly known as elephantiasis.

The fact that ancient Indian writers were acquainted with elephantiasia, whila
Gelsus does not appear to have known the disease, and according to the writing of
nillary and Hendy that this disease was rare in Barbadoes at the beginning of the lOtb
century, and furthermore Hillary's view that elephantiasis was introduced by the
Ne^ro slaves from Afrira, gives rise to the belief that the endemic home of filariasisis
Asia and that it so spread from hence to Africa and from Africa to America. In
America, filariasis is especially common in the West Indies and it is believed that in
Porto Rico, in certain districts, about 20 to 30 per cent of the population is affected
with the disease. Filiarasis is also common along the Gulf of Mexico and all alomc
the Atlantic coast in the tropical regions of Central and South America.

FUBUO HBALTH AND MIDIOINB. 99

▲NCTIfOSTOMLlSIS.

The AncylostomlMw or hook wwm dieoaio is produced by a peradtic nematodes
which inhabit the small intestine of man. The parasite lives attached to the mucus-
BMmbrane of the intestines by means of special oigans of attachment in the form of
hooks or plates, which produce laceration and ulceration at the point of attachment.
The parasite in general is the source of gastro intestinal and constitutional disturb*
ances. It has been diown by Smith and Loeb that the parasite is provided with a
pair of glands at the cephalic end which empty into the mouth and that the secretioii
of this gland has an anticosgulating action on the blood which prediqMse to aconstant
ooeing of blood from the ulcerations at the point of attachment of the parasite. Occult
blood in the stools is a constant symptom of the disease and this slow but constant loss
of blood in the patient gradually gives rise to a secondary anemia pernicious in type.
The abdomen is usually distended, and the internal organs such as the spleen, Uver
and kidney are the seat of organic lesions. The physical and mental faculties gen-
erally diminish and it is not uncommon to see among these unfortunate patients such
a deppsnerated stage of the mind which almost reaches imbecility. The parasite is
transmitted by the mouth with infected food or polluted water or through the skin
in the larva stage of the parasite. The ^ggs of the worm are discharged with the feces,
and in soil there hatches a larva which infects man.

A8CARIA8I8.

By Ascariasis is meant that group of morbid conditions produced by the presence
of oseorat Iwnbrieoidei in the intestine of man. This parasite is commonly found in
children and only occasionally in adults. The disease is of importance in the Ameri-
can tropical couiitiies in so far as it is responsible for a variety of morbid changes in
children in those regions which not uncommonly cause death. The presence of the
parasite also is the source of gastro intestinal disturbances, distension of the abdomen,
emaciation and a certain degree of anemia. If the infection is persistent it may lead
to a retardation of growth in the child and is apt to leave permanent organic lesions.
The parasite is transmitted in the larva stage by contaminated water, food, etc., or
directly introduced with the fingers. It is a common habit among the poor and the
lower class in the Ammcan troiHcal countries to lay the child on the ground, when
naturally he soib his fingers and introduces the larva into his mouth with the dirt.
The eggs are discharged with the feces, then undergo development in the soil and
water into larvas which are transmitted directly as above staled, by the contaminated
food or water.

y. GbNBRAL CONSmSRATION AND CONCLUSIONS.

The above brief description of the most common parasitic diseases in the American
tropical countries clearly shows that these diseases per se are not as a rule the causes
of death, but they predispose to secondary complications and more especially give
rise to permanent organic disturbance in man, leading to a physical and mental
impairment. These diseases, as may be seen, are especially common in those places
where the hygiene have been neglected, thus countries like Cuba, Panama, and
Costa Rico, in which special stress has been placed by their respective govemmenls
lor the eradication of these diseases, clearty diow the beneficial result of these prophy-
Uctic measures, and also may be taken as an example that if such a regulation was in
force in other trof^cal countries in America, equally as good results would be obtained.

The importance of sanitation of American tropical countries can not be too highly
emphaaizad. It is almost superfluous to say that for the normal performance of our
mental faculties a normal ccmdltion of the body is essential. The human race, of
course, is constituted by the aggregation of those units of which man is the representa-
tive, and it is only when those units work in harmony and with sound body that they
664»^17— Tocix 8

100 PB0CEEDIKQ8 SECOND PAH AMBBICAK SOIBKTmO OOITQ]

can produce sound and efficient results. It is almost useless to expect that a man
afflicted with these chronic diseases can perfonn his duty in the same way as a normal
man will do it. In vain will be all the effort toward the progress of civilization among
the Latin-American people, if the most essential part, the hygiene of these countries
and the health of the community, is neglected. How can it be expected that a man,
with an enlarged liver or enlarged spleen and in which other organs at the same time
are not performing their ncmnal function in the elimination of the poison from the
system, would perfonn the same tasks as another person with a n<»mal body? The
blood we know is our vital liquid and supplies us with food, and it is easy to under-
stand that our physical and mental faculties will be greatly impaired by any degree
of disturbance in the circulatory system. We know that ideeping sickness in Africa
IMxxiuceB a complete lethargy in the patient who usually dies in the comatose .omdi-
tion. We know that similar symptoms are common, though in a mild degree, in
chronic malaria, ancylostomiasis and other parasitic diseases, the lethargy character-
istic of the people of the tropical countries and the well known "mafiana*' symbol-
ized the character of the people. This ** mafiana," of course, could be made today
any time if efforts are directed to the sanitation of the tropics.

The CHAntHAN. The next paper is called ''A review of the present
yellow fever situation/' and is by Dr. Arfstides Agramonte, of the
Univeraity of Habana, Cuba.

A REVIEW OF THE PRESENT TEtLOW-FEYER SITUATION.

By ARtSTIDES AGRAMONTE,
Pro/e$$or of BaeUriology and Experimental PatiicHogy^ in ike Umvenity qfHabana, Cuba.

At a moment when the most enlightened and civilised nations of the world are
engaged in a merciless and devastating war, the like of which has never taken place
in history, ancient or modem, at least with reference to its magnitude and the means
employed for the destruction ol man and all that man holds dearest, it is well to con-
template this gathering of representatives from other nations no lew enlightened
or civilised, this side the Atlantic, intent upon the cultivation of the sciences, upoa
the quest for truth, and thus directly upon the conservation and the moral and physical
betterment of man. It is such a spectacle as the one here made evident, that serve*
to support the tottering faith in the ultimate emancipation of mankind from the evil
passions of the primitive inhabitants of our world, and yet congresses of the greatest
import, scientific and religious, have been held repeatedly in the very lands that
to-day are steeped in the blood of their men, throughout their confines raging unutter-
able misery and woe, ruin and desolation.

We can only hope that the present conflict may stand as an awful example to the
future generaticms, and that our respective countries may never see the like among
themselves. In this connection, regardless of enervating pessimism, very much can
be accomplished by the frequent intercourse of our representatives and their meeting
upon a higher plane than mere politics or commercialism. And what plane may be
considered higher, of greater moral worth, than the earnest endeavor to suppress
disease and human suffering?

It may be pointed, I may say with pride, by every one here, to the almost extinction
of yellow fever, for so long considered a Pan-American disease, as the result of that
concerted international action in a good cause, intelligently and peraistently main-
tained. Because of its gradual disH>p6arance (aside from my personal shortcomingi)^
the subject that I was invited to treat upon has been particularly difficult to handle*

FUBUO HBALTH AND lODIGIKB. 101

Yellow fever has been enuiicated from its fanner haunta, if not entirely, at least to
sach an extent that the common diseases of infancy, not to say other infections like
malaria, dysentery, or tjrphoid fever, have become more worthy of the sanitarian's
consideration. This, notwithstanding, we can not lose sight of the grave problem
which its appearance would imply to those countries that never had it, or that have
managed to stamp it out in their territory, and so, the maintenance of a condition of
preparedness, is no less important in connection with this contingency than with any
other of a political or financial character.

This is the only excuse I can offer for having accepted the honor of contributing
this paper.

In view of the present status of yellow fever, which I shall endeavor to make evi-
dent, what should be our attitude towards the pml it involves? How stringent
should our quarantine regulations be? What may be allowed now, formerly prohibi-
tive, that will make commerce, and international relations less cumbersome?

If we determine these points in any degree to our common satisfaction I shall fee
thftt my efforts have not been entirely in vain.

mSTOBIOAL SKBTOH.

Barely to outline the history of yellow fever one must delve into the musty annals
dating back centuries, perhaps to the period of the discovery of America. We know
now that the records were kept then in a manner far from accurate; how ''fancy"
took a prominent part in the description of common, everday occurrences; how the
most trivial event was exaggerated and distorted by repetition, for the sake of
notoriety if not for fame and profit; how iniquity, misery, and discontent were made
light of, or silenced, if silence was conducive to the attainment of a desired purpose.
Hence we can not wonder at the difficulties encountered by our contemporaries in
their efforts to remove the veil that enshrouds the origin of this dreadful scourge.
One thing seems definitely shown by the investigations made in that direction,
namely, that whatever may have been the extent of its dissonination, the cradle of
yellow fever was either Mexico or Central America on this side of the Atlantic, or the
western coast of Africa upon the other side.

Some historians, our immortal Finlay was one of them, believe that yellow fever
existed among the Indian tribes of the Mexican and Central American coasts, even
before the coming of Columbus, and that the discoverers carried the infection back
with them to the Canary Islands, from where its propagation to the African Coast
aeons feasable. Others, in view of recent finHingn as to the endemicity of yellow
fever in west Africa, where it may have existed through centuries unknown, are
inclined to believe that the slave trade may have been the means of infecting our
westam hemisphere.

Be that as it may, the fact remains that the best authenticated record of epidemics
of yellow fever in America corresponds in time to early slavery days, and to the clearest
description of the disease on board a vessel plying the west African waters; I refer
to the epidemics in Habana during the years 176^1769 and to *' the fever which raged
on board the Weasel sloop of war during the rainy season at Oambia in 1769."

Since then the great disproportion between the increase of the white population in
America and that of west Africa has undoubtedly been the reason why our attention
was ever turned toward home in the desire to solve the problem of etiology and prophy-
laxis, and how seldom we seriously considered, until very recently. Sierra Leone and
the Gulneacoast as endemic fod of yellow fever. And so Mexico, the West Indies, and
South America have borne the stigma of being the home of pestilence and a danger
to all other civilised countries during a period of more than two centuries.

Definitely established as an endemic disease in cities of the Gulf of Mexico, the
West Indies, and Braail, yellow fever made incursions, causing terrible ravage into
the United States and across the Atlantic, invading European p<nrts of France, For-
toga], and Spain.

102 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NGBB88.

In 1698 the expedition intended to capture the Island of Martinique brought yellow
fever to Boston, losing 1,300 sailors and 1,800 soldiers, at the same time infecting the
town. In 1689 Philadelphia, only 17 years established, suffered the first epidemic;
in subsequent years many outbreaks occurred, the severest being in 1797 (with 1,900
deaths), 1798 (3,500 deaths), and 1799 (with a mortality of 1,000).

New Orleans was the American dty most attacked by yellow fever; its commercial
relations with, the West Indies and the Mexican Gulf ports, kept infection, if not
permanently, with yearly exacerbations from 1817 to 1858; after this the worst eftt-
demics took place in 1867 (mortality of 3,093), 1878 (mortality 4,600). In 1905, we
hope the last epidemic that will be seen in America, New Orleans lost about 460 lives.

All the Southern States were destined to be overrun by this disease whenever it
gained entrance through any of its ports, and so the epidemic of 1878 invaded 132
towns and caused a mortality of 15,934 out of a total number of cases exceeding 74,000.

In South America importations from the West Indies and Mexico established
endemic foci after causing severe epidemics in various cities of Brazil as early as 1686,
in Pemambuco, having also developed in epidemic form in Montevideo, Buenos
Aires, and other cities on the east coast from where it has disappeared.

The last epidemic invasion of yellow fever at all important occurred at Tocopilla,
Chile, where the diseas«3 spread with wonderful rapidity, but was as quickly stamped
out by the local sanitary authorities. And so, wherever it may have been bom, I feel
that we are coming siurely to its death; it no longer holds for us that nameless dread
which follows all mysterious things.

QBOORAPHICAL DISTBIBUTIOK.

We find that yellow fever has vanished from some of its former homes, probably
forever, now constituting endemic areas of comparatively slight importance in other
localities; for instance, Cuba and the Mexican Gulf ports have been free for many
years, as well as the Isthmus of Panama and the West Indies, where no cases at all
have been recorded for two years.

During the first half of the present year (1915), yellow fever in America has been
confined to a part of the Mexican Republic, probably kept alive by the movement of
troops, that is, by the renewal of nonimmune element in the endemic areas, mainly
in the peninsular of Yucatan. Sporadic cases, or cases at long intervals, without a
dear history as to their source, have appeared from time to time at the places shown
in the following table:

Yellow fever cases reported in 1915 (U. S. Public Health Service): Brazil, Bahia,
February to July, 5 cases; Ecuador, Guayaquil, February to April, 6 cases; Mexico,
M^da, up to April 10, 4 cases; total, 15 cases.

The very complete reports of the English Yellow Fever Commission, first and second,
though not giving us an exact idea as to the present conditions in West Africa, point
very directly to the fact that fever is endemic there. The commission says:

We have therefore to recognize the occurrence amongst the natives of theWeit
Coast of Africa of two types ol yellow fever, the one a mild type accompanied by such
slight symptoms that its diagnosis is often very difficult, and another, tne hemorrhagic
type, presenting all the grave and fatal characters of the disease as it commonly affects
Europeans and newcomers into any area in which it is more or less constantly present,
(maladie habituelle).

If we accept, as we should, that yellow fever is an endemic disease in that part of
the world, equally affecting blacks and whites, though not in the same degree of inten-
sity, then we know where it shall make its last stand, when we drive it, as I am sure
we will, forever, from America, because the implanting of prophylactic measures in
an uncivilized community is well nigh impossible, so that it may render a sense of
security at all in proportion to the expense and trouble it entails.

PUBUO HEALTH AND MEDIOINE. 103

OIS8BMIKATION OF YELLOW FEYBR.

It has often been said, in fact, a paper was read upon the subject at the last Inter-
national Medical Congress held in London (1918), that the opening of the Panama
Canal, facilitating as it does the more active commercial intercourse between the
Americas and their opposite seacoasts, as well as the more rapid and therefore more
frequent r^ations between eastern America and Asia, was sure to be the means by
which the disease would travel across the Pacific Ocean, thus endangering a tropical
region of the Earth, until now, as far as we know, free from that plague.

I took occasion to point out then, as it has been proven by the time elapsed, how,
instead of a danger, the Canal Zone, was in fact a sanitary bulwark, or at least a veri-
table filter through which, neither yellow fever nor any quarantinable disease could
pass, for I was convinced that the United States Government would necessarily main-
tain there, the wonderful sanitary control established during the period of its con-
struction.

Of course the danger of its spreading from one of the above-mentioned foci to any
other part of the country or to any other country is just at present to-day as ever, except
that the scarcity of cases where they occur now, and the better knowledge of its etiology
and preventicm, render this danger less acute than formerly, when great epidemics
laged in one or several ports of the Atlantic and Pacific coasts.

In this regard it is proper to consider for a moment, the present knowledge and prac-
tice, respectively, of the

SnOLOOY AND PROPHYLAXIS OF THB DISEASE.

No organism has been discovered that may be accepted upon good scientific grounds
as the causal agent of yellow fever. Needless to say, many claims have been made by
enthusiastic investigatorB, but all of them, from Domingo Freire, of Brazil, to Harald
Seidelin of the Liverpool School, have been shown definitely as in grave error. The
exact nature of the germ is therefore still unknown, though we have learned that it is
found in the blood during the first three days of the disease, that it passes through the
pores of a filter which holds back bacteria, that mosquitoes, who take it into them-
selves by stinging a patient can transmit it to other persons after twelve days and that,
if these persons are not imjnune to the disease they wiU develop an attack within six
days. These facts were first demonstrated by the United States Army yellow-fever
board, thus confirming and converting into a doctrine, the theory advanced 20 years
before by Dr. Carlos J. Finlay, the theory of the man to man transmission of the dis>
ease by mosquitoes.

It was the establishment of these facts (the period of infectivity in man, the period
of incubation in the mosquito and that in man), as well as the knowledge of the kind
of mosquito, its habits, that led to the first rational campaign against yellow fever, sue-
cessfully carried out by the then Maj. W. C. Gorgas in Habana, during 1901. As
though by the wave of a magician's wand, the epidemic there and then subsided;
immediately after, the same thing in Mexico; then in rapid succession, Laredo, Tex.,
Rio de Janeiro, Bahia, and Sao Paulo in Brazil, were subjected to the same methods
of mosquito destruction and protection of the sick from ^eir bites, with the results
that yellow fever soon disappeared from all those cities.

Another fact of the greatest interest to the welfare of commerce and international
relations, also demonstrated by the Army board, was the innocuousness of "fomites,'*
tiius doing away with disinfection as practised until then, of the person, baggage,
clothing, etc., suspected of being infected or considered as tainted.

Sanitarians when dealing with yellow fever became interested only in the mosquito;
the problems which they then had to solve were principally (a) to obtain knowledge
of the relative proportion of the species Stegomyia in the locality, (6) breeding places
of same, (e) poesibitity of their transportation at a distance, (d) their extermination by
all means poemble. The cases of yellow fever themselves occupied a secondary plane

104 PBOGEEDIKQS SECOND PAH AMERICAK SOIBirnFIO OOKOBBBCL

in the order of importance inasmuch as it was presumed, when a case was discovered,
that it had already infected every mosquito in the immediate neig^boihood; once
the patient was put into protected wards it ceased to be of interest from epidemblogic
standpoint.

No mosquitoes naturally means no yellow fever; but such a consummation, much as
it is devoutly to be wished, seems at all events impracticable and so the countries,
whidi we may term most threatened, have been compelled to be satisfied with keeping
down the number of insects in their towns and cities, "below the yellow fever level'*
as expressed, I believe originally, by Gen. Gorgas, and trust upon their power of watch-
fulness to ward off the introduction of the infection, in the hope that if by any unforseen
circumstance such a misfortune should occur the scarcity of mosquitoes, since their
absence is impossible, will make the chances of propagation comparatively less.

INTERNATIONAL PROPHYLAXIS.

This depends, as in the case of every infectious disease, upon the knowledge of the
facts concerned in its etiology and epidemiology. As regards yellow fever they are
mainly such as I have outlined above. Of no less importance in this connection, de-
pendent upon the period of incubation in the mosquito, is the fact first pointed out by
Surg. H. 0. Carter, of the United States Public Health Service, to the effect that
secondary cases never occur before two weeks or 18 days after the primary or initial
case; needless to say, the greatest difficulty has been, and no doubt always shall be,
to discover the primary case in any emergency.

The question of international defense was considered of sufficient importance by the
Governments on this side of the Atlantic so that it was taken up at the sanitary con-
ference which met in this city in 1905, making such additions to the articles adopted
by the International Sanitary Conference held in Paris in 1903, as to make them ex-
tensive to yellow fever as well as to cholera and plague. And now that the means of
propagation became well known, it seemed more within our power to prevent its
entrance into new fields; this could only occur by the introduction of infected mos>
quitoes in ships, railroad cars, or in any other way transported, or by the introduction
of cases during the period of incubation, or both ways.

The question of quarantine as it was imposed against yellow fever, before 1901, is
now entirely obsolete. All effort has been naturally directed to prevent the convey-
ance of mosquitoes in vessels, cars, stages, or whatever are the means of communication
between the countries concerned and to guard against the introduction of an infected
individual. When this is said, one is tempted to dismiss the subject as sufficiently
expounded, but there are certain details such as must necessarily interest more par-
ticularly a gathering of international character, which, at the risk of "going beyond
my depth " I beg to at least place before you for deliberation.

We must not lose sight of the fact that tiie great epidemic foci have disappeared and
we would not be justified in thinking of any city to-day wiih the dread that inspired
Habana, Vera Cms, or Rio de Janeiro in former times; for that reason we can not hold
the same quarantine measures against localities which are known to develop now and
then a few cases of yellow fever, that we formerly did when the disease raged there in
epidemic form, in hct, other quarantinable diseases are to-day more prevalent and
should demand greater attention on the part of the sanitarian if we hope to ever accom-
plish in regard to them what has been attained with reference to yellow fever. I do
not mean by this that we should fail to watch and look with some degree of suspicion
upon certain ports, for an evil reputation justly acquired throughout a lifetime, in
spite of all that may be said for it, can not be suddenly and ^vorably changed.

There are fundamental opinions that must be modified to accord with the progress
of international sanitation, not the least important being, what constitutes a person
ijomune to yellow fever to-day? Formerly, aside from having suffered an attack of

PT7BLI0 HBALTH AND MBPlOlHIt 105

tbe disMse, ih^ fact of having lived for 10 coMecative yetn in a well knofwn yeUow
frrer focoa, waa considered saffident evidence of immunity. Theee fod having
pcacticaUy difl^ipeared the increase in the popobAlon since the diseaae waa eradicated
from there, metns a nonimmune element that is growing with the years <A indemnity
whidi the locality may enjoy, at the same lime that it makes so mudi keener and
more dreadful the danger of a reintioduction of the infection and thus demands that
it be more carefully guarded against.

We can no longer look upon ships coming from ports where yellow fever may be
pteaent only, with the same suspicion that in epidemic times they formerly inspired,
since the decrease in the chances of their infection should in justice be considered
favorable to them and permit lees restraint in the quarantine measures, that are now
applicable if compliance with the letter of the law must prevail over good judgment
and a sound sanitary policy.

Althou^ there is no room for discussion as to what constitutes an infected vessel,
inasmuch as only one having the disesse on board or within seven days after leaving
port can be so considered, the question as to what circumstances should warrant the
term "suspected vessd" when applied with reference to yellow fever is one that must
be further eluddated. I think the definition as made by the last International Sani-
tary Conference in Paris (1911), in acceptable then, ou^t to satify the majority of
my hearers now, more so, in face of the present status of yellow fever in America.
''A vessel is considered suspected (or suspicious), when it has had cases of * * •
yellow fever on board at the time of departure, or during the voynge, but no new cases
lor seven days."

In connection with the whole subject of international prophylaxis, it becomes urgent
tiiat exact and early diagnosis and prompt notification of cases be made. Only thus
can a feeling of confidence be maintained that will be condudve to a better imder-
standing between the various governments interested.

I firmly believe that within a short period of time, as time is measured in the history
of the world, yellow fever, if it was not so originally, will be relegated to the condition
d an African disease; that it shall be endemic only in the semidvilized states of the
Central Zone, which, regardless d what we may hope or strive for, shall continue to
be for many decades, if not the white man's ''grave" at least a peril to the white
man's final settlement there.

Having taken a small part in its undoing, I find it the source of greatest satisfaction
to witness the final passing away of this terrible scourge.

RSFSBSNCB8.

1. Conference Sanitaire Intematbnale de Paris. Proces vorbaux, 1912.

2. Apuntes aobre la Histoda Pkimitiva de la Fiebre amarilla, Dr. Carlos Finlay,
Habana,1884.

8. Dicdonario de la Ida de Cuba. Introducci6n. Pezuela.

4. Report on the Etiology and Prevention of Yellow Fever. G. M. Sternberg, Wash-
ington, 1890.

6. Reports, first and second, d the Yellow Fever Commission, (West Africa), Lon-
don, 1914.

6. Public Health Reports, United States Public Health Service, Washington, 1915.

7. Yellow Fever Bureau Bulletin, Vol. Ill, No. 4, Aug. 1915.

The Chairman. A brief paper under the title of ''Liceaga and
yellow fever'' has been prepared by Maj.T. C. Lyster, of the United
States Army, and will now be presented as a discussion of the paper
by Dr. Agramonte.

106 PBOOEEDINGS SECOND PAK AMEBICAN SCIBIHIFIC C0NGBB88.

UCEAGA AND YELLOW FEVER.

By ICaj. T. 0. LYSTER,
OffiM o/th$8wrgeon Oemral^ War Department

We have seen in the last 12 yean the yellow f<»ver endemic centers shifting farther
south, and cities, such as Habana, Panama, and Vera Cruz, have lost their unenviable
reputation. There is now remaining but one endemic center (Yucatan) in the North
American Continent. We know the work that has been done by Americans, but
it may not be known to all of us here the noble part played by one of the great men
of Mexico, Dr. Liceaga. There is a country which needed and still needs men of
his high character, to bring up a greater Mexico, after all these years of strife and deso-
lation.

It was my good fortune to have access to records and official letters bearing on sani-
tary matters concerning Vera Cruz for the last 15 years. Had T the talent for biogra-
phy, the literature showing the reasons for the widespread knowledge of yellow fever
would surely be enriched by a detafled history of the relations of Licesga to the excel-
lent sanitary work which has been done in Mexico. A man can not be really jn^eat
unless he is sincerely modest and wins his countrymen through tbeb love and affec-
tion, as well as by their faith in his ability. liceaga had, and still has, the active
support of those who were working disinterestedly for Mexico, and is idolized by
those who serve under him.

As early as 1903 Liceaga had submitted a comprehensive plan for the elimination of
yellow fever from Mexico. Native lethargy in endemic centers, such as Vera Cruz,
together with an acquired immunity to yellow fever, and indifference in the City of
Mexico, on account of geographical immunity, were the most di.-ficult of sanitary
obstacles to overcome.

Liceaga believed that the immunity of those in Vera Cruz was acquired in an
unrecognized form of yellow fever in childhood. Uis letters to the health authorities
iA Vera Cruz put emphasis on the control of all doubtful and ill defined forms of fever.
Funds were provided both by Vera Cruz and the Mexican Federal Government to
eliminate yellow fever. As a result, we found Vera Cruz in May, 1914, after three
years of internal war&ure, not only free from yellow fever sini^ 1909, but also provided
with an annual appropriation of nearly 52,000 pesos for preventive yellow fever

We found evidence of how other money was spent, and wisely spent. We found a
city well paved and lighted, good sewerage, and an excellent water supply for a normal
population of 35,000 to 40,000. These were the results of sani tary education, and made
possible by such men as Liceaga as the heads of Mexican national affairs. We also
found a network of outlying drainage ditches which only necessitated clearing out
and extension to make diem thoroughly effective.

By enforcing his plans for the destruction of breeding places both within and with-
out the city. Vera Cruz became practically free from mosquitoes and thus insured
against the spread of yellow fever.

While the elimination of yellow fever from Vera Cms was but one of Licea^'s
many sanitary achievements, it was a most worthy one and all America should be
proud to claim him as one of the brilliant products of the Western Hemisphere.

The Chairman. I shall now call for the next paper, ''Carlos Finlaj
on the house mosquitoes of Habana," by Mr. F. Enab, of the Bureau
of Entomology, United States Department of Agriculture.

PUBUC HBALTH AISTD MEDICIKE. 107

CARLOS FINLAY ON THE HOUSE MOSQUITOES OF HABANA.

By FREDERICK KNAB,
United Siatea Bureau of Entomology,

Historical accounts of the discovery of the agency of the mosquito in the trans-
mission of yellow fever usually minimize Dr. Finlay's share in the work. This is
largely attributable to the tendency of more recent writers to content themselves
with statements obtained at second hand. In consequence it is not generally appre-
ciated that Finlay's theory resulted from deductions based upon the closest observa-
tioQ. We frequently find the earlier suggestion of Beauperthuy mentioned together
with the theory of Finlay, whereas their ideas were totally different. The former
thought that mosquitoes caused yellow fever by inoculating man with poisonou-
substances extracted from swamps and foul places. It is not even clear that Beaur
perthuy distinguished between the yellow-fever mosquito {AUdea caloyus) and othes
similarly marked species occurring al>undantly along the coast, such as Akki trniwr*
h(/nchu»,

Finlay , from a close study of yellow fever, had become convinced that it is not trans-
utted in the manner of ordinary contagious or infectious diseases. He was *' con-
vinced that any theory which attributes the origin and the propagation of yellow
fever to atmospheric influences, to miasmatic or meteorological conditions, to filth
or to the neglect of general h>'gienic precautions, must be considered as utterly inde-
fensible." In his conception there was concerned some virus or microOiganism in
the blood and that this was transmissible from man to man solely through the agency
of some blood-sucking insect. This naturally led to mosquitoes. He found two species
of house mosquitoes at Habana, known to him under the Latin binomials respect-
ively of Ctdex moBquito and CuUx euhennt. The former is the species now generally
know under the names Aides calojms or Stegomyia fasciatci; the latter is the species
better known under the names Culex quinquefa^ciatus and CuUxfaHgam, Finlayin
studying these two species found such marked differences in habits that he was able
to eliminate CuUx eubenns (quinquefaseiatus) and incriminate the species which was
afterward proved to be the transmitter of yellow fever. He pointed out the character-
istics of Culex moBqidto (^Akles calopus) which are essential to its rdle of transmitter.
In his paper read before the Royal Academy at Habana in 1881, "El mosquito hipot^ti-
camente considerado como agente de tran6miBi6n de la fiebre amarilla,'*^ are to be
found recorded all the important details in the life history of the yellow fever moe-
quito which were afterward brought forward in more elaborate form by the French
commission to Rio de Janeiro, by Goeldi, aud by other workers.

Finlay clearly understood the domestic character of the two species of house mosqui-
toes. He contnk^te their habits, pointing out the bearing of the dififerences on the
question of transmission. Cidex cubemis is strictly nocturnal, and according to his
observations, if not interrupted during feeding takes but a single blood meal.* He
was never able with captive females "to obtain a second bite, whether it had or had
not laid its o^a.*' As in the European CuUx pipiens the eggs are all laid at one time
in a mass directly upon the surface of the water and the death of the female follows
shortly. "After having laimched their little boat of eggs, they often stretch them-
selves out to die upon the water, and I have wondered whether the dead insects
which R^umdr attributes to new-bom ones which have been wrecked and drowned
at the moment of leaving their pupa shell might not be the cadavers of mothers who
had died in order that their bodies should remain close to the ova so as to contribute
to the feeding of their progeny."

> Anales R. Acad. Clendas med., fls. y n«t., Habana, vol. 18, pp. 147-160 (Aug. 14, 1881).
* Thb statameiit Is not altogether correct. This species feeds at less frequent intervals and, for the rea>
SOBS Indicated by Finlay, is shorter lived under normal conditions of activity.

108 PB0GEEDIKG8 SECOND PAH AMEBICAK SOIBirTIFIO C0KQBB88.

Finlay inBistB that Cukx mosqtdto is a strictly diurnal mosquito. The finale
must have blood for the development of her ova and begins to suck blood after having
been fertilized. The eggs are not all developed at once and are deposited at intervals
in groups of from 9 to 15. They are sometimes placed upon the water and at others
''upon solid bodies not too far removed from the level of the water, so that a moderate
elevation of that level will allow the water to cover them." Accordingly this mosquito
is longer lived and requires and takes repeated blood meals at intervals. A female
kept alive for 31 days fed 12 times during that period. Finlay points out that these
repeated blood meals are an important postulate for disease transmission:

Evidently from the point of view which 1 am considering the Culex rnosquito is
admirably adapted to convey from one person to another a dieeape which happens
to be transmissible through the blood; since it has repeated opportunities of sucxing
blood from different sources and also of infecting different persons, so that the proba-
bilities that its bite may unite all the conditions required for the transmission will
thereby be greatly incrc^tsed.

The sluggishness of this mosquito after a blood meal and its unwillingness to under-
take long flights are discussed at some length and their significance in relation to the
peculiar manner of spread of yellow fever pointed out. The often noted failure of the
disease to spread beyond narrow limits when no appreciable barrier appeared to exist
found a ready explanation in the reluctance of the mosquito to leave the house where
it had fed . On the other hand the outbreaks of yellow fever at distant points could be
explained by this same sluggish habit of the mosquito, its tendency to hide causing
it to be carried long distances in baggage and clothing.

The importance of all these i>oint8 has since been fully recognized and discussed
at length by many workers in the field of yellow fever investigation. However, but
few even of the best informed authors have realized that Finlay clearly understood
and discussed them about 20 years before the question of the mosquito transmission of
yellow fever was definitely settled by the immortal work of the United States Army
commission.

Dr. AoBAMONTE. I do not wish to decry the great glory that is due
to Dr. Finlay. At the same time I believe we should not forget the
work of a man who was a pioneer in the same line of investigation,
since his conception of the transmission or the propagation, as he
called it, of yellow fever deserves consideration. Beauperthuy was
traveling aroxmd as early as 1840 with a microscope examining his
patients — the skin, the excreta, the urine, etc. — things that at that
time were only imdertaken by a man who really had great scientific
enthusiasm and devotion to his medical practice. While he did not
point to the transmission of yellow fever by the mosquito, he very
directly mentions in his works that if there were no mosquitoes there
would be no yellow fever; and he mentions, for example, the town
and the island of Guadeloupe, in which there were great numbers of
mosquitoes and in which yellow fever prevailed, whereas only a league
away in an inland town where there were no mosquitoes yellow fever
was not usually developed. Now a great many points in the history
of this man Beauperthuy, I believe, are worthy and we should treat him
with greater respect. I mxist take exception to the attitude taken
by Dr. Eoiab and express my belief that his remarks were unjust in
trying to show that his work was valueless. It was so only so far
that it was published and buried, as usually has been the case with
the work of our tropical investigators. In this manner Dr. Finlay's

FUBUO HBALTH AHD MIDIOIHB. 109

work was buried. For 20 years he defended a theory that he could
not demonstrate, and I am sure that if he had lived in a different
'Country, where such work was better appreciated, his worth and the
value of his work would have been sooner apparent.

Dr. Carter. I certainly agree with Dr. Agramonte in hoping that
we shall soon see the end of yeUow fever. I also agree with him in
saying that the endemic foci are becoming fewer and fewer. The
greater ones have already disappeared. But along with the safety that
that gives us it introduces a certdn element of danger. There are a
great many places that used to be endemic foci of yellow fever, or
partially endemic foci, into which the introduction of yeUow fever in
days gone by made practically no difference, the population being
whoUy or largely inunune to yeUow fever. As time has gone by, the
proportion of susceptible people is becoming greater and greater.
Take the town of Habana. In 15 or 20 years the introduction of
yellow fever there, if there were any reasonable number of stegomyia,
would spread as it used to do in New Orleans. We have to look at
the thing then from two points. I wrote a memorandum to the
health officer of Porto Rico and to the governor, stating that the town
of San Juan was in a dangerous condition; that there had been no
yeUow fever there for about sixteen years and they were raising up
a susceptible population; that it was not possible for any maritime
quarantine, comparable with any reasonable commercial advantages,
to keep out yeUow fever eventually from such a place; that it was in
a worse condition than New Orleans, where yeDow fever will spread
only six months in the year, whereas in San Juan it will spread 12;
and that it was necessary for them to do antistegomyia work.

Instead of being too hopeful we should be, not by fear but by
hope, stirred up to introduce into the Tropics antistegomyia work
now. The fact of a disease being on the run is to my mind rather
a reason for attacking it. Twenty or 25 years ago plague was con*
fined to a small section in south China and I believe that four or
five millions would have stamped it out; I do not believe a thousand
millions would now do so. We have yeDow fever now in but a few
places and it seems to me that we should not belittle its threat. Its
threat is greater because it is in a few places. Its threat is greater
because many places are becoming filled with susceptible people that
were not susceptible then.

One word in regard to quarantine. That is a big subject. It
should be made, as Dr. Agramonte says, without any consideration
of the rules that were in force prior to 1901. That is true; that is
correct. It is absolutely right that oiur war is against the mosquito,
not against fomites. Many of oiur rules, however, were founded on
experience and, though empirical, hold good still; and I can not
think that the rules of the Paris convention have any foundation in
reason or experience or correct theory. I can not think that a ship

110 PBOCEEDINGS SECOND PAK AMERICAN SCIENTIFIC CONGRESS.

that has had no case of yellow fever aboard for seven days is simply^
suspicious. Why the ship may be loaded with stegomyia that have-
had no opportunity of showing their infectivity after, say, 17 days —
12 plus 5. The time element cbes come in, but the time element
scarcely enters in in counting a ship immune against yellow fever.
Unless I am mistaken, one has recently come to your port, Dr.
Ouiteras, that had been out many more than seven days, and when
conmiencing to load developed ycdlow fever.

Dr. GuiTEBAS. Many more than seven days.

Dr. Carter. I know well that in 1911 one went from Acapulco
to Honolulu and that, when commencing to unload, yellow fever
develoi>ed and a case developed later on in the interior. They had
carried yellow fever as much as four weeks. To my mind time can not
be counted as freeing a ship from stegomyia tmless you coimt a very
long time.

I also think, and I have preached it all my life, that quarantine
must be used only for protection; and yet I remember Dr. Liceaga
saying that he was able to get sanitary measures down in Vera Cruz
partly by showing the effect that the brutal quarantine of Carlos
Finlay had upon their commerce; that if they rid themselves
of stegomyia and of yellow fever it would greatly diminish their
commercial obstacles. I think, then, to be easy on the places that
will not free themselves from yellow fever may be an injury to them
as well as a risk to ourselves.

There were further discussions in Spanish of this paper by Dr.
M. G. Lebredo, of Habana, Cuba, and Dr. Rafael Gonzalez-Rin-
cones, of Caracas, Venezuela. The discussion in Spanish was not
reported.

The Chairman. If there is no further discussion, I shall now call
for the reading of the following papers:

Consideration sur la fiftvre dite "Fiftvre de fruits," by Dr.C.Mathon
and Dr. L. Audain.

La profilaxia de la fiebre tifoidea por medio de la vacunaci6n,
by Dr. Justo F. Gonz&lez.

La Buba (Leishmaniosis Americana), by Dr. L. E. Migone.

CONSIDERATIONS SUR LA nfiVRE DFTE "FlfiVRE DE FROTTS.'*'

Par C. MATHON,

ProfesBewr h la FaculU de Mideeine de Part^M-Prinee^ J7aUt,

et L. AUDAIN,

Direeteur du Laboratoire de BacUriologie de Port-au-Prinee^ HtAti.

Lee aliments et les boisBons que nous in^^rons sont Buseepti^ les d/introduire dans
notre organiame dee maladies plus on moins sm es. L'appareil qui est le plus expose

1 Cettt ll^vre que Its Indigtaes attribuent ftux frulu wt bien oertaintment d'orlgtaie intesttnile oomns
en ftJt fol r^tttde cUnlqne que nous allons encreprendr*.

FUBUO HBALTH AKD HEOIGINB. Ill

-k ces maladies est, saas contredit, k cause mdme de see fonctioiis phyiiologiques,
I'appareil digestif. Aussi, rhjrgi^niste a-t-ii pour de oir de d^truire, par tous moyens
-en son pou-. oir, ces gennes, a\ ant leur penetration dans le tuhe digestif et de maintenir
I'oiganisme en bon ^tat de defense, afin que par ses seuls moyens ii arrl.e k lutter
victorieusement contre les germes qui peu ent Ten ahir.

Mais, a^ant d'entreprendre un tel ou.rage ie m^decin hygieniste doit connattie,
-dans ses moindres details, riustoire clinique de ces maladies.

U existe en Haiti, tant6t k I'etat endemique, tantdt k I'etat epid^nique une maladle
infectieuse d'origine intestinale dont je Aais faire ici une courte etude clinique,
d'ailleurs indispensable pour la direction intelligente d'une honne prophylaxie.

S'il est vnd que les ententes pro oquees par une hygiene alimentaire defectueuse
ont ete etudiees de temps immemorial, il est un fait incontestalle, c'est la grande
-confusion qui existe encore dans la classification et mftme dans la terminologie de ces
affections. Quand on dit d'un malade qu'il est atteint de meningo encephalite
<;hronique diffuse, chacun comprend et il n*est plus rien k dire; mais, quand on dit
d'un malade qu'il est atteint d'enterite, de d3^senterie, de diarrhee erte, de diarrhea
de Cochinchine, etc., on n'en isage qu'un cdte de la question que Thabitude seule
nous permet de comprendre, sans qu'il soit donne en aucune maniere de voir la cause
premiere de la maladle, Tinflammation, ni le si^ de TinHammation.

Des considerAtions d'ordre anatomo-pathologique, symptomatique et pathogeni-
que nous ont permis en Haiti, sous I'impulsion de notre Mattre Audain, de condderer
-et de denommer les affections gastro-intestinales des pays chauds, comme on fatit
pour toutes les autres maladies. La nouvelle classiilcation d 'Audain est trte simple,
comme chacun pent s*en convaincre.

II faut considerer avant tout qu'il existe du cdte du tube intestinal deux appareila
bien distincts: Tappareil glandulaire et Tappareil lymphatique ( aisseaux et tissus
adenoldiens) qui, pathologiquement, reagissent d'une fa9on speciale, et, clinique-
ment, d'une fa^n absolument differente. La cause pathologique porte-t-elle see
effete sur le syst^me ^andulaire? Vous aves une inflammation des glandes iatesti-
nalee et les symptdmes d'une entente glandulaire.

Agit-elle sur la partie lymphatique de Tintestin? Vo\is a^es, sui ant que cette
action reste localisee aux lymphatiques, une lymphangite intestinale comparal le k
la l3rmphangite simple des mem) res, sans retentissement ganglionnaire important.

Cette action s'etend-elle au tissu lympholde de Tintestin? Vous vous trou es en
presence encore d'une inflammation: lalymphango adenoTdite intestinale ou enterite
lymphatico-adenoldien, comparable a la lymphangite des membres a\ec adenite
aecondaire.

A. II existe, au i>olnt de vue anatomique, une grande analogie entre la peau et
Vintestin. Les differences de structure que nous obser ons entre le derme interne
et Texteme ne tiennent qu'i leur rdle phyoiologique different. Du cdte de la pea«,
couche epidennique pl\is ou moins epaiase, plus ou moins dure sui ant le si^. Da
cdte de rintestin, couche de cellules cylindriques, epitheiiales, cellules calcifonnei^
leucocytes. Au-dessous de la couche epidermique sous-cutanee se trou e la couche
papillaire riche en vaisseaux sanguins et lymphatiques et surtout en f lets ner eux.
Pour rintestin, au-dessous de la couche epitheiiaie, couche des \ iUositee, sorte de
papilles sdllantes. Chacune des villosites posikle: une arteriole, une \ einule et, de
I'une k I'aute, un reseau capillaire tr^ ridie. Le centra de la \ illosite est occupy
par un lymphatique special, dit chylif^re. La villosite est compietee par une char*
pente de tissu conjonctif et dee faisceaux musculairas horisontalement places et
leUes par des fibres anastomoiiques o' liques.

Pour la peau, les lymphatiques niissant au tiers da la hauteur des papilles par ua
Cttl de sac ou una extremite affiiee. (Is aboutiasent k un reseau sous paifnllaira dani
las mailles sont meiees k cellas des reseaux vasculairse sanguiaa de la region. De
cel«i-ci partent das troaca i^ua voluBainattxqai aa randanl au reaeau da tlasu oallula*
adipeux aous-cutane.

112 PBOCEEDINQS SBOOKD PAK AMEBIOAK SCIBKTIFIC C0KQBE8S.

Pour rintestiix, les lymphatiques nainent de deux sources diff^ntes: des villosit^
(vaisseaux chylif ^res) et de la tunique musculaire. ' ' Les canaux chylif^res se rendent
directement dans la muqueuse en passant entre les glandes de Lieberkun, ou bien
ils fonnent d'abord un r^seau horizontal superfidel situ6 k la base des villosit^ et
autour des orifices glandulaires. Dans la tunique sous-muqueuse, les chylif^res
constituent, en se r^uni^sant. un r^seau tranffv ersal form^ de conduits, tantdt Straits,
tantdt larges; ces conduits accompagnent les vaisseaux de r^seau sanguin autour
duquel ils fonnent mdme des gaines." Jusqu'id Tanalogie est trte giande entre \m
lymphatiques de la peau et ceux de Tintestin. Les diff^nces qui existent pnr. ien-
nent surtout, d'une part des modifications qu'a dd subir Tintestin pour assurer la
progression du chyle (fonction motrice) et d'autre part pour pr^ser v er Torgamsme tout
enUer des dangers qui Teussent & tout moment menace du fait m^me de la fonction
•p^ciale de Tintestin: I'intestin est un puissant laboratoire de poisons, il est aussi
un formidable reservoir de dangereux microbes.

Du cdt^ de la peau, le syst^me lymphatique est d'une grande simplicity, parce que
r^piderme offre une resistance infranchissable aux germes pathogi^nes moins nom-
breux et surtout en contact moins intime avec les tissus.

Pour les intestins, les dangers ^tant plus nombreux et constants parce que P^pi)
thelium intestinal est beaucoup plus d^cat et plus fragile que T^piderme sous-
cutan6, la nature dans sa sage pr^. oyance a multipli^ les ouvrages de defenses:
ganglions mtent^ques, rlchesse de tissu lympholde du chorion, folUcules clos isol^
follicules agmin^, tons organes dont la structure est analogue k celle des ganglions;
leur rdle est le mteie.

Au point de vue de la physiologie g^^rale de Tintestin, qu'un germe p^n^tre, soit
k tra^ ers T^pith^um sain, soit par effraction de cet 6pith^um k tra. era les espaces
lymphatiques que voyons-nous: les leucoc}rtes migrateurs se portent k sa rencontre et
la bataille s'engage; qu'il p^n^tre dans le r^seau lymphatique, le \oUk cheminant \en
les follicules clos et les plaques de Peyer oti la lutte est encore plus \ iolente. Ge
processus de defense toume parfois au detriment du folllcule ou de la plaque de Peyer.
Pour mieux faire face k I'ennemi, la nature redouble d'efforts, les vaisseaux sanguine
se congestionnent, les leucocytes se tassent, les tissus se compriment, des abcte se
fonnent qui s'ouvrent g^n^mlement dans Tintestin, d^terminent des ulcerations
plus ou moins etendues ou bien des eschares se produisent, s'^liminent, ocrairionnant
des pertee de substances fort grandes.

En resume cette courte etude nous permet d'avancer que (en mettant de cdte les
inflammations ganglionnaires primiti-. es qui doi\ ent dtre plac^es dans un cadre special)
la plupart des maladies se . ^res microbiennes ayant pour si^ Tintestin debute par
une lymphangite. L'analogie se poursuit done m6me au point de vue pathologique
avec ce qui se passe du cdte de la peau: lymphangite localisee, lymphangite plus eten-
due determinant la tume&ctlon des follicules et plaques de Peyer, comme on voit
une lymphangite de la jambe, par exemple, produire la tume^tion des ganglions
de Paine; suppuration de ces organes comme pour ces ganglions; eschares k cause de
leur structure spedale.

En resume, le premier acte de toute attaque microbienne de Pintestin est done
une lymphangite. Lorsque celle-ci n'est que de moyenne intensite, qu'elle n'en-
tratne pas Pulceration des follicules, la situation est claire; la maladie e^. olue comme
une lymphangite ordinaire.

Si, au contraire, la lymphangite est d 'intensite plus grande que les germes franchia-
sant le syst^me lymphatique intestinal, que les ganglions mesenteriques soient im-
puissants k les arrdter, la fi^v re toxhemique intestinale devient une infection \ eritable
qui peut etre eberthienne, choierique, tuberculeuse, etc.

G'est se basant sur ces conBiderati<ms qui viennent d'etre expoeees et s'appuyant
iur des observations cliniques, hematologiques et bacteriologiques que le Docteur
Audain a propose la classification suivante des maladies intestinales; dasrificadon
qui est generalement admiae en Haiti:

PUBUO HEALTH AND HXDIOIHB. 113

1. Lymphangite intestmale ou ent^te lymphatique, caract^ris^ cliniquement
par un acc^ de fi^vre unique ^v^ durant une p^riode de 24 li 36 heures; aprte quoi
tout rentre dans Poidre.

Get BcckiB de fi^vre pent faire penser k du paludLame; mais il n'existe jamais de
parasites dans le sang. Cette mioladie pouirait dtre identifi^ avec la fi^vre dite
^ph6m^ des auteuis.

2. Lymphango-ad^oldite intestinale ou >ent^rite lymphatico-ad^noldienne, carac-
tdris^e par une fi^vre tantdt intermittente, tantdt r^mittante ou continue, d'o(i la
Bous-diviabn en forme l^^re, moyenne et grave. Cette demi^re ayant toutes les
allures de la grande tjrpholde des pays temp6r^; mais la 6^ro-r6action de Widal, de
m6me que la diazo-r^tion, reste native dans tout le cours de la maladie, dont la
dur^ est de 12 ii 30 jours. Notons ^alement Tabsence totale de parasites de Laveran.
Mais, ce qui est int^ressant de noter dans ces cas, c'est la reaction sanguine.

A. Dans la premiere forme, elle est caract6ris6e par de la leucocytose polynucl^aiie
decourte dur6e(12^24 heures) et suivie d'une mononucl^ose tr^ fort6(60 k 90 pour
cent).

B. Dans la forme 1^^ ou moyenne, il y a toujours une dissociation entre les deux
focteurs: facteur leucocytaire faible et facteur mononucl^aire fort ou inversement.
En tout ^tat de cause, la mononucl^ose est toujours moins €ie\6e que dans le cas
pr^Ment.

C. Dans la forme grave, les deux facteurs sont faibles: h3rpoleucocytose et hypo-
mononucl^ose ou formule leucocytaire normale. Ce n'est qn'k I'approche de la
garrison que les deux facteurs se reinvent ou mdme un seul, ordinairement la mono-
nucl^ose.

8i je ne craignais d'outrepasser le cadre assign^ par le Gongr^, je m'^tendrais davan-
tage 0ur les conditions biologiquee qui r^^issent ces diverses vari^t^ d'entMte. Mais,
c'est I'^tude ^tiologique surtout qui doit nous arrdter un instant, car c'est elle qui con-
ditionne les indications que doit remplir Thygi^niste.

Abstraction faite de Tent^te glandulaire, dont Tune des principales causes reside
dans la d^fectuosit^ de Thygi^ne alimentaire, et qu'on 6vitera en recommandant une
alimentation saine; les ententes lymphatiques, elles, reconnaissent pour cause la
penetration dans les lymphatiques intestinaux et le d^veloppement intensif de cer-
tains microbes, soit par suite de leur grande virulence, soit par suite d'une defense
ivganique faible, nulle ou tardive.

Cette penetration est f avorisee par les eraiUures, si petites soient-elles que peuvent
Iffoduire les corps etrangers fins, pointus ou tranchants: aretes de poissons, * * *
larves de vers qu'on rencontre dans certains fruits. Ces larves en penetrant dans
rintestin produisent des eraillures ouvrant par ainsi des portes d'entree aux divers
agents microbiens qui stationnent dans cet oigane. Mais ce que font ces larves d'autres
helmintes qui ont pour habitat Pintestin peuvent aussi le faire. Les ascaris lombri-
coldes si puissamment armes, les trichocephales qui s'enfoncent par leurs extre-
mites cephaliques dans la muqueuse intestinale; le strongylus, Pundnaria duode-
nails qui vit en grande quantite dans I'intestin greie de Thomme, implante sur la
muqueuse o(i il produit de petites hemorrhagies, les vers du fromage (larves de Piophila
casei) pourvus de crochets aceres, peuvent, ^ n'en pas douter, produire la porte d'entree
necessaire k I'invasion microbienne.

En Haiti la croyance populaire est que certains fruits (cirouelles, mangues, sapo-
tilleB) sont susceptibles de provoquer une fi^vre que Ton designe pour cette raison
sous le nom de "fi^vre de fruits." Cherchant si quelque part de verite pouvait se
cacher sous cette crojrance populaire, j'ai constate que, reellement k I'epoque des
Iralts, il existait dans les selles des enfants surtout un certain nombre de vers vivants.
Etudies au point de vue de leur armature, ces vers, ainsi qu'en fait foi la description
•uivante, sont puisBamment armes.

114 PBOGEEDIKGS SECOKD PAK AMEBIOAK 8CIBNTIFI0 00KQBE8B.

La larve d'une longueur d'un centiiatoe, de couleur blanche, poesMe, au niveau
de rorifice buccal, une paire de crochets ac^r^ dont voici les caract^ristiquee: de
la base k la pointe 384/ii. L'armature est form^ de deux partiefl, Tune rectangulaire
a une longueur de 204/ii but ime lazgeur de 60/c. Lee deux angles sup^rieurs de ce
lectangle sont surmont^s de deux pointes ayant Tune 48/c et Tautre 60/c. A cette
partie rectangulaire s'ajoute le crochet proprement dit, incurv^ sur lui-mtoie de fa^on
i former un bord interne tr^ concave, {^a longueur de ce crochet est de ISO fi,

Je ne crois pas qu'il soit possible de mettre en doute le Me des vers intestinaux dans
la production de la lymphangite intestinale: il faut seulement se dire que les vers
n'agissent pas par eux-mdmes, mais par les lesions qu'ils d^terminent et Tinfection
qui en pent r^lter. La prince de ces vers est grande en Haiti. La statistique du
Laboratoire de Bact^ologie de Port-au-Prince accuse 50 pour cent. C'est bien cer-
tainement Ik Tune des causes les plus s^rieuses des diverses vaii^t^s d'ent^te lym-
phatique qui font tant de ravages dans notre pays.

Le Me des vers intestinaux, bien que secondaire, n'en est pas moins important.
Aussi, Targument qu'on oppose parfois d'individus ayant des vers et ne faisant pas de
pouss6e d'entdrite lymphatique n'en est pas un. Que d'^raillures de la peau non
suivies de lymphangite I L'organisme qui se defend a vite fait de d^truire les microbes
et, par une infranchissable bani^re de leucocytes, d'ext^ioriser une plaie jusqu'ii
cicatrisation complete.

O'est k la favour de Peau de boisson, des l^mes non cuits que les oeufe d'helminthes
et les larves de fruits p^n^trent dans I'intestin et s'y d^veloppent. Leur seule presence
ne suffit certes pas pour provoquer la maladie; d'autres conditions sont requises. II
faut qu'ils aient produit des ^ndllures d'une part, et d'autre part que I'individu soit
en 6tat de receptivity. C'est pour cette demi^re raison surtout que tous les porteuis
de vers ne sont pas atteints de fi^vre. Les conditions de receptivity ou de non-r^cep-
tivite morbide dans les infections intestinales d'ordre lymphatique peuvent %tte
determin6es h^matologiquement, comme le d^montre Texamen d'un grand nombre de
malades que nous avons suivis k ce point de vue.

Voici les conclusions auxquelles nous ont conduit dix annees d'observations
cllniques, h^matologiques et coprologiques:

1. Dans rhelminthlase intestinale, sont k Pabri des infections de causes bactdiio-
logiques diverses qu'occasionnent les vers arm^s, tous ceux dont la defense intestinale
est caracterisee par la grande activity des elements lympboldes de Tintdstin, c'est-^
dire par une forte mononucieose en m6me temps qu'une fortd leucocytoee (associa-
iioB de deux elements de la defense).

2. lis sont k Tabri, tant que dure cette condition favorable, condition qui peut
persister des ann^es enti^res, touta la vie m^me; mais il faut savoir qu'elle peut dis-
parattre momentan^ment et pour un temps plus ou moins long. Lorsque le fait se
produit, les individus qui ^taient en ^tat de non-r6ceptivite perdent cet etat et sont
susceptibles d'etre infect^s.

3. Lorsque Tun des elements de cette bonne defense faiblit, par exemple, qu'au
lieu de rbyperleucocytoae, il se fait de la leucop^nie avec mononucieose ou inverse-
ment, Tindividu est susceptible d'etre infects.

Point n'est besoin d'etemiser cette lutte entre hygienistes et parasitolpgues. Le
Professeur Chantemesse a bien raison de vouloir que Ton ne boive pas d'eau cental
min^e, paice que s'il n'existe pas d'Eberth dans Tintestin. la typhotds ne pourra pas
se produire, mdme en presence d'une eralllure intestinale. Mais les professeun
Blanchard et Guiart ont raison de recommander la destruction des vers intestinaux,
parce que mdme si TEberth existe dans la cavity intestinale, la fi^vre typbolde ne so
declarera pas en Tabsence d'^raillures produites par les vers intestinaux. Ces der-
niert surtout sont une des causes les plus puissantes de la maladie.

En resume il faut se mettre k Tabri des causes vuln^rantes capitales puisque suis
elles la penetration microbienne est, sinon impossible, du moins trhe difficile, et so

PUBLIC HEALTH AND MEDIOIKB. 115

floavenir que ai <m peut k la rigueur emp^her la typhoide de se d^velopper par lea
pr^autions hygi^niques, on est d^sarm^ en presence du colibacille, hdte normal de
Pintestin, cause probable de la plupart des ent^rltes lymphatiques ou lymphatico-
addnoi'diennes dont nous venons de faire T^tude. — ^Audain: Fi^vres Intertropicales.

Dans de telles occurrences, quel devra 6tre le rdle de I'hygi^niste? Quelles mesures
prophylactiques doit-on recommander pour arriver k un r^sultat satisfaisant?

Deux indications sent k remplir:

(a) Chez les indivldus d^jk atteints, suppnmer tout apport nouveau de poison
dans Toiganisme, ce que Ton obtiendra par un regime di^tique s^v^re; augmenter
par tons les moyans en notre pouvoir la d^ense oiganique (MMication leucog^e),
travailler par consequent k fortifier la puissance phagocytaire des globules saDguins.

(b) Chez les non-infect^, empdcher 1' ingestion des eaux pollutes, des legumes non
cuita, de certains fruits arrive k une maturity trop avanc^, autant d' elements qui
constituent les principaux vecteurs d'oeufs de vers; maintanir Toiganisme en bon
^tat de defense, afin que, par ses seuls efforts, il puisse arriver k d^truird les germea
qui, malgr^ tout, auraidnt pu Tenvahir. Surveillez par consequent que sa resultante
leucocytaire soit normale.

LA PROFILAXU DE LA FIEBRE TIFOmEA FOR MEDIO DE LA

VACUNACION.

For JU8T0 F. GONZAlEZ.
Profesor Agregado de Baeteriologia e Higiene de MantevideOj Uruguay,

La fiebre tifoidea tlene car&cter end^mico en la Keptiblica del Uruguay, y ademds
empujes nuurcados durante el verano y al otofio. Declina en los restantes meses del
afio.

Obs^rvanse en nuestro pals los preceptos generales de profilaxia, para evitar el
desarrollo de la enfermedad de la cual vamos a ocuparnos y que incluimos en el grupo
de las infeccionesde origen hfdrico, no obstante la dificultad que presenta, la compro-
baci6n del bacillus de Eberth en las aguas destinadas a la alimentacidn.

La dotienenterfa sigue en nuestro pais una marcha casi invariable a pesar de los
esfuerzos bigienicos que se realizan, con el fin de evitar la propagaci6n de la enfer-
medad y su dasarroUo epid4mico.

Hace unos meses, en el Hospital yi]ardeb6 de Montevideo, se produjeron varies
cases de fiebre tifoidea entre los enfermos alH asilados y entre el personal de enfermeros.
Comprobamos la enfermedad clfnica y bacteriol6gicamente y procedimos a investigar
el foco inicial del mal Eberthiano.

La investigaci6n en el agua de bebida, del bacillus de Eberth, re6ult6 negativa.
Se sospecba entonces que el suelo de este establecimiento hospitalario, en la zona
destinada a la plantaci6n de legumbres alimenticias, podria estar contaminado, porque
el agua empleada para el ri^;o de las hortalizas provenfa de un pozo, es decir, de la
nappa subterr&nea. Las verduras podrian muy bien vehiculizar el agente pat6geno
y producir la enfermedad entre los anlados y entre el personal de servicio, que ae
alimentaban con eaa clase de legtunbres sospechoaaa de contaminaci<Sn.

El an41\sis bacteriol6gico del agua del pozo, no di6 el bacillus de Eberth, en cam-
bio, ae encontr6 una dfra elevadisima de bacterias per c. c, con predominio del coli-
bacillus.

Entre tanto se piensa eaterilizar eee foco de contaminaci6n haciendo un eatudio m^
liguroao y prolijo de la nappa aubterr&nea. Pero la tarea no aiempre f&cil, no fu^
poaible llevarla a cabo per tratarae de una localidad urbana. For otra parte el
68486— 17— VOL ix 0

116 PROCEEDINGS 8E00KD PAK AMERICAN SCIENTIFIC CONGRESS.

nneamiento del suelo no logra influir a veces sobre la marcha de la fiebre tifoidea en
algunas localidadee, y sabemos lo diffcil que resulta en dertas ocaeionee llevarlo a la
prictica.

Luego, puee, deede el punto de vista higi^co las reglas de profilaxia general obser-
vadas resultan insuficientee para luchar con eficacia contra la infecci6n Eberthiana.

Es natural y 16gico que en el memento actual, que disponemos de una arma pre-
ciosa de profilaxia, basada en la etiologia de la enfermedad, pensemos en sacar de ella
el mayor partldo deede el punto de vista higi^nico.

Per razones f^Udlee de comprender que entran en relaci6n con la naturalesa de este
certamen no podemos ser extensos y dar toda la amplitud que esta cueeti6n modema
merece.

El agente patdgeno de la fiebre tifoidea perfectamente individualizado a pesar de la
afinidad con otras especies microbianas patdgenas, slrve para prevenir el desarroUo
de esta enfermedad en las colectividades amenazadas. £1 resultado obtenido en las
agrupadones humanas, no puede ser mia sugestivo desde el pimto de vista de la
profilaxia verdadera y racional de la fiebre tifoidea.

En nuestro pais preparamos un material vacclnico segdn la t^cnica del Profeeor
Vincent. El procedimiento seguido por el Profesor Camelli, jefe del Laboratorio
Bacteriol6gico Municipal, consiste en la de8trucci6n y eeterilizad6n por el 6ter sulfd-
lico de los bacillus de Eberth procedentes de culturas de 24 boras en agar y en la
emulsion de ^stos en una soluci6n fisiol^ca clorurada.

Este procedimiento representa sobre los anteriores un verdadero addanto en la
elaboraci6n de la vacuna.

La acd6n biol6gica de la vacima antitffica sobre el organismo bumano, es susceptible
todavfa de mayor esclarecimiento y es de esperarse que nuevas manipuladones e
investigaciones biol6gicas traigan aparejada ima simplicaci6n mayor en la t^cnica.

La vacuna que be tenido ocasi6n de emplear en el Hospital Vilardeb6 con motive de
los cases de fiebre tifoidea mencionados, es preparada con 10 espedes procedentes de
distintas localidades de la Repdblica. Es inoculada por via subcutdnea cada 8 dfas
basta llegar al ndmero de 4 inyecciones. El primer centimetre ctibico inyectado
contiene 100 miUones de bacillus, que aumentan basta U^ar a 300 miUones de gdr-
menes muertos en la tiltima inyecd6n.

Abora bien, teniendo en cuenta que en el memento actual se tiende a admitir que
en el protoplasma microbiano, estd d prindpio albuminoideo que deepierta en el
organismo la acd6n biol6gica defensiva, cabe esperar que las investigadonee encau-
zadas en esa nueva via bagan innecesaria la numerad6n de las bacterias en la vacuna
y que derta doeis de protoplasma microbiana que contiene el prindpio albuminddeo
dtil sea sufidente para producir en el organismo la misma inmunidad antitifica basta
boy conseguida.

En esta investigad6n estamos ocupados actualmente pero nada concrete podemos
comunicar por ahora a esta distinguida asamblea.

El nuevo criterio con que encaramos la cueeti6n de las albdminas especificas micro-
bianas, tiene data relad6n con un nuevo producto prepaiado y ensayado contra la tos
convulsa por d Profesw Krauss, director dd Institute Bacteriol6gico de Buenos Aires
y conocido en el mundo dentffico por sua numerosas producdones.

Ei Profesor Krauss ba dado a conocer la tunica sobre que reposa la a acuna, contra
la ''coquducfae" por d obtenida. Se trata de un procedimiento andlogo al dd
Profesor Vincent.

Ei esputo de un enienno atacado de toe convulsa, pre\ ia inve8tigad6n bacterio-
16gica referente al badlo de Eocb, es tratado por el 6ter sulftirico pure y agitado
durante laigo tiempo y emulsionado con una solud6n fisiol^ca clorurada. Td es la
tunica de la llamada impropiamente vacuna contra la coqueluche, siendo en realidad
un producto albdmino ter&pico obtenido por el m^todo de Vincent, el cual tiende a
generalizarse df a a df a para la obtenci6n de la vaou na antitifica. No es en vano esperar

PT7BU0 HEALTH AND MEDIGIKB. 117

que las alb^lminas especfficas del badllus de Eberth nos lleven a aceptar el criterio
ebaenado para la alb^hnino-tenpia.

£«ta aWimino-Eberih-iprofilaxui puede conducir a una nueva via de investigaddn
paia el tratamiento bacterioter&pico de la fiebre tifoidea.

Teniendo, pues, ana anna poderosa para combatir el deaarrollo de la infecci6n
Ebeithiana, la idea de una proHlaxia racional y dtil tiene que acudir a la mente de Ice
higienistas y las raaones expuestas sobie profilaxia eepedal de la fiebre tifoidea, debe
ante todo tener per base la \acunaci6n.

El flaneamiento del suelo, la protecci6n de orden hfdrico, la deeinfecci6n, etc.,
deben ser relegadas al s^gundo range, como auxillares o coadyuvantes de la \ acunaci6n
pre- enti% a.

Per lo tanto debemos difundir el valor de esta vacuna en todos los pafses de AmMca
donde la fiebre tifoidea es una preocupaci6n de la autoridad sanitaria; y llegar a la
Yacunaci6n ^Kniltati'. a u obligatoria segdn los casos, para defender a las colecti idades.
La vacunaci6n en las escuelas, en los cuarteles, c&ireles, establecimientos fabriJes y
boepitales, debe hacerse con el fin de llegar al domlnio del mal si es posiYle, o por lo
menos a los beneficiosos resultados que para las colectiv idades ha alcanzado la \ acuna-
ci6n anti ari6lica frente al a irus varioloso.

En ciertas profesiones la fiebre tifoidea hace mayor nthnero de vfctimas, debemos
tenerlo presente para conducir la lucha 16gica y racional contra el bacillus de Eberth a
buen tannine, aconsejando en esos cases, que los sujetos comprendidos dentro de ese
grupo de profesiones, deben ser inmunizadoe por medio de la ^ acunaci<Sn, contra la
fiebre dotienent^rica.

Finalizamos aconsejando la ensefianza de ciertas nociones de profilaxia entre las
eolecti idades, desde el punto de \ ista de la higiene social, con el fin, en nuestro case,
de difundir los deberes y derechos que tiene el indi iduo aisladamente y frente a la
colecti \idad ante la soluci6n del problema profilictico modemo de la fiebre tifoidea.

BBSUMBN.

En resumen llegamos a las conclusiones siguientes:

1. Declaramos que la vacunaci6n antitifica es un excelente recurso profilictico, para
pieA enir el desarroUo de la fiebre tifoidea.

2. Que la profilaxia de la fiebre tifoidea por medio de la vacunaci6n debe ser difun-
dida en todos los palses donde la infecci6n Eberthiana es una preocupaci6n de las
antoiidades sanitarias.

3. Que debe aconsejarse la inmunidad antitffica para ciertas profesiones.

4. Que la vacunaci6n, indirectamente, favorece el saneamiento del suelo.

5. Que deben esperarse resultados andlogos a los obtenidos por la vacunaci6n anti-
Tari6lica, por medio de la vacunaci6n antitffica.

6. Que serA con- eniente difundir entre la masa popular, nociones sobre los deberes
J derechos del indi iduo aislado y de la colectividad frente al problema profilictico
modemo de la fiebre tifoidea.

7. Que la vacunaci6n antitffica debe ser &M:ultativa u obligatoria segdn los cases.

LA BUBA (LEISHMANIOSIS AMERICANA^

Por LUIS E. MIGONE,
Pro/e$ar de la Faeultad de Medicina de Aiunci&n, Paraguay.

Desde hace tiempo se desarroUa en el norte del Paraguay, entre los obreros de los
grandes establecimientos industriales de esas regiones, que trabajan en la preparaci6n

> SicAn tl aotor bntUefio, AostregwUo, 1a palabra "baba" proTleiw de 1a •IiUmdm "boaba."

118 PBOOEEDINQS SECOND PAN AMERICAN SCIENTIFIC CONQBESS.

de la yerba-mate y entre loe obreros que labran maderafl, una enfennedad llamada
"buba," enfennedad ulcerosa, de car^ter cr6nico, de deeenvolvimiento lento, que
ataca las partes descubi^tas del cuerpo, pies, piernas, brazos, cuello y cara, y mis
tarde invade las mucosas nasales, forlngea, laringea, paladar y labios.

Muy a menudo eeta enfennedad detennina la imposibilidad, pasajera o completa,
para el trabajo.

Esta enfennedad ha penetrado, seguramente, en este pais per contaminaciones
sucedvas de los Estados braailefios limftrofes al Paraguay, donde existfa ya esta
enfennedad con el mismo nombre deede hace muchos aflos, segtin los autores braailefios
y europeos que de ella se ban ocupado. Hoy dla, estas llagas se deeenvuelven en estas
regiones de tal manera que, s^tin los enfennos que vienen de esos lugares, no hay casa
en la que no se encuentren uno o varios atacadoe del mal.

Hemos observado esta enfennedad en los nacionalee y en los extranjeros, en los
hombres y en las mujeres, en los viejos y en los nifLos de pecho.

La enfermedad se hace sentir tan teniblemente que a voces en ciertos lugares de
100 obreros que entian en loe bosquee para el trabajo, dos meses despu^ sal^i 70 u 80
enfermoB a la vez, con una o dos llagas, con 10 o 20, con 30 o 40 llagas repartidasenel
cuerpo. Esto obliga a suspender la empresa.

Varios insectos son acusados como inoculadores del virus: Ixodes, t4banos, mosquitos,
Bimulinidos, pero los mia son los primeros.

En el Paraguay, como en todos los pafses donde existe esta enfermedad, se considera
a la buba como id^ntica a la sifilis, pero una sifilis rebelde al tratamiento eq>eclfico:
de allf resulta que su estudio etiol6gico pennaneci<S abandonado; su tratamiento,
siempre mal dirigido, era infructuoso y el mal progresaba.

Los m^cos, que por primera vez examinan estos casoe, sin tener en el espfritu la
patologfa propia de estos pafses, pueden confundir con mucha frecuencia esta enferme-
dad con la sffilis, con el lupus, con la esporotiicosis, el cincer, etc., sobre todo si ella
se encuentra en un estado avanzado, atacando la mucosa de la nariz o del fondo de la
boca.

Hoy en d(a ya hay muchos trabajos pubUcados sobre esta enfermedad.

Ella parece ser descrita ya en el afio de 1759 por Sauvage y Charluis con los nombres
defranboesia tropical y papiloma tropicuTrif respectivamente.

Los doc tores J. Moreira y A. Austregesilo de Rfo y B. Sommer, de Buenos Aires, han
preeentado en el Congreso Latino Americano de 1904, que tuvo lugar en Buenos Aires,
trabajos muy importantes sobre esta enfermedad.^ El doctor L. Zanotti Gavazzoni,
de Asuncidn, ha publicado unas observaciones importantisimas en los anales de
nuestra Universidad sobre el mismo tema.' Se puede decir que sea ^1 el primero que
se ocup<S en este pais de la buba y de su diferencia con la sffilis.

En los primeros trabajos de Charluis y de Austregesilo se encuentra la historia de la
enfermedad en America y un notable cuadro diagn6stico de la buba.

Los trabajos del Profesor Aquile Breda, de Padua, los de Majochi, y BoselLini, de
BoloHa,' los de Fiocco y Verrotti ^ tambi^n nos son conocidos. En todos ellos se
eucuentra la bul a diferenciada de la sffilis.

Por otra parte, en todas las obras cUsioas de enfermedades tropicales y de derma-
tolofffa se encuentra la buba confundida o como id^ntica al pian o/ramhoesia o al
yawos^ 0 en confusi6n con tilceras de loe pafses tropicales. Hoy dk, gracias a loe
estudios modemos, se puede diferenciar estas enfermedades, antes confundidas, y
unificar los diferentes nombres que se han dado a la misma enfermedad en los diferen-
tes pafses.

i Segundo Congrao Latino Americano, 1904, Boanos Alrei, T. lU.

1 Lute Zanotti Cavauonl. Analei de la UnlTenidad del Paraguay, 1904.

• Soil 'Btlologia del Babas, Bolofia, 1900.

« Undeeima rlankme de la Societa Italiana di Dennatologia. Roma, 90 de abrtl de 1906*

PUBLIO HEALTH AND MHDIOINB. 119

En el Pang:i]ay, sele dael nambrede "buba" alaqueenel Bnsil se llama ''bouba;"
Etfntndia en Boli* ia y Perd y tUeera Torrealba en Colombia; yo cieo que la iUeera d$
Baurik de Fbianhofl, Leiihmaniion$ rino-bueo-foaingea de Splendore y Carini, etc.,
etc., son todas una misma enfennedad, con manifestacionea olceroeas del cutis y de
lai mucosas naBo-buco-faringea. Es una sola enfennedad produdda por una sola
espede de LeUkmania,

Escomel,^ de Arequipa, ha dado una buena descripci6n dfnica de la Etpundia del
Perd; Laveran y N. Lanier* han descrito la LeMmania, agente de la infeccidn, bajo
el nombre de Leishmania trdpiea^ yariedad ameiicana. Laveran ha propuesto el
nombie de LeUhmanium$ amerioana.

En el Paraguay hemos tenido la oportunidad de estudiar esta enfennedad en toda
■u evoluci6n. Hemos visto que en la primera fas (Jaz eutdMa) cuando las llagas se
encuentran en la superficie cut&nea de las extremidadee, sobre el cuello o cara, ellas
tienen mucha semejanza con el Bot&n de Biskia o de Alepo, con la dJUii, etc.

Generalmente la enfermedad comienza por uno o varios eritemas papuloses, muy
proriginosos, como si fuesen producidos por las picaduras de insectos, tan abundantes
en esas regiones. Dos o tres dlas despu^ se fonna sobre uno o varios de estos eritemas
un punto pustuloso, grueso como la cabeza de un alHler que no tarda en vaciarse.
Al vaciarse queda una pequefia cavidad profunda, de donde sale un Ifquido sero-
gomoso que al endurecerse forma una costrita negrusca.

En las regiones donde abundan estas llagas exists la creencia que ellas son produd-
das por picaduras de ganupaUu o ixodn* {amhlyommM).

En efecto casi todos enfermos que hemos examinado acusan a estas garrapaUu como
etigen de sus males.

Cuando el deatro ha logrado hacer penetrar su rostro en la piel, es diflcil desprenderlo
sin que esa parte no quede incrustada en la piel. Esta picadura causa un prurito
intense que obliga al enfermo a rasparse continuada y fuertemente con las ufias hasta
escOTiarse. Los obreros que conocen esta consecuenda, no arrancan violentamente
el 4earo, lo calientan ligeramente con un dgarro encendido hasta que de por s( se
desprenda; en este case la picas^n no es fuerte.

^ embargo he visto enfermos cuyas llagas iniciales est^n en la caia, en las orejas,
consecutivas a picadunw de mosquitos o t4banos {critopt) u otros insretos. Otias
▼eces he visto desarrollarse sobre picadunu o raigufios con espinas en las plantas de
loe pies. JanUui he visto desarrollarse sobre el cuero cabelludo, como si una solud6n
de continuidad de la piel fuesenecesaria para que el virus penetre y origins la Uaga o

Una ves la dlcera fcmnada, crece, se cubre de su costra negnuca espesa y dura, la
ptel drcunvedna se pone turgescente y un poco edematosa; de muy pruriginosa que
em al inidarse, ahora se pone o poco dolorosa, o dolorosa. Si se aprleta la costia, deja
vpKncen a loe lados un Ifquido 9er(hjiundenU> de olor f^tido.

Estas dlceras son orfgenes de linfangitis, verdaderos cordones duros, de color rojo,
subcutineo que a la preei6n deja aparecer sobre su extremidad en la dlcera un Ifquido
uro-pwuUnU). En el trayecto de esos cordones linf&ticos se notan unos n6duloM
bastante gruesos que se abren y foiman nuevas llagas.

Cuando se eleva la costra de una llaga, se ve un fondo rojo, camoso, botonado, que
saogra con la mayor ^Mdlidad; el borde est4 cortado a pique y no hay descolamiento.
Este borde tiene todos los caiacteres de una herida at6nica: maigen Ifvido, hipertro-

> BnlltUn dt Pftthologto BzoUqne, T. IV-JaUo 1911.

SBonttlndtPiUbolocieSzoUqMT. V-1913.

* 81 rrolwor Nwmuam, de Ie Bacoela de V<twlD>ria de Toloaa, haolMlfkisdo lew isoin into tnwlimnadoi
fM MB los AmUl9^mmm$ fXtUMk Bmeajd o ftliM eerbaU m AvMifomma KmMMii Keeh (ivfcM teespi
Isfv) Amti^ommt fo$$mm Ntumtnn (gMteb^ pptaml o piUM) poropi en ninfat de AnM^ommM^^^'
mtntt,} Nueetns forrspeiM de montes ofreoen edn variedadee dwoonoeWM tegdn el Profeaor Nottall
de 1* UnlTenldad de Cambridge.

120 PBOCEEDINOS SECOND PAN AMEBIGAN SCIENTIFIO C0NGBB8B.

fiado, un poco dirigido hacia fuera. Estas dlceras al cabo de aiete u ocho meoes,
cuian espont&neamente, sea en su totalidad o en parte. Las llagas qne se cuian dejan
una cicatriz indeleble, de boide m^ o menos estrellado o iiregular, de centre apeiga-
minado, acr6mico, trasliicido, dejando ver las pequefias arterlolas neo-fonnadas.
Esta cicatriz es caracteriiBtica.

Los ganglios linf&ticos regionales son dolorosos al principiOi despu^ el dolor desapa-
rece; ellos no toman nunca su tamafio natural.

Oomo sfntomas genendes, es notado una fiebre veepenl, dolores articulases, cefa-
lalgia, curvadura pero en el perfodo de infecci6n cut^ea.

Las tilceras que quedan se desenvuelven lentamente, algunas se elevan sobre el
nivel de la piel, se hacen papuloeas, o camosas y hdmedas, dejando correr un Ifquido
seroso sin tener tiempo de fimnarse la costia: ^sta es la huba karddeea hUmsda; o bien
la llaga se hace seca, se cubre de costra y se llama a ^sta la bvba $eea.

Hay dlceras del tamafio de una moneda de 20 centavos, otzas son m^ grandes y
otras son tan grandes que cubre todo el dorso del pi6 o toda la parte anterior y posterior
de la piema o del brazo o antebrazo. Al cabo de dos o tares meees, o m^ tarde, que
las llagas descritas sean o no dcatrizadas, empiesa su manifeetaci6n sobre las mucosas
nasalee o laringeas, esta es la faz segunda que comienza: la/at muoomi.

Cuando la llaga inicial eet& en la cara, entonces la mucosa nasal sufre muy pronto.
Hay casos tan de^graciados que dos o tares meees de curarse unas Insignificantes llagas
ya que est6 o no completamente cicataizada la piel, ya empiezan en las mucosas nasales
las ulceraciones.

£1 enfermo experimenta una dificultad en la respiracidn nasal, la pronunciaddn se
hace nasal, un catarro sero-pwrulerUo, miB o menos tefiido en sangre, aparece. Si se
examina la mucosa, se la ve infiltrada, roja, cubiwta en parte de una costra amarilloita
sobre el septum nasal.

Sobre uno de eetos puntos se prohindiza la leaidn y perfora con frecuenda el septum
pero sin epistaxis.

La infiltracidn progresa, el enfermo no tarda en sentir una aspereza y sequedad
de la garganta o del velo del paladar. Poco a poco se espesan y se ponen granulosas
estas mucosas; se espesan los pilares, las amigdalas, la campanilla. £1 enfermo sufre
un poco al tragar los alimentos secos. M^ tarde el enfermo toee y la voz se hace nmca:
la laringe se infiltra, las cuerdas vocales se cubren tambi^n de granulaciones.

Cuando se observa un caso ya un poco avanzado se ve una infiltraci6n general de la
mucosa del fondo de la gaiganta con neoformaciones granulomatosas caracterfsticas.

Del septum nasal destruido, el cuerpo mismo de la nariz es atacado, ella se hace roj%
espesa, aumentada de volumen y edematosa. £1 labio superior prdzimo a ella,
tambi^ sufre la miama infiltracidn, los pelos caen, los ptoulos se infiltran y se pone«
tuigescentes. La ulc^aci6n invade de la mucosa nasal, la piel de los hordes de las
narices, de los ptoulos y labios. La piel destruida es reemplaiada per una gra-
nulaci6n ya seca o ya hdmeda que de el aq;>ecto de un verdadero lupus ulceroso y
con el cual muy a menudo se confunde.

A medida que la ulceraci6n se extiende en el exterior, en el interior las mucosas
tambi^n se espesan, se hacen granulosas a tal extreme que el velo del paladar, la
<ivula, los pilares, las amigdalas forman una masa comtbd enrojedda, granulosa,
sangrando con la mayor facilidad. £1 itmo de las fouces se encuentra aaf reduddo,
estrecho; la faringe y laringe sufren lo mismo.

El enfermo, en esta drcunstancia es ifono y se nutre dificilmente, m4xime cuando
todos los dientes estan atacados de una infiltraci6n periiSstica o de una alveolitis
secundaria.

Jam^ he visto, aun en los casos muy avansados, lesiones sobre la lengua y lesiones
oseas verdaderas.

Como f^kdlmente se comprender&, un medico que no haya observado enf ermos de
esta naturaleza, conftmdird ttdlmente con la if/liiff, el luptu, el otfnoer, etc.

PUBUC HEALTH AND MEDICINE. 121

Esta segunda faz del mal podrd formar un capftulo especial de rinolaringologia,

Cuando el enfermo lleva este mal durante 10, 15 o 20 afios, se ve que la infiltraci6n
progresahastallegaraloBgrueeos bronquios, provocando fiebre, hectiquez, denutricl6n
o coiisunci6n hasta la muerte.

Jam^ hemofl observado lesiones de los 6igano6 digeetivos, o lesbnee deeas pfodu-
ddas como continuaci6ii del mal.

Aflf mueren los bubdticoe que no ban tenido la precauci6n o la oportunidad de
hacer curar su llaga inidal.

Todoe los enfermos avanzadoe, con ledonee en la mucosa naso-bringea, precisa-
mente moetiar&n la dcatriz de una llaga inicial que data de 2 o 3 afios ati&B.

Etiologia, — ^En el curao de esta exposiddn, nosotros bemos dicbo, segtin afiimacidn
de los enfermos, ser un ixoda el que inocula el virus. Pero bemos tenido la oportu-
nidad de atender otros enllagados cuyas llagas no provienen de picaduras de insectos
pero que sf se ban desarrollado sobre una pequefia excoriaddn de la piel, becba con
la ufia o con las espinas en esas regiones, como si el virus espeiara una soluci6n de
continuidad de la piel paia penetrar y desarroUar el mal.

Examinando el pus que sale al lado de las costras las mis nuevas, y coloreando
con el Azul de Marino o con la 8oluci6n Giemsa, es muy ttcil comprobar la presencia
de numeroeoe eorpHMCuloB de IMhmann. Las gruesas cilulas epiteliodes ton las que
contienen mis.

Este parisito se parece mucfao al oorpiiKulo del Botdn de Biebra o de Alepo, expli-
cindose asf la identidad attibuida por Ulysse Paranhos entre el bot&n de Biskra y
^Ueera de Batard estudiada por Hj^ la cual seria un caso de buba en su primera b» de
desarrollo.

En los casos avansados es dificil comprobar la presencia de Leiihmannia^ pero se lo
«ncuentra siempre. En el caso de C. A. de 14 afios, con aspiiar con la jeringa un poco
de linfo del tejido gianuloeo, se pudo encontrar iicilmente.

Asf se ha llegado a encontrar los mismos corpdsculos, encontrados por Paranhos,
Carini y Splendore, etc., en los casos semejantes a los mfos.

Lo que yo no he podido conseguir es lainoculacidn en los animales. Lahe ensayado
sobre perro, gato, nuestro mono {Sebus lividinoBta^ sin obtener ningiina lesion impor-
tante.

He examinado lesbnes cutineas de los penos de casa de los obreros que trabajan
en las regiones infectadas sin encontrar Leiekmannia. Tampoco nada he encontrado
enlasangre.

Digno tambi^ de notaise es que el bubitico no preeenta Leuhmannia en su sangre.

He pretendido ensayar las culturas de los medios de Novy y MacNeal y en sangre
citratada pero sin obtener 6xito. Esto seri por ^ta de una buena ttoiica.

Blitoiogia patoldgica. — La biopda practicada de algunos tumores en su primer
estado de desarroUo y en su completo desanollo, ofrece algunos caracteres en el tejido
sabcutineo y en el cutis propiamente dicho. Si se compara un poco de piel sana
al lado de una plena llaga, se ve que el dermis es edematoeo; las papilas de Malpi^
€0tin como aplastadas algunas o prolongadaa otzas pero separadas de entre sf, a causa
del edema

Las papilas a medida que se van acercando a la parte del dermis infiltrado, se ven
extenderse en profundidad, hasta que ll^gan al pleno irea infiltrado en que ellas
•e deshacen. La fluxi6n inflamatoria esti caracterizada por el cdmulo de c^ulas de
pequefia dimension, linfositos y por c^ulas polinudeadas que se efectda en la extremi-
dad de una papila de Malpighi como si alll estuviera el virus quimiotixico.

Poco a poco la infiltraci6n celular se hace espesa, eUa forma un verdadero n6dulo
inflamatorio, las papilas desaparecen observindose restos epitdiales entre las c^ulas
invasoras. Lo mismo pasa con la c^lula de las glindulas sudoriparas y cebiceas. Una

ildeatldsd dtlaitflMrsttfc BuMHtf Boidn d€ AUpo o 4€ BUkn por Ulysse Paranhos. Instltnto Pas-
tMTde San Pablo, IMO.

122 PBOGEEDINOS SECOND PAN AMERICAN SCIENTIFIC CONQBESS.

ves destniida la capa basal de la epidermiB, ella no tarda en destruirse por complete
7 la dlcera se fonna. Los vasos capilares lin^ticos se hincban, dlstingui^dose bien
las c^lulas endotelialee y algunas con par&sitos.

No hemoB notado la formaci6n de ovinias gigantes' en las lesbnesbubiticas, aun
en loe casos muy antiguos.

Los m^todos empleados para la coloraci6n y fijad6n son: Soluci6n Giemsa y Schau-
dinn, sirvi^ndonos del xilol acetona en diveraas proporciones paia decolorar.

Para el diagn^Ico <}e Leishmannia se necesita raspar un poco los "granulomas,"
o tomar los Uquidos que salen por los bordes de la costra o bien aspirar con una jeringa
y colocarlo despties con Giemsa.

Resumen del tratamientc—CuBudo el mal estd en su origen el tratamiento es fdcil:
catistico, termocauterio y un poco de yoduro de potasio y de ars^co por boca, son
sufidentes.

Cuando el case es avanzado, es diffcil de sanar. Las cauterizadones igneas y el 606
dan bastante buen resultado, pero es necesario aplicarlo tres o cuatro veces consecu-
tivas.

Cuando el mal ba penetrado en la mucosa bucal o nasal, es muy tenaz. El mal se
modifica notablemente con la hectlna con el 606 o con el orsudan o la soamina, pero
la curad6n se hace lentamente y ayudado con los catisticos locales. Las granula-
ciones de las mucosas oirecen poca resistencia al termocauterio como si fuesen de
manteca.

Los trabajos redentes de Caspar Viana ' nos ban llamado la atend6n y podemos
asegurar que el em^tico produce efectivamente, ei) inyecdones intravenosas y en la
proporcidn al 1 por dento, muy buen resultado. Solo que la sal es muy iiritante en
case de tratarse de em^tico no muy puro.

Conviene hacer notar que todavfa despu^ de tres o cuatro aplicadones del 606, atbi
se encuentran los par^itos, y a veces hasta despu^ de tres meses de tratamiento por
medio de la soamina, como si estas sustandas arseniales no tuviesen acd6n alguna
sobre estos protozoarios especfficos.

La Leigkmaniosis Ameritana existe en el Paraguay, probablemente introducida por
contaminaciones sucesivas de los fistados limftrofes brasilefioa. Ataca a la especie
bumana sin distinci6n de edad ni de sexo. Esta enfermedad es producida por una
Leiskmaniay la Leiskmania trdpiea.

Los medicos que no conocen esta enfermedad, la pueden confundir con el lupu$,
can la lepra, con el cdncer o con la sifilis,

Los patologistas americanos o europeos que de ella se ban ocupado le ban dado
diferentes nombrea, o bien la ban confundido con otras enfermedades tropicales,
cuyos agentes pat^genos son distintos.

En los pafoes americanos tambidn recibe nombre distinto. Asf en el Paraguay y
en la Argentina la llamamos Bxiba; en el Brasil, Buoba; en el Perd, Espundia o Uta;
en Colombia, iflcera de Torreaiha, etc. Es necesario pues una deBignaci6n cientlfica
y t&nica de esta enfermedad en los diferentes pafc^ en donde ella existe.

La enfermedad se manifiesta por una o por mdltiples llagas cut&neas en su primer
perfodo, y por tilceras de' las mucosas nasales, feiingea y palatina en su segundo
periodo. Las tilceras pueden ser secas o bdmedas. Son por lo general redondas y
de bordes cortados a bisel. Aparecen de preferencia en la partes descubiertas del
cuerpo, brazes, piemas y cara. Las manifestaciones mucosas, o sea las del segundo
perfodo, pueden faltar si la cura de las llagas iniciales ba side rdpida u oportuna.

Esta enfermedad no es aguda sine eminentemente cr6nica.

1 FrtDobliildallBftUiitoPMtmirqMtnlM^flntllaborfttoriodeLftTt^
oon Mta indloaoI6ii noestia. 6l en tmoaso de t^leen buba M Br*$Uf eocontndo flo Roma, podoeompiro-
bar la prflsaoda de oflolas gigantet, elementos no eocontrados por nosotros. No habii habldo elementot
baoUar«8 en aqofiUa manUvtaoidn flstodiada por ^r La baba no ezoloye al lop». "BoUeUn de Patho-
logle Exotlqae, mano, 191S."

* Arohl. brafUero de medhina, alio U, ntUnerol .

PUBLIC HEALTH AKD MEDIODirE. 128

8u anatomfa patol^ca es dlstinta de la de la sffilis, del lupus y del epitelioma.
Su ageute pat^geno ee ya bien conocido y merece pues que sea una enfennedad
distinta.

En cuanto a su manera de infecci6n hay mucho que estudiar. Lo m^ verosfmil
es que algiin insecto la facilite, aunque a vecee basta una 8oluci6n de continuidad
superficial para que se desarrolle.

El tratamiento preventivo es atin nulo; el curative se reduce a los c&usticos, anti-
86pticos o estirpaddn de la dlcera Inicial una vez bien diagnosticada. £1 606 da
bastantes resultados favorables, pero ayudado siempre con los antis^pticos extemos,
para combatir la infecci6n mixta. El em^tico tambidn da buenos resultados.

The Chaibkan. The following pap>er8 will be presented before this
session of Section VIII as read by title:

Nota sobre a extinc^fto completa da febre amarella no estado de
S. Paulo (Brasil), by Dr. Emilio Ribas.

La fidvre typholde en Bolivie, by Dr. Nestor Morales V.

NOTA SOBRE A EXTINCgAO COMPLETA DA FEBRE AMARELLA NO
ESTADO DE S. PAULO (BRASIL).

Per EMILIO RIBAS.

S. Paulo come^ou a combater com successo esta molestia antes mesmo que os
estudos realixados em Cuba indicassem a applica^fto das medidas espedficas pan sua
extinc^.

E isto verificou-se, porque nfto se conhecendo os meios scientificos para combatel-a,
todas as annas foram empregadas e, entre as medidas de excellente efficacia
prophylactica, destacou-se a remo^fto das aguas estagnadas, providencia indispensavel
e de exito seguro na guerra de exterminio do unico agente provado na transmiss&o da
febre amarella. Este resultado foi de mode evidente notado em Campinas e no
importante porto de Santos, cidadee flagelladas intensamente por esta molestia
durante longos annos.

Deede que foram conhecidas, porem, as experienclas da commisrik) norte-ameiicana,
cbefiada pelo Dr. Walter Reed, e depois de repetidas em S. Paulo com o fim de
arredar objecyGes menos justas contra as conclusdes tiradas em Havana, o combate &
febre amarella foi entfto firmemente dirigido e com exito seguro em todos os f6cos da
molestia.

Embora convencido dos resultados brilhantes das experienclas da commissfto
americana, nfto s6 pelos detalhados relatorios recebidos, como por cartas e tel^grammas
que me foram dirigidos pelos Drs. Carlos Finlay e James Carroll, pedi ao Govemo de
8. Paulo a repeti^fto dos estudos sobre a transmissfto da molestia, porque surgiram no
nosso paiz ob jec^Oes que pareciam fundadas, por parte de profissionaes honestos e com-
petentes, alguns at^ professores das nossas faculdades de medicina, que, partindo
do facto de ser Havana um f6co intense e secular da molestia, admittiam a hypothese
de ter side a febre amarella propagada por outro mechanismo que nfto o mosquito nos
casos dos estudos experimentaes.

As experienclas sobre a propaga^fto da febre amarella, realizadas no Hoq[>ital de
laolamento de 8. Paolo, e as piovas epidemiologicas obtidas em diversos f6co6 deste
morbus muito impressionaiam e concorreram para a acceita^fto immediata da pro-
phylaxia especlfica no Brasil. Foram seis as pessoas que expcmtaneamente se deixa-
imm picar p^os moequitos que haviam sugado sangue de doeotes graves de typlio
icteroide antes do quarto dia de moleetia.

124 PBOOEEDINGS SBOOKD PAN AlCEBICAN 8CIENTIFIG OONaBESS.

O resultado foi o mais convincente pofldvel: tres pacientes que, com grande fre-
quencia, permaneciam nos f6cos intensos da doenga, n9o apresentaram symptoma
algum do mal de Si&o e oe outaros tree, residentes em localidades immunes, revelaram
evidentemente o quadro clinico do vomito preto.

No primeiro grapo noe achavamos o muito conhecido e estimado scientiBta Dr.
Adolpho Lutz, o Sr. Oocar Moraiia e eu.

Fasdam parte do segundo gnipo os Srs. Andr6 Ramoe, Domingos Pereira Vas e Ja-
nuario Fiori, que foi um caao clinico muito claro, como se veiifica no seguinte diagram-
ma, que moetra alguns detalhes interessantes Bobre propaga^fto do morbus.

PXIBUO HKALTH AKD MBDICIITE.

125

ANtMS

*»

!»•

«e

•*

OBITOS

5
^1

■

5*^

<•

2400

2200 ■

1000 H

1600

tioo HI

—

1400 HI

t200 HB—

^B^B Hi HI

1000 HI—

$00

ioo

400

—

HRtm'

iliil~"

IH'hI

—

h—

200

Hh*! B HiIiH

■

.. 1

Li.

>- «

4|orudidade pela fetyre amanUa em u>do o Ettado d« 8. Paolo (180»-1914).

AMnos

■•

«4

T«^

•2

MtTOi

o*b

—

MO^

■

too 1
#»o 1

ioff B

■

MiMOf

"•

!i:==l

oirros

o o

■

pete febre amarella em Sorooabe (1900- Mortalidade pela febre amarella em Rfbelrio
Wii). Preto (1908-1914).

126 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

Como Be sabe o typho americano, oiiginario do Novo Mundo, teve oe seus principaes
f6co8, desde de epocamui remota, no golpho do Mexico, nas Andlhas e na America Cen-
tral, irradiando-se deetes pontoe, geographicamente estrategicos, para flagellar oe outros
paizes das duas Americas. Em consequencia das enormes devasta^des deete flagello,
contam oe historiadores que na terceira expedi9&o de Colombo, i qual nSLo adheriram
OS homens livres, pelo terror que inspirava a despovoadora peete, teve o govemo
hespanhol necessidade, para o fim de fundar as primeiras colonias, de lanyar mSuo dos
condemnados, promettendo-lbee a libeidade.

Este facto e muitos outros, poeteriormente conhecidoe, demonstraram claramente
que a febre amarella foi, atravez dos seculos, o maior estorvo ao progresso das
naydes americanas.

0 nosso Brasil victiraado por diversas vezes em remotes tempos, foi ultimamente
flagellado durante nais de meio seculo.

Agora, grayas, porem, & prophylaxia espedfica, a sua transformaySU) sanitaria foi
completa, vencemos o inimigo capital do nosso progresso. A nota que apresento,
al^ de documentar os resultados obtidos com a exclusiva applicaySo das medidas
para o exterminio do unico agente provado da transmiasfio do mal — a Stegomyia
/(uciaia — 6 tambem uma justa homenagem aos sclentistas norte-americanos que, com
o seu saber, direotamente concorreram para a soluySo do humanitario problema.
De facto, nada 6 mais significativo para provar que os ensinamentos de Havana
tiveram decisiva influencia nas campanhas contra a febre amarella em S. Paulo, do
que 00 dlagrammas s^:uintes:

Estes diagrammas demonstram claramente que ha 11 annos completes cessaram em
todo o territorio do Estado de S. Paulo as aasoladoras explosOee do typho ictoxnde,
gramas i guerra de exterminio aos mosquitos.

Em Sorocaba, depois de uma enorme epidemia definida por 2.322 doentee e 877
obitos, nem um s6 case de febre amarella se verificou no decorrer dos 14 annos
seguintes.

Nesta cidade foi obtida nitidamente a prova epidemiologica, antes de se conhecerem
detalhadamente em nosso meio os brilhantes resultados a que chegou em primeiro
logar o General Wood, govemador da ilha de Cuba e medico do exercito americano,
que empregou para o saneamento daquella ilha os mesmos preceitos postos em acySU) em
Sorocaba e finalmente o mesmo resultado favoravel foi alcanyado em Ribeirdo Preto,
onde a observaySU) epidemiologica 6 por certo muito interessante, pela circumstanda
de nSo se terem feito ahi desinfecydes ou obras de saneam^ito.

LA FlfiVRE TYPHOlDE EN BOUVIE.

Par NfiSTOR MORALES VILLAZON,
DirecUur de VlmtUut National de BacUriologie, ex-Doyen de la FacuUi de Midedne de

La Paz, Bolivie. •

LA VAOUNOTH^RAPIB DS LA FitVBS TTPHOIDB EN BOLIVIB.

Parmi toutes les entity morbidee connues en Bolivie, la fi^vre typholde a toujours
^t^ une de cellee qui out fait le plus de victimes dans toutes les classes de la 8od6t^.

Cette maladie existe k I'^tat end^mique dans preeque toutes les villes populeuses,
at tout particuli^rement k Cochabamba, Sucre et La Paz.

La forme end^mique est ordinairement bdnigne, et sa courte Evolution se termine par
la gudrison. U n'en est pas ainsi des cas 6pid^miquee qui, d'habitude, fauchent des
villages entiers et laissent des zones immenses de territoire sans bras pour les cultiver.

Les 6pid6miea apparaissent rarement dans les villes ou dans les villages considto-
blee; elles attaquent de iMr6f6rence les cantonnements des indiens et y produlsent,

PX7BU0 HEALTH AND MEDICINB. 127

quand olles s'y sont enracin^, jusqu'^ 90 pour cent dee d^te. Pour bien com-
prendre ces effets teiribles de la fi^vre typholde, il eet n^cessaire d'avoir presentee 4
Pesprit lea drconstancee qui d^terminent la vie de Tindien, soit dans la plaine, soit
dana lea hauteurs dee Andes.

Sa maison, a neuf metres carr^ au maximum; les murs et le toit sont faits de terre
m^langte avec de la paille; Tentr^, tr^ ^troite, n'a qu'un m^tre cinquante de haul,
sur 50 il 60 centimetres de laige. Ge n'est que par cette petite ouverture, close la
nuit par un grosder tissu de laine ou par quelque porte rudimentaire, que Tair pent
pto^trer 4 Tintdrieur. C'est dans ce mis^ble r^uit que vit toute la famille, qui
compte tr^ souvent de huit k dix personnes, sans compter qu'avec les maitres du
logis vivent les animaux domestiques, tels que poules, canards, dindons, cochons
d'Inde, etc.

Les agglomerations comportent un nombie variable de ces pauvres chaumi^res,
extr^mement froides en hiver; il y en a des groupes de huit, de cinquante, cent et
quelquefois davantage, abritdes contre la violence du vent, au pied d'un monticule, et
prte de quelque courant d'eau.

L 'alimentation de Tindien qui vit dans la plaine est tout k ^t diffdrente de celle
de rindien qui habite dans les regions froides. L'indien de la plaine se nourrit
surtout avec le ma!s cuit ou en forme de soupe; il ne mange presque jamais de viande;
quelques pommes de terre cuites et quelques legumes font son bonheur; il faut ajouter
la feuille de coca qu'il a dans la bouche du matin au soir; cette coca et le maXs griU6
fonnenty dans les 6poques peu productives, son unique alimentation.

La boisBon ordinaire de Tindien est I'eau, que tons les habitants puisent k la m6me
source. Lee jours de f^te ou de r^jouiBsaaces publiques, tons boivent la "chicha,"
qui s'^bore de la fayon suivante: Lee femmes moulent le maXs et ferment avec la
fiurine de petites boules qu'elles introduisent dans leur bouche; elles les mastiquent
avec ardeur, p^n^trent de leur salive cette farine et Texposent ensuite au soleil. Cette
substance, que les indiens appellent **mucku, " est r^l^ment principal de la chicha
(tchictcha). On melange le mucku avec une quantity plus ou moins grande d'eau que
Ton fait bouiUir, puis on la met fermenter dans de grands vases de terre qui peuvent
contenir jusqu'^ cent litres et quelquefois davantage. On a soin de boire cette
preparation aussitdt que la fermentation tumultueuse a cess6; sans cette precaution
la chicha se convertirait bientdt en vinaiere.

L'examen microscopique montre que le ferment de la '* chicha" est un saccharo-
myces tr^ ressemblant k celui du vin.

Avec une augmentation de 800 diam^tres on pent distinguer des cellules ovales et
arrondies, les unes plus grandes que les autres. On y voit aussi des cellules qui se
divisent directement par "mamelonnement."

Au contact de I'hematoxyline, le corps protoplasmique se colore et laiase aperce-
voir des granulations di verses et aussi de petites vacuoles qui ne se colorent pas.

Si Ton mdle ce saccharomyces avec du mo(it de vin, la fermentation est visible
»pr^ 24 heures et se manifesto par la production de grosses bulles de gaz. A la
snperficie du mo(it, le ferment depose une pellicule de couleur blanch4tre. II eet
remarquable que dans ce milieu, en plus des cellules que nous avons d6}k signaiees,
il se forme de longs filaments semblables aux elements cellulaires que nous avons
decrits plus haut.

En resume, le ferment de la chicha n'est qu'une variete du microderme du vin.

L'indien du haut plateau se nourrit de mala moulu et de '*chufio" (tchugno). Le
chufio est la pomme de terre que Ton a soumiae k Taction combinee du froid de la
Gcmiill^ et du deae^hement ; operation qui a pour effet de la reduire d'un cinquieme
ou d'un aixitoe de aon volume primitif et de lui donner la propriete de ae conaerver
indefiniment. Get indien ne mange preaque jamaia de legumea, maia il conaomme la
coca en plus grande quantite generalement que Tindien de la plaine.

Ge n'eat qu'exceptionnellement qu'U mange de la viande fratche; il uae de viande
deaaechee de brebia, connue ici, aoua le nom de chalona (tchalona).

128 PBOGEEDINGS SECOND PAN AMEBIOAN 80IENTIFIC 00NGBE88.

Sa boiflBon est ^galement I'eau; il ne boit I'alcool que dans les grandee f^tee, en
lui ajoutant deux ou trois parties d'eau; dans cee occasions il en absorbe une grande
quantity.

Je fais noter ce fait afin de faire mieux comprendre le poorquoi de la mortality
excessive de cette race causae par la fi^vre typholde, ainsi que les grandes difficult^
qui s'oppoeent k son traltement efficace. De tr^ nombreux et tr^ distingu^ m^e-
cins boliviens attribuent unanimement k la doth^ent^rie de la race indigene, des
caract^res sp^ciaux, qui en font un type particulier.

Un m6decin tr^ competent et qui a fait ses Etudes en Europe, le Dr. Hermog^e
Sejas, fut chaig6 de combattre la fi^vre typholde dans la province d'Arque et publie
les remarques suivantes sur les caract^res de cette fi^vre:

''II y a deux causes pour lesquelles la fi^vre typholde qui attaque les indiens du
haut plateau soit tr^ maligne et d'une gu^rison difficile:

''1. L'extraordinaire malpropret^ dans laquelle ils vivent. Jamais ils ne se bai-
gnent ni ne se lavent la bouche; jamais ils ne nettoient leurs habitations qui ne sont
que de misdrables huttes de 3 metres de haut, avec une seule porte d'un m^tre de
pur n'a huttes pleines de fum^e oh n*a jamais p^n^tr^ la lumi^ du soleil, oil Pair
hauteur; jamais circuit. Dans ces trous obscurs et ^troits, au milieu d'un amas inde-
scriptible, les indiens pr^parent leurs repas, mangent et dorment; ils s'y entassent au
nombre de cinq, six ou davantage, hommes, femmes et enfants, sains et malades
fi^vreux k cdt^ les ims des autres, m&chant la coca nuit et jour.

'' 2. L'indiff^ence, T^tat de l^thargie dans lequel est plough Tindien I'emp^hent
d'observer les precautions hygi6niques les plus ^l^mentaires ou de prendre les remMes
les plus salutaires. Si on lui recommande, par exemple, durant une forte maladie,
de laisser sa coca ou de ne prendre aucun aliment solide qui augmentera sa fi^vre,
11 feint ne paa comprendre et il mange le chufLo et les pommes de terre comma
d'habitude. A cause de ces imprudences, la fi^vre augmente tr^ rapidement et
la mort s'ensuit g^ndralement vers le huiti^me jour, c'est-^-dire dans la premie
p^riode, quand, au contraire, dans les villes, la fi^vre typholde n'atteint ses victimee
qu'apr^ quinze ou vingt jours, c'estr^^iire entre le premier et second sept^naire.

*' II faut encore ajouter k ces causes la terrible coutume qu'a Tindien de boire
Talcool pur, ce qui le predispose k cette maladie.

" J'ai remarque que cette rapidity des progr^ de la fi^vre est due k la coutume
fatale qu*a Tindien, de ne jamais observer de di^te pendant sa maladie; il continue k
mastiquer des substances solides et aussi la coca. La mort survient, comme je Tai
d6j^ dit, presque II la fin du premier sept^naire.''

La consciencieuse observation du docteiur Sejas montre Textraordinaire malignit6
de la fi^vre dans la race indienne; il est facile de comprendre par la description faite
plus haut, combien est difficile Tassistance k des malades qui se trouvent k de
grandes distances des centres peupl^e, manquent de m6decin, de remMes et desquels
U est impossible d'obtenir aucun changement ou modification du cours de leur vie
ordinaire, et qui n'acceptent pas les meeures ordonn^es par Thygi^e.

BA8B DB LA VAOGENATION ANTniPHIQUB.

Nous connaisBons que les vaccina produisent Timmunite, en determinant la forma-
tion dans I'oiganisme animal, d 'elements de defense connus sous le nom general de
"anticorps."

Les essais preiiminaires de vaccination remontent k une epoque tr^ lointaine, et
Ton pent dire que ses premiers principes furent etablis en 1798, d'apr^ les etudes
faites par Tillustre investigateur Jenner.

Plus tard, en 1881, le Professeur Pasteur fit entrevoir par ses deiicats travaux sur le
bacille antracis, les avantages que la therapeutique pent obtenir des vaccines micro-
bicnuoa. En co qui concpme particuli^rement la vaccination antitiphique, c'est le
Profoasour rhantcinnss'' qtii, on 18S7, o'^n\'a 1p premier de don ner rimmunlte aux

PUBUO HBALTH AND HEDIOIKB. 129

•nimaox de laboratoire contre rinfection Eberthienne, grftce 4 rinjection sous
eotan^ de produits Bt^rilis^ par la chaleur. PuIb les travaux de Widal, Kliockwicz,
Snarelli, Bruchettmi, qui firent au«i dee eends sur lee animaux pour 6tudier Taction
preventive dee vaccinee bacillairee, firent soup^onner Tavenir r^eerv^ k la vacuno-
th^rapie.

En 1896, Pfeifler et KoUe en AUemagne, et Wright en Angleterre, appliqu^rent
cee m6thodee prophylactiquee k Teepee humaine. Quelque tempe apr^, en 1899^
GhantemeBse vaccina tout le personnel de son service d'hdpitaux, employant des
cultures chau£F^ 4 100^.

Les r^niltats de la vaccination antitiphique, sent aujourd'hui pariaitement v^rifi^,
et il nous suffira de dire que pendant la guerre du Tnmsvaal, dans I'lnde et pendant
la guerre contre les Herreros, la vaccine pr^eerva compl^tement lee soldats qui y
furentsoumis, tandis que lee non-vacdn^ avaient une morfoit^ plus ou moins 61ev^
et une mortality qui n'^tait pas k designer.

Poet^eurement on put observer un fait semblable, pendant les ^pid^mies d'Avignon
O'uin et ao(it 1912), de Paimpol et de Puy-PEv^ue (octobre et novembre 1912) dans
lesquellee la vaccine eut une double action: limiter I'^pid^mie et garantir toutes les
personnes susceptibles de contagion.

On commen^a la vaccination dans la flotte de guerre fran^aise en 1912 et les r^sultats
furent parfaitement appr^iables. Sur 67.947 personnes nonvaccinto, dans le terme
de sept mois, on put observer 549 cas de fidvre typholde et 118 d'embairas gastriques-
f^rilee; tandis qu'en ^galit^ de circonstances et conditions, 3.650 personnes vac-
cin6ee, biisant vie commune avec les pr^^entes, ne pr6sent^nt pas un seul cas
de fi^vre typholde.

Le Profeeseiur Vincent, qui, avec Ghantemesse, fut le grand propagandiste de la
vaccination antityphique en France, rendant compte devant le Congr^ International
de M6decine de LondriBB de Tann^ demi^, de ses investigations, fait remarquer lee
brillants r^eultats obtenus dans Tarm^e fran^ise du Maroc, Alg^rie et Tunisie, lieux
oh la dothi^nent^e qui atteignait jusqu'4 168,48 cas, avec une mortality de 21,13 pour
cent, deecendit rapidement k une proportion pas plus grande que 0,18 cas et 0,09 pour
mille de d6c^.

VAOGINS BHFLOTAs CONTRB LA SI^VBE TTPHOIDE.

On pent les grouper en quatre vari^t^:

1. Ceux qui contiennent des bacilles vivants, chaufif^ ou non. A ce groupe appar-
tiennent les vaccina employ^ par Castellani, Nicolle, Connor et Gonsey.

2. Ceux qui contiennent des bact^ries mortes; ceux eont les plus nombreux et les
plus connuB. Nous pensions le vaccin Wright, qui est compost de bacilles peu
virulents de 10 k 12 jours, st^rills^ k 60^ et m^lang^ k une petite quantity d'une
substance antiseptique; le vaccin Leishman, qui difif^re de Pant^eur uniquement par
sa culture qui dure seulement 48 heures, et la sterilisation qui se fait k 53^; le vaccin
Bassange-Mayer; cultures tr^ virulentes sterilis^es k 90^; le vaccin Wasserman-
Kitassato; cultures sur g^ieose, sterilisees k 90^ evapor^es au dixi^me, pr6cipitees par
I'alcool; le vaccin Snarelli; cultures en g^ieose de cinq k six jours, sterilis^es k 120^;
le vaccin Shiga; cultures sur gei^ose, sterilis^ee k 60^; le vaccin Pfeiffer-KoUe; cultures
sur g^ieose chauff^es k 60° et m^lang^es avec trols pour cent d'adde ph^nique;
le vaccin Fierbert-Moreschi; cultures sur g^ieose, sterilisees k 120°; le vaccin Chante-
messe; cultures sur g^ieose sterilisees k 56°, emulsionnees dansde I'eau physiologique;
le vaccin Ferr£n. En ce qui conceme ce vaccin, je dois falre remarquer que le
c^l^bre bacteriologue barcelonais, docteur Jaime Ferrin, me prie, dans une lettie que
j'ai re^e de lui le 17 Janvier de Tann^e en cours, de faire remarquer qu'il y a 25 ans
il a commence Templol de son vaccin, ayant fait les premiers essais de vaccination
en 1887. Le Dr. Ferr&n signale que sa methode est tr^ ressemblante h la methode

130 PBOGEEDINOB SBOOKD PAN AHEBIGAN 80IBNTIFI0 G0KGBE8S.

claseique de Wri^t, et qu'elle a beaucoap de details tedmiquee, qui la font semblable
au produit 61abor^ k La Paz; vaccln am^icain de Riusell; poes^de grande reaeem*
blance avec celui de Leiahman; lee cultures se cbauffent de 56^ k 56° ; on lee ^muleionne
dans du s^rum pbysiologique, puis on y ajout« 1 pour cent de tricresol, que Russell
d'apr^ see Etudes d^uit Hre le meilleurantiseptique, ajrant la propri^t^ tr^ impor-
tante de faire conserver plus longtemps k la vaccine son activity; vaccin Morsdes;
^labor6 k PInstitut National de Bact^ologie de La Paz.

£n ce qui conceme ce vaccln je dois entrer dans quelques details car, quoique
dans sa preparation on suive un proc6d6 semblable a cehn couramment employ^ dans
les produits similaires; 11 a, cependant, quelques points techniques qui le diff^ren-
clent dee autres vacclns.

D'abord, pour faire les cultures, au lieu d 'employer la g^l^ose qui aujourd'hui est le
moyen d'^lection, pour la plupart dee bact^riologistes; j'emploie le bouillon qui,
d'apr^ mon opinion, a Tavantage de profiter, int^gralement, des produits grace
auxquels le bacille d'Eborth provoque la formation d'anticorps defensifs.

Afin d'^viter de multiples details de technique bact^riologique, je mentionnerai
seulement que les organismes bact^iens d^terminent Taction defensive, soit par les
endolisines, soit par les exoiisines, dont la production est plus abondante dans le
liquide. Pour ne citer qu'un seiil exemple il suffit de signaler ce qui se passe avec le
bacille de Klebs-LoefBer, dont les cultures en s^rum, de mdmequ'en g^l^ose, donnent,
une quantity m^prisable de toxine, tandis qu'il y a une abondante production dans un
milieu liquide, comme le bouillon Martin.

Ge principe g^n^ral de bact^riologie s'e£Fectue avec le bacille d'Eb^th, cette
affirmation pent 6tre v^rifi^ en filtrant lee cultures k travers une bougie Kitassato.
Le liquide clair, qui reste dans la partie filtr^ et qui ne contient pas d'organlsmcs
bacillaires, est dot^ de propriety immunisantes qu'on peut facilement verifier par des
inoculations dans la s^rle animale. Partant de ce principe, il est facile de comprendre
que, quand il s'agit de preparer un vaccin actif, 11 est indispensable d 'employer
des cultures liquides qui, forewent, doivent contenlr une quantity plus grande
d'antig^ne.

Je prepare le bouillon de la mani^re suivante:

Je fais mac^er pendant deux heuris dans de Teau bouillie et froide, les parties
les plus puepeusee de la viande apr^ les avoir depouUl^es deleurs parties grasses
et les avoir d^coup^es en petits moreen ux. Oes temps ^coul^, je jette le liquide de
maceration, le remplagant par un nouveau dans la proportion de 500 grammes de
viande k litre d'eau distiliee. Je laisse de nouveau cette maceration en repos pen-
dant deux heuree et je prepare ensuite le bouUlon peptonise selon le precede ordi-
naire. Moyennant la leg^re modification apportee dans la preparation du bouillon,
j'obtiens que celul-ci soit beaucoup plus limpide et clair que celui qu'on emploie
generalement; j'evite en plus qu'un exc^ de substances solides, specialement
d'hemoglobine dissoute et de peptones, se predpitent pendant la culture, donnant
u la formation de grumeaux.

Le bouillon est distribue en ballons Pasteur, d'une contenance de 250 granmies*
ayant soin de ne mettre dans chacun d'eux que 100 grammes, afin qu'il y ait une
abondante oxygenation qui favorise le vigoureux developpement des bacteries.

Pour les semis j 'emploie sept espies de bacteries de differentes pro enances, et
dans la forme suivante: Allemagne, Paris, Vienne, Etats-Unis du Nord-Amerique,
Argentine, Chili et La Paz.

La purete des cultures se verifie, grSce k des semis en gelatine. De la gelatine je
e^me k nou\eau k la geieoee, laquelle se maintient k la chaleur d'une etuve k une
temperature de 37° pendant 48 heures. Ce temps ecouie, je prends les cultures en
geieose, pour les resemer dans du bouillon. Dans les semis je n'emploie pas le fil de
platine, parce que je ctoLb qu'il est difficile de prendre la mdme quantite chaque fois,
d'oik, comme consequence logique, un developpement plus abondant dans les ballons
qui ont re^u plus giande quantite de semis.

PUBLIC HEALTH AND MEDICINE. 131

Dans moQ procM6, je fads lee aemlB moyemiant im ase de platiLne, de deux mili-
gnumneB de capacity, ce qui me donne la certitude d'avoir 8ein6 met balkma, avec
one quantity plus ou moins ^gale de bacilles.

Selon la quantity de vaccin que Ton d^eiie preparer, j'ensemeeoe avec chaque
race bacillaire, Bolt deux, tmis ou quatre ballons, ayant soin que' chaque race mnt
repr^aent^ toujouis par un nombre ^l de ballons.

La culture se &dt dans Tetuve r^l6 k 37^, la retirant au bout de 42 heuie exactea;
on numtote ensuite par centimetre cube, suivant le procM6 ordinaire de compaiai-
son avec les globules rouges.

Si la proportion nous donne le chiffre d^sir6, qui est de 1,000,000,000 de bactMes
par centimetre cube, on continue Top^tion jusqu'^ la fin; en cas contiaiie, on
r^jette les ballons qui ont un d&. eloppement excessif ou insuffisant.

Les cultures sent soumises k T^hauffement au bain-marie k 53^ pendant deux
beures. On melange ei^niite le contenu des diff^rents flacons dans un ballon d'une
contenance de 2 ^ 3 litres et Ton ajoute au tout une solution de lysol, dans la proportion
de 0,25 gramme pour cent.

U ne reste plus qu'ii distdbuer le vaccin dans des ampoules st^rilis^es en verre, de
1 & 2 centimetres cubes, que Ton sterilise de nouveau k la temp^ture de 53^ pendant
deuxheures.

Pour r6pondre k certaines indicatbns, je prepare aussi un vaccin deiay^ que je
distingue moyennant la formulesui ante: V.M.2V. Ceproduitcontient 600,000,000
bact^es par centimetre cube, et il est £orm6 de parties ^gales de bouillon, de culture
et d'eau physiologique.

8. Vaccins sensiV ilis^: Le type en est constitu^ par celui de Desredka, qui de-
puis 1902 pr^onisa sa m6thode d 'immunisation moyennant les vaccins sensibilis^
£Ue conaiste en r^um^ k mettre les bacilles d'Eberth en contact avec le s^rum
antit>i>hique et k filtrer le s^rum apres les 24 heures, k laver les bacilles, et finale-
ment k les mettre dans une solution d'eau sal^. Les bacilles, ainsi pr6par^, con-
tinuent ilAivre, ce qui permet, d*apres Topinion de leur auteur, une plusgrande
^ergie d'action.

La premiere application de ce vaccin k I'espece humaine se fit par Broughton
Alcock et les r^sultats obtenus permirent leur grande gdndralisation.

Nous pouvons, dans ce mdme chapitre, inclure le vaccin Ranault, qui consiste en
cultures de bacilles typhiques qui ont perdu toute virulence, gr&ce k une exposition
prolong^ aux ra3ron8 ultra-violets.

4. Vaccins qui emploient des agents chimiques: Le plus connu et qui, pendant
ces demiers temps, a acquis une juste renomm^ est celui du Professeur Vincent.

L'auteur emploie des bacilles typhiques de di£f^ntes provenances (10 races) ; il les
cultive pendant 24 heures sur g^lose en bottes de Roux k dS^. Ensuite le contenu
des bottes est 6mulsionn6 dans 200 cc. d'eau physiologique sterile, puis on y ajoute
de rather. Le melange est fortement agit^ plusieurs fois et maintenu pendant 24
heures k la mdme temperature que celle du laboratoire. On recueille la partie de
r^ulsion qui sumage sous la couche graisseuse et on la soumet k Taction du vide,
moyennant la trompe d'eau. Par ce procM6 on obtient Tdvaporation de Pother.

La preparation est r^partie dans des ampoules de 5,10 et 20 cc. fermees k la lampe.
Chaque centimetre cube de cette Emulsion contient 400.000.000 k 420.000.000
bacteries.

Le laboratoire de Val-de-Grftce prepare aussi un vaccin par autolisie.

MANltEB DB PRATIQUBB LB VAOCIN.

Les vdes qu'on emploie pour introduire le vaccin dans Toiganisme humain sent
qnatre: 4:la rectale, la bucode, la sous-cutan^e et Tintrarveineuse.

Voie bnccale: On emploie des vaccins morts k 53^, faisant ing^rer 10 & 20 centi-
metres cubes par jour, avec des r^sultats, paraft-il, favorables. Le docteur Abraham
P^res MiWS de Cuba est un des premiers qui ait employe cette methode.
68486— 17— VOL ix 10

182 PBOCEEDINOS SECOND PAN AMEBIOAN SCIENTIFIO GONGBESS.

Voie rectale: O'est k Conrmont at Rochaiz, que revient le m^rite d'avoir, les premien,
pr^oziis^ la voie rectale, moyennant dee todmee compoe^e de 10 k 100 cc. de
vaccin st^rilis^ par la chaleur. La r6action est presque toujoursnulle, et lee lavements
s'appliquent k cinq jours d'intervalle. Le Dr. Darier croit que cette m6thode est
siire et efficace.

Voie sous-cutan^: Est celle qu'on emploie de pr6f6rence et elle 8'iq)plique moyen-
nant une petite seringue de Pravaz, par injections sous-cutan^.

Les precautions k prendre pour appliquer Finjection ne different en rien de cellee
coununment employees pouries inoculations hypodermiques.

Les points d'ilection varient quelque peu selon les auteurs, chacun d'eux ayant
des r^ons auxquelles ils donnent la preference. Ainsi quelques-uns indiquent la
partie posterieure du thorax, dans le point interscapulidre; d'autres, la paioi de
I'abdomen et quelques-uns encore la partie posterieiire du bras.

Pour moi je conseille la partie ext^rieure du bras, au niveau de Tinsertion deholde.
Les raisons pourlesquelles j'ai cette preference sont: la sensibilite qui, k cet 6ndroit»
est insignifiante, et la facilite pour decouvrir cet endroit du corps sans deshabiller
rindlvidu, comme il arrive quand on choisit la region interscapulaire.

L'injection doit se faire de preference Tapr^midi, ayant sotn qu'elle soit
rigoureusement sous-cutanee, car j'ai vu que les reactions douloureuses et violentesse
sont toujours presentees dans les cas oh Taiguilld d'inoculation avait penetre ou tiop
superficiellement ou trop profondement.

RiAcnoN phovoquAb par le vaocin.

Les differentes formules de vaccines donnent aussi lieu k des reactions differentes.
Ainsi la primitive de Wright doime lieu k des phenom^es assez douloureux, avec
augmentation de volume sur le point injecte, hausse de temperatiire souvent con-
siderable, vomissements, diarrhees et cephalalgie. Avec d'autres types de vaccins,
lee reactions sont moins importantes, de mdme que la douleur est presque insignifiante.

Je ne discuterai pas si le vaccin qui prodult une reaction ou celui qui ne la produit
pas est meilleur; je crois que les deux extrtoies sont nuiaiblee et que I'ideal d'un
bon vaccin deviait 6tre, et serait, celui qui, avec une moindre reaction, donnerait un
inf^-rTTw^im d'immunlte.

Quant au prodult eiabore k Tinstitut, nous pouvons grouper les phenom^es aux-
quels il donna lieu, en trois categories: peu importants, moyens et violents.

Au premier groupe appartiennent les cas dans lesquels la temperature est monteet
jusqu'^ 38^.5; au deuxilme de 38^.5 k 39^.5 et au troisi^e k40^et mtoe davantage.

II resulte de mes observations que le premier t3rpe se realise sur 10 ii 15 pour cen
des cas, le deuxitoe sur 80 pour cent et le troisitoe sur 5 pour cent. Done la reaction
moyenne est presque constante.

Le type de la courbe thermique, est le suivant: Au bout de 4 heures la temperature
attetnt son maximum, puis elle commence k decliner pendant 24 heures jusqu'i
revenir k son etat normal.

II se produit dans certains cas, dans I'apr^midi du deuxidme jour, une leg^d
hausse de la temperature de 2uelques dixi^mes, toujours peu importante.

Quant aux manifestations locales elles n'ont aucune importance, se bomant k un
durcissement peu douloureux k la pression, de la grosseur d'une pidce de monnaie de
5 francs. Parfois se preeentent aussi dee Infarctus ganglionnaires sous-axillaires, qui
disparaissent rapidement.

Sur un nombre de 5.000 k 6.000 inoculations preventives que j'ai faites, ei
suiviee de pr^, pas une fois je n'ai remarque lee nausees et vomissements signaies par
la plupart des auteurs.

En fait d'accidents rares, Tunique signaie jusqu'li present par un des aides du
laboratoire, est une violente epitaxie, survenue l*aprfefl-midi m@me de la vaccination.

PXJBLIO HBALIH AND MBUdNE. 138

Nous avons efifectu^ daas la pratique deux inoculations succeesiveB a^par^es par
un intarvalle de 10 joun.

Oidinaiiement, la deuzi^ma Injection pioduit une reaction means intense que la
premiere. La temperature ne numte qu'4 38^ et descend compl^tement au bout
de 10 ou 12 heures, de mani^ que le cycle ^volutif s'effectue dans un temps plus
court qu'A la premie.

Pour mesurer rimmunit^ donn^ par le titre du s^rum en aglutinines, au troisi^me
ou quatri^me jour apr^ la seconde inoculation, j'extrais de Textr^mit^ digitale de I'in-
dividu quelques gouttes de sang et je fais ensuite la reaction d'aglutination m61angeant
i une goutte de s^rum jusqu'ii 100 et 150 pour cent de bouillon de culture. Dans
la grande majmt^ des cas, la reaction a 6t6 absolument positive, mdme k la doee
de 1 pour 250, ce qui prouve sans discussion la bont4 de mon pioduit.

Je ne pretends pas que la quantity d'aglutinines dans le s^m sanguin soit suffi-
sante pour juger en dernier r^sultat d'un produit de cette nature. O'est un
chapitre tr^ pen ^tudi^ de la science bact^iiologique et tr^ probablement destine k
sttbir des modifications s^rieuses; mais il est certain que n'ayant pas un autre nxoyen
de contrdle, r^aeigie de la reaction aglutinante est digne d'dtre prise en compte
et sous ce point de vue mon vacdn a produit la formation d'aglutlnines en proportion
plus grande sur les autres produits similaires.

PHASE NBOATIVS.

"Wrigfat le premier, et d 'autres auteurs ensuite, d^rivirent sous ce nom une tend-
ance plus grande, de la part de ceux qui avaient 6t6 vaccinas, k contracter la fi^vre
penduit les 8 ii 10 jours suivants celui de Tinoculation. Plus tard des observa-
teurs d'un m^te incontestable mirent en doute Texistence de cette p^iiode negative,
se baeant sur le fait de ne Tavoir pu verifier.

Pour ce qui conceme mes Etudes, je dois d^larer que je me suis tiouv^ dans des
conditions particuli^rement favorables pour constater ce ph^omkie, car comme je
I'ai prte^emment dit, dans la race indienne Tisolement n'est pas possible et les
individus malades vivent ensemble avec lee sains, dans de misdrables huttes d'lm
espace excessivement rMuit.

11 est Evident, que si la pMode native existait r^llement, la contagion devait dtre
beaucoup plus facile et fr^uente, ce qui n'eut pas lieu ime seule fois.

Les diff^ientes commissions qui vaccin^rent dans les peuplades d'indiens de Arque,
CSiangolla, Isladel Sol, Carangas, Punata, Jestis de Blachaca, Mocomoco, Comarapa, Piil-
quina, Umala et autres endroits situ^ k des bauteurs de 500 k 4.100 metres au-dessus
du niveau de la mer, d^larent parmi les individus vaccinas et vivant dans les
m6mes babitations oil se trouvait la fi^vre en pleine pMode, n*avoir pas observe
un seul cas de contagion, ce qui prouve le pouvoir pr6ventif de la vaccine, la non-ex-
istence de la p^iiode native et ce qui est tr^ probable encore, que dans un indi-
vidu d^j^ avec des prodromes, on pent, grftce k la vaccine ^viter le d^veloppement
de la maladie.

D08B PBiVBNTIVE.

Quant k la quantity de bacilles qui est ndcessaire pour produire rimmunit^
effective, Tavis des auteur^ varie dans des limites trop amples, en soite qu'on peut
affirmer, qu*il n'existe pas une dose unique et d^termin^ avec caract^re gto^ral.

Chantemesse indique le nombre de trois mille millions de bact^ries, distribu^ en
4 injections, s^par^ les unes des autres par un intervalle de sept jours minimum et
14 maximum.

Ardin, Delteil, N^gre emploient le vaccin sensibilis^ de Besredka et effectuent
4 injections k intervalles de trois jours.

Jaime Ferrto fait une premiere inoculation de 2 centimetres cubes, moiti^ dans le
bras droit, moitie dans le gauche. Sept k huit jours apr^ il refait une application de
la mdme quantity.

134 PBOCEEDINQS SECOND PAK AMBBIOAN 8CIEKTIFIG OOKOBESS.

Pour Vincent, le mieux serait pratiquer 4 injections, k doees cioiaBantes de 0,50,
0,75, 1 et 2 centimetres cubes distributes de huit en huit jouiB. II est 4 remarquer
que ce vaccin contient seulement 400.000.000 de bact^es par centimetre cube.

Dans ma pratique je me borne k faire deux injectums d'un demi centimetre cube:
la premiere, avec une teneur de 500.000.000 de bact^ries, et huit jours apr^s une
autre d'un centimetre cube.

Pour la race indienne il est n^eesaire de chercher un pioc^6 d'immunisatioa
qui ne n^cessite pas beaucoup d'inoculations successiveB, et ced pour plusieun
raisons. D'abcnrd k cause des ^aormee distances auzquellei se trouvent les villages et
hameaux; dans des endroits d^poiurvus de toute renource avec dee chemins d^tes-
tables pour les mulets les voyages font beaucoup souffirir les envoy^ et leur caosent
d'innombrables fatigues. Le caract^ supontitieux et apinr^hensif des naturels est
ensuite la cause que, si Ton a pu obtenir qu'une fois ils se soumettent k Timmunisa-
tion, la l^g^re fatigue quails ^prouvent lee terrorise et il est ft peu pr^ impossible
de leur faire accepter une deuxi^me, et, comme il est naturel, bien moins une troisieme
ou quatri^me vaccination.

On doit pr^tendre en Bolivie, plutdt que des immunisations de longue dur6e, une
immunisation qui, rendant refractaires, quand mime ce ne serait que pour peu de
temps, tons les individus d'un endrdt d^termin^, emplcherait la propagation de I'^pt-
d^mie et T^pouvantable mortality qu'elle cause.

B^SULTATS DB LA VACCINB PRl^VENTIVS.

J'ai signal^ en passant dans un des chapitres de la pr^sente ^tude les avantages
obtenus par la vaccine employee comme agent pr^ventif. Je vais maintenant ctter
quelques statistiques en plus, pour ^tablur une compaiaison entre ce qui s'est pa8i6
dans d'autres pays et ce que j'ai pu observer en Bolivie.

J'ai d^}k fait remarquer que c'est k Wright que Ton doit les premian essais de
vaccination antitsrphique; en cons^uence c'est I'Ang^etene qui la premiere
b^n^fida de cet agent th^peutique.

Tout le monde sait que Tarm^ anglaise au Transvaal eut k subir dans une proportion
alarmante, la prince, parmi les troupes, de la fi^vre typholde, qui causa de nomlneux
d^^e. C'est ]k que les meilleures Etudes statistiques furent iutes en mime temps
que comparatives et dont les chifEres sont lee suivants:

Ladysmith, gu^re du Transvaal, 1906, vacant, 1.705; cas, 35—2,05 pour cent;
morts, 8—0,47 pour cent Non-vaccin^, 10.529; cas, 1.489 — 14 pour cent; morts,
329—3,13 pour cent.

Dans d'autres colonies anglaises les r^sultats furent: Inde, 1900, vacdn^ 5.999;
cas, 52—0,87 pour cent; morts, 8—0,13 pour cent. Non-vacdn^ 54.554; cas, 731 —
1,69 pour cent; morts, 24—0,48 pour cent. Inde, 1901, vacdn^ 4.833; cas, 32—0,66
pour cent; morts, 3—0,06 pour cent. Non-vacdn^ 55.955; cas, 744 — ^1,33 poor
cent; morts, 9—0,36 pour cent. Inde, 1907, vaccin^ 2.207; cas, 0,68 pour cent;
morts, 0,13 pour cent. Non-vaccin^, 8.113; cas, 2,13 pour cent; morts, 0,52 pour
cent. Malta-Gibraltar et Cr^te, 1910, vaccin^ cas, 0,53 pour cent; morts, 0,89 pour
cent. Non-vacdn^, cas, 30—0,04 pour cent; morts, 1,69 pour cent.

Amirique du Nord. — Dans ce pays grftce k la generalisation de la vacdneet aux lois
qui Ta dfclar^e obligatoire dans Tarm^e, la typholde a diminu^ dans une proportion
telle qu'elle fait penser que sous peu les statistiques n'enregistreront pas un seul cas.

Etats-Unis, 1909, cas, 175; morts, 16. 1910, cas, 142; morts, 10. 1911, cas, 44;
morts, 6. 1912, cas, 9; morts, 1.

Allemagne, 1904-1907, vaccinas, 7.287; morts, 24—0,35 pour cent; non-vaccines,
9.204; morts, 116—1,26 pour cent

Fhmce, epidemie d'Avignon, 1912, vacdn^s, 1.366; cas, 0; morti, 0; non-vacdne^
687; cas, 155; morts, 22.

PUBLIC HEALTH AND MEDIOINE.

135

Alg^rie et Tuniaie, vacdn^ 10.794; caa, 0; morts, 0; non vacdn^ 6.293; cas,
168—44 pour cent; morts, 21.

Bolivief 191S, — ^Ma statastiqiie ne peut dtare conduante sur ce point; j'ai d^k
indiqu^ lee raiaons qui m'emp^ch^nt de faire une 6tude plus complete.

La vaccination ayant 6t6 6(tectai6e dans une region d^tennin^, la commiasbn
Banitatre attend seulement 8 2i 10 joun, et» si dans ce terme aucun nouveau malade ne
se pr^nte, elle quitte rendroit infect^, laisnnt k Tautorit^ locale le soin d'averUr
imm^diatement si de nouveaux cas de typhoSde se pr^eentaient

Par cons^uent ropinion sur laquelle je me base pour juger de reflScadt^ de la vac-
cine, repose sur le fait snivant: Dans les villages soumis k la vaccine, Tdpid^mie a dis-
paru compl^tement, de nouveaux cas ne s'6tant pas pr^sent^ dans un tenne qui,
jii8qu*4 present, atteint huit mois comme maTimum et un mois comme minimum.

Uniquement dans deux endroits la fi^vre fit un retour offensif , ce qui me permit
de faire une ^tude importante sur Tefficacit^ pr^entive de ma vaccine; ces deux
endroits furent Arque et Punata, dans lesquels T^pid^mie, apr^ avoir disparu,
revint au bout d'un certain temps avec nouvelle vigueur, ce qui motiva renvoi de
nouvelles commisBions, chaig^ d'annoter soigneusement les cas dans lesquels une
p^sonne vaccinae aurait contracts la fi^vre.

A Arque, tant par la d^laration des autorit^ qui par ocdre du Gouvemoment
firent une soigneuse Investigation, comme par le rapport du commisaionn6, Ton sait
que pas une seule fois on ne vit que les individus vaccinas eussent pns la maladie;
quoiqu'ils v^cufisent dans des huttes infectes et malsaines avec leurs parents maladee.

A Punata le Dr. Villarroel d^lare avoir vu deux cas uniques d'individus qui
iqyrte avoir M vaccinas prirent la fi^vre. Ces deux cas sont les seuls od dee indi-
vidus vaccinas aient subi la typholde. Dans les autres endroits, comme on peut le
voir d'apr^ les tableaux que je transcris ci-dessous, les ^pid Ernies ont disparu dans
un terme de huit k quinze jours.

Vaceination,

Dates.

1918.

CommlnioD Dr. Mendoia,da34 de Joillet

aQ28d'aoCkt.

Commission NavArro, mraie dAte

Commmton R«A)el, saptembre 14 k sep-

timbrsSO.
Commisalon Balcanr, septembre 90 aa

15 octobre.
Commlsikm OilhiMla, ootobre 8 k ooto-

bnl4.
CommJssloii NaTarro, ootobra 21 aa U

novsmbre.

CommtasioiiaTai^,ootobn39

Commisstoo Dr. PeOaranda, ootobre 14. . .
Commissioo Antonio MoraJes. noTsmbre 30
Commission Dr. Villarroel, dsoembre 9.

CommiBlon Dr. Aramayo, dAwmbre 80..
Dif

1914.

eommlssion Dr. Mercado, JauTler..
Commission Dr. Saens, terikr 18. .

Tribunal do mMedne, mars 4

Commission Rooabado, mafs 28. . .

Oommisslon Vargas, mafs 10

DiTsraeaoommisdons

Endroits.

Arqae, Colcha, Berengoela
y Torsmna.

Changolla e» Tarata

WadKTsoL

Arqoe, Coloha, Berengoe-
la, Toosoma.
Provinoe de Carangas

Mooomoco

Tarij^TllleetTlUages.

Umala..
Ponata.

Potosi, Tille et Tinans. . . .
Pnlacayo. Hospltaks,
Achacachi, eto.

Comarapa et TamMllo

Vallasrande

TarlJa

Qoechisla

sioasioa

Omro, Potosf,eto

Nombre
de vao-
dnte.

250
800

427

850

600

850
800
220
500

150
780

4,427

800
200

100

500

1.000

lUsnlUts.

L'^pid^mie se pr^senta

de nouveao.
Ne se pi^senta plus.
Ne se pr^senta plus.

Ne se prfeenta plos.

Ne se pr^senta plus.

Ne se prteenta plos.

Ne se prteenta plos.
Ne se pr^seota plus.
Ne se urtfsenta plus.
L'^piddmie se prteenta

de nouveau.
Ne se pr<Ssenta plus.
Ne se prteenta plus.

Neseprteentaplos.
Ne se pr^senta plus.
Ne se pr^senta plus.
Ne se presents plus.
Ne se pr<<senta plus.
Neseprteentaplos.

186 PBOOEEDINGS 8BC0KD PAN AMEBIOAN 8GIEKTIFI0 G0NGBE88.

Vaocin CUBATir.

PBSMiiBES Etudes.

La presque totality dee auteura qui ee eont occup^ de bact^rioth^rapie accordent
k Eug^e Fraenkel d'Hambouiig le m^iite d'avoir ^t6 le premier k appliquer 1e vac-
cin comme agent, non pas prophylactique male curatif . C'eet en 1892 et 1893 que
cet auteur mena k bonne fin see ^tudee, ayant compris dans see expMenree 57 malades,
8ur leequelfl le nouveau traitement donna des r^sultats si favorables qu'ile faisaient
d6}k pr^voir les avantages qu'avec le temps on pourrait retirer de son emploi.

Weisgeberber, dans son excellente th^ sur ''L'6tat actuel de la vaccination contre
la fi^vre typhoTde/' croit que ce fut Eichhols, qui dans I'Airique AUemande du Sud,
sur 68 malades fit avant Fraenkel des exp^encee avec la vaccine comme agent
curatif.

Ferrdn affirme que c'est k lui qu*on doit Pemploi du vaccin comme agent curatif;
ayant depuis 1887 fait diverses investigations, qui revendiqueraient pour lui le
m^rite de droit de piimaut^.

De son c6t4 Chantemesse fait remarquer que c*est k ses Etudes et k celles du Pro-
f esseur Widal que le triomphe de la vaccinot^rapie antityi^que est dA.

Plus taid une v^table phalange d'investigateurs ont effectu6 des essais plus ou
moins favorables; les mdmes que je transcris d*une commimicatbn faite par le
Professeur Arnold Netter, k la Soci^ M6dicale d'Hdpitaux.

PUBUC HEALTH AND MKDICINB.

137

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188 PBOOEEDINGS SECOND PAN AMEBfCAN SOIENTHIC C0NGBE88.

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FUBUO HEALTH AND MEDIOIKB. 189

Examinant le tableaa pr^c^ent, on voit que jusqa'aujourd'hoi let statifltiquen
pluB nombreuBes sont cellee de Petrowitch avec 460 malades et la mienne avec 344.

Je dole faire noter que je ne marque pas plua de deux cents cas qui de diff^nta
points de la R^publique m'ont ^t^ communique (Dr. Qerahi d'Oruro, Dr. Aremayo
de Potosf, etc.), parce que je ne possMe pas les observations cliniques completes et
que je d^ire que ma statistique soit s6v^ autant que possible.

Ajoutant aux 344 cas les deux cents pr^cit^, j'aurais une statistique globale de 544
malades soign^ avec un r^ultat toujours favorable, ce qui me placerait & la tdte de
tons les auteurs d'apr^ le nombre de malades traits.

Pour 6purer ma statistique, je vais supprimer les cas sans ^tude clinique complete,
et les 100 de 1914, dont la documentation ne m'est encore pas parvenue totalement;
de mani^ que ma statisique sera r^uite k 234 malades, avec deux d^c^.

D'apr^ les tableaux trac^ par le Dr. Villanoel, on pent classer les 234 malades
en 6 groupes distribu^ de la laigon suivante:

Premier tableau. — Nous prendrons comme type Dionisio Gonz&les, 7 & 13 jours de
maladie, commence le traitement: Premier jour, temperature 40*^, injection vaccin
Morales d*un demi centimetre cube; deuxi^e jour, temperature 36*^.5, injection «
6tat general, bon; troisi^e jour, temperature 36^.5, injection vaccin national,
quatri^e jour, convalescence. Dans ce tableau sent compris 126 malades.

DenxQme tableau, — Francisco Delgadillo, 4^8 jours de maladie, temperature 39*'
le premier jour du traitement, injection vaccin; deuxi^me jour, temperature 38^.9,
reaction locale intense, injection Tapr^ midi; troisieme jour, temperature 38",
reaction locale intense, injection; quatrieme jour, temperature 37^, langue et etat
general normaux; convalescence; comprend 43 malades environ.

Troiiihne tableau, — Juan Ml. Garcia H., quatre jours de maladie, avant traitement,
temperature 39^.8, injection; deuxi^me joiir, temperature 38^; troisieme jour, tem-
perature 39^, une heure apr^ Tinjection, frissons, hallucinations, deiire violent;
quatri^me joiir, injection, etat le mdme; sixi^me jour, m^me etat, injection; douzi^me
jour, temperature 39^; vingti^me jour, convalescence. Comprend 42 malades.

Quatrihne tableau. — Antonio Ugarte, quatre k huit jours de maladie. Premier
jour, temperature 40^, injection vaccin Morales, deuxi^me jour, temperature
38*^, injection d'un quart de centimetre cube; troisi^me jour, temperature 37^.8,
traitement voie interieure; cinquieme jour, bypothermie, i^petit demesure, con
valescence. Comprend 9 cas.

Cinqmhne tableau. — Escol^ica Quinteros, ftge avance, 60 2i 80 ans, 7 & 10 jourH
de maladie, temperature 39° le premier jour du traitement, injection matin, et soir
hausse de temperature pendant deux heures plus ou moins. Deuxi^me jour, hypo
thermie, traitement voie interieure; troisi^me jour Thypothermie s'accentue;
necessite cafeine et autres tonicardiaques; quatri^me jour, suit Thypothermie,
mauvais etat general; cinqui^me jour, dec^s. Comprend deux cas.

Sirihne tafr^eou.— Type: Mariano Condori. Temperature au moment de Tinjec-
tion 40^.5. Inoculation matin et soir d'lm demi centimetre cube le premier jour;
un centimetre cube le deuxieme et le troisieme jour; demi-centimetre cube le
quatrieme et le cinquieme jour. Dans ce tableau on remarque la chute brusque
de la temperature apres la septieme injection.

Je dois 4 titre de document d'etude ajouter un dernier tableau, ainsi caracterise:
Non jeune, du service des hdpitaux, k son arrivee en Italie prit la fievre typholde
par contagion. Traitee par un coUegue, elle presenta comme caractere special
rhyperthermie excessive, avec des temperatures de41 et42 degree qui ne cedaient
k auctin traitement. Au bout de 15 jours et en plein etat de toxhemie, le coeur
defaillant et pouls filiforme; on fit plutdt par acquiescence que parce qu'on attendait
une action efficace du vaccin, des injections d'un demi-centimetre cube pendant
deux jours. La temperature ceda k la premiere inoculation, tombant de 40 ^ 38,
et retat general de la malade fit concevoir quelque espoir. Au bout de deux jours

140 PBOCEEDIKGS SECOND PAN AMEBIGAK SCIEKTIFIO 00NGBES8.

la tozh^mie avait continue see progr^ et une hemoptysis abondante survint, dont
la cause m'est inconnue, et la mort se produlsit imm^iatement.

Je ne mentionne pas ce cas dans ma statistique, de mdme qu'un autre dans lequel
au bout de dix-huit jours et en pleine p^ode d'agonie, on fit, k titre de tentative
desesp^r^e, Tapplication du vaccin.

Dans lee deux cas T^tat des patients ^tait tr^ grave, et on eut recoura k la vaccine
comme une demi^ ressource.

lUduisant les tableaux qui i»^Ment k une expression plus concrete et aboolue,
qui facilite leur interpretation, nous avons les chiffres suivants:

234 malades trait^s.

190 (tableaux 1, 2, 4, et 6), dans lesquels la dur6e maximum de la maladie fat
sept jours.

42 avec une longue Evolution, sans complication et sans d^c^.

Deux malades qui moururent au cinqui^e jour, mab de typholde des vieillards
qui est tr^ mauvaise.

La proportion de mortality des statistiquee plus nombreuses est la suivante: Fraen-
kel, 8,77; Petrovitch, 3,04; Sadler, 10,22; Morales, 0.85.

D08B8 THiRAPBUTIQUBS.

L'avis des difF^rents auteurs qui se sont occup^s de cette question varie beaucoup
en ce qui conceme la quantity la plus convenable de vaccin qu'il est n^cessaire
d'employer et au moment 1e plus favorable pour faire les injections.

Cette diversity d*avis se doit autant au different crit^rium des exp^rimentateurs,
conune k ce que chacun d'eux employa des produits diff^rents, avec un index bext^-
rien divers; de sorte que les r^eultats ne peuvent, dans aucun cas, 6tre comparables.

Josu6 et Belloir injectent trois fois 200.000.000 de badlles, avec douze heures d'in-
tervalle; la culture est prise du mdme malade.

Netter applique 500.000.000 de badlles (sterilises) sensibilises k chaque fois, pendant
trois jours suivis.

Meakins emploie la dose de 1.000.000.000 de bacteries chaque hult jours; Ardin-
Delteil, la mdme quantite mais chaque trois jours. Boinet, egale quantite durant
quatre jours suivis.

On voit done, avec quelle difference la valeur therapeutique de la vaccine est
appreciee. Pour les uns les doses massives doivent, de preference, etre employees;
tandis que d'autres croient que les doses moderees, frequemment repetees ont plus
d'efficacite.

Quant k moi, void mon procede: Matin et soir pendant deux jours consecutifs,
j'injecte des doses de 500.000.000 de bacteries. Si apr^ ce traitement la temperature
baisse k 38, je suspends les inoculations; mais, si la temperature se maintient eievee,
alors je fais une cinqui^me, sixi^me et exceptionnellement une septi^me injection.

Seulement dans un cas on employa des doses plus fortes; ce fut avec le malade du
Dr. Luis Martinez Lara, auquel on fit trois applications de 1. 000.000.000 de bacteries.
Je crols qu*il n'y pas de ralson pour employer des doses aussi eievees.

ACnON DU VACCIN.

Pour donner une idee complete de la mani^re dont le vaccin agit, je vais raconter
le premier cas ot il fut applique.

Vers la fin du mois de mai de Tannee demi^re, au numero 41 de la section de Mede-
cine de THdpital Landaeta se trouvait Tindien N. N., ftge de 20 ^ 25 ans. L'examen
clinique reveia une typholde dans le quatri^me ou cinqui^me jour de son evolution,
avec tous les caract^res classiquee. La reaction de Widal et la diazo-r^action de
Eh rlich, confirm^rent pleinement le diagnostic . Nous pouvons classer cette tyi^olde
entre celles de moyenne intensite, avec une certaine tendance k rhyperthermie qui
B'Avait pas cede aux fortes doses de quinine. Decide k easayer la vertu curative

FUBLIG HEALTH AND MEDICINE. 141

du vaccin et apr^ une longue et Uborieuse ^tude sur la s^iie animale, coura-
grasement coUabor^ par lee Dra. Juan Medina Vaca et Luis Martfnes Lara, je fia la
premi^ injection d'un demi-centim^tre cube le matin du 27 mai.

Deux heures apr^, la temp^ture, qui au moment de Tinoculation ^tait de 39^,
monta 8/10, tombant le lendemain k 37,8. On r6p6ta lea inoculations, la tempera-
ture se maintenant k 38, et baissant le quatri^e jour d'une fagon definitive k la
normale.

L'observation qui pr^cMe est, avec peu de variantes, la mdme qui se r^p^ta dans
touB les cas, exception faite de ceux lemarqu^s par le Dr. Villanoel dans le D^parte-
ment de Gochabiunba, et dont revolution fut plus longue.

Je dois {aire remarquer que les reactions douloureuses avec deiire furent frequentee
sortout dans les individus alcooliques; tel qu'il aniva durant repidemie de Punata.

Je dois de mtae appeler Tattention sur le {ait particulier que, hors trois ou quatre,
peut-^tre cinq, malades qui {urent soumis au r^ime lacte, U hit impossible avec les
autres de r^gler leur nourriture, ni mtoie d'obtenir leur isolement et de leur faire
boire de I'eau cuite.

Les indiens ont constamment re{use tout changement dans leiur coutumes ordi-
naires.

COMPUCATIONS.

Je ne puis sur ce chapitre dtre tr^ aflSrmati{, car comme je Tai d^}k dit plus haut,
les differentes commissions chaigees de combattre la typholde, rest^rent seulement
huit k dix jours dans les lieux inlect^; de sorte qu'elles ne purent appr^der les
complications qui ont pu survenir apr^ la maladie.

Quant k celles qui pendant le cours de la maladie se presentent, je peux unique-
ment affirmer que les frequentes hemorragies, signaieee par quelques auteurs comme
un fait habituel du traitement vaccinotherapique, ne figurent pas dans mes observa-
tions ni comme plus graves ni plus {r^quentes que dans des autres formes de traite-
ment.

CONVALS8CBNCB.

Un fait flignaie par les Drs. ViUarroel, Mendoza et Sejas, est que les malades trait^s
par le vaccin ont une convalescence beaucoup plus rapide que quand le patient est
flonmis k d*autres moyens thdrapeutiques.

Les forces re iennent rapidement, Tapp^tit est exag^re, et au bout de six & huit jours
maximum, le malade a repris ses energies; de sorte qu'il ne consen e aucune conse-
quence de son infection. L*exemple le plussurprenant que j'aie remarque dans cet
ordre est celui de Mile. Maria Teresa Olagui el, ftgee de 14 ans, qui attaquee de
dothienenterie exceptionnellement gra e le 19 fe^ rier, put le 28 du mdme mois aller
jusque chez moi pour m'exprimer sa gratitude, ne donnant aucun aigne que seulement
one semaine aupam ant elle avait ete sur le seuil de la tombe.

LA ttfhoIdb bn bouvib.

La typholde fut en Boli^ie une entite morbide, d'une vaste etendue geographique
M ses degats se {aisaient sentir dans tons les coins de la Republique.

I^es epidemics etaient parfois tellement gra es qu'en 1912 les proprietes voisines du
he Titjcaca perdirent presque 70 pour cent de leurs laboureurs, et demierement k
HauilUunarca d'apr^ le teiegramme que je transcris ci-dessous et qui fut remis par
la premiere autorite politique de cette pra ince, on remarque qu'avant Temploi du
%accin il y eut dans un seul Aillage 200 dec^. L'aide Nestor Orihuela, emoye
quelques jours apr^ cette \ eritable hecatombe, guerit, grftce k une acti % e campagne,
49 malades et eteignit compl^tement repid^nie.

Void le teiegramme: "Eucalyptus, le 14 Octobre. — Directeur de Tlnstitut de
Bact^iologie, La Pas.— Vaccine k Carangas succte complet.— Nous parcourilmes les
villages de Corque, Curaguara, Turco, et HuaiUamarca, c'est4-dire, une etendue

142 PBOCEEDIKOS SECOND PAN AMEBIGAN 80IBNTIFIG CONQBESS.

d'environ 80 lieues. Trois cent cinquante vaccmations preventives furent ftdtes
et 40 malades gu^is. A^ ant de pratiquer la Aaccination, deux cents indiens monru-
rent k Huaillanuurca, d'apr^ les renseig:nements des indiens. Details par courrier.
A. Illdnez, Sou8-Pr6fet de ia Province."

De ce moment^ k I'instant oh y^cna ces lignes, il n'y a pas dans toute la R6pa-
blique un seal cas de fi^vre typhoTde; de sorte que beaucoup d'existencee sent con-
serve pour le commerce et la richesse publique.

LB VACCIN A l'i&TRANGBR.

Sur demande faite par diff^ntes autorit^ sanltaires ou politiques et par per-
Bonnes particuli^res, nous avons remis du vaccin aux endroits sui^ ants: Ctdli
(Santiago, Arica, Tacna), Argentine (Salta), Cuba (Sagua ia Qrande), P^rou (lima),
Mexique (Yucatdn), Etats-Unis (New-York).

durAb du vaocin.

II n'ost pas encore possible d'assurer pour combien de temps le vaccin conser ; e
son acti it^ complete. Les premieres Amissions 6iabor6es Pan dernier vers la fin de
mai, se sont consen ^ sans alteration dans tous les climats, depuis le climat presque
glacial du plateau andin, sous des temperatures de 10 et 12 degr^s au-dessous de zero,
jusqu'au climat ardent des plaines de Santa Cruz, avec 30 et 35 degres au-dessus
de zero.

En date du 20 avril, afin de verifier Pacti^ ite du vaccin, on fit des experiences
sur la serie animale dont les r^ultats, qui feront Tobjet d'une seconde communi-
cation k TAcademie de Medecine, sont les suivants: un lapin des Indes de 460
grammes, qui Cut injecte de 1 cc. de vaccin antityphique, de la premiere emission,
qui fut eiaboree vers la fin du mois de mai 1913, eut une eie . ation de temperature
deux heures apr^s Pinoculation de 40,6 degres. Le lendemain cette temperature
tomba k 38,2, chifFre normal.

Injecte, un autre lapin pesant 490 grammes, d'une dose ^ale de ^accln anti-
typhique mais de treizi^me emission, eiaboree pendant le mois de mars de Tannee
en cours, donna comme elevation de temperature 40,5 deux heures apr^s, re v enant
le lendemain k 38,2, ou ce qui est la mdme chose k la normale.

Cette seule obsen ation dans laquelle les temperatures s'eie\^rent d'une Ca^on
tellement ressemblante dans les deux cas, ne serait pas suflSsante pour en tirer des
conclusions definiti\es et deduire que le premier vaccin a\ait conserve toute sa
force, et pour avoir un renseignement de plus k ajouter k cette interessante question,
j'ai precede k Texperience sui ante: Deux lapins de mdme poids furent respecti.e-
ment injectes avec du vaccin antityphique de la premiere et demiere emission;
huit jours apr^ on injecta aux deux par la voie intraperitonienne 1 cc. de culture
virulente de bacille typhique. Chez le lapin traite par le -vaccin de la premiere
emission, la temperature s'eieva rapidement k 41 degres, baissant deux heures apr^s
k la normale. Celui injecte avec le \ accin de la demiere emission, eut une eleva-
tion de temperature qui arriva k peine k 39,8, tombant au bout de 24 heures au type
egalement normal.

D^ ce moment ils ne subirent aucun malaise; leur appetit etait excellent et ils
paraissaient n'avoir aucunement souffert de I'inoculation de cultures virulentes.

Deux lapins injectes en m^me temps avec des cultures typhiques, mais qui n'avaient
pas subi Taction du vaccin, eurent des temperatiures tr^s variables, qui se main-
tenaient encore au bout de dix jours k 39,8 et seulement apr^s vint ime longue con-
valescence avec ime perte considerable de poids.

Les observations precitees sont convainquantes d'apr^s mon opinion et prouvent
deux choses: 1% que le vaccin eiabore k Tlnstitut National de Bacteriologie de La Paz,
au bout de 11 mois a conserve toute son activite; 2*, que son action efficace de defense
s'est montree egalement moyennant I'inoculation de cultures de bacille typhique ,

PTJBLIO HEALTH AND MEDICINE. 148

c'e0t k peine si une l^g^ et inaigmfiante fi^vie 66 produisit (^i^vation de tempera-
ture), tandis que lea t^moinfl souffrlrent gravement.

CONCLUSION.

Pour terminer, je croifi de men devoir de manifester que, d'apr^ mon opinion, la
v-accinoth^rapie de la fi^vre typhol'de est destin^e h substituer toutes lee autres formes
de traitement connues jusqu'aujourd'hui, et siur lesquellee elle a les avantages suivants:
facility d 'application, mortality minime et le manque jusqu'^ ce jour de centre-
indications qui pourraient faire craindre son application.

Monsieur le Directeuo' de Vlnsiitui National de BacUriologie Dr, Nistor Morales F.,

Prhent.

Gomme membre de la Commision Sanitaire, chaig^e de combattre r^pid^mie de
fi^vre typholde qui se d^veloppa dans lee Provinces de Arque et Tarata du D6-
partement de Oochabamba, j'ai eu Toccasion d'exp^iimenter Tapplication de votre
vaccin antityphique dont j'ai Thonneur, me r^f^rant k Tordre de rintenogatoire
formula par vous, de certifier les r^ultats sur les points suivants:

Premier. — Dans les multiples foyers ^pid^miques qui existent k Arque, comprenant
neul r^ons dans les hauteurs de la section de Golcha, deux dans la section de Chan-
goUa, Tacopaya, et trois regions de la Province de Tarata, le personnel de la commis-
sion ex^cuta d'apr^ les tableaux nominaux remis k cette Direction, 700 vaccinations
preventives et 40 inoculations curatives, obtenant un r^sultat plus que satisfaisant,
tel que la gu^rison de tous les malades et I'extinction de repid^mie en moins d'un
mois; d'oii Ton d^duit que le vaccin fut employee non seulement comme agent
]Nn6ventif mais comme agent curatif .

Deuxiime, — Dans les reactions autant locales que g^nerales des vaccinas pr^ven-
tivement, jamais aucun accident malheureux ne s'est pr^sent^. Dans lee typhiques
les reactions thermiques auxquelles la vaccination a donn^ lieu, se sent montr^es du
cdte de la defervescence, apr^ la troisi^me inoculation dans la plupart des cas et
dans quelques-uns apr^ la deuxi^me, comme le font voir les graphiques port^s k
votre connaiasance; avec la baisse de la temperature ont coincide I'attenuation et
Parrot des autres symptdmes morbides, obtenant au bout de quelques jours la guerison
du malade. Base sur ces faits de contr61e personnel et sur les r^ultats obtenus avec
un succ^ semblable par les Drs. Sejas et Villarroel, qui eux aussi, ont combattu
repidemie precitee, je consid^re que la vaccine antityphique constitue un puissant
remMe capable par lui-mdme de faire disparattre et de prevenir I'infection typhique.

Troisihne. — Dans le cours de repidemie des provinces citees plus haut de Oocha-
bamba, on employa seulement le procede vaccinotherapique excluant tout autre
traitement.

QyatrOme.—Aytait intervention de la vaccination antityphique, la mortalite etait
considerable, d'apr^s les renseignements foumis par les autorites et les doutes. Lassi-
tude, manque d'appetit, epitaxis (presque tous les malades presentaient ce sympt6me)
mal de tete violent, insomnie, enfin le tableau initial de I'infection t3n;>hique; puis
la fi^vre, le deiire, le caract^re de la langue, les perturbations intestinales les roulades
de la fosse iliaque, quelques manifestations bronyhiales et pulmonaires, si frequentes
dans cette maladie et autres symptdmes que je ne mentionne pas pour dtre plus bref,
guid^nt mon jugement pour faire le diagnostic que j'ai signaie. Les sept malades
etaient dissemines en different hameaux voisins du Saladillo de la fa^on suivante:
2 k Agua Blanca, 3 k Jagtle, 1 k TEstanque; 1 k San Pedro; la plupart etaient dans le
second septenaire, k San Pedro c'etait une jeune fille de 14 ans, plongee dans la plus
grande mis^ et qui presentait la forme typique de la fi^vre ataxe adinamique. H
est inutOe de dire qu'aucun d'eux n'avait ete traite si peu que ce sdt, ni qu'ils ne
pratiquaient mdme pas les r^lesd'hygi^e les plus eiementaires, vivant en repugnant
pdle-mdle avec les individus sains, mangeant et buvant ce dont ils avaient envie, et
se levant pour faire leuis necessites. Tout ceci explique Textraordinaire gravite de
revolution du proems morbide.

144 PROOEEDINQS SECOND PAN AMBBIGAN 80IBNTIFIG C0NQBB88.

En presence de la sftret^ que lee renaeigneinente cliniques me donnaient, je n'h^ritai
pas k appliquer imm^diatement lee injectioiui de e^rum antityphique, pr6par6 k
rinstitut de Bact^iiologie, par le Dr. Nestor Morales yillaz6n, et que le Pr^fet avait
eu la gentillesBe de me procurer.

Matin et soir je pratiquai k chaque malade une injection d*un demi-centim^tre
cube et j'eus la satis&u^on de constater un r^ultat splendide k partir du deuxitoe
jour du traitement. Chez un malade il suffit d 'im jour de traitement pour que la
temperature revint k son ^tat normal et les symptdmes qu*il pr^ntait disparussent;
chez les autres une tranche amelioration se produisit k la quatri^me injection, et chez
la malade de San Pedro k la cinqui^me injection je pus la considerer hors de danger.

Apr^ la demi^ injection je restai deux jours de plus observant les rdsultats d^fi-
nitifs et attendant de nouveaux cas qui ratifiaasent les triomphes obtenus sur les an-
terieuiB. Aucun ne se pr^sentant j'entrepris mon voyage de retour, regrettant de ne
pas pouvoir repasser k Gapillas par manque de temps et k cause du r^tablissement non-
d^finitil de ma sant^.

Je dois faire un acte de justice envers le jeune honmie Manuel Montafio qui fut
mon collaborateur d^vou^ et qui m'accompagna dans toutes les excursions que matin
et soir j'avais k faire pour visiter les malades. Cest 2l lui que je recommandais de
continuer k me foumir teiegraphiquement des renseignements sur les malades; ces
renseignements ont confirm^ pleinement la complete gudrison de ces derniers.

Je traitai aussi la convalescence de tous ceux qui» avant mon arriv^e, etaient tomb^s
malades, employant pour cela le r^ime tonique et reconstituant consellie pour
ces cas.

Avant mon arriv^e k Saladillo il y eut les malades suivants: Agua Blanca, 25; 5
d6ckB; k San Pedro, 12; 2 d^c^; k Saladillo, 3; pas de d^c^; k JagUe, 14; 3 morts; k
I'Estanque 9; 1 d^c^, qui ajout^s aux sept cas trait^s par moi donnent un total de
70 malades et 11 d^c^.

Refiechissant sur les causes qui ont pu determiner ce proc^ infectieux, j'en ren-
contre Pexpllcation dans la mauvaise quality de Teau. Ce sent des lieux depourvus
d'eau courante et leurs habitants doivent employer I'eau qu'ils retiennent dans
des excavations faites dans ce but. Pendant la saison des pluies ces depdts-li se
renouvellent constamment, mais dans la saison s^he, Teau qui n'est pas renouveiee
prend mauvaise odeur et subit des decompositions de tout genre, et Ton sait que
le microbe d'Eberth, agent producteur de la typholde trouve dans Teau un excellent
milieu de developpement; Pingestion de ces eaux produiairent les premiers cas,
la malproprete, le manque de precautions hygieniques se charg^ent de propager la
maladle sous forme epidemique.

Je dois faire remarquer une circonstance: le village de Comarapa est k mi-ch^nin
entre Capillas et Saladillo et cependant repidemie sauta, on pent le dire du premier
au deuxitoe point sans attaquor un seul individu du village; cellt est dfi 2l un ruisseau
.que ce dernier possMe et q\ii l\ii foumit de Peau propre et pas contaminee, qui le
sauvegarde des infections intestinales du genre de celle dont nous nous occupons.

Je terminerai. Monsieur le Prefet, ce point de mon rapport avec les conclusiaDS
suivantes:

1. L'epidemie qui se developpa aux environs du village de Comarapa fut la fi^vre
typholde.

2. Les sept typhiquee tndtes avec le vaccin preparee k Tlnstitut National de
Bacteriologie par le Dr. Nestor Morales Yillaz6n ont gueri compietement.

3. Hors le traitement hygienique general, aucun autre que le serum n' a ete employe
pour les 7 malades predtes.

4. Je crois que dans la mauvaise qualite de Teau reside Torigine de Pepldtoie.
Je profite de la presente occasion pour exprimer au Gouvemement, par Fintenne-

diaire de Monsieur le Prefet, la necessite d'etabHr d'urgence un service reguUer
sanitaire dans cette region.

PUBLIC HEALTH AND MEDICINB. 145

Toute cette region se prdte & ragiiculture et mtoe & P^evage du b^tail, car h eziste
en eCfet sur les collinee et dans lee vall^ dee labourages plus ou moins 6tendus, et
dans lesquels les produits de la contr^ viennent admirablement; mais iin obstacle
eziste qui s'oppoee & son prpgr^ puisqu'il d^cime lee bras ou lee inutilise pour an
labeur actif. c'est le paludisme. C'est la maladie dominante dans toute la contr^
et, enracin^ et propag^e de telle fagon, qu'il n'y a pas dans toute I'ann^e une saison
dans laquelle elle ne se pr^sente, et il est trke rare qu'un m^ecin ne rencontre dans
tous les habitants de cette h^on quelque vestige lointain ou r^ent de Finfection^
malarique.

n est certain que le paludisme dee r^ons temp^r^ ne rev^t pas la forme aiguS et
maligne des climats tropicaux que nous avons eu Toccasion d'observer au Beni, mais
il n'en est pas moins vrai que, malgr6 sa b^nignit^, il finit par causer de s^eux boule-
versements, affaibUssant les personnee auxquelles il s'attaque, minant Porganisme
le rendant prdt k contractor lee infections secondaires. D'autre part c'est Ik Tunique
obstacle qui empdche la population d'augmenter, car il s'abat surtout sur les enfants
du premier ftge, et ceux q\ii en ^*happent se d^veloppent alors dans une pauvret6
ovganique extreme, soutenue souvent pendant leur existence par la t^nacit^ de la
maladie.

L'histoire de la decadence de la valine de Mizque, florissante auparavant, est
un ttooignage frappant du labeur destructif du paludisme. Fampagrande qui 6tait,
il n'y a pas longtemps, un centre de commerce assez important, se trouve aujourd'hui
converti en un triste hameau depuis que le paludisme y fit son apparition et je ne
m'avance pas trop en disant que cette maladie est 1' unique entrave au progr^ de ces
r^ons.

Maintenant que les pouvoirs publics s'int^ressent k encourager notre commerce k
renforcer noe Energies productrices, k aider I'augmentation de notre population, qui
est la base de Pagrandiseement national, ils sont oblig^ d'entreprendre I'oeuvre
homanitaire de combattre la maladie qui flagblle ces malheureux villages, en employ-
ant pour cela les ressources dont dispose la science.

Tout d'abord, et comme oeuvre initiale, s'impose la n6ceesit6 de la crtetion d'un
poste pour un m6decin titulaire, dont la rMdence serait fixte k Comarapa, et qui
serait chaig6 de surveiller les environs et de Mre surtout une guerre sans merci au
paludisme. Cette base Stabile, on pourrait ensuite accorder un vaste plan sanitaire
qui en peu d'ann^ donnerait les plus beaux r^sultats.

Propi^taires des lieux infect^, ayant atteint dans quelques endroits le tiers de la
totality des habitants. Avec le traitement par vaccinothtopie il y eut seulement
on d6c^ sur lee quarante malades traits.

Cinqmhru. — Quant k la dur6e de la maladie par le traitement vaccino-antityphique,
on a observe que la baisse thermique s'effectuait du troisi^me au quatri^me jour,
c6dant graduellement les jours successifB les autree manifestations symptomatiques,
jnsqu'au sixidme ou huiti^me jour oti la gu^rison du malade s'accentuait.

Ces r^sultats mettent en Evidence la bont6 et Tefficacit^ de ce nouveau traitement
qui non seulement attaque la cause m6me de la maladie, mais r6duit considerable-
ment le temps de son Evolution.

Dr. Jxius F. Mkndosa..

La Paz, le 13 novembre, 1913.

The Chaibmak. Through the courtesy of the author, the following-
named printed volume is presented to the congress through Section
VIII: La blastomicosis humana en el Perti y Bolivia, by Ekimundo
Escomel. Arequipa, Perti, 1914.

The session adjourned at 6 o'clock.

GENERAL SESSION OF SECTION Vm.

New Ebbitt Hotel,
Wednesday morning, December £9, 1915.

Chainnan, William C. Qobgas.

The session was called to order at 9.30 o'clock by the chairman.

Dr. Caeteb. Mr. Chairman, we were imable to avail ourselves of
the assistance of Dr. Vital Brasil, as he foimd it impossible to be
with us. The following report prepared by the majority of your
committee on the amendments suggested by Dr. Guiteras is now
submitted:

Referring to the matter of amendments to the International Sanitary Convention
submitted to us, this committee is of the opinion that all changes in said convention
oug^t to be considered and acted upon by the Sanitary Conference of the American
Republics, which meets at Montevideo for that purpose, and therefore the amendments
proposed should be matter for such conference to consider, together with such opinions
as may have been expressed by other members of this section. No report on this
subject, then, from your committee seems called for.

Dr. Kobeb. I move the adoption of the report.

Seconded and approved.

Dr. George M. Kober took the chair.

The Chaibman. The following papers wiU be presented at this
session:

The alcohol and drug habits and its prophylaxis, by Dr. Harvey
W. Wiley.

Os fumadores de maconha: efiFeitos e males do vicio, by Dr.
Rodrigues Dona.

El problema del alcohoUsmo y su posible soluci6n, by Luis L6pez
de Mesa.

Lucha contra el alcohoUsmo, by Dr. Ricardo Sarmiento Laspiur.

THE ALCOHOL AND DRUG HABIT AND ITS PROPHYLAXIS.

By HARVEY W. WILEY,
CarUribuUng Editor, Good Housekeeping Magazine,

What is a drug habit? The taking ol any stimulating, exciting drug which has no
food value, and which produces directly excitation of any of the organs of the body
or nerves controlling them in such a way as to suggest or compel a repetition of the
dose, is a drug habit. The drugs which are commonly used for this purpose are alco-
hol, tobacco, opium and its derivatives, chloral, cocaine, acetanilid, phenacetin,
146

PUBLIO HEALTH AND MEDICINE. 147

andcaffein. There are many other drugs which tend to produce a habit without
appealing to the sense of artificial relief, as, for instance, those which are used habitu-
ally to correct constipation. These drugs, however, are not so commonly employed,
nor is the habit which they induce difficult to overcome. A very distinguished friend
of mine told me recently that he had been taking for years sodiiun phosphate, regu-
larly, as he would his meals. He had grown into the conviction that his physical
well-being would be so disturbed by the omission of this dose that he did not dare to
leave it off.

The habit-forming drugs which are most extensively used are alcohol, nicotin, and
caffein. If we class as drug addicts those who have acquired the habit for one or more
of these drugs the number of them in the United States would be very close to half
or two-thirds of the population. When we speak of drug addicts, however, we usually
have a mcnre restricted sense and refer rather to those who are slaves to opium or the
coca leaf and their derivatives. I, however, for the purpose of this paper include all
drugs of the class mentioned above.

The methods of acquiring these habits are so well known that I need not dwell
long upon them here. Unfortunately for the reputation of the medical profession, it
is certain that a very large percentage of the cases of opium addiction is due to the
use of this remedy in some form in regular medical practice. The same is true,
though to a less extent, of cocaine. In regard to alcohol the case is quite different.
A half or a third of a century ago alcohol in some form was very conmionly adminis-
tered as a remedy, and doubtless in these cases the alcohol habit was often acquired
in this way. At the present time the use of alcohol in any form in medicine, except
as an external application, is becoming extremely rare, and no notable percentage of
alcohol addicts to-day can justly claim that they have become so through the minis-
trations of the medical profession. In so far as the use of tobacco is concerned, the
medical profession is entirely innocent, as tobacco is rarely, if ever, used as a medicine.

The drug habit is usually the result of imitation — ^in oth^ words, of example. If
parents use a drug at home the children fall into the same habit. It is rather embar-
rassing to explain to the child that father or mother may use wine, or whisky, or
brandy, but ^e child must not. It is equally difficult to explain why the grown per-
sons of the family may use tea and coffee and the children are denied this privilege.
The child learns from his parents. He imitates his parents. He wants to act as they
do. He makes the same motions with his body as they make. He leams to walk as
they do and to talk as they do, and naturally he leams to eat and drink as they do.
But every child who has been properly taught to avoid tobacco, when he grows to be
a schoolboy or a freshman is very likely to think it more or less manly to use tobacco.
How many boys have been led astray by this false idea of what manliness consists of.
If a classmate uses tobacco his chum is likely to indulge in the same practice.

F^tunately in many States fhe use of tobacco, especially cigarettes, by minors is
an offense against the law. In many colleges and universities, also, the use of tobacco
is discouraged. But nevertheless the use of tobacco is not in any way regarded as a
social crime. In fact, it is looked upon as an indispensable adjunct of social affairs.
When the dinner is over the men retire to the smoking room. In so far as equal rights
are concerned there is no reason why the women should not do the same instead of
going to the gossip room. That men should segregate themselves when they smoke is
a silent tribute to the other sex. Otherwise there would be no reasonable excuse for
segregation. Often young women encourage their admirers to smoke. In all these
ways the tobacco habit is encouraged.

In this country, at least, the use of alcohol is, as a rule, discouraged by all persons,

except at dinners. The youth of the country are not by any means so obnoxious to

the acquirement of the alcohol habit as they were in former years. More and more

restrictions of a l^gal nature against the use of alcoholic beverages are coming into

6848(^-17— VOL IX 1 1

148 PKOOEEDINGS SECOND PAN AMEBIOAN SCIBNTIPIC C0N0BES8.

vogue. The area of prohibition is constantly expanding. The social protest against
the use of alcoholic beverages is growing stronger. The propaganda for prohibition is
becoming more widely spread, and all of these forces are tending to repress the
communication and spread of the habit.

In regard to the more potent drugs, such as opium and coca and their derivativee,
the restrictive legislation is more effective. Not only is there State and municipal
regulation of the traffic, but now we have a national law which, while far from per-
fect, is doing much to curb the possibilities of the acquirement of the habit of using
these two drugs. One of the chief faults of these restrictive laws is the concession
which is made to almost all of them of the use of certain minimum quantities without
restriction. There is no question of the fact that the insertion of such proviso in
National and State laws is a mere concession to Mammon, which was secured by a
desire to placate the dealers in these drugs. If one can secure with impunity a pre-
scription containing a small amount of opium or coca or their derivatives, he has only
to make arrangements to get a sufficient number of doses to secure the effect which
he is seeking. The regulatory laws applying to conmierce in these articles should
extend to even the minimum quantities which are employed in ordinary medi-
cation. In point of fact, the administration of any of the derivativee of opium or of
coca should be surrounded by the strictest safeguards. There are so many other ways
of relieving pain which are not likely to form the habit that the physician should
hesitate a long while before either morphine or cocaine is employed. It is a re-
sponsibility which should affect the conscience of the physician keenly, and which
in no way should be subjected to evasion.

It is difficult to make a census of the number of drug addicts in the United States.
In most cases the victims of the drug habit are thoroughly ashamed of their pitiable
condition. No one, as far as I know, is proud of the fact that he is a drunkard. No
one that I know boasts of the fact that he takes morphine or cocaine daily. No one is
proud of the fact that he uses tobacco. No one boasts of the fact that he could not
live without coffee, tea, or coca cola. The progress in ethical culture and in manli-
ness and womanliness of conduct have driven drug addicts to cover and made it more
or less a stigma to be known as such. Thus, any attempted census of the number of
addicts must be more or less difficult to make.

Commissioner of Health Lucius P. Brown, of Tennessee, made a very extensive
study of the probable number of drug addicts in that State, and he found that there
were registered in Tennessee in harmony with the provisions of the antinarcotic law
of that State 2,370 persons of all ages and colors, of whom 33.1 per cent were males and
66.9 per cent females. This was a census of those persons only who used opium or
cocaine or their derivativee.

Dr. Martin I. Wilbert, of the Public Health Service, has contributed an interesting
and valuable document on this point. In a pamphlet entitled ' ' The nimiber and kind
of drug addicts, " basing his computation on the data obtained by Dr. Brown, he esti-
mates that in the United States there are 118,000 drug habitues of opium and cocaine,
consuming approximately 1,416,000,000 doses per year. Including the illegitimate,
that is, illegal, use of narcotics, at a certain estimated ratio over those declared, Wilbert
finds that there are not more than 187,000 users of opium and its derivativee in all
parts of the United States, and he adds that there are probably 150,000 cocaine addicts
in the United States, making a total of something over 300,000 of both kinds of victims
in this country. The committee of the American Pharmaceutical Association esti-
mates that in this country the total number of victims of opium and cocaine are not
much in excess of 200,000, and Wilbert is of the opinion that this is a figure that ia more
nearly correct than that based upon the data gathered in Tennessee.

One of the principal objections to the enforcement of the Federal antinarcotic law,
known as the Harrison law, was an appeal to sympathy for addicts suddenly deprived
of their daily dope. While it is true that there may be some intense suffering, as with
the delirium tremens after a debauch of alcohol, it is better, in my opinion, to let a few

, . .. I PX7BU0 HEALTH AND MEDIOIKB. 149

victimfi suffer acutely rather than to threaten the whole mass of the people with dis-
aster. Wilbert quotes from the coroner's chemist of Cook County, as reported in the
journal of the American Medical Association, that during the month of March, 1915,
seven deaths occurred in Cook County that were indirectly due to the sudden cessation
of the use of morphine. Four died from taking an overdose of morphine. One of
them died from a dose of Dr. Wetherby's Remedy, a morphine cure containing over
17 grains of morphine sulphate per ounce.

'Mlbert has collected data, also, relating to the origin of drug addition, particularly
that drug addiction of opium and cocaine, and quotes from Dr. Terry, the health officer
of Jacksonville, Fla., in the Journal of Public Health for 1914, that 54.6 per cent of
morphine victims came from the use of physicians' prescriptions or similar prescrip-
tions administered personally; that 21.6 per cent acquired the habit through the
advice of acquaintances who were, for the most part, themselves drug addicts; through
dissipation and evil companions, 21.2 per cent; through chronic and incurable disease,
2.4 per cent. These conclusions of Terry agree very well with those found by Dr.
Brown, of Tennessee, who is of the opinion that from 90 to 95 per cent of the persons
habitually using narcotics never have had and never would have any necessity for
their use.

It is of interest to inquire how long it b necessary to use a drug of this kind, especially
opium or morphine, in order to acquire the habit. There is no possible way of defi-
nitely answering this question, because it is more a personal factor than it is a factor
of the drug itself. Some persons would acquire the habit after a few days of use, while
others might use the drug for a month, two months, or three months, without acquiring
the habit. It is of little utility, therefore, to discuss this point, as the only safety lies
in abstention.

From what has been said above the means of preventing the drug habit are apparent.
First of all, education. Education, not of the drug addict but of the people at large,
and this education must begin at the bottom and not at the top. Children must be
instructed from the very beginning of their career in regard to the dangers of drugs
^f this kind. Parents are imder obligations to protect their children, by a proper
instruction and example, from these dangers. The school is the next place where
this instruction should be continued. The school teachers of the country should be
thoroughly acquainted with the facts relating to the acquirement of these habits and
the dangers of acquiring them. Regular instruction should be given in our schools
respecting the desirability of refraining from the use of alcohol in any of its forms,
tobacco, opium, cocaine, tea, coffee, and synthetic drinks, such as coca cola, con-
tuning caffein.

I believe more in education than I do in legal restriction. I must confess, however,
that legal restriction seems necessary in respect of some of the more dangerous drugs.
In other words, I would faivor rigid control of traffic in alcoholic beverages, in opium
and its derivatives, and in coca leaves and their derivatives. I would not be in favor
of any restrictive legislation respecting tobacco and tea and coffee, except in so far
as children are concerned. I would, however, apply very restrictive legislation to
all 83mthetic drinks or preparations containing any of tiieee habit-forming drugs.
The natural articles might go, as far as grown people are concerned, without regula-
tion, but the synthetic articles should be rigidly forbidden. What advantage is it
to the parent, for instance, who teaches his chil(hren at home not to drink tea or cof-
fee, while they go to the drug store and buy a synthetic beverage, which contains
the very element, caffein, which the parents are guarding their children against?

Dtb. Fisher and Fisk say in their new book ''How to Live, " page 65:

Among the poisons which must be kept out of the body should be mentioned habit-
forming drugSj such as opium, morphine, cocaln, heroin, chloral, acetanilid, alcohol,
caffein, and mcotin. The best rule for those who wish to attain the highest physicai
and mental efficiency is total abstinence from all substances which contain poisons
including spirits, wine, beer, tobacco, many much-advertised patent drinks served

150 PROCEEDINGS SECOND PAN AMEEICAN SCIBNTIPIC CONQBESS.

at soda-water fountains, most patent medicines, and even coffee and tea. Many so-
called patent or proprietary medicines contain habit-forming drugs, especiall^r mor-
phine, coal-tar preparations, caffein, and alcohol, and depend lately for their sale
upon the effects of these harmful substances.

In a recent article in Good Housekeeping Magazine on the dangers of the use of
tobacco I say:

While tobacco, next to alcohol, is the most generally used narcotic or sedative, it
stands on an entirely different plane from that occupied by alcohol, opium, cocain,
and other dangerous and seductive drugs. As has been indicated in the preceding
sections, the use of tobacco is popular and does not yet generally off^id the public
taste. To be sure, its use is surroimded with restrictions which oug^t at least to call
the attention of the people to the ^t that there is something wrong with it. From
the ethical point of view this condition is, of course, restrictive, but from a moral
point of view the use of tobacco is practicall>r unhinaered. The man who indulges
to excess in alcoholic beverages loses, to a certain extent, his standing in a community,
but from a moral point of view the character of the smoker still stands untouched.
As long as ministers of the Gospel, school teachers, business men, captains of industry,
women leaders of high society, and young girls, continue to promote and encourage
the use of tobacco, the habit will not be re«krded as a moral obliquity. The readers
of Good Housekeeping ought to consider tne promiety of consiBtently discouraging
such an expensive, useless, and dangerous habit. Their boys and girls should be told
the truth about tooacco and the havoc it works. They should be taught by precept
and example that it is not manly or womanly to use it. If it were mamy to use
tobacco it certainly would be womanly, and yet 90 per cent of the readers of Good
Housekeeping would be horrified to think ot the use of tobacco becoming as general
among girls and women as it is among boys and men. Let us take care that no such
condition arises. Let us, by precept and example, discourage the tobacco habit.
Let us encourage our formers to plant a less acreage of tobacco and a greater acreage
of potatoes.

Many pathetic letters are received from wives and mothers asking for a *' tobacco
cure,'' that the habit may be vanquished merely by dosing, without any effort or
self-denial or duffering on the part of the habitu^. There is no such cure known,
though tonics, restraint, and certain drugs mav be used under observation to assist
the patient if he is ready to cooperate, ^ut tne patent medicine man who sends a
secret preparation, and at long distance guarantees a ''cure" is only indulging
false promises of his kind. Strength of will can not be supplied from a bottle or a pifi
box. The football player lays aside his cigar, pipe, or cigarette, aided only by a
nourishing diet, fresh air, exercise, and an overwhelming desire to throw aside every
handicap that he may "make good" and win the game. Surely any sensible boy or
man. when once convinced of the dangers of the habit and the physical and mental
hanoicap that it represents, would and could make an equal effort to "make good''
in the race of life.

I appeal to the mothers of the country. Consider the following facts concerning
the boy who uses tobacco:

1. He will acquire a habit which will bring him into sympathetic associations
with the boys who are going to the bad.

2. He will be a slave to a habit which segregates him from the decent crowd ol
travelers and spectators.

3. He will join the procession that is made up of maichen with hesitating stept,
shaky hands, and palpitating hearts.

4. He will unfit himself for athletic sports and high attainments in his studies.

5. He will weaken his resistance to disease and fall an easy victim to infection.

6. He will exclude himself from many activities leading to higher pay and
preferment.

7. He will waste large sums of money while doing himself lasting and even iaM
injury.

8. He will mcHre readily become a victim of alcohol, cocain, opium, and otiier
narcotic drugs.

9. He will mar the efficiency of his work.

10. He will shorten his life.

11. His presence will disclose itself to the nostrils of the next.

12. He will finally become a slave to tobacco and other kindred masters of misery.

PUBLIC HEALTH AND MEDICINE. 151

OS FUMADORES DE MACONHA: EFFETTOS E MALES DO VICIO.

Por RODRIGUES DORIA,

Prcfiuor de Medicina Publica da Faculdade de Direilo e cathedraticOj em dispanibilidade,

da Faculdade de Medicina da Bahia.

ActQeUement daos la plopart des pays da monde, I'homme, ft qnelque rang de la soei^t^ qa'il apparti-
• nne, ftdt osage poor sa satisltetlon personalia daoertalnes substances toziqnce, particnlidrement excitant ca
twar son STSttena nenrenx. Get osafo remonte anx ^poqoes les pins reoul^, se perp^tae de gdn^ration
•a ftetfration en se translbrmant parfois soivant les caprices de la mode, et va souvent Josqu' h Tabus
oocasionnant alors les tronbles les plos varlte oomme formes at oomme intensity.— Dr. Roger Dapony,
Le$ Ophmami.

Os Chinezes, vencidos em 1842 peloB Inglezes, tdveram de se submetter & ganancia
commercial dos brancos civilisados, que os obrigaram a abrir de novo os sous portos
e consentir na importa$&o do opio, que tan to tem estragado e deterlorado a milhdes
de filhos do Celeste Imperio. 0 vicio de fumar a dr6ga n&o ficou, porem, limitado
^uelles povos orientaes; acompanhou os usuiaiios desse commerclo nefasto, e hoje
Ua as suas devasta^Oes em varios paizes da Europa, espedalmente na Inglaterra e na
Franca, onde se encontram em maior profus&o as casas de fumar o chandoo ou o droes,
"]6 o vencido que se vinga do seu vencedor/' diz o professor E. R^gis, no Prefacio
do Le$ Opumianee do Dr. Roger Dupouy, " inoculando-lhe sua perigosa paixfto atavica,
o que Brunei soube com propriedade chamar uma avaria Extremo Oriente."

Outrotanto podemos tambem dizer: os nossos antepassados, avidos de lucro, fizeram
o baizo trafico da came humana, no come9o da nossa forma^&o, at6 1851, quando foi
decretada a prohibi^fto de impc^tar os pretos africanos, arrebatados & fnii9ao selvagem
das suas terras, para serem aqui vendidos, como escravos, que as leis assim os recon-
hedam. Em 13 de Maio de 1888, por entre alegrias e festas, foi promulgada a lei
que aboliu a escravid&o no Brazil e integrada a nacionalidade com os libertados, tor-
nados ddadfios; mas no paiz j& eetavam inoculados varios prejuizos e males da exe-
cravel institui^fto, dlfficeis de exterminar. Dentre esses males que acompanharam
a ra^ subjugada, e como lun castigo pela usurpagfto do que nuds precioso tem o ho-
mem — a sua libardade—nos ficou o vicio pemicioso e degenerativo de fumar as sum-
midadee floridas da planta aqui denominada fumo d*Angolay maconha e diamba, e
ainda, por corrupt, liaTii&a, ou riamba,

A paJavra yumo, que quer dizer propriamente os gazes nuds ou menos densos que
se desprendem dos corpos em combustfto, substituiu no Brazil, quer no conmiercio,
quer em outras relayOes, o vocabulo tabaco para designar a nicotiana tahacuMy seja
a planta viva, sejam as folhas preparadas para serem fumadas, como quando sfto
enroladas em corda, ou dlspostas em mandcas — expressilo brazileira dada aos m61ho8
(manojos) de folhas proprias para a confecg&o dos charutos. A analogia do uso das
fdhas da diamba e da nicociana certamente determinou a denomina^ de fumo
d' Angola, derivada ainda dessa parte da Africa occidental, possess&o portugueza,
donde naturalmente nos veio a planta. Por este nome ouvi muita vez chamar o
vegetal em Sergipe e Alagoas, nas maigens do rio S. Francisco.

Nos diccionarios da lingua portugueza de Adolpho Coelho, Aulete, Silva Bastos e
outros, 16-ee que a palavra "liamba,'' o mesmo que pangoy indica herva do Brazil,
da iamiHa das myrtaceas (canjidbie eatxva indica) ^ ^'de cujas folhas, diz Moraes, os
negros usam como tabaco, que fumam em cachimbos, e Ihes produz o effeito pemicioso
do opio; por isso fd em tempo a sua venda prohibida por posturas munidpaes da
Camaia da Cidade do Rio de Janeiro; tambem Ihe chamam liamba e riamba.'' *

I Fwtoras da Oamara Mimidpal do Rio da Janeiro, Seocio Prlmeira. Sands PnbUoa, TH. 2*. Sobre
▼«iidadaisiisrasareBadle8,asobrabolleario9.|7*. HaprolifbldaavcodaeoasodoPiodoPango,bem
eoao a suassriaplB dalla sa easts p«rt)lloasi m aoatraTantores serto moltadoa, a saber, o Ttndedor em
901000, a €assoravos,emaispcssoas qua dalle nsarem, em SdiasdeCadte. Pago da Camara Manidpal do
Rio da Jaoslio am sesslo de 4 de Ontnbro de 1880. O Presidente, BmUo it OUoMm Bra§a,Joafuim Jcei
aom, Ammh Joet Bfbdro is (^nJka, /oOo JoU is CitnU, BmHtmi JoU ie Amitj9,

152 PB0CEEDING8 SECOND PAN AMEMOAN SOIBNTiriO C0NQBB8S.

A planta n&o 6 entretanto brasileira, como pensam os primeiroB lexicographos
citados, e informam algunB fumadores, que dizem f6ia primitivainente usada pelos
indios. Minha atteny^o foi chamada para a maconha, e seu uso no Brazil, depois
da leitura de um trecho da obra de Bentley — A manual of hoUm^ — no qual, tratando
da familia das Gannabinaceas, e referindo-se & Cannabis saJtiva^ e a sua variedade
indica, diz o autor: ''Esta planta 6 igualmente conhecida sob o nome de Uamha,
na Africa occidental, onde i empregada para fins intoxicantes sob os nomes de nuiconta,
ou makiah,** Conseguintemente, o facto de ser o vegetal largamente usado pelos
pretos africanos, nas antigas provincias, hoje Estados, onde elles abundavam, a
paridade dos nomes que aqui so&eu ligeira modifica^So, mudanga apenas de uma
letra— maconha, llamba ou liamba — e o appellido de fumo d' Angola, indicam bem
a sua importa^SU) africana. Em 1910, quando eetive na presidencia do Estado de
Seigipe, pude fazer a identificag^U) da maconha coin, o canhamo, cultivando alii a
planta com sementes adquiridas nas margens do rio S. Francisco.

]6 principalmente no norte do Brazil onde sei achar-se o vicio de fumar a maconha
mais espalhado, produzindo estragos individuaes, e dando por vezes lugar a graves
consequencias criminosas. Neesa parte do paiz, primeiramente se desenvolveu a
lavoura da canna de assucar, e foi grande a importac&o de escravos, que mais tarde, com
o augmento grandemente remunerador do plantio do caf^, nas provincias de S.
Paulo e Rio de Janeiro, eram vendidos para o sul. Os indios amansados aprenderam a
usar da maconha, vicio a que se entregam com paix&o, como fazem a outros vicios,
como o do alcool, tomando-se habito inveterado. Fumam tambem os mestizos, e 6
nas camadas mais baixas que predomina o seu uso, pouco ou quasi nSo conhecido
na parte mais educada e civiU^ula da sociedade brazileira. ''Na Africa, diz Charles
Eloy (Diccionaire encyclop^dique des sciences m^cales, artigo nasch\dt\ das
margens do Mediterraneo at4 o Cabo da Bda Esperan^a, 6 vulgar o empr^go da cannabis
indica, e nas diversas partes da Asia mais de duzentos milhOee de homens tSko escravos
deste habito." A esse numero pode-se accrescentar o de centenas, ou antes, de
milhares de brazileiros.

A Africa jd havia recebido a planta da Asia, onde nasce espontaneamente ao p6 das
montanhas al6m do lago Baikal, e em outros sitios, e com a qual preparam o luucMch.
Taes sSU) os sens effeitos pemiciosos, que delle deriva a palavra assassino, vinda do
arabe hachich, ou p6 das folhas do canhamo, com que elle 6 preparado (Adolpho
Coelho) . 0 Diccionario da lingua ingleza de Webster consigna esta mesma etymologia.
Conta-se que na idade media, entre 1090 e 1260, os principes do libano, espedalmente
Hassam-ben-Sabak Homairi, appellidado o VeUio da Montanha, fazia os sous soldados
usarem a planta, para fanatizal-os, e, com furor, assassinarem os inimigos, e a l^enda
chamou-o principe dos haschischinos.

O cultivo da maconha, ou do canhamo, entre n(56, n&o 6 laigamente espalhado, por
nSo ser aqui utilisada a liamba na industna das fibras textis, e somente empregada
como planta da feliddade, causando as delicias dos que a fumam pelo extasis em que
entram. Esse cultivo 6 acompanhado de praticas fetichistas, que bem fazem lembrar
a celebrada mandragora da antiguidade. Os mysterios que cercam os cuidados com
a planta concorrem para Ihe dar mais valor, exal^ar as suas virtudes, excitando a
imaglna^^U) dos ignorantes, suggestionando-os. Os meus coUegas e amigos Drs.
Aristides Pontes, clinico em Aracajd, e Xavier do Monte, em PropriA, attendendo
bondosamente as minhas solicita^Oes, fizeram em Sergipe, nas suas respectivas cidades
inqueritos, que muito me v&o auxiliar na confecgSU) deste ligeiro e despretendoeo
trabalho.

A planta, da familia das cannaUnjaceaM^ ^ herbacea, annual, attingindo em Sergipe,
como verifiquei, um metro e meio mais ou menos de altura, dioica, com folhas inferi-
ores oppostas, e altemas as superiores, estipuladas, de limbo profundamente fendido,
com 5 e 7 lobulos, de bordas serrilhadas. A inflorescenda feminina 6 em esplgas
compostas; as flores s&o regulares, na axilla de uma bractea persistente, que envolve

PUBLIC HEALTH AND MEDICINE. 153

o fructo, o qual 6 urn achenio, amarello eecuro, com venulaydes claras. As inflores-
cendaa masculinas silo em cachos de cymos. As inflorescencias occupan os vertices
das hastes.

Dizem os cultivadores que o vegetal macho nfto attinge o cresclmento, nem tem a
abundancia de ramificac&o da planta f emea, e s^ mais delgados os seus ramos. Isto
talvez devido aoe culdados malores que teem com a femea, empregada do preferencia
em todos os mysteres, excepto, na medicina popular, quando d&o em infusfto contra
as colicas uterinas. Somente neste caso recommendam as infloresceuclaa e folhas da
planta ma$culina,

E* sem a menor duvida o vegetal cultivado e usado no BrazU sob a denomina^ de
maconha, fumo d' Angola e diamba, nada mais do que o canhamo— CcmTui&M sativa, ou
a sua vaiiedade incftca, que nos paizes quentes adquire propriedades mais activas e
eneiglcas, e com a qual os asiaticos preparam o haschich e outras misturas, e cujas
folhas, colhldas na ^pocha da flora^&o, e deseccadas, sSU) por elles fumadas, sob a de-
nomina^ de gunjah,

Quando a planta attinge certo desenvolvimento, e tende a serami£car, procedem ao
processo da capa0o, que consiste em cortar o olho ou o rebento terminal, para provocar
o desenvolvimento de olhos lateraee, e, portanto, produzir maior ramificag&o, & semel-
han^a do que fazem os cultivadores da nicociana.

Essa opera^, effectuada no segundo mez da vegetal, nSo deve ser feita em
presen^a de mulheres, que n&o podem tocar o vegetal, principalmente em occaaifto
das regras, pois faz machear a planta, isto ^, esta produzird inflorencias masculinas
que 8&0 as menos apreciadas. Essa lenda a respeito da mulher menstruada 6 bem
velha, e j& Plinio, o Antigo, dizia que t&o violenta era a toxicidade do sangue menstrual
que o seu contacto, ou mesmo o seu vapor, podia azedar o vinho, tomar estereis as
sementes, queimar as plantas novas, matar os enx^ios, seccar os fructos, e diversas
coisas mais. Durante a opera^ feita sobre o fumo d' Angola, o operador deve ter
o ciddado de n&o dizer obscenidades, nem assoviar, o que commumente fazem os
lavradores durante o trabalho do campo, porque dar-se-iam os mesmos resultados que
a approxima^ ou o contacto de uma mulher durante o catamenio.

A colheita se f az na maturidade da planta, e sfto usadas de preferencia, ou quasi
excluaivamente, as inflorencencias femininas, com os envolucros floraes e bracteas.
Essas partes sfto deseccadas & sombra, expostas a correntes de ar, e depois algumas noltes
ao rolento para reeeberem o sert^no e ficarem curtidaSf ou sofirerem fermenta^fto,
o que as toma, dizem, mais agradaveis ao fumar, modificando esse proctsso a acrides
da planta e abolindo as suas propriedades nauseabundas.

A maconha 6 ordinariamente fumada pura, ou mlsturada ia vezes ao fumo — nicoc-
iana— em cigarros, cujo envolucro 6 felto de bracteas de milho (Zea mais) das mais
centraee, por serem mais delgadas e maclas, ou em cachimbos, depois de separados
oe fructos, o que fazem collocando as infloreecencias na palma de tuna mlio e com a
outra Imprimindo um movimento rotatorio sobre a massa. O f omilho do caoiiimbo 6
na maioria dos casos de barro, grosseiramente confeccionado, e ennegrecido, depois
de cosido, com a fumada de certos vegetaes reeinosos, que os toma luzidios exterior-
mente. Nas maigens do rio de S. FVancisco fazem tambem o cachimbo de pedra.
A capaddade do fomilho ^ igual a dos cachimbos conmiuns de g^sso, ou de espuma,
ao qual 6 adaptado um tubo de desprendimento da fumada, f eito de madeira. Esco-
Ihem para isto ramos de um vegetal a que donominam canudeiro^ pau de cachmibo ou
canudo ds pita, Carpotroehe brazUientit Endl, Bixacea$f em virtude de ter o caule
fistuloso e do mesmo diametro em grande extensfto. Com um furfto aquecido ao rubro
removem os restos da medulla, e ds vezes enfeltam-nos toscamente com annels e
liscos, exteriormente, feltos a fdgo (pyrogravura). Alguns servem-se tambem dos
ramos da coirana, Centrum laevigatum, Schl«»cht, da familia das solanaceas. Para
mitigar a acp&o irritante da fumaya que provoca tosse, e ia vezes faz espirrar, adaptam
o cadilmbo a um dispodtivo, em imitagfto ao cachimbo turco, e pelo qual a fumada 6

154 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

lavada, deixando n'agua, se^ndo dizem os fumantee, o sarro, e ficando mais fresca,
agradavel, aromatica (?) e activa. Esse dispositivo consiste em uma garrafa com-
mum, ou em uma cabaya, que 6 o fnicto de uma cucurbitacea, Lagenaria vulgaris^ do
qual extrahem as sementee e a pdlpa por um furo no ponto da inser^fto do pedunculo.
Esse fructo tem a perspectiva de 8, sendo o bdjo inferior muito maior do que o superior.
Chamam-n'o tambem grogoi6, nome proveniente de grogolxy que quer dizor ''vaso
cheio d'ae^a em que se immerge o tubo dos cachimbos para reahiar o fumo'* (Silva
Bastos, Dice, portuguez). Como se v6 dos desenhos, introduzem o tubo do cachimbo,
que tem uns 30 centimetros, mais ou menos, pelaboccadaf2;arrafa, at^ mergulhar na
agua, que em certa por9ao ostA no interior. Este 6 o dispositivo mais rudimentar, e
fumam applicando oslabiosdirectamentesobre a bocca dagarralaquenSo fica de todo
obturada, e onde chupam, precisando um certo exercicio para conse^i^uirem af«pirar
hem a fuma^a. Uma dapla tubuladura, sendo um dos tubos curvos para embocadura,
ji 6 um apdrfeiyoamento. No dispositive da cabapa fazem um orificio no bdjo menor,
onde collocam um pequeno tubo de taquary, meroitachys daussenij gramineaSy onde
chupam, puxam a fuma^a, como se exprimem os praticantes. As vezee aspiram
directamente, pondo os labios sobre a cabala. Esses carhimbos constituem um
arremMo do narghileh ou cachimbo turco, usado nas casas de fumar o opio, ou nos
bazares arabes onde se fuma o haschich. Ao cachimbo com o dispositive da garrafa
ou da cabala dfto, na giria dos fumantes (Aracajd), o nome de Maricas, Os mais
refinados no vicio, fazem no tubo do cachimbo, na parte que fica fora da garrafa ou da
cabala, um pequeno furo para se desprender um pouco da fuma^a^ que nSo f oi lavada, e
provocar espirros, irritando a pituitaria, e const^tumdo isto um epiphenomeno po^^tico
do vicio. O Maricaa 6 companheiro inseparavel dos canooiroe e barcaceiros. E'
tambem apreciado entre elles o borborinho que ao atravessar a agua produz a fuma^a
sorvida em profundos e esfor^ados tragos.

0 uso do canhamo 6 muito antigo. Herodoto falla da embriaguez dos Scythas que
respiravam e bebiam a decocgfto dos grftos verdes do canhamo. No livro de Botanica
do Dr. J. M. Caminhod, que foi professor desta materia na Faculdade de Medicina do
Rio de Janeiro, l^se que o famoso remedio das mvXhera de Diospolis, bem como o
nepenlheB de que falla Homero, e que Helena recebera de Polymnesio, en^ a cannabis
indica. Os Cruzados viram os effeitos nos Musulmanos. Marco Polo observou nas
cdrtes orientaes entre os emirs e os sultOes. £' muito usado no valle do Tigre e Euph-
rates, nas Indias, na Persia, no Tukerstan, na Asia Menor, no Egypto e em todo o
literal africano. Com o canhamo se prepara o Aaac^icA, como jd foi dito, e ainda
pouco conhecido na sua manlpula^; o povo do Oriente fuma o p6 das folhas e flores
no narghileh.

Entre as differentee mistiuus em que entra a planta formando a sua base, e que tem
nomes diversos, os mais usados sfto o dawamec (da Arabia), o mapouchan (do Cairo) ,
e o maoou (de Calcutd). Naquellas partes os hachahs, comedores, bebedoree u fuma-
dores, consomem o Juuchieh em estabelecimentos especiaes ou matdieehdi, semel-
hantes ia casas de fumar o opio.

Entre n^ a planta ^ usada, como fnmo, ou em infus&o, e entra na compoeig&o de
certas beberagens, empregadas pelos /«t<tceiro9, em geral pretos aMcanoe ou vdhos
cabocloe. Nos candomblh-AeBiaB religioeas dos africanos, ou dos pretos creoulos,
delles deecendentes, e que Ihes herdaram oe costumes e a f4, ^ empregada para pro-
duzir hallucinacOee, e excitar 00 movimentos nas dansas selvagens deesas reunites
barulhentas. Em Pemambuco a herva 6 fumada nos ootimM*— lugares onde se faz^n
06 feiti^os, e efto frequentados peloe que vfto alii procurar a sorte e a f^cidade. Em
Alagdas, nos sambas e batuquee, que efto dansas aprendldas doe pretoe africanos,
usam a planta, e tambem entre os que porfiam na coleheiaf o que entre o povo mstico
consiste em dialogo rimado e cantado em que cada replica, quasi sempre em quadras,
come^a pela deixa ou pelas ultimas palavras do contender.

PUBLIC HEALTH AISTD MEDICINE. 155

Dizem que a macoDha os toma mais eepertos, e de intelligencia mais prompta e
fecunda para encontrar a ideia e achar a consonancia. Vi algumafi vezes, quando
crian^a, nas feiras semanaes de Proi^rid, minha terra natal, & noite, ao ceasar a vendagem,
individuos se entregarem i, praticade fumar a herva nosdispoedtiroBrusticos jd deecrip-
tos, dos quaes muitoe se servem promiscuamente, sorvendo em haustos prohindos a
fumarada apetecida, depois do que entrava o desafio ou o duello poetico; alguma vez
a contenda tomava fei^ differente, e exigia a interven^fto da policia para apaziguar
OS contendores exaltados. E' fumada nos quarteis, nas prisdes, onde penetra ia
eecondidas; 6 fumada em agrupamentos occasionaes ou em reunifies apropriadas e nos
bofdeis. Muitos fumam isoladamente & semelhan^a do uso do tabaco.

Os symptomas apresentados pela embrlaguez da maconha s&o vaiiaveis com a dose
fumada, com a proveniencia da planta, que pode center maior quantidade dos prin-
cipioe activoe, com as suggestGes, e principalmente com o temperamento individual.
Urn estado de bem estar, de satisfac^ao, de felicidade, de alegria ruidosa sfto os effeitos
nervosos predominantes. E' esse estado agradavel de euphoria que leva a maior
parte dos habituados a procurar a planta, a cujo uso se entregam com mais ou menos
aferco. As ideias se tomam mais claras e passam com rapidea deante do espirito;
OS embriagados fallam demasiadamente, d&o estrepitosas gaigalhadas; agitam-se,
dansam, pulam, caminham; mostram-se amaveis, com expansOes fratemaes; v6em
objectos phantasticos, ou de accofdo com as ideias predominantes no individuo, ou
com as suggestfies do memento. Dizem que a embriagues da maconha mostra o
instincto do individuo, como se attribue ao vinho— tn vino verittu. Algumas vezes
dfio em beberagem para obterem a revela^ de segredos. A esse estado segue-se in
veses somno calmo, visitado por*Bonhos deliciosos. Ha na embrlagues da maconha
o facto intereesante de, 9,p66 a dissipa^ dos phemomenos, lembrar-se o paciente de
tudo 0 que se paasou durante a phase do delirio.

O Dr. Aristides Pontes, que conversou com Pescadores habituados a usar da maconha,
ouviu que, quando se encontram no mar em candas ou jangadas, fumam em grupos
para se sentirem mais alegres, dispostos ao trabalho, e menos penosamente vencerem o
frio e as agmrasda vida domar. Denominam a$»embleia a eesa reunifto, e come^am
a sesBfio, fumando no cachimbo Maricaa, no qual cada um puxa a iua tragada,
na i^irase por elles empregada, para exprimir o esfor^ que exige o cachimbo tosco e
a quantidade maior da fuma^ que procuramabs(Mrver. Depois de algumas fumaradas,
tocados pelo efifeito da maconha, tomam-se alegres, conversadores, intimos e amaveis
na palestra; uns contam historias; taes fasem versos; outros teem hallucina^fies
agradavelB, ouvem sons melodiosos, como o canto da sereia, entidade muito em v^
entre elles. Um deeses, caboclo, robusto, de 43 annos de idade, fumando a herva ha
nuds de vintia annos, sem apresentar perturba^ da saude, informou que a usava,
quando se sentia triste, com falta de appetite e poucadisposi^So parao trabalho, princi-
palmente i noite, quando ia para a pescaria, flcando saturfeito, disposto e podendo
comer copiosamente. Dizem que faz cesMr as caimbras que exi>erimentam ao entrar
n'agua, & noite. Ao Dr. Xavier do Monte releriu L. 8., a quem conheyo, homem de
45 annos de idade mais ou menos, robusto, que fumou a maconha, como experiencia,
sentindo-se al^gre, achando gra9a em tudo, dando estridentes gaigalhadas a todo
pioposito, como um louco e tinha muita feme. Comeu desmesoradamente, e ap^
cesBou o delirio, entrando em somno profundo e calmo. Dizem que o assucar de canna
fas cessarem os phenomenos da embiiaguez. Alguns misturam-no com as folhas no
cachimbo.

Jd Moat e de Lens aconselhavam o uso do canhamo na hypocondiia, na morosidade
e no spleen.

E' tambemnotado portoda a parte esse augmento de appetite, que fas emprsgar a
planta como aperitivo, excepto nos iniciantes, que iM vezes teem nauseas e vomitos.
Kaempfsn menciona a feme eamna como symptoma do hoKhUhmno. O appetite,
porem, se perde e embota nas intoxica^fies intensas e na fcnrma chronica.

156 PBOGEEDINGS SECOND PAN AMBBIOAN 80IBNTIFIG G0NQBES8.

Villard, citado per Charlee Eloy, observou no Cairo, entre os himadoreB do ha»(Mch
esBSk erupgSo de alegria retuinbante, palrice, comgrandevolubilidade, gestoe rapidos e
gaigalhadas. Notou que as hallucina^Oes se relacionam, nas casas de fumar a herva,
com as figuras pintadas nas paiedes, e que muita vez reflectem as ideias dominantes
na pessda e d'ahi o estado de beatitude, de sena^Oes indiziveis de felicidade, de
languidez, com crea^dee imaginativas bizazras dos oiientaes.

Em uma nota do livro Lea OpiomaneSf jd citado, se 16 a seguinte descrip^fio de Sachs:

"0 hadndi produz 00 effeitoe seguintes: 0 ar se adelgaga e paiece center suaves
perfumes. Tudo 6 bello e radioeo. Sente^e prazer em viver. Sob sua influencia
fiz passeios soberbos; meu arrebatamento foi alem de toda expresBfio. Sua influencia
depende do temperamento de quem o usa. Faz alegria; produz gargalhadas pelo
motive o mais futil. Exagera o appetite, toma eloquente, gracioeo, encantador.
Sob sua influencia durante duas horas me ezprimi em versos livres; as rimas eram
ricas e as ideias perfeitamente sensatas e sQguidas. Sens inconvenientes sfto a sensa^So
de um estrangulamento mais forte do que no opio, uma tinta livida, esverdinhada, uma
feme que nada aplaca, algumas vezes desejos sensuaes loucos, com requintes impos-
aiveis de sensualidade * * * a produgSo de ataques epilepticoe e perturba^Oes
ataxicas."

Nas expeiiencias de Villard, as ideias se succedem com rapidez, se contradizem, se
entrechocam, as palavras se comprimem para exprimil-as, e toman-ee incoherentes.
O intoxicado ouve o murmurlo de luna fonte, julganae no meio do mar, transportado,
embalado em um barco, ao lado de bellas mulheres; ora assiste a um fdgo de artificio,
tendo a cabe^a cercada de uma aureola brilhante, a brincar com os anjos. Wood diz
que para o haschichado a dura^ de um minuto representa um seculo, um estreito
aposento alaiga-se at4 a immeniddade; transpCe mares, continentes, atraveesa os ares,
seu esplrito perde o sentimento da extens&o.

0 quadro symptomatico pode ser diverso. £' conhecido nos lugares, onde abusam
da maconha, 0 delirio, a loucura transitoria, e mesmo definitiva, causadas pela planta,
e com phlaionomia perigosa. Os embriagados tomam-ee rixosos, aggressivos, e vSo at6
& pratica de violencias e crimes, se nSo sfto contidos. Um trabalhador, pardo, de 30
annos, robusto, referiu ao Dr. Xavier do Monte ter fumado a maconha, como remedio
para ddresde dentes, elogo sobrevieram-lhe suores fries e abimdantes, lingua pesada,
pegajoea, e delirio. Tudo o amedrontava, via-se perseguido pelo povo, sentia fome
devoradora, e depols de ter comido uma por^^ de batatas doces e f arinha de mandioca,
foi melhorando, at^ voltar ao estado normal.

Do inquerito feito pelo Dr. Aristides Pontes, que 6 medico da Escola de Aprendizes
Marinheiros de Aracajd, ouviu a um saigento da mesma esc61a, ccmtando 28 annos
de idade, que, quando aprendia na Escola de Macei6, aos 16 annos, vendo frequente-
mente um preto velho africano fumar a maconha no Mcarioa$^ experimentou a herva em
cigarro, sentindo-se logo tonto e vendo tudo gyrar ao redor de si. Per mais baixo que
Ihe fallassem, ouvia as vozes em alta tonalidade; tlnha hallucina^Oes auditivas e
visuaes, ouvia cantos de passaros, e via vagalumes no ar. Tinha a impressOo de que
tudo la cahirsobreelleeestendia OS brakes para seamparar. Sentia as pemas pesadas,
fatigadas, e a impressOo de que estava a subir uma ladeira; as ideias eram confusas.
Adormeceu, e quatro horas depots despertou, sentindo apenas fome intensa, ch^gando a
comer 6 p&es de 200 grammas cada lun.

Um preto carregador, de 39 annos, de disposi^fio alegre e risonha, fumou a maconha,
e sentiu forte excita^fto, deu para pular, coirer; depois dormiu, e sonhou coisas mara-
vilhosas, passando mais ou menos neete ultimo estado por dois dias. Diz ter melhorado
de caimbras e ddres rheumaticas de que sofiEria.

Essa incessante necessidade de locomogfto ^ refoida por Henri Cazin que diz tel-a
visto sQguida de proetra^So e syncope.

Um magistrado de Seigipe referiu o facto de um seu estribeiro, rapaz de 16 annoo,
mais ou menos de modes humildes, 0 qual teve delirio furioso, aggressive, tendo side

PUBLIC HEALTH AND MEDICINE. 157

trancado em um quarto onde entiou em somno prohmdo, do qual despertou, eentiiido
canaago elanguidez.

Referiu-me o phannaceutico militar Oandido Correia que, em Obidos, no Estado
do F^tfi, onde estadonava o 40 batalhfto de artilhaiia, um soldado, ali^B de boa con-
ducta, foi Bubmettido a concelho de guena, e soffreu penas, por haver fumado a
diamba, pela pimeiia vez, e entrado em delirio furioeo, tentando matar um capitfto
em cuja caaa entrou, armado de &ica, tendo ferido uma outara peesoa. Tambem
rdeiiu-me o phannaceutico Mafifei, que funccionou na GommiBBfto militar, a qual,
nestee ultimos tree annoB, tra^ou os limites entre Brazil e Venezuela, ter visto metter
em camiaa de for^a dois soldadoe, em delirio furioso, por haverem fumado a herva.

Ob commandanteB doB batalhOeB, noB Estados do Norte, tiU> for^ados a terem uma
grande vigilancia, para evitar que a maconha entre nos quarteis, pelaa conBequendas
deBBstroBBB, como brigaa, aggreasOes e crimes.

Em Penddo (AkgOas) para evitar perturbagOea que se davam naa feiras, as autori-
dadea poUdaefl^ rigoroaamente, prohibiam a venda da maconha.

A loucura pode ser a conaequencia do uao da herva. Officiaea do 33 batalhSo de
in^mtarla, que jd eatadonou em Aracajd, referiram que o aoldado Jofto Baptista, de
30 annoB, moreno, entregava-Be ao vicio de fumar a liamba, e tinha exaltacCea me^Jo-
maniacBH, dizendoHse general, Deua, etc.; deeenhava no paaseio do quartel navioa,
noB quaea, em marea tempeBtuoaoa, &zia longas viagena. Uma vez tentou agredir
um official, acabando na loucura que o fez excluir do exerdto, aendo mettido em
cuBtodia.

Utitiaam-Be ia vezea da droga oa soldadoa que querem dar baixa, para aimular a
loucura e illudir a inBpec^fto medica.

"A aliena^ mentel, eBcreve Charlea Eloy, 6 um doa phenomenoa terminaea do
vicio. No Egypto, o numero de alienadoa augmentou parallelamemente ao uao do
ha$Mehf e a loucura tem a f<kma monomaniaca com hallucina^Oea.

No livro Le$ OpiomaneSf j& citado, Id-Be que, ao contraiio do que ae obaerva na
intozica^U) pelo opio, em certaa fdrmas do hawchichiamo agudo, a embriaguez 6 muito
maiB povoada de hallucina^GeB, maia barulhenta, e Pouchet deBcreveu-a do aeguinte
mode: "Alguns individuoa tiU> tomadoa de delirio furioao que obriga a amanal-oe,
paia pdl-oa na impoasibiidade de offender; dfio gritoa estridentea, reviiam e quebram
tudo o que ae acha a aeu alcance; tdm oa olhoa fixoa, a iauce injectada, a aneatheaia
completa. Oa malaioa e oa javaneaea chamam a ease OBtado de furia Amohf porque
aadm gritam oa intoxicadoa: Amok! Amok/ (matal matal) ''Se ae interrogar, diz
Roger Dupouy, eaaea individuoB, ao aahirem de uma criae de amok, dizem que viam
tigrea, javalia, veadoB, cftea, diaboa, que ellea qumam matar. Etiologica e clinica-
mente o amok deve ser imputado ao ha$chieh, e nAo ao opio. Ellea misturam o can-
hamo ao opio e, aegundo Jeanaelme, o bangy que 6 uma mistura de folhas e fructoa do
canhamo, 6 no Oriente frequentemente aasociado ao opio, e provoca uma agitato
particularmente violenta. O Chang ou gimjah doa indioa, o etrar, o hif doa arabea
(extiacto de canhamo deatinado a aer fumado), o chira da TuniBia, nfto bSo outra coifla
aenfto preparadoa do hasckickf diz o meamo autor, deatinadoB a aerem fumadoe; Bfto
aa vezea miBturadoa ao opio, e aeua effeitoa bSo mais nocivoa."

O uao da maconha, em d^aea moderadaa, eatimula a circula0U>, augmenta o calor
peripharico, e acalma oa gaatialgiaa, deapertando o appetite, e exdta oa oigftoa da
locomogio. Ab d^aea altaa, m^mente noB novi^oa, produz nauaeaa, vomitoa, languidei
peao noa membroa.

Sobre oa oigioa aexuaea parece exercer uma ac9fto exdtadora, que pode levar a
grande lubriddade. A maior parte doa fumadorea ouvidoa diaaenm que a herva
oorrige "oa eatzagoa da edade." Um aoldado contou ao Dr. A. Fontea que quando
fumava a maconha aentia effeitoa aphrodiaiacoa, tinha aonhoa eroticoa, e poUu^Oea
Doctumaa. Ease effdto ae eetende ia mulherea. O Dr. Alexandre F^reire, medico
que execceu a diiuca em mna vilk do interior de Seigipe, referiu ter viato uma mulher

158 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

embriagada pela maconha de tal f6nna excitada que, no meio da nia, nfto mostrando
o menor reepeito ao pudor e fazendo exhibiydee, solicitava oe transeuntee ao commercio
intenexual. As prostitutas, que ^ vezes se dfio ao vido, excitadas pela dzoga,
quando fumam em sociedade, entregam-se ao deboche com furor, e praticam entre
ellas o tribadismo ou amor leebico. Villard viu em um bazar, no Cairo, uma mulher,
que se fazia notar pelas excentriddades, maniiestando uma grande excita^So: rosto ver-
melho, olhoe brilhantes, cabellos em deec^em, narse sem motivo e falava sem cessar,
agitava-ee feizia meneios, ia de um individuo a outro . . . com grande hilaridade
<^ aasembl^a, e soltando de vez em quando um ah prolongado, que os arabes presentee
imitavam, e que entre elles 6 indicio de uma profunda voluptuosidade.''

0 abuso da substancia tem effeito opposto; todas as func^des nervosas se deprimem.
Os inveteradoe e os insaciaveis no vicio podem entrar em um estado de cachexia, que
nfto permitte viver muito tempo. Emmagrecem rapida e consideravebnente, ad-
quirem cdr terrea amarellada, dyspepsia gastio-intestinal, phy8ion<«iia txiste e
abatida, depressfio de todas as func90eB, broncbites. Neese estado quasi sempie a
morte sobrev^m em pouco tempo, e diz o povo haver uma phtyaica da maconha, de
f6rma aguda e rapida, exterminando a vida em dois ou tres meses. Nesse estado de
maeonkismo chronico, o vicio 6 imperioso, dominante e tyrannico. Villard observou,
nos bazares arabes, os viciosos irreductiveis '^acooorados a um canto, extranhos ao
que ali se passava; rosto sombrio, olhos fixos, tragos repuchados, s6 despertando para
de novo tomar o naighileh, onde aspiravam bruscamente alguns servos, para em se-
g:uida deixar cahir a cabe^a pesada sobre os joelhos/' Sahem um instante do torpor,
olham embruteddos ao redor, e apenas respondem aos que os intenogam. Neese
estado perdem toda a aptidfio profissbnal e toda habilidade. Os nossos arruinados
pelo vido voltam ao cachimbo logo que se vae disaipando o deliiio, e deq>ertam do
torpor.

A embnaguez causada pela fuma^a da maconha pode-se estender a outras peesoas
que nfio a fumam, e apenas respiram o ar della impregnado. Contou-me o pharma-
ceutico C. Correia, j& mendonado, ter visto em Obidos cahir em narcose a senhora de
um medico militar, que se achava perto de um fumante na mesma sala.

Sfto dtados os phenomenos de atordoamento e vertigens causadas pelas emana^Oes
das cultures do canhamo, e que sSo iavoreddos por um sol ardente. Frovavelmente
sSo effeitos da canabina ou sen prindpio volatil que ee derrama na atmosphera.

Entre n^ este effdto nfto 6 mendonado em virtude de serem limit4>das as planta^Oee
do canhamo, somente com o fim de ser fumado, nfto se conhecendo a utilidade industrial
das fibras do liber, devendo ali^ a actividade da planta, aqui pioduzida, ser grande.
O canhamo obtido na Inglaterra, diz Bentley, varia tanto em actividade que nfto sfto
certos OS sens effdtos, e por isso nfto 6 muito empregado. Na Sueda nfto tem ^eito
embriagante, e na Russia os fructos, de albumen deoso, sfto empregados na alimenta^
das aves, e mesmo do homem.

Na medidna popular 6 enize nde empregada a maconha como fumo, e raramente em
infusfto; 6 dada na asthma, onde ali^ a toese provocada pela fuma^ fee receiar um
ueo mais extenso na moleetia; nee perturba^dee geetio-inteetinaee, nee nevralgias, nee
colicas uterinas, e finalmente como aphrodisiaoo. Pereira chama o canhaieo hileii-
ante, inebriante, fatntasmegotico, hypnotico ou sopoiifico, e estupe&cieiite ou neiootioo,
tees sfto OS effdtos multiples por eUe produzidos.

Como devem ser coneiderados os actos praticadoe pelo individuo em eetado de
embnaguez pela maconha, ou pelo canhamo?

Quel o grfto de imputabilidade que se Ihe attnbuir, e, conseguintemente, a reeponea-
bibdade peloe arimee commettidoe nesee eetado?

Quel a capacidade para exercer oe actoa da vida dvil?

O codigo pmud brazileiro, de referenda ft reeponsabilidade, die:

Artigo 27 Nfto rfU) criminosos:
i 4^ Os que seaduurem em estado de completa piiva^ de sentidos e de inteUigenda
no acto de commetter o crime.

PUBLIC HEALTH AND MEDICINE. 159

Comqnanto a redac9&o defeituosa deste paragrapho j& tiveose dado occasifto ao
redactor do Codigo de dedarar que por um erro typographico figura a palavra sentido
em vez de eensO) comprehende-ee bem que a lei penal nfto pode tomar responsavel
peloB crimes commettidoe aquelle que no momento da acg&o se acha em estado de
nfto c<Hihecer o val<»r do acto praticttdo e suas consequendas, e nfto esteja em estado
de liberdale de pratical-o, condi^Gee esBenciaee ao d61o e ft culpa. "Qualquer acto,"
dis o Prof. Ziino, "que esteja alem da esphera racional, volitiva e moral, nfto pode
eer itnputavelt e quem o pratica nfto 6 obrigado a responder por elle diante da justi^a
doe tribunaee. Crimen enim oontrakitur n et voluntas nocendi intercedat Const. 1^
ad. L, Comeliam d$ dear,, C. IX, 16; " ou como ensina Pellegrino Rossi, "1^ que o
agente tenha podido conhecer a existencia do dever e a naturezadoactoem si; 2** que
tenha comprehendido que o seu acto tenha por indole violar o dever; 3^ que seja livre
de commettel-o, ou de se abster."

Aos crimes praticados durante a embriaguez i>ela diamba se devem applicar as
di8po8i90eB penaes relativas ft embriaguez alcoolica — O estado de delirio produzido
X>ela maconha coUoca o indivlduo em um estado de loucura ou insania, que o priva da
consciencia e da liberdade necessarias ft responsabilidade; mas pode-se a respeito
desta embriaguez raciocinar como o prof. Dr. Charles Mercier acerca da embriaguez
alcoolica. *'E' perigoso admittir em absoluto a excusa da embriaguez na justifica^fto
do crime; e quem voluntariamente bebe at6 o ponto de se tomar um pengo para a
sociedade, deveria ser punido em toda a plenitude por qualquer offensa praticada
no estado a que o reduziu o seu proprio abandono." O sentimento de justi^a, porem,
se oppde ft puni^fto sem as condi^des da imputabilidade acima reiferidas. A lei
ingleza nfto admitte a embriaguez como escusa do crime; colloca-se, portanto, num
dos extremes da questfto, desde que por si s6 a embriaguez jft 6 considerada um de-
licto. A lei penal brazUeira, sem deixar de admittir a excusa do que pratica imi
crime no estado de delirio que traga a aboli^fto da consciencia e da liberdade, qualquer
que seja a causa, fez da embriaguez uma circumstanciaattenuante dos crimes, somente
quando ella 6 accidental, e nfto procurada para infimdir coragem, ou 6 habitual e
turbulenta.

O f 10 do art. 42, que enumera as drctmistancias attenuantes, assim resa: — "Ter
o delinquente commettido o crime em estado de embriaguez incompleta, e nfto pro-
curada como meio de o animar a commetter o crime nesse estado, nfto sendo acostumado
a c(»nmetter crimes nesse estado."

Esta disposi^fto pode ser perfeitamente applicada ao embriagado i>ela maconha.

Relativamente aos actos da vida civil a embriaguez aguda, transitoria, nfto justi-
ficaria medidas de interdi^fto, alifts i>erfeitamente applicadas ft embriaguez chronica,
tal como a descreveu Villard. Todavia, o estado de euphoria que o individuo, nfto
dominado e perturbado permanentemente i>elo vicio, sente ao fumar a herva, pode
conduzil-o, nas suas expansOes, a ]»raticar actos da vida civil, que Ihe tragam serias
obriga^Oes, como contractos, doagOes, vendas, assignatura de letras, os quaes nfto
deven subsistir, provado o estado em que se achava o individuo no momento de assumir
essas obriga^^tes, sendo at6 certo ponto comparavel esse estado ao da primeira phase,
ou ao periodo medico legal da paralysia geral.

0 testemunho do individuo intoxicado pela maconha nfto pode ter valor. E' em-
pregada peloe africanoe para obter declara^des, confissOes, revela^Oes de segredos
e abrandar lesistencias em materia de amor (filtio).

De que meios se pode lan^ar mfto para extinguir, ou dominar o vicio?

Extnordinaria ft a fasdna^fto que exercem as drogas estimulantes e narcoticas
sobre o organismo humane, muito principalmente se o terrene estft preparado para o
bom deeenvdvimento do habito, se alguma tara degenerativa exists congenitamente,
ou se vidoe anteriores predispuzeram a economia a novos vidos; sfto frequentes as
assoda^Oes do alcooUsmo com outros vidos, e com o habito de fumar a maconha.
Do inquerito a que tenho procedido a respeito do use de fumar as summidades flori-
das da planta que faz o objecto deste trabalho, 6 elle muito disseminado entre pessdas

160 PBOCEEDINGS SECOND PAN AMERICAN SCIBNTIFIO C0NGBE88.

de baixa condiy&o, na maioria analphabetos, homens do campo, trabalhadores
nuaes, plantadores de arroz, nas margeoB do lio do S. Francisco, canoeiroe, Pescadores^
e tambem nos quarteis pelos soldados, os quaes ainda entre n6s sfto Urados da escoria
da nossa sociedade. Todos os soldados do exerdto que estadonaram no Amazonas,
Pari, Maranhao, e nos outros Estados do norte at6 Sergipe, mas prindpalmente noa
primeiros mencionados, e com quem conversei sobre o assumpto, me dedararam ter
visto fumar a maconha, e os sous effeitoe ddeterios. Varias pessdas tdm-n'a usada
por munitos annos, moderadamente, sem inconvenientes palpaveis, experimentando
apenas a sensa^fto de uma ligeira euphoria. Sfto os sobrios, como os ha em rela9fta
ao alcooly que parcimoniosamente usado, pode at6 ser uma neceesidade, no pensar
do prof. Charles Mercier, para fazer desprender as energias latentes ap^ o esgotamento
das fadigas do dia, assim como f&z o assucar que se ajunta ia aguas gazozas, provo-
cando novo desprendimento de addo carbonico.

O systema nervoso, no seu aperfeigoamento evolutivo at^ o homem, parallelamente
com as vantagens adquiridas, como uma intelligencia penetiante, sensibilidade
apurada, tomou-se mais exigente pdoe estimulantes, e por isso mabindinadoesujeito
aos habitos pemiciosos como o vido da morphina, da cocaina, do alcool, o toxico
rei, ao qual Shakspeare achou mais apropriado o nome de diabo (cfevtZ), da nicodana,
do canhamo, e outros. ''Em rela9&o d moral/' diz W. A. HoUis, ''na, historia da
vida dos animaes inferiores ha sem duvida muitas outras leipdes, que seria vantajoso
copiar." Nos degenerados e tarados, nos descuidados, o habito se estabelece, e com o
habito o embotamento do systema nervoso, que reclama novos e cada vez mais fortes
estimulos, e conseguintemente nudor d6se do veneno.

"0 gosto do homem i>eloe toxicos embriagantee, escreve o Prof. E. lUgis, querido
ou instinctivoy ^ em todo o caso, tfto velho quanto o mundo.'' Sujeito ia dores phy-
sicBs, como todos os outros animaes, e ainda &b penas moraes, diz Botta, o homem se
eeforya por escapar a sua existencia real, e procura em imi mundo imaginario a felid-
dade fictida de sous insaciaveis desejoe.

Na Penitenciaria de Aracajd, onde de alguns annos para c4 6 prohibida a entrada
da maconha, por causa dos disturbios por ella motivados entre presos, os sentendadoa
se entregavam ao habito de fumal-a "para alliviarem o espirito acabrunhado pela
pri^U), e terem por esse modo momentos de distracy&o e alegria."

A ddr physica 6 muitas vezes a causa do vicio. As nevralgias dentarias, as d^es
rheumaticus, as gastralgias, as colicas uterinas em estados dysmencHrheicos, deter-
minam muitas vezes o emprego da planta pelos sens efteitos narcoticos e analgeeicos;
e obtido o resultado benefico, nfto hesitam os pacientee em voltar d herva em um se-
gundo accesso, ou como preventivo, e dahi se gera com facilidade o habito e o vido
de fumar a maconha.

Os pezares sfto outra causa frequente do vicio: para esquecer, embora transitma-
mente, incommodos moraee, suavisar a dureza de uma vida atribulada, e passar mo-
mentos alegres, distrahidos, esperan9080s, acalentados na phantasia alacre que os
embala no espa^o, como as espiraes voltejantes do fiuno traiyceiro, os abandonadoe
da sorte se entregam ao dominio da herva; se nlU> 6 um forte, o naufragio 6 irremediavel,
prindpalmente se & ddr moral estd assodada a tara organica.

A imitagfto 6 frequentemente uma causa do habito, espedalmente nos jovens.
Como na nicociana, de uso universal hoje, muitos se entregam ao vido de fumar a
maconha por ver fumar aos outros, que por sua vez influem aos inexperientes, con-
tando-lhee com enthusiasmo os gozos ineffaveis e os prazeres encantadores que a herva
proporciona. Di-se coisa semelhante ao que se passa com o vicio do opio, somente
aqui n&o s&o instruidos e letradoe os propagandistas, como os de que falla o Prcrf. E.
R^gis, nos seguintes termos: "Coisa ciuiosa, todo letrado que aspira os vapores da
dr6ga (o opio) se julga na obriga^&o, sincera ou n&o, de glorificar publicamente os
sous encantos; todo fiunante toma-se um tentador; por um requinte de vdupia per-
versa, esse pecador tem necessidade de arrastar outros em seu pecado.'' £ um senti-

PUBLIC HEALTH AND MEDIOIKB. 161

mento genJ do homem nfto querer eetar 86 na queda, e eese sentimento egoista se
exprime bem no riffto popular: "Mai de muitoe consdlo 6/' quando consdlo e satis-
fa^fto devem ser o bem de todos.

O amor doe prazeree e da sensualidade, uma vida indisciplinada e deecuidosa, sempre
avida de novas e extranhas sensa^Gee, que 6 o apanagio doe gozadoree e sybarifitas
conduz igualmente oe desregradoe a procurarem no viclo a felicidade e oe gozoe, que
artificiaes e passageiros Ihes caiisam o extasis produzido pela absorpip&o da fumaga ^
planta maravilbosa.

Uma instruc^o bem dirigida, refor^da por principioB de eft moral, o conhedmento
claro do mal, necessariamente revigoram e f ortificam o animo para a reeistencia ao vicio
de qualquer natureza: nfto obstante espiritos lucidos, geniaes, instruidos, como T. de
Quincey, Coleridge, Edgard Poe, Baudelaire, e outros, entregaram-se ao uso do opio,
que tanto exaltaram nas suae produ^des literarias. Recentemente se tern chamado a
atten^So, na Franca, para o vicio de hmiar o opio, espantosamente disseminado, sendo
as casae de fumar a dr6ga frequentadas por pessoas de certa instruc^fto, como os officiaes
da armada, nos portos de Toulon, Marseille, Brest, etc. Comquanto o uso de hmiar a
maconha, no Brazil, ainda esteja, como foi dito anteriormente, limitado Is classes
ignorantes, tenho noticia de alguns fumadores com um grio de instruc^fto regular, e
de um funccionario publico, bastante intelligente, dominado pelo vicio. Como quer
que seja, creio na instruc^So e na educay&o como bons preservatives do habito pemi-
doeo, incumbindo aos poderes publicos melhor cuidarem deste magno problema, t&o
deectirado entre n6s, onde o analphabetismo 6 a regra.

A prohibig&o do conmiercio da planta, preparada para ser fumada, puderd restringir
a sua dissemina^ progressiva. Sei que em alguns Estados do norte as violencias com-
mettidas durante a embriaguez da maconha tto levado as autoridades policiaes a
prohibir a vendagem da herva nas feiras. Em Penedo, segundo informa^Oes que me
deram, eesa prohibi^fU) tem dado reeultados, quasi extinguindo as brigas provenlentes
da embriaguez pela maconha.

A cura individual depende da capacldade revigorante do animo do vicioso e da
disdplina de sua vontade, sem a qual nada se pode obter. A respeito deste vicio t§m
perfeita applica^ as palavras de Lydston, com rela^fto & embriaguez alcoolica.
Exaltando a educa^&o physica como elemento poderoso no tratamento da embriaguez,
accrescenta: *'o elemento psychico deve ser sempre tomado em considera^fto, pois sem
a sua coopera^lU) todo tratamento 6 futil."

E 6 assim que nada existe sobre a terra absolutamente bom ou absolutamente mdo:
ccmipete ao homem, no seu aperfei^oamento, utilizar-se da primeira face, dominando e
tomando inefficaz a s^^unda. Os dons da natureza podem se transformar em verda-
deiras calamidades quando mal empregados. As mais notaveis e maravilhosas desco-
bertas do genio e do saber do homem, por maiores vantagens e proveito que possam trazer
& especle, muita vez se tomam em arma destruidora e fatal. No processo da evolu^fU)
nto chegou ao homem a capacidade de voar, que parou em certos reptis, no dragfto
voador (Draco volans), o qual, no dizer de W. A. HolUs, '*reteve a arte de deslizar
atravez do ar." A vida de peixe por sua vez desapparece no memento em que a
creatura humana se destaca do seio matemo para viver vida propria. ''E esse primer
da arte que 6 o homem,'' na phrase inimitavel e sublime do autor do Hamleto, "nobre
em sua razfto, infinite em suas faculdades, expressive e admiravel em sua for^ e em
sens movimentos, semelhante ao anjo pela ac^&o, pelo pensamento semelhante a Deus, ' '
se corta os ares nas azas dos sens inventos surprehendentes, fazendo a viagem das aguias,
que perderam o dominie das alturas atmosphericas; ou quando corre debaixo das ondas,
espantando os peixes no seu viver aquatico; nem sempre est&o colhendo beneficios ao
b^ estar de sens irmSos na superficie da terra: esses portentosos engenhos de seu in-
comparavel talento, quaes sfio o dirigivel ou o aero-plano, e assim tambem o barco sub-
marbiho, estfto actualmente empregados exclusivamente no funeeto mister da dee-

162 PBOOEEDINGS SECOND PAN AMEBIOAN SOIENTIFIO 00NGBE8S.

trui^fto, da extermina^fto do que ob pdvos europeuB, empenhadoe na maiof guerra que
jamaifi o mundo vio, tdm de maifi eeperan^oBO e forte«

No terreno da therapeutica, os reeultadoe esplendentes que fomece, nas mftoe jmi-
dentes e praticas do medico, essa gomma concreta das papoulas^—o opio— o rei da ddr,
e sob cuja ac^fto marvilhosa cessam estes sofirimentos physicos, que tanto perturbam o
cuno das molestias, tern o seu reveno no habito nefasto de comer ou fumar a dr6ga.
A cocaina, de recente descoberta, se causa estupenda admirac&o peios sous effeitos
analgesicos locaes, permittindo sem ddr a realiza^fto de deticadas opera^Oes druigicas a
que assiste, quasi como um extranho, o proprio padente, tem-se tornado entre oe povos
civilisados e nevrosthenicos um flagelo.

E o quanto se poderia dizer do mais antigo talvez dos vicios, da intozica^fto por ex-
cellenda, da embriaguez alcoolical

A raga preta, selvagem e ignorante, resistmite, masintemperante, se emdeterminadae
circumstancias prestou grandes servigos aos brancos, sens irmftos mais adiantadoi em
civilisa^fto. dando-lhes, pelo seu trabalho corporal, fortuna e commodidades, estragando
o robusto oiganismo no vicio de fumar a herva maravilhosa, que, nos sens extasis lan-
tasticos, Ihe faria rever talvez as areias ardentes e os desertos sem fim de sua adorada
e saudosa patria, inoculou tambem o mal nos que a alstaram da terra querida, Ihe
roubaram a llberdade preciosa, e Ihe sugaram a seiva reconstrutiya; e, na expressfio
incomparavel do grande e genial poeta americano, o mavioso Longfellow, a ra^ ex-
poliada, como o Sans&o da Biblia

*'The poor, blind slave, the scoff and jest of all,
Expired, and thousands perished In the fall."

NoTA— S6 ap6s a minha volta do Oongresso Scientifico Pan- Americano f oi que recebi
o resultado do inquerito, a meu pedido feito, pelo meu collega e amigo Dr. Francisco
Fonseca, clinico na cidade de Marolm (E . de Sergipe) , na zona de sua pratica. Essas in-
forma^des confinnam pontes tratados nesta Memoria, e foram princlpalmente fofnecidoe
por um fumante inveterado de 60 a 65 annos, robusto, musculoso, sadio, attribuindo o
seu vigor ao habito de fimiar maconha, desde rapaz, no Estado das Alagoas, de onde 6
filho, residindo ha muitoe annos em Pirambd, povoagSo e prala de banhos em Sergipe.
Nessa povoayfto, e outras proximas, onde existem muitos pescadores, o vicio 4 grande-
mente disseminado. Em logares de Sergipe e Alagoas, nas margens do rio de S. Fran-
cisco, cultivam a planta, que vendem, preparada para ser fumada, sob a denomina^
de pelotas, pela f6rma que tomam as inflorescencias, e d razfto de 3|000 o kilo, e 301000 e
401000 a arroba.

Os informantes fazem as declara^6es com difficuldade e timidez, receiosos de uma
acgfto policial. Nesses logares fumam em reunnides e logares determinados.

Indaga^des obsequiosamente feitas em Penedo, por obsequio do Ooronel Job6 An-
tonio da Silva Costa, e em Villa Nova, do Coronel Los^ Lessa, tambem me chegaram Is
mAos tarde, mas me eram conhecidas as ref erencias feitas, e estavam exaradas no meu
trabalho.

LUCHA CONTRA EL ALCOHOUSMO.

Por RICARDO SARMIENTO LASPIUR,
Cirujano Je/t de lo» Ho$pitdU$ de Buenoe Airee, Argentina.

"Contra un enemigo que amenaza al individuo en su salud moral y fldca, la faniilia
en su foco, la raza en su reproducci6n, el pais en su vigor, la humanidad entera en su
esencia, la ciencia y la filantropfa deben dirigir en comdn acuerdo una formidable
coalici6n."*

> Rene Bromard.

PUBLIC HEALTH AND MEDIOINB. 163

Siendo, indlscutible que la de6poblaci6n, la degeneraddn, la criminalidad y la
locura, no reconocen en la mayorfa de los casos otro agente detenninante que el alco-
holismo, y ante el numeroso contingente que aporta el alcoholista y su prole a las
enf^medadee infeccioeafl, los gobiemos, los medicos e higienistas, economistas y
legisladores, deben aprestarse a la lucha, extremando todos los medios para salvar
de 8U acddn a media humanidad.

Desde lu^o, hay que dirigirse al factor etiol^co, combatir el mal en su esencia,
puesto que la cura del alcdliollsmo adquirido, no hace nada mis que atenuar el mal
de algunos, sin consecuencias serias para las otras vlctimas, porque detria del alco-
holista quedan una cantidad de nifios, retardados y empobreddos en sus medios
iisicos e intelectualee, los que a su vez predispuestos y siguiendo el camino trazado
por sus padres, hai^ otras tantas vfctimas.

De manera que tratar al bebedor, y aislarlo, del medio social en que vive, para
evitar su deplorable influencia, no es sino resolver una parte del problema, puesto
que, como hemes dicho, no evita al mal reproducirse, y hacer nuevas vlctimas que
^stas a su vez procreando lo etemizarto afectando intensamente a la colectiLvidad.
Asf, pues, es indispensable tratar la causa; pero como esimposiblesuprimir el alcohol,
hay que dirigirse y luchar con todas las energfas para suprimir o por lo menos amen-
guar la alc6holizaci6n.

Es alll donde se han dirigido todos los pueblos civilizados que han comprendido
y han palpado los terribles peligros que entrafia el vicio del alcohol. Y es por ello
que la lucha ha adquirido una intensidad gradualmente credente en Inglateira,
Am^ca, 8uiza, Suecia, Alemania, etc., y Rusia donde la cuestidn del alcoholismo
es un objetivo permanente no s61o para los poderes ptiblicos, sino tambi^n para las
clases ilustradas de la nacidn

Las sociedades de temperanda se han multiplicado, la propaganda en contra del
alcohol asume las propordones de verdadera guerra, se han creado establedmientos
eefpeciales, privados y ptiblicos para la cura de la borrachera; asilos donde el alco-
h61ico puede no s61o encerrarse espontdneamente, sino tambi^ ser legalmente
secuestrado y mantenido con un fin de utilidad y seguridad pdblica.

Los pafses del Norte de Europa, donde menos se habfa arraigado el abuse del alcohol,
fueron los que dieron el ejemplo m^ radical. Uno de los primeros en ponerse en
campafia fu6 Magnus Hus, en Suecia, y sus indicadones fueron eepedalmente teni-
das en cuenta por las autoridades, tanto que el gobiemo sueco dict6 en 1885 una legis-
lad6n especial que di6 fructlforos resultados. Las 1,300 destilerias con que el pais
contaba, fueron reduddas a 300. Se facult6 a las munidpalidades para prohibir las
ventas de alcohol al por menor, y se disminuy6 el nfimero de despachos de bebidas,
lo que progresivamente ha ido acentdandose hasta el extreme de que existiendo en
el memento de entrar en vigenda dicha ley una tabema por cada 100 habitantee,
diaooinuyeron en poco tiempo a 1 por cada 5,000.

En Finlandia la prohibid6n fu6 m^ absoluta todavfa, hasta el extreme de no
permitir bajo ningdn pretexto la venta al menudeo de ningiina clase de bebidas
alcoh61icas. Sin duda alguna, sus resultados fueron soiprendentes, hasta el punto
de que en 1850 habla 1 tabema por cada 100 habitantes y en 1900 s61o habia 1 por
cada 9,000.

Inglatena tambi^ ha tomado severas medidas, gravando con fuertes impuestos
la venta de alcohol bajo sus diferentes formas, y tratando de neutra4^ las casas
donde se exi>enden bebidas espirituosas, creando cafto y restaurants de templanzas.

Estadbs Uuidos, es el pais que mds se ha distinguido en la campafia contra el alco-
holismo. El gobiemo ha anexado al ministerio de instrucddn ptiblica, el departa-
mento nadonal dentffico de temperanda, que da ensefianza antialcohdlica a una
gran cantidad de educandos.

Y exige a todos los fundonarios ptiblicos que formen parte de esa sodedad, que
Ueven el distintivo espedal de ella. La primera sodedad de temperanda fu6 fundada
68436— 17— VOL ix 12

164 PBOCEEDINGS SECOND PAN AMERIOAN SCIENTIFIO CONGRESS.

en New York en 1808, eu vida fu6 corta, pero dej6 la eemilla, y lu^o se fundaron
muchas otras, hasta que en 1826 se fund6 la gran sociedad The American Temperance
Society.

En Italia y Alemania se ha tornado m^ o menos id^nticas medidi^. En la primeia,
por una ley que no data de mucho tiempo, deroga las franquicias a la libre producci6n
del alcohol, dando con ello un gran paso en el terreno de la lucha anti-alcohdlica.

Como hemes dicho, todos los palses han bajado a la lucha, empleando todos los
medios a su alcance, todos en^rgicos y algunos particularmente originales, como el
empleado por Suecia, conocido con el nombre, de aistema de Gotembouig, que con-
siste en que el privilegio de vender bebidas fuertes lo tiene una compaflla por acciones,
cuyos miembros estiman menos el interns pecuniario que el de disminuir la venta y
vender bueno. Establece un cierto nthnero de tabemas, cuyo reglamento tiende a
disminuir la venta, tanto como sea posible. Los empleados de esta compafila son
pagados por afio y no tienen ningtin interns en vender.

Y, los beneficios pecuniarios de esta compafifa son empleados en obras de interns
ptiblico. Ha dado resultados notables, puesto que ha disminufdo grandemente el
alcoholismo y sub consecuencias.

Rusia participa del mismo principio, pero lo ha hecho de otra manera; ha cerrado
una cantidad de tabemas y ha puesto muchas por cuenta del estado sin ningtin interns
de vender. Tambi6n ha obtenido excelentes resultados.

Los medios propuestoe para detener la marcha invasora del alcdiolismo son de
dos 6rdenes distintos: unos se concretan a la curacidn de los bebedores y a la protec-
ci6n de la sociedad, otros a la profilaxia del alcoholismo y disminucidn del consumo
de las bebidas alcoh61icas. Para conseguirlo es necesario que la acci6n pdblica y
privada se unan, desarrollando una labor proffcua, perseverante y entusiasta.

Para Uegar a tales resultados hay que insistir en el aumento del impuesto al alcohol,
Bobre todo de las bebidas destiladas, en raz6n de su pemiciosa influencia sobre la
salud pdblica.

Reducir el alcohol de consumo a su minimum de nocividad, evitando los fraudes
y falsificaciones por un severe control, efectuado constantemente por inspectoree
t^nicos.

Poner obstdculos a su fabricaci6n.

Hacer efectiva la rectificacidn obligatoria de los alcoholes, y llegar pronto al mono-
polio de la venta de los alcoholes por el estado. Este se puede ejercer sea sobre la
fabricacl6n, sea sobre la rectificaci6n, sea en fin sobre la venta de este producto. El de
la venta, es el que debe adoptarse, puesto que sabemos que los alcoholes comerciales
contienen ima cantidad de productos t6xicos, y que cuando son librados al consumo
sin previa rectificacidn, importa un grave peligro para la salud pdblica.

En varias naciones de Europa se han establecido, sobre diversas bases, slstemas de
monopolio del alcohol, pero el que ha dado los resultados m^ satisfactorios es el de
Gotembourg, implantado en Suecia y Noruega.

Para restringir el consumo de bebidas espirituosas se han propuesto dos clases de
medios: los medios de represi6n y los medios morales.

La represi6n de la embriaguez ha dado lugar a numerosas discusiones entre los l^gis-
ladores en lo que se refiere a las medidas que deben adoptarse a ese respecto, y a sub
resultados. Sin entrar a analizar la mayor o menor rae6n, que tenga cada uno de ellos,
debemos ace^tar como beneficiosas todas las medidas que se tomen; sea la aplicaci6n
de multas a los bebedores, sea la permanencia en las casas de correcci6n; todas pueden
obrar y obran, aunque sea muy d6bilmente sobre el espfritu d^ borracho; y si no
obrase sobre 61 directamente, por lo menos serviria homo ejemplo para aquellos que no
Bon inveterados.

Deben pues, dictarse severas medidas a este respecto.

Otro medio para reprimir la borrachera, consiBtirfa en la inteniacidn de los alcoholistas
en los asilos y caaas creadas al efecto; mixime cuando se sabe que el beodo es un ser
peligroso para sf mismo, para la sociedad y para el estado.

PUBLIC HEALTH AND MEDICINE. 165

Esta 66 una medida que se impone, tanto mis, cuanto que es reparadora para al
sociedad y para eilos; debe hacerse en asiios especiales, donde olvidando el vicio, se
lee haga trabajar, y se lee haga comprender por medio de ensefianzas diariae las terri-
bles coosecuencias que les acaireard el vicio a que se ban entregado.

Entre los medics morales, debemos citar en primer lugar, la reglamentaci6n y la
8upre8i6n de las tabemas; en s^undo lugar, la propaganda antialcob61ica y la funda-
ci6n de sociedades de temperancia, y en tarcer lugar, los medios morales propiamente
dichos.

Las tabemas desempefian im grau papel en nuestra sociedad modema, y ee sin
duda una ds las causas m^ poderosaa del alcoholismo.

La instrucci6n y moralizaci6n del pueblo, debe tenerse muy eepecialmente en
cuenta. Es el nifio, el que debe ser el verdadero campe(5n del anti-alcoholismo del
porvenir; debe ser preparado para la lucha desde su primera edad, la que debe con-
tmuar en la segunda infancia y en la adoleecencia, de manera que cuando adulto
ya, empiece a ejercer su influencia ^i la lamilia y en la sociedad, eet^ impr^gnado
de BUS deberee y pueda luchar con resultados.

La ensefianza en la escuela; el maestro, desempefia tambito un papel importantisimo
en esta magna campafia; ensefiando a sus pequefLos discipulos las verdaderas pro-
piedades del alcohol, el uso que deben hacer de 41 y los peligroe que les acarreard su
abuse. En la Argentina se dictan cursos obligatorios, clases especiales, conferenciaa
sobre alcoholismo, a los obreros, a los soldados, etc.

Hemos dicho ya, que todos los pueblos civiUzados, dindose cuenta de los progresos
que hace dia a dfa este terrible flagelo social, se hablan aprestado a la lucha fundando
sociedades de temperancia, que son m^ eficaces en la lucha antialcohdlica que todo
el cdmulo de medidas fiscalesque hadictado el legislador para impedir la propagaci6n
del flagelo.

La influencia de las sociedades de temperancia en la campafia contra el alcoholismo,
es de resultados incontestables, y su obra salta a la vista en los pueblos que las han
institufdo, como: Estados Unidos, Inglaterra, Suecia, Noruega, B61gica, etc.; y donde
han adelantado notablemente en estos <iltimos afios, debido a haber incorporado aa
movimiento a las mujeree y a los nifios.

En nuestra Repdblica, algo se ha hecho, debido a la pr^ca constante de hombrea
de ciencia, como el doctor Domingo Cabred, que no ha perdido oportimidad de
difundir por todos los medios a su alcance, los peligros y las medidas que deben
adoptarse, para oponerse a la propagaci6n del flagelo que mina las bases de nuestra
sociedad.

La lucha antialcoh61ica en este memento se ejercita de la manera siguiente:

1^. La ensefianza obligatoria antialcoh61ica en las escuelas. Sobre esta medida, se
pronunci6 el Congreso Pedag6gico reunido en Buenos Aires en diciembre de 1900,
aprobando undnimemente el veto propuesto por el Dr. Cabriod, sobre ensefianza anti-
alcoh61ica y sobre f imdaci6n de sociedades infantiles de templanza. El curso libre y
gratuito sobre alcoholismo, establecido, por Decreto del gobiemo nacional, bi6 el
primer paso dado en el sentido de la ensefianza antialcoh61ica obligatoria en las escuelas.

2°. Restricci6n de la fabricacidn y de la venta del alcohol, por grandes impuestoe.

3°. Disminuci6n de los derechos de importaci6n al caf4, al te y a la yerba mate.

4°. Disminucidn de los impuestos a las lecherlas.

5°. Aumento de los derechos de importaci6n a las esencias y 6teres usados en la
fabricacidn de licores y aperitivos.

6^. Se establecieron penas privativas de la libertad para los autores del delito de la
de8tilaci6n clandeetina.

7^. Ho6pitalizaci6n obligatoria, de los alienados alcoholistas y de los ebrios con-
Buetudinarios, dejando al criterio m^ico fijar el tiempo que debe durar la existencia
hospitalaria del enfermo.

8^. Creaci6n de una cobnia agricola para la asistencia de bebedores no alienados.

166 PEOOBEDINGS SECOND PAN AMERICAN SCIENTIPIO CONGRESS.

9°. Educacidn obligatoria de los hijoe de los alcoholistas.

En cuanto a las medidas que corresponden a la iniciativa piivada, y que se ban
puesto en prdctica eon:
1^. Creaci6n de sociedadee de templanza, para adultos.
2°. Creaci6n de sociedadee infantUes de templanza.
3^. Fundaci6n de cal6s y lestaurants de templanzas, de salas de lectura, etc.

EL PROBLEMA DEL ALCOHOUSMO Y SU POSIBLE SOLUaON.'

Per LUIS L6PEZ DE MESA,
Bogotdj Colombia,

Una de las funciones mis dtiles de los Congresos Intemacionalee es, a mi mode de
ver, la de dar un veredicto sobre las cueetiones cientificas ya dilucidadas en el eetudio
pormenorizado de los tratadistas, el presentar a la sociedad bumana la sfnteeis de los
eshierzos parciales que inicie aplicaciones pr&cticas.

En este sentido nada m&s importante para un Congreeo Intemacional de Medicina
que el estudio de aquelloe flageloe que como la tuberculosis, la sifilis y el alcobolismo
constituyen la m&s seria amenasa para nuestra eepecie.

Por ello voy a proponer un voto razonado sobre la re8tricci6n del alcobolismo,
siguiendo de un mode preferente las fases que este problema tiene en mi patria, y
atendiendo s61o a las ideas generales, sin entrar en pormenores ni citas de textoe.

OAUSAS.

El alcobolismo es ima enfermedad social en el triple sentido de que es consentida
impunemente por la sociedad, transmitida por el contagio moral y creada por dese-
quilibrios tambi6n sociales. A la manera como las virtudes en determinada exalta-
ci6n se truecan en un vicio complementario, tambi^n asi las funciones de nueetro
organismo pasan en voces de su ordenaci6n fisioldgica a perturbaciones que son del
dominio de la patologfa. Gada funci6n desviada o exagerada es ima causa patoldgica,
desde la irritabilidad elemental, dig&moslo asf, basta los m&s nobles procesos morales.
Es el case del tomador de bebidas alcobdlicas que pervierte el simple acto de satis-
facer la sed en una toxicomania delet^rea.

Sobre el instinto de satisfacer una necesidad orgdnica como es la ingeetidn de llqui-
dos, causa primordial fisiol6gica, y sobre la existencia en el mercado de bebidas alco-
b61icas, causa social, tambi6n primera, tejen su marafia inextricable las mil causae
secundarias del alcobolismo, que bacen de 61 un problema de mdltiples factores indi*
viduales, sociales y legales.

Hfbrido de la miseria y del lujo, la bumanidad tropieza con 61 en todas las edades
y en todas las esferas. Compaflero de la tristeza y de la alegrfa, de la fatiga y del ocio,
es la sirena l^endaria que fascina y estrangula al individuo bumano en el encanta-
miento de sus parafsos artificiales.

En el individuo aproximadamente normal se inicia el alcobolismo segdn las leyes
psiquicas del bdbito por la repeticidn, por la pasi6n que engendra y que, como todas,
es una idea tenaz que dilata en tomo suyo emociones subordinadas con un imperio dea-

1 Bste trabigo fii6 presentado al oonoono que el Ministerio de iDStmoddn PtlbUoa abfM eon motlvo del
Congreeo Cientiflco Panamericano de WaahlDgton, y el J uradocaliflcadoroompueeto por los doctores Roberto
Franco, PomplUo Martines, Carloe Esgoerra y Jorge Vargas exposo: "El problema del aloohoUsmo y ia
posible soloolon ha llamado tamblto particolannente noestra atencidn. DebemoB alabaren 41 mis que
todo la importanola de stks ooncloBlones y sa hermosa redacddn. Dleho trabi^o pnede Uegar a ser panto
de partida de la luoba antialoohdUoa y atkna U eeriedad de on JBiolo rigoroeamente cicDtf^
y elegante que oonrenoe y agrada.

PUBUO HEALTH AND MEDIOINB. 167

p6tico sobre toda la economfa orgdnica, y por la rnds y m^ acentuada decadencia
general que exige para el complemento de las funciones el t6nico fugaz, pero ya
impreecindible, del alcohol.

En eeta clase de individuos se verifica el contagio por la sugestidn que ejercen las
bebidas alcoh61icas mediante su presencia, curiosidad; mediante la insinuaci6n
amistosa, compaflerismo; mediante la oportunidad de eludir un eetado de tristeza
ocasional o de exaltar una emoci6n alegre.

En nuestra patria hay regiones en donde sigue un camino m&s francamente social,
como en Boyaed y Oundinamarca que han hecho de la chicha un complemento de
alimentaci6n y un liberador de la humildad y melancolfa de la raza indlgena, que
vegeta tristemente en la pobreza y en la mugre. En el Tolima y en la Costa Atlintica
satisface la sed de esas llanuras ardientes bajo la forma de guarapos fermentados y de
ron. En Antioquia obra sobre la raza a mi ver por tres causas primordiales: por la
cuidadosa difusi6n que hacen del aguardiente de cafLa los rematadores de esta renta,
pues crean en los pueblos tabemas que, con el nombre de eatancoSt son el sitio mds
atrayente como lugar de descanso y de solaz, y difunden en cada una de las veredas^
con un esmero industrial prodigioso, las ventas de bebidas alcohdlicas; siendo una con-
dici6n de notoria superioridad en los empleados de esta renta de aguardientes el que
sepan difundir y estimular el hAbito, como me consta por las excitaciones y aplausos
que transmiten los rematadores a bus subaltemos y por el sobresueldo que cobran
6stoe de su misidn propagandista. Tal sistema de privilegio fu6 ensayado en Suecia
p<v Gustavo III en 1780 con tan alarmante resultado que hubo de suspenderlo poco
despu^; y si en Antioquia ha side hasta ahora benefice es por el celo riguroso de los
contrabandos y el alto precio del aguardiente que estipulan los rematadores, lo que
CQmx>arado con la destilacidn ad libitum y la consiguiente baratura de otros tiempos
constituye un progreso en la restricci6n del alcoholismo. Otra causa se deri va de una
condici6n psfquica de la raza antioquefia: dotada de una grande capacidad para el
trabajo y de una imaginacidn verdaderamente prodigiosa, se encuentra con mucha
frecuencia ante el malestar de una suma de energlas ociosas que crea el aburrimiento
y dste a su vez incita a la bebida seductora y eflmeramente eficaz, pues la falta de
snficientes industrias y el escaso movimiento comercial hacen que en muchas pobla-
ciones la vida se deslice dentro de una monotonia abrumadora y de una ociosidad
inconveniente, a pesar de las notables cualidades de ese pueblo para el trabajo, verdad
Ma que denota las corrientes de emigraci6n a que tiene que condenarse. Por dltimo,
hay una causa social, que es la carencia de distracciones honradas en un pueblo que
b61o tiene trabajo y fiestas rellgiosas, que es poco sociable, porque la mujer no desem-
pefia ahf su acci6n social de refrenadora de la juventud, como es el hecho dondequiera
que se comunica discreta pero frecuentemente con los hombres, pues estoy conven-
cido de que ella es doble t6nico: funcional, haci^ndolos m&s emprendedores y viriles,
mis audaces, en una palabra, siendo como es y hay que decir las cosas cientlficas con
paUbras exactas, su tercera gUndula genital; y un t6nico moral educative, suavizando
las duras maneras del hombre, credndole una atm^sfera de idealismo en derivaciones
artlsticas, y de seducci6n pundonorosa.

Las distracciones sociales, los sporU, los cinemat6grafoe, los teatros, etc., alejan
prodigiosa^iente de la bebida, pues el vicio es sobre todo ocasional. Una observaci6n
fdcil nos demuestra la disminuci6n que ha sufrido en Bogotd con las representaciones
cinematogr&ficas y el reciente entusiasmo deportivo, que distraen de la tabema a
centenares de individuos. La vida de los estudiantes americanos que tienen la
imaginacidn pura y los mtlsculos fattigados por el ejercicio se revela como ejemplar al
lado de los estudiantes del centro y del sur de America que Uevan la imaginaci6n
calenturienta y la voluntad propicia al desenireno moral.

El aislamiento relative en que se educan loe j6vene6 antioquefios respecto de la
eociedad viene, pues, a sumarse a las otras causas del alcoholismo. Ese pueblo no se
ha degenerado en el alcohol, a mi ver, por la resistencia de su raza, hablando en

168 PBOCEEDINGS SECOND PAN AMERICAN SCIENTiriO CONGRESS.

t^rminoe imprecisos para una aplicaddn diferencial, de su raza, digo, y de aquella
coetumbre, resto de una moralidad excelente, de no tomar bebidas alcohdlicas aino
ocasionalmente, es a saber: en los dfas feriados y en descansoe de su ruda labor, lo que
hace que el alcoholizado cr6nico sea relativamente escaso adn. Quizd el aguardiente
que consume sea tambi^ menos dafioso, pues no tiene sino pequefias cantidades de
esencia de anis que mezclan en la destilaci6n de los guarapoe. Pero no es diffcil prever
un deterioro de la raza, y ya se ven las psicopatfas y neurosis con bastante frecuencia, y
la criminalidady homicidio y heridas es muy notoria; el misticismo domina a la mujer,
sobre todo, que depositaria inmaculada de la moralidad de la raza, se desvla mis bi^n
hacia el idealismo asceta. Y hago un poco de hincapi6 en este pueblo, porque 61 es
atin la mejor reserva nacional para la colonizaci6n de nuestras selvas y el desarroUo
de la industria, fecundo, vigoroeo e inteligente como se muestra todavfa.

Y no es que sea un pueblo vidoso, abstinente me parece, ya que no alcanza a con-
Bumir dos litres de alcohol per capita: mis ello es que otros factores confuses atin me
inclinan a pensar que en nuestra zona y en nuestras condiciones de vida social el
peligro se hace sentir con menos cantidades de alcohol que en otras partes. ^Nuestra
pereza, nuestra ne\m)si6, nuestro metabolismo viciado no indican acaso un teneno
propicio para la intoxicaci6n alcoh61ica? Estudiando en este mismo pueblo antio-
quefio no ya al individuo o a la sociedad en general, sino las familias, podemoe ver
con relativa frecuencia un decaimiento por el alcohol: de hombres patriarcales que
se hicieron a una posici6n sobresaliente por su esfuerzo personal, surgen despu^s de
una o dos genera<;iones seres viciosos que conducen la familia a la oecura esfera del
proletariado. Familias enteras son una aflictiva trama de intelectuales, locos y alco-
holizados, en quienes el talento, superior a veces, 86I0 sirve para hacer mis visible y
penosa la d^eneraci6n. Pero hay un fen6meno social interesantfsimo en Antioquia,
que hace mis plausible una lucha antialcoh61ica, a saber: algunas poblaciones que
surgen al amparo de industrias como la minera, en regiones aisladas y de mal clima,
se forman en gran parte con los deeechos de la sociedad, viciosos, vagabundos y bandi-
dos, y no pasan dos generaciones sin que esa cepa, al parecer tan peligrosa, est6 repre-
sentada por muy virtuosa sociedad, tan cambiados a veces, que hasta de radicales se
truecan en conservadores muy sumisos e irreprochables feligreses. Y no es esto uno
contradicci6n de las leyes de la herencia, sino el ejemplo de que los factores del vicio
son atin menos orginicos que circunstanciales, como fu6 mi objeto hacerlo notar al
insistir sobre las condiciones en que se desarrolla el joven antioquefio.

La miseria, causa econ6mica que estudian con ahinco los soci61ogos europeos, es,
entre nosotros al menos, un factor menos importante, porque generalmente me ha
parecido consecuente y no casual. Mucho se ha hablado entre nosotros de una deficien-
cia de alimentaci6n en la Altiplanicie andina oriental, que dizque conduce al use de los
excitantes alcohdlicos. Esto merece un estudio muy razonado, pues creo que el
problema es inverse, a saber: que el abuse de las bebidas engendra la Insuficiencia de
alimentaci6n.

Hay en el habitante de esta Altiplanicie una di8minuci6n de la urea y del icido
drico que va hasta 8.02 en las 24 horas para la primera; y un aumento de los productoB
amoniacales intermedios que alcanza a 0.15, lo que %ignifica, ademis, que no hay
una compensacidn. Esta inperfecci6n ureogen6tica es mis notoria en la clase obrera.
Por otra parte tenemos ima temperatura normal de 36.5. Como la media de gl6bulos
rojos por milimetro cdblcos es entre nosotros de 4,800,000 con 83.21 de hemoglobina,
y respiramos veinte veces por minuto una atmMera pobre en oxigeno— 0.192 de
gramo por litro— nos queda un deficit de oxigenaci6n, a pesar del desarrollo toricico
que en parte la compensa, y un deficit del metabolismo azoado.

El consume de came del habitante de Bogoti apenas alcanza a 124 gramos por d(a,
y en la clase pobre hay necesariamente una participaci6n menor de este promedio, y
las albdminas vegetales no son suficientemente compensadoras por su elaboraci6n
mis diffcil, mis alejada de la capacidad digestiva del hombre. Este dato serfa conclu -

PUBLIC HEALTH AND MEDICINE. 169

yente ai no se pudieran aducir razoneo en contra: el eoldado nuestro tiene por alimenta^
ci6n principal una eopa abundante de maiz, trlgo, cebada o legumbree con un plato
de papaa, irn pequefio troBO de came cocida y un pan pequefio y hace un trabajo que
exige 2,800 csJoiias por lo menos, adquiriendo, ademis, desarrollo fisico notable. Esta
alimentaci6n es semejante a la que el pueblo consigue a 20 centavos diarioB, mitad de
8U Balario mds o menoe.

Qu4 eo, puee, lo que ocurre? Que el soldado no toma chicha y el obrero sf ; que ^ta-
va creando una insuficiencia hep&tica con infecci6n gaatrointeetinal cr6nica; primer
factor, org^mico. Y que el ai>etito por la bedida hace consumir en ella el dinero que
puede servir para una Bana alimentaci6n; seguno factor, econ6mico. Luego la insu-
ficiencia de nutrici6n depende de la chicha, segtin mi mode de pensar razonado, y
de las condiciones del clima.

La elaboraci6n defectuoea de esta alimentaci6n esti comprobada por la casi uni-
versalidad del artritismo entre noeotros y nuestra depresidn de &nimo el reumatismo
articular agudo es de ima frecuencia alarmante y algunas afecciones neuroartrfticas,
la colitis mucomembranosa, y la neurastenia sobre todo, crecen dia por dfa en todas
las esferas sodales.

La £ona en que vivimos ejerce tambi^ una acci6n depresiva. Pensando muchas
vecee en la alegrfa sana y fecimda que traen los viajeros que de nuestra patria van a
Europa y Estados Unidos, en aquella exaltaci6n de la voluntad que demuestran en
el tono franco y vivaz de su conversacidn, en la frase predsa que lanza ideas con brio,
y en la imaginaci6n que asocia proyectos de trabajo en dUatadas perspectivas de
futuro, pensando en todo ello, digo, comprendf ima vez que hay un factor meeol6gico
importante. ^Qu6 les ocurre a ustedes cuando van a Europa? pregunt^ a un inte-
lectual que regresaba por entonces, y con una maravillosa imagen me respondi6:
"Es que alU sentimos por primera ocasi6n, despu^ de los dias de nuestra adolescencia,
una primavera espiritual. " Y es cierto. Algo les ocurre como un rejuvenedmiento
como el entusiasmo de ima primavera, con la placidez de su verdura y el nuevo
despertar de la luz.

Buscando ima explicaci6n de la influencia depresiva de nuestra zona, he pensado
que la repetici6n mon6tona de una misma percepci6n o serie de percepciones fatiga
los sentidos y el alma, asi como la vista de una luz igualmente coloreada conduce a la
locura a los supliciados que a ella son sometidos, o como la repetici6n de un sonido y
aun de una palabra nos trasUnma. Creo yo que nuestra zona con la monotonia de su
estacidn permanente, la eecasa variedad de su naturaleza y de su atmMera, apaga la
vivaddad del espiritu, enerva el musculo y deprime la voluntad. Esto puede com-
probarse por el mayor entusiasmo que se observa en un dfa que aparece luminoso
despu^s de una serie de inviemo, y aun en las horas de un torrencial que sigue a laigos
dias de verano.

Por eso he crefdo que el Tr6pico no dar& nunca una clvilizaci6n aut6ctona sino una de
infiltntci6n, por la acci6n capilar, dig^oslo asf, de las corrientes circundantes.

De otra parte surge tambi^n el alcoholismo: la herencia similar de los padres alco-
h61icos y la desemejante de los psic6patas, neur6ticos, sifilfticos, debilitados por la
senilidad y los agentes pat6genos, trae al mundo seres de un funclonamiento inarmd-
nico que los \\e\& por un contagio mis r&pido, predispuestos, o por una \ erdadera
toxicomania, degenerados mentales, al alcoholismo.

Me adhiero a la opini6n que hace del quimismo celular el sustenticulo de la herencia
y creo que el germen sufre en su composici6n f ntima — micelas de Naegeli, plaamonas
de Wiener, como quiera interpretarse, variaciones adn desconocidas, pero en algima
manera Imaginables, segdn los experimentos realizados en los vegetales (vid europea)
para la creaci6n de ^ ariedades por medio de una modificaci6n quimica. Asf es mis
ficil entender que un organismo intoxicado de ima u otra manera d6 g^nnenes vicia-
dos que no pueden diferenciarse en 6rganos armdnicos ni veriflcar las asimilaciones y
adaptaciones a que deben someterse para prosperar dentro del mode de ser de su
eepecie.

170 PEOCBEDINGS SECOND PAN AMEBIOAN BOIENTIPIO OONGBEBS.

Este vicio constitucional de las c^iilaa germinativ&fi se traduciii en el ser adulto
por deficiencias oig^cas, las que, a su vez, pueden afectar directa o indirectamente
al sistema nervioso, como ee el case de las neurosis y psicosis que se producen en el
adulto por la alteraci6n directa del cerebro o de cualquier otro 6rgano.

En lo que respecta especialmente al alcoholismo, encontramos en los predispuestoe
una nerviosidad que puede venir de un desequillbrio funcional del sistema nervioso
o de otro 6igano cualquiera. Esta nerviosidad presenta todoe los grades, desde la
emotividad casi normal hasta la fobia.

La felicidad es resultante de la armonla; y la euforia es el resultado de un hinciona-
miento arm6nico de nuestro organismo. Los predispuestos al alcoholismo, como
en general todos los toxicdmanos, experlmentan como resultante de su funciona-
miento perturbado una intranquilidad continua o peri6dica que se traduce en timldez,
melancolfa, miedo, ansiedad, en una palabra, en las emocionee y sentimientos de-
presivos; y mds tarde por una reaccidn de rebeldia en irritabilidad, odio, misantropia,
egoismo, caracterlsticas de todoe los desadaptados sociales, famlliares, individuales y
sexualee. Un dfa de esos el desequilibrado oig&nico tropieza con una droga o con un
licor que le da una armonla fugaz a su organismo: \e roeados los horizontes de la vida,
una cenestesia engafiosa le da percepciones de propio vigor y entereza. Es el paraiso
artificial que surge como espejiamo en el desierto de una melancolfa conturbadora, y
ya no ser& posible desechar el nepente.

En mi pr&ctica he anotado procesos similares, conformes al deecrito en los morfin6-
manos, dips6mano6, eter6manos, etc. Y es ya de obser\-aci6n comdn el recurso de los
toxic6manos que cambian de excitante, haci^ndose tomadores de caf^ los dips6manos,
de cocafnalos morfin6manos, de cloral, de 6ter, etc., segtin hallazgos de ocasi6n.

Puede uno preguntarse si hay una pasi6n definida por las bebidas alcohdlicas antes
del resultado de un primer ensayo, y yo llego a dudarlo en mucha parte. La pre-
sentaci6n clfnica que hace un dips6mano es la de ima locura peri6dica depresiva, ya
complicada de ideas delirantes, de fobias, de un estado en general francamente psico-
p&tico, ya en nftida diferenciaci6n. Uno de ellos con quien habla hecho previo
compromise se me presenta un dia y me dice: ''Tengo el ataque.'' No se ha tomado
una copa adn, estd d6bil, presenta la cara del suMmiento, temblor r&pido, miedo
obsesionante, anorexia, insomnio, inquietud, sus manos frfas eet&n cubiertas de sudor
y en su cara hay como una sombra de vejez. Ye en perspectiv'a la copa redentora y
s61o se contiene por un esfuerzo de voluntad ya prevenida por mi. Le aplico una
fuerte dosis de estricnina en inyecci6n hipod^rmica y le veo transformarse. Esa noche
estd con amigos, ve licor y no lo prueba. Cesa la acci6n t6nica antes de veinticuatro
horas y recae en su depreai6n de la cual vuelvo a sacarlo con nueva dosis de estricnina.
Ahf no hay vicio, es psicosis y nada m^.

Los morfin6manos org&nicos que he tratado me han hecho revelaciones semejantes
de melancolfa con fobias de una gran perturbaci6n psfquica. Desde pequefios han
sidoraros:retrafdos,alocados, irritables. . . . Lamorfinafu6unhallazgoparaelequili-
brio fugaz, como las combinaciones y sustituciones que hacen lo confirman.

I Hay, me he preguntado a voces, una dipsomania permanente, no peri6dica7 Asf
lo creo, como hay melancolfas cr6nica8, psicastenias y neurastenias y definiti\as.
Gonozco un case en que el ciclo dipsomanfaco es semanal.

Por todo esto, que no analizo m&s por ser otro mi objeto, me incline a que es preciso
hacer dos capf tulos aparte, el de los viciosos accidentales y el de los \ iciosos orgdnicos,
y llamar a esta fonna sencillamente, sin m^ divisiones, la psicopatfa toxicomanfaca,
adscribi^ndola a las locuras depresivas.

Tenemos, pues, varias causas del alcoholiono, que para precisar mejor podemos
reunirlas bajo denominaciones sint^ticas: causas antropoI<5gicas, como dicen los
tratadistas de Derecho Penal modemo, a saber: las perturbacionee oi^nicas que
conducen a una depresidn, toxicomanlacos, abtilicos, desadaptados por debilidad o
pen^ersidn. Causas sociales: la industria de bebidas alcohdlicas, la deficienda eco-

PUBUO HEALTH AND MEDICINE. 171

ndmica que posteiga la elevacidn moral, la deficiencia de educacidn que deja inculta
la Yoluntad leactiva, la faltA de distracciones sanas que den el tdnico de la alegrfa
a las multitudes. La iufluencia de loe climas enervanteS) causa mesol6gica. Y, por
tiltimo, el ejemplo, causa moral. IL&y tambi^n causas familiares que por reducirse
f&cUmente a las anteriores no hay para qu6 diferenciarlas.

Entre nosotroe prlman los siguientee &u;tores: la existenda de bebidas alcoh61icas
al alcance de todos; la acci6n depresiva del tr6pico; la deficiencia de la educacidn;
la transmisi6n por herencia similar y desemejante, y por contagio; y la carencia de
distracciones sustitutivas.

XTB0TO8.

La humanidad cuenta con las bebidas alcoh61icas desde la ^poca legendaria de Dioni-
806 Osiiis y Xo^. Pero hay dos grandee dif erencias entre el mimdo antiguo y el mo4^mo
respecto del alccdiol: la antigtiedad no conocla las bebidas destiladas y aromatizadaa,
con mucho las mia peligrosas, pues fueron quizd los ib:abes los primeros en ensefiar a
Europa la destilacidn del vino, y en llamar a su producto ''el sutil/' con una palabra
que resulta ir6nica. Al siglo de las luces corresponde el triste honor de haber per
fecdonado y en su mayor parte inventado la destilaci6n de las melazas y de los distintos
miUceos, entre loe cuales la papa con su alcohol amilitico; y a 61 corresponde la
industria de centenares de licores aromdticos con base de esencias deletdreas. El
mundo antiguo se embriag6 con vinos y bebidas fennentadas, siendo, pues, franca-
mente enolista, al modemo le cupieron en suerte el etilismo, el absintismo y el usismo
en general. La otra diferencia fundamental es que los antiguos se embriagaban y
los modemos se alcoholftan. Porque si bien es verdad que la cirrosis, Hipdcratee y
S6neca lo dejan entrever, y las perturbaciones nerviosas existieron, como ocurri6
a Lticulo en el ocaso de su vida y de tantos otros se dice, no habia una producci6n
suficiente, ni una vida propicia para el hdbito alcoh61ico genenJizado.

£1 siglo XIX marca el progreso del alcoholismo a la vez que inicia su estudio y su
remedio. En 1850 se consumfa 1.46 de litre por cabeza, y lleg6 en 1900 a 4.66. Hubo
en verdad, y subsisten, altemativas de consume que ajMnrtan dos ejemploe aprove-
chablee: la acci6n ben^ca de la lucha antialcoh61ica y la necesidad de intensificarla
en una ruta definitiva para que no recaigan los pueblos en el vicio.

En Colombia tenemos cuatro bebidas dominantes: el aguardiente de cafia, la chicha,
el guaiapo y la cerveza. El consume de licores extranjeroe aunque no es despredable,
comporta menos peligros por su precio y menor radio de consume.

Colombia, con una poblaci6n aproximada de seis millones, consume anualmente
unos once millones de litros de alcohol o sea poco m^ o menos dos litres por cabeza.
De estos solamente unos ciento veinte mil litros de licores extranjeroe y el reeto de las
bebidas nacionalee enunciadas, que eet^ en la proporci6n de cinco millones cuatro-
cientoB mil en chicha, tree millones quinientos mil en aguardiente, im mill6n seiscien-
tos mil en guarapo y doscientos mil en cervezas, anotados en ntimeros redondos y
segtin cilcuios meramente aproximativos pero razonables.

El consumo de estas bebidas se reparte en la NacitSn distintamente, siendo generali-
zadoB el consumo de los aguardientes y cervezas, con un m4ximum en Antioquia y
Caldas por lo que hace a los primeros, m^ circimscrito a la Cordillera oriental el uao
de la chicha; y peculiar de los climas templados el guarapo.

Pueden considerarse como grandemente adulterados y nocivos los licores extranjeroe,
cofiac, whisky, vinos blancos, tintos y secos, como de vicioea preparaci6n algunoe
nacionales, a saber: la chicha, que es una fermentaci^n de la haiina de maiz y que
tiene de 6 a 10$!^ de alcohol, 10.65 de azdcares, 10.80 almidones, 7.70 de glicerina, 6.15
de ^dos de fermentaci6n, 1.60 de aceite especial de mafz y sobre todo un principio
azoado t<Sxico, del orden de las ptomafnas, que parece ser la causa de las perturbaciones
m^ serias del Uamado chichismo.

El aguardiente es producto de destilaci6n del guarapo (jugo de cafia de aztkar fer-
mentado) o bien de una soluci6n de panela (producto de evaporaci6n de este jugo),

172 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

con un poco de esenda de anls. Tiene unoe veinte gradoe Cartier. Con un poco mis
de esencia y alcohol se le denomina anisado superior.

Las alteraciones que producen estas bebidas son muy conocidas y apenas las anotar^
ligeramente por lo que respecta a los aguardientes y a la chicha.

Las cervezas, siendo un mal menor, no las considero sin embargo tan descuidables
como lo suscriben algunos higienistas, porque el vicio no se detiene en dosis pruden-
tee, y en hallando excitante se cuida de alcanzar la proporcidn suficiente, como es
fdcil observarlo y ocuni6 en Suecia en grande escala cuando empez6 a sustitulr los
licores destilados.

Las perturbaciones que produce el aguardiente son las mismas estudiadas en todas
partes. Pueden dividirse en dos grandes capftulos: de los tejidos y de la nutricidn.

La nutrici6n tiende a espaciarse, las combustiones son incompletas y aparece un
recargo de grasa que se localiza de preferencia en el tejido subcutdneo, el mesenterio,
el coraz6n y los rifiones. Las reacciones defensivas contra el frfo, la fatiga y las infec-
ciones se hacen deficientemente. La decadencia general fisica y psfquica es quizi
motivada por esta inferi(»idad y se traduce en pereza, inconstancia, tristeza, ansiedad,
indiferencia moral y afectiva, de una parte, y en afecciones artrlticas de otra.

Bajo el influjo del alcohol los 6rganos de toda la economia se deterioran, principal-
mente los emuntorios y el sistema nervioeo.

Con las primeras dosis una vasodilatacidn se establece que causa las congestiones del
perlodo inicial de la embriaguez con bus sensadones de cabr, de agilidad, de euforia,
de viveza mental, hasta cierto If mite en que intoxicada la c^lula, sobre todo la cortical
del cerebro, de suyo m^ d^bil, viene un decaimiento de las fimciones que constituye
la torpeza mental y muscular del ebrio. El alcohol recorre y afecta preferentemente
el est6mago y el duodeno, la vena porta y el hlgado, el pulm6n y el cerebro, meninges
y capa cortical sobre todo.

El organismo vuelve a la normal por las primeras voces, pero poco a poco el dese-
quilibrio mental se convierte en deterioro org^co. Es la gastritis con degeneraci6n
gr&nulo— grasa de las gUndulas prepil<Mcas, con la tiinica mucosa comigada y esclero-
sada en partes, en partes inyectada. Lu^^o los adenomas de las gldndulas mucosas
y las ulceraciones m^ o menos profundas. En el duodeno obra el alcohol alteraciones
semejantes y algunas notorias en el ciego, en el pdncreas y gUmdulas salivares. Pasa
a la vena porta que afecta tambi^n y va al hlgado a establecer el cuartel general de
ima patologia mis grave atin, haciendo degenerar el pam^uima hacia la transforma-
ci6n grasa y esclerosa. En ^1 y en los pulmones se asocia con el bacilo de Kock para
terminar su obra delet^rea por congestiones y degeneraciones sucesivas. En el cere-
bro ataca las meninges que se cubren de placas opalinas, y vegetaciones fibrosas, como
en general todas las membranas serosas del organismo. Hace deprimir por atrofia las
circunvoluciones cerebrales, produciendo en la c^lula cortical una degeneracidn
granulosa y en los vasos nutricios dilataciones que son un dafio definitive y una ame-
naza de muerte. Los nervios perif^ricos se inflaman. Neuritis 6pticas pueden sobre-
venir. El coraz6n experimenta mdltiples alteraciones, entre las cuales ban anotado la
vegetaci6n en las vilvulas y manchas lechosas en el pericardio y en el endocardio.
El testlculo se hace flojo y amarillento, en degeneraci6n grasa. El rifidn puede
aumentar de volumen y haceise pdlido y adiposo.

Ante eete eecono de anatomfa patol^gica, ^il es hacer la 8eparaci6n de todas las
afecciones mis o menos diferenciadas que crea el alcohol. Por 61 se explica uno las
gastritis, cirrosis, eeterilidad, deliiios, demencias, neuritis, etc. Y si a esto se aflade
que el organismo asi lesionado es presa de cualquier infecci6n, comprendemos lo pre-
cario de su porvenir y del porvenir de bus g^rmenes.

Un punto me ha llamado la atencidn y es el de la cirrosis. Creen algunos cUnicos
europeos que el vino da la cirrosis atnSfica clisica. En mi prictica he visto dos clases
de cirrosis como mis frecuntes: la atr6fica en un sindromo nltido, hlgado muy pequefio,
serosidad peritoneal abundante y pura, etc., de pron<38tico relativamente benigno;

PUBUO HEALTH AND MEDICINE. 173

y la cirroBifl combinada con el bacilo de Kock, de hlgado graso, de seroeidad a veces
turbia, y que es mortal. En ningtin caso ha intervenido el vino, bebida por otra
parte escasa entre noeotros, ni tampoco el sulfato de cal.

El alcoholismo agudo, la embraguez, ee diferencia seglin la bebida productora, la
C0DStituci6n individual y grado de intoxicaci6n. Es asi como existe la embriaguez
moderada^ alegre, optimista; la delirante y convulsiva, m^ propia del ajenjo; la
impulsiva, tambi^n detenninada por esencias o por hibridaci6n con un temperamento
epil^ptico. Sabido ee que cada cual hace la embriaguez a su manera y quienes hay
que ezageran los senldmientoB altruistas y urbanos como ai hubiesen tomado haahich,
eegtin el relate de un tomador de eeta droga; quienes son agresivos; quienes en fin son
flilencioeos y como de inteligencia embotada. Dentro de ciertos Umites, se entiende,
que la ingesti6n muy abundante a todoe iguala en un como final y en todos se inicia
cuando menos, una confusi6n mental y una amnesia mis o menos profunda.

Alcoholismo cr6nico es t^rmino empleado en psiquiatrfa para designar la alteraci6n
de las facultades mentales que ya tienden a la demencia, pero en los cases en que
, ^sta no es atin muy marcada. En 6\ predomina la p6rdida de los sentimientos fami-
liares, de la moralidad y de la voluntad, y ya se inicia una perturbaci6n del juicio,
de la autocritica sobre todo, un debilitamiento de la memoria y un comienzo de delirio.
Las pesadillas son caracteristicas por la frecuente zoopsia en el ensuefio, el temblor
tambldn diferenciado, las neuritis, desde el simple dolor a la presi6n muscular hasta
la par&lisis. Y, en fin, todo el cuadro de la intoxicaci6n alcohdlica como la perturba-
ci6n de los reflejos, la pereza del iris a la luz, la neuritis 6ptica, la impotencia, las
alteraciones del aparato digestive, de sus anexos y la alteraci6n de los aparatos circu-
latorio y renal. Signos notorios dif erenciales son de parte de la inteligencia lavivacidad
incongniente y la ironia que anima un rostro de capilares dilatados; y el cardcter de
los delirioe, que parecen ser la prolongaci6n de un ensuefio.

De alil en adelante se va marcando la demencia que intensifican las alteraciones
ateromatosas de las arterias cerebrales y las lagunas de desintegracidn que crean sus
pequefias rupturas. Es frecuente, como en general en toda demencia, el transferir a
otro lo que les parece desagradable en elloe mismos, como resto de crltica de una per-
cepci6ii errada. Esta demencia diferenciable por los signos fisicos y los caracteres del
delirio predominante es en voces tan diffcil de distinguir de la par&lisis general que
exige la investigaci6n de una linfocitosis c6falo-raqufdea.

Sobre este fondo de alteraciones oigdnicas, y desde las piimeras fases del alcoholismo
hasta la demencia, pueden suigir otras manif estaciones clasificadas aparte como el de-
lirio tremens, el delirio de persecucidn (paranoia alcoh61ica), la melancoUa alcoh61ica,
el delirio de celos y el aindromo de Korsakoff. He observado algunas de estas moda-
lidades, entre ellas la melanc61ica en un caso que no podr6 olvidar por la presentaci6n
clfnica del enfermo, que presa de una ansiedad incurable vela aproximarse el fin de su
existencia en medio de un malestar que comunicaba al espectador la angustia de su
pena, respirando cuarenta voces por minuto, con un pulso d^bil y de gran frecuencia
que a voces pasab'a de ciento treinta pulsaciones: el relajamiento demencial se marcaba
en la p^rdida de sus afectos, en el descuido de su persona y en la inmoralidad de algunos
de BUS actos. Era un antiguo dips6mano y habfa tenido una infecci6n sifiUtica atacada
en^rgicamente, a raiz de cuyo tratamiento sobrevino la crisis melanc61ica, como re-
sultado de la doble intoxicaci6n y de las preocupaciones consiguientes sobre un
flistema nervioso de suyo degenerado.

Esto que anoto a la ligera como delineamientos generales provoca a hacer un anilisis
detenido de las perturbaciones nerviosas, con mucho las mis importantes en esta
materia. Es que en efecto las nociones de la neurologfa contempor^ea, si bien hipo-
t^ticas en muchas de sus aplicaciones, aportan cierta luz explicativa del mecanismo
de la degeneraci6n nervioea que no puede menos de detener un poco al observador.

Dada la estructura de la c61ula nerviosa y su funcionamiento, ^c6mo la modifica el
alcoholismo en cada una de sus etapas?

174 PROCEEDINGS SECOND PAN AMERICAN SCIENTIPIC C0NGBE88.

La vasodilataci6n que se establece en las primeras copas de Ucor causa una hiperhe-
mia cerebral. La c^lula nerviosa entra en un funcionamiento activfsimo, pues sub
excitantes m^ poderosos son la hiperhemia y el CO'. Una r&pida artlculaci6n de las
dendritas por su amebofsmo activado y la influencia de los nervi nervorum establece
asociaciones que se manifiestan por la vivaddad de las ideas y el torrente de imigenes
peculiares del comienzo de la embriaguez, por la agitaci6n muscular y la exaltaci6n de
todas las funciones. Avanzando esta intoxicaci6n los vasomotores no reaccionan ya, la
c61ula adquiere un veneno que trastoma su quimismo y tiende a paralizar su funcio-
namiento. En consecuencia una relajaci6n muscular y mental sobreviene. Es el
estado de embriaguez avanzada en que el individuo no equilibra su marcha ni sus
ideas; en que es un sondmbulo sin memoria de fijaci6n, ni juicio, pues le ocune como
a los animales fatigados que tienen sus c61ulas corticales desconectadas por la retracci6n
de las dendritas en estado perlado. Esta falta de asociaci6n hace que no reconozca
las personas ni las cosas a que estd mis habituado, que no d^ con su casa y se olvide
hasta de sf mismo.

La sucesi6n de estas intoxicaciones va formando un proceso degenerativo. Los
corptisculos de Nissl, sustancia energ^tica celular, van desapareciendo del centre hacia
la periferia; la redecilla celular se espacia tambi^n: las biomeras, bioblastos del retf-
culo neurofibrilar, mueren, el nticleo y el nucleolo, centroe tr6ficos y funcionales, no
reaccionan, se fragmentan y desaparecen . La albtimina protopl4smica delicada y com-
pleja se fracciona poco a poco en granulaciones grasas y crom6genas, un estado vacuolar
se inicia: es la cramatolisis con un cambio de constitucidn qu(mica aparente, pues ya
no se tifle con los colorantes con que se combinaba en su estado normal. Los leuco-
citoe penetran en ella, no para restituir los cuerpos de Nissl, como es el hecho ordinario,
sino para englobarla como a organismo muerto. Las c^lulas van desapareciendo asf
y dejando en su lugar grasa y tejido escleroso. Las circimvoluciones se hacen m&a
duras y pequefias. El cuadro anatomopatol6gico de la demencia gen^rica queda
establecido. En efecto al hacer cortes de la sustancia cerebral se nota la escasez de
las c^lulas, y al examinar a los dementee se observan sus lagunas de de6integraci6n en
el orden intelectual y moral, sus perturbacionee tr6ficas y funcionales en el orden
fisioldgico.

Cdanto m£s dafioso sea el alcoholismo en los jdvenes nos lo ensefia el hecho de que la
c61ula nerviosa es la mia lenta en sU desarrollo, pudi^ndose decir que no es adulta
hasta los veinticinco o treinta afios, y sabiendo como sabemos que no tiene r^eneracidn
posible, que una vez muerta no tiene sustituto. La educaci6n estd fundada fisio-
16gicamente en el ameboismo celular, que facilita la articulaci6n de los penachos de
Unas c^lulas con otras, que las asoda en una complexidad inextricable. La voluntad
probablemente se conduce por los nervi nervorum a los prolongamientos protoplismicos
para constitulr las asociaciones apetecidas. Si una intoxicacidn de la c61ula, por
cambio en su quimismo normal, paraliza su acci6n, ni la educaci6n, ni la voluntad
podr&n ef ectuarse, y de ahl eeas perversiones de los heredo-alcoh61ico6 y de los adultos
alcoholizados.

Si de este cuadro de la demencia pasamos al delirio, podemos decir que unairritaci6n
de las c^lulas exalta su funcionamiento en una inconexi6n que no permite asociar, y
por lo tanto comparar, criticar y refrenar. Esta exaltaci6n perturbadora se traduce
en alucinaciones por el proceso de la transferencia, es decir: la localizaci6n en la peri-
feria sensorial de lo que es central efectivamente — transferencia que es funcidn del
hdbito — y asf se constituye el fondo mismo del delirio. Luego asodando la idea per-
turbada seg(in las conexiones restantes, se forma lanovela interior de los delirios, l<3gica
en su misma desviaci6n.

Esta mecdnica nerviosa es cuanto podemos vislumbrar hoy por hoy, sin pretender,
ni mucho menos, afirmarla como una verdad definitiva en este misterioso reino de
lapeiquis.

PUBLIC HEALTH AND MEDICINE. 175

Analizando ahora el efecto de nuestras bebidas alcohdlicas podemoa decir que el
aguardiente produce una embriaguez agredva y que la chicha da un embotamiento
y una insensibilidad caracterlsticoe. Si fuera posible un paralelo absoluto diria que
el aguardiente produce una irritabOidad moral y la chicha una insensibilidad tambi^
moral. Quidn sabe si a estas dos causas se deba en mucho la frecuencia de las rifiaa
en Antioquia y el predominio del raterismo en el bajo pueblo de la Altiplanicie» la
altanerfa all& y la socarronerla en esta otra regi6n. Son problemas de criminalogia
apenas esbozadoe.

En efecto, la chicha produce peculiar embriaguez que se traduce con una palabra:
toipeza. Torpeza mental y muscular. El alcoholizado con chicha marcha a paso
corto y contracturado, atiende mal, responde tardfamente. £s un confuso mental,
descuidado de su persona y torpe en todas sus reacciones. Presenta a voces el sin-
dromo de la pelagra. El alcoholizado cr6nico por aguardiente, en camino de la demen-
d&y da la impresi6n de cierta inquietud imaginativa y motora con gesticulaci6n r&pida,
palabra tumultuosa y una ironia a voces feliz. El intoxicado cr6nico por chicha es un
alelado con m^ estupor y una incuria personal incomparable. Hay, pues, dentro del
cuadro gen^co a ambos una modalidad en cada uno que hace del chichismo una
intoxicaci6n m^ profunda y enervante.

La chicha esti causando \ma degeneraci6n de la raza india en los Departamentoe de
la Cordillera oriental. Es de f&cil observacidn la viva inteligencia de los nifios del bajo
pueblo l)ogotano hasta la pubertad, 6poca en que, asf lo juzgo yo, aparece una pertur-
baci6n por herencia homocrdnica, que los hace lerdos, himiildee, perezoeos y no poco
inmorales. Lo creo asf aun descartando la influencia directa del licor que toman deede
antes de ser destetados, pues en esa vivacidad de la infancia se esbozan ciertas degene-
neraciones, a saber: la vagabunderia, el raterismo, la insensibilidad moral, la copro-
lalia (notable por ser un pueblo de gran delicadeza en el trato con sus superiores).
Begiones hay en el oriente de Cundinamarca en las que la acci6n combinada del bodo
y del alcohol (chicha fermentada) ha conducido a la raza a una degeneraci6n alarmante
a pesar de tener mucha sangre eepafiola, a una postraci6n moral intelectual y ffsica que
es serlsima amenaza futura y ya triste preeente. En todo este Altiplano he visto tam-
bidn un ndmero crecido de reumdticos y de cardiacos a los veinte afloe que me llam6
la atenci6n.

A esto se afiade que la falta de bafLo frecuente es una causa poderosa del metabolismo
vidado y de la depresi6n funcional, y que la tuberculosis y la sffilis crecen en Bogotd
en muy serias proporciones. La mortalidad infantil, de uno a diez aflos, ha alcanzado
en algunos perfodos (1910) el 44 por 100 en esta ciudad. En ella misma la mortalidad
por tuberculosis alcanz6 en 1912 y 1913 el 9 por 100, y en el Hospital de San Juan de
DioB ha habido afio de Uegar a 29 por 100, (1895 y 1896). La slfilis crece en nuestros
medios urbanos, y me atrevo a pensar que adn prospera. La debilidad de la raza, el
recargo nervioso de la vida contempor^ea y los tratamientos mal conducidos son una
cosa alarmante a este respecto. He observado tantas voces la sffilis cerebral precoz
(menos de un afio) que me pregunto si es que hay variedades de triponema hiper-
t6xico y neur6tropo. La sal de Ehrlich aplicada en un tratamiento discontinuo es una
amenaza muy seiia, y a mi modo de ver en esta forma es a la sffilis lo que el opio al dolor,
un sedante, que disimula apenas, si una prudente temp^utica no viene a conjurar el
peligro. Remedio heroico bien empleado y combinado, requiere ima prudenda digna
del mayor encarecimiento.

Son, sin embargo, los efectoe familiares aquellos que mSm apenan al monJista. La
literatura ha logrado condensar en dramas de una emod6n angustiosa el proceso fntimo
del hogar af^ctado por el alcohol.

Son loe primeros ensayoe del hijo o del espoeo que furtivamente Uega a su casa,
ocultando con pundonor el trastomo mental y el desequilibrio de las i»imeras embria*
gueces. El remordimiento del dia siguiente en una atmMera de reticendas. La
esposa 0 la madre que inclinan la cabeza ante un vago presentimiento y arrojan sobre

176 PROCEEDINGS SECOND PAN AMEBIC AN SCIENTIFIC CONGRESS.

el ser querido el manto de iin disimulo carifioeo. Es la primera cnsiB familiar que
estalla cuando el borracho va perdiendo la timidez de las reacciones moralee y se llega
a la casa con la cara vultuoea y el lenguaje ofensivo o altanero. La reciiminacidn
primera y el primer desenfado. Las Idgrimas que empafian ojos discretes y queridoB
ante el ejemplo conturbador que el ebrio da a los nifios que le contemplan con mirada
at6nita, desconcertados y medrosos. Las Idgrimas que se deslizan silenciosamente en
la penumbra de la alcoba conyugal antes nido de amor y hoy refugio de dolores. Las
Idgrimas intitiles de quien ve un golpe de deshonor y de miseria cemerse amenazante
en future que avanza con premura impasible.

Y tras de esas rebeldlas contra el martirio que comienza, van surgiendo en el hogar
las consecuencias fatales. Es el hambre que uno de esos dlas aparece. La desnudez
que se inicia en las primeras desgarraduras del traje, m^ penosas ciertamente para el
iJma que para el cuerpo aterido. La noticia del escdndalo en la tabema. La primera
prisi6n. Y, por tiltimo, el golpe mortal: la aparici6n del vicio en otro de la casa.

La esposa envilecida en un ambiente de dolor y de miseria ve descorrerse los dfas sin
esperanza; ve llegar con horror la noche en que el borracho, inmundo de la cabeza a
los pies, ocupard su lecho, y torpemente lascivo, en uto entusiasmo fugaz le dejari en el
cuerpo un desgraciado y en el alma asco profundo.

En onda dilatada la suma de los dolores no se cierra nunca. Tras de la vergdenza,
de la desnudez y el hambre, cuando ya se va embotando la sensibilidad emotiva y
moral, sugird m^ y mds aiiada la catistrofe interna: un dfa Uegari la tisis con su
cortejo de orfandades y otro dfa la prostituci6n abrigard los cuerpos desnudos con loo
(iltimos harapos del honor . . . Despu^ el olvido recogerd las pavesas de un hogar
que consumi6 el alcohol.

Sin embargo, no sucede siempre asf . Sobre la sociedad repercutird la onda de este
naufragio.

Consultando estadlsticas vemos que los asilos y las cdrceles encierran de \in 20 a 30
por 100 de las vfctimas del alcohol. 20 a 30 por 100 directo a que debemos agregar las
consecuencias de su acci6n mediata que lo elevan a la abrumadora proporci6n de un
50. Y como los hospitales siguen ese mismo derrotero, y como la mortalidad infantil de
^1 toma su mayor contingente, y como los d^biles mentales, que ser&n el ludibrio de la
sociedad y el tormento de los institutores, los retrasados con el cortejo de perturbaciones
moralee y su frecuente epilepsia, los imb^iles que a(in conservan un asidero intelec-
tual, los idiotas, ciegos ys. de entendimiento: una verdadera falange de infortunadoo
que son problema social que crea en su mayor parte el alcohol; y los neur6patas,
locos, los vagabundos, los perezosos, los mendigos, los rateros, los criminales natoe le
deben tambi^n un crecido porcentaje; tenemos que inclinamos ante la evidencia de
que es la plaga m&s lesiva que pesa sobre la humanidad. Y si pensamos que los otros
grandes flagelos con 61 se hermanan y de 6\ reciben su mejor abono, hay para meditar
un instante en si hacemoe o n6 sonar la hora de una lucha definitiva.

Un hilito de tristeza se cieme sobre la vida contempordnea. El desequilibrio mental
ha hecho posible la profecfa de que la humanidad sucumbird en una locura universal;
el problema del proletariado se complica diariamente; el ndmero de hospicios, asilos
y cdrceles crece hora por hora sin ll^ar a satisfacer la demanda mSa y mds urgente.
Es, pues, hora de reaccionar antes de que el esfuerzo sea superior a nuestras capad-
dades.

TBRAPiunOA.

El alcoholismo es una endemia social que se acentu6 prodigiosamente durante el
siglo tUtimo y que ha desafiado el rigorismo de todas las medidas profiUctieas.

Hay restricciones policiacas, pedagdgicas, m6dicas, financieras y comerciales, etc.,
que van desde la propaganda abstinente hasta la prohibici6n absoluta, ensayada de
un mode oficial en algunas partes.

PUBUC HEALTH AND MEDICINE. 177

La restriccidn ofidal por medio de ordenanzas de policia eetd eetablecida entre
uo0otTO6, como en todas partes, sin resoltado promisorio. Deja a cubierto el alcoho-
lismo ''a potu nimio" y se cuida 86I0 de lo que ya es irremediable: la embriaguez.

Los impuestos m^ y m^ altos que peean sobre la industria y el comercio de las
bebidas alcohdlicas s61o ban servido para encarifiar a Ice gobiemos con las pingtles
rentas que de ellos derivan.

La restricci6n en el ntimero de establedmientoe de venta hasta determinado por-
centaje de poblaci6n es un tratamiento tenue, una terap^utica de fomentos sobre una
gangrena alarmante, como lo prueba una comparaci6n entre Holanda y B61gica, que
consumen ''per capita" igual cantidad de alcohol, habiendo esta restricci6n en una
deeUas.

La labor educacionista es tambi^n palanca de poco alcance, porque necesitarla cu-
brir con su protecci6n todas las categorlas sociales en un esfuerzo de educaci6n intensa
para lograr quizd 86I0 efectoe parciales.

£1 tratamiento m6dico est& reducido a tres recursos: el de la educaci6n de la voluntad,
tarea diffdl como pocas, que requiere cierta vocacidn de parte del medico y no poca
voluntad ya del enfermo, el de la correcci6n fundonal: los t^nicos nervioeos ffsicos y
qufmicos, los correctivos de insuficiencias org&nicas espedales, y por dltimo el
remedio heroico, el intemado en una casa de salud. Pero el medico es recurso de
mgencia 0 ya de angustiosas situaciones, de suyo impropicias, y su acci6n estd cohi-
bida por la voluntad del padente y la deficiencia legal respectiva.

Ninguno de estos tratamientos aislados podri, pues, considerarse sufidente. Pero
tres de ellos darin una combinad6n saludable: la prohibid6n absoluta de vender
bebidas alcoh61icas, la legislad6n conducente a establecer el intemado en un asilo a
los que se embriaguen determinado ntimero de voces, y la educad6n profiUctica
respectiva.

Vamos a analizar estas medidas draconianas, porque superficialmente parecen un
juego de imaginad6n.

El alcoholismo es una endemia social que va minando la espede humana hasta
constituir su peligro m&ximo. Estamos en presencia de un enemigo capaz de efectuar
un aniquilamiento de la espede, como lo acredita la r&pida desaparici6n de los Pieles
Rojas, polinesios y africanos tratados por el alcohol de la cristiana dvilizad6n euro-
pea. Ante 61 queda justificada toda medida de repre6i6n, como se justifica el destie-
rro de los leprosos, la priai6n perpetua de los criminales patol6gicos, el aislamiento
social de los pervertidos. La moral lo autoriza, y la justida humana no serd cruel si
redime las generadones futuras, como lo manda el espfritu de conservaci6n y la misma
dignidad de la eepetde.

Las vinculadones tiuniliares tambi^n reclaman a grito herido la Uberaci6n de la
mujer y de los pdrvulos, a quienes el alcoholismo martiriza impunemente con hambre y
deshonor.

El altruismo, la caridad cristiana, la simpatia del pr6jimo— como quiera enten-
derse— necesita dejar atr&s este fardo de miserias para consagrar su acd6n al creciente
desequilibrio del bienestar hmnano. La Asistencia ptiblica no debiera tener en un
futuro feliz sine doe aplicadones: la de dar trabajo al adulto y asilo a los ancianos
que rindieron ya una jomada de lucha.

Ante los destines de la especie estd, pues, justificada la prohibid6n absoluta.

Los financistas que se han encarifiado con la renta que rinde el vido tienen que
cuiar la miopia de sos ojos y comprender estas dos verdades de sentido palpi tante:
1.* que la contribud6n que sumimstra el vido puede subsistir e^ otra forma, puesto
que es un hecho indestructible que prueba esa capaddad contributiva; y 2.* que el
Estado y la sodedad pagan con creces en gastos de correcddn del vidoeo y de pro-
tecddn de sus victimas el rendimiento de tan monstruoso recurso fiscal. Como lo
ensefia un libro de propaganda antialcohdlica, en 86I0 los Estados Unidos hubo de

178 PROCEEDINGS SECOND PAN AMEBICAN SCIENnFIC CONGRESS.

1860 a 1870 un gasto de m^ de quince mil nuUonee, cien mil nifloB en las casas de
caridad, ciento dncuenta mil condenadoe a piisi6n, diez mil locos, mil quinientoe
aseslnatos, dos mil suicidioe, y un mill6n de huManos a causa del alcohol. Las pdrdi-
das ocasionadas fueron calculadas en Francia un afio en mil millones de francos; y en
1895 ga8t6 Inglaterra m^ de tres mil millones. Puede decirse que el impuesto sobre
el alcohol es apenas el logaritmo de los gastos que 6ste ocasiona, y que un pueblo se
harfa instant&neamente rico si, conservando los otros Stores econ6micos, desechara
en un memento dado el alcoholismo.

Y podemos preguntar a estos pseudo estadistas cuinto vale una vida humana, cudnto
valen todas lasvidas humanas tronchadas por el alcohol. £1 espiritu humane queda
adn como un enigma. Las CompafLfas de Seguros podiin valuar el precio econdmico
de un hombre aeg6n su categorfa; pero es predso preguntarse si hay peso o medida
paia la energla moral y la eneigia intelectual como factores ineecrutables del progreso
de la especie. Ante un nifio fracasado pasa indiferente la estulticia humana, pero
el fil6eofo vuelve la vista y se pregunta si alguna nueva ruta se ceg6 con esa siega.

Ante el problema del opio en Asia y del alcohol en Africa se ha levantado este aigu-
mento de la renta con la discrecidn que es del case, pero los m6dicos no vacilan en
lamentarlo, como que tiene sus rafces en el cultivo de la miseria humana, y lo hacen
para con pueblos colonos y tribus salvajes tenidoe en poco estimaci6n. ^C6mo pudie-
ra, pues, sostener un ciudadano de un pals libre y culto la validez de un beneficio
fiscal a cambio de una perturbaci6n econ6mica infinitamente superior y de una per-
turbaci6n moral no menos alannante? La sola coeecha de vinos de 1890 vali6 m^
de cuatro mil millones de francos. ^Cu4ntos miles de millones valdrd lo que el mundo
consume intitilmente en alcohol? ^ Y cudntos miles de millones hay que afladir a este
gasto por los dafios que ocasiona? ^No se debe, pues, pensar que el desequilibrio eco-
n6mico mundial tiene ahl un factor inequiparable, que quizd es este el factor supremo
de la miseria en el mundo?

Luego ante los presupuestos nacionales estd tambi^n justificada la prohibici6n
absoluta.

Si adn subsisten argumentoe en contra no alcanzo a vislumbrarlos. Quizd tma pro-
hibicl6n brusca causarla un desequilibrio comercial ruinoso y tma rebeldia tan intensa
que podria causar la calda de un gobiemo. Para este doble peUgro politico y econ6-
mico hay ima Boluci6n f&dl: un impuesto adicional y tenazmente progreaivo, de los
que ya pesan sobre las bebidas alcoh61icas, destinado a la creaci6n y conservacidn
de Casas de Salud para el tratamiento preventive y curativo de los alcoholizados ini-
ciarla la restricci6n sin lesionar imprudentemente a los industriales y comerdantes, y
crearla los recursos suficientes para la profilaxis cientlfica, siendo asaz justo, porque
devolverla a la sodedad en bienes lo que por males le sustrajera, y cerrando m£s y
m4B el clrculo de las restzicciones se ll^arla en tiempo no muy remote a la abolici6n
completa, verdadero desideratum*

Y si ocurriere que el impuesto adicional encuentra ''saturado^' ya el precio de las
bebidas alcoh61icas— K^ue no lo estd generalmente— -cumpli^ndoee entonces las leyes
econ6mlcas disminuird el consume, y obtendremos diractamente lo que buscamos de
im mode indirecto.

La disminucidn del consume en Antioqula en mis de un litre por cabeza en los
tiltimos dncuenta afios indica que es posible una dlsminuci6n de consumo con
aumento de la renta.

Los pueblos que tengan la costumbre de tomar vino en las comidas y los que tengan
su mayor riqueza en esta dase de industrias resolver&n el problema mia diffdlmente
que nosotros. Pero*no serla juidoso el que continuara el alcohol siendo en nuestra
patria un peligro sin raz6n sufidente para tolerarlo, ni siquiera una costumbre ancestral
universalizada.

El segundo capltulo de tratamiento, el intemado, queda a<in como lo finico radonal,
pues en ^1 beneficia el padente de una abstinencia absoluta, de una educaci6n de la
voluntad y de un corrective sodal.

PUBUO HEALTH AND MEDICINE. 179

Y es indispensable para complementar la acci^n prohibitiva, puee el fraude se
inidaii con ella de un modo audas y astuto.

Pero esto comporta graves problemas. £1 intemado de loe ya dementes, ^ inler-
uado transitorio de loe dipsdmanos, hecho generalmente cuando no lo necesitan, es a
saber, al terminar sus crisis, son medidas inocentes. Como hay casas de correcci^n
para menores debe haberlas para los que se inician en ^ alc<^olismo. Besulta, es
▼erdad, una aparente restricckki de la libertad individual Ak tratar de cohibir en el
libre ejercido de sus dereciios y tiabajos a una peisona que apeoas haya cometido la
lalta de unas pocas embriagueces, o de hacerse notar como bebedor ooddiano de pe-
quefias p<»rcioneB. Mas ello es que se castigan dos delitos simllares: ^ infantiddio, y
^ alcohdizado atenta contra su prole; el suiddio, y el que abusa de las bebidas
alcob61ica8 tiende a 61. iiia adn: se trata de una defeosa social, superior per lo
mismo a los intereses individuales.

£1 intemado para ser benefice requiere una legislaci6n reguladora que establesca
la autorizaci6n para los mien&bros de la iamilia de sc^idtaria de las autoridades com-
petentes, y la obligad6n de estas aut<mdades de proceder de ofido cada ves que llegue
a 8U conocimiento un case determinado.

Este intemado, por otra parte eficaz trattodose de individuos pundonorosos a6n y
conscientes, serfa una cura por el trabajo, sobre todo muscular, y la educaci6n de la
yduntad. Debwia inidarse desde el prindpio de la restricci6n y confirmarse a la
generaci6n siguiente de la que sufriera la prQhibici6n definitiva, pues deiotro modo
no habrla espado ni recursos sufidentes para aplicar justamente la ley. Es sabido,
ademis que una generaci6n abstinente levanta el nivel de la raza de una manera
-prodigiosa, y el intemado es un tratamiento tan eficas, que hoy mismo alcanza un
40 por 100 de curadones.

Por lo que respecta al tercer capf tulo, la educaci6n profiUctica, basta con enundarla
para comprender cu^ seria su radio de acci6n y la contribuckSn que pudiera prestar
a la soluci6n de este problems, pues es quizd el campo donde se ha inidado mis
en^icamente la lucha antialcoh61ica.

Quedan por tratar dos graves cuesUcmes: las bebidas alcoh61icae causan mudias
voces un espardmiento amistoso, que discretamente usadas Uevan al espfritu el
entusiasmo memorable de una hora de oompafierlsmo o de galanter^ social. iQu6
hacer? ^Se tolera esto, previo permiso de una autgridad o de una junta de hlgiene, o
se hace tabla rasa de toda tentad6n7 Ckm lo primero la espada de Damodes no serfa
vuelta a su vaina completamente. Con lo segundo robarlamos a la humanidad un
poco de expaDfli6n alegre cuando en verdad la vida es Arida y el dolor insiste tenaz-
mente. . . .

£1 otro problema es el expendio como droga, en verdad iicil de resolver aparente-
mente cuando se piensa que comportarla una prescripci6n m^dica, pero ezpuesto sin
embargo cuando sabemos que la UMHrfina y sus hermanos de vicio son propinados
abundantemente a los padentes sin que haya modo de sorprsnder el fraude p<Mr aquella
etema connivenda entre el interte del comerciante y el inters del consumidor, bene-
fidados mutuamente a su manera.

Mas ello es que atin asf tendrfamos hecho mia de la mitad de nuestro camino profilic-
tico, y estarfamos preparados para un futuro m^ riguroso.

No quieio de prop6sito deliberado entrwr en la enumeraci(ki de las bebidas que
deben ser eliminadas del mercado, poique este es un detalle indtil en un estudio de
ideas generales y sencillo de establecer en la hora propida. Bespecto de nosotios eg
predso anotar desde ahora, eso sf , la necesidad urgente de que la chicba sea eliminada.
Recuerdo que en un tiempo, reciente atin, se implant6 en Galdas este vicLo con tanto
entusottono, que en pocos meses se observaron caeos de alcoholismo, y bast6 un grava.
men pn^bitivo para desarralgario. Algo semejante deberfa haceme en los Departa-
mentos con este y otros licores como el aguardiente, el ron, el cofiac y ese mundo de
vinos mSm o menos adulterados que se consumen en variadas proporciones segdn loe
b&bitOB regionales.

6848^-17— VOL IX 18

180 PBOCEEDIKGS SECOND PAN AMEBICAN SCIENTIFIC C0N0BE8S.

CONCLU816N.

No es diffcil prever sordas resistencias, entre las cuales no seiia la menor el calificar
de ut6plco eete intento. Sentemoe desde ahora la v^ad y digamoe que iit6pico 86I0
ee lo que no puede realizaise con las fuerzas normalee del hombre, y que fuerzas y
derecho le asisten en eete case para enarbolar la bandera de previ8i6n y de cultura
con un gesto que no tiene de heroico m&B que el no ser frecuente: y nunca eeril una
audacia el pensar que las facultades del hombre ae hicieron para veneer laa dificul-
tades de la vida.

Oreo, puee, haber dejado razonado el siguiente voto que someto a la aprobaci6n del
Congreso:

£1 Congreso Gientifico Fanamericano de WAshington encarece a las Naciones repre-
sentadas en ^1 la restriccldn gradual del alcc^olismo haeta su aboUci6n, inici^dola
con un impuesto adicional y prudentemente progresivo sobre las bebldas alcoh6licas,
dedicado exclusivamente a la creaci6n y conservaci6n de OaBas de Salud donde eean
intemados por disposicidn legal los reincidentes de embrlaguez y los notoriamente
incllnados a la bebida, para que en ellas beneficien de un tratamiento "preventivo."

Col. John Van R. Hoff. I move that the resolution proposed in
the paper of Dr. Mesa be referred to the committee on resolutions.

Seconded and approved.

The Chaibman. These papers are now open for discussion.

Dr. Tom A. Williams. The problem of alcoholism is even more-
extensive and profound than the prevention of overt bad habits like
alcohol, morphine, etc. It is rooted in the psychic foundation of the
individual who indulges. I observed a smile in the audience when
Dr. Wiley told of his boy, but I can confirm what he says with my
own boy, who is now 9^ years old, and from what I have seen of
many little patients who have been directed by me in rational
psychological ways when I was consulted about the nervous troubles
which arose from mismanagement.

Persons who become addicted from social reasons or because
they are oversuggeetible are easily reached by prohibition. They
have no real inner temptation. The diflBcult problem is the psychas-
thenic person. In the search for euphoria, such persons adopt many
other expedients than alcohol. One girl, for instance, an account
of intense mental suffering, used to pour boiling water on her feet.
Some have recourse to superstitious practices, carrying this even to
the way in which they put on their clothes. One of my patients
woidd take two hours to dress in the morning, even though helped
by his father and mother — ^a time they could ill spare, the father
being a United States Senator. The agony of the obsessions of
these people can hardly be comprehended by those who have not
felt it. Even suicide may be tried to escape from the sxiffering.
The cause of their sufferings is often purely psychological and can
be removed by proper readjustment of their attitude toward life.

The reaction to narcotic drugs is more dependent upon the indi-
vidual than upon the drug itself. Either expansive and joyous,

FOBLIO HEALTH AND MEDICa[2ra. 181

or depressive and sad, reactions may residt from the same drug in
different people.

Even the removal of the speqific craving for alcohol, if it could
be done by an antibody, woidd not cure these individuals, as the
problem is much deeper. Dr. Doria's very learned treatise upon
the takers of cannabis indica in Brazil is a beautiful illustration of
this very point. These people seek for happiness and they find it
in the temporary stimulation of the drug they take. They have
the sensation so well described by the poet Bums when he said,
"Kings may be blessed, but Tam was glorious, o'er all the ills of
Jife victorious." When a miserable, half-starved peasant can feel
like this, who can blame him for taking narcotics ? Let us beware,
lest in prohibition of alcohol, we do not drive people to worse vices.
To prevent this we must see that human lot is ameUorated and that
wise psychological management is given our children.

The Chairman. I shall now call for the reading of the following
papers:

An inquiry into the causes of crime, by R. B. von KleinSmid.

Pauperism, by Edward T. Devine.

AN INQUIRY INTO THE CAUSES OP CRIME.

R. B. VON KLEINSMID,
PrenderU, University of Arizona.

A student in the field of criminology ia forced to wonder at times whether there is
any other field in which it is possible for him to encounter so great a diversity of
opinion or such extreme and opposing views. It is to be said, however, that con-
dnsions heretofore reached have come laigely from empirical sources alone rather
than from scientific investigations, and that the extreme positions held are those
dictated by the an^es from which penal and conectional problems have been ap-
pfoacbed. In genersl, these conclusions may be grouped as four in number.

The first is that, to a greater or less extent, every man is guilty of crimes— the detec-
tioQ, conviction, and sentence of some avoided (mly because of concomitant circum-
stances. Were the eye of the law trained as carefully upon the free as upon others
who are compelled to pay the penalty of their misdeeds they too must suffer the di^
grace and the punishment meted out to other ofienders. In other words, all have
conunitted and do commit crimes, and it is very laigely a matter of chance as ta
which ones reap the just luurvest of their antisocial seed sowing. Out of this theory
has grown the belief that, by no means, are all of our criminals incarcerated in insti-
tntions, nor indeed our wont ones, but that there are many, as Tarde points out,
who even go 80 far as to make a profession of the criminal life, operating with a cunning
which, with rare exceptions, evades detection, and so escapes the poialty.

The eecond belief on the part of certain of those who give attention to the problem
ci crimen is that all criminals are vicious men, and consequentiy it is the duty of so-
ciety to hunt them out whefever they may be found in order to mete out to them
that degree of punishment appointed by legislation for the particular crime committed. .
Out ci the attitude at this faith have grown the hi^ wall, the whipping post, and tho^

182 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

dungeon, together with all means of discii^iiie and puniahment which humiliate ayid
degrade, in the conviction that the vidous must be cowed and made afraid to vent
their nefarious temper upon a society strong enough and determined enough to cope
with them and to demand of them an eye for an eye and a tooth for a tooth.

Another view held particularly by these of sociological interests is that tcanQgresson
4>f the law would be very few in number, if any, except f<n' the peculiar and con*
laminating social environment. Those of this belief hold that society is to blame
-directly for the existence of the so-called criminal class because she neglects to con-
duct her economic and social afburs so as to surround all of her members with those
influencee which make for good alone.

BtSl a fourth omdusion is to the effect that all criminals are defectives and that
no man of normal mental and physical status commits a crime. On the grounds of this
belief there have sprung up among us, in the last few yean, a number of serious
and, more recently, oiganised attempts to investigate the field of crime for the pur*
pose of detennining the degree of abnormality of those who have been convicted
and incarcemted.

While the truth is not to be found exclusively in the theory held by any one of
these particular groups, it is not at all unlikely that there is a considerable element
of soundness in the aiguments of all; in foct, may it not be the case when investiga-
tions will have continued for a greater length of time and more exhaustive study
will have contributed more generously to the sdence of criminology that it will be
discovered that there is a large element of identity in the theories advanced and that
these various condusions are not antagonistic to so great a degree as supposed? Until
quite recently the sdence of crimindogy was regarded as a legal sdence exclusivdy.
Now there are indications that there are many who believe it to be a purely sockd
sdence. On the contrary, if there be a sdence of criminology— which some deny —
there are those who insist that it has its origin in the sciences of medicine and psy-
chology. The legal sdence emphasizes the responsibility of the present criminal;
the social sdence, the responsibility of society from which he came; the medico-
psychological sdence, the responsibility of his ancestors not less than that of the
individual criminal himself. May it not be that these different positions, too, have
come about only because of varying ai^pioaches to the same truth? U we grant that
the individual offender is vidous and should be punished according to the law, we
still have to account for the fact that this man is vidous and some other iBemben at
aodety are not. If we giant that the eaymaameat from friiidi he came wae am-
dudve to criminal activity, we still have to account Ux the fact that many othMs
from the same environment do not beccnne offenden. Giant a vidous attitude in
his case and cardessness and neglect on the part olsodety to create a proper ettviimi-
ment for him and we are conhxmted with the fact that it waa this particular individual
who committed the crime who doubtlev carries within himself the cause of his mi*-
deeds. However, just as surely as we discover from a dinical study of the individual
that the probaUe cause of his own downfall rests in his constitutional inferiority, we
shall find it neceonry to lay the Uame lor his condition in laife part at the door 6t
short-sighted society and her instittttiona. Rwm the standpoint, then, of tiie dinical
research laboratory let us see what situation presents itselL

One has not labored long among those convicted of crime belore he is steoogly
impressed with the fact that he is dealing with beings of retrograde type— beings
who fall api«edably below the recegniied standard of normality, and who, in a very
large percentage of cases, bear about in their bodies the marks of this degenenusy.
In this matter, however, one must needs exerdse the greatest care to avdd the common
error of conduding that the presence of one or more diaicatsristics, usually accepted
:4 stigmata of degeneracy, is proof positive that the aubfect is subnormal: the Darwin
•ear, the Mord ear, or the ear marked with the entire abssnco of the lobulus, the mal-
formed palate, pdydactytism or hypertrichosis any ol these sMy be fouiid in the

PUBUC HEALTH AND MEDICINE. 183

particultt individuAl in wbom the cloeeflt ftnftlysifl will fftii to find any hma for a
daaification Mow the normal; and yet the nmnber of these Btigmata and their vario^
oomhinations so frequently found among those convicted, of course, is soflicient to
cause their presence to be regarded as a usual accompaniment of criminal aetiTity.
Assymetry of the face, microcephaly or macrocephaly, dental deformities, strahimuB,
microphthalmia, pigmentary retinitis, albtnisn, syndactylism, misplaced and mal-
formed limbs, flat feet, hypospadias and hermaphrodism— these ^and many other
signs of degeneracy are constantly met with.

We do not seek to establiih a causative relation here but merely to observe the
accompaniment of stigmata with crime, lliis of itself is of the utmost importance.
On the otiiflr hand so frequent and so serious are the various physical and physiological
abnormalities and defects as to challenge our earnest efforts to discover this dowrgla-
tionship. Phimosis, enlarged tonsils, adenoids, bad teeth, defective vision, poorly
developed chest, stooping shoulders, pulmonary lesions, valvular heart lesions, and a
serious nervous condition brous^t on by eye trouble of one sort or another; "a sub*
normal temperature, associated with an accelerated pulse and respiration," as noted
by Dr. Sleyster, "perversions of the sexual instinct, uncontrolled desire for liouors^
migraine, disorders of the nervous system, insensibility to pain, defects of speech and
reduced physiological tension,*' as pointed out by Dr. Bowers; impotency and ster-
ility; while by no means is this list to be accepted "in toto" as naming positive evi-
dences of degeneracy, all of these conditions are bound to assert themselves among
either the primary or secondary causes of crime.

Ftom the philosophical standpoint it may be that we are not ready to admit of any-
thing more than a parallelism between mind and matter, yet it must be admitted
that a oetiouflly defective body could not express rig^y a mind of even supernormal
capabilities. "Aye, there's the rub." As though not sufficiently afflicted with
l^ysical and philosophical defects, the criminal elate are lacking pathetically in
mental abiUty, and it is an invest^tion along this line that, in my thinking, we
anive at the real, fundamental, efficient cause of the greater proportion of crime.

It has been recognized for some time that the criminal class, as a whole, are of a low
mental order, and yet only within the last two years have a sufficient number of
laboratories been operating to furnish sudi data as would support a rather wide^qfiread
belief by the results of sdentifk; investigation. In this work, however, there is much
yet to be desired. The tests themselves applied in the various clinics are to be more
thoroo^y tested, cotrected, and adapted through a longer period of time and with
a greater number of aubjects. Too few scientists wdl trained for the work are in the
field ; and there is lacking at present a sufficiently strong public sentiment to demand a
breaking away from tradition in the handling of law violators, and to insist upon the
adoption of metiiods prescribed by the sdentBIc diagnoses of the cases. Nevertheless
the returns to date are indicative and of very valuable significance. The New York
State Refbrmatory for Women at Bedford HUls reports that 87 per cent of its inmates
are defective. J>t. Ftank L. Christian, of the Reformatory at Ehnira, reports 42 per
cent defective. Results of our own laboratory work in the Indiana State Refcmnatory
at JeffenonviUe, show quite 50 per cent to be subnormal. Returns from reliable
sources at work among juvenile delinquents show a percentage as hig}i or higher.
Iliere is tittle question that when terminology and definition, standards and methods
of procedure are agreed upon among the various laboratories, the variation of results
win fall within a rsasonably small margin of difference. All of this suggssts that in
the past we have disregarded quite entirely the peculiar mental conditions of what
likely will prove to be at least one half of the population of our penal and correctional
institutions. This situation belies the very purpose for which these instituttons
are founded and maintained. Moreover, were this condition of these offenders known
before trial, conviction, and sentence, it is quite certain that the necesnty of diff^rr 1 1
disposition of the cases would have been recognised.

i84 PROCEEDINGS SBCQNP PAJ^ AMBWOAN SCIENTIFIO 0ONGEE8S.

Ilie r&ng6 kai degree of delectivenesB affoid ftn inter^flting study. We have those
'of x>ositive psychosie— the insane, including alcoholics, drug fiends, epileptics, and
4eeble-minded — ^imbeciles, morons, and those of but slight subnonnality. As a class,
vt course, all these reveal to the clinician a long list of symptoms and reactions, which
would have led an alienist at once, under any circumstances and surroundings, to a
correct diagnosis of their condition. While this group, representing approximately
50 per cent of the population of our prisons and reformatories, is disposed of com-
paratively easily* the remaining inmates, sharing with the subnormal many of the
mental and psychic stigmata peculiar to the criminal class, form a group which fur-
nish a problem of the greatest complexity. Anomalies of intellect, emotion, and wiU
are ever3rwhere presenting themselves for analysis. Dr. Harold W. Wright, in a
recent niunber of the Journal of the American Medical Association, calls attention
to the fact that all offenders are characterized by one or more of the following attri-
butes: ''Exaggerated suggestibility; exaggerated egotism; emotional instability; a
lack of altruistic or unselfish sense; a lack of the power of sustained energy; that is,
abnormal nervous fatigue; a tendency to the easy disintegration of consciousness,
which permits the brutal or inferior qualities of the subconscious mind easily to
become dominant when temptation occurs, and to be ungovemed by the critical
quality of the conscious mind; even when the critical function is sufficiently aroused,
the power of direction by the wiU is in abeyance.'* The offender is marked, too,
by instability and eccentricity, is given to self pity, moroseness, fault finding and
hatred, and is therefore resentful and retaliative; he is lacking in the ethical sense
and consequently is presumptious; he is deplorably deficient in judgment. All or any
of those characteristics may be possessed in such a degree as to make it practically
impossible for the unfortunate so to deport himself as to satisfy the conditions of good
citizenship and healthy social relationships.

Responsibility for crime in the manifestly subnormal is quite out of the question;
these wiU always be mere children and require a guardianship; the perpetuity of
their kind among us is quite entirely a matter of eugenics; but who shaQ say tl^kt tlM
majority of those not classified as defectives by present-day tests would not be able
to find Actual defense of th^ crime in their own infirmities? Indeed, there are
those who chose to call such ''bordepdand cases,'* bdieving that as all feeble-minded
persons are potential criminals, so large numbtts, at least, of tiiose criminals usually
regarded as normal require only a peculiar series and setting of stimuli to reveal such
serious defects as to prove the existence of positive subnormality, and Qften dear-cul
psychoses.

If asked the question, "Why did. you conmiit the crime for which you are paying
the penalty?" and pudied for an answer beyond that bom of the memory of the
mere [Measure or gratification in the reward of the act, many must honestly answer,
** I really don't know; I guess I couldn't help it." Either some instinctive tendency
of low order, undeveloped and uncontrolled, pushed on the unfortunate individual
to criminal reaction, or aome specific mental function, too weak to do its office work
or perverted in the nature of its activity, compelled an inability to resist temptation
when it offered. Take a case or two in point.

Westlake, No. 40M, is an habitual criminal, a native of the State of Kentucky,
whose mother committed suicide at the age of 39. For some time previous she had
been a nervous wreck, and had been separated from her husband for two years. The
son never saw or heard of his fitther after the separation, at which time he was 7 years
of age. Ait&c the death of his mother he fell into the hands of an aunt and attended
public schools mum or less rogulariy. He fadled of pnunotion twice, because of lack
of attention to hiswork,.and finally left school at the seventh grade. His associates
were bad. He drank moderately, smoked cigarettes, and early suffered venereal
diseases. His first anest was at the instance of his aunt, who, no longer able to con-
trol hini, hoped by this means to ke^ him off the streets at night. His second arrest

PUBUO HEALTH AND MEPICINB. 185

ms for petit larceny— he took money from the cash drawer of a pool room at night.
He next broke into a store with others, stealing kidves and revolvers. Again, with
companions, he attempted to burglarise for the purpose of getting money with which
to secure a room in a hotel for unmoral purposes. The crime for which he was sen-
tenced to the reformatory consisted of the theft of a motorcycle.

His physical condition at this time is fairly good. He is small in stature, but fairly
well developed and not unattractive in appearance. He is not lacking in genend
intelligence. The Binet test classifies him adult, while he grades of high ordering
information and other tests. In general, however, there is revealed an unsettled
condition of mind. The nervous status of his mother, probably before his birth and
during his early childhood, her consequent neglect of him and her suicide, all must
have served to react upon him in such a way as to impress him for life with a lack of
normal nervous organization and to stamp his subconscious mind with a character
conducive to instability and consequent immorality. The correctives of judgment
have never been furnished. For him the easiest way out is the best way. Some
worthy ideals of boyhood may have prevented criminal activity earlier in life; but
after the first offense relieved the tension, others, all of the same nature, followed
with quick succession. He is of the type that seeks pleasure in the activities sug-
gested by the complex of emotion, as completely regardless of the intellect as though
it did not exist. When once an action is begun the power of inhibition is paralysed.

An example of the bom criminal is found in Eastman, No. 4062, about 21 years of
age, swing a sentence of from 2 to 14 years for assault and battery with intent to kill.
He is a native of Buffalo, bom of Polish parents. His father was a common laborer
up to the time of his death by accident four years ago. Eastman had no formal school*
ing prior to the age of 8 years, when he was arrested and sent to a private reform
school at Buffalo. Here he remained for six years. After his release, arrest followed
arrest, until he was sent to the Elmira Reformatory on the charge of burglary* Panded
in 1912, he, with three companions, worked his way West to Indiana as a common
tramp. On being ordered out of a box car wherein they were stealing a ride, the gang
opened fire on the train conductor, severely wounding him. From an early age East-
man's companions were bad. His' jail and reform surroundings probably only accen-
tuated his disregard for the rights of others. He used both liquor and tobacco, con-
tracting the habits when a mere boy. His physical condition is fair, though he is
not free from certain physical stigmata. He cbdms to have suffered a fracture of the
flkull some years ago, from the effects of which he has not fully recovered. This acci-
dent, however, was not experienced until after his life of crime had well begun.
His mental tests were marked by a general spirit of indifference on his part. He
cared not at all to make a creditable record for himself. Attention and application
were out of the question with him, though he did not lack so seriously in point of
general information. He was not interested by those motives which usually govern
action. He confessed that he had never worked and did not care for the money
iR^ch labor earned. Thorou^y selfish, he has no r^;ard for ideals of honor, and no
respect for law and order. He is not impressed with the heinousness of his crime,
nor feels any pity or remorse because others have been made to suffer throu^ him.
He furnishes a q>lendid example of those in whom there is an entire absence of the
normal development of the instinctive tendencies in the ethical q>here.

A type of criminal throu^ passion is Southern, No. 4065. He is 20 years of age, son
of temperate law-abiding American parents, both living and living together. He
remained in school through the eighth grade, where he failed in grammar, because, as
he says, he liked arithmetic so much better that he put in his best efforts on that branch.
After leaving school he purchased a car and opened a taxicab business, which he con-
ducted for three years. After bankruptcy he became an instmctor in a school for auto-
mobile drivers. He smoked cigars, but confessed to no other bad habits. He was
both honest and industrious. His single crime consisted of stealing an automobile

186 . PBOOEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NGBE88.

&oin an old gentleman who employed him through two weeks to overhaul his machine
and then refused to pay him a fair wage, taking advantage of the fact that no contract
had been made at the time of engagement. Enraged beyond control at this perfidy,
Southern ran the car away to be revenged . His only motive was to get even . He was
arrested, convicted, and sentenced for grand larceny. Physically he is none too strong.
He has suffered from hernia from childhood and has had venereal disease. His men-
tality, in general, is of high order. He easily grades adult with no marked deficiency
in the tests applied, and yet, brooding over a wrong so accentuated his anger at his
un&dr treatment as to cause him to lose all control of himself. Here, too, as in the
second case, the power of inhibition under severe strain was not sufficiently operative
to support good judgment by strong will.

Time will not allow a consideration of examples of the merely accidental criminal
and of the weak subject of suggestion. These classes, too, show a defect of specific
function which places the subjects completely at the mercy of circumstances.

Crime, then, is more than a mere accompaniment of defective mind . It is the natural
outgrowth of faulty mental processes. This doubtless accounts for the fact that pun-
ishment can not ciire the criminal, nor even deter others from committing crimes. It
is foolish to insist that punishment deters the criminal even from repeating his crimes.
Surely there is no fact more clearly proven to the criminologist than this one. Insti-
tutions of pumshment only serve to augment the antisocial attitude of the criminal
and to return him to society even determined to perpetrate more daring crimes than
he had known before. Statistics from investigators the world over call our attention
to the fact that crime among us is increasing at a very inpid rate. Treatment, not
punishment, is what is needed^ intelligent, sympathetic, and scientific treatment under
the best conditions and by the best advised scientiBts that can be seciired for the work.
This is not a call for the intioductibn of sentimentality; there are indicati<ms in many
quarters that we have too much of the maudlin already. Warden Francis insists that
the greatest menace to our progress in institution affairs to-day is "the long-haired
man and the short-haired woman," and he is rig^t.

Instead of indulging in expressions of sentimental regard for the unfortunate offend-
ers, society should rather give herself to the most careful investigation of those tolerated
and even encouraged practices which everywhere are shown to be those agencies that
contribute to the perpetuity and to tiie multiplication of the criminal class.

Of a total of 416 new arrivals at the Indiana Reformatory in 1913, 246 came from disor-
ganized families, and approximately this same proportion has been maintained through-
out the last 10 3rearB; that is to say, that 60 per cent of the criminal class, as represented
by ttke boys of our institution have not had the possibility of normal family training.
In a very laige number of the disrupted homes divorce had been granted. In other
cases the father, the mother, or both have died. Neglect of youth makes directly for
crime. Clearly, it seems to me, society has a duty to perform by the children in disor-
ganized homes. No one of us but recognizes the large place the home should and
does take in the normal development of the child. Where its influences are made
impossible because of one reason or another it is obligatory upon the state to act in loco
parentis in <Mder to assure the child that training without which we can not hope fen-
his normal development.

Again society not only harbors but seeks to profit by such agencies as play upon the
weaknesses of the weak. Fifty-nine per cent of the inmates received within the past
8 years at the same institution were users of intoxicating liquors, 80 per cent used
tobacco in one form or another, while 50 per cent were addicted to .the use of cigarettes.
Whatever may be said in the way of excuse for a moderate use of alcoholic beverages
and tobacco among adults, there can be no justification whatever for the use of these
drugs on Uie part of adolescents; but in spite of legislation, the one purpose of which in
to make it impossible for the ruination of the boys of our country to follow from these
sources, the process continues among us to an ever increasing extent.

PUBLIC HEALTH AND MEDICINE. 187

Most States of our Nation boast rigid compulswy education laws. In spite of this
fact, over 10 per cent of the men entering one institution are absolutely illiterate,
while the number who have reached the high school in educational progress is prac-
tically n^ligible. Of nearly 500 arrivals last year II only claimed to have completed
the twelfth grade; three of these had entered college and one the theological seminary.
The greatest number left school at about the fourth grade. Here again so loi^ as we
are content to legislate merely for the purpose of keeping our State assemblies out of
miKhief while in session, with little thought of enforcing the laws which they make,
we need not look for a bettering of those social conditions, out of which we annually
recruit our law violatora.

Fully one-third of the new registrations of last year were idle at the time of commit-
ting the crime for which they were convicted. This is not to place the blame either
here or there, and yet it was no more true in the days of our youth than it is now that
the devil himself puts to work any man who stands on the street comers with Ids hands
in his pockets.

It may be argued that the various social agencies are not to be blamed for the lack of
results in their attempts to train those whom we have shown to be either mental defec-
tives or at least more or less seriously disturbed in mental function. Nevertheless, we
do insist that where the peculiarities of mental reaction are due to a lack of proper
nurture rather than to a defect of nature, such oversight could and should have been
exerdsed as would have enabled a considerable number of these men to live lives of
happiness, harmlessness, and comparative usefulness. While investigatioB in this
field IB still in its infancy there can be no doubt that the coming years will prove con-
clusively what seems now to be indicated that, while the real efficient cause of crime
is to be found in defective mental condition, the contributing agencies, in large part^
are those social institutions which faO to interpret the visi<m and with consecrated
effort 80 purge themselves of carelessness and neglect as to rec<)gni£e not only their
splendid opportunity but their grave and undeniable responsibility.

PAUPEBttM : AN ANALYOg,

By EDWARD T. DEVINE,
Pro/e$»or of Social Economy, Columbia Ufdveniiiif, and Director of the New York S^ool of

FkikmihFopy.

Legally, in Engjaad and in covmtiies wMch have foOcwed Engjidi usage, pauperism,
as diatinguidied from poverty, consists merely in the habitual receipt of official public
r^ief.

BtymologicaUy, the word is derived from the Latin pauper, meaning, as in it»
modem French and Spanish equivalents [panvre, pobie], simply po<Mr, without meana
of support; but when pudied farther back to its Latin and Greek origins [paucus,
Qk. rem; pario, Gk. «op] the word signifies not indigence but inefficiency. Making
little, rather than needing much, is its original suggestion. The pauper is thus not
one iHio from sudden, unfercsoon misfortune is reduced to need, even if that need ia
to be supplied by public relief, but one who brings forth littfo or nodiing, the incapa-
ble, the nonproducer.

Economicidly, pauperism describes the state of the social debtor, the one who ie
carried as a burden on industry and does not himself take any effective part in the
production of wealth.

Biologically, pauperism represents a primitive type, surviving in the straggle for
exirtence only by parasitism; or a pathological type, emerging from abnomial
environment.

188 PBOGEEDIKGS SECOND PAN AMERICAN SCIENTIFIO C0NQBB88.

Sociologically, the pauper is a deviation from the normal, incapable of assimilation
through ordinary economic motives and social forces; presenting a distinct social
problem, as do the criminal, the inebriate, the prostitute, the monopolist, and the
revolutionist.

Psychologically, pauperism is poverty plus a mental attitude in which are mingled
discouragement, lack of ambition and imagination, thriftlessness, irresponsibility,
passive resignation to a parasitic relation to society. Vagrancy, the technical offense
of living without regular employment when not having other visible means of sup-
port, and mendicancy, the soliciting of alms from passers-by, are the more active
expressions of pauperism, of which the ordinary, superficial test is simply the neces-
«ity for some form of pennanent relief because of fault, deficiency, or weakness of
character.

Pauperism must be clearly differentiated from poverty — the larger and more impor-
tant problem — ^which presents many aspects that may be wholly unfamiliar to those
who know only pauperism. Some of those aspects face toward economic refonn;
others toward health, housing, or the administration of justice.

In recent years there are two clearly distinguishable, often antagonistic views of
poverty, one of which we may call, broadly speaking, the economic, and the other
the biologic. According to the first view the differences among men are due mainly
to their environment, their training and opportunities; according to the other, mainly
to their inherent nature, their biologic inheritance, their i»otoplasm. True, biology
concerns itself also with environmental influence, and economics recognizes unalter-
able differences in human beings; but there is justification for the distinction, if not
pressed too far, in that the main preoccupation of economics is with the wants and
activities of men in society, with their actual behavior in view of the rewards obtain-
able for given efforts; while that of biology is with generation, reproduction, and the
<tevelopment of characteristics derived from ancestors.

Both views are indispensable and they can be reconciled. By economic, sanitary,
and social reforms, public hygiene and social insurance, effective organization of
'Charity and the development of educational measures, economic poverty can be
reduced in amount and the distinct hygienic problem of pauperism can be isdated.
This residual problem is largely one of mental defect, calling for segregation and
liumane treatment of individui^ and the gradual elimination of defective strains;
but it involves also far-reaching measures which affect pauperism incidentally and
4ure to be advocated chiefly in the interests of those who are in no danger whatever of
l>ecomlng paupers.

The reconciliation or assimilation of the biologic and the economic view of poverty
justifies its consideration in a scientific congress. If we think of pauperism as mental
<lisease or mental defect, and of poverty which is not pauperism as an economic and
aocial condition, the former to be eliminated or relieved by eugenic and sanitary
•measures acting on the individual, the latter to be eliminated or mitigated by economic
prognn and social reform, resulting in greater efficiency and more just relations, we
•are at least thinking in scientific terms, and relying upon remedies which science can
•examine and assess.

This view of pauperism and poverty is in contrast both with the legal conception
which underlies English and North American poor laws and with the religious con-
•ception which has more especially colored the charity of Catholic countries in Central
4Uid South America. The Englidi law recognizes A legal right to relief. It creates an
elaborate machinery for the administration of this poor relief. The almshouse * is
its central featiue. A hospital or infirmary, and in recent years a sanatorium for con-
eumptives and other special institutions, supplement the almshouse proper, which is
mainly for aged infirm or chronically disabled dependents. Outdoor relief, by which

1 Also called poor lurase, poor Item, oountj home, etc; the eqaiyalent of the Eagllsh workhouse.

PUBUO HEALTH AND MBDIOINE, 189

is meant assistaiice given to the poor in their own homes, is another recognized feature
^ poor relief in nearly all communities in which the traditions and customs of the
Engliaih poor law have been established. The fundamental idea of the English poor
law is that the state is responsible for the relief of destitution and for the prevention
•of mendicancy and vagrancy; that whatever is required to maintain life and prevent
actual suffering from hunger and exposure is to be done from funds raised by local
taxation, except of course in so far as these needs are met by relatives, neighbors,
relief societies, churches, trade unions, or other voluntaiy agencies. When other
sources fail, in the last extremity, there is always the public relief ofScial— overseer
of the poor, as he is oftenest called— whose duty it is to relieve the distress. This is
-conceived to be one of the most elementary and imperative obligations of the state,
to be dischaiged through some appropriate governmental agency.

The religious conception of charity, as a means of spiritual edification to the giver,
not unfamiliar in English-speaking countries, but more emphasized and exemplified
in Latin America, involves a different conception both of charitable relief and of the
-destitution which charity is to relieve. Not the right to relief, but the privilege of
:giving, is its central feature. Not the prevention of begging and of vagrancy, but the
inevention of indifference and hardness of heart, is its aim.. ''Our families," says a
writer in the Buenos Aires General Census of 1910, ''have been essentially charitable
«t all times; the poor have never called at their do(»s in vain. Religious by tradition,
inheritance, and personal connection, our ancestors were imbued with such definite
-charitable principles that they never passed a poor p«son by. " "This is the cause, "
4Mk]8 the AxgttitiDe commentator, "of the existence of the legion of false beggars."

The scientific view of poverty is that it is the result of maladjustments, biologic,
oconomic, and social, but above all psychologic, i. e., the survival of instincts and
moiives suitable to an eariier and more primitive stage of existence, but out of place
In the modem world, and especially in the conditions of Uf e of the western hemisphere
in our generation. The scientific view of pauperism is that it is one of the worst, the
most extreme of these maladjustments, with no adequate defense or justification from
the religious point of view, no adequate provision either for r^ef or for pfevention in
any system of poor law yet devised, yielding neither to such coercive measures as have
been applied by the state nor to acts done under the charitable impulse, however
«elf-sacri firing or heroic those actions may be.

The bad traditicm, inherited equally through church and state, is that poverty is a
t»art of the natural order of things, to be constantly relieved by charity or by the poor
law, but constantly repeated in each generation in order that charity may be kept idive
and that the poor law may function* The new view, the natural view, as I venture
to suggest, for North and South America, if by natural we mean that which cQReqx>nds
to the conditions among which we live, is that poverty is not necessary or tollable,
tiiftt we may confidently lode forward to a time when misery, squalor, a positive lack
of the necessaries and ordinary decencies and coadorta of life, shall be absolutdy
onlmown among us; ^riien a standard of living sufficient for physical and moral well-
being shall be possible for every class in society; when education, recreation, and
leisure shall be within reach of all; when childhood shall be univenally protected,
tile efficient working life ptolonged, disease greatly diminished and its financial bur-
dens distributed through insurance, old age postponed and amply provided for, so that
it does not mean economic distress.

For the realisation of such an ideal the whole course of events in the western world
in modem times has bemi preparing. The enormous increase of capital, the inven-
tion and improvement of machinery, the expansion of the scale of production, the
oiganisation of industry, the division of labor, the development of transportation, the
widening of markets, the progress of science and of technical educati<m, the increase
d efficiency caused by higher standards of living, and the conquest of disease, espe-
cially of the tropical diseases, the perfection of administrative as well as of technical

190 PKOCEEDINGS gECOKTD PAN AMEBIGAN SCIENTIFIC C0NGBE8S.

proceases — an amazing series of revolutionary changes familiar to the whole world, bat
of greatest significance when they are brought to bear upon the undeveloped, the alt
bitt untouched, natural resources of our still sparsely populated continents of th»
west — ^make possible here a civilization without poverty, a manner of Mte in whidi
self-respecting economic independence shall be as much a matter of course as pditkat
and civil liberty.

This contiut between the old world and the new, between Europe and the Amer-
icas, was obvious before the devastating European war. It will be unhappily mom
obvious still in the yean which immediately follow the destruction of resources for
which the war is responsible. In that destruction all the world suffers, but in th»
nature of ttdngp the countries at war suffer most, and even the hi^iest tedmicat
efficiency is no substitute for the capital, the productive energy, and the raw materials-
which the war destroys.

Our productive capacity, if it can be devoted to peaceful ends, our economic re- .
sources, if they can be applied to the legitimate wants of man, are ample tor a civil*
ization without poverty. We have only to apply the knowledge we afa:eady have, to
take the trouble and meet the expense, in order to abolish poverty in the sense that
means actual deprivation of the conditions essential to a rational, prosperous, and
enlightened existence for all those who on their part meet its essential Individual
conditions. The comprehensive means to this end lie beyond the scope of this paper.
The prevention of pauperism is a part— a very specific and exceptional part— of this
larger task.

The first and most strategic point of attack is in the treatment of the mentally^
defective. The report of the English Royal Commission on the care and control of
the feeble-minded in 1908 sets forth conservatively and authoritatively the con-
clusions on which we may base a sound public policy:

1. That both on grounds of fhct and of theory there is the highest decree of nioba-
bility that feeble-mindedness is usually spontaneous in origin — that is, not due to
influences acting on the parent— and tends stroni^y to be inherited;

2. That, especially in view of the evidoice concerning fertility, the pievviilkm eC
mentally defective penons from becoming parents would tend laigely to dimfniah
the nuinber of such penons in the population;

3. That the evidence for these conclusions strongly supports measures, which on
other grounds are of pressing importance, for plaonff mentally defective penMBS,
men and women, who are livQigat lai|p and uncontrolled, in institntions wMe they
will be emj^yed and detained; and in this, and in many other ways, kepi under
efifec^ud supervision as long as may be necessary.

Dr. Blartin W. Barr, of Pennsylvania, writingin Charities four yean eariier, mienei
to the modem institational care of the feeble-minded as the utitiaation oi a warts
product, a forcible illustiatiQn of one of the greatest cufaninatiooB of the ninetevith
century. The recognition of the possibilities and limitations of the mentally defactire
leads to the creation of a sphere for him in which, trained and enconnged in con-
genial occupations, he may attain to a certain degree of independence, and ceise te
be either a menace to society or a helpless burden.

It is not merely because of their biologic character that the mentally defective ai#
unfit for parenthood. They are unfit guardians for children, being unable to give
them moial or economic training. Their income, if earned throu^ wages, is irregular
and insufficient to support a stable home life. Poverty, intempeianee, immondity^
and neglect, even of the elementary phyacal needs of childrsn, are the natural,
almost inevitable, characteristics of their homes. Unfit to maintain domestic lifo»
the mentally subnormal are equally ill-adapted to industrial life as oigniced in a
regime el free competition. They can not earn minimum wages and they dag the
wheels even of the best organised and most enli|^teiied industrns. They need
occupation, but under special supervision and protection. Their tasks should be
carefully selected and suited to their capacities, but need not, as is sometimes hastily

PUBLIC HEALTH AKD ME0IOINB. 191

iafened, l>e the dlrtieBt and most dimgreeable. The recognition of the iMrindple of
guardianahip from in&tncy; the segregation of retarded and backward children in the
•chools, in order that they may be studied individually, their physical defects dis-
covered and remedied, and those who are definitely feeble-minded early identified
and removed to appropriate institutions and colonies, except of course in those cases
in which without undue expense or difificulty efiicient care can be given at home; the
removal of the feeble-minded from prisons and reformatories to these special insti-
tutions, legal punishment and reformation being obviously wholly inapplicable to
them; and the creation in each State of a central authority— chiefly medical— com-
parable to our commissions of lunacy, to have the oversight of all mentally defective,
are the main features of a progressive policy for dealing with the chief cause of
pauperism.

Probably not more than 15 per cent of the demonstrably feeble-minded in the
United States are as yet segregated in special colonies or institutions suitable for their
care. It is estimated that 85 per cent of the insane are treated in hospitals constructed
and maintained especially for them. If it were necessary to choose it is a question
ididther it would not be i»eferable to reverse these proportions, leaving the insane at
large, in spite of their disease, and segregating the mentally defective whose minds
can not be cured but who can transmit their defect, with its train of pauperism,
prostitution, criminality, and other grievous consequences.

Alcoholism, although a recognized complication in mental instability and defect,
deserves also separate consideration. It has been attacked as a vice, as a crime, as a
habit, as a weakness, as a disease. It is all of these things, but here we are interested
in it chiefly as a disease, furnishing a problem for mental hygiene and resulting in
pauperism. The international list of causes of death recognizes alcoholism, acute
and chronic, and from this specific disease as distinct from all organic diseases attri-
buted to alcoholism, the United States census reports 3,744 deaths in the registration
area in 1913, approximately one in 240 of all deaths — a number larger than the com-
bined number of deaths from malaria, pellagra, rickets, lead poisoning, smaUpox,
anthrax, and rabies. Its importance, however, is of course but ftuntly indicated in
mortality tables. As an obstacle to economic independence, as a cause of that unre*
liability and inefficiency which result in pauperism, it is probably surpassed only
by inherited mental defect. In many parts of the world there has been organized a
campaign against the manufacture and sale of alcoholic bev^ages, on the theory that
the beet way to affect the mind of the inebriate, present and prospective, is to withhold
Absolutely the means of feeding the appetite. This is a drastic, but certainly not an
Illogical, method . Just as we seek to exterminate the tuberculosis bacillus by spitting
ordinances, and the malaria germ by warfare on the mosquito, both of which represent
attacks on the external or exciting cause of the infection, rather than attempts to
buHd up resisting power, so by removing completely the exciting external cause of
alcoholism we may hope to stamp out that disease. There are some dissenting or at
least doubting voices in each case. Perhaps immunity or tolerance of an infection
may be lost if for a generation or two the disease is kept at a distance through purely
merhaniral devices. So a j^hibition era may be followed by a greater destruction
if alcohol comes back into use. The analogy seems to be warranted. Unless we are
afndd of humanity's loss of immunity from the conquest of tuberculosis, we need not
lear the loss of immunity from the conquest of strong drink. Nevertheless prohibition
Belies upon a material and coercive method, and if it should prove to be possible
within a reasonable time to exterminate alcoholism on a spiritual basis, through a
genuine temperance (which certainly for all those in danger of alcohdism means
abstinence) there are those who will prefer it and think no jptice too high to pay for
such a conquest. A wise procedure would be to found local and national associationa
for the prevention of alcoholism, similar to those already enlisted in the world crusade
against tuberculosis. The medical profession, recognizing the weaknesses of soma

192 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

of itB own membera, but recognizing also its peculiar reepondbillty in all such hygienic
campaigns, would naturally take the initiative, preventing laeh mistakes and giving
its unique support to sound measures. Alcoholism as a physical disease, as a mental
aMction, would thus be subjected to the same painstaking Scientific study, the same
many-sided attack, that medical authorities and laymen have given cooperatively to
tuberculosis and hookworm, and are now beginning to give to venereal disease and to
iniant mortality. Out of such study and the sane experiments to which it would
lead would come a program of social action, of mental and physical hygiene, directed
towards the elimination of alcoholism.

The drug habit and sexual immorality and excesses of all kinds contribute to the-
problem of pauperism. Certain diseases like malaria and pellagra and the hookworm
disease, which especially affect the spirit, undermining eneigy, reducing efficiency,
lowering the standard of living, would likewise demand consideration in any complete-
discussion of pauperism. Indeed, sickness of any kind in wage-eamerB* faunllies,.
unless its expense is amply covered by insurance, may lead to just that kind of dis-
couragement and hoplessness of which the pauper spirit is bred.

Even if the native stock is not degenerate and the original capacity entirely normal,
the educational system may be so inefficient and so ill adapted to existing conditions
as to produce in effect a generation of paupers. Neither general nor technical edu-
cation can make efficient workers from the mentally defective; but an inefficient and
badly organized educational system can create a semblance of relative feebleness of
mind and economic incapacity in what was originally the healthiest and most vigorous
stock.

Industrial exploitation is a contributing cause of pauperism, whether it take the
form of excessively low wages, or a long working day, or a seven-day week, or the
speeding process with its exhausting fatigue. So also are irregularity and uncertainty
of employment, such as result even in periods of comparative prosperity from the
custom of keeping about any industrial establishment, on the bait of occasional casual
labor, a larger number of laborers than is normally required to do the work of the
industry.

Revolutionary changes in industrial processes, throwing out of employment those
who can not readily adapt themselves to the new methods, are responsible for much
of that pauperism which may be called a by-product of industry. Beneficial they
may be to society, and at the same time disastrous to those individuals who can not
quickly adapt themselves to the new demands.

Any economic institution which discourages thrift and self-dependence, such as
slavery or peonage, develops a mental attitude which may remain to the third and
fourth generation, after the system itself has been abolished. Oppressive forms of
taxation and of land tenure have similar effects. Class legislation and uneven admin-
istration of justice in the courts, when long enough continued and when there b no
adequate means of resistance or reform, may produce a pauper proletariat.

Militarism, a feudal organization of society, and other rigid caste systems, however
efficient they may appear externally, contain the germs of pauperism for the sub-
ordinate classes, ^ough these germs may first develop their baneful influences only
after democracy has replaced the social order in which they were planted. Probably
the pauperism of backward communities in northern sections of the United States
might be traced through genealogical studies to imported convicts of the colonial
era, to inferior Irish immigration of the middle of the century, and to assisted criminal
and pauper immigration from the Continent of Europe in more recent years. Proba-
bly much of the criminality and inefficiency of large classes of southern negroes is in
effect high grade feeble-mindedness, which did not seriously interfere with the pro-
ductivity of directed slave labor, but is revealed under the conditions of free com-
petition. We may expect that natiural eugenic influences, arising in the one case
from more stable marriage and family institutions among the descendants of the slave

PUBLIC HEALTH AKD MEDICIKB. 193

population, and in the other from the freer mingling of urban, oemiurban, and rural
p<^ulationfi made possible by modem methods of communication, will tend to elimi-
nate these kinds of paupaism together with the mental inferiority to which it is due.

Mental hygiene has its tasks with those who have the pauper spirit and with those
who are in danger of acquiring it; but it has its tasks also with charitable givers, with
public relief officials and with the citizens whose ideals the public relief policy of
the State represents. Both official public relief and voluntary religious charity
have been at bottom consciously or unconsciously pessimistic. They have assumed
the continuance, if not tiie desirability, of a permanent daas of dependent poor.
The hanih, unsympathetic attitude of almshouse keepers, and the sentimental,
spiritually selfish attitude of volunteer dole-givers, are bolii out of harmony with
the pragmatic, humane view which challenges the very existence of pauperism^
whidi hoi>es to put an end to the need for official poor relief and for voluntary charity
alike. Organized charity is the embodiment in practice of this new view. It dis-
countenances indiscriminate almsgiving and every other custom, however sanctified
by tradition and sentiment, which encourages the pauper spirit. It demands accu-
rate knowledge of the individual circumstances in each case of need as a basis for a
plan of relief. It advocates inquiry and careful records and intelligent cooperation.
It ministers to the strength and not to the weakness of those who are in trouble. It
emphasizes family solidarity and family responsibility. It believes that the best
occupation for a sick person is to get well, that an able-bodied married man should
support his fomily, that mothers of young children should nurse and nurture their
offspring, that aU who are earning to their full capacity should save something for
future emergencies, and that those who are in need of charitable assistance should
receive aid which in kind and in amount is determined not by the accident as to
whether a benevolent individual passes their way, or a relief agency is or is not in
funds, or an institution has or has not been established to provide for that need, but
is determined, on the contrary, by a painstaking and discriminating study ojf the
present situation and the previous experience of the individual or the family in
question. It insists that diagnosis rather than charitable impulse should be the
basis of every decision, though charitable impulses, thus guided and directed to
wise action, are by all means to be encouraged and strengthened.

Doing different things for different persons, as organized charity demands, if they
are to be in any high degree the right things, involves the training of professional
social workers for relief societies, for the social service of hospitals and dispen-
saries, for the probation and parole work of courts, and for many other kinds of work
in which a technique and special literature already exist. Such trained workers do
not replace volunteers, but increase their number and their efficiency. We might
well hope that this discussion would give an impetus to the establishment in one or
more of the capitals of South America of a school of philanthropy for the training of
social workers in all the gathered wisdom of the church, enriched and supplemented
by the social sciences and their practical applications in all countries.

We come then to the conclusion— that every rational economic reform, every step
in the humanizing of industry, every means of preventing disease and of relieving
the i>eople of its financial burdens, every substitution of a reasonable adjustment for
a social or economic maladjustment, will have a beneficial result in drying up the
sources of pauperism; that the frontal attack upon pauperism lies in the segregation
and humane care of the feeble-minded, the prevention of alcoholism, and the devel-
opment of social insurance against sickness; that to these ends the professional and
technical training of sanitarians for the public health service and the professional
and technical training of social workers for the tasks of relief and prevention are of
paramount importance.

194 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NQRES6.

Dr. John N. Hubtt. We have listened to two papers fnnn mas-
ters of their respective subjects, and I believe that every word they
have told us is true — i. e., that it is within our power largely to get
rid of crime, pauperism, and poverty. The fact that these evils
exist seems to me to be evidence at the present time of our own
incapacity to govern, to handle things. In order to bring about
better conditions I believe that the chUd oreed which has been pro-
jected by the Indiana State Board of Health lays a foundation.
It runs this way: That evory child has the inalienable right to be
bom free from disease, with pure blood in its arteries and veins;
every child has the inalienable right to be trained in mind, body, and
soul, and to be protected from evil persons and evil influences, and to
have a fair chance in life. Those inalienable rights we do not secure
to our children. The essential thing to do is to see to it that they
are well bom. We have long been told that you can not have figs
from thistles. You can not, and yet we are striving for that very
end. In these problems we may well consider the fact that the
human race since tiie beginning of time has bestowed an enormous
amount of energy in simply striving to find a substitute for right-
eousness. It does not exist; and as long as by relief, by doctoring
and by all such practices we strive to find a substitute for right-
eousness, we are simply wasting time and energy, for it does not
exist. In a word, my whole argument is this: Instead of striving
to keep men out of hell, let us strive to keep hell out of men.

Adjourned at 12.20 o'clock.

GENERAL SESSION OF SECTION VOL'

New Bbbitt Hotel,
Wednesday afternoon^ December S9, 1915.

C3i«iniiiiii, Cdi. Sokr Vak R. Hoff.

The session was called to order at 2 o'clock by the ehairman.

The fdlowing papers were preseiited at this seosioii, wveral of
wfaicdi were read by title:

Mechanical appliances in the treatment of Pyorrhea Alyeolaris,
by Dr. Felipe Gallegos.

S^ene del embarazo y de la primera infancia, by Dr. Atilio
Narando.

Puericultvra, by Dr. P. Rueda.

La Novocafna Olicero-iodada, by Dr. Juan D. Susini.

Los dispensarios para lactantes (gotas de leche) oomo medio
para disminuir la mortalidad inf aatil, by Dr. Julio A. Bauza.

O error esseueial d» peeaoa na ki brasikifa do eanmttito wrk^
by Dr. Rodiigues Doria.

M6todos modemos para la preyenci6n de la mortafidad infantil|
by Dr. Arthur L. Guerra.

Prophylazia do ophidismo aa America^ by Dr. Vital Braral.

Nota sobre tratamiento de la infeeeite puevperal por ka baAaa
iibios proloi^ados, by I^. A. FiaDo Oatnnd.

Accite respiratoria del depresor eordb, by Dr. Teodoro Huhm.

Lepra y autosangroterapiai by Dr. liuis Zanotti Cavazzoni.

MECHANICAL AFPUANCBS IN THE TREATMENT OF PKMOHEA ALfB-

OLA1II9.

By FELIPE QALLEGOS,

Suntary tf tht Famkif e/ Ikntal Surfftry, Cotia Jlioa, Cmiir^ Jmeriea.

Pyonfaea alyeolariB is here, m in all parts of the world, a problem which confronts
the dentist almost daily. My experience in 29 yean' practice can be condensed as
Idlows:

When about half of the teeth in a mouth are badly involved with the disease^ espe-
ciaOy when the bicuspids and fiist molars are affected, all efforts for a successful cure
will faU. The lower indson and the bicuspids of the upper jaw can be cured more
often, especially in the early stage of the disease. By a successful cure I mean, of
course^ three thingpi: 1, Tho disappeaKaaoe of pus from the pockets; 2, the reaffirming
of the teeth as they originally were; 8, the nonrecurrence of the disease.

The litoAture on pyorrhea alv<eolariB written in the last 10 years will fill many vol-
umes, yet I do not see many reports showing that success has been as frequent as is
necessary and desired. Tfa^ majority of writers deal almost exdiMively with the
cleaning operatioDS and the use of drugs, but no mention ii made to the use olmechaii"
ioal appUanoss to help in the matter.

1 There WM DO ftttiofnphie report of thto Msloo.
68486— 17— VOL IX 14 lOi

196 PBOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC C0NGBB8S.

I make this statement: That deanlinesB, medical treatment, and rest of the diseased
organs— 4hese three things are needed and help each other in the final success of the
operaticm.

As to the cleaning part I can not say anything new. The medical treatment may be
difficult in cases needing constitutional treatment. Locally, the iodide of zinc tincture
IB about the best that we can use, if not too strong. We are now in a very interesting^
period of experimentation; so tut the emetine injections, both subcutaneous and in
the mouth, are reported by many writers as very beneficial in destroying the endame-
has, found in the pus of the pyorrhea; and sudi discovery marks a progressive step,,
throwing much lig^t in the etiology of this disease.

Speaking now of the facts that I wish to emphasise in this paper, it is my expeiienoe
that no matter how well the diseased teeth have been cleaned, and how great the care^
taken in the washing ahd medication of the pockets, the final effort of tiie battle has
to be won by mechanical appliances used to hold the loose teeth in as secure a position
as possible. No clumsy appliances, of course. Every dentist can make something to-
suit each individual case— -narrow bands of gold, fitted on the firmer teeth; gold wire,
either on the inside or the outside of the indsoro, resting on the gold bands; and then,
platinum wire to tie the loose organs to the bands or gold wires. In many cases, and
in the early stage of the disease, the platinum wire is all that is necessary to hold them
firm. The use of such mechanical appliances is only common sense. If the ortho-
dontist, working on healthy bcme, after he has put the teeth in the rigjit position,
must make a good appliance to hold the teeth firmly in its new place, so that nature's
process of repair finishes its work, how can we expect that loose teeth with a diseased
alveolus can get well if we do not treat them similarly? The general surgeon puts the^^
broken bone in plaster to insure rest. Why should we dentists not do something
similar?

In mikVing this plea for mechanical appliances in the treatment' of pyorrhea I do not
daim originality; nevertheless, I consider it worth while to insist on the matter, as
it seems that many dentists expect everything from the use of drugs ahme. And
writers in general do not mention mechanical appliances at all; some oL them because
they consider it, perhi^, as a matter of course; othen because they have fdgotten it
or do not give it great value.

In finishing this paper let me call the attention of the profession to a good astringent
medicine to be used on the gums, one whidi I have found of great service in making-
the teeth firm again. It is a resinous red fluid obtained by making an incision on the
bark of a tree very common in Central and South America, the Tar^ua eolarado. I
find a notice of this tree by H. Fittier, as follows:

Targua euphorbiacea, Croton Gossyphiifolius, Wahl.-Symb.-Bot.: 98.1791. Croton
Xalapensis H.-B. O K. Nov. Gen. et Sp.: 85.1817.

I find, on inquiry, that other persons think that this tree is very similar to that
described in the National Standard Dispensatory, Philadelphia and New York, 1905,
as a kind of dragon's blood. I have used this astringent, mixed with two parts
alcohol, and I think it is worth while to experiment more with it.

BEBC— mOIENE DEL EMBARAZO T DB LA PRIMERA INPANCLL

Por ATILIO NARANCIO.
De la FacuUad de Medicina de Montevideo^ Uruguajf,

^Ptura que sirve este trabajo?

Oe dirfa que mi obra es innecesaria y casi afirmaria la verdad. Hay en eUa taata*
cosas conoddas y tal repetid6n de conceptos yulgaree que proclamada su inutilSdad^
no podrfa desmentirse.

PUBUC HEALTH AND MEDICINE. 197

Y sin embaigo entre bus p^igtnas hty algo.

08 dirla m^s; cada texto de ciencia ampllfica loe criterioe que yo soetengo en dia-
qukicumee seiias y traBceudentales, que me han hecho meditar laigamente y que
▼ilflii den veces m^ que mis deehilvanadaa disertaciones.

Y an embaigo hay en este mi libro, que lo es tambi^ de voeotras, madres por
piimera ves, nifiae que aq>ir&i8 con legftimo oigullo a ostentar en fecha no remota eee
honroso atiibuto, una derta drnpliddad que me atievo a inainuar, peee a mi modeetia
y que seri seguramente la finica causa de que 41 pueda Uegar hasta vuestio cerebio de
una manera mds suave que loe infolios de sesudos pensadoras.

Es que mis conodmientos no son simple teoria ost^n fundados en la experienda y
este estudio es n^ia la obra de un padre que la de un medico.

^Peio, cu^ es mi preteno^ al esciibirio?

CoiXf mno la de seios dtil a vosotras, madies piesentes y futuras, y por ello, me
verbis a menudo huir de las explicadones ambiguas para deciios daramente la veidad,
tal ouDo la sientD y c(Hno pude expresarla.

Soniefos pues, de mis atrevidas pretensiones, p^o leedme, leedme que al pasar
notaidia nia de una yea que algo de amor, de sincero afecto» de sano optunismo se
respiia en las p^iginas de mi estudio; algo que os hai& tanto bien como una caiida de
madre que adn siendo indtil es bienhecfaora; algo» que llegaii a vuestios corasonee
oomo U mizada de un padre, que sin ser severa os encamina al bien; algo que no es
BkkB que mi deseo de seios dtil.

Y a lo consigo, a amablemente me decfs un dia "una vez encontr^ en esta obra un
buen conaejo, una palabra de tranquilidad en un instuite de sosobra, una frase de
aliento en un s^gundo de dea&nlmo, un concepto condujrente en un memento de duda, ' '
colmav^ mis satisfaociones, porque tal era mi dnica protenaUSn al escnbirlo.

CAPtruLo I.— El BbbA EstX bn Oaiono.

PRDCBRA TISrrA.

SifUomas generaU» de embarazo--Cfuidadoi convenientei-'Lo que duhe y lo que no debe
hacerse—MkHcoB y parteroM—iLa eUcd&n et dudoeaf

Sefiora: os tengo que dar ese nombre, y vuestra soncisa me revela que adn no os
hab& acostumbrado a que se os llame asf. Hace dos meses cuando en vuestra casa
patema me anunci^istels la deci8i6n de formar un hogar, era yo quien sonreia: ocultaba
ad mis intensos sentimientos, mis temores, mis preocupaciones.

El trato del mMico habia con los afios afianzado la amistad y no era sdlo mi cliente,
la que emprendia una nueva y misterioea ruta, er&is mis, er&is mi pequefia amiga, caai
mihija.

Al contemplar vuestra figura, vuestro talle fuerte, vuestro pecho amplio, al pensar
que OS halUbais dotada de una voluntad tranquila y una dega fe en el porvenir, rena-
ci6 en mf la confianxa y dije: "cumpliri perfectamente su nueva vida."

Hoy OS vengo a ver por una indisposicidn pasajera; como tal la ha clasificado vuestro
carifioso eqxMo. ^Yqu^T ^Sefiora, mareos, niuseas, dolores raros, arrebatos de calor
al rostro? ^Sf? t^ tambi^ vdmitosi |Ah, sefiora} esto es m^ grave de lo que
pens&is. Esto tendri consecuendas, pero no os alarm^is, ellas ser&n de tal grade que
colman&n todas vuestras esperanzas. Me hab^ comprendido . . . es claio y era
Idgico.

iQa6 deb^ hacer? Por ahora nada. Cuidaros en vuestras caminatas, moderarlas
hasta transformarlas en paseoe hlgi^nicos, no viajar^ en coche o autom6vil, no hards
ejercicioe violentos y comerds . . . comed todo lo que os plazca y mucho — sano,
nutritivo, poco condimentado a fin de que el organismo asimile por dos, ya que ese
alimento serviiA tambidn para dos.

Haced vuestras digestiones tranquila, reposada en un diviUi, satisfecha de la alta
mi8i6n que estiis cumpliendo, la mis grande, la mis noble de cuantas Natura 00 h;'; a

198 PBOCEEDINGB SBOaiO^ PAK AMBBIGAK 80IBNTIFIC C0NGBE88.

^epaithdo. Manteneos C(Hrrecta en vuestrov plaeorav dn olvidar per eei» vneBtnw
aecesidades. No txansaodit^m y eepera que vueetra* afickmee al balle aeite faihibMM
par lai nuevae de madre que d^b^ ctdtivw eemendanieiile. Esto aacriflcio, pee
otra parte, no durarA mucho y serft resarcide ooa ereoee por lae eatiBfiftoeioaea poeteriMea.
No abandon^is vneetro higidniea bailo templado, matinal, que o# aal^asidemiK^UM
afeeciones cutimeas m^ ttethoettte adq^oiriblea en esloa mamenKUB en que oe eneoii*
tMa Irente al p^igre, en eendiekmee de Ugora iohriaeiM^ j cuidad TweCiPoe eeaoa,
que a m^ de 8U ''toSette'' habitual loe deb4i9 frotavdianimie&to oon una parte de
idcohol, agua de Colonia e el agua de vuesti^ftMnKier, en dee fleagva linpia.

No elvid^ie de volTerme a llaaiar ti quiato mee^ o bien nquerid a ▼ueaCia pariera
de confianza. Gualquiera de loa doe oe haremoenniche bien pieviniendo laa pequefiae
complicadoneB podblee que nada valen cuaado se puedes tttcfimentefemediar, pere
que ae baoen gra^ee €fttanda luMonde eldo abandonadae ee agigaataa paia tnaam-
formaiBe en obstdculoe sevloeen el Hemettle Moldgko dek nadmoanta

^ A qui6n debris llamar? ^A m(, o a la madamat He aU ma cuoatidn que me
Aole8ta«e0p<mder. Sxlitea bueeaa, muyboenaay exeelenlCB partene, a td gnideque
a eUae lee conffe d poner al mvade a mii kijoa. Pedid qw aeaa limpiaB, eacrapa-
loeae en su eemetldo f ceOkbs aae obUgad^ Anfaa deajradar a^bien naoer Bensal-
nrante, exjgid que al ttenor iMpAiae aeodan al fM^nltatifYO y aerte bim aervida.
Feio, pqriairqtnocaentregoftiaeMMadwmagfliBtitnlequehacattUprt^
de BUS dientea y que no eaben de libros, ni ban pisado' una gala cb m^arnidai. Bn
falta de leepoanbfildad lae haoe mie atMirlte y oe deMi cooveaoev que la sej<v
prActfea ne podii pcrangoaane a qeien ha hecfao una laiga y Tigilada caiieta ea laa
auIaeieumendoalaerpefieBdadeleaeaaoa, ladeneladeloaliieoe.

^Pero, i^Btdk que eea yo qaien mantenga la dinedtet BiaB-*4aay peonlo ea
har6 una nueva visita. Eepero no echto en aaoo zoto mis observadoneB y oe ruege
recofd^ie siempre que hab^ perdido vueetza libertad de acd)5n y 00 hallaMia obli-
gada a obedecer la voluntad del peq^iefto tiiaao que eet& en camino.

aae«miML TianA.

Fufa oZ a«re lihre—iQuJi deUia eomerf—El corU adminlieido de tortur<t^Lo§ pa$$o$ f let
dJaeviovMa^^JSeiMBlMbuf tf Maoittci db eaiCiiaiftfw*

Sefiora: Amablemente 00 digo que oe habile equivocado. Yuestro deeeo ha ide
mas alU de mis indicaciones. Anotadio bien. Yo no oe exigf un enderro rlguroae
en vuestro domidlio dedicado a vuestrae mon6tonas costumbres que penniten tejer
la red de vuestros pensamientos alrededor del hedio ilsiol^co foturo. Os dije, Sefion^
nada de exceeos, caminatas, bailee, conerfes. Os ban didio quietud, y vueetre
razonamiento ha coirido al extreme dej&ndoee dominar por el prejuido. EstAIs
dentro del tercer mes; ee derto que no es conveniente haoer locuras, pero ee tambito
yerdad que ese enderro es pemidoeo para vos; por ende para 41. Ese pequefio beb6
que esti en akmino llena toda vuestra vida. Lo deeedis bello, fuerte, el mia her-
moeo de los beb^ pasados, presentee y futures. T bien ^quer^is conseguirlo? Le
repito, vida amplia, tranquila, sin agitadonee morales 0 ffsicas violentas. Ahf tendia
un resumen de mis pretensiones.

Pero, quiero inculcaroe hasta vuestro aburrimiento mis ideas, quiero convenceroa
hasta el cansando de que mis instnicdones os serin benefidoeas y por eeo os repetir6
lo que pretendo de vuestra amabilidad y dd respeto que os debe imponer la denda.
M^ a6n cuando sols, sefiora, tma de las privflegiadas de la suerte que podto ohridar laa
necesidades de una vida material para entregaros a vuestras comodidades o a vuestroa
capridios.

^T si no fuera aa(7 i Ah sefiora I si fu^rais una obrera que mantiene con sn aalaiie
la familia entera, no podrfan llegaios estos consejoe, pero recibiriiia con mia mia
grandee simpatias^ los fervlentes votoe que expreao de una pronta aanddn de leyea

PUBUO HEALTH AJfTD MSDICONB. 199

de proteccidn y el deaBo que albeigo de una zealizacidn amplia de la matemidad en
todos lo6 pafaes.

En cambioi, 09 encoateiia en condiciones inmejocablee y dd>6iB olnne. Vuestio
^)etito probablemente 0e redoblat^. ^Qu6 debris hacer? Comer, corned todo lo
que 08 plasca y refos de los prejuicios de la gente que os dir^ que ciertos alimentos
daben aer preferidoe en el estado en que oe encontriUs. Todo sirve cuando el <Ncga-
niamo lo pide. La voz de la naturaleza, salvo en casoe patoldgicos, debe ser obedecida
ci^gamente.

Pero, defendeoa de loe caprichoe de la moda y de las ebligadones de la vida mundana
y Buprimld vuestro con6. No os asombr^is. £s necesario absolutamente que b dej^
xelegado para el dfa de vuestra primera salida con el beb^ y entonces, quizd oigullosa
de b que hab^is sido capaz, no os acoid^ls de H. Es una pequeila imposicidn que
exige explicaise. ^Verdad, sefiora? Pues bien, tened en cuenta que aiin modera-
damente apretado ser^ perjudicial al diente futuro que adoptar^ segiuramente una
mala posicidn, Impuesta por el enci0rro obligado. ^Y sab^s a que consecuencias
conduce una posici6n vidosa? Hay n^is, el cors^ ser& tambi^n perjudicial a vuestro
estado porqu^ la pared abdominal^ ampliamente eldsdca, colocada entre dos fuersas
que se contranestan— el empuje interne del pequefio que asplra a engrandecerse y la
presidn externa del aparato de tortura— se afina, se adelgaza, pierde su elasticidad
que no recobrar& jam^ y que es necesaria para vohrer a dares esa figura airosa que
00 caracteriza y que servird, con s^guridad, de modelo a un cincel ezigente.

Si OS presentdis a vuestras viaitas con un ampUo vestido, bien libre, colgante, SS^
hard quiz& patente vuestro estado, pero a las sonrisas deb^ responder con laafirmaddn
oigullosa de la veidad, que no os debe produdr rubor la satisfaccidn de cumplir la
mis alta misi6n que la naturaleza depara a la mujer.

Deb^ sefiora, y vuelvo antes de terminar a leferirme al tema inicial, abandonar
Yoestra inmovilidad. No os dli6 que bajo pretexto de hacer ejercicios, os dediqudis
a deportes violentos, tales como el ''tennis" o la caiiera, tampoco os animar6 a que
aprovechdia vuestras veladas en fiestas 0 bailes, pero s( os aconsejo que no dejdis vues-
tro paseo cotidiano en tren y a pb. Un viaje a las afueras en tren; un ligero paseo en
los parques os har^ la vida amable y abandonar^ quisi esa preocupaddn violenta
de socesos que se realizar&n fatalmente. Haced visitas, ocupaos de vuestros qu&-
haceres y de la direcddn de vuestro hqgar, abundonando las tareas pesadas al servicb
J pensad siempre que ningfin sacrificb es poco para cons^guir ver fuerte, sano, vigo-
rose, al pequefio beb^ que estd en camino.

TEMCEMA, VXairA.

iOuUn aUmenkard oL hMt—Al^jaot de la nodriaa^Una /aUa y un erimenr-Difi-
cultad de Ut tUcMn de nodrin^Una mala y aen peora.

Sefiora: Redbid mis felidtadones n^is sinceras. Eso, progresa evidentemente.
Eso es ya viaibb. No, ^For qu6 niborizaros? ^Es acaao un dellto? Gumplida la
miixima bfblica de la multiplicacidn, os deb^ sentir rcgodjada, oigullosa, capas de
acometer grandes acdooes.

No dir6, sefiora, que deb^ imitar a vuestro marido que en su jtibilo de padre futuro,
ae conddera sufidente para repoblar la Europa; pero al menos vanagbriaos de vuestra
aeddn. La frente alta, d pecho exguido, sois cad madre.

Anotad con cuanto m^ ardor beaar^ vuestra mamita cuando deje caer sobre loa
Tuestros, sus ojos mansos, sondentes y lacrimosos de lutura abuela.

Y ya que la he recordado, mientraa d prdximo diente viene en camino tratemoa^
asfiora, una grave cuesti6n. ^Quidn alimentaril al beb^7 Si no escuchiis n^is que
la voe de la Naturaleza y las pdabras de vuestro corazdn estarda dispuesta a cumplir
hastad final vuestros deberesde madre. Td es vuestra opinion, tal la mfa. Pero, he-
ahi el partido opuesto. Lo encabaza vuestra mam4. "Sf, dice, yo os amamant^ a*

200 PKOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONGBE88.

todoe, pero eran otroe tiempos; yo era fuerte, sana, mientras td, tan d^bil, tan nerviosa,
te fatigas tan pronto y adem^ te defonnarias. E0O es hoirible. Cuenta dies, quince
meses eeclavizada, sin teatros, sin fiestas, ^comprendes, hija? ^No ser& demasiado
para tl? Y tu marido tan bueno pero tan delicado ^no perderla sus ilusiones vi^ndote
denodriza?''

Vuestro espoeo, pooo preparado para su papel, no quiere seguramente que se le
eche en cara que por ahorrar unos pesos que pueda costarle el ama os obligue a cumplir
tan desagradable como pemiciosa misi6n y se pondr& de parte de la abuela futura y
vos, Sefiora, i qu6 v4is a hacer?

Vuestra madre, vuestro esposo, las personas a quienee quer^is entrafiablemente os
empujan y decidis abandonar vuestro beb^ en manos de una mercenaria que expende
su leche al mejor poster.

He llegado a tiempo por suerte, aunque veo que ya habfan hablado del punto.
Prevenir mejor que curar, tal es nuestra misidn. Y bien, Sefiora, prevenida quediUs.
Mi consejo es tenninante: Vos y nadie m^ que vos tiene la obligaci6n de «^mfttnflTi^|^
■sX beb^ que estd en camino; si asf no lo hici^reis cometerfais una falta y un crimen.

Una falta contra vos misma, un crimen contra el nifio de la nodriza a quien le
robdis su leche, y ser6is, la piimera castigada. Supiimir, despu^ de la matemidad,
la lactancla, es dejar a medias un proceso fisioldgico, es detener la marcha regular y
hermosa de los hechos. No lo otvid^, la naturaleza no marcha a saltos y la ordena-
cidn de las funciones naturales es suave como la caida de los p^talos.

tCu&ntas madres despu^ de exterlorizar tma o dos criaturas sin haberlas lactado
quedan deshechas, quebradas, viejas y cu&ntas se han hermoseado, han vista por
primera vez colores en su rostro y se han vuelto fuertes, vigorosas, espl^didas en
plenas funciones de amasi

Oometer^is adem&s, una grave falta contra vuestro hijo, el que se habia formado
recibiendo la vida por vuestra sangre y que notari seguramente el alimento extrafio
que le proporclonarla el seno mercenario.

Quiero suponer, Sefiora, que os hayan elegido una buena nodiisa; que gracias a mi
intervenci6n eetSB segura de su salud , que sea sobria, que sea honesta. Pero, ^ddnde
encontrar ese fen5meno7 Por tma buena, darto con cien malas, y estad segura,
Sefiora, la vuestra estari entre las cien. Os dir^ muy pronto el porqu^ de una afirma-
cl6.% tail tcrmmajxte. Sabed tan 86I0 que 611a estd basada en una laiga experiencla.
Mientras, no oe preocupto, yo os garantiso que sola, serais capas de llevar a hombre
a ese pequefio beb6 que estd en camino.

CUABTA VIBITA.

El ama es siempre tma mercenaria—'El kijo de la nodrita — Injluencia del medio en el
cardcur del ama—DelUo no penado por Uu leye$^La venida del ama impiica la venida
del kijo.

SEf^oRA: ^HabdisreAexionadoiobremisdltimascQnfidencias? |Ahl ... ^pero
quer^ saber porqu^ os habl6 de crimen? Oreo que me seri f&cil explicdroelo. ^Ha-
b^is p^isado alguna ves en el porqu6 de la existencia del alimento en el seno del
ama? Y si lo hab^is pensado, vos, Sefiora, tan caiifiosa, tan amorosa de los pequefkM,
tan alecta del futuro que viene to marcha, ^no hab^is meditado un s^gundo, en d
hijo abandonado por la nodriza, quien corre tras vuestro dinero, vendiendo un ali-
mento que no es suyo, que es usurpado a su hijo, thiico propietarlo de la leche matema,
6nico con derechos y a qui^ le es necesaria como el sol al capullo de rosa?

Vuestro hijo es despojado de su alimento porque vos esteriliziis la fuente de vida
con que laphSdiga Natura os ha dotado, para transf(»rmarla en un adomo de vuestro
cuerpo que no necesitarfa de 61 para ser hermoso, y en cambio le d&is una extrafia
alimentaci6n robada a otro pequefio que gracias a 611a vivirfa y que sentiri su falta al
par que el beso de amor que le hac6is impoaible, rob&ndole su madre.

PUBLIC HEALTH AKD MBPIOINB. ^1

^V^, Sefiora, cuiuato mal?

iV^ c6mo amaigdiB intitilinente vuestra vida, porque siendo como tob todo
CQra£6n, cuando el ama 06 diga que au hijo muere en manos extrafias, porque se le
alimentaba mal, recibir^is la noticia lacrimoea y triste como si os arraocaran un pedazo
de vuestro aer intimo?

Y miezxtras— haBta por egoismo— comprended, Sefiora, que vuestra ama sabiendo
que 8u hijo e6t& enfermo, no nutriiA vuestro rico beb^ m^ que por la bilis del dieguflto
y no con la sana savia de la alegrfa.

Cuando ella os diga, ' ' Sefiora, me voy , me anuncian que mi hijo esU grave y recobro
mis derechoe de madre. Vuelvo a su lado, aunque no sea mis que para verlo morir.''
^Con qu^ derecho la retendr^? Y la verbis marchar pesuosa y doliente y oe pon-
dr^ frente al conflicto de una nueva ama.

Vuestro marido y vuestra madre negarin duramente la patemidad de los males
consejoB y he ahf que una nube iombreaWL el cielo de vuestra dicha con un matis de
tristezas que no se borran porque repercuten sobre la vida del ser mis querido, que es
dlbeb^.

Os decia, Sefiora, vuestra nodrlza seri mala. Y no puede so* de otro modo. Colo-
cada en un medio que no es el suyo. Planta de arenal trasplantada a una rica capa
oig^Lnica "se iri en vicios," he ahf el caso. Golosa, encontrar& como producirse una
indigesti6n y la hari con vuestro asentimiento, porque pensar^is siempre en que el
alimento del ama no debe ser discutido. Discola, sabri imponer sus caprichos que
le tolerar^is por no diflgustarla. Sucia, capas de beear al nifio en la boca, con vuestra
tolerancia porque no os sentir^is lo suficientemente en^igica para impedirseb, estando
en ju^go la vida de vuestro precioso beb^.

i Ah, mi buena Sefioral No olvid^is que no hay peor tiranla que la de la ignorancia.

Hay mis, Sefiora, comet^is al contratar una ama un delito castigado por las leyes.
Dad por sentado que el alimento es propiedad del nifio. £1 ama roba ese alimento
para vend^roslo. Heahl el delito. Sereis c6mplicedel hurto. ^Ossonrefs? Si
b comprendo, no serais penada por 6II0, pero ^es por esoun delito menor? |Ahl mi
buena amiga. La naturalesa sabri castigaros mucho mis en^igicamente que lo
harlan los hombres.

Me decfs: "Doctor,^ y si no tuviera leche?" No olvid^is, Sefiora, que estar^ a vuestro
lado y que mis recursos son infinites dentro de la relatividad del poder humano. Si
no tuvierais leche, cosa improbable dado que os halliis espl^ndidamente armada para
que esto no suceda • . . si no tuvierais leche . . . nada . . . ni un poquito . . .
transarfa con el ama . . . pero no creiis que caiga en una contradicci^. N6. Os
traerla el ama con su nifio a vuestro hogar. Meditad, Sefioara, el valor de mi trasac-
ci6n y comprender6is que aunque ello imp<Mrte un sacrificio, es necesario hacerlo, por
cuanto, y os dir6 porque— ello importa la salud futura de vuestro precioso beb^ que
esti en camino.

QUINTA VI8ITA.

Bl dtmnoUo de utia nueva vida — Owmdo ee oonvenienU el ejerdeU^^DediacUndo pre-
juidoe^Alarffor la vida inirauUnna ee ameeguir un ntAo ya cnado.

SbAora: Perddn, me he detenido quisi demasiado sobre el tema del ama, pero
^comprend^is, Sefiora, cuinta importanciatiene para la vida del fnturoT Ha quedado
por dilucidar, el porqu6, si la necesidad obliga, os debris quedar con el ama y el
hijo — lo dejaremos por hoy, porque los dfas pasan y el memento final de vueetras
fattigas se va a coronar a corto plazo con el resplandor de la dicha.

^En qu6 lo he notado?

Seficnra, hace ya tres meses que el futuro cliente nos ha avisado de su existencia.
Fu^ suave, carifioeo en su aviso, pero persistente. Ha dicho el "aqui estoy** con
vehemencia— y recordiis que os hice notar la cara de dicha con que me b advertfsteis.

Oada movimiento, cada golpe se traducia en una sonrisa de vuestro rostro lelix.
Vive, pues, y sigue su marcha presurosa hacia la luz. Me acusdsteis despu^ ciertos

202 PBOOEEDIK€» 8800HD 1^AX[ AMBSIOAN 80IBKIIFI0 OONQBB80.

dolores en las caderas y oa afinn^ que no eran mis que defectos de capacidad. Pedia
plasa para migrandecene y vos, Sefiora, obediente a su padido sufristeis la ampliacidn
de Tueatra pdvis decidida % no entorpecer su marcha promisora.

Nofl im>puaimo8 ensog^ida ayudarlo y luchando contara vueatra mal entendida
vergQenza, deaobediente a mis mandatoa, que oa aconsejaban las aalidaa en pleno
dia, reconiateia las calles de la Uibe del braso de vneatro eeposo, trotando fuerte en
medio de la noche, cuadraa y mia cuadraa— y me decla hoy-— que ya no estiia fatigada,
que oa aentis mejor, mucho mia aliviada.

Oa dii^y Sefiora, que ai tal aucede es que el futuro diente ha encontrado el camino
y la rata amplia que habfan elaborado loa hueaoa de vueatra cadera al separarae ha
aido Uenado por la cabeaa del pequefto. Bien, muy bien, todo marcha a la medida
de vueatroa deaeoa. Se cumplen fielmente las leyea fiaioldgicaa. Os dais cuenta
ahora, en que se basa nuestra ciencia: leyes inezorables, fatales, rigen los destines
de la vida y de la muerte; todo est& previsto por reglas observadas y siempre igualea,
y cuando la excepcidn aparece fundando la regla, no vacilamos en afirmar que se han
torcido los preceptos naturales, y tratamos de corregir el error. He ahl todo.

Os halUis, Seftora, en la entrada de la dltima luna, sat^lite cuya traslacidn divide
▼uestros meses, vale dechr, comenz&is el dltimo mes. iQn6 debris hacerT Vuelta
«laquietud. ''H<»ror,"dir&vuestramadremanteniendounviejoprejuicio. "Ahora
es cuando es m&s necesario que camines, chiquita.'' Error, digo yo que soy vuestro
medico y quiero explicarme, x>orque me entender6is ttcilmente. El divine beb^
en camino est& ya perfectamente complete. ^Me entend^is? Ouanto m&B largo sea
este dltimo perfodo, m&s perfeccionado vendrA a la vida y por lo tanto mis apto para
afrontar sus peligros.

Mi» fuerte, sufriri lasindemendas del cambio con energfas y os encontrai^is, sefiora,
con un pequefio pronto a todo, hedio y dlspuesto a triunfar contra la enfermedad;
▼igoroso, que absotberd su alimento con la tranquilidad y glotoneria de un ga8tr6nomo
aeeudo.

^Os figuriUs, sefiora, qu6 memento inestable de la vida, es el del nacimientoT

G6modamente encerrado en predoso eetuche, arrobado por el calor ambiente, ali*
mentado directamente con vuestra sangre, sin tener que cimiplir los trabajos inhe-
rentes a la vida libre, pobre ciisdlida parasitaria que cumple su dclo en un instante;
traneformarse en nn ser que lucha, se af ana y crece por cuenta propia.

^ Y pretend^ lanzarlo cn&nto anteflt

|Ah! n6, aefiora, detenedle, que alU progresari sin peligro. AUf os sacrificar&
mis, es cierto, pero os ahorrar^is temores futures.

Vuestra madre aigumenta peligros para vos. ^Pero, cuilesT ''La enormidad del
pequefio" . . . ''Es el primero yquisA— el memento es diffdl." Estad tran-
quila, aefiora. Estftis bien constituida, sois fuerte, vuestros diganos son sanos y
Mbr&n cumplir fielmente su misi6n. Ser4 quiz&, un poco mis de dolor que se equili-
brarA despu^ con un mayoi carifio.

Por otra parte, 400 os sentMia berida en vuestras ilusiones al ver a vuestro beb4
enclenque, raquftioo, todo vioMceo y tambkroao, cuando pod& obtener orgulloea,
un rico infante, ya orlado, gordo, fuerte, sano y vigoroso? Estad iranquila, pues,
cumplid mis consejos que yo velar^ porque vuestros ideales se cumplan y que sea
hermoso ese pequefio beb6 que estd en camino.

aSXTA VI8ITA.

UtUidad de eitoM etmvenacionei^Paldbras que deben ter egcuchadoi por la$ madne y por
Ia$ que nolo aoii Oon/imUeneia de vulgaritar la denokH-^hurra dl pudor miUU y a
laforM,

Sefiora: Mis palabras llevadas a los ofdoe mib pddicos no produdrlan ni la nUis leve
intend6n de pecado. Pr^dicas cientfficas, no aon para dichas en el altar de las pA-

FUBUO HEAIJXH AHD MSmOINB. 203

blkas criticas, sino ptam escuchadas en el ambiente familiar, junto al ledio donde el
doUv engendra vida y donde la vida vivifica amores.

Como tal, sefiora, os he venido hablando dalce y amidblemente, mientras vueetro
sacroaanto destino ae cumplfa, tranqtiilo y aonriente como un cabdlero del Men.

Fero hoy, aefiora, una filoaoffa amarga, puso on pesar en mi corazdn y una doda en
mi cerebro

VoSy aeftora, aab^is el bien que os deeeo, sab^ el fin de mis conaejoa, y IO0 recibfa
con IO0 ojos bajos y el of do atento; ^serA lo mismo para todasT

Ellas son, o ser&n madres, eea es mi fe y es por eeo qae a ellas, van mispliticas. Lo
demis, sefiora, serd coreado por mi sonrisa tranquila.

La maledicencia no llegarA a producirme encono, la sdtira hip6crita de los qne
nada valen engendnuri mi desprecio y peso al mundo, marcharemos por el tinico para
noeotroe, suave camino, el del cumplimiento del deber.

Vos, sefiora, y con tos esa legi6n de madres que me leen, sentirdn algtin dfa esa tran-
quila alegrfa de quien se aiente sostenido en los momentos amaigos y i>eligrosos. Yo,
en cambio, ver6 esa nueva generaci6n vigorizada asf como el labrador contempla sus
mioses la&a lozagantee, aeguro de que en algo ha asrudado a la santa obra de natnra
madre.

^Pero por qu^T me decls, sefiora, ^por qu6 doctor?; esa divagacidn, ese pai^ntesis a
nuestras charlas amables y provediosas? \Ah por qu6! ^Lo quer^is saber? Sefiora,
sabedlo, se ha hablado de mi discreto cuchicheo a vuestros ofdos matemos, como de
una charla pomogrifica, se ha hecho caso onuso de su utilidad, para colocarlo en el
** index " de las novelas pecaminosas. Se ha dicho m&a, se ha dicho de la conveniencia
de Impedlr sus lecturas a las pequefias, futuras madres.

iVeis sefiora, que malos! Vuelven a la rutina, no salen del prejuicio. Pretenden
Yolver a las conversaciones secretas de am^as avezadas que repiten lo que ban podido
entrever en el descuido de los padres y que por lo tanto describen como un misterio
horrendo cualquler hecho fisioldgico.

Quieren mantener aquella pemiciosa ignorancla que hacfa que nuestras madres
rompieran el Uanto colgadas del brazo del esposo idolatrado en el momento de la des«
pedida con igual vigor lacrimoso que el de los soldados estrechando a los suyos en el
supremo Instante del adiiSs.

Pero est^ peididos, pobree avechuchos pr^ist6rico6; la verdad penetra con pre^
teza en todas partes y ya nadie conserva esa castidad mal entendlda, efectista 0 hip6-
crita de conventual que era pemiciosa y nociva en la formaci6n del hogar.

^Y si igual, sefiora, se ha de saber, no vale m^ que claramente, cientfficamente
Uevemos a loo cerebros adn obsenrecidos, la luz de la verdad?

Ah! sefiora, disculpad mis enojos, pero es demafdadoparami . . . y quizA para
vos tambi^n, que hab^is oido indulgente esta expansidn de mi ser intimo amargado.
QoiiA . . . pero . . . hemos perdido miserablemente el tiempo y no hemoa
dicho ni una sola palabra del tema que hubiera querido tratar hoy— tema muy intere-
Bante-^p<ffque atafie directamente a lasalud de ese pequefio beb4 que estd en camino.

sinncA yxstta.

EgpUeaaAn dd porque e$ neeemrio aoeptar d ama eon tu Mjo — Carifio y al%menU>—
Dor para reeibit~^D\ficuUade$ $alvadie» — Un hum eompaHero,

Sefiota: Os debfa la explicacidn del porque era necesaiio, ea la f&nica diconatancla
tolerable, que el ama fuera acompafiada por su hijo.

Oa veo ya convendda y por eUo no har6 mia fuertea loa aigumentoa de mi diaerta-
ddn. Sin embargo, deb^ tenor preeente que toda vuestra tranquilidad depende de
^llo y no puede ser de otro mode. Comprended, eefiora, que como reza en la "Ver-
bena," "la gente del pueblo tiene tambi^n su corazondto,'' y que pueato a la pmeba
ese conkz6n late y se sacude con igual f uerza que el vuestro. S«^ais impfa si afirmiiraia

204 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

lo contaurio, y no caben en vueetra gran alma fellz pequefios distingoe de clase que por
otra parte no albergar^ jam^ vuestro cerebro bien intencionado.

Y bien, sefloia ^qu6 pasari teniendo a vuestro lado la nodriza con su nene? Ella
respirar^ el aire de felicidad con que rode^ al vuestro, y la paz de su alma se tradudrd
«n un mejor rendimiento con benepldcito para vos y con utilidad evidente para
vuestro pequefto.

No mis sobresaltos. Su nifio crecer& bajo la mirada maternal asf como el vuestro y
basta quedar^is ampliamente autorizada para erigiros vos tambi^n en su egida pro-
tectora.

Ademis, ese exceso de carifio que ya manilestdis para ese pequefLo beb6 que esti
en camino, lo repartir^is generosamente con el otro, a quien vos, sefiora, no considera-
r^ jam^ como un ''parvenu" porque ^1 cede amablemente parte de su vida para
d&rsela al vuestro. ^V^ la compensacidn? il os da una cosa que es suya para que
con eUa consign hacer hombre a vuestro hi jo; vos le ced6is algo de aquella vuestia
extrema bondad, en cambio del daflo que le ocasiondis.

Adivino, sin emba):go, vuestra pregunta: ^Doctor, aeri bastante, para los dos? Si,
sefiora, si. Sana vuestra nodriza, feliz, bien alimentada; si en su hogar de pobre,
Uena de sinsabores y desdichas, 611a puede criar un hijo sano, hijo quizd de un engafio
y que viene para su dolor y su vergQenza, y puede llevarlo a hombre ... contenta,
sinti^dose bien querida, halagada por la seguridad de que no habri zozobras en el
porvenir de ese ser que adora, sentiri doblar su vigor y llenari perfectamente su doble
mi8i6n.

Pero quer^, ya que os veo alarmada daros una dltima voluntad. Si vuestra ama,
cosa improbable, no pudiera con los dos, se salvard el mal trance de una manera muy
sencilla aunque peligrosa. Se les dar& antes de cada vez una pequefia dosis de leche
de vaca. {Oh, sefioral os causa asombro mi trausacci6n. Es que los peligros de la
leche de vaca se aminoran cuando es &u:tible que ella vaya seguida de im poco de
leche matema que le sirve hasta para apresurar su digesti6n.

Tengo, seiiora, un argumento final que me resulta convincente. ^Sab^is cuil es?
No tiene nada de cientffico, es 861o de experiencia de la vida.

Al proceder como os aconsejo, tendri vuestro beb^ un compafiero fiel, amoroso y
devoto para toda su vida, por que el amor que se inicia en el seno comdn es imborrable.

^Y sab^is, sefiora, lo que eso vale?

El &rbol crece m^ vigoroso cuando otros mis pequeflos lo libran de los embatee del
viento bajo.

El hombre-cerebro iiradiari mis nltido su valer cuando otro se preocupe de desvas-
tarle el camino de esas pequefias minudas embarazantes que preocupen intitilmente
su marcha futura. Y eso, vos y yo, sefiora, deseamos para el pequefio beb6 que esti
en camino.

OCTAVA VI8ITA.

La$ inyeceUmea y loi ane$Uiia$ en el terrible tnomenio^El doroformo^ la toaxnalgina y
la parUxmalffia—Camejoi y dudae^La verdad et que la naturalexa e$ eabia,

Sefiora: Pod^ preguntarme. Soy todo oidos y sabedlo bien que no quiero que
06 intranquilicdis por nimiedades.

^No las conaider&is asf ?

Ah! Sefiora, cuin equivocada est&is. Es patrimonio de los d^biles el hacer de un
fluspiro un vendabal y vos, a^&oia, no sois d6bil ; capaz como sois de acometer la magna
acci6n de dar vida, no pod^ conaideraros ni por un instante como una cobarde.

S6, sefiora, c6mo os him hablado del terrible memento; de inyecciones, de anestesias.

Os han dicho, ademis, que natura f\x6 vencida por la ciencia; que el mal trance se
pasa entre soniisss, o durmiendo. . . .

|Pero, qu6 mal os han aconsejado, sefiora!

PUBLIC H£ALTH AND MEDICINE. 205

•
Hidsteis bien, habldadome previamente y vueetra prueba de confianza merece una
explicaci6n.

Os han dicho: "La aefiora X ha tenido uno, doe, tree alumbramientos bajo el cloro-
formo, y ^ viraas qu6 bien? Nada, ni un dolor, ni un peligro, su m^co fu6 tan amable
que 86 lo admini0tr6 por pequeiiafl doeis, como elloB dicen 'a la reina ' y ahl la tienes,
madre tree veces sin saber lo que cuesta tener un hijo."

No ofl har6 la crltica de la actitud del m^ico porque me temo tener que discutir
con inc<m8cientee, pero, mi deber ee poneros irente al peligro y preg:untaroB: ^Sa-
biendo que os pod^is morir en la anestesia serais capas de dejar a vueetro divino hi jo
sin madre? ^Por no sufrir un instante har^is desgraciado o sacrificar^is a eee peque£k>
beb6 que eetd en camino?

£1 dolor, sefiora, y amiga mla, lo verbis transformado en amor y enjugar^is la Uigrima
de vueetra desdicha con la sonrisa de la felicidad.

Con dolor, seflora, amasar^is vuestro carifio y perdonad, que os corrija esa muequita
ir6nica con que reveUis vuestros pensamientos intimos que se podrian traducir en la
frase que no viene a vuestros labios por siempre respetuosos, pero que traiciona vues-
tro eetado de alma. "Ahl doctor, como se conoce que sois Sombre y no os toca
sufrir." Sf, seflora, hombre soy, pero ^qui^n os ha dicho que los hombres no suiren?
Pobree eeposos ante el dolor de madre, de nuestra compaflera, una sensscidn de impo-
tencia angustiosa se apodera de nosotros y cada quejido es una dilaceraci6n de nuestara
alma.

Natora ha sido injusta con vuestro sexo. Ella os ha deparado los dolores fisicos;
es gentil que los hombres guarden para si las amarguras m<»ales y s61o asi se resta-
blece el equilibrio y la igualdad triimfa. Por ^Uo, sefiora, me v6is tan altamente
respetuoso de vuestro sexo, y sin querer me incline reverente ante la mujer presin-
tiendo en cada una de ^llas a una madre que sufre, a un ser que el dolor engrandece.
No ha mucho, sefiora, nuevos procedimientos han venido a suplantar al cloroformo
^'U el memento solemne. Las inyecciones de tocanalgina y de partoanalgla parece
que caiman por complete los dolores y que su influencia podrfa producir un trance
menos amaigo sin peligros.
^V^is que os hablo dudando?

£0 que yo, sefiora, no tengo experiencia de tal medicamento y conmigo la gran
mayorfa de los medicos.

Sin embargo, me aseguran que son una composici6n a base de morfina o simple-
mente morfina a alta dosis y que en los casos empleados la enf erma queda en un estado
let^ogico prolongado y el pequefio nace muy a menudo en semi-asfixia.

^Os propon^is, sefiora, servir de experiencia? ^Os animiis a exponer a vuestaro
heM a un peligro probable? ^Y si tuviera consecuencias?

Dejad, sefiora, a la inhnmana ciencia que busque la comprobacidn en las clinicas,
pero no me exijdis que os someta a lo desconocido, a lo im>blemitico, a lo pfrobable-
mente male, para libraios de una cosa tan pasajera como un dolor que no ser4 tal
cuando podiis mitigarlo con la solemne al^grla de sentir en vuestros brazes a ese divino
beb^ que eet4 en camino.

CAPfruLO II— El BbbA ha Llboado.

NOVBNA VSBITA.

8ai» madre — La obra magna de dor vida — Fe en la denda y en la experiencia — No m4$
vitiUu—El papel del eepoio,

Sefiora: Sois madre; el grave trance^ ha pasado. Mece en vuestros labios la sonrisa
de la dicha. Vuestro eeposo afligido me ha contado horrores. ^Seguramente hab^is
sufrido mucho? pero no demasiado. !AhI — hio tanto como esper4bais! Gracias, Se-
fiora, veo que sols sincera. Al oir a vuestro eeposo pens6: *'mi buena sefiora, me

206 PBOGEEDIKOS SECOND PAN AMEEIGAH 8CIENTIFI0 COKOBESS.

recibiri teguxiamente quejosa, me dir& frases cradas talef oomo: Se conoce ^e na
8oi8 voe— podfais haber sido mia amable." Pero n6, con vuestro gesto, con eaa dolce
miradA d« agradecimimito me pagiia con creces lot desvelos pasados.

Sois madre, vale decir, hab6is aacendido on ancho p^afio en la escala de la vida^
aaf como en el mundo de loa aeres inferiorea cuanto m^s alta es la especie, mis compli-
cada es au vida oig^ica; en loa hombrea, cuanto mia ae ban elevado, mia mlaionea
deben cumplir.

Pero, Sefiora, esta que Natura oa ha deparado mereceri vuestraa aatiafacctenea al
par que vueatroa desvelos y cuidadoe. Gonatrair un hombre ea graade obea, ptept^
rarlo para la vida, es magna. Os encaminiia por una ruta nueva.

^Guiles ser&n loa eacolloa que hallar^is al recorrerla?

^D6nde la infructuoaidad en que choqu^is y recibdia vueatro primer dolor?

En la guerra conocer al enemigo y la poeici6n que ocupa ea ganar la batalla. En U.
vida ai conoo^ia loa peligroe Uev^ grandea ventajaa para aalvarloa y combatirlos
aerenamente preparada. Tal aer& nueetra miaidn; y nueatra cienda y experienda,
Sefiora, caeiin amablemente de nueetroa labioa, dichoeoa de aer ^tika a voa, encama-
ci6n de eaa caiavana^e madrea que al recibir al hijo, ae encuentran extxsviadaa en el
miaterie de au ciianza.

No 08 amedrentda, aefiora, nada nuevo exiate, que no haya aido piofundamente pre-
viato y las leyea naturalea ae cumplen irremediablemente como profedaa de un aer
infallible.

Aaf, que ai vueatroa temorea oa pueden llevar a aer extremoaa en loa cuidadoa hada
eae pequefLo aer que ha nacido, no deb^ enloquecer ante el miaterio del future que oa
dar6 a conocer con mis palabras.

Pero, aefiora, un primer cuidado hoy. Oa hall&ia convaleciente, debilitada fiaica-
mente y preparando alU en la intimidad de loa tejidoa la vida de vueatro beb6.

Deb^, pu^, permanecer tranquila.

Mafiana, cuando el nuevo cliraite reclame con aua Uantoa aqudlo que eat^ia elabo-
rando, debris reqwndeiie con hechoa y n6 con palabraa.

Y 61, sefiora, cuando pide, exige y no entiende razones.

Para ello, sefiora, nada de viaitaa. Vuestro eapoeo mia locuaa que de coatumbre,
tea contari alU en la aala toda eaa aerie de infamiaa que me ha dicho antes de ll^gar
haata aquf, lea dir& que peea 4 kilos y 200 gramoa, que ya rfe, y quea61a61oae parece.
Todo eao, y mdui me ha dicho, aefiora, y asombraoe; no ae ha quejado adn de aua ne-
{ocioa, ni de au eatancia en caaa. Ya v^, aefioim, cdmo, ain querer, hab^ enloqueddo
a un hombre. Y oomo debo predicar con el ej^npk), mafiana hablaremoa de vueatzoe
cuidadoa a fin de que pod&ia, sola, conaeguir ver en marcha % eae divino beb^ que ha
Uegado.

DiOIMA ViaiTA.

Airef luz, 9ol para la madre y d hijo — El cigarrillo patemo — El ealdo es agua — Menu
de parttmerUa — Ledie contra ctrveza — Menik definilivo.

Sefiora: i Y estaa tinieblas pavorosaa que os envuelvenT i Sab^ia que en la calle
reina un sol otofial magnlfico y que paaamos por uno de los mejores diaa dd afio? | Todo
cerrado! ^Por qu6? ^Teneia fiebre o cefalalgia? Nada. ^Entoncea a que eata
tumba T Ah, vueetra mamil ha dicho ... Lo comprendo.

Os dije tranquilidad, nada de charlaa importunaa pero no por eao oa iba a ezigir d
enclauatramiento total. No, sefiora, aire, luz, vida para voe y para vueatro beb4.
No teng&ia miedo. La luz le har& entomar los p^urpadoa pero jamia le har& mal, a tal
grade que cuando €i pueda moverae lo tendr^ia dempre curioaeando por eaa ventana
por donde entza d rayo de ad vivificante y aano que cdorear& aua mejillaa con tonoa
de roaa. No temiia al aire libre. iX dari amplitud a aua pulmonea que ae adaptan
eapl^ndidamente d medio ambiente. Temed m^ d confinado, d que ae reepira en
eata piesa en d que ae sobreagrega el acre dor de tabaco dd cigairillo patemo.

PUBLIC HBALTH AND MBIUOIKB. 207

lAh>aefioi»l ^ Pretond^ justificar a vueetro aqposo ? ^^fumadopoco? Pues
biea^ safion^ decidl«: ''£1 doctoc ha dicho que os prohibe fumar e«Eca dal nene,"
porque, sefiora, mis mal le hace eao al pequefio <diente que im aire Mo pexo caigado
deeodfene.

I Y que bebida indigna es eaa que veo sobre vueetoa meia de ioa? Oaldo . . .
flaco . . . degaUina . . . Vueetra mam& tambi^n . . . Eadecirquedeadeayerno
^abwb^e alimentado m4i que con tasaa de caldo. i No oabiie sefioia que el caldo es
ag«a.coag!ueto a Ml y a veces con aabor de algttxia lefumbre pei» Guyo valer alm^
eenulo?

Abandonad eaa; Becentiis algo nutiitiiw, fl^ido» que oe d4 iuenas. Tmatemes de
coDapagiBar un "BMnn." Pzimeio uu poco de jam^ cocido. No os alarm^ie^ Sefiera
Mayw, lo digeriii vuestzo nieto en cuanto cumpla sub doe afios y pcetendiie que a
traestra eefioia hija en plenitud de salud le pueda ser nocivo. Bn seguida ua buen
floto de sopa de avena, excelmite alimento mientzas necesit^ Uenar el est^nago
inoaciable dei duke tkanuelo. Desde luego un buen pui^ de papas, del que ped^
flerviioeimplatobieaeolxaado;ycomopestie^ ^ Que querela depoetie? Unacramay
ima ooBipela, frutaa, lo que gttst^, sefioia, y he abi Yuestro 'hne^

Ak enanto a bebidas, es han hablado de la cervesa y oeme de opeitunidad paisa la
funci6n que estdis por cumplir. i Os han vanagli»iado la negia y basta ban aaeguiado
i|ae la extiaiijefa con un jabali di«akndo oomo aarca, eala mis b^vofable?

Puee taiea, sefioia, ahl toa<Sle otro piejuido. Eso no sirve paia aada. No aportaiA
ni ana sola goCa al alimento del pequefio clioite, y en eambio le propotcionai&sedoa
delew de Tieafare por el aleohol que contiene.

Agya, agua puia, be ahf la bebida y leehe en cantidad, abunifi^te, mejer a^&n si
eacottlBtts algttia que no haya side dilulda per la mano mereenaria del exp^mdedor.

(km esoe dos liquidos tendinis aseguiadas las funcioBeB fisiel^gieaa ngrresarias paia
coneofvar Yuestra salud.

TeMid eataadidoi, sin embargo^ que d mend propuesie^ es de oeaaida, amfianap
Hiidis psflMk), viAym^M a vuestza alimeataGi^ erdlnaiia, p^rqae ^la sola sei4
■rapm dasadar el colosal apekito del ezigente beb6 que ha Uegado. ,

unbAgima tisita.

La/khckMfdma p $e wntagict^^Oomit^ isnmkt p Ooror— JSvorie 4$ la alimtmlmiiit
Dupertad a un nifSo dormUAn — Comer dormido.

Sefiora: Ese req>etable caballero que estd a vuestro lado y que segthi asQguia
Tuestio idolatrado esposo comienza a tiranizar el hogar, va a merecer hoy una severa
lecddn. No, no oe riiis. lEa veidad que anoche atrond la dulce quietud de vuestza
casa am Ilantos intempestivoB? ^Es cierto que no quiere desprenderae del lugar
de SOS delicias?

{Ah picar6n{ hiimos ligeramente tolerantes dada su pequefiez, pero comienza a
crecer y requeriri un fuerte correctivo a fin de que una vez por todas sepa que fl
es aquf un intniBO, sin gobiemo y cuya tinica misidn es comer y dormir, y lo demis
cuando le d^ la real gana. . . .

^Anotiis, sefiora, mi tone chacot6n de hoyT Es debido al aura de feliddad que
aquf se respire.

Vos^ am la placidez del deber cumplido, el beb6 con la modorra del future buigu^
adinerado, vuestro esposo con esa sonrisa de superioridad de sujeto capaz y que lo
ha probado hasta la evidenda y vuestra mamita con la mirada de bondad infinita
que embellece el rostro de las abuelas; todos preparan mi espfritu hada la al^grla.

Es que, sefiora, la yida es hermosa, cuando sabemos disfrutar de ^a, y esto que
parece a primera vista una majaderla encierra su fondo filosdfico que quizd no pueda
{amis desdMroslo.

208 PBOCEEDINGS SECOND PAN AMEBIGAN BOIBNUFIC G0NGBE88.

Y bien, sefiora, iqa6 hace nuestro p^equefio cliente? Gome y du^me, iBdemim
lloraT Tres eosas que reglamentar a &n de hacerle comprender de una vez per todae
que en la vida hay siempre uno que manda.

Gomer: vuestro beb6 en este primer mes de su vida no debe satiflfacer su apetita
mds que cada doe horae y media.

^ Y ai llora, el pobrecitoT

Hay un solo recurso, y es algodonane loe ofdoe. Gomprended, seflora, que ai tot
le diia vuestro alimento antes de las hona prefijadas ^ste caer6 en el estdmago aatee
de que el anterior lo deeocupe y el proceso fiaiol^co no podri cumplirse.

Estos intervalos se espaciar&n pasado el primer mes, hasta tres horas.

Adem^, sefiora, se requiere un descanso nocturne de seis horas por lo menos, a
fin de dar descanso al6igano.

Estos conceptos, dichos asf, a la ligera, merecer^ vuestra meditaci6n y seguramente
en el proceso cerebral que los presida aparecer& el recuerdode c6mo fuenm ciiadoa
vuestros hennanos y vuestra bien querida Mamita aigumentar& que ^a nunca us6
reloj para llevaros a todos, a mayores, y sin embai]go, estSSs todos sanos y robustos.

Podria dedros tambi6n que ''hoy las ciencias adelantan que es una temeridad/'^
y que por ende hay que marchar a su vera, pero quiero mejor que septo en que est^n
fundadofl mis asertos.

El est<knago del niflo es extremadamente tolerante. Admitiri seguramente que
lo caigu^ cada 30 minutes o quiz&s m^ a menudo, teniendo come tinico llmite la
glotonerf a de su poseedor. Pero un drgano a quien le exijiis tal trabajo tendr& hctal-
mente que suMr y lo piimero ^sab^s?, lo primero que sucedeii con ^1, es que se
dilataii, y ya en ese camino se har& disp^ptico y comenxari a devolver su contenido.

AI principle lo arrojar& inmediatamente despu^ de recibido, caso f&dl y perfecta-
mente curable; despu^ lo volver& a arrojar a la media hora, o a la hora, caso y% mto
diffcil y al final ya no digerir& y vuestro beb^ enflaquecer& hasta el marasmo.
• Quedamos, pues, convencidos, sefiora, que para que vuestro admirable pequefio
se haga hombre, deb^ cumplir estrictamente estos preceptoe, evangelios de la buena
nodriza. Y disculpad, sefiora, por que oe honre con ese tltulo, porque 41 es vueetiO'
mejor galaiddn.

Sucede a menudo, sin embaigo, que a pesar de ser espadados los momentos de
alimentacidn, el estdmago devuelva inmediatamente despu^ de ing^idoe, parte
de su contenido.

No OS alarmar6is por eso ^veidad?

No, pero deb^ conegir la causa.

Vuestro beb^ devuelve por que es un tragdn. No le quite un dpice al adjetivo.
Trag6n, si— que ''chupa"— demasiado. Pues bien, sefiora, ^qu4 hay que hacerlef
No dejarlo.

He ahi resuelto el problema. Si comprobdis que escando quince minutos prendido
devuelve, dadle trece; si con trece, dadle doce. En fin moderad el tiempo hasta
que notdis corregido el defecto.

Y si duerme, decis ^debo darle el alimento? Tentado estoy de respoiiii^ros: quien
duerme, come; pero si eso dijera podrfais acusarme de error. Es que hay nifios pere-
Bosos que no se acostumbran fdcilmente al horario alimenticio. Con 4Mob nos queda
un tinico camino: ponerlos al seno adn dormidos.

Gomprendo en vuestra mirada de compa8i6n la pregunta que me v^ a hacer:
''^Pero doctor no tento Ustima de despertarlo cuando estd tan plicidamente dee-
cansando?" No, sefiora, la listima es un sentimiento que debe ser regido por la
necesidad y el beb^ necesita alimento.

iPor qu6?

Por que si lo dejiis dormir cuando despierte tragard demasiado y se enfermari.

Los nifios asimilan una cantidad fija a igualdad de edad y el perezoso que olvida su
hora tiene para alcanzar al diligente, que absorber el doble con menoscabo de su
salud.

PUBUC HEALTH AITD MEDICINE.

20&

D^ftmoe sentado pueo este otro precepto: ^'cuando Hegada la hora vuestro peque-
fluelo duenne, lo pcmdr^is al eeno."

Pero, i>od6i8 decirme ^cdmo hacer si estd profandamente donnidoT

Nada mia f&cil. ^Hab^is visto alguna ves cebar a loo pichonee? Con apretarle lao^
conmisuraB del pico y x>oi^^l6 ^^ alimento sobre la lengoa ^los se apuran a deglutirlo.
Vuestro pich6n hard lo mismo con la tinica diferencia que, como 61 no tiene pico, se la
deber^is poner entre los labios y hacerle ligeras compresiones en las mejillas. He ahf
resuelta la grave cuestidn.

Os ruego amables clientee, que con deferencia me atend^is, que vayiis anotando-
mis procedimientos porque 611os haWm factible vuestro deseo de ver truisformado en
un perfecto hombre a ese precioso beb6 que ha llegado.

DUODtoMA TIBITA.

La revUaeidn HtU de midico — E$tudio de las fontanelai — La balama del pobre y la del
rieo — Lai pe$adai^iC&mo daher ti vuestro nene progresaf — Tahlas maUmdHeas para
coda easo.

Sefiora: ^Os admir&is de la revisacidn prolija que bago de vuestro beb^T Goth-
prended, sefSora, que es una m^uina pequefia, ea verdad, pero no por 6II0 meno»
compleja, y con mi revisacidn me aseguro de que cada pien estd en su lugar, apta.
para hacer funcionar regularmente el mecanismo.

^ Y bioi, seftora, que he notado? Nada y mucho.

He obeervado la cabeza, palpado su tenue eequeleto, estudiado el eqpacio de separa-
cidn entre sub huesos (fontanelas), las he visto latir y me he as^gurado del estado de
tirantes de las menbranas que llenan los eepacios libres.

^Para qud? Os dird, sefiora, para nosotros el hallar bien Uenos esos espacios noa
garaatisa la buena alimentacidn del bebd asi como su hundimiento nos advierte que*
hay alguna causa que impide la asimilacidn. Es "2a balanM del pohre'* quien sigue
religiosamente sus indicaciones. No es necesario que os afirme que el cliente ha
aprovechado bien del surtidor y que sus fontanelas lo exteriorizan patentemente.

Voe, sefiora, no necesitiis observar eeo, pues, he puesto en vuestras manos una
balanza de relativa precisidn. ^Para qudT Ah, sefiora, sois curiosa y sin embargo,
OS aa^gnro que no me alarman vuestras ansias de saber, al contrario, vuestras amabW
preguntas, me llenan de satisfaccidn.

La balanza, sefioii, serA el medio de probaroe que son ilegftimos vuctotros temores de-
falta de secrecidn.

^Cdmo? Pesad al bebd antes y deepuds de cada ves que dl extrae su alimento y^
anotad la diferencia. Os asombrardis de su glotoneria. Verdis como al cuarto d^
Uega a tomarse hasta cuarenta gramos por ves, es decir, que en el dia ingiere, el tu-
nante, casi cuatrocientos gramos de rieo y sano alimento, y que iri, poco a poco,.
ascend iendo hasta absorber al noveno mes escasamente un litre.

]Un litre, verdad, que es asombroso! i Esta fnfima personita, capas de chuparse uik
litro en seis vecest

Pero tened, sefiora: ahl os dejo un cuadro consoladcnr para los casos de duda:

Edad.

NAflMro
deTfloes
pordla.

CMltidMl
pOTTiS.

Total tn
•Idia.

Bdad.

Nttmcfo
deTBCM
por dia.

pofTis.

Total «n
•Idfa.

Idia

10
10
10
10
10
10

Oniiiioi.
4

10
25
85
40
45

Orama.
40
100
350
850
400
450

l«ra€8

Oraaiot.
70
75
00
180
100
170

OraaiM.
080

aSi;;:::;:;;;:;;;

2*iiia

f7ft-

84I1S. ..

3* mes

790-

A^tm

0*m«s

910^

0*mc8.! 1...

90O<

> ittmuia ,

lafto

i.oaoi

210 PBOGEEDINOE 8B0O]n> PAK AMBBICUK SCIEirTIFIG G0KQKB88.

Notad deid« luego la utilidad da voastra balansa para conocer como aainula el
cliente el n^tar que le diBpenaftiB y con ^llo oa c<»venc0r6is a menudo que vuentraa
lamentacionea aobre el poco credmieoito del beb4 son ixifundadas. Peaad al beb^
inwediatamanta deq>u^ del bafio todoa las diaa e inacribid oi vueatra libieta de
ordeaada aom de ca8% sua progreaiyoi aumeutoa. Oa produdzi admiraci^n ver como
imestro beb4 Uega a hombre:

25a30gramoapordia, el primer mes.

23 a 25 gramos par dfa, el Bes:undo, tercero y cuarto mea.

20 a23 gramoa por dia» el quinto y aexto.

18 a 20 gramoa por dia^ el f^ptimo y octavo.

12 a 18 gramos por dia, loa tree tiltlmos mesea del primer alio.

8 a 12 gramos por dia, el primer semestare del segundo afio.

Retened estas ci£ras que no son ezactas pero que casi siempre se acercan a la verdad.

Veo en vuestros ojos la duda y la alarma. ^Porqu6, Sefiora? |Ah, sil lo com-

prendo, vuestro bebuS ha bajado de peso estos cuatro primeros dias y yo os lo habia

advertido, como una regla fatal. En cambio ahora, afirmo aumentoe progreaiyos*

^No comprend^is mi dualldad de criterioT Es que aqudllo es la excepddn. La

primcra wmanaaariampre dereba|a» poirqueel niAo descaiga 8a» deaperdicioa acunm-

ladoa y eto ae traduce en una diaminuei^n de peso, disminucidn ml «i la baIaBs%

pero iluaoria ai deaoeatamea el lactov ennncaada. Vueairo nifio progresa desde au

nacimiento y s^guiri poco mis o menoa^ la aigiiientft eaeala que copio de un impreao

repartido profusamente pot d Oon^ulkine ''Gata de lacbe" <pie dirige en Moateyideo,

el Doeloa Ju]i» ▲. Saaai:

Onmot.

Pesoalnacer 3,250

Peao el primer mes .« 3, 850

Peso el segundo mea 4,500

Peao a los trea mesea 5^200

Peso a loa cuatro meses 5,000

Peao a los cinco meses 0,500

Peso a los aeia meses 7,000

Peso a los siete meses 7,450

Peso a los echo meses 7,850

Peso a loa nueye meses 8,200

Peso a los diez meses 8,500

Peso a los once meses 8, 770

Pesoalaiio 9,000

Peaa a loa doa afioa 11, 500

Oanaofvad tambi^n^ eele cuadro. Oa preataii el gran aarvido de cafanar vueatiaa
aanrosas alarmaa. Peaa, no ea cifi^ demasiade a sua totalea matemdticoa, pot^ue
cada ser tiene una regla propia que no ae encuadra en tablas demawiado aeyeraa.
Yer^laen 61, adem&s^ el p<»yeBir riaoefio que mpem al diyino diante y que se cumpliri
realmente, siempre que sig^ los consejos que disperso en estas p^c^naa y que Ueaa-
rin W aspicaci6n real qiue albeigAia de yer pueato en maicha a eate ptecioK) beM
hallegado.

DtaMATBBCIA yiSITA.

^fifi^ la nmsocitfn: Lo$ ofoB mno$ y en/lu nim La i^Mnki purukiUa-'hmimmit
Uamado del oeuliita^Loi ganfflkm M emlio-^Bl corardiir— JffI eamine ie Uu hmnm.
i Vuutro hM 4% wmplitof

Sefiora me pregunt4bais ayer" ^Pero, Doctor, es que los nifios pueden nacer con los
ojos enfermos?" T lo hac^, al ver con que cuidado los reyisaba en mi examen
general.

Si, Sefiora y muy a menudo. £1 pasaje del beb^ es un escobill6n de anastre de
<:uantos g^rmenes hay en su camino. Por eeo, y nada m^s que por eso, oa recomendaba
«xtremar las medidas higi^nicas los ditimos dfas, y la m^or prueba de que hab^is
•cumplido mis instrucciones est6 en la carenda de todo f endmeno irritatiyo en el aparato
ocular del pequefio. ^Y si no fuera aai? Si aai no fuera, me yeriais correr con vuestro
bebd a casa de un oculista. Estas afecciones de la yista en un red6n naddo son gene-
calmente fatales, cuando por un deacuido no se tratan inmediatamente.

Rguraos d horror de una madre, y no os hablo de una descuidada, aino tan sdlo de
una poco preyenida, que al lleyar a su querido ingel al consultorio del medico, oye el

PUBLIC HEALTH AND MEDICINE. 211

fatal diagn63tico de ceguera. Y eao, que la mayorfa de las veces ^llas habfan agotado
el repertorio caflero de medicaci6n ocular, enjuagaban loe p^adoe supurantes con
aguaboricada; buscaban colirios de origen fannar^utico y con la convicci6n de la
pronta desaparicidn de Iob slntomas, vivfan tranquilas.

La oftalmla purulenta es una afecci6n grayMma que exige los mayoree desvelos
para su cura y aobre todo el m4B ripldo tratamiento, a fin de que el pus no lunrade la
c<3Tnea y la Ie8i6n eea incurable.

Atenci6n, pues Sefiora, y cuidad en el futuro con los prdximoe bienvenidos, que
tal desastre no llegue a suceder.

Observe adem^s, el cuello del pequefio. ^Pua qu^7 Os responder^ en dos pala-
bras: Buscaba gUndulas (ganglios). ^Y qu6 oe indica su existencia? 8u existencia
me revela, Seflora, segdn la dlspoaid^n que 611as adopten, afecciones del oido, de la
gaiganta, de la boca, del cuero cabelludo o estados generalee deficientes. Cu^tas
veces la existencia de un ganglio noe obliga a investigar cuidadosamente la causa.
Y con ^0 comprobamoe afecciones que hubieran pasado inadvertidas a expertos
ojos de cllnico. Os ruego, teng&is en cuenta esta indicacidn para Uamarme apenas
confirm^is su aparici6n.

Revis^ cuidadosamente el coraz6n y comprob^ su ritmo normal, que nos asegura
que el pequefio ha completado cuidadosamente su tabicamiento antes de venir a la
luz. Por €[, pod^is estar tranquila, sefiora, que, como medico y amigo os afirmo que
vueetro beb6 es ya de buen coraz6n.

Comprob^, ademius, que los caminos vulgares de las hernias se hallaban perfecta-
mente cerrados y que por ende era improbable su produccidn atin en los mayores
esfuerzoe, y cuando me hube convencido de que los diganos todos ocupaban el lugar
elegido para su perfecto funcionamiento, os dije: ''Sefiora, vuestro beb6 es completo,
donnid tranquila y sofiad con dias de felicidad que os depanuri, a buen seguro, la
vida de este divino beb6 que ha llegado."

DtoMAOUARTA VISITA.

Manteniendo el orden — Energia de lo$ primeroe dic»—El llcmto no oau$a hemioB — La
utilidad del llanto — La diemmucidn del alimerUo caueada por noehe$ de vigUia.

Sefiora: Oir^ vuestras lamentaciones con la estoicidad de un confesor y al final
hablar6, porque creo que en mis explicaciones encontrar^ un lenitive a vuestras
penas.

Decls: "Doctor, el beb^ no espera la hora; Uora, se sofoca, grita, se revuelve en
esa bendita cama en que me hab^ exlgido lo coloque y no puedo comprender la
causa."

"Doctor, me han asegurado que llorando mucho se podrfa quebrar.''

"Doctor, temo que con estas noches sin dormir, disminuM la provisi6n del pe-
quefio."

^V6is como os he escuchado? Ya no podr^is decir que mi tiranfa dentffica hace
ofdo de mercader a vuestros lamentos.

Os he entendido y quiero que la tranquilidad vuelva a esa almita de madre carifiosa
que se desvela por el bien amado.

Vayamoe en orden y no me intemimp&is mis que al final de piurafo, porque yo
como ciertoe oradores, me inmuto, pretendo contestaros atropelladamente y quedan
al concluir mis visltas varias preguntas sin respuesta, con pesar para vos y afliccidn
para mi.

Sefiora, vuestro beb^ no espera su hora porque es un vud edueadOf y al calificarlo
asl me acuso de haber side d^bil para con €L.

Pero, estamos siempre a tiempo para su correccidn.

^Sab6is c6mo?

68436— 17— VOL ix ^W

212 PBOOEEDIKQS SECOND PAH AMEBIOAK SOIEKTIFIO 00K0BE88.

£1 niiio no es mis que un pequefio hombre, y td Me es un animal de costumbre,
aquel cuyo cerebro no tiene atin trasadas mis visSf ee impregnaiA ttdlmente con los
h&bitoa que le dejamos adquirir.

Vuestro divino nene vivid tree o cuatio dfas a vueatro lado con la fuente de sub
satisfacciones junto a los labios, amparado al calor de vuestro cuerpo.
En esas condidones, creed sefiwa, que es t&dl acostumbrane, y tan i&cil.
Bien; resolvemos instituir el oiden, compramos la cama, que yo miamo exigl ser
quien la eligiera y que segdn vuestra buena mamita es fea, demasiado simple y pobre
como la de una prisi6n, calificaclones las tres que dicen verdad, pero que mafiana,
OS explicar^ por que no son justas, lo colocamos en ^lla y comienzan los Uantos del
cHente.

Llora entonces porque no est& a vuestro lado.

Pero, como alii esti bien, convendr& que de alii no saiga, y con vuestro asenti-
miento, que revela sensatez, no se mover^. iQa^ puede faltarle en esa camita que
es un nido?

Nada.

^Galor? lo tiene; est4 rodeado de ponones que cuidadosamente envueltos y ale-
jados, le proporcionan un calor suave. Su estdmago se colma cuando es necesario
para su vida. Su limpieza est4 cuidadosamente vigilada y lo mud&is frecuentemente,
y a medida de sus necesidades.

lQa6 mis quiere?

Si, yo 8^ lo que quiere.

Quiere a vuestro lado tiranizaros, impediros hasta dormir tranquila.

^ Por qu6 no me digdis, sefiora, que dormiais feliz cuando no sabiais, si en plena
inconsciencia, al daros vuelta, lo ibais a aplastar con el peso de vuestro cuerpo?

Y no me mir^is como afirmando que lo que os digo sea una exageracidn, porque
cudntas madres lloran, por un nimio descuido de resultados tan pavorosos.

Hay m^, a vueetro lado no podridis resistir el fmpetu de besarlo apasionadamente
cada vez que entreabriera los p^adoR, el de mecerlo en cuanto hiciera un mohin de
disgusto ese pequefio rostro de dngel.

Eso no le conviene al beb^ porque si lo desedis sano y fuerte es necesario no balan-
cearlo y os dir^ el porqu^ mafiana.

Es necesario, adem^, dejarlo Uorar a fin de que se amplifiquen sus pulmones, que
entre en ^llos el aire a raudales y se forme alto y ancho el tdrax de atleta, que carac-
terizard al beb^ ideal que pretendemos formal.

En cuanto a las hernias de que os he hablado permitid que me sonrfa.

Otro prejuicio que os ban pretendido inculcar y que no resiste ni un segundo a un
anilisis un poco severe.

Si el nifio tiene una hernia hay aparatos especiales que casi seguramente se la curar&n
en los primeros afios de su vida y si no estari el bisturf del cirujano que ante su persis-
tencia hard la cura radical en pocos minutos.

Pero, sefiora, ^cr^eis poi ventura que una hernia se forma por el solo hecho de Uorar?
Con tales ideas, podriiis as^urar que no hay solo nifio que no sea quebrado, porque
todos han llorado.

lY que pretend^is que hicieran?

^Saben cantar, gritar, silbar? No. Entonces lloran.

Permitidles ya que no tienen otra, su mon6tona manifestaci6n de vida.

Pero esa no serd seguramente la causa eficiente de una hernia.

Cuando existen son debidas a un defecto de formaci6n, a la persistencia de un con-
ducto que debfa haberse cerrado antes de que entrara el aire en los pulmones del nifio,
y que permaneciendo abierto permite la salida de las vlsceras con el esfuerzo del
llanto.

No tomto entonces como causa principal la que no es m&s que cooperadora, con
un papel secundario y sin efecto a no existir la primera.

^ PUBUO HBALTH AKD MBDIOINB. 213

Quedamo6, puee, que a un nifio quebrado, que Uora se le hace viable su hernia;
Tentaja al fin porque obliga a la instituci6n inmediata del tratamiento.

No 06 aflij&ifi, porque el vueetTo llore, (\ ha sido cuidadosamente reviBado y os
garantiso que eetd perfectamente concluldo.

En cuanto a vueetro temor, no os dir^ que ee infundado; las malas noches os hacen
mal segfuramente en vuestra misidn de nodriza y por ^llo es que me apresuro a enca-
irilar la vida del beb^ que es tambi^n la vuestra y, como si a 61 lo dej&is uno, dos,
tres dfas, si no es un obcecado, en las condiciones que os he impuesto, la tranqui-
lidad volverd a vuestro esplritu y podr^b entregaroe al sueiio de^pu^s de besar son-
riente en su nidito de amor a ese pequefio beb6 que ha llogado.

DlftCDCAQUINTA VISITA.

El chupete y 9U8 peligrv — El poblador de microbiaa — Calmdis d lUmto y adminxBtrdii la

muerte-^uerra al chupete,

Sefiora: He ahi un verdadero instrumento de tortura.

Ese aparato indigno que hab^is olvidado sobre vuestra mesa de luz. |Qu6I ^No
lo habe^ dejado por olvido? Ahl ese es su sitial de honor.

Cerca de vuestras manos y de la boca del dngel.

^Pero, entonces, sefiora, sois inocente del gran error que os hacen cometerT

^Y qul^n?

Vuestra mamita y varlas amigas os han dicho que con esa tetina pod^ pasar buenas
noches, plicidamente dormlda, y que cuando vuestro beb^ llore con solo sumerglrlo
en un poco de agua azucarada y pon^reelo entre los labios, 61 Pe calmard y rumiar^
8U rabieta tranquilo.

Ah! OS han dicho eso, y vos, sefiora, etemamente obediente, claro lo habits mandado
buBcar y estdis dispuesta a usarlo.

Pero ^llas no contaban con mi visita.

iTirad eeo; a la basura con 611

Ese maldito ''chupete" ha hecho m&s vfctimas que la eecarlatina y todavfa hay
quien lo use.

Oidme, sefiora, madre del hermoso nene que debe ser para vos vida y felicidad,
presente y porvenir, que debe — iqu6 digo — debe?, que ee un trozo de vos misma,
encamado en ese misterio divino que respira, escondido en su nido de amor.

^Quer6i8 su vida?

Sf, y entonces, sabed: esa tetina es mala, ee peor, es perversa.

Pero quiero justificar mi enojo, quieio que os ddis cuenta del error.

VueetTD beb6 mantiene entie sus labioe la fuente hermoea que le brindiis y se
lecrea en 611a seguio de que de allf no Baldr& m^s que un sano y puio alimento en
el que la industria no se ha innuscuido y en donde la flora bacteiiana no puede ser
prolifica porque es ahuyentada por los medios defensives con que os ha dotado natura.

Vos, en cambio, le pon6is entre los labios un pedazo de caucho en el que se albergan
cuantos microbios existen y del que no extraeril seguramente ningtin jugo.

Y lo perjudic&is, no s61o porque le robiis sus derechos adquiridos al nacer de una
mejor calidad de C(msumaci6nf sine tambi6n porque en ese pequefio "chupete" va
muy a menudo escondida la muerte.

No vale que lo hirv^; &talmente inaidioso y desleal como es, 61 buscar& microor-
ganismos en vuestros vestidos, en vuestras manos, perfectamente lavadas pero no
aB6ptica8, en la ropa de vuestra sirvienta, o en las del mismo beb6 y con su armamento
olenaivo se recreaid en poblar la boca del cliente con cuanta bacteria maligna genuine
bajo el sol.

Nada digo de cuando cae al suelo y que vuestra nifiera se apresura a levantar y
restituirlo entre los labios, porque s6, sefiora, que vuestra vigilanciase mantiene ante
unpeHgro.

214 PBOGEEDINGS 8E00KD PAN AMEBIOAK 80IEKTIFI0 CONQBESS.

^Pero olvidiis seflora, que a menudo vuestrofl ojoe pueden diatiaene y el hecho
acontecer?

Por otia parte, razonad: el chupete causa los pequefios mdsculos destiiiadoe a la
Bucci6ii y cuando vuestro beb6 prepare su0 fuerzas para la acometida real a que tiene
derecho, laa encoutiar& debilitadas par el excedvo ejerdcio.

Ademis provoca las secredones natuiales que se desperdidan dn cumpHr sub fines
digeetivos. Verbis que la saliva aparece en abundanda en la boca y no debds olvidar
que esta secreddn lleva aparejada por fen6menos reflejos la de los demis 6rganos,
l^es como estdmago, hlgado e intestines que serin indtilmente perdidas, desaproye-
chadas, siendo tan necesarias para el momento efectivo de la digestidn de los alimentos.

Tirad, pues, sefiora, eee invento malhadado o mejor sefiora, didmelo. En nd
bolaillo estoy seguro que no redbir& honores por mudio tiempo, porque pronto pasarA
al verdadero lugar que le depara la cienda, que es el caj6n de los desperdidos.

He ahf, sefiora, como sin querer he roto mi plan. Pretendla convenceros de que
esa, mi cama, no es ni mala, ni pobre, ni lea, como lo asegura vuestra buena mamita,
pero iq\x^ querela? hoy me he detenido demasiado, aunque creo no haber perdido mi
tiempo, librando de un real peligro a ese predoso b6be que ha llegado.

DiCIMABBZTA. YISTIA.

La coma — Condiciones esencidUt — TuleSf hUmdat, cintas y puntiUaa — Coma firme,
sin movimiento — Avi$o importante aunque jactaneioto,

Sefkva: esa cama que ha redbido las ciiticas de cuantos la han visto, que se ha-
hecho la vlctima de los adjetivos amables de vuestra Mamita, se impondr6 hoy a
nuestra atend6n.

Me decfais, ^por qu6 la habds elegido doctor, tan sendllota y deqgarbada? y d
no OS he respondido ee porque todo llega a su debido tiempo, y ni yo quiero morinne
ni lo har6 a mi gusto sin antes haber terminado nuestras amables pUticas — que aunque
^llas etemas fueran, m^ lo ser&n seguramente mis deseos de vida laiga, pUUdda y
fructifeia.

Pues bi^, sefioia, ahl la tenuis, no hermosa en verdad, pero sf c6moda— y hasta^
casi . . . cad . . . afirmaria que no es fea. . • .

Cuatro patitas rectas, dos laigueros, doe barandas, cabecera y pi^ de barrotes iguales,
eUstico de metal dn muchos resortes ni demasiados adminfculos, y un laigo soporte
que desde la cabecera se eleva para terminar en un gancho que mantendrti el mosqui-
tero, he ahl todo.

Sencilla es, tenuis raE6n; pero est& toda niquelada.

^Querds m^ lujo?

No tiene tules, blondas, ni puntillas, pero, i para qu6 le serviiin a ese predoso p^ijaio
tales adomoB, verdaderos nidos de tierra, focos de bacterias, guardadores de insectos.

La dencia os dir& siempre que eso no hard mds que poner al alcance de sus pulmonea
un aire viciado, llenar el ambiente de impurezas, dafiar bus vlas respiiat(vias extre-
madamente irritables con la presencia de cuerpos extrafios.

Nosotros, ^verdad, Sefiora? no queremos eso para vuestro beb^.

Todo lo contrario: aire piiro, oxigenado en demasia, que al distender d alv6ob
pulmonar renueve el oxlgeno de los gl6bulos vertiginosamente; eso pretendemoe, y
eso no se conseguiri jam&B, entre tules y cintas, entre blondas y puntillas.

Admirad la sabiduria de la Naturalexa que ha sabido en el nido dd ave mantener
la dificil sendllez de sus consejos.

Pero, d la admirdis, imitadla.

Cada hecho, cada observad6n, debe alecdonaros en la lucha por la vida.

Habrds notado, sefiora y seguramente lo ha advertido vuestra Mamita que las
barandas tan altas con bus barrotes parecen mantener en las celdas de una prid6n al
predoso beb4, y es que asf debe ser, pues su middn no debe ser otza que protegeilo
contra una podble caida.

FUBUO HBALTH AND MEDIOINB. 215

Los pdjazos previsoree, ahondan el nido a fin de que las sacudidas producidas por
el viento no volteen las crfas, y habr^s observado que cuando un cicl6n eacude con
impetus inesperados el sost^ de bus viviendas, una catistiofe conmueve los cimientos
de la voUtil familia, dando por tierra con los pobres pichones.

Tsxsk nuestro caso, no debemos tener en cuenta las causas naturales extrinsecas, por
k) excepciouales, pero sf las intrfnsecas, dado que un pequefio movimiento hecho por el
beb6, puede hacerlo caer con la suficiente fuerza para produdrle serias lesiones.

Y pasemos a otra cosa. Notdsteis que mi cama es firme, fija, sin movimiento alguno.
Sin las cuatro ruedas habituales, sin el eje que le permita balancearla. ^Por qu6T
{Ah, Sefiorat he hecho la elecci6n de exprofeso.

No quiero movimientos paia el beb6. Nada de sacudidas; aunque 61]as fueran
levee como una brisa suave no son necesarias para su vida y son perjudidales y dir^
m^, altamente nodvas.

Ese temblor, amable Sefiora, que en vuestras manos es una caricia, en las de vueetra
nifiera se transforma en un vendabal funesto para la salud del cliente; y si el cerebro
del hombre reeiste el sacudir de una hamaca, no as! el del niflo tiemo y delicado, casi
OS diila gelatlnoeo y que en cada vaiv6n se moviliza y golpea contra las paredes. A
tal grado, que el sueflo del beb6 es en tales condiciones, no el pUcido reposo natural,
Bino m4B bien un mareo provocado.

Por otra parte, el niflo que ha probado el amable "balanceo" acompafiado por el
dmtico suave del "arrord" matemo, se acoetumbra, y el pequefio tirano que hay en
cada alma humana se rebela e impone condiciones.

iCuidado, Sefioral

Serais entonces su esclava y ya no s61o no donniii, sino que no podri vivir sin el
dulce balanceo o las amables caireritas de uno a otro lado de vuestro dormitorio.

No olvid^is lo "del irbol que crece torcido, " y apresuraos a imponer condiciones,
porque aquf es efectivamente cierto aquello que ''quien da primero, da dos voces."

(Ah, SeiSoral me (dvidaba, nada de plumas, en las almohadas, 611as dan demasiado
calor y provocan fen6menos congestivos.

Una buena almohada de g^nero de algod6n, un par de buenas colchas y porrones,
y estad tranquila; vuestro hijo no sabr& resfriaise.

Y par dltimo, Sefiora, un consejo final que no lo tendr^is en cuenta, seguramente,
peio que para mf tiene un fin capital: poned a los pies de la cama im cartel que diga:
" iObjeto de artel lAdmirad, pero no toqu^isl "

Tal aviso puede pareceros innecesario y hasta de mala educaddn. Pero no lo credis
asi, Sefioia, son tan amantes a los besuqueos vuestras visitas y tan indiscretas que
aabiin pasarle de mano en mano como im mufieco de trapo a ese divino beb6 que ha
Ikgado.

DtCIUJLBimMA VISTTA.

Im wpa~-IfW€nUario de un ropero rieomenU pertredwdo—Mamra <U vuUr oZ bM—Lo
que debe y lo que no debe hacer9&—El kngtuje del nifio—Lae reeervae natunUei,

Sefiora: Me he detenido hablando con vuestro esposo, quien me ha mostrado su
tnbajo de hoy.

iSs^^is en qu6 se ha ocupadoT

iN67 Pass bidn; con bus etemas manias de orden ha catalogado, conjuntamoite
con vuestra mamita, la ropita del bebd y me ha interrogado severamente sobre las
necesidades del pequefio.

" ^ que cre^ necesario, Doctor, para el bienvenido, tan colosal twui$eauV* " ^O
est^ de acuerdo conmigo, que es una exageracidn de mi esposa?" ^

He revisado cuidadosamente la lista, y iqn^ creels que he opinado? "Que dadaa
vuestras condiciones de fwtuna no era demasiado y que con ella cuidadosamente
guaidada serviria para la "seguidilla'* de que €i era capas."

OiguUoeo de mi contestaddn, con una sonrisa de fuerza protectora que parecia decir
"verdad que no ser6 el (hiico^, cohnada su satisfaccidn me entreg6 la lista que oe
leer^y porque estoy seguro no la conoc^:

216 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONaBSSS.

ExUtencicu del ropero del hebi.
Seccidn ropas.

Gamisitas de g^nero muy fino, 4 tamafios, 1 docena de cada uno.

Gamlsitas de franela, 4 tamafios, 1 docena de cada uno.

Camicdtas de bombasf , 4 tamafloB, 1 docena de cada uno.

Paflales cuadradoe de maddLs, 6 docenas.

MantUlas de franela, 3 docenas.

Mantillas de bombasf , 3 docenas.

Fajas de un metro y medio de largo, 2 docenas.

Rebozos de lana, N* 6.

Batitas de lana (compradas) N* 12.

Batitas de lana (regaladas), N® 7.

Baberos de bombasf, festoneados, 4 docenas.

Baberoe de hilo con puntillas (compradoe), 6.

Baberos de hilo con puntillas (regaladoe), 5.

Escarpines de lana (comprados), 24 pares.

Escarpines de lujo (regalados), varioe pares.

Pafluelos de batista, 2 docenas.

Fajitas de franela pua el vientre, de 1} metres, 2 docenas.

Gorras de lujo (regaladas), N* 4.

Gasa as^ptlca en pedazos de 10 x 10, 3 metros.

Falddn de lana bianco con encajes para paseo, N* 1.

Oapa adomada con encajes para las ocasiones, N* 1.

Faldones de bombasf para salidas ordinarias, N* 3 (salvo error u omisidn).

Os admirdis, SetLora, y lo comprendo.

Os hab6is excedido ampliamente i>6ro i es acaso una falta?

Si vuestro bienestar fuera mis dudoso esa lista podrfa ser reducida a la mitad; mii
adn, si os encontraseis en las condiciones de las m4B, que se preocupan de mantener
la higiene de las ropas del pequetLo en su propia casa, imposibilitadas de pagarse el
lujo de lavanderas para sus nifios.

Pero veamos, Sefiora, ya que las ten^, ic6mo deber^is usarlas?

Ante todo, os comprar^is un catrecito de patas laigas (1 metro, 60 centimetros), que
OS lo hardn en cualquier carpinteria y que os prestari grandes servicios.

^Para qu6, Doctor?

Verels: mudar en la falda al pequefLo, es inc6modo, m4B que mudarlo en la cama,
seguramente, pero como ^sta es en general baja, tendr^ que agacharos par demiis y
ceder6is demasiado pronto a vuestra nifiera, la vigilante y i>erwana1f«ima operad^n de
la mudanza del beb6.

Por eso 06 aconsejo el catrecito que no debe tener m4B de 1 metro y medio de laigo
y que doblado no ocupard casi espado para ser guardado.

Os aseguro, Sefiora, que recibir^ vuestro agradecimiento por mi consejo.

^C6mo vestirdis a vuestro beb6?

Oolocad la camisita fina, enchuflada en la de franela y ^sta a su vez en la de bombasi
y con las tres asf preparadas pasad imo y despu^s otro brazo del pequefio, guidndoles
con vuestros dedoe en su travesia por la manga, dejando las aberturas de las tres hada
atris.

Extended sobre el catrecito, primero el cuadrado de bombasf, encima el de lana y
arriba el de madr^ doblado en trlAngulo; de mode que el lado mia largo (hipotenusa)
coincida con el borde superior de los cuadrados.

Acostad encima de 611os a vuestro pequefio que ya tiene el tronco cubierto por las
camisitas y seguidme ahoraen la operaci6n: paso la punta inferior de triimgulo entre las
piemas del beb6, bien; envuelvo con otra pimta el vientrecito cubriendo la parte

PXJBLIO HEALTH AKD MEDIOIKE. 217

inferior de las camisetas, muy bien; con la otra marcho en direcci^n contraria y
vuelvo a envolver el vientre y la parte inferior del torax, y ya tengo mi primer paflal
colocado.

Pero, seflora, ^veis como soy prdctico? y sin embargo me he olvidado de algo
previo: un cuadrado de gasa as^ptica en el ombligo y para mantenerlo un par de
vueltas con la pequefia faja de franela y ato con la cinta de hilera.

Sigo, y OS mego no os alarms, que esto es m^ diffcildesciibirlo que hacerlo.

Coloco los escarpines y ato d^bilmente la cinta de sost^.

Vamos ahora, a nuestro cuadrado de franelas. Un lado lo arrollo al cuerpo del
cliente y como excede mucho a los pies, lo doblo en su parte inferior a una altura tal
que permita a los piececitos extenderse libremente; con el otro lado paso en direcci6n
contraria por encima, y pronto el de franela;

Repito la operaci6n con el de bombasi.

Tomo la faja, previamente arroUada con la cinta en la parte m&i interna y a la
altura de la parte m&s inferior del t6rax, sin comprimirlo. ^Ois bien? sin apretar,
fluavemente le doy tres vueltas cuerpecito y ato.

Con el rebozo, repito la operaci6n de los pafLales y lo fijo con dos alfileres de nodriza,
uno en la vuelta de abajo y otro asegurando el borde libre y con la batita de lana hago
la misma operaci6n que con las camisitas, pero, dejo la abertura en la parte anterior;
fijo el babero y cantando victoria puedo, Seflora, marchar con vuestro beb^ al polo.

Nada de gorras, dejad que el buen aire y el buen sol desinfecten el cuero cabelludo
y no tem^is que vuestro beb^ se resfrie por eso, porque no conozco ninguna especie
microbiana que atraviese el crineo para albergarse en la nariz y provocar un resfrio.

Las guardar^ para las visitas de cumplido cuando el cliente se aderece con el rico
fald6n de encajes y la soberbia capa que hard estremecer de envidia a cuantas madres
flientan sobre d la irritante desigualdad de nuestra sociedad cristiana.

{ Perd6n, Seilora, es un grito del alma, que como es el primero,deb^ perdonar?

^Sab^ que me ha costado trabajo la descrii)ci6n?

Pero, tenia tanto inter^ en hacerla, que no lamentar^ jam^ el haberla producido.

Hab^is oMo hablar m&i de una vez de la conveniencia de fajar las piemas a fin de
que no crezcan torcidas, de envolver los brazos hasta una cierta edad, de arrollar al
pequeiLo como si fuera uno de esos largos caramelos que compribamos en nuestra juven-
tud y chupdbamos con Igual fruici6n que la experimentada por un buen sefior fumando
su habano de postre.

Esos errores han desaparecido cad en la sociedad que habitamos, corridos por la
ciencia que demuestra que un nifio que pueda libremente mover sus piemas camina
tres meees antes que un enclaustrado.

Pero todavla verbis a muchas madres que comprimen el tiemo cuerpecito del nifio
con la faja, temerosas de que un frio les provoque un ataque de colitis.

Con ^Uo demueetran no entender el lenguaje del nifio, tan f&cil de interpretar para
una madre inteligente.

Ver^, Sefiora, c6mo se traduce f^ilmente ese lenguaje.

Vuestro beb^ Uora; bien, estari mojado, os decis.

Lo acostdis y comenziUs a desprenderlo.

£1 llanto cesa; es sdlo un gemido. El beb^ os dice con eso ''esto v& bien, mamita,
seguid sacando.''

Lo dejdis completamente desnudo, el beb6 sonrie, juega con sus mamitas, pretende
Uevarseun piececito a laboca, ^qu^osmanifiestaconeso? ''Estoy en la gloria, dejadme

Gomenzdls de nuevo a envolverlo y la sonrisa desaparece, es que el nene expresa:
^'estoy mejor; en verdad que estoy limpio; ^pero porqu^ recluirme?''

lY esa, tan ttcil interpretaci6n, cu&nto trabajo ha costado vulgarizarla?

Sabed, sefiora, que el nifio no podri ser jam^ un abandonado de la naturaleza que
d 611a da medios de defensa a los animales, con mayor raz6n debe d&rselos a los hombres.

218 PBOCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGBESS.

Somos noeotros, sefiora, loe civilizados, los que ensoberbecidcw en nuestro papel de
seres superiores pretendemos torcer leyes inevitables.

Nosotros que en nuestros prejuLcios y nuestros errores ponemos en peligro la vida
de nuestros semejantes. Por eso, sefiora, os asombrar^is m^ de una vez, cuando os
diga, dejad haoer, no oe amedrent^is; las reservas de la natuialeza son infinitas y cada
ser trae en sf , aquilatadas, las necesarias para su triunfo definitive.

Y ese optimismo bienhechor con que os hablo debe tranquilizaros respecto al porve-
nir de ese pequeflo beb^ que ha llegado.

D^CIMAOCTAVA VI8ITA.

ExageradoMs de la vesHmentorSalida del hebS^-El bafio—iQwUn debe efeetuarlo^ —
Condiciones del mismo — Manera de sostener ai nifio dentro del agvar-LoB lavados par^
dales — Necesidad de higiene.

Ssfi^OBA: He ahf una cosa que os Uamard realmente la atenci6n«

Dir^is: ''^c6mo doctor, c6mo, esa carga de ropa, vos que sois tan amante de laa
leyes naturales?"

Me adapto al medio, sefiora.

La civilizaci6n ha defendido al hombre de las inclemencias del ambiente, ddndole
ropas y vuestro hi jo, nacido de padres que saben usar del agradable calor de una buena
cobertura de lana y despellejan animales para envolverse en pieles, no puede menos
que pagar tribute a esa modalidad.

Pero ^sto no quiere decir que yo no hay a exagerado un poco la vestimenta. Hablaba
para un inviemo inclemente, rigiiroso, y no para todas las ^pocas.

En verano, por ejemplo, podr^is restar ropas hasta admirar la blancura de su cutis
en todas partes como gust^ y el chico sabr^ mantenerse en plena y lozana salud.

Quiero recordaros, Sefiora, que es necesario lo saqu^is tan abrigado como desedis,
transijo en ^llo, pero lo llevaHais a respirar el buen aire sano y puro que oxigenard sua
incipientes pulmones.

Llegada la tercera semana, elegir^is un dfade sol y alas doce o una de la tarde
debris abrir ampliamente la puerta de la habitaci6n a fin de que por 611a pase airoso y
fragante ese capullo que va a recibir el bautizo de la vida libre, y he tardado tanto en
daros tan grata nueva por el rigor de la estaci6n, si fuera en pleno estfo, hace ya echo
dfas que vuestro divino beb6 entomarfa sus p&rpados admirados d^ tanta luz y entre-
abrlrfa sus labios al recibir la brisa, ansioso de acapararla para si.

Quiero tambi^n, Sefiora, antes de terminar eeta segunda serie de amables conver-
saciones iniciadas, cuando el divino beb6 hizo su primer mohin de disgusto, hablaros
de algo que aunque b6, que ya estd instituido en esta vuestra casa no b6 como se ha
hecho hasta ahora.

Se trata, Sefiora, de la ''toilette*' del cliente.

^Quer^ saber c6mo debris hecerla?

Os lo dir6 en cuatro palabras.

El bafio es una costumbre sana, de sabia higiene pr^tica, que asegurar& una salida
franca de la trasudaci6n cut&nea, permitiendo una r^ulacidn de la temperatura
interna y siendo una ayuda eficiente a la funci6n renal.

Traduciendo mi frase un poco libremente, os dir^ lo linico que deber^is recordar:
"El bafio del beb^ ser& para vos una r^la invariable. Serd una de vuestras obliga-
ciones primordiales; sano, dadlo todos los dfas y enfermo todas las vecee que el medico
ordene."

iPero, c6mo?

Muy fdcil.

Tenuis en vuestras manos la pequefia bafiadera pintada al esmalte que si no fuera asf ,
08 dirfa, tomad cualquier recipiente de lata suficientemente amplio, lavadlo cuida-
dosamente y pedidle a vuestro esposo que os d6 una prueba de sus mdsculos com-
primi^ndolo lateralmente, hasta ovalizarlo.

PUBUO HEALTH AND MEDICINE. 219

Ten^ un jab6n de coco, de Espafia, Marsell^s de almendras, cualquiera que no
tenga esencias violentas, una eeponja fina, on poco de talco finamente pulverisadoy
agua fria y caliente y ya tenuis de todo.

Un poco de voluntad y a la obra.

Preparad el bafio a treinta y aiete grados, o m^ f^il combinad aguas hasta que
sumergida vueetra mano no Bint^is ni frfo ni calor, y cuando llegu^ a eee punto,
agregad un buen jarro de agua frfa.

Desnudad rdpidamente al beb^ y colocaos a la derecha del bafio.

Con vueetra mano izquierda envolved el nacimiento del brazo izquierdo del beb^,
cuatro dedos pasando por debajo y el pulgar por el hombro.

De este modo la cabeza del cliente tendii un apoyo en vuestro antebrazo que la
har& levantar o bajar a voluntad.

Sumergidlo rdpidamente en el agua y con vueetra mano libre enjabonadle r&pida-
mente la cabecita cafda hacia atr&s, a fin de que el ]ab6n no vaya a los ojoe y enjuagad.

Lateralizad la cabeza a uno y otro lado y repetid la operaci6n, cuidad entre las
piemas y en todas las partes donde se formen esos riqufsimos rodetes, eetirando la
piel a fin de impedir que en 611ob se hagan f ermentadones, origen de eczemas y otras
afecciones de la piel.

Ya todo enjuagado, en la operaci6n completa no deb^ emplear aniba de tres
minutos, lo retirdis y lo envolv6is en la toalla, friccionando suavemente con 611a, lo
empolv^ con talco impalpable.

Ahl tenuis desciita una operaci6n que nadie mia que vos debris practicar.

iPoT qu6?

Forque vueetra miiada vigilante y amoroea deecubriii en la piel delicada del nifio
la m&i pequefia alteracidn y permitir& a vueetro medico daroe im remedio o un consejo,
caei elempre lo tiltimo y en caso extremo lo primero.

Nada de perfumee. ^Para qu6? ^Quer^is algo m&B bien oliente que un beb6 limpio?

£1 bafio general podr& ser repetido en el dia, en el beb^ sano y lo ser& seguramente
cuando enfermo, x)ero no ahorr^is pequefias'' toilette" beneficiosas para la delicada
piel del nifio y el ol&to de los circunstantee.

^No OS figurdis, sefiora, con que sensaddn de di^gusto y de compafli6n repaiamos a
menudo en madres que no olvidarfan jamais el mis pequefio detalle de eu peinado o
de Bu veetimenta y que os presentan un beb^ mal oliente?

^Cuintas veces, sefiora, asistiijcios a una afeccidn de la piel que se inida en el polvo
de ahniddn lermentado en los pliegues de gordura del pequefio?

^En fin, sefiora, y cu^to tenemoe que luchar con el prejuicio de madres que ocultan
una llaga supurante del nifio porque por ^llas salen los nudos humoree del (nganismo?

Pero, quedad tranquila, sefiora, que pronto antes de lo que pens&is, quizi verbis en
marcha este divino beb6 que ha llegado.

GAPtruLO III. — ^El BsBi bn Mabcwa.

DtoMANONA VI8ITA.

SH primer raJHo-^us eiMido9 y nu eompliieadoni$^Sl bono en ea$o de enfarmedad
Loe ecMemae — Origen inUetinalSufieU y neoeearia curMlidad.

Sefiora: Heme aqui obediente a vuestro Uamado, dispueeto a oiroe seguro de que
voestioB temores no Uegarin jam^ a impresionanne seriamente y no porque yo no
tenga una migaja de carifio a esa ricura de beb6, aino porque ^Uos son hijos de vueetros
amantfgimos sentimientos de madre novel.

El evidente, ofgullosa mamita, que vuestro beb6 ha progresado rdpidamente ^gracias
ami?

No. GiaciaB a vos y a su con8tituci6n que le permiten salvar los obst^ulos de la
■abida con la tranquilidad de quien Uene alas.

Hoy, sefiora, es vuestro primer diqgusto; mi cliente se ha resfriado.

220 PBOCEEDINGS SECOND PAN AMBBIOAN 80IBNTIFI0 C0NGBE88.

^Por qu^? Vale, quiz& m6B, no averiguarlo, por cuanto es tan leve la cauea, que a
menudo queda en el teireno de las supodcionee.

^Exceeo de abrigo habitual?— Quizd.

Una corriente de aire Mo que ha pennitido a las bacterias vulgares hacer presa en la
la mucosa nasal del beb^. Puede ser.

£n fin cercior^monos del hecho y trataremos de curarlo.

El punto de origen del mal es la nariz. Pues a 611a. Una 6oluci6n de sales de plata
que 06 receto depositada en gotas dos o tres veces al dfa, dominai& el mal.

Lo tendr^is abrigado, en una atmdsfera tibia, peio ozigenada.

Plretendo con 611o aBegurarme de que no ser^ capaz de colocar, en un reverbeio a
alcohol o kerosene, en una estufa a lefia, carb^ o gas, im recipiente con agua y hojas
de eucaliptus dentio de vuestro dormitorio cerrado.

Permito si, calentar la habitacidn, mantenerla a una temperatura constante de 16
a 18 grades, hervir eucaliptus, etc., pero a condiddn que una de las puertas permaneeca
abierta, de manera que vuestro beb^ no redba directamente el aire, pero que 6ste se
renueve ampliamente.

Aire tibio, htimedo y oxigenado.

Tres condiciones que apresurar&n la cura del resfrfo.

Haciendo asf , no tem^ complicaciones puknonares.

Alguna vez, quiz&B, un poco de inflaniaci6n a las ftm<gH<^lfta (gUndulas) que curar^
con lavajes de agua b6rica, o una obturaci6n de la comunicaci6n del ofdo con la naziz
que podr& i^roducir una inflamaci6n del oldo medio, o fiebre de origen intestinal posible
ya que los pequefios degluten las flemas, y nada m&B.

lY nada m^? ^Os parece poco doctor?

No, no 06 alarm^ revistaba posibilidades, quedad tranquilla, ten^ medico, 61
sabrd hallar la pista de los males y no permitirles tomar cuerpo.

Os repito que debris quedar tranquila, i)ero conviene a vos, que sois inteligente y
cuidadosa, el poneros sobre aviso a fin de que cualquier coea inexplicable que encon-
trdis, aumento de fiebre, Uanto frecuente, reqpiracidn anhelosa, me llam^is.

iY suprimo el bafio, Doctor?

I Ahl no, sefiora. ^Por qu6?

^Vos tambi^n cre6is que pueda hacerle mal? Gonvenceos de lo contrario.

Si hasta ahora el bafio era conveniente, ahora es neceeario.

La limpieza de la piel abre una via de escape a una cantidad de sustancias t6xicaB
disueltas en el sudor, y si no lo bafi^ la descamaci6n natural de la piel, con la secre-
ci6n grasa de bus gUndulas y el polvo del ambiente formar&n im dique insalvable a
aquellas secreciones naturales.

Hago notar para vuestia satis&ccidn personal que entre los divines rizos no he
hallado caspa.

Es una reviBaci6n estrat^gica que hago a menudo, y que me asegura que mis pree-
cripciones han side bien Uenadas.

No caig^is, sefiora, en el grave prejuido de permitir que vuestro nifio se llene de
eczemas (arestfn) con la convicci6n que 611o lo library de afecdones mis graves.

Esa horrible afecci6n que pone en un tormento al beb6 y a su madre, que os priva
de la satisfacci6n de cubrirlo de besos, que os obliga a ocultarlo ante la mirada de
horror que descubrfs en los ojos de vuestras amigas, no es por cierto fidl, ni necesaria,
ni siquiera diffcilmente curable.

Libraos, sefiora, de aquel error que cometen algunas madres afirmando que por allf
van a salir las impurezas de la sangre, de aquel otro que os garantiza que vuestro nene
va a ser bello, porque le dej^ su eczema, error este tiltuno fundado en que el arestfn
toca mia ^udlmente a los nifios de tez fina y delicada.

Pensad, sefiora, en lo espantoeo del suplicio que le produds a ese pedazo de vuestra
alma, envolvi^ndole las manitas para que no se frote ni se arafie, con sus ufiitas cuando
le pica.

PUBLIC HEALTH AND MEDICINE. 221

Recordad con que fruici6n os rasdub cuando una atrevida pulga forastera se ensafia
en vuestra piel y como no ced6i8 en ahinco hasta exterminarla y figuraoe ahora, que
aquella superficie costrosa y supurante produce el ardor de miles de pulgas juntas y
convendr^ entonces conmigo, que es horrible y criminal la ignoranda de loe que
persisten en mantener la expectativa en un eczema infantil.

M&xime teniendo en cuenta, sefiora, que aquel se curar4 r&pidamente con simples
medidas de higiene.

Higiene de la piel, con vuestros bafios y lociones; higiene del intestine, foco de origen
de todos esoB males, cambiando el regimen alimentido que es, seguramente, en esos
casos, defectuoso, o las mia de las veces metodizando las horas de la alimentaci6n del
beb4 0 la cantidad de alimento ingerido.

Pero vos, sefiora, no os preocup^, que no rezan con vos estas advertencias, por
cuanto b6 que vuestra obedienda inteligente conseguiri ver libre para siempre de
tales plagas a este predoso beb^ en marcha.

yio^sncA visiTA.

Lo$ dienU9—8u erupei&n^Las enfermedade$ que se le cUrUmyen — Cuidadae del preeente y

delfutwro,

Sellora: Si; esos son losdientes,lejosatin del horde de la encfaproducen sin embargo
fen6menoB irritativos que son la causa de la baba que hab^is notado.

Os advierto que me admira vuestro inters en conocer la causa aun de los detalles.
^Por qu6? Ah, sefiora, quiz& me dir6is que soy male por mi respuesta. Pero la vida
del mWco trae aparejada terribles reveladones y alii donde uno espera madres tiemas,
carifiosas, que vean aunque fuera por egofsmo en sub hijos la prolongaci6n de sf mismas,
se encuentsra con pequefias almas envaneddas, que tienen del beb6 un concepto un
poco m^ elevado que el de su mejor sombrero.

Ayer, sefiora, visitaba a una iajnilia, pero; dejemos eso— no hagamos dLtedra de
diinnograffa. Los dientes, sefiora, aparecen generalmente en el correr dd sexto,
a6ptimo mes, por lo general mia tarde en los varones que en las nifias, pero, pasado el
cuarto mes comienzan a incomodar al beb^.

No producen sin embargo, en su erupci6n esa serie de terribles fen6menos que se lea
atribuyen. Un nifio sano, el vuestro, por ejemplo, amamantado convenientemente;
sin distorbios intestinales conseguir& exteriorizar sus dientes con un mf nimo esfuerzo.
Un poco de dolor en las endas, un poco m^ de baba y nada m^. Ni un quinto de
fiebre. Las atfecdones que generalmente se le atribuyen no son m^ que vulgares,
pero graves empacho^(gastro-enteritis), que requeririn la presenda dd m^co.

Ved, sefiora; que en esos casos la dencia se resuelve siempre a recetar un purgante o
un desinfectante intestinal, y no seri, seguramente porque area que con €i conseguiri
apresuiar la salida de los dientes, sino porque es en el intestine donde est& la causa del
mal.

Cierto es, que la aparid6n de los dientes, por las molestias que causan, por las
incomodidades que producen, ponen al organismo del nifio en un estado de menor
resistenda que lo hace m^ vulnerable a cualquier ataque microbiano.

^Pero, deds, sefiora; si es tan poca cosa Doctor la salida de los dientes, como expli-
dds ese debilitamiento?

Ah, sefiora, olvidiis acaso lo que es un beb^. Tan pequefio, tan fragil, una ligera
escaramuza para nosotros es una batalla cruenta para 61, de la que resulta victorioso,
siempre que se halle atrincherado en un estado general perfecto que le permita no
distraer sus reservas.

H6me aquf, sefiora, que sin querer, he abusado de los t^rminos ^picos. Perd6n,
porque son de actualidad y se hacen por ende ttdlmente comprensibles.

^Quer^is saber ahora, como calmar esos dolores de las endas? ^Algdn jarabe,
alguna droga? Nada de eso sefiora, todas las que se emplean contienen opio o cocaf na.

222 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIO CONGBESS.

Por 660 ddman ^pero no dafiar&n la salud del beb^? ^Puede benefidar a iin nifio el
HBO de alcaloidee?

YenenoB extremadamente tdxicos, aim administrados en pequefias doeds son nodvos
para los adultoe, con mayor raz6n para el pequefio. Os permitir6, sin embargo, que
llev^is a sub encfas con vuestro dedo, previameimte lavado, \m poco de miel pura.
Con ello calmar^is su llanto, fomentando en verdad la glotonerf a pero conseguir^is con
eso que la lengua se pasee largamente por bus encfas inflamadas prududendo una
acd6n sedante y i)or ende bienhechora.

^ Y me pennitir^is Doctor el uso del aro ? S(, pero con condlciones. Aro de marfil
0 de hueso, euficientemente grande para que no pueda Ber tragado pcH' el beb^, sin
adomo de ningdn g^nero, ni cascabeles, ni cintas, nada que Uevado a la boca del
nifio pueda infectarla. Un aro pelado a fin de que podiis sumergirio en agua hirviente,
den veces al d(a si fuera neceeario. Eso, no os parecehL elegante, no bonito, pero es
dtil y no perjudicial.

Y ganando tiempo, sefiora, un aviso para el porvenir. Vuestro nene tendr& dientes,
nacerdn sanos, bien colocados, en muy buenas condiciones. No olvid^ eus cuidados.
No caig&is en el error de muchas madree que pasan mil pesares temiendo 'por el mo-
mento de la salida y que ya en la boca olvidan higienizarloB y permiten a la carie
hacer un nido a las bacterias mis terribles.

Cuanto antes ee necesario cepillarlos con un poco de creta preparada o de jab6n
bianco y enjuagarlos cuidadosamente a fin de sacar de los interstidos los restoe de
comidas que fermentadas producen substancias corrosivas para el esmalte de los
dientes.

No olvid^ls que la acd6n de una buena dentadura es fundamental para asegurar
una buena digesti6n y que una funci6n bien empezada en la boca, diffcilmente tendr&
un fin nodvo para la vida del nifio.

Pero, sefiora, debris dlsculparme, el haber corrido demasiado. Son tan grandes mis
deseos, que ya veo a mi cliente masticando pliddamente grandes cburrascos y quiero
convenceros de la necesidad de mantener su aparato dentarlo apto para tal funci6n.
Disculpad, pues, mi apresuramiento, pero no olvid^is mis consejos. Ellos ser&n
dtiles cuando llegue el momento que no tardari seguramente dados los progresos que
hace este divino beb^ en marcha.

YIoiSIMA PBIMSBA YIBITA.

El deateU — iCSmo hacerlot — Marchar despacio es apreswrar elfin, — La mamadera y su
preparacidn.

Sefiora: La fuente vital con que os ha dotado Natura ha respondido a vuestro deseo
y vuestro hijo ha cumplido su primer afio de vida, feliz, robusto, rozagante alimen-
tindose del ideal surtidor.

Os dirfa, sefiora, ^no es un crimen desprenderlo de tan rico bocado, a ^1 que ee
gcdoso y ferviente admirador de la calidad del artfculo elaborado?

Es que en verdad cuanto m^ tiempo permanezca adherido al lugar de sub deticias
m&B benefidos obtendWL de eea sana alimentad6n.

Sin embargo, ha llegado la hora de que hablemos seriamente del destete. Tema
antip&tico a mi entender y que he hecho lo posible por alejarlo, por cuanto tengo la
abeoluta convlcci6n de que cuanto m&s tiempo pennita mamar al nifio m^ garanti-
zamoB su porvenir.

Sefiora, vuestro nene se prende cada tres boras, es decir mama a las seis, nueve,
doce, de la mafiana y a las tres, seis y nueve de la tarde.

iC6mo hacer para iniciar el destete?

Nada m£s f4cil. Suprimid el seno a las doce y lo reemplazdis por una mamadera
de leche de vaca. ^Y c6mo prepararla? Verbis: tomad leche pura y f resca, hervidia;
tomad agua y hervidia. Tomad, ahora, un frasco nuevo o una pajarita de porcelana
de las que tambi^n Uaman patitos y que se expenden en todas las farmacias, hervidia;

PUBLIC HEALTH AKD MBDIOIKE. 223

comprad una tetina de caucho y como los anteriores, hervldla. ^Vdis c6mo repito
*'hervidla?" Lo hago con el fin de que 06 convenz&is de que la ebulllci6n es el
dnico medio pr&ctico de mantener as^ptico todo lo que pueda estar en contacto con
la boca del beb^.

Todo estd pronto. Echad ahora ocho cucharadaa de la lecbe preparada y cuatro de
agua hervlda dentro del fiasco o la pajarita, a la que enchufar^ifi la tetina.

Palpad por afuera si est4 a una temperatura conveniente o para mayor seguridad
yerted sobre el dorao de vuestra mano, yolcando el frasco, unas gotas del preparado y
si lo toleriis, pod6ts adnunistrarlo sin temor.

Si durante siete dfas notdis que nada ha cambiado, que vuestro beb4 sigue pro-
gresando, aumentad dos cucharadae de leche y disminuid doe de agua. Si slete dias
daspu^ todo permanece igual suprimid el agua y dadle la leche pura que os traerd
vuestro lechero de confianxa.

Biea, ya ten^ instituida y probada una mamadera. Probemos doe. ^C6mo hacer?

Mod^ic&is el horario, una le dar^ a las nueve y otra a las tres de la tarde quedando
la bora de las doce reservada para el seno.

Asi, sefiora, quince dias y entonces, (siempre, si no hay novedad, es claro), entonces
agregiis una nueva mamadera a las doce. Es decir que vuestro beb6 tomard tres
veces el seno y tres la mamadera.

Dejad un nuevo intervale de quince dias y suprimid el seno a las seis de la tarde
para darle una nueva mamadera. Qued&is asl alimentindolo con vuestros medios a
las seis de la mafiana y a las nueve de la noche y d&ndole en las demds horas leche de
vaca.

Dejad paaar un nuevo periodo y suprimid la de la mafiana y tras otro t^rmino igual
oe ittdep^idizto del todo.

"^Peio a qu6 Doctor, un m^todo tan largo si yo he visto a madres que en veinte y
cuatro horas ban destetado al beb^?''

Peor para ^llas y para el nifio.

Os decla, Sefiora, Natiua no marcha a saltos y este es un caso probatorio de mis
asertos.

Gomprended, sefiora, que una madre que suprime de golpe la funci6n de bus 6rgano8
lactantes se expone a terribles sufrimientos. Las verbis recurrir a purgantes en^rgicos
a fin de conseguir se les retire la leche, ese n^tar divino que tanto necesitan sus hijos
porque no me dig^ que no, sefiora. Si eetk, por algo estd, para algo sirve y no para ser
desperdiciada. Ahora si fuera el caso de una madre que hubiera tenido la horrible
desgracia de perder a su hi jo, ni consejo serfa que echara el purgante a los peiros, porque
con ^1 no ver& disminuir ni una gota de su leche, y que levantara por un gran vendaje
algodonado sus senos, lo que aliviarfa los dolores y le permitiifa poco a poco suprimir
lasecreci^.

Os decfa, ademds, peor para el nifio. Y es asi. ^ Si en esa 6poca crftica de la vida
del beb^ una nana cualquiera lo ataca, a qu^ clase de alimentaci6n recurrirfa eea madre
para su hijo? ^No sab^is que la leche matema ee el mejor remedio para un nifio
enfermo?

Y despu^ sefiora, i a qu^ p^petuar eea t^rible tragdia feuniliar que se desarrolla
entre el deeeo del nifio y la obstinaci^ de la madre cuando se sui^ime bruscamente
el seno, si siguiendo mi consejo el beb^ va a abandonar por olvido su fuente actual de
delicias? No seamoe peores de lo que somoe, sefiora, y hagamos las cosas bien cuando
podemoB.

Vuestro beb^ consume en el memento que terminiis el deetete un poco m6a de un
litro de leche por dia y como no debris sobrepasar esa cantidad ee necesario supHr las
necesidadee crecientee de la alimentaci6n con otros manjares nutritivos que ayuden a
laledie.

Pero, por hoy basta, hablaremos otro dla de esas nuevas comidas que conseigaixin
mantener y vigorizar las fuerzas de este precioeo beb^ en marclut.

224 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIO CONOBESS.
YIOisnCA SEOUNDA YlBSTJi,

iDMis eorUtnuar criando ri o$ senAs con novedadesf AlimerUaciAn progresiva — BM*
da$ — Nada de alooholr^Los bombones y hs ccarameloa — PdigroB.

Sefiora: ^Hab^s cuchicheado la pregunta y la he cazado al vueb? Si sefiora, ei; se
puede seguir criando. ^ Y porque no?

El nuevo beb^ que se va deeorroUando en la intimidad de los tejidos aomenta de
15 a 20 gramos por dfa. Eee aumento lo conBeg:uii& robando elementos a vuestra
sangre, la que para cubrir su dMcit no neceeitaii m&s que of deddiiB a aumentar un
poco vuestra alimentaci6n.

Lo de los peligroe para el nilio que atnaTnanUiw o para vos o para el nuevo, ee puio
prejuicio que conviene destruir. Yo s6 que oe digo revolucionar& las ideas de cuantoe
OS rodean. Vuestra mamita encabezaii la rebeli6n y a la menor indisposici6n del beb6
me pretender^ demostrar que yo por mis consejos modemistas soy el culpable, aun-
que la afeccidn que padece el beb6 sea una fiebre eruptiva. Pero no temo el ataque
X>orquetengo convicci6n en mis afirmaciones ysi mucho me exigfs os dir6 exagerando:
"sAcar del pecho al mayor para poner al reci^ nacido. " I Ahl sefiora, no est^ atin
en el caso. Me alegro, pero ^sab^s por qu^? Porque hay verdadeia convenienda en
espaciar los nacimientos a fin de que conBig6is criar y encaminar el uno antes de que
Uegue el otio.

Os decfa, sefiora, evacuada la consulta interpuesta, os decfa en mi charla anterior
que la leche ya no bastard para seguir el avance victorioso de vuestio beb^ y que eia
necesario recuirir a otros alimentos.

Seguir^is para ello el m^todo que empledsteis para el destete. A las 12 cambiar6is
la mamadera por una sopa de una harina cualquiera prepaiada en la leche que le
tocaba absorber.

En cuanto a harinas todas son buenas y mejores las vegetales, de avena, de anoz, de
papas, de cebada, de lentejas, de malz, etc., las que usar^ altemando a fin de no
cansar al beb^ y exciter su apetito.

Quince dfas deepu^ le dar^is tres sopas, despu^ cuatro y nada mds. Mantened de
leche solo las mamaderas de las 6 de la mafiana y de las 9 de la noche.

Altemar^s la leche con caldo de legumbres que preparar^is hirviendo laigamente
las l^;umbres de eetaci6n adicionadas de porotos, garbanzos, lentejas y papas. En
seguida tamizadlas por un pafio y moderadamente salados servir&n de subetractum a
las harinas que empl^ para hacer una buena sopa con que altemar con las de leche
que le admimstr&is.

Pasado algtin tiempo agregar^is una media yema de huevo a dos de las sopas diarias,
perfectamente batidos en el caldo o en la leche.

Y poco a poco Uegar^is, sefiora, a una alimentacidn mds amplia, una cdscara de pan,
un poco de ensalada de verduras cocidas, unas pastas de Italia en la sopa, im pur6e de
papas, habas o lentejas, im poco de pescado hervido si es fresco y no tiene eqpinas,
una crema, im arroz con leche y frutas. ^V^is como voy ascendiendo? Lentamente,
sefiora, ilegar^is a comidas mds s6Hdas: tallarines a la manteca, polio hervido, seso,
sopas de fideos fines, budines, huevos pasados por agua, o fritos, jam6n cocido, frituras
de papas, verduras de todas clases, etc. Llegar^is a darle came cuando alcance a una
mayor edad, cinco afios por lo menos.

En cuanto a frutas os aconsejo mantengdis con severidad su administracidn. Ellas
no ser&n jamds nocivas cuando sean elegidas por vos misma (lo que me garantiza su
estado de madurez y su limpieza) y cuando se coman como poetre despu^ del almuerzo
y de la cena.

Y en cuanto a bebidas, no voy aquf a iniciar una campafia antialcoh61ica, porque
OS conozco inteligente y amorosa de vueetro hijo, pero os adveierto que m&B de una
vez he visto nifios de dos afios que terminaban de almorzar y ostenti^an en su labio

PUBLIC HEALTH AND MEDIOIl!^. 225

saperior un x>ar de bigotes de vino. {Hay padres para todo, sefioral El agaa y la
leche bastar&n como bebidas a fin de mantener la funci6n renal.

Yneetat) beb^, sefiora, serd bien educado y no aaldrd de sua cinco comidas diarias,
desayuno, almuerzo, merienda, cena y refrigerio noctumo. Admlto, sefiora, que en
las doe grandes comidas se satisfaga plenamente, pero quiero aconsejaros contra el
grave peligro de las pequefias comidas entre boras, fuera de las cinco citadas. ^Que
el buen papito trae caramelos, bombones y masitas o frutas, con que saciar su glo-
tonerfa x>er8onal? ^Que el amigo o la vecina ban comprada para el beb6 pastiUas o
confites? Y ya me veo al divino cliente con una estdpida indigesti6n.

No olvid^is, el estdmago es un 6rgano, no una m^uina industrial — ^por ende necesita
deecansoB-— y adenUuB foment&is la gula del pequefio, el que no conseguiri la mia
pequefia moneda sin que com al almac^n de la esquina a traducirla en comestibles
de la peer calidad de acuerdo con su precio.

Hago puee un Uamado a vuestra energfa de madre inteligente que sabri sobrepo-
nerse a las debilidades de una bondad mal entendida, a fin de conseguir ver pronto
hombre a este divino beb^ en marcha.

YlQiaiMA TBBCBRA VI8ITA.

Terruu triatea pero cuyo cofuycimiento es necesario — Afecciones ponhles — La vacunaciSn —
Sus $egwridade9—La8 conimlHones—Su tratamiento inmediaU) — Las lombrice%—Su
rrUtodo terapSutico,

Sefiora, mi presentacidn de hoy serd severa. Es que debo hablaros de coeas serias,
debo preveniros de los peligros posibles, de las complicacionee de la vida del beb^,
y^v^is? Ya sin querer, vuestros ojos alarmados se ban dirigido al nifio y a mi como
damando misericordia para vuestro hijo.

N6, no es eso, sefiora. Gonocer donde est& el punto d^bil, donde la causa, donde
el contagio probable, es aseguraros de que, si es necesario, los sabr6is mantener a
distancia. En la vida, el conocimiento . . .

^Decidme pronto, Doctor, qu^ puede pasarle a mi beb^7

Os hablar^ largamente de ello y quedar^is tranquila. Primero, sefiora, es necesario
vacunarlo. No os babia indicado antes esa necesidad porque no es ^poca de epidemia,
pero ya es hora que pensemos seriamente en ello. No os alarm^is. En un minuto
quedard vacunado con una preparaci6n freeca, suficientemente garantizada de otras
inf ecc iones asociadas. Puede suceder, sefiora, que al tercer dia de la operaci6n vuestro
beb^ tenga unos quintos de fiebre y una ligera incomodidad en el brazo y los ganglios
de la axila se hagan pasajeramente dolorosos. Si en eeo quedan las cosas, os conten-
tar6is con mudar las gasas as6pticas con que proteger6 el lugar de la inoculaci6n, si
no, me llamar^is y acudir^ presuroso a vuestro llamado.

Pero sabed, sefiora, que estas molestias que ocasionamos a mi cliente serin resarcidas
con la absoluta seguridad de que la viruela no estigmatizard jamis el roetro divino del
beb6 con esa serie de irregularidades indelebles que caracterizan a los que sobreviven
a tan terrible enfermedad.

Ya este mal alejado, pensemos en otro. Las convulsiones.

iSon acaso posibles con el r^imen que bab^is ordenado a mi beb^?

Deegraciadamente si, aunque poco probables, y digo si para colocarme dentro del
terrene de la seguridad que he querido mantenerme con vos, que sois iuerte y valerosa.

Sin embargo, como casi siempre el origen est& en el intestine y como el r^imen
alimenticio adoptado mantiene la integridad de sus funciones, casi os podria afirmar
que ser4n extremadamente raras en vuestro beb^.

^Pero, si suceden, que debris hacer? Una cosa os exijo y es la tranquilidad. Nada
de deeesperaciones embarazantes que en estos cases, obrar pronto es obrar bien.
Inmediatamente un buen lavado intestinal, que limpiari el cabo inferior. Unos

226 PBOCEEDINOS SECOND PAN AMEBIOAN SGIENTIFIO CONGRESS.

buenoB buches de agua tibia que Uenaidn el estdmago y permitir&n su y6niito l&cil, un
buen bafio caliente, y esperar al m6dico.

^Cu&ntas coaafl, verdad? Verbis que sencillas. Una pera de caucho de laa m&a
pequefLaa, con pico del mismo material, hervidla r&pidamente y cargadla con dos o
tree cucharadas de glicerina. Introducidla en direcci6n al ombligo, sin que tiemble
vuestra mano y vaciad eu contenido, y ya tenuis hecho el lavado.

Inmediatamente le har^is absorber unos cuantos buches de agua tibia y con vuestros
dedos o con una pluma de gallina que desinfectar^is por ebullici6n en agua, le har^is
cosquillas en la garganta hasta provocar el v6mito.

Con estas dos operaciones, habdis hecho cuanto podiais para limpiar el tube digestive.

Ahora, sumergid vuestro beb^ en el agua, a 38 o 39 grades, poni^ndole contfnua-
mente pafios de agua fria en la cabeza y dejadlo alii, media, una hora, no importa,
hasta que lo vedis calmado. Entonces, m^s tranquila, esperad al m^ico que hard el
res to.

Una cosa, repito, es necesaria y es la tranquilidad. Os conozco bien y s^, sefiora,
que con los pertrechos con que os he armado no temer^is ya a las terribles convul-
siones, cuya sola menci6n hace palidecer a las madres y cuyo origen aunque
miiltiple estd casi siempre en las vfas gastrointestinales.

Y para no salir de ese terrene, hablemos ahora, de las lombrices:

^Sab^, sefiora, que en un tiempo no remoto todas las afecciones de los nifios se le
atribulan a las lombrices?

Que un nifio era demasiado llor6n, que comia demasiado, que se restr^aba por
demds las narices, que tenia retortijones intestinales, que tosia, todo era debido a
lombrices. A tal grado se lleg6 en eetas afirmaciones que se form6 una corriente
contraria que neg6 su existencia. La verdad estd, como siempre, en el t^rmino medio.

In medio Veritas. Hay a menudo lombrices y ellas pueden ser la causa de deearreglos
Intestinales o nerviosos. Pero de allf, a atribuir a tan modestos bichitos la causa
eficiente de todos los males, hay un continente.

Colocadas pues, en su verdadero terrene, veamos c6mo hacer para descubrirlas.

El m^todo es verdaderamente fdcil y estd f undado en la observacidn de las mateiias.
Si Tin dia, dos, dies, observdis lo que el nifio arroja, notardis, si tiene lombrices, unos
pequefios bichitos blancos, tales como 'Vermicelli*' que se mueven rdpidamente o
una gran lombriz semejante a la que se halla en las tierras bdmedas y que todos cono-
cemos, con la (inica diferencia que la ariojada con las materias es blanca.

^Qu6 hacer en estos casosO?

Nada mds fdcil, Uamar al mddico. Desconfiad, sefiora, de los especfficos que oa
oCrecen y que son capaces de curar desde una callosidad en un pie, hasta la calvicie.
Desconfiad de la ''Santonina'' que a menudo las madres administran sin medida,
ignorantes de sus grandes peligroe, y Uamad al mMico el que conserva adn en su
recetario el vermifuge necesario para su destrucci6n.

Ya no temer^is, pues, si os hablan de lombrices. Sab6is c6mo descubrirlas por
ende, c6mo atacarlas, y sobre todo, sefiora, no olvid^ jamds, que la ciencia vela
sobre la cabeza de este precioeo bebd en marcha. . . .

VIO^IM A CUARTA VISrrA.

ContinHa el tema trisu — Las heridas — Sus cuidados—De c6mo os podHs transformar en
una ayudanu ikil—El aislamiento como medida general—El aiskaniento debe ser

efectivo.

Sefiora, contimiio alecciondndoos sobre los peligros posibles. Entended que os digo
posibles, no probables y por ende convenceos ima vez por todas que elloe no tendrdn
fatalmente que descaigarse sobre la cabeza de vuestro divine bebd.

^Querdis que hablemos de heridas? Pues bien, sefiora, comencemos por ellas:

^Frente a una herida qud debdis hacer?

PUBLIC HEALTH AKD MEDIOIl^. 227

Como siempre, lo primero es no alarmaros. Sale saogre, mucha sangre que impre-
Siona por su cantidad y sobre todo por ser sangre. ^Vdis acaso a tomar vueetro pafiuelo
o a recunir al viejo e inmundo procedimiento de la tela de arafia para aplacar la
hemorragia? iVerdad que no, eefiora?

Ante todo si no tenuis a mano gasa as^ptica y la farmacia se halla distante, sumeigld
en agua hirviendo unas tiras hechas con eibanas o pafiales viejos y mlentras eso hierva
lavaos friccionando fuertemente vuestras manoe, lavaos en seguida con alcohol y ya
ad preparada emprended la cura.

Deeinfectad cuidadosamente loe hordes de la herida con agua, jah6n y alcohol coioo
hicisteifi con vuestras manos y tomando las gasas o los trapos que hab^ puesto a
hervir limpiad de codguloe la herida. Tapadla en seguida con esas gasas o esos pafios,
cubrid el todo con algod6n y vendad bien comprimido.

Pod^ asl esperar tranquUamente a vuestro medico que no hard m6a que aprobar
vuestra conducta y felicitaros por haber procedido de acuerdo con la ciencia. lQn6
peligros puede tener una herida de vuestro beb^?

La hemorragia que combatiscon la compresidn, la inf eccidn que prevents con la asepsia
He ahf todo simplemente descrito porque la sencillez del tema no permitiria hacerlo de
otro modo.

Veamoe como debris proceder frente a una enfermedad. Ante todo deb^ aislar al
pequefio, m&xime cuando segtin las profeclas de vuestro esposo; este es el principio
de una laiga serie de preciosidades de la que serais capaz dada la muestra.

Aislarlo por cualquier malestar ; no cuesta nada y os da planas garantlas de no espazcir
la afecci6n. ^Sab^is acaso, sefiora, si esos tres quintos de fiebre que tiene el beb^ no
son el principio de una enfermedad contagiosa?

Aislad, pues, que vuestro medico dir& si hab^is hecho bien en adoptar tal medida.

Al hablaroe de ese aislamiento quiero haceros preeente que ^1 debe ser efectivo,
porque figuraos corriendo de un cuarto a otro y siendo vos misma la portadora del
microbio. . . . ^Cu^ seria entonces [el aislamiento? Ninguno o muy deficiente.
Entrad al cuarto del enfermo cubierta con un guarda polvo o con una de vuestras
camisas de noche que al salir abandonarto y previo un cuidadoso lavado de manos os
entregar^is tranquila a vuestras otras obligaciones.

Cuidad vos misma de las tazas y cubiertoe, de las s&banas y fundas del enfermo.

Todo lo que ha sido tocado por el beb^ debe restituirse a la comunidad previa
desinfeccidn.

Asf y s61o asi har^is un aislamiento efectivo el tinico que ser& beneficioso para la
salud del hpgar.

Y ya qup sab^is practicarlo pasaremos re vista a las multiples afecciones que lo han
de menester y de las que conoci^ndolas me ayudar^is a luchar a fin de salvar a este
divino beb6 en marcha.

VIQ^SIMA QX7IMTA VISTTA.

Fin del mitmo tema — Sarampidn — Varicela — EsoarUUina — Tos oonviiUa — Difieria —
Viruela — Paperaa — C6mo ayudar al r/Udioo — Es proceder sensato no abandonar al hebi
y recurrir a la ciencia. —

Sefiora: ^Os halldis preparada para continuar nuestro tema de tristezas? Si.
Toca hoy a las enfermedades contagiosas.

Os dir^, previamente, que en 6pocas de epidemia todos los cuidados son pocos para
defender al beb6 del contagio. Aun contando con ^llos puede vuestro divino beb6
caer enfermo sin que poddis descubrir d6nde estuvo la falta, d6nde la ranura en el
circulo de cuidados con que le rode&is, que permiti6 la entrada del mal.

Permitidme que, sin intemmipir nuestras charlas haga ligeras descripciones que
06 servir&n de gula y que ser&n ratificadas por vuestro medico cuando lo llam^is.

Sarampidn. — ^Enfermedad cuya incubaci6n es insidiosa, por ^llo de diffcil diagn<58-
tico hasta el instante de la erupcidn. — Fiebre de invasion generalmente moderada,
38 a 39 grados, ojos del niflo inyectados lagrimeantee, resfrlb de nariz, estomudos, tos
68436— 17— VOL EC 16

228 PBOOEEDINGS SECOND PAN AMEBICAK SCIENTIFIO C0NGBE8S.

hueca y fuerte, a veces angina y ligera erupci6n en la garganta y velo del paladar que
precede a la erupci6n de la piel, la que aparecerd en primer t^rmino en la cara al
tercero o cuarto dla, para extenderse a todo el cuerpo al dla siguiente. Cuidados:
encerrad al nifLo en su habitaci6n, la que calentar^ a 18 a 20 grades, temperatura
que debe permanecer invariable, purgad al beb^, desinfectad su boca con agua b6rica,
administradle lavados intestinalee y llamad al m^ce que se har& neceeario para pre-
caverlo de posiblee y graves complicaciones.

Varicela,—Afecci6n contagiosa, poco grave en general, se caracteriza luego que se
produce la erupcidn, aparecen primeramente pequefias Tnanchan rojas, diseminadas en
la cara y en todo el cuerpo y extremidades, en ndmero de quince o veinte, que se
ir&n reprodudendo en los dlas sucesivos. En cada mancha se forma una ampoUa con
liquido transparante el que se transforma a las veinticuatro horas en pus. 8e notan
adem^, pdstulas en la garganta y paladar.

Los cuidados necesarios se reducen a medidas de higiene y ciiando pase el periodo
eruptive, bafios jabonosos que os ordenard, sefiora, vuestro m6dico a quien no deb^
olvidar de llamar.

Esoarlatina. — ^He aquf algo m^ serio y que merecerd todos vuestroe cuidados por
un laigo periodo. Es que en esta afecci6n la gravedad del mal o sus complicaciones
puede prolongarse y ser en todo tiempo de resultados funestos.

La inva8i6n es generalmente brutal, precedida por chuchos, v6mito6, dolor de
cabeza y angina. La fiebre alta, en la mayorla de los cases alcanza a 40 o 41 grados,
y aparece en las primeras veinticuatro horas la erupcidn acompafiada de picaz6n y
desasoeiego. La garganta se llena a menudo de llagas y en 411as mora muchas veceo
el bacilus de la dilteria. Llamad inmediatamente al medico qui6n instruiri segura-
mente un tratamiento en^igico que servird para prevenir graves complicaciones.
Desconfiad, sefiora, de las erupciones que vienen sin fiebre y que estamos tentados
de clasificarlas como benignas. Entre ^Uas se esconden escarlatinas que no son claras
porque no traen complete su cortejo de slntomas.

To$ convmha. — Afecci6n muy contagiosa, cuyo primer sfntoma es la tos, sin ninguna
caracterlstica en los primeros echo dlas; para hacerse en los periodos subsiguienteo
por sacudidas, por accesos en que despu^ de seis, siete, diez expiracionee viene una
inspiraci6n silbante. A menudo al niflo se le inyectan los ojos por efectoe de la bni-
talidad de los accesos, o vomita por la misma causa. Tiene complicaciones, por ende
08 aconsejo Uam^is al m^co que aunque por el memento se halla poco armado para
la tos misma, puede imponeros el regimen conveniente para salvaros de las compli-
caciones.

Dt/lema.— Enfermedad grave, gravisima, mortal si os descuid&is un instante en
llamar al medico. Aqul si se hace necesaria vuestra diligencia. Fiebre m&s o menos
violenta, decaimiento general, lengua sucia y dolor de garganta. Observindosela
notar^ una membrana blanca que cubre una o las dos amlgdalas. Pensad que esa
membrana crece por instante, que puede llegar a la laringe, obstruirla, ahogar a
vuestro beb6 en un ataque de crup,

Llamad al m^co y prevenidle de vuestros temores, a fin de que no pierda tiempo
y tenga en su visita todo lo necesario para darle el suero Salvador.

Tendrla que hablaros ahora de la viruela, afecci6n grave, a menudo mortal; pero
ya 08 habl^ de la vacunaci6n, que nos asegura el alejamiento de tan virulento mal.

Es evidente, sefiora, que cada dla se desconoce m^ esa afecddn, por cuanto la
vacuna la va relegando a los palses de baja civilizaci6n o a las gentes no creyentes o
descuidadas.

Los hechos, a despecho de los poco convencidos, demuestran hasta la evidencia que
la viruela no ataca a los nifios vacunados y cuya vacuna les haya prendido, o si IO0
ataca lo hace de una manera benigna y ^ilmente curable.

V06, sefiora, que tenuis locura por vuestro beb6; que os horroriz&is ante la sola
idea de que una mindscula cicatriz se grabe en el rostro terse del cliente, os hab^

PUBLIO HEALTH AND MEDIOIHE. 229

mpresurado a vacunarlo y goziis de la tranquilidad de haberos prevenido contra el
peligro que acecha.

Y una palabra final, sobre las paperasy afeccidn tambi^n eminentemente contagiosa
y que se caracteriza por un dolor por delante de la oreja, con tume£acci6n que baja
hasta el borde del maxilar, e impedimentos para la masticacidn. Esa enfermedad
trae aparejada graves complicadones que os obligar^ a recurrir al m^co a fin de
que las prevenga u os dirija en su curaci6n.

Y bien, sefiora; termino mi revista Itigubre, que os habrd impresionado. Todo
600 puede tocarle a este precioso beb4, todo y m^.

Pero no valen lamentos ni desesperaciones.

La vida del nifio es una etema cueeta arriba sembrada de piedras sueltas que debris
m su paso separar con cuidado, pero si una de ^llas se os pusiera irreparablemente en
el camino, ee necesario que sepdis como salvada con ^xito.

Tal ha sido mi misidn de hoy. Deciros, ''Sefiora, tal enfermedad es asi, poco mis
o menos. " "Frente a 611a debris proceder de este mode y no de otro. "

Y vuestra buena voluntad, la ciencia de vuestro m6dico y sobre todo el poder
vital que trae acumulado desde su nacimiento y que como ^gel de la guarda, de la
Leyenda Gristiana, acompafia al beb^, — os garantizar&n que aunque grandes fueran
loe obstdculos, mayores son los recursos con que contamos.

Poddis, entonces, Sefiora, entregaros plicidamente a vueetra misi6n, sin temores,
dn aprensiones; el mundo es de este pequefio beb^ en marcha.

TIOlftSIMA SBZTA YISITA.

La marcha, — Cudndo d behi debt comeruar a oaminar. El mamje preparador. De la
manemecnnodebeinidarieelaprendizaje. Mediosnaturalesporendebuenos, Elcastigo,
Ignoranda o talvajumo.

Sefiora: Los plazos fijados se cumplen religiosamente, es hora ya que vuestro
beb^, fuerte, vigoroeo, active nos demuestre su poder. Me decls: "Doctor, cuando
lo tengo entre mis manos se sostiene solo y hasta creo que ha ensayado pasitos. **

iEbo es una creencia o una seguridad? |Lo hab^is probado, verdad? |Ah Sefiora I
cuidadosamente habfa obviado mi converBaci6n sobre la marcha a fin de no apresurar
el memento solemne del primer paso. ^Porqu6? Sefiora es conveniente y es necesario
retardar lo m^ posible el instante de independencia porque si comienca tarde lo
har& mejor. Ya a los nueve meses habr^is notado que se para solo, que tiene fuerzas
floficientes para inidar el aprendizaje, que se siente capaz de emprender la marcha
y sin embargo os disteis cuenta de mi mutismo al respecto.

Es que esperaba a que sus mfisculos se desarrollaran con el ejercicio de vigoroeo
pataleo en el bafio y cuando lo mud&bais y me aseguraba como dentro de sus roUitoe
de gordura se iban desarrollando progresivamente los mtisculos. Por eso, institul el
maaaje. Os dije, ^lo record&is7: "despu^ del bafio deb^, con vuestras manos cu-
faiertas de talco, hacer fricciones ligeras de las piemas y muslos del divino beb^ e in-
tensificarlas progresivamente. Deb^ pellizcar entre vuestro pulgar e fndice, de un
mode suave y acariciador como sois capaz de hacerlo, las masas musculares, de abajo-
arrilm, es decir, del pie al muslo. Debris practicar enseguida movimientos de flexi6n
y extension de los miembros, varias veces y sin esfuerzo.

^Con qu6 fin os orden^ todo eso, sefiora?

Ahora deb^ comprenderlo. Era necesario fortificar los mfisculos, los ligamentot
a fin de que resistan el pesado organismo de vuestro beb^ sin necesidad de andadores,
ni de sostenee de clase sJguna.

^Ore^ que no not6 vuestra impaciencia?

Todas las madres sois igualee. Cuando notiis que el l>eb6 mueve sus piemitas, se
aacude o endurece afirmiis su capacidad pedestre.

Y sin embargo no ee asf .

230 PBOCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

£1 beb6 aprenderd a marchar como supo Uorar, mamar o reir, vale decir, que lo
hard solo, con vuestra ayuda o sin 611a, pero a su debido tiempo.

Para 611o iqu6 oe aconsejo, eefiora?

Nada o muy poco. Dejad al beb^ en el suelo, sentado sobre una alfombra y vigilad
que no saiga del espacio tapizado. Lo verbis, primero, caer hacia atr^ y volver a
sentarse; en seguida, vol tear sobre s( mismo quedando alin el vientre piano sobre la
aliombra. Este ejercicio repetido lo llevar& a encoger sus piemas y qnedar de rodillas
apo3rado ademds en sus manitas, en cuatro patitas, gateando.

Un buen dfa cuando ya lo not^ un diestro marchador, le acercar^ una silla de
Viena y en su asiento colocareis el juguete que m&s agrade al cliente. Lo ver6ia
entonces tomar apoyo en bus manos e irse elevando gradualmente hasta pararse en
sus pies. R4pidamente tomard al chiche y al pretender darse vuelta caerA cu4n largo
ee. Entonces, nada de aspavientos proque sabed sefiora que una cafda de tan pequefia
altura sobre una alfombra no le producird jam^ una Ie8i6n seria. Refos y os asom-
brar^is de ver como el valiente amigo corea vuestra risa y pretende repetir el acto.
Y pronto, mucho m&s de lo que cre^, verbis al beb4 marchando presuroso como si
muchas obligaciones fatigantee le absorbieran su contado tiempo.

Un nifio que comienza a caminar, corre al igual que un aprediz de ciclista cuando
empieza el pedaleo hace disparar a su miquina.

Es que, sefiora, es m^ ^il mantener el equilibrio andando ligero.

Nada de andadores ni de fajas de sost^n, pues tlenen el sezio inconveniente de
comprimir el t6rax y hacen adaptar poaiciones viciosas al pequefilo y adem^, seflora,
un beb6 que se convence que tiene un apoyo donde librarse de una caida no querri
jamds desprenderse de 611a, tomard miedo a andar solo y costari el doble conseguir
verlo en marcha.

El m6todo que os aconsejo es muy sencillo. ^Por qu6? Porque es copiado de la
Naturaleza y tiene pues el sello de lo mds prdctico y beneficioso.

No olvid6is, sefiora, los cuidados que en estos momentos requieren las manos libres
e inteligentes del pequeilo beb6.

Nunca mis que ahora es que debris vigilarlo porque sus manos tomardn cuanto ob jeto
e6t6 a su alcance y r&pidamente lo Uevardn a la boca. Vigilad, pues, y apartadle los
objetos cortantes, los sucios, los que puedan ser un peligro en sus manos. Vuestra
actividad estd en juego y vuestras energlas sufrirdn una ruda prueba.

La arcilla estd blanda; es a vos a quien toca modelarla. El nifio forma en estos
instantes su cardcter y se adapta tal como la arcilla.

Ahora bien, si pretend6is el triunfo neceeitdlB energfa firme y persuadva; nada de
gritos ni de castigos.

Vuestras manos hardn menos que vuestra mirada.

La obstinacidn del pequefio la verbis doblegarse ante vuestra constanda, y penaad
en el cuadro horrible de una madre que castiga brutalmente a su hijo porque se Ueva
a la boca un juguete I

Si no fuera ignorancia se dirfa salvajismo.

Por eso vos, sefiora, educada como lo hab^is sido entre mimos y halagos no senttrdis
la tentaci6n jamis de levantar vuestra mano sobre este divino beb6 en marcha.

VIOlftsIMA S^PTIMA VI8ITA.

itliima vitita — Tendencias convenientu — Bxiena direccidn al ptincipio — DiscipUna
de amor — Nada de gritoe — Constanda pertuasiva — El halago y el miedo — Las relado'
nes con el mSdico — La riqueza moHvo de orguUo—La superioridad de los mayores — Los
compafleros del bebS — El maestro — La madre Unica cons^era.

Sefiora: Mi tiltima visita la dedicaromos a hablar del porvenir.

iQu6 serd vuestro beb6?

^M6dico, abogado, ingeniero, arquitecto u honrado comerciante couk) lo es su padre?

PUBLIC HEALTH AND MEDICINE, 231

He ahf una grave cuestidn que no os atrev^ a conf esar pero que ya la hab^is medi-
tado en lo m&s hondo de vueetro cerebro.

iVerdad?

Hab^is hecho bien, sefiora, porque es a vos a quien toca decidir.

lC6mo a mif , Doctor?

Sf a vos, sefiora. No os dird que encarril^is brutalmente sus gustos hacia un fin
determinado. No, porque cometeriais un grave error de resultados funestos para
el porvenir de vuestro beb6; pero, es a vos, seilora, a quien toca observar donde estd
la afici6n, donde estd el interns mayor de su inteligencia, hacia que punto se orientan
BOB habilidades, cu&L es la senda que le ser4 m^ fdcil recorrer, y, armada de esos
elementos proceder en consonancia.

Depende de la buena direcci6n del principle, la formaci6n del cardcter que va a
preeidir los actos de su vida entera.

Os debris apresurar pues, en guiarlo hacia una buena iniciacidn, y asf como para
loB cuidados f (sicos me vlsteis siempre partidario de dejar hacer a la Natundeza y so
cooperar a su obra; en la parte moral, en cambio me encontrar^ en un terrene
decisiones absolutas que os causardn admiraci6n.

Primero y ante todo, el nifio debe ser disciplinado. No vayiis a creer que en tie
per tal la disciplina del cuartel. Nada de eso, sine una mezcla de carifio, respeto
y obediencia que serdn altamente beneficiosos a su marcha futura.

Habituadlo a comprender que no valen llantos y rabietas para satisf acer sus caprichos
y que a vuestra negativa no le queda otro camino que el silencio.

Comprended, sefiora y amiga mia, que si cuando pequefio le permitis conseguir sus
deeeos con llantos y gritos, cuando hombre, sentird pesar sobre sf amaigas contrarie-
dades, pues en la vida, el ^xito estd muy lejos de ser obtenido por los que solo saben
hacer geetos.

Cuando vueetro nifio acostumbrado a conseguir sus satisfacciones personales im-
poniendo sus caprichos obtenga la primera decepci6n, ^Ua ser& funesta porque va
contra los hdbitos creados que forman su segunda natiiraleza.

Pero tampoco os acostumbr^ a dar voces, cada vez que pretendiUs imponer vuestra
voluntad, una negativa severa ahora que sus f acultades comprensivas no estdn todavia
desarroUadas, una n^ativa explicada m£s adelante; pero nada de gritos, ni golpes.

^Sabdis por qu6? £n cada hombre por m£s pequefio que ^1 sea existe el secrete
placer de exacerbar a quien manda y vos, sefiora, foment^ ese mal instinto exhibiendo
vuestros enojoe.

No buaqu^ para imponer vuestra voluntad loe doe vulgares y pemidoflos medics
del halago y del miedo. ^Sab^ a qu^ me refiero?

Con solo deciroe dos frasee frecuentemente empleadas, os dar^ cuenta: "Beb6,
fli te quedaii quieto te voy a comprar caramelos.'' "Beb^, si no te portas bien td va a
comer el Cuco."

He ahl, sefiora, propoaicionee que jam^ deben aparecer en vuestros labios. La
primera porque transforma a vuestro beb^ en un ser interesado que no procederd
jamds sin la esperanza de una remuneraci6n, serd honesto con paga, vale decir, no
0er& jamds espiiitualmente honesto, y la segunda porque inculdds un sentimiento
nodvo para su vida: el miedo, y porque iarjiiB un ser imaginario que obrard sobre el
esplrita del beb^ como una etema pesadilla dolorosa.

Con mayor raz6n atin os pido no supldis al Cuco de la s^^unda frase con el Doctor,
porque si 4ete no es un ser imaginario es al menos un sujeto dtil y con quien conviene
que vuestro beb^ conserve las mds amplias amistades, amistades que desaparecerin
en el instante mismo que lo transformiis en un instrumento de terror.

Por eso tambi^n, os pido no cometdis la torpeza de muchas madres que cuando el
medico le dice al nifio ''Mu^trame la lengua,'^ se apresuran a agregar: ''Mu^etrasela
querido, no te hard mal,'' y el nifio aleccionado de que es posible que el buen sefior
que pretende hacer obs^rvadones en su lengua puede producirl^ un mal, se apreeurari
a cecrar la boca, apretar los dientes y mmiar una rabieta.

232 PHOOEEDINQS SEOOND PAN AMEBIOAN SOIEHTEPIO 00NQBB88.

De todos estos detalles, nace esa comedia de llantos que se reproduce en cada viaita
del medico a nifioe que han Eudo mal enBefiadoe.

Madres, que preguntan, al medico en preeencia de su hijo enfermo: ''^ Y c6mo hago
doctor para administrarle el medicamento si no quiere tomarlo?" o que ponen en
duda la obediencia de los hijos a sua drdenes, diciendo "all doctor, lo toma por que
eetd Ud. delante y despu^?" V^is, Sefiora, con ^llo conaiguen avivar la perspicacia
de BUS hijos que saben asf, que si ^Uos no quieren, van a salvarae poniendo obst^ulos
o que es necesaria la presencia impositiva del Doctor para obedecer a sus mandates.

VoB, s^uramente, no proceder^is asf, por cuanto espero que vueetra inteligenda
comprensiva os habrd evidenciado los perjuicios que reportan tales procederes.

Vuestra posici6n social, aunque descubierta por el nifio, no deberd ser jamis on
motive de oigullo. Para 6II0 ee necesario, Sefiora, que busqu^is entre sus compafieros
de colegio a un hijo estudioso, de laboriosos obreros, que serd su amigo, y hasta H os
debeis inclinar para repartir vuestro carifio.

Hacedle ver que la desigualdad de fortuna no es un m^rito y que 61 es, cuando mds,
igual a su amigo 0 inferior a 61, si aquel tiene condicionee intelectuales superiores.

Demostradle que el dnico prestigio entre los hombres lo da el talento y que para
conseguir ese prestigio no bastan las dotes naturales sine que ee necesario su perfec-
cionamiento por la labor diaria.

Hacedle comprender que el dinero no es el fin de la vida, que hay algo mis grande,
mds noble, y que vale mds que la riqueza material, pero no por eso dej6is que lo
malgaste en nimiedadee pemiciosas e instituid el ahorro deede la primera edad.
Con 6II0 se acostiunbrard vuestro beb6 a ser econ6mico, empleard su dinero como un
medio de producirse satisfacciones honestas y de un orden superior.

Alejar^is los peHgros realee que rodean al beb6 tales como los del ju^^, los objetoe
cortantes y las caldas pero no vaydis a cometer el error de infundirle miedo. Este
sentimiento es mds de educaci6n que innate. Pensad que si cada vez que lo dejdis
solo agregdis "No temas, ehl, que ya vuelvo," el beb6 razonard asl: "Mi madre dice
que no tema, en ^once8 algo me puede suceder'' y es claro que a la segunda vez que
tent^is la experiencia romper tfen llanto y os seguird.

Es necesario que el nifio comprenda la superioridad de sus m&i73res para lo cual us
evidente que no os debris mostrar jamds en vuestros instantes de debiUdad.

Por ello OS digo, sefiora, no mintdis jamds al nifio. Si una vez comprueba que no le
hab^is dicho la verdad dudard de vos para siempre, y esa duda se traducird en deeobe-
diencia.

Las pequefias querellas dom6sticas tampoco deben ser preeenciadas y vuestra vida
debe ser de etema annonla para 61. S6, sefiora, que hasta ahora se prolonga la luna de
miel de vuestros amores. Sabed que la deseo etema, pero si alguna nube oscurece el
cielo de vuestra dicha, el beb6 nada deberd saber.

Ese respeto mutuo, ese carifio constante, esa igualdad de opinionee y de procederee
que hacen la paz del hogar, deben quedar en evidencia para vuestro beb6, que al
notaros de acuerdo se sentird tentado a plegarse a la mayorfa, y modelard sus acciones
a vuestros deseos.

En las conversaciones que entabldis poned siempro el sello de vuestra superioridad
y no mantengdis jamds una duda. Cuando la pregunta ee del g6nero de 6sas que no
querela responder, amparaos en una supueeta ignorancia y no aliment6is su suspicacia,
diciendo: "jAhl pillin, eso no se pregunta:", por qu6 isab6is entonces qu6 hard
vuestro beb67 Inquirird hasta satisfacer su curiosidad animada por vuestra respuesta,
mientras que vuestra ignorancia confesada lo dejard conforme y con la convicci6n de
que cuando vos no lo sab^is, 61 tambi6n puede ignorarlo.

El nifio debe ser para vos como un pdjaro en la jaula. Con amplia Ubertad para
sus pequefios vueloe pero defendido por los bairotee de vuestro carifio que aunque
diaminuyan su independencia lo amparan y protegen contra el abuse de la vida 7
BUS contagios pemiciosos.

PX7BLI0 HEALTH AND MEDIOINB. 238

For eeo debris elegir sua compafieroe y cuando ^ vaya al colegio, que seid lo mis
tarde poeible, debris cooperar a la acci6n del maestro a quien conmderar^iB un amigo
y para quien prodigar^is en todoe loe instantee y con conociniiento del niiio vueetras
alabanzas y agradecimientos. Tal proceder influird en la mente del educando quien
sentird amor y respeto por su profeflor, amor y respeto que se traducii&n en una mayor
dedicaci6n y provecho en sue estudios.

Pasaron los tiempos en que se afirmaba ''la letra con sangre entra''; se abolieron los
Idtigos y las palmetas y el reinado del caiifio hace de nuestros profeaores seres dignos
de veneraci6n para quienes no basta el agradecimiento de nueetra vida entera.

Ensefiadle pues a amar al maestro que en ello vuestro beb6 pagahl un poco del
enorme saciificio que importa la brega diaria por su instruccidn.

Y continuad la acci6n del profesor en vuestracasa. ^Sab^is c6mo7 Interes&ndoos
Yos tambi^n en bus estudios, haci^dole notar sus progresos, sosteni^dolo en los
mementos de desaliento, demostr&ndole que todo se consigue, pero que es menester
luchar.

Ese aprendizaje demoetrativo de que no hay nada ficil en la vida, lo ensefiahl a ser
pertinaz y constante y le ahorrar6 enormes decepciones. Frente al fracaso se dir&:
"no he trabajado bastante'^ y no se entregaii a la desesperaci6n de los seres d^biles
que se creen siempre vfctimas del error o de la injusticia de los hombres.

Habladle a menudo al ofdo de vuestro carifio y de vuestra amistad a fin de que
sienta en vos su mejor confidente y os permita vuestro consejo en todos los actos de su
vlda infantil.

Y llegado el memento de su independencia total cuando sintdis que aquel ser
bien querido ya ha formado las alas que le permitir&n escalar libremente las alturas,
OS sentir^ r^ocijada de haber procedido segtin mis consejos, porque habr^is cons-
titufdo un ser fuerte de cuerpo, sano de alma, conformado con la esencia de vuestra
bondad y con la pujanza de vueetros sentimientoe de madre.

PUEMCULTURA.

Por P. RUEDA,
Jtft de la Sala de CHnica Midica del Hospital de Niffos, Rowrio de Santa Fe, Argentina

El nifio enfermo exige un cuidado mde prolijo si es posible, que el adiUto, pues mientras
hie tiene el recurso de la queja, aquel recompensa con el carifio mds sincero y el md$
prof undo olvido hasta las f altos de cuidado que podemos hacerU svfrir,

Es hoy dfa de intima satisfacci6n, porque puedo realizar en la forma que aspiraba
im proyecto que me ha ocupado m^ de ima vez; la Ensefianza Prdctica de la Pueri-
cultura — que por primeravezse implanta en el pais' — a una entidad social tan
respetable como lo constituye el noble gremio del magisterio.

No es mi idea precisamente aumentar la densidad de vuestros conocimientoe,
pues ello estd m^ que garantizado por la vasta erudlci6n del personal docente de
vuestra casa, mi finalidad es contribuir dentro de mi modesta esfera a la 8oluci6n de
un verdadero problema social, de ima cuesti6n de la mayor trascendencia en nuestro
pais — como en muchos otroe — de un asunto, dirfa, tan viejo como la historia y que
sin embargo espera reeolverse todavla. Me refiero como ya lo sab^ vosotras al tema
de actualidad etemamente palpitante: La protecci6n del nifio.

Compleja y diflcil es la aplicaci6n del remedio a mal tan viejo, si no se estudia
con m6todo la cuesti6n, explorando minucioeamente su origen, sus causas y sus
modalidades; como seria imposible curar una difteria, por ejemplo si el encaigado

> Primer corso prtfctloo de puerlcultura dictado en la Rep<&blica Argentina, inldado en seDtiembre d«
1915 por el autor. Dedleado a 4* afio de la Ssonela Normal da liatftroa.

234 PEOCEBDINGS SECOND PAN AMEBICAN SCIENTIPIO CONGEESS.

de tratar la dolenda desconociera el mal. £1 problema se aclara empero y el ^to
se f acilita, cuando el terapeuta poeee pleno dondnio de la enf ermedad y el medicamento
que debe aplicar. Pretendo yo si no se me apura ofrecer la completa curacidn del
enfermo.

Desde luego, pienao que loe libros ban becho ya eu tiempo, agradezcdmoeleB su
enaefianza y sin dejarles del todo, reconozcamoe que su sola acci6n no es suficiente.
En efecto, la vieja difuai6n impreea no ha podido reeolver la cuestidn, como lo prueban
por una parte la excedva mortalidad infantil y por otra la neceddad en que se ban
visto las nadones m^ eivilizadas de seguir nueva via. La enaefianza de loe libroe
ee incapaz de corregir el nud, por vanas razones; pero bastard enumerar la siguiente:
porque mucba gente que sufre no sabe leer y muchos de los que saben no leen.

Las conferencias tedricas muy dtiles son signo evidente del esfuerzo que bace la
sociedad para llegar al fin deseado; es esto un buen slntoma porque nos muestra que
el pueblo empieza a preocuparse de veras, constituye pues un gran progreso hacia el
perfeccionsjniento.

Pero ee indiacutible que la tinica forma razonabley v&lida ee la ensefianza esencial-
mente pr^tica. Es tiempo ya que la acci6n se inicie, que los hechos reemplacen
a las teorfas, para que se infiltre en el hogar el pleno dominio de los sanoe e indiq>en8a-
bles consejos.

Ensefiar baciendo, enaefiar mirando, ensefiar palpando y sintiendo en todas las
formas posiblea a conocer el alma y el cuerpo del nifio para interpretar mejor sus
necesidades y sufrimientos y alejarle un tanto del mal que le acecba, es como baremoa
obra dtil, mediante el concurso inestimable de nuestra feliz intervencidn en esta
cdtedra.

Hadendo pr^tica, ae impreaionard vuestro eeplritu con aenaadonee diveraas: txiatea
y doloroaaa laa mia, matizadaa a vecea de alegrea ra^goa, cual la mirada riauefia y
picareeca de un bebe robuato y aano. En esta forma, lo eepero, coeecbaremoe 6pimo8
frutoa.

Impreeionando la exquiaita aensibilidad de la mujer, ae marcar&n buellaa profundaa
en el coraz6n y aobre todo en el cerebro que puedan guiar laa pr^ticaa cientfficas, ora
ejerdtando en came propia, ya predicando con criterio firme para aUviar mucbaa vecea
laa amarguraa del bogar ajeno.

Sin deaecbar por complete el libro impreeo, pienao que al le^ en eate libro viviente:
que llora, rfe y aufre, que ofrece au frdgil cuerpedto bambriento a vecea, y a vecea
lastimado por acbaquea m^ cruelea, al leer eata p&gina aentida y palpitante en la
fuente original y pura de laa neceaidadea aocialea, aprenderda de la manera m^
pat^tica, a reflexionar con provecho y a reeolver con 6xito algunoa problemaa que con
barta frecuencia ae preaentan en loa bogarea. Procederemoa aaf con laa ventajas de la
prevision aobre loa lamentoa de la deeeaperanza.

iCuando veaia eae nifio que llega anbelante, pilido y anaioao torturado deapiadada-
mente por interne mal, ain aliento para lanzar, ni un d6bil quejido, til time recurao
que le queda para implorar el auxilio, llegado en una palabra en eatado fisico miaerable;
cuando veaia repito eae nifio tan pr6ximo a la muerte, capaz todavia de recuperar la
aalud de que parecia irremiaiblemente privado, cuando auaculteia laa mil circuna-
tanciaa que como una conaigna fatal le acechan; babrda llegado a comprender la
magnitud d d problema y la urgencia de reaol verlo 1 Mia atin, ai penetr&ia (ntimamente
la prdctica boapitalaria, podrda comprobar la nefoata acd6n que la ig^orancia ba
provocado en el vulnerable organiamo del nifio; podrda comprobar tambi^n con que
frecuencia, felizmente, la victima tan gravemente atacada reacdona a preacripdones
de la m&B pura 16gica.

Reunid todas eaas impredones, considerad todas eeas contingenciaa y oe aaom-
brar^ia con juato motive de la inexplicable apatfa con que ae ba mirado dempre eata
faae de la bigiene infantil, aaf comprenderda mejor la juatida de mi entuaiaamo por
eata verdadera lucba, la neceddad impreacindible de difundir los conodmientoe de
pueiicultura en loa bogarea, implantando el tinico siatema eficaz para au enaefianza.

PUBLIC HEALTH AND MEDIOINB. 236

Con este prop<5eito decia yo en un pioyecto elevado a la Direcci6n de Ensefianza
Primaria y Especial, en el alio 1912, solid tando la creaci6n de cdtedras de puericultura:

''Podrfa objetaree a primera vista que es este asunto del resorte exclusive de la
medicina, no dudo empero que si eeta ciencia estd encargada de profundizar, de espe-
dalizar por asf decir su estudio, de la puericultura, necesita a su vez, como auxiliar
poderoso la preparaci6n del pueblo, la difusidn de conocimientoe en la sociedad, fonnar
d ambiente, en una palabra, para conseg:uir una penetraci6n ^Ldl y obtener el resultado
que al coeechar sus fnitos constituiri el engrandecimiento de la patria."

Es la maestra por su doble cardcter, particularmente en el ejerdcio de su nobilisimo
ministerio, en contacto fntimo con la masa social, quien desarrollard un gran papel en
la impregnacidn de cuestiones tan vitales para el progreeo de nuestro pueblo; es la
maestra, el factor poderoso que contribuird con su pr^dica constante y tenaz a la
realizadi^ de la gran obia, que en 6poca no lejana nos pennitird mostnur nuestra patria
como un modelo en el concierto universal de las naciones. Ser& solamente por su
inestimable concurso que lograremos alcanzar la perfecd6n obtenida en la actualidad
por los suecos que ban hecho descender la mortalidad infantil a una cifra verdadera-
mente ideal, vale decir, al 4 por dento (40 por 1,000) de la natalidad.

Es un pals joven, en iormBci6n como el nuestro, son mdltiples las preocupadones
que solidtan intensa y urgentemente la atend6n del estadista, necesitan por ello —
tanto las instituciones, como los problemas vitales, como el que me ocupa — el esfuerzo
individual, la tenaddad del luchador in&tigable, para que hecho came en el espfritu
del pueblo, pueda merecer el apoyo eficaz y decisive del Gobiemo.

Emprendamos pues la tarea y cuando hayamos aimado esfuerzoe, orientado ten-
dendas, marcado rumbos definitives, madiuado en una palabra el problema, confiemos
en que la acd6n ofidal se plasmard en forma f&cil y estable.

iQae bagaje de conocimientoe lleva, hoy por hoy, al nuevo hogar la futura madre,
por lo que a la higiene infantil se refiere?

^Como inidar^ el cuidado de su primer hijo?

Ser& fatalmente inevitable la acd6n peijudidal de su intervenddn en los menores
actos, es entonces que empieza, todavla no siempre, a apreciar la neceddad del
eetudio de estos conocimientoe y el im)vecho que su f^cil dominio le prestarfa, impi-
diendo la aplicaci6n tan difundida de las m^ detestablee pr^U^ticas a que irremisi-
blemente tiene que conducirla la ignorancia de los preceptos dentfficos.

Puedo afirmar satisfecho que con la perseverante visita de vosotras a este hospital
supiimiremos una serie no escasa de sufrimientoe y dol(H:es a m^ de un niilo.

Es de esta manera que cumpliremos la sabia miJTima de Emerson, es asf como
protegeremos al niilo, fuerza latente que enderra tanta esperanza.

Es practicando ampliamente que podr6is formaros un criterio nUis liberal y eeca-
pards con seguridad de caer en la rutina, tambi^n comprenderds que a voces puede
uno distanciarse im discrete trecho de la vfa que marcan los rumbos generales y asf
por tiltimo aprenderds a reflexionar m^ detenidamente sobre las mil cuestiones que
tan diversas ofrece la vida diaria.

Guidemoe pues dentfficamente a los nifios, los continuadores de nuestras obras, de
esa masa espiritual en formacidn saldr^ los artifices que perfecdonen nuestros cono-
cimientoe, eUoe aliviar&n muchos males que todavla pueden atacamos.

La nifiez proveer^ los heroes de la acci6n y el pensamiento.

La nifiez resarcird con creces el mfnimo esfuezo que deearroUemos en su proteccidn.

Nifiez sangre de nuestra sangre, prolongaddn interrumpida de nuestra ezistenda
que al iluminar su camino en la vida no hacemos nUis que condudmos a nosotroe

236 PBOOEEDINGS SECOND PAN AMEBIOAN SCIENTIFIC CONGBESS.

LA NOYOCAlNA GLiCERO-YODADA.

Por JUAN D. SUSINI,
ExrJtft Interino del Servicio Odontoldgico del Departamento de Polida de Buenm Airee,

introducct6n.

Se puede soetener, con justicia, que estin a nueetro alcance una variedad de anea-
t^icoe locales, que con mayor o menor 6xito vienen preetando grandee servidoe y
llenando una alta misi^n en dentistica operatoria.

Estas subetancias agregadas a la t^cnica de las inyeccionee, hacen que las opera-
ciones en cirugla dental sean casi indoloras o indoloras por completo en la mayorfa
de los casos.

£1 perfeccionamiento credente de la anestesia en esta tiltima d^cada, hace que
nuestro trabajo sea complementado por el padente que ya no llega a la clinica con
el temor y la excitad6n de antaiio, resignado a sufrir un dolor realmente grande,
que ni la habilidad del operador ni la rapidez de la intervenci6n podlan evitar.
Felizmente, hoy estos inconvenientes se hallan descartadoe en gran parte por la acci6n
segura de los anest^icos, y el enfermo, ayudado al grade de ilu8traci6n general de
la 6poca presente, se nos presenta casi siempre en un estado de dnimo m&s bien sereno
confiado en su acci6n comprobada, salvo ese temor instintivo al dolor, aumentado
muchas voces por observar de cerca nuestros preparatives e instrumentos, y otras,
raras por suerte, por consejos sin fundamento de ciertas personas pesimistas en cues-
tiones de medicina.

En poder de tan preciosos elementos, nos ha colocado en condidones de actuar con
seguridad adn en los casos que antes eran de una dificultad absoluta. Y esa acd6n
segura, por demils comprobada en la pr&ctica cientlfica, va abriendo cada dla nuevos
horizontes en dentistica operatoria, o mejor dicho, en el campo de la cirugla en
general.

Preetando siempre preferente atend6n al estudio de la anestesia local, elemento
precioso que complementa de una manera eficiente nuestras intervenciones, he eetu-
diado detenidamente la acd6n, ventajas e inconvenientes de las prindpales subs-
tancias en pr&ctica actualmente, y despu^ de muchas observaciones dlnicas, he
utilizado una combinaci6n que por sus cualidades especiales, ha Uenado por completo
nds aspiradones de hallar una fdrmula que en los casos de extracd6n del 6igano
dentario a causa de periostitis alveolo-dentaria, a la par que se obtenga con ella la
anestesia local, posea una acd6n antis^ptica, a fin de ayudar de este mode al trata-
miento post-operatorio. •

Los casos cUnicos ^ constatados que acompafian este trabajo demueetran un resultado
altamente satisfactorio, que me ha decidido hacer esta comunicaci6n.

CONSIDERAaONES OBNBRALB8.

La periostitis alveolo^entaria, puede ser originada por causa diversas: traumatismos,
aparatos de ortodoncia, cambios bruacoe de temperatura en la boca, dep6sitos de
tdrtaro, restos de ruberdam o hilos de seda en el cuello de los dientes, absorcidn de
substancias medicamentosas (cdusticos, desinfectantes), mechas de a]god6n abando-
nadas en los canales, descomposid6n parcial o total de la pulpa, y en una palabra, toda
infecci6n o irritaddn que ataque al periostio alveolo-dentario.

De m4s estd dedr que con los medios que hoy posee la odontologla, existen siempre
muchas probabilidades de un tratamiento conservador; pero cuando la complicaci6n
peridstica es rebelde a todo tratamiento poniendo al 6rgano dentario en la imposibilidad

> La aplicaddn de mi fdnxmla fa6 heoha a un gran ntUnero de enlennos, oon excelentes resultados. Sdk>
aoompafio algnnos casos detaUados, que he oonsiderado de verdadero interns clinico. (£1 Editor: Se
somete un oaso al fin oomo ilustraddn del trabajo.)

PUBLIC HEALTH AND MEDICINE. 237

de seguir desempefiando sua fundones fidoldgicaa y comprometiendo el estado general
del padente, la extracddn eeUl indicada, m^bdme trat&ndoee de rafces.

La extracd6n en tales casos trae gran alivio al paciente. Y se explica, ella es de-
congestionante, y la distensidn de las extremidades nerviosas por los vasoe dilatados,
desaparece. Esa decongestidn en uni6n de la acci6n aneet^ica, hacen que el padente
se encuentre en pocos mementos en un estado de alivio complete y se retire tranquilo,
contrastando con el estado en que se hallaba mementos antes.

Pero, generalmente, este alivio es moment&neo y el dolor aparece de nuevo per-
sistiendo por horas y muchas voces algtin dfa. Por lo regular, los buches antis^pticoe
y analg^cos no actdan como debieran en eetos casos obligando a una medicaci6n
interna. En otros, m^ delicados, donde el proceso se ha abandonado, el dolor re-
crudece, entra un malestar general que es favoreddo por la falta de alimentaddn,
insomnio, etc., aparece la fiebre y nos encontramos en presenda de una infecddn grave
en la regidn donde se ha hecho la extracci6n.

lOuil es la caiisa efidente de esta persistenda del dolor en la ma3roria de los casos,
y de la nueva infecd6n en otros?

^C^mo es posible suponer, admitiendo que el padente haya seguido las prescrip-
dones del case, que sea tan probable una nueva infecd6n, hall&ndose la herida bajo
una acd6n antis^ptica regularmente continuada poniendo barrera a la invasidn
microbiana?

La decongesti6n produce un alivio caai inmediato. Pero debemos tener presente
que existe una infecd6n del periostio y que la hemorragia que produce la extraccidn
no la hace desaparecer. Con el diente quitamos la causa de la infecd6n, pero ^sta
adn queda en el alveole.

La extracci6n produce una herida grande, y esta herida abierta favorece el avance de
la invasidn microbiana, que en organismos debilitados, ya por la misma afecd6n, por
una enfermedad general o una di&tesis, la hacen inminente, mdxime ai se dene en
cuenta la septicidad del medio bucal.

La acci6n fagodtaria del oiganismo, es de nuevo llamada a contrarrestar la nueva
infecd6n, y esa nueva reacci6n inflamatoria, ayudada al estado general de la region,
produce al paciente ese dolor continuado de mayor o menor intensidad de acuerdo con
el grade de la inflamad6n.

De manera que lo indicado serfa poner la herida en condiciones tales, que la reinfec-
d6n no pudiera realizarse inmediatamente; y que, complementado luego con los
buches antis^pticos, est^ a cubierto de nuevas infecciones.

En una palabra: preparar el terrene antes de produdr la herida; escudar ese tejido
debilitado all! donde mementos despu^ estard en condiciones de ser vulnerable.

El tratamiento preventive de poner tintura de yodo en el alveole despu^ de la
extracd6n, como desinlectante y revulsivo, no Uena el fin que se destina. Porque
hay que tener presente que la tintura de yodo actda mal en un terrene htimedo. La
hemorragia, mucha o poca que sea, impide se deposite como debiera en el tejido, y
que, unido a la saliva y a los buches que hace el paciente despu^s de la extracd6n,
obstaculiza su acd6n a tal punto que su efecto desinlectante es fnfimo. Y si adem^
de esto se agrega el tiempo que pasa desde la extracci6n hasta el memento que el
paciente se halle en posesidn del antis^ptico prescrito, vemos que transcurre un
tiempo bastante apreciable que es bien aprovechado por los microrganismos que
acttian sobre un punto debilitado.

Y ^sto siempre en el supuesto de personas aseadas que siguen las indicadones de no
tocarse la herida, no fumar, etc.

En consecuencia, he crefdo que es indispensable unir al aneet^co, una substancia
que sin neutralizar su acd6n, ayude al tratamiento post-operatorio, que despu^ de
la extracci6n pueda defeMerse de un nuevo ataque exterior, y en una palabra, como
lo he dicho antes, que prepare el terrene antes de producirse la herida.

238 PKOCEEDINGS SECOND PAN AMERICAN SCIENTIFIO CONGBEBS.

Eso me ha inducido a agregar a la novocaiiia, la tintiua de yodo y la glicerma, qu e
he denominado '* NoYocafna-gHcero-yodada, " solucidn que a la par de ser aneetMca,
ee revulaiva, desmfectante y ligeramente c&ustica, y que Uena ese fin, como prueban
las observaciones clfnicas que acompafio.

La inyeccidii se hace in situ * procurando que ella se d^Kwte con preferenda en
la regi6n afectada. La tintura de yodo durante el tiempo que pasa antes que el
anest^co actde, va esteiilizando el medio, cujra acci6n ee facilitada gradas a la cons-
tituci6n anat6mica del diploe, de modo que, cuando la aneetesia se ha producido, el
terrene se halla en condicionee de resistir a una nueva infecci6n despu^ de la
extracci6n, pues gran parte del medio estd ligeramente cauterizado.

La reyul8i6n produce decongestidn de loe vasoe del periostio, y en consecuencia
menoe dolor, por cuanto la irritaci6n de las extremidades nerviosas por loe vasos dila-
tados desaparece, y por tanto ayuda la acci6n del anest^sico.

La esterilizaci6n que produce antes de la extracci6n, igualmente favorece, por
cuanto la initaci6n microbiana igualmente disminuye. Y por tiltimo, la cauteriza-
ci6n pone al tejido en condicionee favorablee de no infectarse de^u^e de producirse
la herida, que complementado con los buches desinfectantes, hacen un ambiente
impropio para los microorganismos impidi^ndoles romper el equilibrio.

Y si atin asf se produjera una nueva inCeccidn, ella siempre serd sin importancia, y
el organismo estari en condiciones de contrarrestarla en una forma r&pida y segura.

De ahi, entonces, que la inyeccidn a la par de ser anest^ca, simplifica y forma
parte del tratamiento al mismo tiempo que proporciona una seguridad del resultado.

En una palabra, la adici6n de la tintura de yodo en la f6rmula, favorece la acci6n
del anest^co, actda como discrete hemostdtico, calma el dolor, poet-operatorio,
dificulta una nueva infecci6n, facilita la cicatrizacidn y es un tratamiento preventivo
que importa una seguridad para el tratamiento general.

Y con eeta nueva pr&ctica, la conciencia profesional estari en un grade tal de segu-
ridad de su tratamiento, que le obliga a convencerse de que una complicaci6n no sea
probable, por haber tratado de esterilizar el medio, atin en personas despreocupadas,
en los refractarios a los medicamentoe, en loe deeaseadoe, y en principal modo, en loe
enfermoe de las clfnicas pdblicas.

NOVOCAfNA OliCERO-TODADA.

Esta soluci6n, como su tltulo lo expresa, se halla compuesta de novocafna, tintura
de yodo y glicerina, y por consiguiente, como ya he indicado, es una soluci6n anes-
t^co-revuMvo-desinfectante y ligeramente c&ustica y hemost4tica.

Los componentee entre si no neutralizan las cualidades que aisladamente poseen
cada uno de ellos, y su combinaci6n forma un Ifquido trasparente de color amazillooro.

Quiz&B podrla suponerse que esta soluci6n fuera dolorosa por el alcohol de la tintura
de iodo y por la misma acci6n c&ustica del yodo, pero los cases observadoe me hacen
llegar a la conclusi6n que no sdio no es dolorosa sino que el poder de la novocafna no
ha disminuldo. Quiz&s su poder anest^co sea sensiblemente menor por hallarse en
di9oluci6n a las doe substancias, cuyo tftulo de la solucidn de la novocafna, es por
tanto menor del inicial, pero atin cuando pueda existir esta diminuci6n del poder
anest^co, su acci6n es completa y suficiente para el fin que se destina la novocafna-
gllcero-yodada.

Como se ve, los componentes son bien conoddos y estudiados, y tal vez parecerfa
de m^ una de6cripd6n de ellas recordando bus cualidades e indicadones, pero ran
embargo, he crefdo del case recordarlas de paso y someramente por ocupar en terapia
un lugar preferente. Novocafna ee un cloridrato de paramino-benzoil-etil-amino-
etanol, ha sido descubierta por Einhom en 1904, es uno de los anest^sicos m&a impor-
tantes que hoy se posee, y lo demueetra de una manera concluyente el gran campo

1 Sin embargo, on varios oasos, la inyeoddn la he heoho subperi<38tioa, gingiyal, con bueo resultado.

PUBLIC HEALTH AND MEDICINE. 239

que logr6 abrirae en cirugla, que en un lapeo de tiempo relativamente corto, las
experiendas clfnicas ban demoetrado bu bondad a tal grade de dejar en un orden
secundario no a61o a otros anest^eicos, sine basta a la miBma cocaina. Su poca toxi-
cidad, BU Mcil eeterilizaci6n Bin que bub cualidadeB Be alteren, su poder anest^Bico
comprobado, que para algunoB quiz^ Bea igual al de la cocafna, unidaB a bub eBcasas
contraindicacioneB, Bon condicionee por ei solaB elocuentee.

Por eBO Be ba viBto en breve tiempo Ber el aneetMco preferido, no b61o en dentiBtica
operatoria, Bino tambi^ en cirugla general, donde basta citar aparte de los resultados
tan balagQefioB en la raquinovocainizaci6n en los hospitales de Buenos Aires,' y los
importantes trabajos de Sonnenburg (de Berlin), del Prof. Reclus de la Facultad de
Paris, de Barker (de Londres), de Pringle (de Glasgow), de Eummell (de Hambuigo),
etc., y por dltimo la opinidn del Prof. Reynier emitida en la Facultad de Medidna de
Paris, en que expresa bub condiciones de esta manera: "La he comparado con otros
anest^sicos tales como la cocaina, la eetovaina, la nirvanina y la eucaina. Esta
comparaci6n ha side favorable para la novoca^ia, puee reune, en efecto, las cuali-
dades que, segdn Braun, debe poseer un buen anest6sico.'"

En dentistica, su ubo es general; su eficada y buenas cualidades la hacen indicada
en todos los cases.

Peraonalmente he tenido oportunidad de observar bub buenoe resultados en nuestra
facultad de medidna por nuestro maestro, Dr. Nicasio Etchepareborda en las inyec-
dones dipl6icas. La aneetesia se produce dentro de un promedio de 6 minutes m^
o menos' cuya durad6n es en algunos cases basta 20 minutos, oper&ndose completa-
mente sin dolor y sin observarse en los muchos caaos he presenciado en la clinica,
intervenidoB por mi maestro, ningdn case de sfncope ni fracaso.

Igualmente, en el curso de mi distinguido maestro Dr. Le6n Pereira, se utiliza en
las extracdones la novocaina como anest^co local, con excelentes resultados.

Respecto del yodo (tintura) su use es universal en medidna y toda ponderaddn que
se haga de este metaloide seria de mds.

Miquel ha demostrado de una manera concluyente su valor como desinfectante; es
revulsive, ciustico y antipdtrido. Su acci6n es en superfide y no en profundidad.

Como desinfectante en drugfa mayor y eepedalmente en cinigia, se ha comprobado •
SUB cualidades del todo inmejorables.

El tftulo de la soluddn de la tintura de yodo usada en la combinad6n, es la del
Codex Argentine o sea 1/12.

En cuanto a las inyecdones de yodo, el organismo las soporta muy bien, dentro
de la dosii de la solud6n que use. Segdn las experiendas de B^Him, un hombre de
70 kilogramos puede soportar sin acddentes la inyecd6n en la sangre de 1} a 2 gramos
de yodo libre. Si bien se ban registrado fracases en operadones que se ban querido
tratar con inyecdones de yodo, se debe tener presente que las cantidades inyectadas
eran muy grandes. Ya se observaron 36 cases de muerte a consecuencia de estas

1 Enrique P. Bagnatl. Contribuddn al estudio de la raquinovocainizaoiOn en cinigla. Dr. Leopoldo
Bard (1S07-8); Dr. Jo66 Aroe en 1909 (Congreso de Mcdicina de Rio Janeiro); Dr. Emilio Dlax Arano (tesis
1913) haoe una estadistica de las anestesias realizadas en el Hospital Italiano dcsde 1904 hasta 1913, en donde
se ve que hasta 1904 elcloroformo se usaba como anest^sicoen una proporcldn de 92.83 por cicnto del total de
las interrenciones, j la raqulnovocainixacidn en el primer semestre de 1913 Uevaba un percent^ 67.87 por
oiento, mientras que la raquinovooainizacidn en 1907 era sdlo de t^.06 por ciento. Por Ultimo el Dr. C. C.
Bagnatl (tesis 1913) en su estadistica deolara que en 4,200 operadones practicadas desde 1911 a 1913 en el
Hospital Italiano, en 2,400 se usd como anest^co la novocaina; y tennina mauilestando que "entre las
4,200 intervenoiones las hay desde la mis pequefia hasta la mis alta drugla. "

Eusebio Albina (revista C. E. Medidna y C. M. Argentine, agosto, 1914), en su trab^Jo titulado la noro-
calna en la cirugla del cuello, mendona entre otros cases, uno operado por el Dr. I'ahr a en el Hospital San
Roque, y se trataba de un sujeto que tenia im tumor de los ganglios de la cadena carotldea dereoha. Di^a
persona, de 63 afios de edad, era un "arterio-esderoso, con insufidenda a<$rtica mal compensada, puet
aoababa de aalir de un ataque asistdlioo." La anestesia tvA hecha looatanente con novocaina, con ez-
oelento resultado.

I E. P. Baganti. Contrlbuddn al estudio de la raquinovocainlsaddn en drugla.

■ Caaos en que me fu6 indicada la observaddn por mi prolesor (1912).

240 PEOCEEDINGS SECOND PAN AMEBICAN SCEBNTiriC CONGRESS.

inyecciones, dice Nothnagel y Bossbach, y en el mayor ndmero de eotoe acddentes
deben ser atribuf doe a las inyecciones hechas de una manera imprudente. ^ Y refiri^n-
dpse al case de Rose, adn no bien aclarado, continda diciendo, que es bien dilfcil
atribuir el fracaso dnicamente a la acci6n del yodo si se admite con Boinet que 200
gramoe de yodo pueden ser inyectados sin peligro en los quistes del ovario, es decir,
en el organismo.

De manera que la cantidad de yodo que se usa en la solucidn anestMca que presento
no puede producir ningtin accidente consecutivo local o general.

Olicerina, — He agregado esta substancia a la fdrmula, como un suavisantea fin de
evitar un pequefio ardor que he observado despu^ de la desaparicidn de la accidn
anest^ca de la novocafna y que considero es debida & la acddn ciustica de la tintuia
de iodo. La adicl6n de la gHcerina para este fin es excelente, corrigiendo ese defecto
y aportando adem^ a la f6rmula sus cualidades andpdtridas y ligeramente desinf ec-
tantes.

Como se sabe, la gUcerina como cuerpo neutro que es, no modifica en absoluto la
acci6n de los otros dos componentee, que, por el contrario, tieiide a favorecer su re-
sultado.

Sttio de la inyeccidn.— Ella debe ser con preferencia dipl6ica, pero sin embargo,
la be hecho subperi^stica y gingival, con buenos resultados.

La inyecci6n debe ser lenta, lo que da lugar a que puede actuar progresivamente
con escaso dolor, pues si se hace con rapidez podrfa resultar dolorosa.

Antes de la trepanacidn de la tabla 6sea, si fuera dipldica, para la de8infecci6n de
la mucosa y anestesia, como tambi^n si fuera subperidstica o gingival, he usado la solu-
ci6n clorof6rmica de yodo como lo aconseja Chassevant, por ser inalterable.'

Se seca bien la encfa y luego se embroca el punto a trepanar.

Este procedimiento f u6 aconsejado igualmente por el Dr. Texo, quien manifeetaba
que con 61 se evitarf a arrastrar elementos s^pticos con la aguja. Con este agente, dice,
cuimtos procesoe infiamatorios y dolores post-operatorios se evitarlan, atribuldos a
otras inocentes causas.'' '

Fdrmula, — ^La f6rmula de la non>ooaina'glicero-iodaday es la siguiente:

Sol. Novocaina al 2 ^ 0 gr. 60.

GUcerina neutra pura Ogr. 50.

Tintura de yodo A de gota.

(Para una ampoUa.)

En esta proporcidn resulta una soluci6n completamente If mpida de color amarillo-oro.
Si se aumentara la cantidad del yodo, aunque en pequefia cantidad, la solucidn se
enturbia y se precipita. La f6rmula citada es estable y no se altera.

CONCLU8I6n.

Comohedicho, lainyecci6ndebeserinsitu, y por esoespreferible que sea intra, o sea
jMuu que actde alll donde la af ecci6n est6 localizada o procurando que abarque gran
parte de ese medio (gingival o Bubperi<5stica).

El yodo es revulsive; de manera que la congestidn sanguinea va deeaparedendo por
su acci6n, lo que trae por consecuencia una dimlnucidn de dolor, por cuanto la disten-
si6n de las extremidades nerviosas por los vasos dilatados, es menor; conjuntamente
a su acci6n revulsiva, es desinfectante poderoso y cdustico, de manera que comienza
a esterilizar el medio cauterizdndolo levemente, teniendo presente la cantidad em-
pleada en la 8oluci6n.

1 Nothnagel y Rossbaoh: Mati^ m4dicale et th^rapeotlque, p. 262.

• Monde mMical, No. 300, p. 957

* La odontologfa. No. 4, p. 280.

PUBLIC HEALTH AND MEDICINE. 241

De modo que por de pronto ataca las causae de la inflamaci6n. mientras se eepera la
actuacidn del anest^co, cuya acci6n favorece grandemente, pues precisamente a(m
ellas las causae que por lo regular le impiden actuar como debiera.

Esta acci6n revulsiva, o en una palabra, vaso-constrictora, es durable. Ouando la
anestesia se produce y se procede a la extraccidn del 6rgano dentario, la hemorragia
ee poca generalmente.

La isquemia se mandene despu^ por largo rate.

A primera vista podrlase suponer que esta propiedad sea debida dnicamente al
anest^co, pero te6ricamente se comprende y prdcticamente lo he comprobado, que
gran parte de esta acci6n es debida al yodo, que si bien al principio su ef ecto es ocultado
por el anest^co, la falta de ese dolor post-operatorio caracteristico, cuando la anestesia
ha desaparecido y la hemorragia inwignificante casi siempre, prueban de una manera
evidente su importante acci6n complementadora al anest^co y al tratamiento conse-
cutivo de la periostitis.

La glicerina favorece la acci6n conjunta de una manera apredable asegurando el
resultado de la formula.

Si se observa el alveole y encfa de un diente, unas boras despu^ de extraldo, vemos
que se hallan en un estado que indica hallarse en camino de cicatrizaci6n. Esta
obeervacidn la he hecho en todos los cases intervenidos, en algunos de ellos con colec-
ci6n purulenta, y en la mayorfa personas especificas, cardio-renales, enfermos del
hfgado, etc.

£1 complementar el tratamiento poniendo tintura de yodo en el alveolo despu^s de
la extracci6n y la prescripci6n de buches antis^pticos y analg^sicos, son precauciones
indispensables para coadyuvar al tratamiento. Sin embargo, en muchos cases he
prescindido de esto, en personas desaseadas (como lo son gran parte de las que he
tratado teniendo presente su condici6n social y el ambiente en que se hallan), unoa
por experiencia y otros porque estaba convencido de que no seguirfan las indicaciones,
la cicatrizaci6n fu^ completa y sin inconvenientes, tinicamente mds lenta y el dolor
deBapareci6 menos r&pidamente que con los buches arriba citados.

Por consiguiente, la soluci6n cuya f6rmula me permito presentar, llena el fin que
me he propuesto, de tener seguridad y abreviar el tratamiento poniendo al paciente
dentro de lo posible, al abrigo de complicaciones que a causa de la eztracci6n puedan
ocunir, muchas veces debida a ignorancia, males consejos, pobreza, falta de comodi-
dad o una infecci6n a que se halla expuesta toda herida abierta con el agravante que
ya tuvo una por la perioetitiB y que es probable otra, no s61o por ser un punto debili-
tado no por falta de higiene, sine por el medio ambiente en que se encuentra localizada.

La e6terilizaci6n se hace en forma completa gradas a la diBpoeici6n anat6mica del
dfploe, y si bien el Ifquido inyectado podri ir mds all4 del sitio deseado, no importa
una dificultad y resulta m^ bien una precauci6n que felizmente noe focilita su consti-
tuci6n aerolar. Pero aparte de esto, la inyecci6n nunca podri abarcar una regidn
muy extensa dada la cantidad inyectada (1 gramo), pero sufidente para toda pre-
vi8i6n.

En cuanto a la cantidad de tintura de yodo utilizada en la aDluci6n anestMca que
aconsejo, es muy sufidente para eeterilizar ese medio en una forma completa y si
tenemos presente que Miquel con s61o 0 gr. 25 e0terili26 un litro de caldo de cultivOy
no hay duda alguna que una cantidad propordonal, esterilizaii bien y completamente
un centimetre cdbico, si asf se me permite calcular el espado del medio a esterilizar
en una periostitis alveolo dentaria.

Con eeto termino este breve trabajo, y contintio extendiendo mis obs^vadonea
en otros cases de medicina general, los que, si bien inidados, la blta de tiempo me
impide incluir en el presente.

Y con esta pr&ctica, no dudo se podri sostener una ves mis el tan ladonal afcmsmo
que dice: Vcii md$ prevmir que cimv irrflmMthda.

242 PROCEEDINGS SECOND PAN AMBBIOAN SCIENTIPIO CONGBESS.

POUCU DS BUMMOS AlBKS, CAPITAL FBDKBAL— DlViai6N SAXIDAD.

E 1 que soaoribe Jefe de la DiyisUSn Sanldad del Departaxnento de Policfa de la Capital, autoriia al Dentista
Doa Juan D. Sosiai para que haga las aplioadones de la sohiddn ** Novoeoina-gUeero-podadti" en el Conmlto-
rlo Odoatoldgloo de este DepartatneDto, a fin de que el personal de esta ofloina oompruebe la eficada del
medioamento, que ha sido, por otra parte, debldamente anallsado en la Seooldn Qulmlca de esta Division.

BuxNOS Amis, Oetubre de 1914,

(Finnado) F. C. Babbasa.

OBaSBYAadM Tebckra.

Feoha: Ootubre 0 de 1914.

Nombre: M. R.

Edad:26afi08.

Ocupaddn: Agente de poUda.

Aparlencla general: Hombre bien formado; buen desarrollo esqueldtico y muscular.

Anteoedentes hereditarios j personales: Sin importanda.

Estado de la boca: En buenas eondidones.

Diagndstioo: Periostitis alveolo-dentaria produdda por raSoes de la segnnda molar inferior irquierda.

Tratamiento: Extraoddn previa anestesia oon novocalna-gUbero-yodada.

Inyeoddn: Gingival.

Cantidad de anestteloo empleado: 2 oenttmetros cdbioos.

Tiempo en que se produjo la anesteda: Un poco mAs de un mlnuto.

Duraddn de la anestesia: Dos mJmitos y medio.

Resultado: Satisfiaotorio. Aousd poco dolor a pesar de ser una extraoddn laboriosa. No hubo mareos nl
malestar. Se retira bien del consultorio.

Revisado: A los tres dias. Durante ese plazo tuvo un poco de dolor, pero un dolor muy soportable.
En la fedia de la revisaddn, casi ha desapareddo. Herida en vlas de dcatrixaddn oompleta.

Comprobado:

(Finnado) Juuo Tkllo,

Dentitta id Departamento,

LOS DISPENSARIOS PARA LACTANTES (GOTAS DE LEOHE) COMO MEDIO
PARA DISMmum LA MORTALEDAD INFANTIL.

Por JULIO A. BAUZA.
Director del ConsuUorio Oota de Leche No, 1, de Montevideo Uruguay.

El criterio cad andniine de los que estudiaD los medios piicUcos para diBminuir
la mortalidad infantil, conaidera a loe Dispensarioe para Lactantee (Gotaade Leche) como
un baluarte que lamodemadvilizacidn oponealcrecimientode lamortalidad infantilde
los dos primeros alios, cuya tendencia a progresar en algunos pafses y ciudades ha dado la
voz de alarma, por cuanto, por su contribuci6n a la mortalidad general ha resultado la
existencia de ciudades con crecimiento n^gativo casi nulo (Paris) o negative (Santiago,
Valparaiso).

£1 movimiento empiendido en todos los paises de civilizaci^n superior en defensa
del nifio ha dado resultados indiscutibles en los tiltimos 10 afios, habidndose produddo
caai universalmente un descenso en la mortalidad en el primer afio, que llega en
algunos paises hasta caai un 50 por ciento.

£1 Uruguay no podia quedar resagado en este sentldo y gracias al apoyo prestado
por el superior Oobiemo, pudo la Asistencia Pdblica, abrir el primer Consultorio Gota
de Leche a principios del afio.1908 en la dudad de Montevideo. Hasta fin del a£k> 1913,
se habfan asistido en este Consultorio 7,000 nifios diferentes, habi^dose distribuido
600,000 litres de leche y gastado 77,000 oro (ddlares). Desde 1914, siete Consultoiios
dirigido cada uno de eUos por un m6dico especialista se hallan repartidos en dlstintaw
zonas de la ciudad, correspondiendo a un consultorio por cada 50,000 habitantes.
Aun cuando la mortalidad infantil en el Uruguay no es muy elevada en Montevideo,
11.5 por ciento naddos vivos, no debe olvidarse que teniendo en cuenta que la alimen-
taci6n natural es la mds dilundida, representa esa cifra un coeficiente bastante elevado
y que podr4 ser reduddo a 7 u 8 por ciento en un porvenir no lejano.

PUBLIC HEALTH AKD MBDIOINB. 248

Es indudable que los DupenBarios para Lactantee, cuando eslin Men diiigidos, y
cuando se emplean todos los medioe de propaganda poaiblee, conlerendas, concuraoa
con premioe en dinero etc., contribuyen poderosamente a difundir la conveniencia
de la lactancia natural y a prevenir loe peligroe de la alimentacion artificial.

La mejor demostracidn de c6mo con pocos recursoe pueden con8Qg:uirBe buenoe resulta-
doe, U tenemos en el hecho de que si se compara el ndmero de nifioe ingresados
alimentados a pecho en 1908 y en 1914 en la Gota de Leche No. 1 a mi cargo, ee
observa que se ha triplicado la proporcidn de los nifios nutridos ezclusivamente por
seno matemo en el afio 1914, en reladdn a 1908. Este resultado lo atribuyo al esti-
mulo que representan los concursos mensuales para nifios a pecho, los que inducen
a las madres pobres a inscribir a sus pequefios en el Gonsultorio desde los primeros
meses, consigui^ndose asf dirigir y prolongar en lo posible la lactancia natural,
suBtituyendo el m^co a la madre en la direcci6n de la criansa del nifio.

£s indispensable para conseguir un buen resultado, que al Dispensario para lac-
tantes posea tambi^n la secci6n Crota de Leche, es dedr que est^ en condidones de
sumimstrar diariamente leche esterilizada o leches espedales, para comfdetar la
alimentacidn a pecho o para sustituirla en los cases en que esta no sea posible.

£s naturalmente ventajoso que sea siempre el mismo mMico, el que atienda a las
madres y haga las prescripciones para cada case; de esta manera se gana mis f&dl-
mente la confianza de las madres, que ven en el m^co que atiende siemi»e a su
hijo, a la persona mis indicada para dirigir su crecimiento o para meJOTarlo en case
de enlermedad.

^Son pdddinicas las Crotas de Leche? Es indudable que originindose buen niimero
de enlermedades, por defectos de alimentaci6n en cantidad o en calidad, y siendo
igualmente dertos trastomos digestivos del nifio secundarios a otra enlermedad para
intestinal, nadie estd m^ indicado que el mMico del Dispensario para indicar el-
gdnero de alimentaci6n m^ conveniente en cada case; por consiguiente los Dispen-
sarios para lactantes, deben ser consideiBdos como verdaderas pdidfnicas.

ConsideriUidolo asf , se comprenderi f ddlmente que la promiscuidad de nifios sanos
y enfermos en un mismo local no est4 libre de inconvenientes. La traamislAn de
enlermedades cantagiosas, mientras madres y nifios est&n en la sala de eepera no sdlo
es posible, sine que es muy probable. ^Gdmo podrfa salvane este inamTenienteT
Lo mia ^pticHco a nuestro mode de ver, es sefialar dias ditoentes en la semana para
nifios sanos y para enfermos. Esteprocedimiento, quehacepocosehapuestoenpiic-
tica en el consultorio a mi cargo, si bien adolece de algdn inccmveniente, habitda
a las madres a la diadplina, y ofrece ventajas indiscutibles en locales cuy
instalaci6n no es completamente adecuada. Por lo juronto se eliminan de los dias
destinados a nifios sanos los enfermos con tos convulsa, sarampi6n, varicela, aaf
como la mayor parte de los enfermos agudos. Las madres que deeen oonsultar para
enfennos en los dias de los sanos, son objeto de un interrogatorio minudoso y son
aisladas en case de sospecharse una enfermedad contagiosa.

En los dias destinados a nifios enfermos, las madres son interrogadas sobre el objeto
de la visita y aisladas en una piesa especial, si bus nifios tienen alguna enfermedad
tnamirible.

Como consecuenda de las consideradones presentee, se comprenderi que es necesa-
ria una instalad6n as^ptica y f&dlmente desinfectable, como una polidinica de un
hospital de nifios. Una enfermera competente deber& intenogar a las madres a la
entrada, antes de pasar a la sala de pesadas y a la de esp^ra; en los cases en que el-
nifio presente sintomas de una enfermedad trasmisible resolveri su aialamiento y
en case de duda requeriri la opinidn del medico. La sala de aiwlamiento deber4
estar dividida en varies ''box," separados por tabiques vidrieras.

Consideramos innecesario insistir sobre la necesidad de que estos establedmientos
estto dotados de cale&cci6n en todas bus secdones, para evitar el efecto pemidoso
del frio, espedalmente en la pesada y en la consulta.
68486— 17— VOL ix 17

244 P&OOSEDINGS SECOND PAN AMBBIGAN SOIEHTIFIO 00NQBBS8.

No meiDos .titil serfa igualmente la instalacidn de una Becci6n de bafioB para nifioe
7 madies, <dado que muchas madres no cumplen con eeta regla higi^nica por no dis.
poner de lina instaladdn adecuada. Aun cuando no ee tan frecuente su ihobservancia
en lo8 nifio8, aerfa yentajoeo una instalaci6n para elloe.

Tambi^n aerfa de mima neceeidad la in8talaci6n de una pequefia fuente, que Buminis-
tre agua pant beber a las madree que lo deeeen, lo que pasa muy frecuentemente en
lo8 dfas caluroeo6 del verano. El agua debe poder beberse al suigir del 8urtid<Mr en
foima de napa directamente sin requerir ledpiente'de ninguna daee.

OOOINA DB LBCHB8.

W La codna paia la elab<»raci6n y e0tmlizaci6n de la leche ee la Becci6n mis impor.
tante del Consultorio; ella reemplaea al seno matemo y ee 8upei€uo dedr que cons-
tituye el cofasdn del dispensario, ya que es la encais^da de nutrir a centenares de
nifioe. En Hontevideo la codna central de leches se halla instalada en el Ckmsultorio
N^ 1, y en ella se i»epaian las leches paia los siete ccmsultorioe. Su instalad^n
oomprende varias secdones.

1^. ManipuladAn de la leche cruda.

El local que le esti destinado pos^ apaiatos para filtrad6n de la leche, enfriamiento
a 4 o 6 gcs^os mediante una m^uina enfriadora en la que se utilisa una mesda
frigofffica de hielo y sal y una llenadora autom&tica que puede llenar simult&neamente
doce botellas hasta de un litro. El derre ee por medio de discos de cart6n parafinado.
Esta seccidn fundona solo en yerano, pues no se considera necesario usarla todo el afio.

2^. Preparacidn de leches espeddles.

En eeta secddn se hace la preparad6n de la leche esterillzada, Baube];re, Sopa de
Malta, Leche Descremada, Pegninizada etc., que se emplean en la allmentaci6n de los
nifios chicos o enfermos. Oomprende: 1^, una cocina a vapor, con dos recipientes de
10 y 20 litres de capaddad respectlvamente y que sirve para preparar sopa de malta;
2®, un aparato mezclador, paia preparar las distintas dlludones y en comunicackSn
con un llenador automitico de frascos; 3^, un autoclave, en el cual se colocan los
irascos despu^B de llenos para ser esterilizados a 104 o 106^ por 16 minutes; 4^, de una
batea en la que los irascos son enfnadoe despu^ de una esterilisaci^, por agua, puL
verizada por medio de un aparato especial; 5^, de una desnatadora, utilizada para
obtener la leche descremada, que ha de usarse sola o que ha de empleane para la
obtencldn del Babeuire, dej&ndola agiiar y agreg^dole 12 gramos de harina y 40 de
asticar por litro.

3^. Limpiexa defrascoB y houlku,

Los frascos son lavados con agua caliente y soda, y despu^ sometidos a la acci^ de
cepiUos intemos y eztemos; finaJiaindose con enjuagados pcnr un chono de agua fria.
La mAquinalavadaraesmovida por unpequefio electromotor. La persona que trabaf a
en esta secddn no interviene para nada, en la preparaddn de las leches.

4^. Oenerador de vapor.

Con dicho generador se suministra vapor de agua para el autoclave y cocina, aai-
mlsmo agua caliente pan la limpiesa de frascos y Utiles.

Finalmente, se dispone tambito de un pequefio laboratorio en el cual se hace el
andlisis diario de la leche redbida para reconocer su pureza. Sirve tambito paia e!
examen qulmico, hematokSgico y bacteriol^co de los casos de la policUnica.

LA LBOHB.

Para que todo el engranaje fundone arauSnicamente, es necesario que todo el
personal cumpla su obligacidn con la mayor escrupulosidad, cosa que se ha con^
seguido deepu^ de varies afios de iM:^tica. Ahora bien, para que el resultado se ponga
de manifieeto, en lo ref erente a la salud de los nifioe que toman el alimento preparado

PUBLIC HEALTH AND MEDIOINB. 24£P

en la cocina de leches, es indupenBable que la materia prima, es decir, al leche, sea de-
calidad Irreprochable. Este es el gran problema, de diifcil solaci6n, que adn no ha
side resuelto en el OonsuHorio Gota de Leche N^ 1, a mi caigo.

£a imposible, que una leche que contiene millones de g^rmenes por cent cub., na
sea peijudicial psia los nifios d^biles o convalecientes, aun cuando sea hervida o esteri-
lisada antes de ser utiliaada.

£s indudable que si no excluoivamente, por lo menos en gran parte es esta la causa
de la ezcesiva mortalidad Inlantil en los mesee de verano. La leche se recibe en la
Qota de Leche N® 1, despu^s de 12 o 14 horas de ordefiada; los tarros de leche que
lUgan a la dudad, deben permanecer varias hons caldeados por el sol de verano
hasta la Uegada del tren que los ha de conducir aMontevideo. A pesur de la i»opa-
ganda que se ha hecho, no se ha conseguido atin emplear vagones Irigorfficos. No debe
extrafiarse por tanto que ciertos dias llegue la leche tan alterada que no pueda sec
ntUisada psia la alimentacidn de los nifios.

Como se comprender6, este hecho, aun cuando no se produce frecuentemente;.
trastoma prctfundamente el fnrestigio de la Institud^ y desorienta a las madres que nor
siben qu6 alimentaciAn deben emplear .

Opino qi|e en estos casos, serfa preferible, durante los meses de verano, suprimir el
reparto de leche a los Dispcoisariosyentregar a las madres gratis, o a precios reducidos,
bomos por la cantidad de leche necesaiia para adquirirla en las vaquerfas o lecherfas
higiAnirai debidamente controladas.

CUNA TBMPORARIA.

Desde que Marbeau fund6 en Paris el afio 1844 la primera Casa Ouna hasta la 6poca
actual, su ntlmero ha ido aumentando r&pidamente, hasta el punto de contarse por
centenares en Francia, Alemania, Italia, Estados Unidos, B^lgica, etc. Su existencia
esU Justificada por la necesidad imperiosa de trabajar, de las madres que no poseen
recursos suficientes, sea por enfermedades o fallecimiento del marido, por abandono o
por insufidencia de salario, etc. En una palabra, su necesidad estd justificada por la
miseria. No siempre la madre puede obtener trabajo, de realizar en su habitaci6n al
lado de su hijo. Muchas voces tendri que procurkrselo fuera de ella, en f&bricas o
talleres, o como criada. En estos casos, ^qu6 se hace del nifio?; o Men la madre la
deposita en el Asilo de Nifios, y las mis de las voces lo olvida, o bien si no tiene alguna
persona de la famiUa que pueda cuidar de 61, lo entregard a una mujer a quien deber6
abonar la casi totalidad de su jomal para que lo cuide y alimente: el resultado ea
depUnrable en la Inmensa mayoria de los casos.

Ahora bien, si la madre se^ que su hijo puede ser alimentado y cuidado bajo el
control mMico en el Consultorio Gota de Leche, su elecd^n no ser& dudosa: lo pre*
teiii por las ventajas de todo orden que le ofrece. Si el nifio esti a pecho, 6ste no le
aeri supiimido. El medico se edonui para que la madre siga amamantando a so
hijo, y eventualmente se podr& consQguir vaya a medio dfa a darle el seno, ofredte-
doaele a ser posible, como en ciertas Gunas de Norte AmMca la comida de medio dia.
Duante la permanencia del nifio en la Cuna b61o necesitard dos biberones de leche y
una comida ligera, si se trata de nifios m^ crecidos.

No ban faltado tampoco en este caso, criterios que se oponen a la instalaci6n de las
Cimafl. Se ha dicho en i»imer t^rmino que favorecen al desarrollo de enfermedades
oontagiosas. ^Ssto puede ser cierto, para los casos en los que la admiai6n se hace sin
contrcd: no es el caso cuando el medico examina diariamente a los nifios a su entrada,
Impidiendo el ingreso de los contagiosos. Una enf^mera competente puede, sin
inconveniente, reemplasar al m^co a la hora de ingreso. Adem^ entendemoe que
la Cuna debe disponer de una secd^n de bafios, en la cual todo nifio al ingreear es*
bafiado y sos ropas son reemplasadas por las que ha de llevar mientras est^ en ella;
I>%asenos ahofa si no esti en mayor peligro de adquirir alguna enf^medad contagiosa
en la prosmicuidad del inquilinato, que en un local que posea las condidones mencio-

246 PBOCEEDINGS SECOND PAN AMERICAN SCIENTiriC C0N0BB8S.

nadas. Se ha dicho tambi^n que la separacidii aunque sea temporaria durante laa
horas del dla, de la madre para con su hijo, afloja IO0 vlnculos matemales. No es este
nuestro modo de pensar. La madre veri todoe los dias a su hijo al retirarlo y apre-
ciar& sus progresos, su crecimiento y su intellgencia; a medida que el tiempo trascuira
aumentar&n los lazos de cariflo que la vinculan a su hijo: su abandono en el aailo es
poco menos que imposible.

Otra ventaja ezistirfa en la anezidn de una "Cuna'' a la Gota de Leche. Los dfas
de fiesta en los que la madre puede conservar a su pequefio todd el dia a su lado, red-
birfa la leche preparada a la que el niiio est4 habituado: se evitaria asf que el nifio
saiga de la Cuna sano, un s6bado, e ingreee enfermo el lunes sigui^ite, hedio com-
probado en muchas Cunas y que esteriliza a voces la labor de toda la semana.

Otra objeci6n que se hace frecuentemente, es su costo relativamente elevado.
Hasta se ha pretendido que serfa mis conveniente abonar un jomal a la madre, y
^vitar asf el ingreso del nifio. Si bien esta objeci6n puede tener cierto valor, y aon
cuando es cierto que las Cunas pueden resultar costosas en Europa, 1 fr. 50 a 2 fnincos
per nifio y por dia, debe tenerse en cuenta, que por ellas la madre aprende a querer y
A cuidar bien a su hijo, atendiendo los consejos de la enfermera.

CUB8O8 DB pirBRiox7i;rnRA..

Son de importancia cada vez mayor para la instrucci6n popular que las madres
adquieren dia por dla, los cursos de pueiicultura instalados con tanto ^to en Estadoe
XJnidos, Franda, Alemania y otros pafses.

Laignorancia y los prejuicios de las madres son las causas de gran n6mero de
^nfermedades del nifio. Este es un hecho que no necesita demostraci6n. No cabe
ningnna duda de que como consecuencia de ello, la mortalidad in&tntil es mfm
elevada de lo que serfa, si la instrucci6n de la masa popular fuese mis avanzada de
lo que es en realidad. La casi totalidad de las madres de la clase social inferior,
atribuyen la mayor parte de las enfennedades del nifio a la saHda de los dientes. La
bronquitis, lo mismo que la gastro-enteritis, son alribuidos a que el nifio esti echando
los dientes y antes de que el medico las interrogue, se apresuran a decir que vienen a
consultar porque el nifio esti enfermo a consecuencia de la denticidn; y como conse-
cuencia de ello, la madre no consulta sine cuando ve que su nifio esti coifenno graye-
mente. En muchos cases, la intervenddn m^dica se electda tardfamente con re-
sultados desfavorables a veces^ o conslgui^ndose la mejorfa despu^ de mudio tiempo
y fatiga de parte de la madre, qui^i se la hubiese ahonado si hubiera practicado
la mixima, de que es mejor y mis ec6nomico prevenir que curar.

En el Uruguay, la alimentaci6n artifidal esti poco extendida. Su poblacidn de
origen espafid e italiano en su gran mayoifa, tiene los hibitos de sus antepasados.
La lactanda natural es la regla, o por lo menos la lactaada mixta. La lactaada
artifidal en los primeros meses es relativamente rara; a pesar de Mo, la mortalidad
infantil en el primer afio es alrededor de 11 por 100 nadmientos, dfra relativamente
elevada si conaideramos, como hemes dicho, que la alimentad6n natural o mixta
<!onstituye la regla. Las gastro-enteritis son sumamente frecuentes en d verano,
hasta d punto de constituir mis de un tercio de la mortalidad total dd primer afio.
Las causas deben buscarse en la falta de reglamentaddn de las tetadas, que general*
mente son muy frecuentes, y en d hibito de dar al pequefio toda dase dealimentos
s61idos e indigestos, hibito general en la mujer dd pueblo. De aquf que las gastro-
enteritis que son relativamente raias en la dase acomodada, sean muy frecuentes en
la clase pobre, asf como tambi^n otras enfennedades debidas a la ignoranda y a los
males cuidados, como por ejemplo: las bronco-neumonfas, la tos convulsa y las infec-
dones umbilicales. Estos hechos demuestran hasta la evidenda la necesidad de que
un Consultorio Gota de Leche tenga otganisados cursos de puericultura para las ma*
dres del presente y dd futuro, en los cuales se les instruya de todo lo rd^ente a la
higiene, cuidados y alimentaci6n dd nifio. Estos cursos cuya duraci6n mfnima debe

PUBLIO HEALTH AND MBDIOINE. 247

Mr de 0010 1116060, do0 V6C60 por 0einana, 0er(an tedrico prictico0, utiluindo0d el mate-
rial del Coii0iiltorio y de la Giina.

8a irecaentaddn con aoidnidad y on examen final darfa lugar a la obtenddn de on
c6rtificado de aptitud60, que podrla 0ervir, a la que lo obtuvi60e, para alcansar una
buena plaza como nifiefa o cuidadora. La alimentaddn natural, la higiene del nifia
y de 0U habitaci6n, la preparaci6n de alimentoe 60pecial60, 9ti como IO0 primeroe cui-
dadoe para el nifio enfenno, coimtituirfan otro0 tanto0 capf tulo0 oobre IO0 cual60 0e
in0i0tirfa 60p6cialmente.

De todo lo que acabamoo de decir, 00 deduce 0in mayor eofuerso, que ya no 60tamo0
en IO0 ti6mpo0 en IO0 que un pediatra d]0tinguido afirmaba que para implantar en
una ciudad "La Qota de Leche," 0^0 00 nece0itaba un mMko abnegado y un aparato
Sozhlet. L06 di0pen0uio0 para lactant60 modemo0 necentan, oi 00 deeea obtener el
TOJTimum de reeultado, una iiuitalacidn eopecial que haga poflible la realuaci6n de
todao la0 ideaa expu60ta0 en eete trnbajo. Montevideo que cuenta con la A0i0teiicia
Pdblica Nacional 061idamente Qiganisada, no debe demorar mSm la inataladdn de una
inatitucidn en la forma que dejo relatada.

a ESRO ESSENCIAL DE PESSOA NA LEI BRAZILEIRA DO CASAMENTO

CIVIL.

For RODRIGUES D0RL4,

Fn]^ie$9or de Meiieina FukHca da Faeuldade de Direiio e eaikedratikOy em diipambU, da

FdetUdade de Medidna da Bakia.

O casamento civil 6 uma in8titui9ao relativamente nova no Brazil: veio com a
Republica, e foi promulgada com o Decreto 181 de 24 de Janeiro de 1890, pelo Governs
Provi0O]io, alterando profundamente 00 co6tume0 e 00 habitoo, e contrariando at
cren^aa de um pdvo, na sua grande maioria catholico e superBticioso, que 06 admitte o-
caoamento perfeito como sacramento, e garantida a unifto firme e perpetua doa conjugee
pela ben9ao oacerdotal. Nfto foram poucos 00 de0a8tre0 havidoo no0 primeiroo annoo da
ezecu9fto da lei, entre pe00d«0 de pouca instruc9ao que fugiam is garantiaa legaea do>
canmento, contrahindo a unifto conjugal aomente diante do altar. Illegitimidade doe
filho0 perante o Estado, perdaa de heranyaa, foram as consequencias doa actoa impon-
deradoa do0 que aasim procederam, e t^m procedido, at^ que um gr6o mais adiantado-
de in0truc9So e civilisa^So fa^a perder as abusOes, e 00 oacerdotea de todas as religiCeo,
syotematicamente, nfto celebrem o casamento reUgiooo 0em que lhe0 0eja apresentado>
documento probatorio da precedencia do casamento civil. ' '0 govenio maisdespotico e
meticuloso, a legiala^fto mais obedecida e rigorosa," diz Tarde, ''60 1100, comprehendldo*
por I0OO 60000 mil e um habitoo recebido0, quer tradicionaeo, quer novo0, que regulam
a conducta privada, nfto de cima e abstractamente como a lei, mas de muito perto »
no inen<Hr detalhe, e que comprehendem todaa as neceasidadea artificiaes, traducgfto
livre daa nec608idad60 naturaeo, todoo 00 gostoo e 00 deflgo0to0, todas as particularidadee
de costumeo e de maneiras proprias a um paiz e a um tempo." E muito mais impe-
liooa 6 easa legislagfto do uso so ella so misturam sentimentoo religio0O0.

Cautelooo o govemo revolucionario, receiando certamente nfto abalar em maior
extenafto 00 habitoo e oe co0tume0 de p6vo, podendo chegar a conaequencias grave^
mente compromettedoraa da aasocia^fto conjugal, nfto creou o dlvorcio, como uma
conaequencia natural, logica e juridica do contracto a que ficou excluaivamente
redusido o caaamento, em que peze ao receio de juriatas actuae0, que, no dizer do feete-
jado juri0conaulto bnudleiro. Dr. Clovi0 Bevilaqua, nfto podendo manter hoje, no-
direito definitivamente 0eculariaado, ease exotiamo do aacramento, dlzem que 6 acto,
comie ae contracto nfto fdaoe igualmente um acto juridico. Contracto 6q>ecial, continda
o aotor do * D ireito da familia, " por ae constituir mediante um accordo de intereasea, uma

^48 PB00EEDIKG8 SEOOND PAN AMEBIOAK 80IEKTIFIC O0NQBES8.

coincidenda de vontade, ou oomo dizia lord Robertson, a mab importante de todas
as transacgOes humanaB, base da constituigfto da sociedade civilaada, ou como
dia Mathew Woods, o mals sagrado dos la^os, a mais profunda das responsabilidades,
incluindo a mais inflexivel das obnga^Oes (Divorce).

Nada impede que esse contracto seja sanctificado pela ceremonia religiosa, que
^atiaCae e tianquilisa a consciencia dos crentes.

0 casamento pode, porto, ser annuUado, e entre as causas de nullidade figura o
■erro esseneial de peuda,

A lei do casamento civil assim dispOe:

Abt. 71. Tambem ser& annullavel o casamento quando um dos conjuges houyer
consentido nolle por erro essencial em que estivesse a respeito da pessda do outio.

Abt. 72. Oonaiderapse eno essencial sobre a pessda do outro conjuge:

{ 1^. A ignorancia do seu estado.

|2^ A Ignorancia de crime inafian^avelenfioprescriptOyCommettido por elle antes
•do casamento.

1 3^. A ignorancia de defeito physico irremediavel e anteric»r, como a impotencia
e qualquer moleetia incuravel ou transmissivel, por contagio ou heran^a.

A annulla^ do casamento por erro essencial sobre a pessda s6 poder& ser pedida
pelo conjuge, victima do engano ou d61o, dentio de dois annos da data do casamento.

O que se deve entender, ou, antes, entende a lei por ettado do conjuge, cujaigno-
Tancia possa dar logar d grave consequenda da nullidade do casamento?

A pressa com que foram mganisadas as leis do govemo piovisorio da Bepublica den
iugar, a]gumas vezes, ao emprego de phrases ou termoe ambiguos, como o i^Mmtado,
o que nfto deve existir num systema de legisla^ bem oiganisado, sem as neoe»>
earias restricgGes ou a predsfto do sentido em que devem ser ent^idos os voca>
bulos. E$tado quer dizer, lezicologicamente, situa^fto ou mode de ser de uma pessda
ou coisa, e nesse case pode a palavra ser entendida de maneiras differentes. "A
applicavel, por exemplo, d situa^So economica de uma pessda, dla o Dr. Glovis Bevi-
laqua, e 6 repugnante a todos os principles que se proponha a annulla^ de um
•casamento sob tal fundamento; e, lembrando essa fei9So do termo, accresenta o notavel
jurisconsulto que apenas salienta "a inconsistencia do vocabulo," que elle ainda
•denomina "vago e elastico, vacillante e equivoco."

Pode 0 termo ser comprehendldo como exprimindo a situa^fto do individuo em
rela^ d sociedade, d familia e ds leis, e tambem d religjAo. O jnojecto de Godigo
■Civil, organisado pelo Dr. Goelbo Rodrigues, fas a restric^fto do estado civU $ religioBo,
e neste case trata-se de saber se o individuo 6 solteiro, viuvo ou casado, se gosa de
plena capacldade ou soffre de alguma interdic^fto, ou se pertence d religifto que repelle
■a do outio conjuge.

Nfto tendo side a lei do casamento civil ieita pelo Gongresso, de cuja discussSo se
pudesse tirar elementos para a interpreta^fto de phrases ou vocabulos incertos, ao ler
e paragrapho apreciado, a primeira ideia que surge ao espirito 6 a da referencia ao estado
•de viigindade da mulher, o que estd excluido pela disposigfto do projecto Ooelho
Rodrigues, e ainda pela Interpreta^fto do Dr. Glovis Bevilacqua. Todavia, este sen-
tido 6 perfeitamente plausivel, pois a integridade da hymen 6 essencial ao casamento,
<:omp testemunha da moralidade e dos costumes da mulher, pois de outros signaes se
|>ode repetir o gracejo bocacciano, citado por Ziino:

Bocca baciata non perde ventura
Ansi rinnova come fa la luna.

Os hebreus chamavam d donzella alma, cUnutra, segundo Galmet, e tal era entre
'elles o valor da viigindade no casamento que a sua ausencia podia ser um motivo de
repudio, e um crime a imputagfto ftdsa de desvirginamento, desde que o pae da mulher
•demonstrasse essa falsidade: et ecce haee $unt iignit wrgmUatit fikae meae: expandetu
tcestinuruum coram senwnlnu civitatis. Deuteronomio, Gap. XXII, 17. A viigindade

PUBUO HEALTH AKD MBDIOINB. * 249

ultrajada sempre encontrou vingan^a nas leis. TSo predosa 6 conAidenuJ)^ easa con-
di^So da mulher, que o Chrigtianiaino erigiu o culto da Vligem. Juato 6 que perca
08 ieu8 effeitoe, como se no houvera, o caBamento em que o deaviigmamento foi
doloaamente occulto ao homem confiante, poia aeria um eacandalo ena co^^fto eata-
tuida no contracto, como profeasa o dlieito eccleaiaatico que a ledua a inlpedimento
impediente, e nfto dirimente.

O prqjecto do Codigo Oivil do Dr. Clovla Bevilacqua, modificado pela^commiaBfto
eq[>6cial da Camara doe Deputadoe, em 1902, comprehendeu o deaviiginamento anterior
ao caaamento e ignorado pelo marido, como eno esBencial de peasda, quer no projecto
primitivo, quer no segundo, que deu melhor diapoaigfto a eate caao particular, e nolle
ae 16: i

Abt. 280. Tambem 8er4 annullavel o caaamento quando um doa conj^gee houver
conaentido nolle, por erro easendal, em que eativease aobre a peesda do o^Hro.

Abt. 281. Gonaidera-ae erro eaaencial aobre a peeada do outio conjuge:

1®. A ignorancia de aeu eatado civil ou religioao;

2^. A ignorancia de crime inafin^vel e nfto preacripto, commettido antee do
caaamento;

3®. A ignorancia de defeito phyaico irremediavel e anterior, como a iillpotencia, e
qualquer moleatia grave, incuravel ou tranamiaaivel;

4?. O deaviiginamento da mulher, ai o marido nfto tinha conhedmento^deaae facto.

Aa nullidadea contidaa noa trea primeiroa numeroa deate artigo podem aar requeridaa
dentro de doifl annoa, a datar do dia do caaamento, ou da data da lei, ae tiver aido anterior ;
prudentemente, porem, foi marcado para o ultimo caao o praao de des diaa, que aegundo
Toulmouche, Ziino, e outroa, conatitue o maior lapao de tempo para q^e a perida
medico-legal poaaa deacobrir aa dcatrisea doa retalhoa da hymen, e determinar a epocha
do defUmunento, evitando por eaae mode poeaiveia explora^Oea e abuaoa.

Releva aqui obaervar: Em um paiz, cuja conatitui^fto preacreve a liberdade de con-
aciencia, em que a egreja eeti aeparada do Eatado, em que eate nada tem que ver com
aacran^aa religioeaa de cada qual, como ae pode admittir figure na lei que aeja annul-
lavel o caaamento civil, em virtude do eatado religioao de um doa conjugea, quando
a celebra^ do contracto, ou do acto, ae quiaerem, obedeceu a todaa aa exigenciaa e
fonnatidadea da lei?

Nfto vi raaOea que juatLfiquem eaaa excreacencia do projecto, nem o aeu autor aa deu.

Parece-me de neceaaidade que a lei, como erro eaaencial de peaada, fiseaae a eapeci-
fica^ da identidade, evitando por eaae mode a repetigfto da fraude de Labfto, aubati-
toindo aaua filha Rachel, eabelta e formoaa, dada em caaamento a aeu oobrinho Jacob,
p<Hr lia, menoa bella e nfto requeatada.

O grande juriaconaulto brazileiio Teixeira de Freitaa, no aeu Eabo^o de Codigo Civil,
admittin como enro eaaencial:

"Quando veraar aobre a peaada, iato 6, quando um doa contrahentee acrediton ter
caaado com uma certa peeada, entretanto que o caaamento foi oelebrado com peeada
diveraa."

A eate propoeito, na Comnuaafto da Camara doa Deputadoa, que reviu o projecto
Clovia Bevilaqua, o Dr. Aniaio de Abreu, da referida comnuaafto, propos a a^guinte
emenda que nfto foi aliia acceita, permanecendo a diapoaigfto do projector

''Ignorancia do aeu eatado civil e religioao, ou de aua identidade peeaoal, ou da
integiidade phyaica da nubente, ae fte eata aolteira" comprehendendo, portanto,
neeae numero, a queatfto da virgindade.

O aegundo caao de nullidade de caaamento por ignorancia de crime ioaffian^avel de
um doa conjugea 6 obvia; nenhum contracto pode aer valido neaaaa.condi^Oea, eape-
dalmente o que prende para uma vida em commum, para a bda ou mi fortuna, na
maior intimidade, duaa creaturaa, uma daa quaea ae apreaenta um monatro aoa olhoa
daoutra.

250 PROOEEDINGS SECOND PAN AMEBICAN SGIENTIFIO C0NQBBS8.

0 terceiro caso de erro essencial de pesBoa ^ constituido por "defdto phydco ine-
mediavel e anterior como a impotencia, e qualquer molestia incuravel ou transmifidvel
por contagio ou heranya."

A impotencia nem sempre se mamfesta por um defeito physico; ella pode ser func-
cional, por falta de erecgfto, que 6 um acto reflexo, cuja determina^ parte do centro
nervoso especifico, collocado na por^fto lombar da medulla.

E como deve ser aqui comprehendida a impotencia?

Distinguem-se em medicina legal duas formas da enfermidade — a impotencia para
exercer o acto conjugal, impotencia coeundi, e a impotencia de gerar ou de conceber,
generandi out concipiendi. Ambas as f^rmas podem-se apresentar no homem, ou na
mulhor.

A primeira f6rma da impotencia, no homem, pode existir com a apparencia normal
das partes genitaes, vidadas apenas na sua funcdonalidade ao ponto de gerar a inap-
tidfto absoluta, quor em consequencia de uma doen^a da medulla espinhal no nivel,
ou adma do centro especifico, quor por estados psychopaticos que annuUem oe estimu-
loB partidos do cerebro, ou por grios de degenera0U>, que comprehendem a natura
frigida do direito canonico — **frigiditas est membrif qwxm vis optime coftformatif flaeei'
ditoi quaedam et inexdtdbilis mollities*^ (G^parri). Esta f6rma da impotencia pode
resultar tambem da ausencia ou defeito do membro viril, impotencia instrumental,
prpveniente, no primeiro caso, de uma amputagfto cirurgica, ou accidental, como um
caso do meu conhecimento, em que a voracidade de um peixe arrancou a um menino
t<^os OS orgftos genitaes extemos; ou no segundo, originar-se de um defeito congenito,
coipo a epi ou a hypospadia, e o hermophrodismo,

Na mulher a impotencia coeundi pode igualmente ser congenita ou adquirida, a
saber: estreitamento exagerado da bacia, nfto dando ao afastamento dos ramos do
pubis ^ amplitude necessaria para permittir a intromissSo do orgfto viril, uma oblitera^So
da vagina, reduzida a cordllo fibroso, a abertura da vagina no inteetino, ou conformik-
90es viciosas do orificio vulvo-vaginal e do canal, por lesOes ou processes morbidos
gipaves, e cicatrizes consecutivas, adquiridas antes do casamento, ou um estado de
hyperesthesia exceesiva (vaginismo doloroso).

A fdrma de impotencia de gerar resulta da aiisencia de cellulas nemospermicas
(eepermatozoarios) no liquldo seminal, ou de affeccdee que impecam a forma^to
deese liquido, como a epididimite blenorrhagica chronica e dupla, e o teeticulo
tuberculoso ou syphilitico. Na mulher a impotencia concipiendi di-se por ausendm
de utero e ovaries, pela obtura^ do orificio ou do canal do collo por versOes ou
flexGes.

Nfto havendo a lei feito dlstincgfto entre as f6rmas da impotencia, qualquer della
pode servir de fundamento d nullidade de casamento?

No tempo do imperio, quando havia religifto do Estado, e somente o casamento
religioBo, reconhecido e garantido pela lei, as questdes de nullidade de casamento per-
tenciam ao fdro ecclesiastico, e se faziam de accordo com os preceitos do direito
canonico. 0 artigo 158 da ''Consolida^fto das Leis Civis" reza:

"As questOes de divorcio ou sobre nullidade do matrimonio, ou sobre separa^fto
temporaria ou perpetua dos conjuges, pertencem ao Juiz Ecclesiastico. A respeito
dellas nenhuma ingerencia pode ter a jurisdic^ secular.^'

O direito ecclesiastico s6 encarava, e encara, como causa de nullidade de casamento,
OS impedimentos dirimentes, e a respeito do impedimento por impotencia, diz Thomas
Bellacosa. — Theologiae moralis rudimenta. — Tertia editio:

" Impotentia est inhabilitas ad copulam habendam. Impotentia dirimit matrimo-
nium an sit antecedens et perpetua, sive sit absoluta, sive sit respectiva."

E em nota acrescenta o autor: "Hunc si quis est habilis ad coeundum et impoe
ad generandum potest contrahere; sterilitas enim non est impedimentum."

D'aqui se v6 que, perante a egreja catholica, s6 a impotencia de exercer o acto
sexual, constitue motivo de nullidade do casamento, com exclusfto da impotencia de

PUBUO HBALTH AKD MBDIOINE. 251

r ou de conceber, comquanto o fim do casamento seja a procrea^fto ou a perpetua0k>
daespecie.

O artigo 56 da lei do caflamento civil diz: ''Sfto effeitoe do casamento: { 1^. Con-
fltitoir familia legitima e legitimar filhoe havidoe de um doe contrahentes com o outro^
flalvo se um deetes ao tempo do nascimento ou da concep^So doe mesmos filhos estiver
caaado com outra peasda."

Em rigor, parece que todos as fdnnaa de impotencia poderiam ser allegadas, coma
motivo de nullidade do contracto matrimonial, pois constituir familia, formar familia,.
tern como objectivo a procreagfto, a perpetua^So da especie. 0 casamento 6 conse-
gttintemente a legitima9fto desse objectivo, a que precede natundmente a satisfacgfto
doe imuseres sexuaee; repugna, porem, aoe noesoe ueoe, tradi9So e costumes, essa
interpretacfto, comquanto sejamos um paiz novo, Carente de populagfto, que nfto pode
dar uniGes eeteris. Seria, porem, um escandalo para A nossa sociedade se um doa
cofnjugee, apto d procreagfto, tentasse a nullidade do casamento, allegando ser o outro
esteiil, ccHnquanto perfeitamente apto ao acto sexual. Poderiamos a este respeito diser
coin 0 Prof. Brouardel em relag&o d legisla^ franceza, comparada com a allemil, da
qual "deduz-ee que a unifto matrimonial tcim um s6 fim, procrear filhos; quando este fim
nfib^attingido, aquelle esposo que possueainda faculdades procreadoras pode procurar
utilisal-as em circumstandas mais favoraveis. Em Franca, continua o autor dtado^
0 legislador se coUocou em outro ponto de vista: um dos fins do casamento pode ser ter
filhos, mas um pacto muito mais solemne liga os conjuges de mode indissoluvel, o»
mie'para seguirem juntos a bda ou a mi fortuna.'*

Fda compara^ da legisla^fto auotriaca e allemft com a brazileira, chega-se i»
mesinas conclusOes do professor da Faculdade de Medicina de Paris. A palavra
familia, cuja constitui^fto legitima 6 principal effeito do casamento, tem tido com a
teinpo iftccep9Ges juridicas diversas, ora comprehendendo toda a descendencia de um
trpnco commum, ora o conjuncto mais limitado de parentes e pessdas vinciiladas aa
gnij^. '*No direito modemo, diz o jurisconsulto brazileiro Dr. Clovis Bevilacqua;
frunilia 6 o conjuncto de pessoas ligadas pelo vinculo da consanguinidade, cuja efficada
0e estende, ora mais Itfga, ora mais restrictamente segundo as varias legisla^Oes.
Outras vezes designam-se por familia somente os conjuges e a respectiva familia. ''^
Portanto, se algum erro de intelligencia me nSo oblitera a comprcdiensfto, a familia.
estd constituida pelos conjuges, mesmo antes da prole, ou quando esta nfto appare^a.

Ji o direito ecclesiastico definia o casamento: Nuptiae sunt conjunctio maris et
feminae consortium omnis vitae, divini et humani juris communicatio. Tr. 1 . D. 23, 2.

O art. 60 do Godigo Civil austriaco diz: "Uma impotencia completa e incuravd i
consummayfto do dever conjugal, produzida durante o casamento dd igualmente direita
ao divorcio."

O art. 696 do Codigo prussiano reproduz pelas meemas palavras a mesma doutrina,
da qual se segue directamente que, se depois do casamento sobrevior a impotencia a
um dos conjuges, pode ter lugar o divcndo pelo motivo de que cessou a faculdade de-
procrear, e, conseguintemente, essa impotencia nfto serd somente a impotencia coeundi,
mas tambem a de fecundar ou conceber, pois alii o que se quer obter com o casamento
6 a prole.

A nossa legisla^, acompanhando a doutrina do direito canonico, exige que a im-
potencia seja anterior ao casamento. Por conseguinte, desde que a enfermidade
aobrevenha ao contracto, nfto pode ser admittida como motivo de sua nullidade.
No ''Dirdto da familia,'' do Dr. Clovis Bevilacqua, 3a edigfto, 1906, ds paginas 162^
e&ooDtra-se a seguinte nota:

"Quando fallamos de impotencia, que consiste na inaptidfto para gerar, referimo-noa-
maSt directamente ao homem (impatentia coeundi); comtudo, ainda que mais ram-
mente, ella se encontra na mulher sob outra fd^fto {impoUrUia condpiendi). No dtado-
Hvio, cujas opinidee afto, com justissima razfto, gruidemente acatadas pelos nosM*
cultores da sdencia do diieito, aiBda se 16, ds paginas 8 :'* Os lactoros da constitui^fto da.

252 PBOOEEDINOS SEOOKP PAN AMEBIOAN 80IEKTIFI0 C0KGBB88.

fomilia bSo: em primeiio lugar o instincto geneaicOi o amor, que approxima 06 dob
«exo6; em segundo lugar os cuidados exigidos para a cooBerva^fto da prole, que tomam
maiB duradoura a aasociac^ do homem e da mulher, e que determinam o surto de
emo9de8 novas, a philoprogenie e o amor filial, entre procreadores e procreados,
emo90eB eaaaa que tendem todas a consolidar a aasocia^ familial."

De tudo o que venho examinando, parece-me poder-ae logicamente concluir que,
«ntre nde, a impoasibilidada de procrear conaidera-ee uma conaequencia da impotenda
^»eutuj»— aquella que pode motivar diasolugao do vinculo matrimonial.^

Entre os defeitoe que podem acarretar a impotenda est^ o hermaphrodiamo, ou a
Teunifto, no mesmo individuo, de oigftos aexuaee, glandulaa, ou canaea excretorea e
oigftoB da copula, aem a poasibliidade da auto-fecunda^fto, como no hermaphrodiamo
vegetal, e em alguna animaea infeiiormente collocadoe na eacala.

XiA a aexta aemana da vida intrauterina o aexo de embryfto 6 indeciso, iato 4, nHo ae
•encontra differen^a de estructura e oiganiza^&o entre o que ha de aer homem, ou
jnulher. A natureaa noe aeua indecifraveia e myaterioaoe proceeaoa de aperfeipoamento,
naa eapecificagOea e aeparaySo daa f unc^Oea, nem aempre caminha pladda e aegurm,
encontrando ia veaee trope^oe que Ihe deaviam a orienta^fto e perturbam a marcfaa do
trabalho in&tigavel. Ou pela heran^a, que 6 uma grande for^a de fixa^So naa eapedea
novaa, podendo no entretanto fiwer recordar fdrmaa antigaa, qualidadea abandonadaa,
levivendo oigfkw quaai extinctoe; ou por um abalo no deaenvolvimento do embryfto,
que 6 uma reproduc^fto da hiatoria ancestral, tomando os indicios primitivos da hi-
aexualidade, demonstrada por Waldeyer, impulao evolutivo em direc^&o paraldla;
•como quer que aeja, quaesquer que posaam aer as influencias perturbadoras da mardia
normal do desenvdvimento, a criatura humana nfto ae acha ao abrigo desae desgarro da
natureza, que redunda ia mais daa vesea em tenivd castigo a aeu portador innocente.

0 hermaphrodiamo apresenta gtioB differentes, e na maioria dos cases, pode ser
uma causa de impotenda eoeundif e consequentemente imia causa de nullidade de
casamento, ae o outro conjuge ae nfto conformar com a situa^ embara^osa que a aocte
the deparou.

(hios menos adiantados desse defdto, o faJso hermaphrodiamo- como a epiwpadia
•ou a hyi>08padia, pode accarretar a impotenda, ae nfto 6 remediavd cinugicamente,
•como at6 certo ponto me pareceu o caao por mim observado, ha um anno, do qual dd
conhecimento i Sodedade de Medidna Legal da Bahia, e que aqui reproduao.

Resta finalmente, o erro essencial de pesaoa que conaiste na ignoranda de moleada
incuravd ou tranamissivd por heran^a.

Hoje, que a tendencia 6 melhorar a raga humana, i semelhan^a do que ae pratica
com 06 diversoa animaea, formando-se uma adencia nova— a Eugenia — para conaeguir
•esse dedderatum, nfto ae poderia admittir um contracto, em que a fraude de uma daa
partes, nfto s6 obrigaase a outra aos riscos de uma molestia que Ihe fosse contaminar
a existenda, como tambem estragar a prole com a infecgSo grave.

Medidas serias deviam mesmo ser tomadas antes do casamento, para que nSo foasem
levadas para o Idto conjugal molestias que, como a syphilis e outras infecyCes venereas^
podem causar a degenerescenda da ra^a, contaminar a mulher, e tomal-a esteril e
•enferma a vida intdra. Todavia jd 6 um progresso a dispodgfto da Id.

0A8O DB HtPOSPADIAS, BmUIAKIK) HBRMAPH&ODI8MO.'

De passagem pela villa de S. Paulo, no aertio do Estado de Seigipe, a 4 de Jandfo
4este anno, fdnne mostiado um menino, que me diasefam, na linguagem popular, a^r
macho e femea. Logo foi grande a minha curioddade em examinal-o, nfto me aendo
^ntfto poesivd faael-o, aenSo, muito superfidalmente, eatando o menino de p6, e
ainda c^erecendo todaa as reaistendas poadveis, chorando muito, com receio de uma

1 Bsta ildnoHa foi remettida ao Ccngrano Sdantifloo Pan Amflrioano antes da ser approvado pelo Coo-
iwo o Codlgo CItO BraiOeiro.
• ObMrraoio apctMatada 4 8ooi«lada da Madlolna Legal a (Mnlnolo^

Bi
I

PUBLIC HEALTH AKD HBDIOINS. 253

operagfto, ou pelo vexame que Ihe caiuava a observagfio do defeito, de que era portador
e que servia de chac6ta aoe outros meninoe. Effectivamente, oe oigfios sexuaee
eztemoe tmham a apparencia de uma vulva com clitoriB grandemente deeenvolvido e
adiente.

Consegui, nfio sem difficuldade, que em principio de Fevereiro o pae o trouxesBe a
Ancajd, onde pude examinal-o melhor, e obter as duas photographias que, sob oe
num^os 1 e 2, junto a esta rapida descripQfto.

F. 0. de M. tem 7 annoe completes, de cdr morena, com mistura de caboclo, e
apresenta regular desenvolvimento. 0 pranto em que estava, quando foi photo-
graphado, deixa ver as costollas salientoe do lado direito, parecendo magrem.

O pae, de estatura regular, ou talves baixa, de boa complei9fto, tem 26 annoa de
idade, e um mais do que sua mulher, acabodada e menos robusta do que o marido.

Beferin*me este que o menino tem, pelo lado matemo, um prime com defeito
semelhante, e que 6 casado e tem filhoe. O defeito desto deve ser bastante menor,
pois F., chegando i idade adulta, nao poderi fecundar, nem mesmo exercer a copula
vaginal.

A photographia numero 1 apresenta o menino de p^, tondo os orgftos sexuaee extemoe
a apparencia dos de peesda do sexo feminino, cnjos grandes labios sfto muitoa&wtadoa
na parte anteriw, pela salienda de um simulado e volumoso clitoris, e respectivo pre-
pucio. Fasendo deitar o menino, e conservando as cdxas approximadas e dobradaa
sobre a. bacia, contintia a aparencia feminina doe orgftoe sexuaee, em virtude de ter o
escroto, na parte m^dia, um profundo sulco, adaptando-se uma a outra as duas metadea
ou lobulos na parte posterior, como se foesem dois verdadeiros grandes labios, de cnja
parte anteriw exhuberava o volumoso clitoris.

Afastadas as cdxas, como na photographia numero 2, separam-ee os dois lobulos do
eactoto, nfto existindo vestigio algum de orificio vaginal, no fundo do sulco, onde a
pelle^liaa.

Naa partea salientes e livres dos fingidoe labios, a pelle tem a apparencia franiida
da pelle escrotal.

Examinando os lobos do escr6to, separadamente, verifiquei em cada um dellea
um pequeno corpo ovoide, como uma pequena oliva, correndo dentio de uma bolsa,
oa quaea eram e\identemente testiculos.

A saliencia que se v6 na parte superior do sulco (photographia n? 2), de 8 e meio
centimetros de ccnnprimento, tem a confOTma^fto de um penis, com a ^ande toda
descoberta, e cujo coUo pode-se distinguir na photographia. Esse penis 6 totalmente
adherenteao sulco pda parte inferior ouuretral,etoma a f^madeumarco. Aglande
6 in^MrfuIada, comquanto se note em sua extremidade uma dei»essfto ligeira, alongada,
em aeguimento ao freio, para diante, e onde devera ser o meato urinario.

Na rais do penis se deacobre, elevando um pouco a glande, um pequeno orificio,
em fdnna de fenda antero-poaterior, que 6 o meato urinario, e por onde o menino fas
a eyacua^k) da bexiga.

A ere^fio tender^ a accentuar a curvadura do penis, e, em virtude de sua adherenda
total, scffi impossivel a intromissfto desse membro na vagina em acto de ajuntamento
sexual, s6 podendo o paciente obter o praser genital por manobras outras, sendo
perdida a ejacula^fto.

Por esta descrip^ se poderd deduzir a situa^&o physica e moral desse menino,
quando chegar d idade adulta. Pareceu-me, no entretento, que uma opera^fto
drurgica, consistindo no desbridamento do penis, despregando-o do sulco inters
escrotal, poderia de algum mode permittir a copula a aginal, sendo assim ranediada
at^ certo ponto a impotencia eoeundi^ persistindo, porto, a de fecundar, pela situa^io
da deeembocadura do canal uretral.

As inf onna^Oes sobre os habitos do menino pouco adiantaram; disse-me a mAe que
elle dava preferenda, ou parecia dar, a brinquedos proprios de meninas. Essaa
infonna90ea, porem, nfto eram filhas de observa^Ao intelligente, e pareceu-me que

254 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

esta queetSo foi despertada no eepirito da mulher pela minha indaga^So. Os brin-
quedofl das crean^as estfto sempre de accordo mais com o meio em que 83o criadaa.
Neste caso 6 preciso attender d esquivan^a do menino em rela^fto aoe de sua idade,
em consequencia do defeito que 6 moti^ o de zombaria doe companheiroe, e por iaso-
toma o menino mais retrahido e cazeiro.

Sem entrar, por eecusadas neste meio, em considerables anatomicas e de (vdem
moral, sobre o defeito com que a natureza, nos sens de8\ ios, marcou penosamente o>
pequeno F., concluimoe:

1? — Que F. 6 um hypospadico, com apparencias, apenas, do sexo feminine, ou de ma
false hermaphrodismo, e victima de impotencia coeundi atqtu generandi.

2? — Que F. estd comprehendido, se algum dia pretender contrahir casamento, no-
art. 72, f 3, da lei do casamento ci il, salr o se a operate cirurgica suggerida viet
remediar o defeito, desde que as nossas leis nfto fazem da impotencia de gerar motiva
de impedimento ou nullidade do casamento. '>-

3? — Caso a cirurgia possa remediar o caso de mode que a copula carnal seja poesivel,
permanecerd a impotencia de fecundar, pela posi^So do orificio da uretra, nfio se
fazendo a ejacula^Ho dentro da \i^na.

MliTODOS MODERNOS PARA LA PREVENadN DE LA MORTAUDAD

INFANTIL.

Por ARTURO L. GUERRA,

Miembro de la Washington Diet kitchen Association.

Al escribir este trabajo no intento discutir Ios tecnicismos relacionados con el
cuidado y alimentaci6n de Ios nifiuM, sine m^ bien dar un lureve reeumen del trabajo
que se esti Uevando a cabo en esta Naci6n, con el objeto de resguardar la salud de loe
niiios, reduciendo por estos medios la mortalidad infantil.

Para dar una idea de la energia con que Ios Estadoe Unidos est4n tratando el pie-
blema, b^tame decir que en algunas secciones de Manhattan se publican libros en siete
idiomas sobre el cuidado de Ios niiloe y se reparten gratis a las madres con el objeto
de que sus esfuerzos al aprender a salvar las vidas de sus hijos puedan ser reducidoa &
lo mfnimo . Los Estados de Louisiana y Texas ban equipado canros de exhibicidn que
Yiajan por lugares rurales y por medio de demostraciones pricticas si^nbran por
doquier Ios principles fundamentales de la higiene infantil. El Departamento de
Niiios estableci6 un Centre de Salud Infantil en la Exposici6n Panam^Pacifieo,
donde grandes auditories observaron Ios miles de niflos que alll fueron examinadoe
y tratados, no b61o haci^doles un gran bien, sine tambi^n educando las masM en
general. Sin discutir m^ lo que la Naci6n estd haciendo, vuelvo a mi prop6sito, que
es el de hablar de lo que la Asociaci6n ''Diet Kitchen " de Washington, por medio de
Ios Centres de Salud Infantil, lleva a cabo con el objeto de prevenir la mortalidad
infantil en esta ciudad.

Anterior a 1905 estas instituciones eran casi desconocidas, y el sistema que al presente
se sigue, se deeanroll6 durante Ios dltimos cinco afioe. Hoy hay en Wdahington cinco
Centros de Salud Infantil, localizados en las secciones mis populosas de la ciudad,
con objeto de que est^n al alcance de las multidudes de madres y niiios que habitan
estos distritos.

Cada eetacidn se compone de un sal6n, amplio, limpio y bien ventilado, donde te
examina a Ios niflos, y otra sala de espera en donde Ios desnudan y pesan. Una o doe
enfermeras asisten a Ios pacientes, y un cuorpo de doctoree atiende las conferencias,
las cuales tienen lugar tres veces por semana.

PUBUC HEALTH AND MEDICINE. 255

Lo6 remiltadofl que se obtuvieron de este trabajo fueron halagadoree deode el prin-
cipio, a juzgar por la eetadlstica de estos afloe: el tanto por ciento de defuncionefl de
menoree de un afio con reepecto al ntimero de nacimientoe fu6 anualmente como sigue:
de 1906 a 1910, 16.18; en 1911, 13.61; en 1912, 12.83; en 1913, 11.99; en 1914, 10.02.
Eeta reducci6n mueetra lo que se puede lograr con un continue y sistemdtico Mai
por instruir a las madres y conservar la salud de los nifios. Las estaciones de la ' * gota
de leche'' eran antes lugares adonde acudlan las madres, porque alK podian obtener
leche a un precio muy bajo. Hoy eetas instituciones modemas ban variado de cate-
goria; no siendo ya estaciones de lecbe, sine mis bien Oentros de Salud Inlantil,
donde las madres reciben instarucci6n en los principios de la higiene y sua nifios son
atendidos por m^icos competentes. Su objeto no es el fomentar los alimentos arti-
ficiales; los centres saben e inculcan en las madres el hecho de que la leche humana es
el alimento ideal para el nifio de pecho y s61o recurren a la alimentaci6n artificial
cuando las circunstancias absolutamente los obligan a ello. Frecuentemente se logra
inducir a las madres a que vuelvan a dar de mamar a sus nifios despu^ de haberlos
destetado y haberse limitado a alimentarlos con mamadera. Los Centres de Salud
In&ntil llevan a efecto dos clases de conferencias, las prenatales, para mujeres
«n cinta, y las postnatales para sus hijos. Las primeras son de suma importancia.
En ellas se ensefia no solamente la higiene durante el embarazo, sine tambi^n el cuidado
de los nifios al nacer; adenUus se les presta atencidn ^ultativa prepar^dolas fisica-
mente para el gran acto de la matem idad . Para mostrar lo necesario que es el cuidado
prenatal citar6 como ejemplo una de las estadisticas copiladas por Williams. Entre
705 fetos muertos cuyas causas ^1 investig6, 186 murieron de sifilis, y tiene rasones para
creer que el 40 por ciento del resto murieron por la misma causa. Como esta en-
fennedad es, hasta cierto punto, curable bajo un r^imen debido, esta alta mortalidad
daberia haber side mucho menor. Mor^ nos dice que el 42 por ciento de los mifioa
que mueren anualmente no completan el primer mes de vida, y siete d^imos de ellea
mueren como resultado de condiciones anteriores a su nacimiento. Si estas mujeres
hubieran side vistas o puestas bajo tratamiento mMico, ^serfa posible estimar cu^tos
de estos nifios hubi^ramos podido salvar?

En la ciudad de Washington las dehmdones ocasionadas por partes prematuros
auben a 35.54 por mil de nacimientoe. Esta propoici6n es 50 por ciento mayor que
la de los muertos a consecuencias de deeiMenes ditoicos que fueron reg^strados
durante el mismo perfodo. Los Centros de Salud con sus medidas priMsticas y su
generoso inters, son un gran ftustor actualmente e influihm mas a<in en el future
an la redueci6n de la mortalidad infantil cauaada por los partes prematuros o
cualquiera otca condici6n evitable o curable, existente antes del nacimiento.

La importancia de este problema se eeti comprendiendo ri^idamente en todaa
partes y actualmente, 38 Departamentos de Salud, de ciudades y 247 agendas par-
ticulares han emprendido el trabajo prenatal en 110 lugares de los Estados Unidoa.
Los m^todos empleados en los Centros de Salud de W&shlngton concuerdan por
f^gla general con los empleados por las miwinaH instituciones en todos los lugares de
los Estados Unidos.

Las madres tienen conocimiento de estos centros por medio de alguna amiga, cuyo
hijo est& aaistiendo a las conferencias y recibiendo vidbles beneficios; otras voces
las madres empiezan a in^ estigar, despu^ de haber leido algun articulo, acerca de
lo que a menudo se publica en los peri(3dicos y en los cuales, se habla del gran bien
que hacen al ptiblico estas instituciones. La Sociedad de Enfermeras Instructoras fre-
cuentemente tiene notidas de estas madres, ya sea por medio de algtin padente
o de la Asociaci^n de Caridades. Una de las enfermeras vinta a la madre y general-
mente logra convencerla de que para el bien del nifio, no podrfa hacer mejor cosa
que llevarlo semanalmente a las conferencias. Los doctores frecuentemente sirvan
da agantes para aumentar la concurrenda a los centros, pues ellos saben bien que

256 PROCEEDINGS SECOND PAK AMBBICAN BCIEKTIFIC C0NGBE88.

^0toe son lo6 lugares por excelencia donde las madres, faltas de recimos, pueden ser
educadas y al mismo tiempo recibir ateiici6n facultativa para ellas y para sus ntfioe.
Otro hctoir que ayuda a atraer la ateiici6n de las madres hacia los centres, conaiste
en las exhibiciones que de evz en cuando se dan en teatros, iglesias y Centrot
de Salud. Estas exhibiciones no b61o educan a las madres, aino que las persuaden
de que el asistir a las conferencias vale bien su tiempo y trabajo, puee su aaistenciA
a ellas no puede resultar sino en favor de sus pequefiuelos.

Cuando las madres asisten a las conferencias prenatalee la enfermera las instruye
cdmo deben vestirse; la clase de trabajoe que deben evitar; cuinto deben donnir, y
en general las hacen comprender que U salud del futuro hijo depende en gran parte
del estado de salud de ellas. Despdee de ^eto el m^co las examina cmnpletamente
y guarda relaci6n exacta de lo que se refiere a su condici6n previa y la presente y
de los resultados del examen ffsico: dimensionee de la pelvis, reeultado del examen
de la orina, pre8i6n de la sangre y reacci6n de Wasserman. Durante los tUtimos
meses se hacen exianenee abdomioales y vaginalee cuando es neceeario. Estas
pacientes se reciben cada dos semanas, obsOTvdndolas, de esta manera, cuidadosamente
durante la gestaci6n. La mira de los Centros de Salud ee que las madres empiecen
a asistir a las conferencias al comensar el embaiaao, para asf poder obeervar y diiigir
cada case desde su <»igen. En las conferencias las madres reciben adecuadas y
cmnpletas direcciones sobre c6mo deben tratar y cuidar a bus futuroe hijoe. Se instru-
yen en la manera de alimentarlos, vestirlos, bafiarlos, y en el departamento llamado
"sewing circle" aprenden a haceries ropa.

Como es evidente, eatos esfuenoe evitan muchas muertes. Frecuentemente es
posiblexyrevenirabortosymalpartos; las presentacionespeligrosBSse pueden corregiry
al educar a la madre se consigue aumentar las probabilidades de salud y vida para it
nifio.* Dos ventajas mis se obtienen tambi^n de las conferencias prenatales: la pre*
venci6n de la ceguera, y el matricular op^tunamente a la madre en los Centros de
Salud.

Uno de los deberes de la enfermera es investigar las condiciones de la casa en que vive
la madre, y si dichas condiciones son tales que impidan el parto allf , se le recomiendan
los nombres de algunos buenos hoepitales donde la mujer recibiri toda la atencidn y
cuidado debidos. Cuando el parto occure en casa las aaisten m^icoe competentes
que han hecho estudios especiales de obstetricia y a quienes siempre puede Uamtodes
por tel^ono. Despu^ del parto, durante la convidecencia son asistidas por una de
las enfermeras del Distiito.

Cuando la madre sale del hospital, una enfermera del Distiito y otra del Centio de
Salud, la viaitan y hacen que siga las Instrucdones que le fueron dadas antes que
naciera el nifio. Despu^ asiste a las confeiencias una vez por semana y allf vuehre
a recibir instrucci6n sobre el cuidado de su hijo.

UNA OONFBBBNCIA BN UN CBNTBO DB SALUD INFANTIL.

Cuando la madre por primera vez trae al nifk) a los centros, sus nombres son regis-
trados en los libros de la Institucidn. La enfermera desnuda al nifio en la sala de
espera y lo pesa. En una tarjeta de tamaflo apropiado se registra la edad del nifio en
semanas, y debajo de esta, su peso. Esto ee hace semanalmente. Cuando gana en
peso, ^ste se marca con tinta negra, y con roja cUando el peso es menor que el de laves
anterior. Las madres temen mucho estas dltimas marcas porque son para ellas una
sefial de peligro que inmediatamente estimula sus energfas para encontrar la causa,
lo cual las hace segulr las instrucciones del doctor con mis cuidado y perfecci6n.

Despu^ de pesar al nifio la madre lo lleva al consultorio donde el m^ico tcmia
cuidadosamente la historia de Ice dos. Las condiciones horeditarias se estudian en
detalle, asf como las circunatancias presentee durante el nadmiento, lugar del parto,

PUBUO HBALTH AHO) HBDIOIHB. 257

estado y peso del niiio al nacer, y cualquiera otro detalle que pueda influir de un
mode secnmdario. Al terminar esta inveBtigaci6n se desnuda al niflo y se le examina
completamente, anotando con cuidado cualquier fonnacI6n defectuosa, eintomas de
raquitismo o de enfermedades cong^nitas. Ouando se termina este examen si el
nlfio se estd lactando debidamente, se le dan completas instrucciones a la madre con
ielaci6n al tiempo que debe estar el nlfio en el pecho, y se le explica como conservarA
mejor su salud si se le da de mamar solamente cada tres o cuatro boras con reguTaiidad .
Tambi^ se la Infonna sobre lo necesario que es darle agua varias voces al dla, as!
como respecto al ndmero de boras que debe dormir. El doctor aconseja luego a la
madre con relaci6n a sf misma, advirtidndole el mejor alimento posible, el debido
ejerdcio y que duenna las mis boras que pueda.

Ouando el nifio no puede lactar de la madre por alguna raz6n que realmente lo
impide, el doctor bace lo posible por encontrar la fdrmula de lecbe que est6 indicada.
En tales cases se siguen las slgulentes reglas: se usa lecbe en estado natural y la madre
la modifica en casa, agregando simplemente cierta cantidad de agua pura, o agua de
cebada, y uno de los asdcares, generalmente el de malta. La salud de algunos nifios
progresa mejor cuando reciben el alimento cada cuatro boras, otros en cambio lo
requieren cada tres. Sm embargo, la cantidad total de lecbe que reciben en las 24
boras es la misma, lo tinico que yarfa es la cantidad de agua que se usa. Cuando se
completa la f6rmula la madre recibe instrucciones escritas que explican c6mo debe
preparar esta lecbe, pues ella prepara diariamente por la mafiana la cantidad total que
el nifio deberd consumir durante el dfa« La enfermera encaigada del Centre de
Salud siempre prepara la lecbe la prlmera yes cuando cada madre recibe su
fdrmula, para ensefiarla a medir y mezclar las simples substancias que forman la dieta
de su bijo. A la primera oportunidad la enfermera visita la casa para cerciorarBe de
que todo marcba debidamente, y para ver si la madre estd Uevando a cabo las ins-
trucciones que reclbi6 en la conferencia.

Los deberes de la enfermera de los Centres de Salud son de suma importancia.
Aparte de lo que bace durante las conferencias, es su deber el visitar a cada nueva
madre el dfa que es admitida a las conferencias y escribir un informe complete acerca
de la condlci6n social de la famllia y la situaci^n de la casa; si est& ubicada en una
secci6n limpia y sana de la ciudad, o en una atestada de gente y malsana, donde los
nifios crecen diffcilmente sin calor y faltos de sol. Da parte tambi^n de la salud
aparente, educaci6n e inteligencia de los miembros de la familia, especialmente de la
madre; de los recursos de los padres y por lo tanto de las comodidades que se pueden
ofrecer a su nifio y de las condiciones bigi^nicas del bogar. ^Hay limpieza, recibe la
luz del sol, se puede calentar debidamente en el inviemo? La enfennera rinde los
informes sobre estos asuntos con el objeto de que el trabajo sociol6gico y medico de las
conferencias pueda Uevarse a cabo mejor.

£1 objeto primitive de los Centres de Salud Infantil es el de cuidar nifios en
estado de salud . Esto, como es natural, es un asunto diffcil de inculcar en las madree,
quienes persisten en traer a sus nifios enfennos a que redban atencidn facultativa.
En estos casos se recomienda algtin buen bospital donde puedan recibir tratamiento
adecuado. Esto no indica que a los centros jamis asistan nifios enfermos. Al con-
trario, allf se tratan de continue un gran ntoero de criaturas que padecen de algunai
de las enfermedades mis graves que un nifio puede tener, tales como des6rdenes
nutritives, y el tratamiento de estos casos se considera como una parte del objeto de
estos centros.

En el tratamiento de estas condiciones no se usan sine remedies sumamente simples,
y se confia casi exclusivamente en medidas di^t^ticas. Los Centros de &dud
Infantil est^ provistos de la mejor lecbe que es posible obtener para el use de los
nifios. Las madres pobres que no pueden p<igar la reciben gratis; las que poseen
medios la reciben al costo.

258 PROOEEDIKQS SECOND PAN AMEBICAN SGIENTIFIO OONGBESS.

He aquf un breve resumen de lo que en esta ciudad estin Uevando a cabo loe Centros
de Salud Infantil. Que estoe esfuerzoe ban sido premiadoe por el 6zito, lo demueetra
la popularidad de que gozan, su ntimero de pacientee que cada dfa ee mayor, y,
in49 que todo, la mayor rebaja en la mortalldad iniantil que anualmente se registia
desde que estas institucione^ ban existido.

Antee de terminar deeeo expreear mi gratitud bacia el director m^co de la Asocla-
cidn "Diet Kitcben" de W^yabington, Dr. Joeepb S. Wall, de eeta ciudad, y a la
Sra. Max West, de la Oficina de Nifioe, a quien estoy muy reconocido por baberme
&cilitado las vistas de proyecci6n.

BIBUOORATfA.

Van Ingen. Am. Journal Diseases of Cbildren, Sept. 1915.

Wall. Escrito in6dito.

Mor&n. Endowment of motberbood.

PROPHYLAXU DO OPHIDISMO NA AMERICA.

Por VITAL BRAZIL,
Dtrector do I'MtibuJU> SenmUherapioo de BuUmtan, 860 Paulo (Brazil),

£ sempre melbor e mais tskcH evitar do que corrigir. Este conceito, tSo simples
e tfto verdadeiro, encontra inteira applica^ aos acddentes opbidicos. Estes sfto
em sua grande maioiia perfeitamente evitaveis. A sua extrema frequencia, em
certos paizes, reconbece como causa primordial a Wta de protec^So dos memlm»
inferiores, tfto usual entre as populagOes ruraes. As victimas de taes accidentes,
em quasi sua totaHdade, ^U> constituidas por operarios agricolas, que em consequouna
de babito inveterado, explicavel quasi sempre por condi^Oes climatericas e econoDod-
cas, nfto usam de calyado, nem jHrotegem convenientemente as partes infeiiores do corpo,
por occasifto dos trabalbos em que elles se p6em em contacto com opbidios pe^onbentos.

As serpentes venenosas da America nSo se deslocam para atacar o bomem. O
accidente se passa sempre quando este, nfio vendo 0 fbanatopbidio, desse se avizinba
demasiado ou pisa^ descuidado. Em uma estatistica oiganizada pelo Institute de
Butantan verificamos que os accidentes sfto muito mais frequentes nos membros
inferiores do que nas outras partes do corpo, elevandoHse a 75 por cento da totalidade
doscasos.

Segundo as nossas experiencias, o uso do calyado ordinario e de pemeins protege,
de mode efficaz, contra as mordeduras de serpentes venenosas, as partes mais expostas
a taes accidentes. Do exposto se conclue mui daramente que a primeira e mais
importante medida propbylactica 6 a protec9So dos membros inferiores de todos

05 individuos, que tiverem de transitar ou de trabalbar nos lugares onde jXMsam ser
encontrados opbidios.

Ao lado da {HrotecgSo individual, uma outia ordem de medidas propbylacticas
deve ser tomada em considerayfto: a da captura ou a destruiyfio directa das serpentes
venenosas feita pelo bomem e a sua destruiyfio indirecta pela protecyfio dos sens
inimigos naturaes.

A captura ou a matan^a de opbidios tem se f eito, tanto na Europa, como na America,
tendoHse mesmo. em alguns paizes estabelecido premios, no intuito de estimular a
destruiyfio desses perigoeoe animaes. No Novo Mundo ficou celebre Peter Gruber
que conseguiu destruir na Florida mais de 50,000 serpentes. O Institute de Butan«
tan, em S. Paulo, no intuito de obter o material indispensavel ao prepaio dos sdros
anti-pe^onbentos, tem promovido a captura de serpentes, que ^U> encontradas por
occasifto do trabalbo agricola nas fazendas. 0 pre^o estipulado por serpente enviada

6 um tube de s^. Desse modo, garante 0 Institute 0 fomecimento continue de
serpentes e colloca o sOro curativo ao alcance das victimas do opbidismo. Este
servigo, estabelecido ba ceica de quinze annos, tem dado excellentes resultados.

PX7BU0 HEALTH AKD MBDIOIVE. 359

CoDflUta^e o augmento annual do numero de ophidios enviados ao InstitutQ. Vo
ultimo decennio houve o seguinte movimento:

Serpentes.

Bml906 437

Em 1906 697

Em 1907 860

Em 1908 2,210

Em 1909 2,042

Em 1910 1^440

Em 1911 8,322

Em 1912 4.744

Em 1913.... 4,680

Em 1914 6,149

A maior parte destes ophidioe afto encontrados per occaaiSo doe trabalhoe agpricolas.
Mo ae trate, poiB, ordinariamente de uma Canada propoatal e aim de uma cUpttilra
eventual. For^oso 6, entietanto, reconhecer que antes da propaganda e doe emdna-
mentos do Inatituto, muitae deaaas aerpentea nfto eram mortaa ou captuiadaa em curiae-
quenda do tenor aupemticioao que inapiiavam e que ja hoje n§o inaphmm. Diafeo ae
depiehende que ao lado doa grandea beneficioa anteiionnente apontadoa, eate aervi^
pode inacrever ainda no aeu activo o da eliminaySo de um certo numero de ophidioa
pengoeoe.

A maior, ai nSo a unica difficuldade, para a cayada doe ophidioa, reaide em encontrar
oa aeua eaconderijoa. De ftusto, aa aerpentea venenoaaa americanaa afto, na aua quaai
totalidade, eepeciea noctumaa, que aaem a ca^ar i noite e que ae occultam, durante
o dia, em buracoa do aolo, em baixo de pedraa, de peda^oa de madeira ou na intrindada
tnama da vegeta^fto h6rJt)acea. Encontral-aa, eia o jHroblema, poia, o captund-aa 4
tare&k farilima. Effectivamente, para capturar uma aerpente baata tomal-a na eztre-
midade de uma vara ou de uma bengala, aui^>endendo-a do aolo. O ophidio nio
tendo ponto de apdo nfto poderi lan^ar o bote e procuiando equilibrar-ae na ezttemi-
dade do inatrumento apprehenaor, aer& levado com &cilidade para o interior de uma
caixa deatinada ao aeu tranaporte. Para maior confian^a doa agricultorea, attendendo
aa ideaa ftdaaa que ainda preponderam no eepirito popular, o Inatituto diatribue um
la^ apropriado para a captuia daa aerpentea. Eaae inatrumento 6 conatituido por
uma al^a de couro montada em uma daa extremidadea de um peda^o de madeira,
tendo na outra um annel mejtallico, adaptavel a uma vara que ae encontra eventual-
mente no momento de apanhar a aerpente. Eate pequeno apparelho ^ aimple e pratico.
Eat4 aendo laigamente utiHaado naa fazendaa do Eatado de S. Paulo e de outroa Eatadba
do aul do Braail, onde a acyfto do Inatituto ae tem exerddo com nuda intenaidade.

it facto conhecido doe ca^adorea de perdisee que ba cftea que afnamm aerpentea,
conatituindo isao um perigo para o ca^ador e um grave defeito para o animal. Eaae
facto noa levou a p^isar que seria talves poeaivel, partindo de um tal animal, crear
uma ra^de cftea ca^adoreade aerpentea. Seria eate omeio nuda efficaaemaiaprompto
para limpar certas regiOea do globo da grande qutmtidade de ophidioa perigoaoa, que
aa infeatam, difficultando em algumaa dellaa o trabalho do homem. Nease aentido ja
ae tem trabalhado no Inatituto de Butantan. Jd temoa obtido cftea que acham com
fadlidade aa aerpentea. Trata-ae agora de fixar atravea de variaa gerapOea no cerebro
do animal, a inclina^eapecial para a ca^ doa ophidioa. 86 aaaim teremoa uma ra^
capas de dar oa reaultadoa praticoa que ae tem em viata. Para o homem aerft um novo
que, ao lado da diversfto, terft, aobre oa aimilarea, a superioridade de aer extrema-
mente util e humanitario.

A protecgfto doa inimigoa naturaee daa aerpentea conatitue um doa meioa que muito
pode contribuir para a deatruigfto doa thanatophidioa e conaecuttva diminui^fto doa
accidentee ophidicoa. No Velho Mundo varioa nuunmiferoa t^m aido precoirftadoe
como animaee uteia aob eate ponto de viata, entre oa quaea devemoa citar o Herpeitm
idbieuimm (manguJBta) e o Erinacmt europeut (ouriyo). Na America nfto conhe-
cemoa mammifero algum que poaaa deaempenhar eaae papel. O porco domeatico que
tem aido preconiaado como excellente deatruidor de aerpentea, nfto parece correaponder
fta eaperan^aa nelle depoeitadaa. £ um animal extremamente reaiatente quasi
6848^—17— VOL IX ^18

260 PB00BEDIKG8 8B00HD PAK AMBBICAK 80IBKTIFIC OOKOBB86.

nfractario ao veneno ophidico; mas, 86 em condi^Oes excepcionaes, atacazi mui
serpente para fazer della o aea alimento. Ab experiencias^ que fizemos c<»ii ease
animal, no Institato, foram completamente negativas.

Entre as aves, a America possne um numero nfto pequeno de espedes, que sKo
apontadas pela tradi^fto, como destruidoras de serpentes. Destas mendonamos as
aeguintes que sfto encontradas no Brasil: /2JUa iUMnama (ema ou nliand6), DukoUifuM
arynUOui (seriema) e o HerpetoUm eaehinaiM (macagui ou acauft).

A grande maioria deases animaes, se nfto a sua totalidade, tanto aves como mammi-
feros, sfto omnivoios ou camivoros que accidentalmente se alimentam de serpentes
encontradas mortas, podendo em algnmaw drcumstandas dar capa apequmiasserpentes.
Temoe em captiveizo ha ji algum tempo um DiMkfiu erjftMiu (seriema) e um
Pe^fftortu (hanu (carancho— especie de gavifto) que sfto aHmentados exclusivamente
per serpentes mortas. Quando, entretanto, se Ihes o£ferece uma serpente viva fogem
espavoiidos.

A drcumstancia de recebermos grande numero de serpentes vivas de varios pontos^
sendo muitas veses obrigados a guardal-as em certa promiscuidade, noe levou a desco-
brir * casnalmente o facto interessante de uma espede alimentar-ee habitualmente de
serpentes venenosas e nfto venenosas, sendo, entretanto, completamente ino£fenaiva
para o homem. Trata-se da Oayrftopuf oloslia Daud., especie que tem side aasignalada
em varios Estados do sul do Brasil. Nfto 6 uma especie que se encontre com muita
irequenda, nfto s6 por nfto ser provavelmente muito abundante, como prindpalmente
por ter habitos noctomos. Esta ultima drcumstancia noe indica o melhor caracter-
istico da sua u tilidade ; pois os sens habitos noctomos coinddindo com o das serpentes
venenosas da r^gifto, nos levam a pensar que estas constituirfto ordinariamente as suae
victimas.

O Institute de Butantan fez construir um serpentario especial, para observa^fto biolo-
gica das serpentes nfto peponhentas, tendo, entretanto, por prindpal objectivo a
determinapfto das espedes ophiophagas. Nesse serpentario que 6 uma sorte de jardim,
se encontram os ophidios em uma rdativa liberdade, podendo ser observados, com-
rela0U> aos sens hi^itos, a sua aliwentagfto predUecta, aos meioe que empragam para
a captura das suae victimas e aos ktibi$at§ pr^eridos. Podemos determlnar, dest'arte,
alem da Oxjfrxopui ciodia (muasurana), outras espedes ophiophagas: Erfftkrokanpnu
asteutapti— parece ophiophaga estricta. Coluber eoniet— parece alimentarse tambem
de passaros. Pkilodrpat aelotti— alimenta-se tamb^n de paasaroe e batrachios.
JB3ap§.camilinu$ (coral venenosa)— parece ophiophaga estricta. Elapifranialu (coral
venenosa)— parece ophiophaga estricta. A estas espedes podemos accrescentar pro-
vavelmente todas as elapi brasUeiras.

O Sr. A. Bertcmi ' intelligente e operoso naturalista constatou o cannibaliamo de
varias espedes no Paraguay. O 8r. Rajrnumd L. Dittman * em sua excellente mono-
graphia sobre "The feedin^i habits of serpents'' estabelece a exlstenda na America do
NcNte de varias espedes ophiophagas pertencentes ao genero Ophibdui, BMnoddlui,
Cemopkora, entre as quaes occupa lugar saliente a OpkiMui giulu$.

i bem provavel que em outios paiaes da America, bem como em outraa r^giOea do
^bo, se enoontrem espedes aimilares, que representem um papel na destrui^fto doe
ophidioe pe(<mhentoe.

Estamos, pois, em piosonga de um facto de interease geral, que podera repreaentar,
quando for bem conhedda a bidqgia daa serpentes, um elemento de i^wedavel vakr
prophylactico.

> V. BniO, U<UinMooiitreroplildiiiiM,p. 182.

•AsnowMpdrndmobwrTagOwdatamdaMIM. V.LadMeii9eooiitrel'oplkldJiiii«,p.204.
• A. Wlnkalrtod BtftonL OttalofotfllstMiiatfoosdalosTirtebrMloedel Panigi»j,l91S.
•BayiaondL.I)ittm>ti,Zoftkiii<^,8cl«itMocontribnttoi»of^ Vtl.l»

iio.ll,p.a3.

PUBLIC HBALTH AND MBDIOIHB. 261

OON0LU86S8.

1. Ob accidentes ophidicos sfto na sua grande maioria evitaveb pela protect do*
membroa inferiorea doa individiios, que, pela naturesa daa suaa occupa^Oea, ae ezpdem
4i picadaa daa aerpentea peyonhentaa.

2. Adeatnucteouacaptuiadoethanatophidioeaer&ummeiodedimmukon
de acddentea.

3. A protecgSo doa inimigoa naturaea daa aerpentea 6 urn bem recuiao para dar-lhea
Gombate.

4. Sntre oa inimigoa natoraea doa thanatophidioa, merece eq)ecial attengao doa
bii^Qgiataa, aa aerpentea oplnophagaa, que doYerio aer protegidaa e eatimadaa como
animaea uteia, quando forem inoffenaivaa para o homem.

NOTA QOBME TRATAIOBNTO DB LA INFBOCION PUERPERAL POR LOS
BAHOS TIBI08 PROLONGADOS.

For ARlSTIDBS FIALLO OABRAL,
Pfpfttof de la FaeuUad de Medkma de la Vnhenidod Central de 8anio Domingor

RepubUea DoMitUeana,

Admirado de la eficada extnK»dinaria de loa bafioa tibioa prolongadoa (m^todo de
Riea), en caai todaa laa modalidadea dfnicaa de la fiebre tifoidea y, particulaxmente,.
en laa formaa p6tridaa y ataxoadinimicaa, aaf como en laa enteritia febzilea o aeptic^
mlcaa i»oducidaa por el colibadlo, luf conduddo a emplear el miamo m^todo en la»
inf ecdones puerperalea Ijgeraa o graves, y en preaencia de loa biillantes resultados que
be obtenido, jucgo de verdadera utilidad darloa a conocer al mundo medico.

La balneaci^ como tratamiento de la infecci6n puerperal fu6 aplicada por piimer»
vea por Play&ir en 1877, en laa formaa septic^micaa; "el m^todo empleado entonce»
era la envoltura con un paflo embebido de agua helada y ae prolongaba el tratamiento
durante once dfaa con ^to complete. GaiUard Tbomaa (1883) preomiad igualmente
la rieirigeraci^, airvi^doae de un dlq>oaitivo un poco espefdaX; deapu^ Tauasky
aconaej6 la loci6n con una eaponja, el empaquetamiento que no es otra coaa que una
envoltura llegando al fin al bafio con ahiaiones frias. Ohabert (1884) estudi6 en
aeguida esta acci6n bajo la inspiraci6n de Vincent (de Lion). En fin Mac6 bft becho
un estudio complete del aaunto en el servido de M. Maygrier en la Piti6 en 1894 y
aconaqa dar loa bafioa deade que la temperatura llega a 38^ 5 con agua a 25^ mia o
menoB. Se mantiene la enferma en el bafio tan largo tiempo como en ^ ae sienta ella
bien; es bastande diffcil preciaar la duraci6n, que varfa aegtin la manera de reaccionar
de la enferma. Actualmente se tiende a dar el bafio a partir de loa 39^ y la tempera-
tura un poco elevada al principio (30 a 36), es enfriada progresivamente basta 26 y
auniOV

Como se ve, se ba becbo uao de los bafioa frfoa, y de una manera tfmida o tardfa, y ae
ba buflcado, como en el m^todo de Bryan para la fiebre tifoidea, la acci6n refrigerante
y t6nica o excitante del agua frfa.

En lo que a mi respecta, salvo contra indicacionea formalee (tendencia sincopal,.
flegmasfa, peritonitis), uso, sistemiticamente, el bafio general desde que la tempera-
tura axilar sube a 38^ o si se soetiene m^ de un dla en 37^ 6. Sostengo la temperatun^
del agua en 36^. La enferma ea mantenida en el bafio, todo el cuerpo cubierto por el
agua, durante no menos de 46 minutes y, m^or adn, como tannine medio, una bor»
treinta minutes. Debo recordar que no se trata de buscar la acci6n refrigerante, come

►Rapport, TMi d* la fasoltad d« lIMIdm da Paita,ptfm«l Dootofado « Me^

^62 PBOOEEDINGS SE00in> PAN AMEBIOAN 80IBNTIFIC 00M0BB88.

'en lo6 m^todos empleados haste el presente, idea que hft conducido al Pirofesor Tanuer
(1895) a prelerir las envolturaa Mas a loe bafioa. La acci6n de loa bafioa tibios probiig»-
do0 en la septicemia tiloidea, en laa infecciones colibacilaiea y en la fiebre puorperal,
requiere tin eatudio profondo y deade otro pnnto de Tiste; el dganiflmo reapoode de
modo ten r&pido y ten maraviUoao, que ae eate obligado a buacar 1* explicaci6n de Im
•eztraordinaria eficacia de eatoe balloa, en una mayvMr tecilidad de laa defenaaa imtnr
•oig^icaa, por el cambio radical del medio ambiento.

Haste khora mis observacionee ban tenido lugar en las E$earai vulvo-vagino^orvicaUi;
•en la fiebre de reab8orci6n, con loquioafttidot, y, particularmente, en la EndometriiU
jmerperal. En el primer caso observado, se tralaba de una multipera; huevo toto con
124 boras de anticipaci6n a la expulsi6n del feto; cinco d^imos de temperatura a la
isalida del producto de la concepci6n; durante este expulsi6n, fetides muy fuerte
procedente de la matris; la piel y las mucosas expuestes del reci^ nacido revelan la
•alteraci6n del contenido intrauterine durante las dltimas 24 boras; del terceio al
•cuarto dfa, eecalofrio con elevaci6n de la temperatura a 39^.8; los loquios espesoa,
-cremosos, de color gris rosado y muy f^tidos, contenfan abundantes ejemplarea de
pneumococos y en menor cantidad, tetrajenos y pequefias cadenas de estreptococos;
•dolor provecanfo-al CDmprtoifr Ids bndes kleralee del dtoo; facies p&lida y acuaadora
•de reacci6n peritonial intensa; pulso en 120. £1 tratemiento consisti6 en tres o
•cuatro irrigaciones con permanganate de potasa a 0 gr. 25 por 1,000; compreaas de
lalcobol sobre el vientre, media bora antes de entiar en el baf&o; dos o ties bafioa
eobre tibios por dfa, de una y media a tres boras de duraci6n.

La aplicaci6n del alcobol provoc6 siempre una diBminuci6n de 6 a 7 d^imos de
temperatura. La mejorfa fu^ inmediate; el beneficio subjetivo se biao evidente y
la enferma deda experimentar movimientos de la matriz que correspondian 4 la
'eliminaci6n de residues de membranas. La balneaci6n comenz6 al elevarse la
•temperatura por encima de 39^; dos d(as de bafios prolongados bastaron para la entnida
-en una convalecencia progresiva y r&pida.

£s muy posible que los resultados varfen en poco m^ o menos SQgdn la especie
onicrobiana que provoque la infecci6n, o que predomine en ella.

La acci^ maravillosa de estes bales se manifieste aunque su empleo sea teidlb,
<pero entiendo por experiencias posteriores, que el beneficio es tanto mayor cuaato
Ai&i temprano los utilisamos.

ACX:iON RBSPEEtATORU DEL DEPRESSOR CORDIS.

PorTEODORO MUHM,
Prqfe$or de la Univenidad de Chile.

El centre reepiratorio bulbar ha side objeto de constantes investigaciones de
parte de los fisi61ogos. 8egdn QwA este centre ocupa toda la formaci6n reticular, y
«u uni6n con los centTOs espinales, para hacer Uegar a ^stos bus impulses rftmicoe, ae
hace por intermedio del manojo reticular situado inmediatamente por detris de los
•cuemos laterales medulares.

La funci6n automitica del centre reepiratorio est& fntimamente ligada a la compoai-
«ci6n y temperatura de la sangre. Tanto la falte de O como la acumulaci6n de GOf en
la sangre son capaces de obrar como excitantes del centre, puesto que el descenso de
la presi6n parcial del O en el aire haste la mitad de su presi6n normal produce req>ira-
•ci6n dispneica, lo mismo que la acumulaci6n de GOf en la sangre, aun cuando este
dltima contenga una proporci6n normal o aumentada de O.

Segtin investigaciones practicadas par Zunte, parece que en estado de repoao la
acumulaci6n de GO, en la sangre constituye el excitante normal. Zunte demaWM

PUBUO HBALTH AND MEDICUHB. 268^

que el 002 empieza a obrar como excitante cuando su pr68i6n en el aire alveolar
alcanza de 19-25 mm. Hg; y como en estado de reposo la presidn del 00, en los alv^loa
08 superior a esa cifra, su acci6n excitante est& fuera de duda.

En el trabajo muscular el aumento de la capacidad respiratorianoserfadebido ala
acci6n estimulante del OO2, ya que su tensidn en la sangre no aumenta. Zuntz se
indina a creer que en el trabajo muscular se forman en el mtisculo, por .combu8ti6n
insuficiente, ciertos cuerpos ^idos, que inundando la sangre, Uegan al centre respira-
torio y ejercen sobre ^ste su efecto excitante.

La actividad del centro respiratorio est6 sometida a la influencia de impulses
tramitidos por las vlai alerentes mis diversas. Deede luego es manifiesta la accidik
del cerebro sobre la respiraci^n, como lo demuestran los cambios que esta sufre baja
la hifluencia de la voluntad o de impresionee morales.

liis interesantes son las modificacionee que sufre la actividad funcional del centrtr
bulbar bajo la acci6n de impulsos trasmitidos por intermedio de nervioe centrfpetos.
Entre ^stos es sobre todo importante, y ha side materia de grandes discusiones, la
acci6n de las fibras tenninales del vago en los pulmonee. Las funcionee reguladora»
que el vago ejerce sobre la actividad del centro respiratorio, quedaron demostrada»
con las experiencias cl&sicas de Bering y Breuer, segdn las cuales la distensi6n pul-
monar en la inspiracidn y la retraccidn pulmonar en la espiracidn provocan un»
excitaci6n medinica de las terminacionee del vago y aseguran la actividad rftmicik
ahemada de los movimientos respiratorios, que aquellos autores designaron con e%
sombre de ''auto gobiemo de la re6piraci6n."

Las respuacionee profundas y retardadas que se observan deepu^ de la vagotomi»
doble son debidas justamente a la ausencia del efecto regulador del vago.

Pero el mecanismo de acci6n de este nervio ha side objeto de las iiiterpretacione»
mis variadas. Aceptaban Bering y Breu^, y con ellos muchos otros autores, do»
dases de fibras centrfpetas en el vago, unas que ejercen acci6n espiradora y son.
exdtadas por la distensidn pulmonar, y otras de acci6n inspiradora son excitadafr
por la retracci6n pulmonar. Sin embargo trabajos posteriores sobre todo de Chd,
Loewy, Lewandowsky y Schenk, parecen inclinarse a aceptar en la respiracidn nor*
mal una acci6n inhibidora del vago sobre el centro respiratorio, aim cuando no niegaih
que existan fibras inspiradoras, como lo demuestra la excitacidn de la extremidad
central del vago seccionado.

Segtin estas investigacionee la distensidn pulmonar excita las fibras tenninales del
vago, las cuales ejercen una acci6n inhibidora sobre el centro respiratorio, provocando
la espirad6n. Los mismos trastomos observados en la vagotomfa doble no serfan nad»
mis que la expresi6n de la falta de acci6n inhibidora del vago sobre el centro, pro-
ducitedoee inspiraciones mis profundas, seguidas de espiraciones retardadas por
fatiga dd centro, SQgdn Qad.

Investigaciones mis recientes de Schenk tienden a demoetrar tambi^n que en li^
respiraci^ normal no interviene mis que una accidn inhibidora del vago sobre d
oentzo respiratorio. Las fibras excitantes del centro 0 de decto inspirador, entaran en
acci^ s61o cuando la retracci6n pulmonar es mayor que en la espiracidn normd, es
decir s61o en los cases de espiraciones activas.

Por lo demis, la excitacidn de la extremidad central del vago seccionado com«^
prueba la existencia en el vago de fibras excitadoras 0 de acci6n inspiradora, y de
fibras inhibidoras y de acci6n espiradora, puesto que ambos efectoe pueden conse-
gutrse SQgdn la naturdesa del excitante empleado.

Fuera del vago tienen acci6n sobre el centro respiratorio muchos otros nervios cen*-
trfpetos; basta recordar la accidn inhibidora de los larfngeoe superior e inferior, deL
trigteiino, del glosofarfngeo, y la accidn inhibidora o excitante de los nervios send*
bles de la pid. 0am puede decirse que no hay nervio centrfpeto que no pueda ejerceo
inlliienda en uno u otzo sentido sobre la actividad funciond del centzo respiratorio.

264 PBOOEEDINQS SECOND PAN AMSBIOAK 80IBKTIFI0 OONOBB88.

En el Archivio di Fisiologia oorrespoiidiente al 1^ de noviembre de 1913 se publica
un trabajo de Giovanni Gallerani sobre acci6n reepLratoria del nervio depresor de
Oyon. Sabemoe que Knoll habia negado toda relaci^ entre el estado de excitacidn
de lo0 nervioe sensiblee del corazon y loe movimientoe respiratorios. La lectura de
las inveetigaciones hechaa por Gallerani me indujo a hacer laa experiencias de, que
doy cuenta m^ abajo.

Segtin Gallerani el depreesor cordis tiene una acci6n respiratoria espedfica, que se
extiende a la fase espiratoria de la reepiraci6n y se debe a la acci6n excitante que este
nervio ejerce sobre un centro eepirador. Con excitantes d^bilee y de corta duracidn
se obtiene una mayor amplitud de la e0piraci6n, que desaparece luego, restable-
ci^ndose el ritmo normal. A vecee se producen todavfa algunas espiraciones mis
amplias intercaladas en la reBpiraci6n normal. Otras veces una excitaci6n d^bil de
la extremidad centaral del depresor da lugar a una fase espiratoria mis laiga seguida de
una detenci6n corta de la respiracidn en espiraci6n. Siempre esta detenci6n de la
espiracidn ee seguida de una inspiraci6n endigica que restablece el ritmo que se habfa
retardado un poco.

Con un excitante m^ fuerte se obtiene un predominio manifiesto de la espiracidn, a
tal punto que en los trasados la curva correspond iente a la espiraci6n desciende muy
por debajo de la abscisa; pero siempre estas espiraciones fcnrsadas y considerablemente
prolongadas vienen seguidas de una reacci6n inspiratoria endrgica. Cuantp m^
duradero ee el tetanus espiratorio, tanto mas endigica ee tambi6n la inspiraci6n si-
guiente. Prueba esto que el centro inspirador no pierde durante la excitacidn del
deprescNT su excitabilidad, sus funciones no estto, pues, inhibidas.

Paia inscribir los movimientos respiratoiios Gallerani introduce en el t6rax del
animal una cinula delgada, que pone en uni6n con un tambor insciiptor. Obtiene
asf una inscripcidn de los cambios de la presidn intnttoiicica en laa dos fMSi de la
fespiiaddn. Por consiguiente en las curvas que acompafian su tiabajo la lama aaoen-
dente del trasado oocresponde a la inspiraddn, y la lama desoendente a la espinddn.

Yo me he valido de otro procedimiento mis sencUlo para rogistrar los movimientos
respiratoiios. Gomo animal de expeiimentaci6n fu6 usado siempie el oonejo, naioo-
tisado con uretano en inyecddn intravenosa. Se hace un pequefio orifido en la
tr&quea, secdonando un andUo traqueal inmediatamente por endma del coerpo tiiddea
y se introduce por este oiifido una pequefia cinula recta de 1-2 mm. de diimetro, como
las que se usan corrientemente para inscribir la presi6n arterial de la car6tida. Esta
pequefia cinula se une a un tambor de Maiey, el que inscribe asf la presidn lateral
existente en la triquea y todos los cambios que sufre esta presi^ En esta forma la
respiraddn del animal no sufre trastomos de ningiina especie; no hay dispnea porque
la extiemidad de la cinula no disminuye el lumen de la triquea, y el animal sigue
respirando por las vfas naturales en perfectas condidones. Si las excuraiones de la
aguja inscriptora son muy grandes, se las puede disminuir ttdlmente por medio de un
tornillo de preei6n aplicado al tube de goma que une la cinula con el tambor inacriptor.

Oon una cinula en T, cuyas dos ramas se introduoen en las dos extremidades de la
triquea secdonada, y la tercera se une al tambor inscriptor, se obtienen anilogos ve-
sultados, pero este procedimiento tiene el inconveniente de obligar a secdonar la
triquea.

La curva No. 1 ropresenta un ejempb de un trasado obtenido por este procedimiento.
Oomo durante la inspiraddn hay presidn negativa en el ixbd respiratorio, la triquea
ejerce aspiraci6n sobro la columna a^rea del aparato registrador; la palanca inscriptora
desciende, pues, durante la inBpiraci6n, y esta fase respiratoria esti ropresentada por
la rama descendente del traaado. La rama ascendente coriesponde entonces a la esi^-
raci6n. El procedimiento es sumamente sendllo, registra las vaiiadones de presi6n
con exactitud y no modifica en absolute la resplrad^ del animal, aun cuando la
expeiidenda sea de laiga duraddn. No bay escape de aire por el pequefk) onficio
traqueal porque la sangre proveniente de la secd^ de la mucosa se a<fliiere a la cinula

PUBLIC HB4LLXH AVD MUHCian. 265

7 obfllniye entenunente el pequefio egpmdo que pudieia qnecUur entie la cinvla y los
boides del orifido.

A veoes la rama descendente del tiasado proionta pequefiaa eleyadonea que oome-
pottden a las contncdones cardkcae, y que pueden vene mis daiame&te dando
nuiyor veloddad al ciUndio lotaUnio del quimdgrafo.

For este aimple prooedimiento se ban obteoido las curvas de la refpind^n que
paeamoe a anaHaar, y que manifieetan los efectoa que hemes podido obtener sobre los
movimientos lespiiatorioB per ezcUad^n del nervio dejuresor.

La laiga serie de experiendas leferentes al tema que tratamos fu6 hedia con la
colabofadi6n inteligente y sostenida del Dr. Jos6 8alas» Jefe de tiabajos pfictioos de mi
laboralorio, a quien me hago un deber en expiesar en esta ocaaidn mis sinoetos agia-
dedmientos per su eficas ayuda.

Se tnbaj6 exdusivamente en oonejos adormeddos con uietano en inyeoddn intia-
yenosa y en dosis propordonal al tamafio del animal. Paialaezdtaddn del nervio se
ue6 la bovina de Du Bois-Rejrmond; la intensidad del ezdtante se ha maicado con d
ntkmeio coRespondiente a la separactdn en centfrnetros de las espirales primaiia y se-
cundaiia del aparato.

No doy cuenta del examen de todas las curvas obtenidas; aqueUos tiaaados en que
la acci6n respiiatoria observada puede interpretaoe como efecto de lamificadones de
la coiriente, fueron eliminados. De las dem^ curvas basta la exposiddn de algunos
ejemploB en que los resultados son bien manifiestos y se deduoen daramente de los
tiasados cotrespondientes.

Exferieneia deSde naviemJbn de 1916. —Ocfoeio de 2,000 gr., uietano 1.20 gr., tiempo.
0.y<. La ezdtadondd depresorisquiecdoconexdtante d^il (14) produce ya una
acd^ dani sobre la lespirad^ oomo lo muestia la curva No. 2, y que coiMiiste en una
menor amplitud de la fase inspiratoria. La Inspiiadmi, mfm snpeifidalf esU ligeia-
mente retardada, de tal modo que a pessr de las inspiiadones menos ampUas penna-
nece sin alteiad6n d ntoero de respiiadones en la unidad de tiempo.

Un efecto aniUogo sobre la intensidad de la inspirscite se encuentn en las curvas-
No. 3 y 4. Pero no hay aquf prdongacidn dd movimiento inqpiiatorb; por oond-
guiente se jHoduce por las insi^radones mU snpeifidales una ligen aoeleraddn de la
respirad^.

Igual acderaddn se nota en la curva No. 5, conespondiente a un exdtante mfm
fuerte, en la cual la memv amplitud de los movimientos inspisatorios se haoe espedal-
mente notable. La interrupddn que sufre la rama descendente dd tiasado durante
la ezdtaddn dd nervio, esdebida a movimientos de de^udto dd animal; no cocies-
ponde, por lo tanto, a una acddn dd nervio wtAnte la respiraddn.

Con ezdtantes muy inteusos, como en la curva No. 6, se produce un retaido de la
respiraddn dd)ido a una carta detend^ki en espirsd^. Las espiradones son activas
y vienen seguidas de inspiiadones profundas por reacci6n mis en^igica dd centro.

En la exdtaddn del depieeor derecho con exdtante 15 (curva No. 7) se obtiene la
mlama acci^ que se produjo en d depresor iiquierdo con exdtante d^bil. La
acderaddn de la respiiaddn y disminuddn de la amplitud inspiiatoiia se presenta
claia con exdtante 11 (curva No. 8), y se hace muy notable con exdtante 10 (curva
No. 9), en que predomina sobie todo la acci<5n inhibidora sobie la inspinMudn.

A medida que aumenta la intensidad dd exdtante, se hace m&B marcada la die-
minud6n de la &se inspiiatoiia, las inspiradones se hacen mim superfidales. Este
doble efecto se observa espedalmente bien en la curva No. 26 en que la acderaddn
es muy manifiesta por la menor piofundldad de la respiraddn.

De las curvas obtenidas en este animal tonuido como ejemplo, se despiende daia-
mente una acddn inhibidora dd depresor sobre d centro respiratorio. Esta acdtfn,
con excitantes d^biles, no tiene otro efecto que disminuir la eneigia de los movimien-
tos inspiiatorios y produdr asf una acderaddn de la respiraddn. La aceieiaddn
es, pues, la consecuenda de la acddn inhibidora.

266 PB0CEEDING8 SBOOKB PAH AMEBICAK 80IBKTIFI0 CONOBE88.

No.l.— Lasoorvasseleendeiaqiiierdasdereoha. Oonejo 2,300 grClorallgr. Inseripcidn de la raspinddn
OOD peqoefia cAnuia arterial en la triquea 7 cApsula de Marey. La inspiracidn oorrespoade a la nsuk
desoeactente, la espirMsldn a la rama asoeadente.

^^^^Al^U!\^

¥ V V u

fHWfHmHH

Ma2.— Ezperienciade3deNovlembredem5. Conejo 2,000 gr. Uretano 1,20 gr.:Tiempo 0,5". Excitadda
del depresor Uquierdo. Ezdtaiite 14.

No. 3.— Bxperiencia de 3 de Noviembre de 1915. Excitacldn del depresor isquierdo. Excitante lOi

Na4.— BxperieiMiadeSdeNoviembradel915. Exoltadda del depfeeor iiqaiexda Ezdtaoteft.

, VANWWiVWiVAWMWM

IV0W 5.— BzperleDcia de 3 de Noyiembre de 1915. Exdtaddn del depresor iiqaierdo. Bxettwite 7.

PCBUO HEALTH AJTD MEDIOnnt.

267

Na <L— ExperieneUt de 3 de Noviflmbre d« 1916. Ezeltaoite dd dcpnsor iiqaterdo. Exoitante 4»

No.7.— ExperleiieUde3deNovi«mbredel916. BxdtMidn del depvMor dtfwha Ezdtante 1&

No. &— Experieooia de 3 de Novlembre de 1015. Exdtacidn del depresor dereoho. Exdtuite 11.

Na9.~ExperlaiMlftdetdtMofliiiBliftdtlfllb XaollMidBdridtpnMrdifwiMw Esdtaoteia

268 PB0GBEDING8 8BC0KD PAN AMBBICAK 80IBNTIFI0 C0NGBBS8.

iMiM.VfVtWA^

No. 10.— Experieneia de 5 de Noviembre de 1916. ConeJo de 2,500 a. Uretano 1, 5 gr. Tiempo, 0, 5".
Bxoitaddn del deprosor izquierdo. Exmtante 12.

No. 11.— Ezperleoela de 6 de Noviembre de 1915. Exoitaoidn del depresor derecho. Exdtaiite 9.

No. 12.— Bxperienela de 7 de Noviembre de 1915. Coneio 2,400 gr. Uretano 1,6 gr. Tiempo0,5". Ezol-
taddo del depiMor itqulerdo. Exdtante 14.

i'/MWrW/iWiWiW

No. IS.— Bzperieoda de 7 de Noviembre de 1915. Ezoltaddn del depntor iiqaierdo. Exdtante 11.

PUBUO HEALTH AND MEDICINE.

269

No. 14.— Expeileiiota de 6 de Noviembre de 1015. Conejo de 2,400 gr. Uretano 1, 6 gr.
J2 Ezoitaddn del deprosor Izqiilexdo.

Tiempo 0^"

No. 15.— Experiencla de 6 de Novieinbre de 1915. Exoltacidn del depresor derecho. Excltante 12.

W<W^ViSW¥M

No. 10.— Experlenoia de 6 de Noviembre de 1915. Excitaddn del depresor iiquierdo. Exdtante 11.

Nowl7.-^xportaieiAde20deOetabredel01fi. Conejo de 2,000 gr. Urr tano 1^ gr. Cloral0^gr.iLSaol-
taddndeldepraioriiqaiMdo. Eaoiteiite9.

270 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NQBE8B.

No. 18.

-Expeiiencia de 9 de Noviembre do 1916. Ckmejo de 2.000 ge. Uretano 1^ gr. Tiempo (V6"..
Excitaddn del depresor icqulerdo. Exdtante 15.

No. 19.— Exporiencia de 9 de Noviembre de 1916. Exdtacldn del depresor izquierdo. ExciteDte la

No. 2CL— KxpvdeiMiii 4« 0 lit Kcidenibr» d« 11116. £lteit>d6a dd depitacir dcrt^iio Kxrltiuilc^ 10.

No. 21.— Ezperiendade 7 de Noviembre de 1916. Conejo de 2,400 gr. Uretano 1,6 gr. TiempoO^'. BxoU
taddn del depresor derecho, de&pufo de la seeddn de ambos vagos. Exdtante 13.

Na 33.-Bzpeiteiida de 7 de Noviembre de 191ft. Bxdteddn deldeprawrdenoho^deqniitdtlA

de ambos «_ -^--^ —

FUBUO HEALTH AND HEDIOINB.

271

Na^.— RxperienciadeatUle()cturle(l«191fi. Coi e)o de 2.000 gr. Urctanol,20gr. donlO^gr. Ezd-
taci6n del depresor Uquierdo. Exoitunte 13.

MoL 34.— Experiencia de 26 de Ootubre de 1915. Exdtacidn del depresor ixquiprdo con excltante 10.
traado inferior ocwresponde a la presidn oarotldea.

No. 25.— Expericncia de 3 de Noviembre de 1915. Excitaddn del depresor derecho. Excltante <L

No. 20.— Expericncia de 3 de Noviembre de 1915. Excitacii^n del depresor derecho. Excitants 4.

272 PROCEEDINGS SECOND PAN AMEBIC AN SCIENTIFIC C0NGBB88.

Pero no pueden explicaree de U miflma mano^ IO0 efectos producidofl por ub ex-
citante intenso. En e0te caso se txata ya de espiraciones activas con gran retzacctdn
toiidca, como lo demuestra la elevaci6n de la lama espiradora del trazado en la curva
No. 6 y tendencia a la detenci6n de la re8piraci6n en e8piraci6n. Aqui ha habido
evidentemente una acci6n eepiradora activa del depreeor, 0 eea una acci6n intenaa
flobre un centio espiratorio.

Con igual claridad se puede ver eeta acci6n en la curva No. 26, que corresponde a
una excitaci6n del depreeor derecho con excitante intenso.

De la miama manera pueden explicarse loe resultadoe obtenidoe en la experiencia
siguiente:

Experiencia de 6 de noviemhre de 1915.— Conejo de 2,600 gr., uretano 1.6 gr., ti^taipo
0.6^^. Con excitante 12 (curva No. 10) aplicado al depresor icquierdo se obeervan
desde el comienzo de la excitaci6n espiradones en^rgicas, seguidas de inspiradones
profundas y muy lentas, que retaidan considaAblemente la respiraddn. Estaa ina-
piradones ((Hrzadas y diffdles son seguramente debidas a la reacci6n intensa del
centaro despu^ de las espiraciones acHvas produddas por la acddn del depresor.

En el depresor derecho (curva No. 11) el efecto espiratorio de la excitad6n se mani-
fiesta por esptradones activas muy en^igicas que vienen seguidas siempre de una
reacddn inspiratoria manifiesta.

La acci6n inhibidora y espiratoria del depresor se hace mucho mka notable al se
trabaja en un animal cloralizado. Bajo la acd6n del cloral se exalta la hinddn
espiratoria del centro, como pudo demostrarlo primero Fredericq, y la acci6n inhibi-
dora del nervio depresor se revela con mucho mayor energia.

Un ejemplo de esta acd6n intensa bajo el etecto del cloral presentan las curvaa
Nos. 23 y 24 de la experiencia correspondiente al 26 de octubre, hecha en un conejo
de 2,400 gr. que habfa recibido 1.20 gr. de uretano y despu^ 0.26 gr. de doral en
inyecd6n intravenosa. La excitaci6n del depresor izquierdo con exdtante 13 pro-
duce ya una menor amplitud de la inspiracidn, con detend6n respiratoria en eqyiia-
d6n. Este efecto se hace mka claro con un exdtante algo mka intenso (curva No. 24),
pues la detend6n espiratoria es de mayor duraci6n y viene seguida de una inqura-
ci6n superficial y una nueva detenci6n en espiraci^n con tendencia a la inspiraddn,
por la sobreexdtad6n del centro respiratorio por la falta de ventiladdn de la san^.

Pero esta acd6n espiradora e inhibidora del depresor no ee constante, como puede
verse en loe ejemploe siguientes:

Experiencia de7 de noviembre de 1915, — Conejo de 2,400 gr., uretano LOO gr., tiempo
0.6^^. Como lo muestran las curvas Nos. 12 y 13, la excitad6n del depresor izquierdo
tiene por resultado una mayor profundidad de los movimientos inspiratorios, que en
el trazado se manifiesta por un mayor descenso de la rama inspiradora. Esta mayor
amplitud inspiratoria trae consigo \m ligero retardo de la respirad6n. El estado de
polipnea en que se encuentra el animal antes de la exdtad6n no impide que se mani-
fieste la acci6n excitante del nervio.

Experiencia de 6 de mmenUn-e de 1916, — Conejo de 2,400 gr., uretano 1.6 gr., tiempo
0.6^"^. Por exdtaci6n del depresor izquierdo (curvas Nos. 14 y 16) se obtiene una
ligera aceleraci6n de la respiraci6n sin que se modifique la amplitud de los movi-
mientos reepiratorios.

En la exdtad6n del depresor derecho (curva No. 16) se produce un notable aoor-
tamiento de la fase espiratoria del trazado, lo cual da lugar igualmente a una acelera-
d6n de la respiraci6n.

Muy interesante es la curva No. 17 que corresponde a otra serie de experiendas
en estudio, sobre el coraz6n suspendido del conejo. Se trata de un animal de 2,000
gr. que ha redbido 1.6 gr. de uretano, y 0.26 gr. de cloral en inyecddn intravenosa.
La exdtaci6n del depresor izquierdo con exdtante 9 produce mayor profundidad de
los movimientos inspiratorios a pesar del cloral administrado.

PUBUO HBALTH AND MBDICIKB. 27S

En eftot ejemplos ae tota sin duda algium de una acd^ exdtante del depniot
■obre el centro respiratorio, acd^n que prodtice inqnradonee mis profundaa, o Men
acorta la feee espiiatoria, como queda de manifieeto en la cnrva No, 15.

Eeta acci6n excitante del depresor se hace marcadlBima si se exdta el nervio deepn^
de la 8eccl6n de Iob vagoe, como lo demuestran las curvae 21 y 22. 8e trata del miflma
animal que BominiBM las curvaa Nob. 12 y 13. A consecuencia de la vagotom(a
doble la reepiiacidn se ha hecho may lenta, sobre todo por mayor duraci6n de 1% faee
inepiratoria. Si en estas condiclonee se excita el depreeor, se c4>tiene una acelefaci6n
de la respiiacidn y una enonne ampliacidn de las inspiiaciones. La acci6n excitant*
se prolcmga alg6n tiempo despu^ de terminada la excitacl6n, y poco a poco la res*
piimoidn vu^ve a adquirir su tipo caracteristico.

Bastan los ejemplos menclonados en esta relaci^n, y escogidos de una serie de
ezperiencias de ani&logos resultados, para deducir que el depreeor de Cyon tiene en
electo una acci6n respiratorla, como la tienen en general los nervios eensibles. Peio
esta acci6n no se manifiesta siempre en un solo sentido; es declr, el depreeor no ejerce
fltempre una acci6n esplratoria, no tiene una aoci6n especificii como, lo sostiene
CMleranl.

No puede, pues, compararBO su acci6n sobre la reBpirBci6n con la acci6n especifica
de los larfngeos, cuya excltacl6n se traduce siempre por una acci6n inhibidota sobre
el centro; ni con la acci6n del eepl&nlco, cuya excitacl6n produce siempre detenci6n
de la respiraci^n en espiraci6n.

Mientras tanto, los trazados expuestos en este trabajo demuestran que el nervio
depresor, adem^ de su acciSn inhibidora manifiesta, puede tambi6n ejercer una
aoddn excitante sobre el centro respiratorio, que consinte en una aceleraci^ de la
respiracidn y mayor amplitud de sus dos fases.

BIBUOGBAViA.

Bonittau. Handbuch der Fhysiologie, I, p. 29, 1909.

Boruttau, Ergebnisse der Physiologie, 1902. 1. Jahrg., II. Abt., p. 403.

Bonittau, Ergebnisse der Physiologie, 1904. 3. Jahrg., II. Abt., p. 89.

Bering y Breuer, Sltzungsber. d. Wien. Akad., 2. Abt., Bd. 58, pp. 909, 1868.

Gad, Du Bois-Reymond, Arch. f. Physiol., 1880, p. 1.

Lewandowsky, Du Bois-Reymond, Arch. f. Fhys., 1896, pp. 195-483.

Amheim, Du Bois-Reymond, Arch. d. Phys., 1894, p. 1.

Meltzer, S. J., Du Bois-Reymond. Arch. f. Phys., 1892, p. 340.

Alcock y Seemann, PflOger's Archiv, pp. 108, 426.

Head, Joum. of Physiol., Vol. 10, p. I.

Knoll, Sitxungsber. d. Wien. Akad., 1883, LXXXYIII, 3, p. 23.

Fredericq, Du Bois-Reymond, Arch. f. Phys., 1883, Supplement-Band, p. 61.

Lewandowsky, Du Bois-Reymond, Arch. f. Phys., 1896, p. 216.

Schenk, Pflflger's Archiv, 100, p. 337, 1903.
. Falk, Du Bois-Reymond, Arch. f. Physiol., 1884, p. 455.

Graham, Pfl tiger's Archiv, 25, p. 379, 1881.

Ishihara, PflOger's Archiv, 106, p. 386.

C. Gordon Doug^, Eigebnisse, 1914, p. 338.

Ademis se encuentran datos completes sobre la literatura de las funciones del centio
resptratorio en:

Boruttau, Ergebnisse, 1904^ 3. Jahrg., II. Abt., p. 89.

B<nruttau, Ergebnisse der Physiol., 1902, 1. Jahrg., II. Abt., p. 403.

Schenk, F., Ergebnisse, 1908, 7. Jahrg., p. 65.

274 PROCEEDINQS SEOOHD PAN AMBBICAK 80IBNTIFIC C0KGBE88.

LEPRA T ArrOSANGROTERAPU— NECESIDAD DE UNA UGA PANABfE-

BICANA ANTILEPROSA.

For LUIS ZANOTTI CAVAZZONI.
Ex Profuor de la Univenidad Nacumal del Paraguay.

La lepra, azote de laedad media y espanto de la sociedad modema, esti tomando un
incremento tal, que es necesario, digo IndispeDsable que loe Foderes P6blicoe y Entes
OientificoB se unan para d^tener su marcha progreaiva.

Hoy no podemos ni debemos Vdyer a las medidaa fahumanan de 8egregaci6a uaada
«ii lo8 tiempoe antiguoe, justificadas Bolamente por el estado de la medidna de anftafio;
hoy en la 6poca de grandes progreeos, al acoooejar medidas higi^caa de rigor, no
■debemos pionundar una condena de muerte dvil para el pobre leproeo, sino, mis bien,
infundir en ^ y en su ambiente la esperansa de una curaci6n no lejana.

LA. LEPRA SB OUBA.

La natundeza misma nos propordona testimonios de casos de lepra curados es-
pontineamente.

La lepra se cura y no ialtan espedalistas que cuenten con casos de lepras sanados.

Si la lepra se cura espont^neamen^ eirf>orque el organismo'^uefita con medios de
<lefensa victoriosos contra el agente pat^no.

Si la lepra es en algunos casos curada es porque el m^co ha encontrado el modo de
<lespertar y exaltar los medios de autodefensa del oiganismo.

Asf pues, hay necesidad de conocer cuales son las fuerzas defensivas de las que dis-
pone el organismo para la lucha, saber en que tejido u digano se encuentran y dosirro-
Han, secundarlas y exaltarias con medidas higi^cas y terap^uticas.

Desde el afio de 1905 me dedico al estudio de la terap^utica antQeprosa, ensayando
cuantos m^todos de cura fueron aconsejados y modificdndolos segdn los casos cUnicos
tan pareddos entre sf y sin embaigo siempre profundamente diferentes; asi, entie
altemativas de desilusiones y de esperanzas de 6xito, en 1008 uno de mis dientes,
atacado de lepra, hombre robusto y joven, redbi6 una herida contundente en el tSrax
•que le form6 un versamento sanguinolento en la pleura isquierda.

£1 enfermo estuvo bastante mal por espacio de varios meees y con medidas terap^u-
ticas apropiadas, con gran satisCacddn suya y mf a al curarse de su pleuresfa fu6 tambidn
mejorando paulatinamente de sus manifestadonee leprosas.

No desperdid^ la ensefianza que la casualidad me brindd. Este padente habfa
mejorado de sus manifestadones leprosas en la relad6n con la reabsorddn de su ver-
samento pl^urico; en la sangre puee, se encontraba el quid que necesitaba su defenaa
natural orginica, que faltaba sdlo ser exdtada para hacerse m&s activa y m&s extensa.

Completamente curado de la pleuresia, continue por varios meses inyect&ndole cada
•odio dias 20 cm. c. de su misma sangre, sin ninguna preparad6n previa y combinando
•este m^todo con varios tratamientos he conseguido hacer desaparecer todas las manifes-
tadones morbosas que tenfa y hoy hace ya siete afiosque contintbicon perfectasalud.

En 1913 he publicado un primer trabajo describiendo el nuevo m^todo de cura de la
lepra que he nombrado autosangroterapia antileprosa.

La autohematoterapia no era nueva en la elf nica, ya en algunas enfermadades habla
«ido ensayada con bastante 6xito por varios experimentadores pero tales estudioe no
habian ll^ado aun a mi conocimiento en 1908 y hasta hoy mismo creo, nunca fu6 en-
sayada contra la lepra.

Hoy la autosangroterapia es muy usada y gran ndmero de enfermedades son com-
batidaa con ella y como ya escribf en 1913 este m^todo es dentifico porque basado
sobre hechos reales, cuales son la presencia en la sangre de cuerpos inmunizantes (aglu-
tininas predpitinas, opsoninas, lidnas y antitoxinas) en estado de particulas ultrami-
<3rosc6picas (emulsion fina o suspensidn) al igual que soludones coloidales el^tricas
^C. Spengler) que se encuentran con mAs abundancia en los eritrodtos, menos en los
leucocitas y plaquetas, escasos en el suero.

PXmLIO HEALTH AND MEDIOINB. 275

Puada ter tambi^ qua U reftbaorcidn de U Mtngre reinyectada bajo U piel oblig:a6
al oiganismo a poner en actividad una mayor cantidad de anticuerpos.

De aquf la neceaidad que IO0 Gentroe Cientificos que disponen de grandes recuiaoa
y de laboratorioa perfectoa se aduefien del leproeo y bajo este m^todo de cura lo analiceni
k) experimenten iobre TMta eacala y lo apnieben o modifiquen o rediaien.

El tiempo concedido paia estaa oomunicadonei a IO0 Congresoa no me permlten
eztendenne mis, peio lo har^ en una prdxima publicaci6n sobre autoeangroterapia y
aieroaina.

Al dar por tenninada esta breve comunicaci6n me atrevo aifoiificar a IO0 iluatradoa
congreaiataa que seria muy honroso para elloa y 6til para la humanidad que de este
Congreso aurgiera la fundacidn de una liga pan<aneneana contra la lepra que fomen*
tando y centralizando IO0 eatudioe iobre la enfermedad emitiera dicUmenea de profi-
laxia social e indicara m^todos apropiadoa de cura, premiando a IO0 que con sua trabajos
mis contribuyeeen a la aQluci6n del problema terap^utico antileproeo y U^gaaen a
deecubrir un tiatamiento especffico.

Col. John Van R. Hoff. I move, sir, that the resolution proposed
in the paper of Dr. L. Zanotti Cavazzoni be referred to the committee
on resolutions.

Secorded ard approved.

Through the courtesy of the writers, the followirg printed volumes
were presented to the congress at this session of Section VIII:

Represi6n del Alcoholismo, by Dr. Atilio Narancio. Imprenta
''El Siglo Ilustrado/' Montevideo, 1914.

£1 Naturismo en el hogar, by Antonio Valeta. Biblioteca del
Cei tro, ''Higiene y Salud/' Montevideo, 1915.

Adjourned at 5.45 o'clock.
68436— IT—VOL ix 19

JOINT SESSION OF SUBSECTION C OF SECTION Vm AND
THE AMERICAN ASSOCUTION FOR LABOR LEGISLATION.'

Shobeham Hotel,
Wednesday afternoon^ December £9, 1915.
Papers presented:

Child labor and public health, by Owen R. Lovejoy.
Legal protection of female wage-earners, by John B. Andrew's.
El trabajo en la mujer embarazada, by Dr. Augusto Turenne.
Factory sanitation, by Dr. E. R. Hayhurst.

CHILD LABOR AND PUBLIC HEALTH.

By OWEN R. LOVEJOY,
OeMraH Secretary Nationdl CkUd Labor CommiUee, New Ybri,

XJntal within two or three years our efforts to protect the health of working children
have been strangely scattered and unscientific. Efforts to secure child labor laws
have usually been based on the presumption that very young children were being
robbed of pleasure or opportunities for education, and should therefcure be excluded
from industry to preserve the territory of childhood. When statements have been
made condemning child employment as injurious to public health, and proof has
been denumded, advocates of child protection have been lamentably barren of facts
to produce conviction. Now, with a Fede^ Children's Bureau, devoting a large
share of its attention to a study of menaces to the health of children,* with an increasing
number of public health boards in our States and in large centers of population, and
with a growing interest in industrial hygiene, we seem to be entering on a new era.
It is possible, indeed, that we have now reached the point at which the public can
be aroused against the practice of exploiting young children by the industrial hygiene
and sanitary aq>ects of the problem with more direct effect than has been seciured in
response to other aiguments.

Prof. Teleky, of Vienna University, has lately published a report * on the physical
effects of labor on wage-earning children. His study shows especially the suscepti-
bility of working children to tuberculosis, but he found also that the general sickness
rate in a given group of children increases as they leave school to go to work. The
increase continues, so that in a i>eriod of four years it is greater the fourth year than
it was the first. That is, the wear and tear of industrial life tells upon the children
and produces in them physical ills that increase rather than diminifth as time goes on .

For eanke years students of child-employing industries and public health questions
have felt that scwiething like this was true, but unfortunately we have not <^ten sue*

1 There was no stenographic report of this session.

s The Federal Children's Bnreau, Department of Labor, Washington, D. C, established Apr. 6, 1913,
Miss Jnlia C. Lathnq^, Chief.

* Teleky, Ludwlg, FOrsorge bei der Bemlswahl mit Rtlcfasicht aof die Tuberkoloee, Wiener kUnische
Wochenschrlft, 1918, XXVI, 421.

276

PUBUO HEALTH AND MEDIQIKB. 277

ceeded in getting the facts efpedfically set forth, as Prof. Teleky has done. We have
been slow to respond to the demands for some system of tabulation and record-keeping
that would serve as a log book of industrial hygiene in the labor voyage of the indi-
vidual child. One of the difficulties has, perhaps, been our unwillingness in this
country to give a proper share of attention to measures designed to prevent unsocial
conditions. We are strong for the cure of flagrant ills, but weak on the constructive
side. Any one of our cities will whip itself to a foam of excitement over the tragedy
of a few score lives lost in an industrial fire inip behind locked doors or in an im-
properly constructed school building, but when, between fires, calm efforts are made
to secure budget appropriations either in State or municipality, we instinctively
revert to our reckless optimism, composed of the elements of hope that the tragedy
will not recur and of the desire to avoid a heavier tax burden.

Perhaps we can best approach a consideration of the present need by asking exactly
what it is we desire to accomplish, and the obvious answer seems to be that we desire
on the one hand a healthy, well-developed citizenship, and on the other hand a
sound industrial organisation, which shall mean opportunity, happiness, and life to
those invdved in it. This analjrsis of our goal requires a more patient and detailed
system of public record-keeping than our intensely democratic peq[>le have thus far
seemed willing to tolerate.

Before presenting a specific suggestion on both these lines, we may wisely consider
Bome of the actual figures that have been presented in the few States where records
are kept of the rdaticm of child labor to health. Nothing can so vivify for us the case
of the working child as do the mere unvarnished facts presented by public health
authorities. We find, for instance, such occui>ational injuries as are described in a
recent report of the Maryland Bureau of Statistics and Information: ^

Fred , age 14, employed by , manufacturers of picture frames. Worked

putting bronze on frames. Produced severe conjunctivitis of the eyes; throat coated
with bronze dust; expectoration of green bronie matter.

John , age 15, employed oy , enameling and stamping company.

Boy handled grease and enamel. Occupational dermatitis, severe irritation of skin
of hands and aims.

James , age 16, employed by , chair factory. Worked sandpapering

woodwork adjacent to jointers and stainers where lead enamel was used, the fumes of
which produced symptoms of headache, gastric pains and nausea, sore and psde gums ;
teeth anected; became pale and weak; metallic lead breath.

Joseph , age 16, employed by , opticians, as apprentice boy. Worked

drilling and cementing in wfaidi wood alcohol is used. Fumes made boy sick, pro-
ducing nausea and vomiting, asthma, inwDmnia, j>upil8 unevenly dialated.

Edward , aced 14, employed by , agar makers, as errand boy. Fumes

of tobacco produced symptoms of headache, sick stomach. He became weak, witii
diidated pupils and tobacco palloi^--a dear case of nicotine poisoning.

In another report* weleam of other injuries to children, this time due to machine
accidents:

F. S. , male, 14^ nail sticker, earning $4 a week operating American listening heeling
madiine. A nail flew out of the loader as nails were released. Injured boy attempted
to brush it off with his finger. He was caught by descending drivers. Bone broken
in forefinger of left hand between first and second joints. Flesh torn and cut.

F. K., male. 16, earning $8.50 a week operating baling press. Gearing wheels
carefully guarded. Notwithstanding, he stooped and placed his hands under the
guard to the gearing wheels. Lacerated first finger, amputation second and third finger
at the firat join.,; lacerated middle finger.

M. C, female, 14, earning $3 a week, operating automatic cutting machine. Was
waiting for work to be given her and took screw driver and was scraping aroung with it ;
she put her foot on the starting lever and drew in the screw driver, also her finger.
First finger of left hand was smashed and apparentiy broken and was later taken off
at tiie firat joint.

1 From a special report of medical examiner of the Maryland Bureao of StatbUoiand Informatlan, BaHl-
more, Md., October, 1918.
< From the second report of the New Yo^ State Factory IkiirMtl0ating CcmmiaUn, 191S, Vol. 1, 1S4.

278 PBOOEEDINOS SBOOFD PAK AMBRIOAN SCIENTIFIC C0NQBE88.

nieee are but a few o! the many cases reported, but they force upon U9 a recognitioii
df the hazards of industry for the working child, and we must r^ard thoM hazards as
all the more serious when we realise that in the cases here cited children were on-
ployed at trades not generally r^arded as dangerous. They were employed at
occupations which in our present state of enlightenment we consider saie. To be
sure, we recognize lead poimning as one of the most insidious of industrial disoaases,
but even where we have forbidden children to work at trades in whidi lead poisoning
is probable, we have not realized that a child working near jointers and stainen
using lead enamel may in a comparatively short time be affected by the poison. In
the same way, althou^ the most advanced States have forbidden the operation of
dangerous machines by children, we have been slow to recognize that machines
apparently safe, and in feict safe for adults, may become highly dangerous at the hands
of the untrained and the immature. A case in point is the employment of children
as slate pickers in anthracite coal breakers. While coal mining is regarded as a
dangerous occupation, it has been pointed out by various officials that the employment
of children as slate pickers in a coal breaker is not a dangerous occupation and that
physical injuries usually occur when children are away from their work running
unsupervised about the building. Some years ago a report of the Department of
Mines in Pennsylvania showed that in this one comparatively safe branch of the
industry,' injuries to children 16 years of age and under were three times as frequent
as those occurring among adult laborers. The report significantly stated that if the
boys would sit at their task constantly and attend to business they would not be
injured but that their injuries occurred iniiile running around the building. Thus
we must recognize not only the hazards connected with a given occupation or with a
branch of the occupation, but the general siuroundings to which a child, lacking in
caution, foresight, and judgment, may be exposed.

A fow years ago the National Child Labor Committee drafted a model for uniform
State laws, know as the "Uniform child labor law." * Thi? received the official
approval of the National Commisaoners on Uniform State Laws and has since been
indorsed by the American Bar Association. This law, which at the time it was
drafted embodied the be«i provisions in various State laws, has seven sections dealing
directly with dangerous trades. Children under 16 are prohibited from working in the
more obviously dangerous trades, such as in operating dangerous machinery, on rail-
roads and vessels, in occupations in, about, or in connection with poisonous adds, dusts,
or gases, in heavy building trades, in mines or quarries, in bowling alleys, and similar
occupations. Another list of still more dangerous occupations are prohibited to children
under 18 years of age. Both lists of occupations are described in fuU in paragraphs ap-
pended to this paper. A feature still more important perhaps than these specific pro-
hibitioni* is contained in two other sections of the bill, one of which empowers the State
board of health to add to the list of prohibited occupations any that are found to be
dangerous to children under 16 years of age and the other section gives the same power to
the State board of health to put the ban on other occupations for children under 18 yean
of age. This is decidedly ^e best law we have to offer herein America as a standard
of health protection for working children, but even in advocating it we should not
regard it as ideal but simply as a first step toward better standards. The power con-
ferred upon State boards of health to discriminate among industries is a feature of
great potential value, because if we are sure that all dangerous elements in industry
have been completely checked up, the more elastic we can make the law, the better.
However, we believe it is the dangerous element in an occupation rather than the
occupation itself which should be carefully specified; that boards of health might be
empowered not only to prohibit children from certain occupations acknowledged to

> Report or PmnsylTtiila Peptitment of MlnM, 1905.

> Uniform Child Labor Law, Pamphlet No. 147, published by National Child Labor Committee, 106 Bast
Twnty-oeoQDd StreH, New York City. (Oat of print.)

PUBLIC HSALTH AND ICXDIOIKB. 279

be daiig«Kous but to prevent their employment in dangerous piocowoo of occupatione
that may be regarded as on the idiole safe. In some States, lor instance, even the
w<(»rk in mines and quarries is not recognized by law as dangerous.' Yet in Minnesota
between 1909 and 1912 there were 224 accidents in mines as compared with 112 in
lumbmng and woodwork, 69 in contracting, and smaller numbers in other industries.
Nowhere is agricultural employment considered unsafe.

Perhaps tor the present we may safely say that if a trade is so dangerous that we
have to take special precautionary measures to safeguard adults engaged in it, or have
provided spedal compensation or medical inspection for the workmen, or if accidents
are known to be frequent, then that trade is one from which children should be
entirely excluded.

The question who shall be regarded as ''children ' receives a variety of answers.
In popular opinion child labor refers to employment of children under 14 years of age^
3ret according to the standards we have been seeking to establish, the r^:ulat]on ol
child employment applies to those under 16, under 18, and in the extra-hasardous
occupations, to children under 21. From the standpoint of social consolation this
seems the only logical answer. The law designates the twenty-first birthday as mark-
ing the beginning of mature life. Until that age no young man is supposed to be
capable of handling {woperty or exercising tiie franchise; although in most of our
Ccoomonwealths girls are regarded as competent to handle property at 18 yearv of age»
they are. on the other hand, never considered competent to exercise the franchise.
Assuming 21 years to be the reoognixed beginning of maturity, we desire to suggest
the two lines of rec<nrd keeping referred to at tiie beginning of this paper.

First, there should be a carefully and scientifically analysed tabulation of industriee
and branches of industries tor the purpose of determining their degree of hazard,
either measured in terms of accident or of effect upon general health. This will
require an amount of investigation and scientific research quite beyond the abilitiee
of any small group of officials appointed from political considerations and starved by
community parsimony. It may mean, in many instances, a succession of record
keeping covering a period of 5 or 10 years in order that the more insidious and subtle
effects (which, after all, are frequently more far-reaching than sudden and tragic
accident) may be carefully checked and evaluated. The public health organisatioiis
of this country, whether municipal. State, or national, must be leagued together in a
campaign to measure the industries upon idiich society depends in terms of industrial
hygiene and sanitation, and whatever expense is involved in carrying out so exten-
sive a program must be undertaken with tiie sure conviction that wherever material
wealth is built up at the expense of safety and health, a mortgage is being tetened
mpon the future too heavy for coming generations to raise.

The second field of investigation is the child himself. Here we venture the sug-
gestion of a continuing physical record of the individual child. During the early
years this would not be difficult since all our children are presumably in school*
We conceive it possible that eVery child on entering school should be examined and
a record made of physical defects, deformities, obvious tendencies, together with
height, weight, and other measurements. This record should be attached to the child
and fdlow him like his own shadow from grade to grade and from school to school
until he severs connection with the school. Annually, at least, new records should
be made, noting any diseases, accidents, or other injuries sustained by the child
within the period, together with tests of general physical condition and growth. At
the end of the school period a record has been made of the child's developmentr-a
record covering 5, 8, or possibly 10 years, of invaluable worth to those whose duty it
now becomes to safeguard the remaining years of minority.

> Among the Indastiiet In whldi ehfldnn of 14 years mey be employed are taidnded minet and
qnarrieK Mimmota ohOd labor law, passed in 19U.

280 PBOGEEDINQS SECOND PAK AMB&IOAK 80IBNTIFI0 00NQBB88.

We are aflBuining here the existence of effective laws r^:ulati]ig general conditiom
of child labor according to standardfl set forth in the Federal child labor law.^

Even in States where the best child labor laws exist, where do we find that any
public school health records are taken into account by those empowered to issue
employment certificates? Yet the snap judgment of a health oQcet^ examining
scores of children who are crowded in at certain seasons for permits to work, is of
doubtful value. This public school record should be made the basis of a thorou^
examination when a child enters an occupation. When our country becomes enough
in earnest to be dissatisfied with an efficiency based on a sixth-grade education, we
shall prevent any kind of commercially-measured child labor under 16 yearn of age
and shall insist that up to the twenty-first birthday whatever occupation the minor
child engages in shall be as a part of his education, a contribution to his effictency
equipment. The occupation, or occupations, for which the child may be certified
without injury to himself would, under such a system, be carefully specified on the
permit, which should furthw forbid the employment of any minor at more than one
task without a reexamination and issuance of a new permit. Such a system would
make it possible during the years of minority for the physical effects of every indus-
trial procosB to be tested on the individual child and would furnish a cumulative
vdume of evidence not only for a mcne complete classification of industry as yean
pasB, but in the case of the individual child, would stand as a record of his physical
working capital when he reaches the age at which the burden of citizenship is laid
upon him.

LEGAL PROTECnON OF FEBfALE WAGE EARNERS.

By JOHN B. ANDREWS,
Secretary American Ai$ociatum/ar Labor Legislation, New Torh City,

There is to-day a world-wide recognition of the need of special legal protection for
women wage earners. On account of their lesser strength and the evil effects on
posterity of an injury to their health, public, legislative, and judicial opinion all
sanction a for greater degree of legal interference in the protection of women .than of
men.

This distinction in favor of women is particularly marked in America in regard to
hour and wage legislation. Laws restricting men's daily hours in general employ-
ments are still held unconstitutional by most of our judges. Within the last few
weeks the Supreme Judicial Court of Massachusetts refused to sanction a law limiting
to nine the daily hours of railroad station employees, yet in 1876, 39 years earlier, this
same court upheld a 10-hour law for adult women in foctories. Only two of our
States, Misdsrippi and Oregon, have passed laws limiting the hours of adult males in
factories. Both these laws are very recent, and the Oregon statute is now before the
Supreme Court of the United States for final adjudication.' On the other hand, the
Canadian Provinces, and all but half a dosen of the United States, restrict women's
daily working hours not only in manufacturing but in almost every employment
except domestic swvice and farm labor, and a number of these statutes have been in
force for 20 years or more. Even among trade-unionists the same cleavage is to be
found. Most union members apparently do not believe in limiting the length of an
adult man's working-day by law, for reec^utions favoring an eight-hour day by legis-

> Federal ohfld labor law, paeeed by Coogrea 1916^ takes effect September l, 1917. Test maj be
obtaJned from Natlooal Child Labor Committee,
s CoosUtntloDaUty upheld In Aprfl, 1917, In oaae of Banting v. On^m.

PUBUO HEALTH AND MEDIOINB. 281

lation were voted down in the two latest oonventiona of the American Federation of
Ltiwt in 1914 and 1915. Neverthelen the federation is on record as supporting
similar laws for women and minors.

Half a dosen Western States and Saskatchewan have the 8-hour day for women
workers, but farther east both in the United States and in Canada the 9 or 10 hour
day and the week of 64 to 60 hours prevails. Until the last four or five years the Amer-
ican tendency has been to set a single maTimum limit for all classes of work. With
the growing tendency, however, to centralize labor law administration under an in-
dustrial commission, a new principle in hour regulation has come to the fore. Where
this principle is carried to its complete development, the legislature lays down only
the general rule that women's hours of work shall not be such as to endanger their
health or welfore. The industrial commisrion is then given power to determine, after
careful investigation, permitted hours in accordance with the varying strain and hai-
ard of different occupations. Thus in Oregon, where the statute law allows 10 hours
in occupations not otherwise regulated, the industrial welfare commission has fixed
elg^t and a third hours as the manmum working-day in retail stores, and nine hours
in fact(»ies. This new method has long been common in Europe, but has not as yet
been developed in America outside of a few of the United States.

In the United States women's hour laws have frequently been questioned and
sometimee declared unconstitutional, but since the case of Muller v, Oregon, decided
by the United States Suinreme Court in 1906, they have uniformly been ui^eld as
health measures within the police power of the State. In this leading case the aigu^
ment for the law was based not upon legal precedent but upon actual conditions in
industry, and in rendmng its decision the court said: ''As healthy mothers are essen*
tial to vigorous offopiing, the physical well-being of women becomes an object of
public intsfest and care in order to preserve the strength and vigor of the race.''

It has proved necessary to set standards for maTimum hours in order to prevent
excesrive fatigue. In the same way it is being found essential to set standards for
minimum wages to secure a sufliclent income to maintain the worker in comfort and
health. As with hour legislation, constitutional restrictions and the attitude of trade
unions have caused this legislation in the United States to be limited to women and
children, although in Qreat Britain and Australia these laws aim to protect men as well
as women. Since 1912 eleven American States have established the minimum wage
by law, and a rapid eztenrion of this means of safeguarding the public health is con-
sidered likely, provided the United States Supreme Court reaches a favorable decision
on the Oregon case now pending before it.^ The Oregon courts, which have already
upheld the law, have linked it with maximum hour legislation as tending to preserve
public health and morals.

Aside from maximum hour and minimum wage legislation, however, America does
much less than Europe in the way of special legislation to safeguard the health of
women workers as distinguished from men. The Americas have, tot instance, very
few laws regulating women's rest periods. Several States and the Canadian Provinces
do set aside time for meals. Half a dozen States insure women workers a weekly day
of rest by requiring the maximum weekly hours to fall within six days. The Argen-
tine Republic also grants women wage earners a weekly day of rest. In addition to
these breaks in the workday, European countries frequentiy provide by law, in the
interests of health and efficiency, short rest periods for women workers in the middle
of the morning and afternoon.

The United States is particulariy backward in regard to that common form of special
I»otection for women and minors, the prohibition of night work. Investigation has
Aown it to be harmful both to health and morals, but largely because of the unfavor-
able attitude of the comrts only half a dozen States have made such regulations and

) ConsUtDtlooaUty iiphAld In April, 1017, in owe of StetUer v. O'Han.

282 PB0CEEDINQ8 SBOOKD PAN AHSBIOAN 80IENTIFI0 CONQSBSg.

none of them i» comprehensive. In 1907 the New York State Court of Appeab conid
•ee no connection between such » metsure and public health or welfare. Only a few
months before this dedsion, through the efforts of the International AssDdation kf
Labor Legislation, 14 European countries had resolved by international treaty to
forbid the night work of women. Argentina and the more important Canadian IVov-
inces have followed European example and made a sweeping prohibitioB of night
woric. The United States courts, however, are growing more liberal as the dangers
of women*8 night woric become better known, and in 1915 the New York court reversed
its verdict of eight years before and upheld a night-work law as a health regulation.

In legislation concerning the physical conditions of workplaces, also, women are
less often singled out for special protection in America than In Europe. In the United
States, general safety and health laws not infrequently applied only to women when
first passed and were later extended to protect all workers. For instance, in Colo-
rado handrails on factory stairways were originally required only in buildings where
women were employed. Several years later it was apparently decided that men
also were in danger of foiling, and all woricers were protected in this way. Nowadays
most special safety and health laws for women rdate only to the provision of seats,
toilets, and dressing rooms. Statutes guarding against the dangers of constant
standing by the provision of seats for women woricers are very common and very
ineffective, for It is practically impossible to see that the use of the seats is permitted.
In almost every European country there are detailed regulations on temperature,
humidity, lighting, and the lifting of heavy weights, which apply only to women
and minors. Such special laws in America are almost entirely lacking.

Again, the entire exclusion of women workers from occupations especially danger-
ous to health or morals is much less frequent in America than in Buinpe. To be
sure, most of the mining States forbid employment in mines and many States debar
employment in saloons. The Canadian Provinces and a few American States also
forbid women to clean moving machinery. Argentina, on the other hand, has regu-
lations comparable to those found in Europe, by which women are excluded from 37
different occupations and in a doien additional special processes, but such careful
restrictions are not usual.

While the American ideal is a fomily supported by the husband and father, with
perhaps some assistance from unmarried children, ecmiomic pressure has forced a
larger and larger number of married women into gainful employment. In 1890 there
were in the United States 500,000 wage-earning married women, and in 1900 there
were aver 750,000. The figure for 1910 has not been published, but it is estimated
at over 1,000,000. In so far as these 1,000,000 women are mothers, their industrial
employment at critical times must result disadvantageously to themselves and to the
offering. Premature delivery, stillbirths, weakened and stunted children, are often
the results of work continued up to the time of delivery, while permanent injury to
the mother follows upon too early return to factory, store, or office.

Accordingly many European nations have estabtiahed and enforced rest periods of
from four to eight weeks for women before or after childbirth. In America since
1911 four States have offidaUy recognised the industrial emplosrmrat of married and
pregnant women by enacting similar legislation, and brief studies which have been
made indicate that there is very little violation of these laws.

There is, however, a serious gap in this legislation. If the mother, who should
be protected in a home, has become a wage earner through deficiency of the family
income, it seems but left-handed protection to restrict her employment just when
the need for extra wages is especially urgent. To bridge this gap 11 European
countries have established systems of maternity insurance, which provide medical
and surgical care, and also (»sh benefits for a limited period, for the wage-earning
woman at the time of her confinement. No American State has yet followed this
example.

PUBUO HEALTH AND MEDIOIini. 288

It should carefully be noted, however, that except in Italy, where health insurance
does not yet exist, all the maternity benefit plans mentioned are bound up with and
kfm an integral part of general health-insurance systems which care for the disability
due to illness of all industriid wage earners, male and female. In the United States,
where careful estimates show an average loss through illness of nine days a year by
each of our 30,000,000 workingmen and women, and an annual wage loss of 1500,000,000,
similar systems oi health insurance can not be much longer delayed. Under such
systems the illness of women wage earners, including disability due to childbirth,
will receive its just indemnity from funds jointly maintained by employers, wipers,
and the State.

Moreover, in a still larger sense will health insurance benefit the woman toiler,
married and unmarried. ''Industrial insurance," says a well-known authority, ''is
the basis of industrial hygiene." As wcnrkmen's compensaticm laws have led to the
movement for "safety first," so health insurance should result in a widespread move-
ment to overcome unhygienic conditions of labor. Like her working brother, the
wage-earning w(Hnan wUi benefit by the general improvement of shop conditions
which may confidently be expected to follow upon the introduction of adequate State
systems of health insurance.

EL TRABAJO DE LA MUJER EMBARAZADA*

Por AUGUSTO TURENNE,
Pro/e$or de CiMea ObMrka de la FaeuUad de Medkma, de MtnUeticko.

Para la redacci6n de este trabajo he tropezado con dos serios inconvenientes que
contribuyen a quitar el sello de ** chose viciu** que quisiera darle; ellos son la d^bil
industrializaci6n de nueetro pals y la ausencia de datos estadlsticos en que fundar
mis conclusiones.

La escasa industrializaci^n del Uruguay explica porqu^, fuera de Montevideo, el
problema obrero de la mujer puede decirse no existe y adn en esta ciudad no ha
adquirido caracteres que Uamen la atenci6n del soci61ogo. Adem^ y por fortuna —
aunque en el memento actual un forzado par^tesis se observa— las caracterlsticas
de nuestro pals, el f^Uul mejoramiento de las condidones de vida del obrero y en un
porvenir pr6ximo una legislaci6n previsora, alejan la aparici6n de situaciones angus-
tiosas que con justicia alarman a los pensadores de otros palses.

Seri pues necesario que me refiera principalmente a lo observado en otros palses,
modificado parcialmente por lo que un ya largo y paciente estudio me ha mostrado
entre nosotros.

En un momento como el presente que el feminismo, o mejor dicho (dejando de lado
una denominaci6n que ha mereddo ser ridiculizada alguna vez) la f unci6n social de la
mujer ee un problema de urgente reeoluci6n, afirmamoe que la funci6n preponderante
de la mujer es la perpetuaci6n de la eepecie.

Podrdn discutirse todos los atributos propioe, todas las similitudes y diferencias
flfdcas o psfquicas que la acercan o alejan del tipo masculino, podrdn aquilatarse bus
aptitudes y deficiencias para su homologaci6n social con el hombre, pero a un terrene
comiin es fuerza converger, a ima conclusion 16gica debe llegarse y es: Que la mujer
debe principalmente conservar y mejorar todos los caracteres que la hagan capaz de
procrear seres sanos y fuertes.

No es posible consegulr un rendimiento integral del factor femenino si no se coloca
a ^ste en condidones de preparar, desarrollar y lanzar a la vida seres que, por su orga-
nizad6n completa y perfecta, por su fundonalismo absolutamente fisiol6gico sean a
su vez, elementos apropiados para la continua renovad6n del tipo zool6gico: Hombre.

284 PBOOEEDINGB SECOND iPAN AMBBIOAN 80IEKTIFI0 OONOBE88.

La r&pida indu8trializaci6n del mundo dTilusado en la segimda mitad del siglo XIX,
intensificada adn en eatos primeros lustros del dglo XX, ha dado nacimiento a cambios
ladicales en el mecanismo social, ha creado tales contingencias que la 0fganizaci6n
cUudca de la familla ha suirido acometidas que han ag^rietado el edifido robusto y hasta
ayw 861idainente anndnico, tal como la severa ley romana lo habfa caiacterisado con
bases al parecer inconinovibles. Pero la industrlaliiacidn credente comeinz6 per alejar
al padre llevdndolo a loe talleres y usinaa, sigui6 con los hijos e insaciable e implacable
ccMno el Moloch f enido atrajo a su 6rbita a la madre, dislocando el eje de sost^n de todo
el edifido familiar y dando lugar a un desmenuzamiento de enecg^ y lo que es poor
a una desaparid^ de principios dlrectores que ezplican fundadamente los signos
claros de disolud6n de la cQncepci6n ancestral de la familia que el menos pefspicaa de
los observadores apreda y que hacen impresdndible la codificad6n de nuevoe prin*
dpios ^ticos y sodoldgicos que den cohesidn a un mode de agrupad^ social indis-
pensable para el desarroUo homog^eo y progresivamente mejorado de la sociedad
humana.

EI alejamiento de la mujer de su hogar por la captacidn industrial, cuyos incon-
venientes ffsicos y morales en general no son del caso discutir aquf , adquiere una im-
portancia prim<ndial cuando'la mujer sometida a las dlsdplinas y a los peligros del
taller o de la usina, entra en eee perf odo de desequilibrio oig^co y fondonal conati-
tuf do por el embaraao.

No es posible ignorar hoy las profundas modificadcmes humorales que la impr^gna-
ddn ovular crea en el organiamo f emeoino. £1 hecho es cruel como tantas manilesta-
dones de la naturaleza ju^gadas con nuestro ciiterio sentimental; desde los primeros
mementos de su desanollo, el nuevo ser exige perentoriamente medios de nutricidny
destruye para alimentane las delicadas c^lulaa matemas, y eeta tiene que defendene
conunareacddncelularintsnsa. Estaluchanoessilendosaymisdeunavesperecela
madresiatiempono ee suprimida la causa de tales trastomoe. Fkuraqueestonosuceda,
para que el embarazo sea, como dice Bar con frase mis elegante que veidadera para
gran ndmero de madres de la clase obrera: una timhioM arm6nira homoghiMy ee menes-
ter que el oiganismo matemo est6 no solamente en condidones de fundonamiento
absolutamente perfecto antes de la concepci6n, sine tambi^n que despu^ de ese
memento y durante los largos meses que lo separan de la completa madures del future
ser, nada pueda perturbar ese fundonamiento, provocando defidencias org&nicas que
vendrin a agr^garse a la perpetua lucha a que el embarazo obliga al oiganismo
matemo.

Debemos preguntamoe ante todo si el trabajo en general puede tener alguna in-
fluenda sobre la marcha del embarazo y d producto de concepd^.

Es m^to indiscutible del IVof. Adolfo Pinard haber sefialado hace ya muchos
afios un hecho sugestivo en su sencilla enunciad6n: Toda madre que descanaa en d
dltimo mes del embarazo tiene hijos mejor desarrolladoa que aquellas que trabajan
hasta d t^rmino.

Pero si el hecho es derto, su interpretaddn es mis diffdl.

I Es el trabajo, por sf solo, d culpable de las defidencias dd futuro nifioT ^No serin
las malas condidones hjgi^pVM, losalojamientos hdmedos, sombrfos y mal ventiladoe,
la alimentad6n def ectuosa e inapropiada, la falta abeoluta de medidas profilicticas, las
que ayudan a la pretendida acddn deletSrea del trabajo?

No debemos olvidar que en las dfras de Pinard van englobadas todas las mujeres,
ya obreras vencidas por largas horaa de trabajo, ya mujeres dedicadas a sus quehaceree
dom^sticos, ya infdices trabajando a deetajo en sua domicilioa.

Hay tantaa modalidades, tantas facetas presenta d problema que debemos detenemos
en algunas de ellas.

En primer lugar no es posible utilizar estadfaticas antiguaa. La pred^ constante
de la masa d)rera sobre las dases dirigentes, y de parte de ^staa una mis clara visiiki

PUBLIC HBALTH AND ICSDIOINB. 286

del porvenir y de bus propios intereeee ha dado origen a toda una serie de medidas
l^gjslalivas que ban modificado profundamente las condicionee en que se deoanrolla el
trabajo colectivo.

La llinltaci6n de las horas de trabajo, la 8upreBi6n del trabajo noctumo y el aleja-
miento de la mujer de ciertas industrias insalubreB, el repoeo semanal, todo un cuerpo de
dispoeicioneB tendentes a proteger al obrero contra los riesgos de traumatismo, de in-
toxicaci^ o de simple insalubridad, la fundaci^ de institudonee de coopaaci6n y de
previ8i6n. los barrios obreros, las cantinas, la facilitaddn y la difusi6n de los ejercicios
ffsicos, la lucha anti-alcohdlica, para no dtar sine las prindpales, hacen cada vez ttdl
dlscemir la importanda que el trabajo por sf solo pueda tener en la higiene de la
embarasada.

Una masa considerable de irabajos de los mSm distintos pafses, correspondientes a
las mSm opuestas organiswdones sodales, pareoe demostrar una primera condusi6n:
El trabajo limitado y en condidones de perfecta higiene individual y colectiva no
parece tener influenda perturbadora sobre la marcha del embarazo, siempre que
sea disminufdo o suspendido en el Ultimo cuarto de su evolud6n.

La observaddb de lo que pasa entre nosotros corrobora dicha condusidn. Un
gran ntimero de mujeres, en su mayor parte dedicadas a los quehaceres dom^sticos, a
veoes fatigosos, Uega a tdrmino complete y expulsa en las mejores condidones fetos
de 3,500 a 4,000 gramos. Fara las que trabajan en las f&bricas se observa otra cosa.
Imposible es documentarse con certesa; numerosss son las que tienen expulsiones
prematoTM, peio la gravfsima crisis dd ab^to criminal provocado que atravesamos,
basta y sobra siempre para afirmar o sospediar fundadamente que a esa causa y no al
trabajo debe atribuirse tal eventualidad.

Otra causa, con excedva frecuenda observada es la gonococda. Sabido es que uno
de los mis graves peligros de la vida de taller o de usina para la mvLjer es la Mdl con-
taminaci^n mond con su cortejo de tranqgredones. La frecuenda de la gonococda
maaculina ezi^ca el cxeddo n6mero de infecdones matemas con la consiguiente inte-
rrupddn dd embaraso. Igual cosa puede dedrse de la sifilis. Pero hay dos iactc»es
que inseparables dd trabajo &bril influendan seguramente el estado gr4vido. Uno
est4 considtoldo por las industrias fundamentalmente insalubres y en las que se mani-
pulan agentes tdxicos o susceptibles por su absorci6n de provocar alteraciones orgi-
nicas. El otro conesponde a eee grupo de trabajos que exigen esfuerzos r&pidos y
exageiados o imponen poddones que determinan trastomos circulatorios abddmino-
pelvianos ya sea directamente ya sea por d cansando muscular que secundariamente
losprodusca.

1^ nuestro pais, en el que aquella dase de industrias escasa extensidn tienen, poca
influenda pueden produdr en la estadfstica. Con excepddn de las f&bricaa de dgarroe
y dgarrillos, de las cerillas fosfMcas, de los artifidos pirot6cnicos, de las velas estei-
ricas y otros derivados de las grasas animales, de algunas f&bricaa de calzado y manu-
factura de artf culos de cuero, y de los frigorf ficos no existen en el Uruguay ttbricas
que por su ndmero y su importanda puedan tenerse en cuenta. Fkura la manipula-
d6n del fdsforo, dada la legidad^n vigente no nos ha ddo dado observar nimca acd-
dentes imputables a este tdxico. La curtiembre de cueros, tan importante en este
pais, y en la que buen ntlmerodemujereses empleado, no propcHxdona un ntlmero
de gr&vidas sufidente para f ormular condudones.

Debo hacer notar— y esta observaci6n vale para todas las obreras que concurren a
£&bricas y talleres--que para ellas d embaraso es cad fatalmente una causa de elimi-
naddn, sea que no se acepten sus servidos por condderarlas capaces de menor rendi-
miento, sea que conoddo su estado, se busquen pretextos para diminarlas, con d
objeto de eludir la obligad6n de continuar pag&ndoles salario antes y despu^ del
parto, tal como se establece en las legisladones modemas de los prindpales pafses.

Las industrias en que los eafuersos podrfan figurar como factores de alteradones
gravfdicas no emplean nuestro pais a la mujer.

286 PBOGEEDINOB SBOOND PAN AHSBIOAK 80IBKTIFIC C0KQRE88.

Bn cambio en tiendas, 60critoiio0, imprentai, hoy figuran mudkas mujeret y €•
indudable que en eeos eetebledmientOB en que rige la prohibid^ de tMitane, la
eetanda prolongada en po8ici6n erecta, trae consigo trastomoe de circulaci6n venoaa
en la sona infra-diafragmitica que pueden explicar la frecuencia de las v^ces de los
miembroe inferiores y de la pelvis, y desequilibrioe drculatorios cuya influenda pemi-
doea no puede negane. Vale sin embaigo para ^atas la obaervaddn geneial sobie
eliininad6n de las gravidas del tiabajo industrial.

A pesar de estas cuestionee de detalle pu6deee afiimar que a medida que se ban ido
dictando disposidonee protedoias dd obrero la acddn del trabajo propiamente didio
sobre la evdud6n del embaraso y dd parlo tiende a reconocene cada vei como menos
nodva, siempre que y salvo tareas de orden eepedal, didio trabajo sea suspendido
durante las dltimas semanas dd embarazo.

Pero hay dos f ormas de trabajo femenino que escapan y escapardn por mudko tionpo
a las reglamentadones legales: d servido dom^tico y d trabajo a domidiio.

Entxe noiotros, en la inmensa mayoria de los casos d servido dom^tico es una esda-
vitud distrazada. Si en eetos dltimos afioe los suddos ban aumentado en propordonat
notables, en cambio las condidones de trabajo son las mismas que hacen 25 o 80 afios.
Emigrantes incultas y desprovistas de ixxia noddn de ''ofido, " trasplantadas brusoa-
mente de las campifias espafiolas o italianas al ambiente urbano, sin mSm conodmientoa
que los rudimentarios de las tareas agrf colas en pafses en los que la vgricultuia sigue
procedimientos arcaicos, anallabetas, inhiU)iles de las manos y dd cerebro, no tienen
mkB posiddn que la de la "bonne k tout faiie," $in>ienia para todo $trwieio, Esle
trabajo rudo y penoso comprende: lavar pisos, frsgar losa, aireglar y limpiar el
mobiliurio, codnar en locales con frecuenda oscuros, mal ventilados y cujra atmMera
est6 vidada por las emanadones de las {Hletas mal dispuestas y dd caj6n de desper-
didos, cuya ubicad6n habitual es debajo dd fogdn. Despu^ de 14 o 16 boras dt
esta tarea vuelven a sus dormitorios que, en la tipica c(mstrucci6n urbana est4n
cad siempre dtuadoe endma de la codna, con un cubaje de aire insuficiente y una
yentilad6n irradonal. Lesmediosde que disponen estas desgradadas no lespermiten
otra cama que un catre de lona y un delgado colchdn de dudosa higiene. Tot excep-
ci6n en las casas hay cuarto de bafio para los sirvientes y estos, poco familiarizados en
su pais con las abludones cuotidianas y abundantes, ni los redaman ni los utilisan.

Esta reuni6n de p^simas condidones de trabajo provoca seguramente un derto
n toero de interrupdones de embarazo, pero sobre todo explica el aspecto de profunda
miseria org&nica con que se presentan a la Polidinica de la Gasa de la llatemidad.

£1 trabajo a domidiio ha ddo sefialado en todas partes y por todos los autores como
un factor delet^reo. En decto aqui no hay limitad6n de boras de trabajo, las condi-
d<mee de local en que se efect(ia son por lo general deplorablee y la remuneracidn
infima. El regateo en dsalariose explica en gente miserable que trabajar& a cualquier
ptedo,

Entie nosotros d giemio de costureras en general, las costureras de oonfecdones y
de ropa blanca en particular nos propordonan un grifico ejemplo. Pensar que se les
paga 40, 50 centimes por docena de ciertas pieaas de ropa, y que tienen que poner
de su peculio el hilo, las agujas, los gastos de conducddn de la costura, la iluminaddn,
que por mucho debe contar, puee para obtener un salario sufidente es menester pro-
longar la velada hasta horas avansadas de la noche, robadas al suefio reparador.

^Qu^ debe extrafiarse d es entre esta pobre gente que obeervamos las m&B lamen-
tables catiitrdee obst^tricas?

£1 mejoramiento de la vivienda obrera, las obras de aaistenda, la persecucidn impla-
cable a los industriales desvergonzados y cruelee que fundan en las angustias de la
miseria lo m^ daro de sus benefidoe, son los medios eficaces de luchar contra un
estado de cosas impropio de una sodedad bien organizada. Basta observar la evolu-
ddn dd embarazo en las mujeres moral y materialmente protegidas durante este

PUBUO HBALTH AND M8DI0IKB. 287

p«Hodo, MmqiM contindan tiibftjando, pftra conTmcene que es en la re^Amentacito»
•n la dorificaddn y en la cla8ificaci6n del trabajo y no en su supresi^n que debemot
oicontrar la Mrmula definitiva.

De lo expueeto hasta ahoia, de la experiencia resultante del tiabajo reg^amenUdo,
Umitado en su duraci6n, de la eliminaci6n de la obrera grivida de las industrias in-
salubres o insufidentemente salubrificadas, resulta evidente que el trabajo per sf
8c^ no ee un factor peligroso para la embarazada.

Son en cambio las condidones de tiempo, de lugar, de forma que acompaftan al
trabajo, las que mds directamente influendan el peri6do gr&vido-puerperal. La
gr&vida puede sin peligro para sf ni para su future bijo continuar en el taller o en la
usioa su trabajo babitual siempre que:

1^. No se dedique a un trabajo que exija eefuersos o posidones que por su peisb-
tenda puedan traer trastomos de drculadon en la sona peligrosa.

2^. No est^ en una atmMera en la que haya sustandas t6xicas o materias que
puedan ser absorbidas por vfa pulmonar o cutinea pudiendo provocar alteradonee
OTRinicas.

8^. Se limite el ndmero de horas de trabajo y se pennitan frecuentes descansoe
cortoe.

4^. S9 suprima el trabajo industrial durante las cuatro dltimas semanas que pre-
ceden al parto, sin perjuido del reposo postpuerperal del que no tenenuM por que
preocupamos en este trabajo.

5^. El local en que trabaje redna todas las condidones higi^nicas indispensablee.

6^. Su vivienda tenga las caracteristicas reclamadas por la higiene para la habi-
taddn salubre.

7*. Durante todo el embaraio y en particular al final sea vigilada del punto de
vista t^nico.

8^. En los casos de abandono o de aislamiento enouentre en las obras pdblicas y
privadas de asistenda el apoyo y la protecd6n morales que le pennitan arrostrar el
presente y e! porvenir con la calma necesaiia para la sana preparaci^n otg^nica y
pefquica de su futuro hijo.

Esta (Ultima conclusidn me Uevaatratar una faz interesante del trabajode la gr&vida.
' Hanta ahora nos hemos ocupado sobre todo de la acd^ ffirica del trabajo de la
embarazada, veamos si dene acci6n moral.

Entre los numerosns tipos sodales de embarazadas que el mMico debe estudiar coo
criterio daro y previsor est& el de la madre soltera.

Lejana estd la ^poca en que prejuidos insosteoibles la ponfan fuera de la sodedad.
£sta no tiene el derecho de juzgar con severidad excesiva situadones que su impre*
visi6n o su indolenda ha cootribuido tan a menudo a provocar.

Frente al hecho produddo s^lo cabe la soluddn que mis encuadre dentro de las
necesidades del Estado y del individuo.

Dos elementos se encuentran con excesiva frecuenda: El an/d/abttumo y la ignth
raneia de toda profiMn. Por excepcidn llegan a neustio servicio obreras hiUi>iles o
pcofesionales de derta cultura. Cuando esto sucede otras son las causas de la caida
y por oierto no menos interesantes.

Uoa primer medida se impone pues y es corregir el analfabetismo y iu idg^ conse-
cuencia la ignorancia. No nos ocuparemos de esto.

El desranocimiento de todo oficio obliga a estas mujeres a dedicane por salaries
mfnimns a la dnica ocupaddn posible: sirvienta.

Ya hemos sefialado las condidones en que por lo general trabajan esas mujeres.
Fiidl ser& explicarse c6mo ante la carenda de trabajo o la imposibilidad de obtener
una remuneraddn sufidente para asegurar la vida en los mementos de inevitable
"chonuige/' la caida sea casi tan inevitable, por poco que venga disfrazada c<m la
esperanza de un mejoramiento. A la cafda sigue casi fatalmente el abandono apenas
I tristes y a menudo venales amores dan su natural fnito.

288 PBOCEEDINGS SECOND PAN AMEBIOAN 80IENTIFIC 00NGBB88.

Es menester haber visto centenaies de veces el miserable estado pefqidco de eeaa
infelices para comprender qu6 justa e impresciBdible obra de elevad^ moral debe
emprender nuestra eociedad paraevitar que las madree rueden a la proatitacidn y kw
hijoe al asilo.

Creemos haber establecido suficientemente en p^lgmas anteriores que el trabajo solo
por excepci^n y en condidones Men determinadas dene accidn perjudidal sobre
el embarazo. Tareas levee, en ambientes higi^icoe no pueden ser sino beneficiosas,
manteniendo una cierta actividad ffMca indispensable al buen fancionamiento de
todo el oiganismo.

Ejemploe, si no numerosos, demostzativos, noe permiten aseg;urar que dando a
esas madres futuras una instruccidn elemental y loe rudimentos de oficios ttciles y
lemuneradores, la reincidencia tiene que hacerse rara y la regeneraddn frecuente.

Golocando a esas gr&vidas en condicionee de repoeo ^co y moral, en ambientes de
honestidad y de trabajo, had^nddes sentir que lejos de ser objeto de repulsa sodal,
lo son de conmiserad6n, aseguiindoles que su r^enerad6n les dar& deredio al apoyo
colectivo, se habii llenado una misidn que ninguna agrupaddn humana consdente
de sus deberes y de sus intereses puede poeteigar.

La enundad6n de esta verdad seii nuestra ^tima conclusion:

9®. Para las madres solteras d trabajo durante d embaraso, convenientemente
reglamentado, no sdamente no es perjudidal, sino que constituye un predoso ele-
mento de elevad6n y regeneraddn numdes.

FAGTORT SANITATION.

By B. R. HAYHURST,
Director Division of Induttrial Hygiene, Ohio State Board of EeaUh.

The subject which I am asked to present, '' Factory sanitation " as a feature of indus-
trial hygiene under public health measures, is one of many angles, and it is difficult
for me to specify the limitations to which I would confine myself. I will endeavor,
however, to avdd the specific fields covered by other speakers upon this program.

To my mind, hygiene is the keystone of efficiency and production. It covers the
relations between man and his environment, or more strictly speaking, between
physiology and concrete facts. Industrial hygiene, of itself, covers (1) the state of
perfection of sanitary equipment in the plant— this is factory sanitation; (2) the state
of physiologic perfection of the worker — ^this is dependent upon information collected
by means of physical examinatioDs; and (3) the extent of knowledge and practice of
personal hygiene— this is conservation of health and energies and is controlled by both
employer and employee. It is only by a well-coordinated interaction between these
three fundamentals that industrial hygiene may stand for effidency, production, and
happiness rather than for ineffidency, loss, and sufiforing.

Of the three features above mentioned, I am limited by title essentially to the first,
that is, factory sanitation, but, I trust, with the understanding that it represents only
an approximate third of the subject of industrial hygiene. It reinresentB, however,
the physical sanitary equipments of the work place.

The hist<^cal side of foctory sanitation, I regret to say, must be omitted in the time
allowed.

The results of several years of field experience with the elements concerned in work-
place sanitation has convinced me that all deleterious agendes are best concdved of
as health hazards, and that the proper method of measuring them is to accept, as far
as possible, the standards which have been laid down by sanitarians and research
workers in this and other fidds, and to analyze industries by them, remembering that
these hazards may be those of geographical location, of workspace environment, or of
the occupation itself.

FUBUO HTUT,TH Ain> MBDIOIKB. 289

Whether a ^tory or work place ib sanitary or iiiBanitary la a question of the prevalence
of any, or all, of the following health hazards within it: (1) The extent of the devitaliz-
ing character of the working atnoosphere; (2) the phyaioal, mental and moral inhibi-
tions resulting from disordered, dirty, or unkempt surroundingB; (3) the qualities of
the illumination; (4) the extent of visible particulate matter in the working atmos-
phere; (5) the extent and manipulations of poisons, whether in solid, liquid, or gaseous
tatm; (6) the extent of communicable disease and the risk of simple infections; (7)
the exposure to extremes of temperature; (8) the exposure to extremes of humidity;
(9) the exposure to extremes of atmospheric pressure; and (10) the state of the equip-
ment for satisfying the natural desires and requirements. To the above should be
added three more health hazards which concern physical equipment, physiologic per-
fection, and personal hygiene all combined; these are (11) exhaustion from fotiguing
applicaticms; (12) lethargy from inactivity; and (13) Uie extent of the inducements
to stunulantism.

In making a survey of industrial hygiene, whether confined to a single plant or ta
an industry or to an entire state, the individual occupations should be investigated
in respect to each and all of the above-named industrial health hazards. This method
of inquiry should be followed, whether the inquirer be a representative of the public
service, of an insurance service, of a self-appointed foctory efficiency service, or of a
treatment and relief service. (My by so doing may the methods of all be standard-
ised, a highly desirable end, since all are seeking the same object, viz, less waste and
greater efficiency. Also, to fodlitate work in various industries and occupations, a
standard nomenclature diould be adopted, such as that of the United States Census:
"Index to occupations, alphabetical and classified."

While this array of detailed specifications may look formidable, this plan was quite
successfully carried out in the smrvey of industrial health hazards and occupational
diseases in the State of Ohio during the years 1913 and 1914.' A half-dozen qualified
physicians, devoting about half of their time, inspected 1,040 industrial establish-
ments, where were employed a total of 235,000 wage earners (clerks and managerial
forces not included), with a total appropriation of 114,000, and a legislative command to
the State board of health "to make a thorough investigation of the effect of occupations
upon the health of those engaged therein with special reference to dust and dangerous
chemicals and gases, to insufficient ventilation and lighting, and to such other unhy-
gienic conditions as in the opinion of said board may be specially injurious to health . ' '

Before we can accomplish anything in the matter of bettering factory sanitation, it
is necessary to gather from all sources possible the effects of known hanrds, the limi-
tations to which physiologic tolerations and adaptations can be extended, and there-
upon to declare standards. Obviously, much of this information is not yet at hand,
and in such instances decisions must be more or less arbitrary, but I insist that they
be made, since there is plenty of evidence to show the disastrous effects upon health
and longevity in the classes of industrial pursuits.*

A discussion of the most feasible measures of counttfacting each of the above hazards
is next in order.

DBVn:ALIZINO AIR.

Sanitarians and physiologists * have in the past few years pointed out that "bad air '^
has one or more properties of the following character, any and all of which may be
found in working places:

I Ohio State Board of Health: A Sonrty of Induftrlal Health Hasards and Oooopatiooal DJunet In
Ohio, by E. R. Hayhunt, February, 1915, 488 p.

* Medioo-Aottiarlal Mortality Investlcatioo, Mr. Arthur Hunter, cfaairman, 1914. Also, United States
CtttSQs: Mortality Statlstlot, 1909, Tablet VIU, IX, 11 and 13.

• Flflgse: Zelt. t Hyg. a. Inf., 49, 1906, 883; Paul, ditto, 406. Sympoaiam oo Ventilation, Jr. Ind. and
Sng. Cbem., March, 1914. See alto Jr. Am. Med. Am., LXm, No.19, Nov. 7, 1914; and solenoe, XLI, No.
No. 1061, Apr. 80, 1915.

S90 PB00EBDIKG8 SECOND PAN AMBBIOAN 8GIBNTIFI0 C0NQBE88.

(a) Stagnaiion.'-Thia magle feature probably affects a greater total of wotk&n
the year around than any other single hazard. There are many ways of promoting
circulation of the air in the woridng place— the use of window boards placed below the
lower sashes of the windows in order to permit air to pass in and out between the two
sashes without damaging draft; the opening of the windows themselves, especially
when work is active or semiactive; the use of the oscillating electric fan or similar
air agitators; the combining of the heating apparatus with a "fresh-air" inlet and with
an arrangement for returning the air to the heating plant, combined perhaps with a
"foul-air" outlet; simple recirculation of the air from heating plant to room ard
return; the forced-air system of exhaustion or propulsion types, in which case it it
also well to consider washed and humidified air; and finally 1 do not believe enough
thought is given to the question of substituting cloth windows for some of the glass
windows. The rapidity of movement may vary from a just perceptible and "reh-esh-
ing breath" in the case of the inactive worker to as much as 600 cubic feet a minute
for active workers.*

(6) Room temperatwre. — ^Invariably this is too high for the vast majority of indoor
workers. It usually runs well above 68^ for rooms occupied by sedentary workers
and much above 60® to 65** for quarters occupied by active workers. Viliere the extra
exposiu^ involved for useless overheating does not appeal to some employers, there
is no more potent argument than to point out that "the cool condition therefore
showed an excess of 15 per cent in actual physical work performed over the 75® condi-
tion and an excess of 37 per cent over the 86® condition." '

(c) Drynen. — I wish to emphasize this feature of de\ita1izing air as one which obtains
in practically all interiors heated by stoves, furnaces, hot-water or steam systems.
Throughout the "closed-up " seasons of the year the relative humidity in most factory
interiors in the Temperate Zones remains much less than 40 per cent— indeed often
much less than that of the air of our great deserts. While investigators have not
yet demonstrated that dry air is in fact harmful (we know, too, that persons are sent
to our arid regions to be cured of certain afflictions), there can be no doubt but that
the alternations from relatively high humidity out of doors to this extremely dry
condition within doors is a most potent factor in the matter of respiratory afflictions,
both acute and chronic.

The average normal humidity outdoors in the Temperate Zone on a fair day is 70
per cent of total saturation; indonrs it certainly would not harm if it were as high as
60 per cent. Artificial humidification, then, becomes a necessity for practically all
interiors when the flow of outside air is curtailed. An exception would be where
processes themselves develop humidity; also where ventilation Is faivored by the use
of the cloth window, which permits ingress of atmospheric moisture, the cloth pre-
venting the escape of heat even better than glass.* Artificial humidification may
be accomplished in many ways. However, the usual pan-ajid water schemes are
quite inefficient. The point is, it must be possible to bring the water to actual boil-
ing as upon occasion this may be necessary. Attachments to steam radiators may
add enough humidity, but usually increase heat undesirably. Several devices to
be attached to hot-air furnaces appear quite successful. They must be connected
with a continuous water supply and placed above or beyond the fire box. The
many devices for humidifying workrooms, usually in connection with the heat-
ing apparatus, can not be gone into here.^ It is to be noted, however, that many
of the devices for home use which are upon the market hill far short of supplying
the requisite moirture. The air should never be allowed to contain less than 40

t MoCurdy, J. H.: Amer. Phys. Bdno. Rov., December, 191S.

* Winslow, a-E. A. et al.: Amer. Jr. Pub. H., ▼. 2, Febfiiary, 1916. Bee al to Lee, F. 8. and Soott, B. Lj
Proo. Soe. Exper. BioL and Med., 1914, Xn, 10.

* Todd, John B.: Engineering Mag., AprU, 1914, lKV-118.

« Air Oonditioning (Bibliography): Monthly BuU. Oamegie Library, PitUburgh, November, 1914.

PUBLIC HBALTH AND MEDIOIKB. 291

per cent and preferably 50 per cent humidity. It requires from 6 to 15 gallona
of water a day to properly humidify an ordinary sized schoohoom.^ Since adding
moisture to the air reduces the amount of heat which it is necessary to have present
in order to feel comfortable, it has been pointed out that as much as 20 per cent of
the coal bill can be saved by supplying the proper moisture to the air. The wet-and-
dry-bulb thermometer should take the place of the ordinary thermometei. Tech-
nically this instrument b called a ''hygrometer/' while the ''sling psychrometer"
is considered as its most accurate form.*

It is also well to mention in connection with "bad air" Its contamination in limi-
ted amounts with particulate matter, such as may be seen, for instance, suspended
in the path of a ray of light. Amounts of fine dust ordinarily Invisible and also of
smoke should be included here. Where these are due to local conditions within the
plant they may be controlled at their source of origin, but where they are due to
factors in the vicinity their control is often problematical.

(e) Chemical changing of the air by the addition to it of gasee, fumes, or vapors, or
the subtraction from it of much of its oxygen content, are very often serious factors
in air conditions. The problems of controlling these matters are strictly engineering
features, but consist, in general, in arrangements for local confinement, withdrawal,
precipitation, or neutralization of the noxious substances. Furnace fires within
workrooms may endanger the oxygen content of the air for breathing purposes, but it
is believed this hazard is rare. It should be noted that the findings of recent investi-
gators have shown that the amoimt of oxygen which a nimiber of persons may use up
in an inhabited room under ordinary drciunstances has no effect up(m the health.
Also, the amount of carbon dioxide and other gaseous emanations which a number
of persons gathered in a room may add to the atmosphere under ordinary drcum-
stances has no effect upon the h^tlth, except that the appetite may be somewhat
decreased. From this, human beings do not cause chemical changes in the air about
them to an extent which is damaging to health, unless, perhaps, a large number of
persQUB are very closely confined, as in the Black Hole of Calcutta incident. The
depressing effects of a "close " room are due principally to stagnation of the air whkk
permits a rise of temperature immediately about the body, and does not assist in the
evaporatioii of moisture from the skin. Ventilation, then, is a potent factor in the
circulator]^ regulation rather than in the respiratory exchanges, and is more necessary
to remove heat than to remove carbon dioxide or to supply oxygen.

(/) PoUutitm of the atr.— A person with a communicable disease of the reepiratory
papstgos may pollute the air in his immediate vicinity with the germs of his disease,
as by coughing, sneezing, talking, and the like. It has also been shown that in
crowded rooms the percentage of streptococci and other disease-producing oiganisms*
is very much increased, and dust and moisture particles may act as the means of
transmitting them, at least for a short distance and time. However, direct pollution
of the air is not considered at the present time of much importance in the spread of
communicable diseases, since the germs are apparently ra{ddly killed by the action
of light and dryness. Direct contact is the principal mode of spread, while flies and
other insects are a most common means of transmission. Physical examinations, per-
fection in personal hygiene, and the abolishing of crowded workrooms appear to be
the chief means of counteracting this hazard.

(g) ObjeeHonabU odon, — For some workers (oil-blast furnace men, fertilizer workers,
chemical workers, etc.) nauseating odors may endanger health by affecting the appe-

t InfBraoll, L. R.: Jr. Home Eoon., vn, M, AprO, 1016.

1 Marrln, C. F.: Piyohrometrio Tables, etc., Weather Bureau, U. 8. Dept. Agr., No. S85, 1919.
•Browne, W. W.* Sdence, XLn, 1060, Sept. 10, 1015, 861. Abo, Whipple, M. C: Am. Jr. Pub. H.,
V, 8, Aogust, 1016, 735-737. Abo, Chapin, C. V.: Jr. Am. Med. Abb., LXH, 5, Feb. 7, 1014, 4

68486— 17— VOL ix 20

292 PBOCEEDINGS SECOND PAN AMBBICAN SCIENTIFIC CONGRESS.

tite or causiDg actual vomiting of food.' Where odors alone are concerned, usually
only peculiarly susceptible persons are affected. Ventilation, confinement, spray-
ing, or high temperature may be used to overcome these nuisances.

DI80RDBR.

Disorder of the work place, lack of cleanliness, accumulations of rubbish and dirt
constitute definite healtii hazards in a number of ways: (1) Generally speaking, dirt
and disease coexist;' (2) a **dirty " place is the first place in which waste matters are
accumulated and bodily excrements, especially sputum, are deposited; (3) how much
dirt upon window panes, skylights, lamp globes, reflectors, walls, and ceilings inhibits
light and its distribution is very little appreciated ,** (4) waste accumulations tend to
gather moisture, and hence favor prolongation of germ life; (5) imkempt surroundings
have a subconscious deteriorating effect upon the inclination to work and upon the
ability to produce, and, particularly, upon the observance of health standards and
health habits and morals by workers, both without as well as within the work place.
The insistance upon a sanitary and orderly work environment is fundamentally
economic from three points of view— physiologic, psychologic, and industrial output.

ILLUMINATION.

Since it is impossible to do all work in daylight, it becomes necessary to observe
certain standards for interior lighting. As a general proposition eye w<HrkerB require
a minimum strength of light equal to 2^foot candles on desk or bench surfaces.^
Those who do close eye work require more than this. General factory room lighting
should be equal to one-four^ candle power per square foot of floor. Where contami-
nation of the air occurs, this should be increased to one-half candle power. On the
other hand, brilliancy and glare must be just as carefully avoided. Ilie vast amount
of importance to be given to the positions of artificial light, to shades, reflectors,
globes, etc.,* usually requires the services of a lighting expert. Many times atten-
tion to these features enable the total expenditure for lighting to be grcAtly curtailed.
A flickering or a dim light can be just as fatiguing from its effects upon the human
eyes as the most laborious work. Many factory workers are also seated fadng the
light and not supplied with eye shades or other protection. Again, contract * of
lights and shadows are very pronounced in some of our best-lighted faciory work-
rooms. Investigators of school sanitation have shown the great influence of dean
windows upon the quantity of light.^ Dark-colored walls and surroundings may
absorb as much as 70 per cent of the available light, whereas light shades absorb but
little and reflect much.'

Windows placed hig^ give better lig^t. Window shades should be attached at
the bottom and pulled upward. Artificial lights should simulate natural light as
closely as possible. The ratio of window area to flocur area should be about 1 to 4 for
semiactive factory workers. In buildings with extensive floor space this ratio will
often be found greatly curtailed. Furthermore, machinery, shelving, and work
benches often greatly limit the amount of incoming light. The great importance of
proper illumination is shown in regard to the following wasteful results: Accidents,
eye strain, with its manifold accompanying health disasters, defective execution,
and defective product. With all of these features corrected, however, defective
eyesight is so prevalent that ocular examinations of workers is also imperative.

> Hayhont, E. R.: Trans. XVth Int. Cong. Hyg. and Dem., 1912, UI, Pt. n, 775.
s However, see Chapin, C. V.: Am. Jr. Pub. H., V, 0, June, 1915, 496.
sninminating Engineering Society (N. Y.): I ight, Its Use and Misuse, 1913 (21 p.).
< Ayies, L. P.: The PnbUc Schools of Springfield, DL, Russell Sage Found., 1914, 28. Abo, BuU. U
S. Bureau of Labor, whole No. 123, 14.

• Clewen, C. B.: Factory I Ighting, 191^ (151 p.).

• Oaster, I eon: Jr. State Med., November, 1913, 506.

'See lef. 14. Abo, SUckney, O. H.: Safety, April, 1915, 96-101.

PUBUO HEALTH AND MEDICINE. 298

DUST.

As a standard, it may be stated that the breathing of any form of ordinary dust
which is present in an amount able to be easily discemed by naked vision for more
than the total of an hour's time in the course of any one day will do damage to the
respiratory tract of the human being.' The extent of the damage will be largely a
personal factor. Mineral, metallic, or poisonous dust may do damage in a much
shcHter time than this. The dust hazard is not always one upon the respiratory
system. Three-fourths of dust breathed is swallowed,' thereby disturbing the diges-
tive system. Furthennore, the skin, eyes, and ear canals may be the principal parts
to suffer. Some of the most dangerous dust is that created by dry sweeping, dusting,
or cleaning during work hours. The personal factor of carelessness is a most impor-
tant one in the production of dust. Besides the usual principles of local exhaust
ventilation, confinement, destruction by fire, laying by sprays, attention should be
directed to the dust-bag collector and separator system and to the Cottrell electrical
precipitation devices for both dust and vapor.' Only as a last resort should workers
be expected to wear respirators or helmets, in which case they should be provided
with tubes supplying pure air under forced pressure * and then required to work but
a limited number of hours at such a process in each day.

POISONS.

Workers in poisons are very liable to develop the specific occupational diseases due
to the particular poLson to which they may be exposed. As a rule, no poisons need
to be dispensed with in industry simply because they are health hazards. Usually,
were as much attention given to the effects upon health by poisons as to the methods
and purposes for which they are used, they would be very little troublesome as health
hazards. All poisons should be absolutely removed from the possibility of damaging
the health of the worker. Instead of this firm attitude most employers, and, indeed,
employees, prefer to withstand or tolerate as much of the poisonous substances as
possible. Habituation to poisons should be looked upon as entirely untenable, since,
with the exception of biologic poisons, no immunity is acquired to any poison. Sys-
temic poiBoning is probably a question of the concentration' of the noxious material
in the blood stream, which, in turn, depends upon resistence to absorption of the
poison into the tissues and the capability of the eliminative organs to rid the system
of the poison. The rule should be that any person working with a poison, or suspicious
unknown substance, who experiences even minor health ccnnplaints, should be
physically examined in regard thereto and instructed carefully in personal hygiene.
Personal peculiarities in regard to poisons are largely matters of personal hygiene,
while the degree of physiologic perfection or imperfection supplies the rest of the
explanation. It is the employer's responsibility * to see that lus workers are jNroperly
instructed in regard to the use of poison. The toleration limits of many of the common
poisons have been experimentally determined.' A few of them are given herewith.
In questions of dispute these figures should be considered in the li^t of standards
(aerial concentration is meant).

Ammonia.—0, 10 per cent will cause local sjrmptoms; 0.33 per cent can be tolerated
for one-half hour; 1 per cent may be borne by habitual workers for varying intervals;
10 per cent may be fatal forthwith.

> This rather mwwihiglww standard has been devised to answer the questlcn ''How muofa dost Is dan-
geroosT"

* Lehmann, K. B.,et aL: Aroh. f. Hyg., No. 75, pt. a, 1911, 134, 162.

•OottieU, F. Q.: Various poblieations, U. 8. Buraaa of MhMa and elsewfaere.

«U. 8. Labor BnlL, whole No. 137, Angnst, 1018.

iEilinmyer: Ztsdir. f. Exper. Path. a. Ther., XIV, 3, Sept. 16, 1913, 310-^33.

• Orlady, Judge, Super. Court of Penn.: Cited from Am. Jr. Pub. H., V. 3, Feb., 1916, 177.

' Lehmann, K.B., et el.: Areh. f. Hyg., various volumes, 1886 to date. See also Rambousek, J.: Indus
trial Poisons, trans, by T. M. Legge, 1913.

294 PBOOEEDIKGS SECOND PAK AMEBIOAK 8CIENTIFI0 00KQBE88.

Amyl ooetote.— O.005 per liter will affect the eyes and respiratory system, but will
produce no headache or pulse changes; 0.035 per liter will narcosize cats after seven
hours' exposure. Amyl nitrate is more poisonous, amyl iodide is less poisonous.

Benzim,—0.02 per liter will cause local symptoms; 0.05 per liter is poisonous.

Benzol,-— 0.015 per liter will cause local symptoms; 0.042 per liter will kill do0B in
20 minutes.

Carbon bisulphide,-^ Mlb per liter is poisonous.

Carbon monoxuie.— O.05 per cent is slightly poisonous; 0.25 per cent is dangerous
to new wc^kers; 0.50 per cent is the limit to which habitual workers may expose
themselves.

Lead oj:t(20.— One-sixth grain (estimated as lead) absorbed daily will produce
symptoms in from two to four weeks.

Methi/l alcohol,— 0.20 per cent in the air is poisonous.

Solvent naphtha No, l,—(90 per cent comes over at 160^ C); 0.036 per liter poisons
dogs in 30 minutes.

Solvent naphtha No. t.—(dO per cent comes over at 175® C); 0.048 per liter poisons
dogs in 60 minutes.

Turpentine. — 0.003 per liter is poisonous.

Zinc oxide,— 0.007 grams in 30 Uteis of air produced in burning pure rinc will cause
brass founder's ague.

In a similar manner maximum limits of toleration for most of the poisons used in
industry have been determined and are upon record. It behooves the respective
industries and supervising agencies to ascertain these limits and to devise means to
keep within them.

Occupational poisonings will not cease until the following factors have been met
and overcome: (1) Ignorance of workers, (2) misbranding of poisons, (3) fancy brand-
ing of articles containing poisons, (4) lack of instructions, (5) disregard of instructions,
(6) wrongful instructions, (7) harmful regulations, (8) absence of medical supervision,
and (9) of mechanical health appliances. Further, (10) the eating at work or in
workrooms, (11) lack of personal cleanliness; even the wearing of mustaches or beards
are vital factors with some poisons. Finally, there must be considered, for given
poisons, the use of (12) gloves, (13) respirators, (14) proper clothes, (15) lockers in out-
side rooms, (16) good washing facilities, (17) water-closets, (18) eating places, and the
development of inventions along the lines of (19) confining poisons, and (20) possi*
bility of the substitution of certain poisons by nonpoisonous, even though perhapi
more expensive, substances. This latter, we believe, is rarely, if ever, necessuy
except when an ignorant and casual class of workers is the policy of employment.

INFBCnONS.

There are two types of infections which may endanger the health of worken. The
first is noncontagious, such as septicemia and tetanus following a wound or bum.
The second class is that of the communicable disease which may be spread by con*
tact (shaking hands, kissing) and by fomites and carriers.

Typhoid fever has proved a menace to thousands of workers in Ohio; in one place
where strike breakers were confined behind factory indoeures without proper sani-
tary arrangements; in another where the offal from a quarry dirtrict, ^^ch was
almost without sanitary provisions, eventually polluted the water supply; in otben
through industrial connections * with the drinking water supply (the plants them-
selves using a polluted river or canal water for manufacturing purposes), etc. Tra-
choma (granulated eyelids) has proven a s^ious menace to factory districts and even
truck garden farmers, mostly through housing conditions, and the question at once
arises whether employers have not a right to demand certain standaids in this direc-

t Van Bnskirk, L. H.: Ohio Pub. Health Jr., V, 8, Mtfoh, 19K, 286-SOl.

PUBUO HEALTH AND MBDIGIKB. 295

tkm in return for the value of the money which is paid in wages. The following
features tend to make infections a common form of health hazards in work places:
(1) Overcrowding; (2) the common use of towels, cups, washing facilities, soap, cloth-
ing, etc.; (3) impr(q;>er closets, especially of the unscreened, vault, or open types;
(4) spitting upon the work floors; (5) absence of cuspidors; (6) sweeping during work
hows, especially by dry methods; (7) the handling of infectious materials (hides, furs,
wiping rags, wool, oil, etc.); (8) the handling or mouthing of articles just previously
handled or mouthed by another person; (9) frequent trivial injuries; (10) flying par-
ticles; (11) Assuring of the skin, eczemas, etc., from the careless use of solutions, dusts,
gases, and vapors. Also (12) callosities which, when incised or punctured, show poor
resistence to infection; hence, in this connection, the great value of early medical
treatment for the most trivial injury, foreign particles in the eyes, etc., the same to be
rendered within at least 30 minutes' time; this does not necessarily mean "first aid,"
the practice of which in lay persons' hands has recently come into disrepute;* (13) the
lack of physical examinations and instructions in personal hygiene, and, finally,
(14) the industrial spread of venereal diseases throufi^ the encouragement of immor-
ality, as by means of suggestive wall writings, pictures, language, etc., especially
when sexes are employed together.

HEAT.

Dry heat may be endured without impairment to health up to about 100^ F., or
even higjier than this if means of rapid motion of the air are at hand in order to cause
evaporation of perspiration from the ddn and thus aid the body in keeping cool.
However, a little rise in body temperature accompanies work in hot places.* This
"thermic fever" should be avoided since persons are readily poisoned through the
accumulation of heat waste products within the system.* All perscms exposed to
great heat should also wear glasses to protect the eyes.^ The means of avoiding heat,
or protecting the workers from the same, are too numerous to enter upon here. They
have been perfected for practically all conditions. Heat combined with moisture
should especially be avoided.* Workers in hot places should all be provided with
shower baths which they should use on quitting the work for the day. By this means
the circulation of the blood is regarded as better distributed and controlled and the
danger of sudden congestions in respiratory mucous membranes, in organs and other
parts inhibited. Furthermore, all such workers should have two suits of clothes,
one to wear while at work and the other for going ar coming to work. They should
also have provided double lockers supplied with heat to dry out wet clothing.

GOLD.

Oold, pure and simple, can not be considered a health hasard under ordinary cir-
cumstances. Woricers in cold places (ice houses, storage warehouses, chocolate d^
ping, etc.) should be properly clothed and provided activity. Oooling of one part of
the body while heating another is eq[>ecially to be avoided.

HTJMIDrrT.

The amount of moisture in the air has been discussed already as one of the features
of devitaludng air, especially from the point of view of the absence of a sufficient
amount. Excessive humidity is a feature of a certain few industries which, however,

iNttional8iifetyConfreM,BoiiiidT»bleDifQiiiaoniinM<dleAl8Mtion Alw

Ivmiglil oat in MOtkm oo Indostrtel H7gi«ne, Anu Pub. H. Aai. MMtJng, Soel^

• Ue, P. B.: Tnns. XVth Int. Cong, on Hyg. and Dem., m, Pt. U, ma, MM-A12.

• Pliks, 0. N.: Amar. Jr. Med. So., CLZV, 1913, M5-S73. Alio WartUn, A. 8.: Pnbllo HMltb, Mkh.,
vn, i, JanowjF-MBrch, 19ia. 07.

«8oo ADoced Dangen to tbo Eyo Disprarod: Bdttodsl, Jr. Am. Mod. Aa., LZm, It, Oot. 17, 1014,
UH.

• Hftldaa^J.S.: Joiir.orHyg.,V,190B. Bom, Ofwald: Traat. ZVth Int Cong, oo Hxg* •nd DoBn V
Pt. n,fiQM06; PlMMhrdl, P. L.: ditto, fiOO-OS, ot al.

296 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

in certain districts employ laige numbers of workers. Particularly is this so in the
textile industries, while it is apt to be found, also, in laundries, bottling works, brew-
wies, paper manufacturing, plating rooms, etc. Where considered a necessity, as in
textile manufacturing, it is pointed out that the process of humidification is usually
considerably overdone to the groat detriment of the health of the workers and the
decrease of production — the conditions are often made much worse because roam tem-
perature is also maintained too high. In fact, a reading of 70^ upon both the wet
and dry thermometers need probably never be exceeded.' Where humidity is not a
necessity in the general atmosphere of the workroom, excesses of vapors diould be
withdrawn at their source of origin. Particular attention should be given to work
of inactive or semiactive character in damp quarters such as basements, warehouses,
and the Uke.

ABNORMAL AIR PRESSURES.

For caisson workers, standards and detailed instructions have been laid down which
require the use of the ''air lock" for workers subjected to any pressure above one
atmosphere.' The opposite condition, working in rarefied air, is rarely one produced
artificially as an industrial process, while physiologic adaptation,* as in the case of
mountain workers, aviators, and baloonists seem to have considerable range.

NATURAL DB8IRB8.

Very often the natural desires are the cause, directly or indirectly, of great risks to
health. Thirst should be especially carefully provided for in connection with work-
places by which the water supply should be safe from bacterial pollution and poison
content, and should be made as inviting as possible through a proper degree of cooling
and its convenience for use. All other substitute beverages should be discouraged.
The devices in the nature of bubbling fountains and individual drinking cups and
the processes of water purification are imperative. Hunger becomes a hazard when
the taking of food is not properly provided for in workrooms free from poisons, dusta,
odors and bacterial contamination; also, when the time factor is not physiologically
observed and, finally, when the character and quantity of the food itself lacks super-
vision. CleanUnesB becomes a hazard when proper and safe means are not at hand
for the use of workers. The desire to be clean under such circumstances may prove
a greater hazard than the remaining unclean. The attention to the natural desires
brings in the consideration of the standards which have been adopted in all of our
leading States and countries in regard to toilets, urinals, sewage and refuse disposal.
The desire for rest and the occasional demands for the temporary cessation of work
requires the presence of rest rooms and an arrangement for necessary rest periods and
simple remedies, especially where females are employed. The desire for sleep should
be satisfied with provisions for at least an eight hours' continuous period out of each
twenty-four hours. The worker should be encouraged to make the day the unit of
routine ^ rather than, as is often the custom, the week, whereupon extra sleep, rest,
cleanliness, diet, etc., are made features. The desire for recreation should be encour-
aged and made recreative, and not dissipative. The value of the money Bpeat for
wages and the maintenance of a high standard of safety should be made to weigh in
this matter.*

1 Bollngs of Departmental Committee, Or. Bt.: On Humidity and Ventilation in ( otton Weavinf Bbeda,
Jan., 1900, 6. See also Lander, C. H.: Ventilation and Humidity in Textile Milta and Factories, 1014,
(183 p.)

• Amer. Ass. for Labor Legis., I eaflet No. 13; also Am. Ass. for Labor Legls. Review, IV, 4, SflO^SM.
« See Editorial, Jr. Am. Med. Ass., I.XV, 13, Sept. 25, 1015, 1113.

4 Fisber, Irving and Fisk, Lyman: How to Live, 1915 (345 p.).

• Taylor. Frederick W.: SdentUlc Management, 1011 (144 p.), and many advocates of his system See
also Thompson, C. B.: Sdentifio Management. A CoUecCion (etc.), Harvard Univ. Studies, Vol. 1, 1014
(878 p.).

PUBLIC UEALTH AND MEDICINE. 297

FATIOUB.

FiUigue, of couree, has a diatincUy pen(mal phase, but a brief Bummary of indus-
trial causes is in order: (1) Laborious work; (2) long hours; (3) piecework; (4)
speeding up; (5) monotonous application; (6) prolonged strains, sudi as constant
standing, sitting upon chairs without back rests, faulty postures; (7) the introduction
of hard floors, as in many of our modem Victories; (8) janing processes, especially in
connection with pneumatic machinery and tools; (9) pressures against the body, or
using the parts of the body for holding objects in place; (10) friction and irritants;
(11) excessive fine work, causing eye strain; and (12) reverberating noises and con-
cussions affecting the hearing. Each of these conditions requires a special study.
Unfortunately, scientific management experts have undertaken to solve certain of
them, especially where moti<m is concerned. They usually fail in their motion study
work to introduce two or three methods for performing an action — ^in other words,
fadl to recognize the great value of variants in securing physiologic relief and so con-
serving enorgy. Frequently the absence of a limit upon output, the presence of the
pace maker, and the inducement of prizes so rapidly wear out individuals that only
an inexhaustible supply of labor can enable sudi systems to continue. The sensa-
tion of fatigue is not trustworthy and can not be accepted as a guide for tiredness.
Excessive work benumbs the sense of fatigue, and occasionally one feels tired who
is not fatigued. The best standard for the activity question appears to be normal
output per day coupled with tound health corUinwrne, Definite signs of fotigue are
inaccuracies of execution with consequent defective product as well as greater liability
to accidents. The effects of fatigue upon health and longevity can not be discussed
here.' "So tired'' is an expression whidi should never be heard at the end of a
day's work.' For the ava:age class of workers probably the greatest single hazard of
pers(mal origin is the lack of enough sleep, and after that the exigencies of the work
which preclude variation of application.

iNAcnvnT.

Inactivity becomes a work hazard where sedentary work obtains, where movements
itfe limited, where the energies are spent principally upon mental concentration,
and occasionally where there is actually not room enou^ in which to move about.
Moderation and diversity of application are the secrets of energy conservation when
it comes to the exercise of the functions of life.

It is necessary to mention industrial stimulantism, whidi may be alcoholism, cof-
feeism, or drugism. It is promoted by (a) almost any of the above health hazards;
(6) the absence of good drinking water plentifully suppUed; (c), the tradition among
workers in certain lines that alcoholic liquors tend to stimulate them and to ward off
the effects of poisons, dusts, gases, and hiurd work; (d) the permitting of the drinking of
intoxicating liquors while at work; and (e) finally, to the bict that there is an absence
of the human interest attitude, or an industrial efiidency department in connection
with an establishment. Coffeeism in females may represent alcoholism in males.

Having laid down the principles of factory sanitation as they have appealed to me,
i believe it well in concluding to mention briefly the general features which tend for
improvement. I would lay stress espedaUy on pointing out to the employer every
relationship in which these features of mal hygiene detract from production. There-
after, upon the great value of not only attempting to standardize the environment of
his employees upon a sanitary basis, but to classify his employees according to the
findings of physical examinations, not forgetting that this should include mental

I See Ooldmark, Josephine: Fatigue and Efllciency: A Study In Industry, Russel Sa^e Found., N. Y.
Ifl3(800p.).

OUTer, 8tr Thos.: Jr. State Med., Loodon, XXn. 6. June. 1014. X21.

298 PBOCEEDIKQS SECOND PAN AMEBIOAK 8CIENTIFI0 00NQB288.

capabilities. After all of this is done, it must not be forgotten that the most perfect
specimen of Apollo Belvedere, placed within the most exemplary environment, may
soon prove a decidedly bad risk if he has no knowledge of and desire for the prmctioe
of personal hygiene, and that it is only by the harmcmioos working of all three of these
elements— the place, the man, and the method— that efficiency, which represents
actual production divided by standard production,' can be secured. It requires the
employer, the employee, and an intelligent social or State interest to bring about
these things.

INQUIRY FORM.

Fcfrm f<jf the mmUary impeetion qfa/adory or work plaee^/cr use byfadorjf fjfidau9
tenrieei, inturanee $ennee$f jmblMnipeetion $ennee$, trmUmeni and rdi^$enfkm,

(NoTS— Uw X fbrsUsht hAttnl (wltblnUiiiltsoriHitiinl totoTBtton); XX, mora marked hAiard (but wfthln
llmlttoriistiinaMlaptatioo,atlMitCoratime); XXX,badhi>rd(liprodiidiigdtoeaw,orwini^idly
dosa)

Workptaot:

Day. Night. Oy«rtlma. Nooottme. OtberraoMMs. PerwMk. HtrnHmm,
'Mt Whw hmMmniouB (fn^fntfOM).

Do9t: Tjrpe Amoant; brMthed, sUii, eyes; pievenUon, oonflnement, removal, niplratiin, care

lewnew; drysweepiiic,divtliif ordeanliigdiiifiif workhoon; prooioteB ioafDdency, aiekiMM

.•.■•■>••■••.••■«•.«••*••■.••■■•>•••••••••■.*•«•*••«••«••■«•«•«*••.•■••.••«■>.•■•.*.■•.>•■••••••••••••>>••

Disorder: (Dirt), Building structure, floors, surroundings, materials, insnflWent fleaning, ordering; ne^
Ugence; pronmtes low standards, ineflldeney, and injuries.

Humidity: Water, steam, Tapon, dampness; oonflned dampness or dryness; promotes li^urtes, sieknem,
and ineflldeney.

Illumination: Obstructed surroundings, limited window spaea, lighting (AKOO and by praoeos);
ihadows, contrasts, fllokerin& glare, briUianoy, ookns, poor sbadee, eye shades, gog^eo, hatmats,
screens; dark-room work; feeing light souroe; promotes sickness, iQjtuies, IneiBciency.

AlR Stagnation, room temperature (high?), humidity (lowT ); flne dust, smoke; leaks d gss, Tapors fumes;
open fires, gu flames; very dose oonflnement; promotes sickness and inefllneoc/.

Heat: Insuflldent protection, rest intenrals, drinking flteOitles, showers, baths, loeken, change rooois,
dothes-drylng quarters; long hours; permitting undue exposure; proaiotes sidmess, li^urlss^ and inef-
fldenoy

Cold: Insufficient heating, clothing; dxmfts, inaetlTa work,altematlons with heat; outdoor dosets; waatbsr
exposure; basement work; promotes sickness and InelBcleney.

Fatigue: Laborious work, long hours, piecework, speeding up, monotony, eonstant standing, prdonged
strains, chaifs without backs, Italty postures, hard floors, jamng proeesses, pressures against body, eye
strsin, noise; insuflldent rest periods, female quarters, variations, rotations, recreations

Inactivity: Sedentary work, limited movements, mental concentration, conflned work space.

Prsssures: Caisson work, diving, high altitude, ooncussioo. Odors: Sickening. Electridty:

Infections: Materials insects, anUnals, persons; mouthed articles, short Intervaled handHi^ of

ol^iects, wiping ra^, oil; frequent trivial Ihlwles, bums, flying particles; proximity to others, spitting
on floors, common towds, cups; insulDdsnt wash ptaces, dosets, gkfves, wonk^ avpldoRB; rntas^ med-
ical care, physical examinations, flrst aid, hospital arrangsments

Veneieal diseases: Suggartlve ptcturss, writings, languags especlslly where sexes work together.

Poisons: Name and form amount of risk, worker ignorant, careieBs; InstixHy

ttons insuflldent, disrsfarded, wrongful, harmful; mislabeling; eating at work, in workroom; mnstadie,
beard, Indifltorenoe, medloal supervision, gloves, respirators, dothes, lodcers, washing iMltttIss, lundi

room ...••

Meehaniral protectloo. Work variation, rotation.

Thirst: Drinking water not good, or convenient, or properly cooled, improper beversges preferred.

Akhohollsm and desire Cor stimulants: Thirst, doit, fitigne, tradition, habit, physical weakness; per-
mitted during work; saloons nsar, ignorance ofefieots; no home fsrdens, no efficiency departmant.

Signed

N. B.— In addition to the marks X, XX, and XXX, use L for haiards whidi are due to the locality (or
neighborhood), and 8 Cor haiards which belong to the space (or workroom) in which the work Is dene.
All other haiards are presumed to be due to the nature of the process itselt

I BrIscOk N. A.: Bconomlos o( Bflldency, 1914, » (385 p.).

GENERAL SESSION OF SECTION Vm.

New Ebbitt Hotel,
Thursday morning, December SO, 1915.

Chairman, William C. Goboas.

The session was called to order at 9.30 o'clock by the chairman.

The Chathmax. There is some preliminary business in the way
of a report from the committee on resolutions.

Dr. GxnTEBAS. Your committee has received the following reso-
lution:

The Pan American Scientific Congreas of Washington bogs of the nations here
represented that they institute measures for the gradual restriction of alcoholism.
The movement should be initiated with an intense educative effort and an additional
tax on alcoholic beverages, the i^oceeds of which are to be devoted to the establish-
ment and maintenance of sanitoila for the sQgrog^tion through l^gal action of recal-
citrant inebriates and those who are intensely addicted to excessive drinking to receive
in such institutions the proper treatment.

The committee, Mr. Chairman, is in accord with this resolution
and reconunends that it be brought before the congress.

Seconded and approved.

The Chairman. The resolution, then, will be presented to the
executive committee.

Dr. OuiTEBAS. The committee has received another resolution
relative to the leprosy problem. The committee, Mr. Chairman,
is rather of opinion that this may not be a matter to bring
before the congress, because it is somewhat restricted in its scope,
and it seems unwise that we should bring before the congress a very
large number of propositions of this kind. Besides in the very
session in which this was proposed one of the gentlemen from South
America, from Brazil, rather objected to the treatment given therar
peutics in this resolution. He said that to make these questions of
real international importance it would be better to develop the pro-
phylaxis side in these attempts at general legislation. Therefore
the committee does not reconunend the bringing of this resolution
to the general congress, wise as these measures are and very satis-
factory as they certainly are.

The Chatkman. The chair wants to emphasize what our com-
mittee has reported on this matter. The chairman of the section
has to submit these resolutions to the executive committee, who
have to approve them before they are submitted to the congress.

299

300 PBOOEEDIKGS SECOND PAN AMEBICAN SCIENTIFIO C0NQBE8S.

I can see that there is a great inclination on the part of the executive
committee to limit the number of resolutions. I think if we confine
ourselves to five or six resolutions we shall have a much better
chance of getting them before the congress than if we brought in 30
or 40. I would like therefore to emphasize the recommendation of
the committee on this subject.

Dr. KoBEB. I move that this section indorse the report of the
committee.

Seconded and approved.

The CoAiBBiAN. Is there any further miscellaneous business
before the section! If not, we will proceed with the scientific part
of the program, which opens with papers treating of the subject of
tuberculosis from the etiological and sociological aspect. The first
paper is on "The etiology and prevention of tuberculosis from the
sociological point of view," by Dr. William Charles White.

THE ETIOLOGY AND PREVENTION OF TUBERCULOSIS FROM THE
SOaOLOGICAL POINTS OF VIEW.

By WILLLAM CHARLES WHITE,
Associate Professor of Medicine, University of Pittsburgh,

The etiology of tuberculoflis has not yet been solved. For 39 years, since the won-
derful discovery of Koch, we have known that no tuberculosis exists without the tuber-
cle bacillus. This one great truth has been established, but it is not all the truth, for
it is just as salient to say there is no tuberculosis without the animal body. Even these
two great factors do not close the discussion, for some relation arises between the tuber-
cle bacillus and the animal body, occasioned by their contact, which must attain be-
fore the essential feature of tuberculosis— the miliary tubercle— is formed.

THE TUBBBCLB BAdLLUB.

From the time of the isolation of the tubercle bacillus by Koch, it has been studied
in many ways. We know in part its form, singly and in colonies, its varieties, its
chemical reactions and chemical composition, its necessary food and environment, its
excretions and enzymes, its life history, in glass, and as a parasite, its resistance to
light, to heat, and to chemicals, but not yet the one essential factor, why and how it
produces a tubercle.

THB ANIMAL BODT.

The study of the tubercle bacillus outside the body has been comparatively easy.
The oiganism is, however, lost when we put it within the animal body. We know it
soon enters a phagocyte cell, probably chiefly one of endothelial origin, but once
inside of this cell, there begins a series of chemical and physiological changes, wholly
obscure to us as yet. After some days, however, we see the evidence in the miliary
tubercle, of the busy life it has led, marshaling against it at least three different armies
of cells, polynucler leucocytes, endothelial cells, and Ijrmphocytes.

It is not surprising that our knowledge of etiology as it relates to the animal body
is limited, for if we seek to reduce our size to that of a tubercle bacillus, retain our
mentality, A.nd start a wandering journey within the animal body, we are soon lost in a

PUBLIC HEALTH AND MBDICINE. 301

maze of poooible reetdng places. Before starting on such a journey, we have the choice
of several portals of entry, each leading to an environment in different oigans and
tissues of widely varying chemical structure. We see a chance of destroying sight
with almost instant discovery, by establbhing a solitary tubercle in the optic nerve,
as opposed to the chance of establishing many thousands of tubercles, without dis-
covery, within the lungs, or in a hidden Ijrmph gland. But such choice of a final rest-
ing place is destroyed by the obstacles we meet on our journey, a blood current to
carry us here or there, a wandering cell to transport us, a fixed cell to engulf us, an
inimical fluid to dissolve us, it is small wonder all the truth has not yet dawned.

Our difficulties grow when we realize that we are just establishing our first firm
basis for accurate physiological and chemical study of the animal body. Through the
efforts of Fischer, Hoppe-Zeyler, Folin, Mendel, Starling, and many others, we have
realized that first, an equiUbrum must be established for the animal body, and after
this an intake of known composition be added before resultant compounds can be
determined. It is not strange when this knowledge i^ so meager that we have not
discovered under what chemical condition of the body the tubercle bacillus can
flourish.

INVB8TIOATOR AND INVI8TIOATION.

One of our best students has recently said to me: " If I had the opportunity to study
tuberculosis, I would not know where to begin; it is like battling against the waves of
the ocean." It is not so bad as this, however; what we need is a new grasp of our prob-
lem on a broader basis. The crux of the problem is the relation existing between
the tubercle bacillus and the animal body.

New problems for research are opened to us daily, by the suigeon, the anatomist,
the physiologist, and the chemist, and probably many of these must be solved before
the true etiological factors are apparent, and relief from our suffering from this disease
attained.

PRIS8INO PROBLEMS.

Such problems are involved in the answers to the following questions:

Why does the tubercle bacillus select the apices of the upper lobes of the lungs in
man and the cephalic ends of the caudal lobes in cattle?

What is the relation of small doses of tubercle bacilli from various sources to later
immimity and a reduction of morbidity and mortaUty?

What is the relati<m of early, localized lymph glandular lesions to later more gen-
eralized tuberculosis, ranging from early lesions in the lungs to general miliary
tuberculosis?

What is the chance of reaching the tubercle bacilli lying within tubercles in tho
body of an animal by chemicals introduced into the blood stream and what hope
does such study hold out of cure or arrest of the process?

What bearing has the physiology of various organs such as the spleen on the general
problem of immunity to tuberculosb?

What hope have we of establishing immunity by vaccination or arrest and cure
by immune sera? and so on, a host of unanswered questions bearing directly on our
relief from the standpoint of control by social measures.

If we choose the lung as the chief point of attack in the animal body as the object
of our study, we are conscious at once of a chemical factory to which every organ and
tissue sends its contributions, throiigh veins, lymphatic vessels and thoracic di:ct —
contributions which vary all the way from the internal secretion of the adrenal gland h
to the neutral fats, changed by the lining membrane of the bowel, and transported
by the lymphatic channels from the food in the intestine.

Any one of these substances may contain the solution of the secret of the choice
of this organ by this widely di?tribrted bacilhiR.

302 PROCEEDINGS SECOND PAN AMEBIGAN SCIEKTIFIO G0KQKE8&

If we seek to solve the question, Why tuberculosis attacks the apex of the upper
lobe in man, one can see how complex even this question is when the following ex-
planations of it are available for study.

I. That it may be due to mechanical pressure from rib and clavicle producing a
quiet area; this, of course, is not applicable to the place of choice of the bovine lesion
in the caudal lobes.

II. There may be a peculiar chemistry of the apices of the lungs in these two ani-
mals dependent upon position and directness of the blood stream, or other similar
factor, determining a peculiar quality of fluid or cell in this region.

III. There may be some pecuUar anatomical relation existing between the p6rtal
of entry, the lymphatic glandular system and various arteries which by directnese
of stream and current, carry tubercle bacilli, once entering the blood, to these regions.

IV. There may be some anatomical relation between the lymphatic system and
these regions, which carries to them tubercle bacilli entering the lymphatics.

Let me point out again the difficulties, by taking the latter as an example. Only
within one year has there been any accurate knowledge of the lymphatics of the
lung and their relation to the intestinal lymphatics, and yet there seems much of evi-
dence to prove that the tubercle bacillus has some definite relation to the endothelial
cells of this vascular system.

These problems may be solved for us by the chemist, the physiologisty or the sur-
geon, or by all combined.

What we especially need are funds and facilities to provide the opportunity for
research, and research workers to take up these problems.

THB SOCIAL AGENT.

Our lack of specific knowledge can in no way be offered as an excuse for laxity in
putting in operation the knowledge we already possess. Our various oiganizatione
(from national to local), the most efficient ever established against a single disease,
stand as evidence that we have not shirked our duty.

Perhaps, however, our wisdom has not always been as prominent as our eneigy,
and mainly we have Mled to realize that our most efficient agents must always be
doctors and nurses with a social sense. These alone can combine skill in diagnoris
and treatment, with a knowledge of social conditions which underlie the spread of
this disease.

One of the most disturbing features of modem work has been the gradual loss of
respect for medicine and nursing as professions. This has become especially marked
in tuberculosb work, where, with liie establishment of laboratories, new agents of
social service and executive secretaries of organisations, the curious condition htm
arisen that there is a widespread opinion that little skill is necessary for the diagnosing
and provision of consumptive people. There is scarcely a dty or State to^ay in
which a layman operating as secretary or agent of a society for the prevention of
tuberculosis, is not able to both get the sputum analyzed and the patient placed in
a hospital, without ever having to see a doctor.

I often wonder whether our whole flimsy construction of medical and nursing
training is not at fault when it is possible for laymen and laywomen to do the work
which our present long course of training leading to degrees, licenses doctors and
nurses to do.

Two great foots, for some years, have steadily robbed the race of the assistance of
these two groups.

First, the exclusion of tuberculods from the institutions of general professional
training, and

Second, the establishment of special institutions in territory inaccessible to stadents
of these two great professions.

PUBUO HEALTH AND MEDICINB. 303

A new and healthy movement in America has lately been evidenced by the work
of the Tuberculoma League in Pittsburgh, the Phipps Institute in Philadelphia, and
Jefferson Medical College, in connection with the schools to which they are attached,
in demanding practical experience in this work as part of the prescribed course.

I am convinced that the single foctor of making the practical education of tubet-
culoeis, from the standpoint of diagnosiB, treatment, and social aspect, a demand of
the prescribed courses for doctors and nurses in the institutions where they are trained,
will do more in five years to reduce the morbidity and mortality from this disease
than all the special institutions for its care that we have heesx at such pains to
establish.

THB SOCIAL FABRIC.

How much of tuberculosis is closely bound up with our houses, our schools, our
food, our workshops, our means of transportation, our dusty streets, our wages, our
poverty, and other sicknesses can not yet be answered completely and finally. We
know enough, however, to mkke these relations part of the education of our whole
population.

For such education three great sources are alwa3rs open to us.

The first and most important, the schools, is most likely to succeed, because of the
legal backing which makes listening and teaching compulsory.

The second, the pulpit. I never attempt a special lecture on this subject that my
effort does not sink into insignificance beside those of my friends and coworkers in
my own community. For instance, when Kabbi Levy, with his wonderful concep-
tion of the Fatherhood of God; Bishop Canevin, with his great and good paternalism;
and Dr. Mcllvaine, with his fearless and loving admonition, and many others, join
on a chosen Sunday each year in teaching the truths of this great problem to their
congregations, I realize that a force for education has joined the ranks of our
special oiganizatlons the world over, that marks a most powerful ally in the direction
of universal education of this subject.

The third great agent of education is the daily paper. I think all who know must
feel disappointment with the help of these powerful agents. I suppose their sin is
wrapped up with the fact that their papers must be sold. The selling agent Ib news,
and not the reiteration so essential to education, but every once in a while the entrance
of tuberculosis to the family of the throne room of the paper brings forth a new ally
of wonderful power.

The essential feature of such education, however, must be truth. Each day reveals
new evidences of sadness, resulting from careless statements, which lead only to fear
and bring the suffering of the outcast to the consumptive populace.

The standardisation each year of knowledge, through some central office, like the
Federal Government or the national association, would tend to lessen the dangers of
each successive period of advance.

CORRXLATBD MOVBMBNTS.

Next to education there is not a movement for the health and welfrune of the race
which has not had its share In reducing this sickness— housing reform, child weUarOt
pure water, better wages, pure food, health laws, school lunches, ventilation, food
lines— all aid.

I often wish to each might be given the credit fcnr all it has contributed to the present
great reduction in tuberculosis, tot I sometimes fear that in our enthuMasm we have
claimed too much and been misled by the establishment of institutions which, while
necessary for housing this excluded portion of the race, have largely failed to rise
above mere housing institutions, and have neglected that perhaps more important
foundation, provision for specific research in this work.

Perhaps one of the most striking conditions of modem municipalities is the large
number of small charitable institutions, each with a laundry, kitchen, bakeshop,

304 PBOCEEDINGS SECOND PAN AMEBICAN BOISNTIFIC CONGBESS.

purcbaaing department, engineering department, and high-priced superintendent
and officers, to which the whole public gives more or less lavishly without any thought
for economic and careful use of their funds. .There ought to be some place, a l^gal
authority, to stop such waste and carelessness, and establish a central laundry,
Idtchen, storehouse, and other such necessities for these smaller institutions.

Many interesting social studies by Federal, State, and local organizaticms have been
made. Among these are the housing surveys by Dr. Biggs in New York, the study of
the children of the tuberculous, as compared with the children of the nontuberculous,
and many others which need confirmation, with the eradication often of sources of
error in the compariscm of results, whidi arise because of variation in technique.

DIVISION OF LABOR.

With such a universal problem and so great a host of agents entering into its solu-
tion, perhaps the two outstanding demands of this work are uniformity and equable
division of the labor.

To what end is all our labor if <me class is helped and another neglected ; if one State
is efficient and another lax; if one race is protected and another left to exposure?

As it appears to^y the poor receive a large percentage of our beneficence, while
the great middle class suffers for its independence by our neglect and the rich wander
from climate to climate and doctor to doctor, hoping that God in His goodness has
vouchsafed some knowledge tor their benefit, which can be purchased by gold and
silver to the exclusion of the rest of the world.

Or again one State provides lavishly for this one feature of public health, while a
neighboring State, separated from it by an imaginary line, turns its back upon its duty ;
or one town attempts efficient handling of its problem, while a near-by borough does
nothing. The source of sudi discrepancies of course lies where the law originates in
the State and Federal Government.

RELATION TO OTHXR HEALTH MOVEMRNT8.

When such a law is at last prescribed, we are apt to make again the mistake of separat-
ing tuberculosis f^om other health and charitable activities and so waste a great part
of the efforts of our agents by reason of a duplication of labor.

THE SOLUTION.

I am more and more convinced of the soundness of the soluti<m for this problem,
which I have offered on more than one occasi<m, and inasmudi as I believe in it so
fully, I am to be guilty of proposing it again to you to-day.

This plan is based on a study of our solution of a similar universal problem presented
by our educational demands.

Emanating from State law there is in general established in educational work a unit
equipment for a unit of population. By this equipment is gained a imiform com-
pulsory and intensive application of the law to all concerned. The money for the
expense of this care is provided by State and local taxation determined largely by
the density of population and the need of the community. Those who are interested
in this phase of the question would do well to read Gubberly's "Problems of State and
Municipal Education . ' *

In the educational field there has gradually developed a knowledge of the equip-
ment necessary for a given population and tbis equipment has been apportioned
so as to be easily accessible by dioee whom it is to serve. The management of these
units is centered in a legally omstituted governing body, which also controls the
expenditure of the funds collected by taxation.

The same form of control is applicable throughout to tuberculosis and other health
problems.

PUBLIC HEALTH AND MEDICINE. 305

In the first place our statistical studies have given us isdily accurate knowledge
of where to place our equipment and of what the equipment should consist.

I should say that for each hundred thousand population there should be a hospital
of 200 beds, a dispensary, and an open-air school. There should be 15. nurses, of
whom five are visiting social-service nurses, and four or five physicians. Such an
equipment mi^t easily expand and include all public activities, child welfare,
pneumonia, syphillis, and other health and public-welfare problems.

The expense should be borne as the educational expense is borne and the demand
made mandatory by State law.

Large centers of population would be looked on as but the multiplication of units
of 100,000 and the equipment would be multiplied accordingly, just as we now mul-
tiply our school equipment. Each unit would be self-governing, but centralized in
some central governing board, which would establish the uniformity of the work and
the prevention of overlapping.

The State that sees fit to establish such a principle will, it seems to me, soonest reach
the land of heart's desire, and will have a machinery as elastic as the problems to be
dealt with; a machinery that can grow as knowledge grows and retract or reconstruct
as necessity decreases; a machinery that can be used as a teaching center for doctors,
nurses, and social agents; and the sooner it comes the sooner will we see spelled on
the wall the doom of our present boarding houses for sick and well consumptives
and waste of effort.

Dr. White. I would like, sir, if I may, to oflfer one resolution to
this section :

. Reiolved, That it is the sense of the Second Pan American Scientific Congress that
it is important in the interest of the control of tuberculosis that the teaching of
tuberculosis as a disease entity be demanded as a prescribed couree of medical
schools and teaching hospitals.

Col. HoFP. I move that the resolution be referred to the committee
on resolutions.

Seconded and approved.

Dr. Agramonte hereupon took the chair, escorted by Dr. Luis
Migone, of Paraguay, and Dr. Jos6 Rodriguez da Costa Doria, of
Brazil.

- The following paper was read by the author, Dr. Joaquim Oliveira
Botelho, and discussed in Spanish by Dr. Luis Migone and the author.
The Spanish discussion was not reported.

TRATAMIENTO DE LA TUBERCULOSIS POR EL PNEUMO*TORAX

ARTIFICIAL.

For JOAQUIM OLIVEIRA BOTELHO,
Miembro de la Academia de Medicina de Rio de Janeiro, BrasU,

El m^ interesante problema que preocupa a las sociedades modemas es el de
combatir la tuberculosis— enfermedad individual, porque asf se habrd estancado la
tuberculosis— ^al social.

Despu6s de los trabajos del sabio Forlanini, de Pftvfa, la curaci6n de la tuberculosis
en corto tiempo se tom6 una realldad, de lo cual puede dar testimonio irrecusable mi

306 PBOCEEDIKQS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

experienda, adquirida dentro y fuera de mi patria. Hablo en este momento fundado
en una pr6ctica de algunos milee de operacionee hechas en centenares de sujetos, \o
cual da autoridad dentffica a mi palabra. Puedo, pues, asegurar desde ahora, que la
operaci6n del pneumo-tSrax art{fieialf de Forlanini, cura la tuberculosis, aun en el
dltimo estado de la enfermedad. Todos mis pacientes ban sido tratados con el m&s
escrapuloso rigor cientffico, teniendo cada uno invariablemente su hoja cKnica con
su anamnes, el ezamen bacteriol6gico del esputo, la radioscopfa o radiograffa del
pulm6n, etc. Dichas bojas clfnicas eran siempre llevadas, sin excepci6n, por mis cola-
boradores y asistentes, doctores en medicina, de mode que no redbfan de mi parte
ni el mis remote concurso — a no ser el examen dd padente, su operad6n y su trata-
miento. ISi archivo dentffico estd, p<nr tanto, exento de toda sospecha y refleja con
la mayor exactitud y serenidad mis labores en el tratamiento de la tuberculosis.

El m6todo de Forlanini consiste en procurar d colapso del pulm6n por medio de
un gas inerte que es introducido en la cavidad pl6urica de mode que comprima y
exprima dicho 6rgano hasta redudrlo a la quietud absoluta.

Esta operad6n, que es becha sin sangre y sin dolor, tiene, sin embargo, sus dificuU
tades y peligros que s61o la experiencia puede evitar. Los pr^ticos que la ban reali-
zado la restringen considerablemente, limittodola por un ndmero creddo de contra-
indicaciones. Despu^ de una experiencia muy larga— porque be tenido que practicar
miles de operadones— yo me creo autorlzado para asegurar que Mo reconoico dos
con traindicaciones :

(a) Insufidenda del pulmdn del lado opuesto al operado; y

(h) Sfnf ece pl6iurica del lado que se va a operar.

Fuera de estas contraindicaciones, que son muy riguroeamente estudiadas por mf , las
otras (bastante numeroeas, por cierto) sefialadas por los pr^ticos, tienen Mo una impor-
tancia relativa. Tanto es asf , que en ml redente pr^tica en mi pais— pr&ctica qu«
dur6 por espado de un afio— yo no he podido operar s61o el 4 por dento de los tisicos
que se ban sometido al tratamiento. Basado en tal experiencia es como aseguro que
el pneumO'tSrax artificial es una operacidn que puede ser de uso corriente, aplicable
en la cad totalidad de los tuberculosos que concurren al estudio dd espedalista.

Lo mis interesante en esta operaddn es que ella produce con frecuencia— no rara-
mente— verdaderas resurrecdones, rehabilitando la salud de individuos a quienes sua
familias y sua midicos jusgaban ya completamente perdidos. Y el fen6meiio es
U/dl de explicarse: d gas penetra en la cavidad pliurica, exprime el pulmdn libertando
sus alviolos de los Ifquidos sipticos que lo infiltraban y que destrufan incesantementa
el organismo por una auto-lntoxicaci6n. Desde que d padente se liberta de estos
Ifquidos, que son evacuados por la compreddn dd digano, todo su oiganismo se desin*
toxica mis o menos ripidamente, de manera que puede reaccionar en provecho dd
estado local y general con inmediato y vidble reflorecimiento del individuo.

Tengo d honor de ofrecer al Segundo Congreso Cientffico Panamericano, las con-
cludones a que Uegui despu^ de una larga experiencia, y que ban ddo llamadaa en
mi pais, por la prensa midica, el Decilogo de los tuberculosos. Espero que, con d
correr de los alios, los espedalistas que ll^guen a adquirir una grande experiencia en
la materia, irin confirmando una a una mis concludones.

Primera. — La gran mayoria de los tlsicos son operables.

Segunda, — ^Las adberendas son apenas una central ndicaddn relativa, pudiendo asr
venddas la mayoria de las ^ eces.

Tereera.—A, pesar de las adberendas, el tldco operado por el pneunuhtArax orHifiaal
puede curarse, de^e que se consiga circunscribir y aislar las adberendas inlran-
queables.

Cuarta, — ^El tldco puede ser operado, aun teniendo ledones bilaterales o extensas,
nempre que tenga sufidente cantidad de pulm6n dd lado opuesto al operado, para
la respiracidn suplementaria.

Quinta, — La cura dinica puede ser conseguida con relativa rapidea.

PUBUO HEALTH AND MEDICINE. 307

Sexta, — ^En lo6 casos de tuberculosiB secundaria de la lanugo y del intestmo, la opera-
ci6n del pneumo-t&rax artificial es parte importante del tratamiento, porque ella
estanca la sementera pulmonar e impide asf la reinfecci6n.

8ipima,—lsa complicadones son nraa: en dento doa (102) enfearmos operadoB por
mi tUtimamente, apenaa obaerv^ tree (3) derrames pl^uricoe.

Oetttva. — La operaci6n puede combatir con rapides complicaciones ya eziBtentes:
hemotiflis, disneaa debidaa a ext6nsi6n de leaiones pulmonares, etc.

Novena, — Las altas temperatuias de los tlsicos son debidas mis Men a las asociacionee
micro> ianas que al bacilo de Koch.

Dicima. — La curaci6n puede ser prolongada o definitiva en enfermos que hayan
hecho su fmeunuht&nx^ artificial completo, aunque no se renue^ en sus operaciones.

Estas conclusiones son mi guia y la gufa de mis aaistentes y discipulos en los tUtimos
tiempos, despu^ de que una gran labor ha cimentado en mi espiritu un conocimiento
cabal de la materia. Ellas contradicen radicalmente todo cuanto se ha escrito sobre
la pr&ctica eetricta del pneumo'4&rax artificial en varios paises de Europa en los cuales
la operacidn ha side empleada en muy pequefia escala. Y ellas son, por otra parte,
el producto de una experiencia progresiva y de una tunica rigurosamente dentifica.
8i hay una espedalidad que demande conocimiento complete por parte del especla*
lista, es la tisioterapia. El tisidlogo debe ser a la es un cirujano de habilidad indiscu-
tible y un cllnico de perfecta y efidente preparad6n. Es del consorcio de estas doe
condidones, reunidas en un solo individuo, de donde proceden los ^xitos obtenidos
en el tratamiento de la tuberculosis y de la tisis pulmonar por los m^todos modemos.

Gomo una contribud6n para el estiidio y el conocimiento de la materia, tengo el
placer de transcribir un editorial de La Gaceta M6dica de Rio Janeiro, de 24 de alril
del coniente afio. El Director de aquel periddico habia ido personahnente a acom-
pafiarme de cerca en mi servido clinico durante varies meses, y a estudiar mi archive
dentifico (ya bastante numeroso y siempre hecho con la mis rigurosa exactitud), para
poder informar con fidelidad a la dase m^dica del Brasil respecto de los ^tos por mi
conseguidos en el tratamiento de la terrible peste blanca.

El referido articulo intittilase '* La cura de la tuberculosis," y su traducd6n fid es
comosigue:

La Oaceta Midioa^ con el propdsito de ser ir bien a sus lectores y a los intereses
dentificos, procur6 acompafiar de cerca en su servicio clinico al eminente medico
brasilefio, Dt, Oliveira Botelho, para poder comprobar, de un mode indudable, las
ventajas conseguidas por nuestro uustre compatriota en el tratamiento de la tubercu-
losis por los modemos m^todos dentificos.

Deepu^B de una minudosa y demorada in^ eetigad6n hecha por d Director de este
peri6aico y gustoeamente permitida por d notable espedalista— que no escatima
tacilidades a quien procura averiffuar la verdad con raqpecto al interesante m^todo
cientifico de Forlanini, por ^ empleado, llegamos a la conclu8i6n de que, en reaUdad,
la tuberculosia es hoy una en/emuaad rdpidamenU curable.

Del precioso archive del Dr. Oliveira Botelho destacamos, de entie otros muchos,
el resumen de la historla clinica de 10 enfermos que ya se hallan en plena con alecen-
cia, despu^ de un tratamiento que fu6 para nosotros una erdadera re\ elad6n dd
extraoroinaiio m^todo sabiamente ejecutado por el medico brasilefio, que est4 justifi-
cando entre nosotros los grandes homenajes por d redbidos en d exterior.

Hubitemos podido propordonar a nuestros lectores hojas clinicas de 20, 30. 40 y
m^ enfermos curados por d sistema de que ha side heraldo entre nosptros d oistin*
guide compatriota. Sin embargo, restiingimos la predosa documentad6n a 10 hojas
dinicas, p<Hrque ellas son, por d solas, bastante elocuentes para probar que la tuber-
cukflis es hoy una enfermedad yetdaderamente curable.

Las referioas hojas clinicas son una prue a irrecusable de cuioito puede actual-
mente la dencia en el tratamiento de aquella enfermedad, y aun de los grandes
ser idos que est& prestando a nuestro pau d Dr. Oliveira Botelho, a quien nunca
agradeceremos lo sufidente tan bellas proezas dentificas.

Al Dr. OUa eira Botelho y a sus ilustres colegas y colaboradores los Drs. Dantas de
Queiroz y Rodrigues Sant' Ana, agradece La (iaceta M^dica la buena acogida que se
Birvieron dispensarie.

68486— 17— VOL ix ^21

308 PBOCEEDINQS SECOND PAN AMEBIOAN 80IENTIFIC C0NQBES8.

HOJA8 CliNICAS.
I.

PacienJU NUmero S.—M, S. M.— Antecedentes positivoB: padre y diez hennanos
han muerto tuberculoaoe. Adenopatla triqueo-bronquica tuberculosa e infiltraci6n
mifl acentuada del lado derecho. Fiebre Tn^Tima, 38 grades del centigrado; expec-
toraci6n diaria, 30 gramos.

Apirexia al cuarto dfa de tratamiento. Termin6 de tarataise en el espacio de un
mes, absolutamente sin fiebre, sin esputos y con aumento de dos kilos de peso.

Cura evidente por ausencia de todoe los s(ntomas cUnicos, a tal punto que no se
hubiera podldo soepechar que hubiese estado tuberculoso.

(Finnados:)

Dr. J. DB OUYBIRA BOTELHO.

Dr. Arthur Dantas de Queiroz.
Dr. Joaqudc Rut db Sant' Ana.

II.

PacienU Ndmero 6. — Reverendo Padre P. A.— Antecedentes tuberculoses positivos:
padres y dos hermanos, muertos tuberculoses. Vertices pulmonares infiltrados.
Campos pulmonares con infiltraci6n menos marcada, que se acenttia mis hacia la
izquierda. Expectoraci6n, 60 ^jamos diaries. Fiebre continua.

£n el se^undo mes de tratamiento, retardado por la distancia de su domidlio y por
«w eeoiaaciones profesionales, se consigui6 un seguro estado de apirexia. Al mismo
tmmao ^ se ve por complete libre de la expectoraci6n, aumenta en dos kilos su peso,
«e soooiteeen sus fuerzas fisicas v adquiere una apariencia saludable.

Al i^ndno de su tratamiento, la cura clfnica es comprobada por un meticuloso ex-
amflB ooDOorde con las afirmaclones del enfermo, quien, por su parte, se siente y se
dedwa pcorfectamente curado.

^Nota del paciente:) Cest Pexacte verity. — Pfere Prosp^re Agaase.

(Finnados:)

Dr. J. DB Ouveira Botblho.
Dr. Arthur Dantas de Queiroz.
Dr. Joaqudc Rut db Sant' Ana.

III.

PamerUe Ndmero 2. — ^A. G. — ^Antecedentes poritivos: tres hermanos murieron tuber-
cidoeos. Depauperaci6n extrema de fuerzas fisicas, a punto de necesitar el enfermo
ser transportado en brazos para el consul torio del Doctor. Infiltracidn tuberculosa en
ambos vertices y en el tercio superior del pulm6n izquierdo. El pulm6n derecho
comprometido en casi toda su extensi6n. En el curso de las operaciones ha dismi-
nufao la expectoraci6n y con ella la reacci6n febril.

El aumento de peso fu^ notable: de 4 a 5 kilos en el espacio de 10 dfas. Rdpido
robustecimiento fteico y moral. Acontecid por este tiempo que el paciente, que habia
venido un mes antes cargado en brazos, pudo caminar a pie la extensi6n de un kil6-
metro para llegar a su casa en Jacarepagud.
(Flrmados:)

Dr. J. DB Oliybira Botblho.
Dr. Arthur Dantas db Queiroz.
Dr. JoAQum Rut db Sant' Ana.

IV.

PacienU Niimero 27. — A. C. L. — ^Tuberculoso de ambos vertices pulmonares.
Adenopatfa trdqueo-br6nquica mds acentuada del lado derecho.

Despu^ de un mes de tratamiento, se anuncia la convalecencia del enfermo por la
mejona gradual de sus sfntomas, estando sin fiebro y sin expectoraci6n, con un aumento
de tres kilos de peso. En estas favorables condiciones continiia tratdndose, hasta que
se le permite marchar a un clima de altitud, de donde regresa un mes mds tarde como
un testimonio elocuente de los benefidos del regimen quirtirgico a que se sometiera.
Guando adn continuaba obedeciendo las prescripciones higi^nicas, el mds riguroso
examen medico no encontraba en su oiganismo el menor vestigio de su enfermedad,
ya vencida.
(Firmados:)

Dr. J. de Ouveira Botblho.
Dr. Arthur Dantas de Queiroz.
Dr. Joaquim Rut db Sant' Ana.

,tir PUBLIC HEALTH A2Sm MEDICINE. S09

PaeienU Ni&nuro SO.— A. L. G.— Tuberculoeo deede hace nueve aftoe, eete enfermo
tenia ambos pulmones comprometidoe: el izquierdo en toda su extenBi6n, y el derecho
con focoe de infecci6n esparcidoe en el campo pulinonar, indicando a la au8cultaci6n
la exJBtencia de alffunas sonas a(in penneabiee al aire inspirado.

Fu6 lenta la meforia de eete enfenno; pero tan reg:ulannente progreeiva, que en el
corto eepacio de 35 diaa— es decir, a la conclusion de su tratamiento — hallabase ya
convaledente.

Habia deeaparecido totalmente la fiebre, era nula la ext)ectoraci6n, el peso del
cuerpo habla aumentado. y sobresalfan las mejorias general es del paciente por las
transformaciones de su decadencia flsica: el bombre que antes era un tronco endeble
y encorvado, presentaba ahora las Ifneas normales, robustecidas por el nuevo vigor
adquirido.

(Firmadoe:)

Dr. J. DB Oliveira Botelho.
Dr. Arthur Dantas de Queiroz.
Dr. Joaquim Ruy de Sant' Ana.

VI.

Paciente Mmero 101.— A. T. S.— Tuberculosis de los dos vertices de los pulmones,
e infiltracidn diseminada en las zonas suporiores de los campos pulmonares. Sefialea
de adenopatfa triqueo-bronco- tuberculosa m6s acentuada del lado izquierdo.

Cuatro dias despu^ de iniciado el tratamiento, entra el enfermo en plena y defini*
tiva apirexia, beneficio seguido de la disminuciOn de la tx>s y la expectoraci6n»

Al tin de las operaciones. la ausencia de todos los sfntomas clinicos de su autigiia
enfermedad fu^ comprobada, y, por tanto, su ouraci6n, y iu6 enviado a un clima de
altitud, donde se halia en el goce de su pleno vigor flsico.
(Firmados:)

Dr. J. DB Omvbira Botelho.
Dr. Arthur Dantas db Queiroz.
Dr. Joaquim Ruy de Sant* Ana.

VII.

Paciente Ntimero 29. — M. C. de R. — ^Tuberculosis de ambos pulmones, siendo el
izquierdo el mia comprometido, conforme al examen cllnico y radiosc6pico.

Al tercer dla de su tratamiento se repiti6 labemotisis, comprobada en su anamnese.
La temperatura subi6 a 39.2 del term6metro centigrado. La operaci6n de ese dla
produjo el brillante resultado de cortar para siempre ese sfntoma grave: la hemotisis.
De abf en adelante va acentu&ndose la mejoria con tal rapidaz, que el 28 de enero, o
ea una semana despu^s de Iniciado el tratamiento, el enfermo se hallaba, como adn
permanece, enteramente sin fiebre.

Terminado su tratamiento quirtirgico en el espacio de un mes, M. C. de R. con-
valcce en un clima de altitud, en p^ecto estado ffsico.
(Firmados:)

Dr. J. DB OuvBiRA Botelho.
Dr. Arthur Dantas db Queiroz.
Dr. Joaquim Ruy db Sant* Ana.

vni.

Paciente Ndmero 63. — ^M. R. — Infiltraci6n tuberculosa en el v6rtice y en la base
del pulm6n izquierdo; en el lado derecho la infiltraci6n es menos intensa y mis disemi-
nada. Tuberculosis secundaria de la laringe con empafLamiento de la voz.

En el perlodo de un mes entr6 esta enferma en franca convalecencia de la tubercu-
losis pulmonar, estando bastante mejorada de la localizaci6n larfngea: su voz se aclara
por el infiujo directo de sus operaciones y de la helioterapia.

Su peso aumenta en dos Itilos; las llneas de su cuerpo nan perdido el precoz encor-
vamiento senil aue prestaba veiez a sus veinte afios. La enferma esti hoy per*
fectamente por el vigor readquirido.
(Firmados:)

Dr. J. DB Oliveira Botelho.
Dr. Arthur Dantas db Queiroz*
Dr. Joaquim Ruy de Sa^nt' Ana.

810 FBOOEEDINQS SBOOND PAN AMBBIOAK SOIENTIFIO 00KQBB88.

IX.

F^ente Nt&mero 78.— J. G. V.— Todo el pulm6n derecho prohindamente infil-
tndo por iin pioceeo tuberculoao ^eralizaoo desde el v^rtice hasta U base, donde
habf a sefiales de mavor condenflacidn tuberculosa. Tambi^ el pulmdn isquierdo ae
hallaba comprometido. Eataa lerioneB eran la expreaidu de una ointomatologf a deaea-
perante. £i padente caai no podfa ya caminar, motivo por el cual laa pdmena
operacionea le nan aido practicaoas en au rendenda, oon el concono de au hennano—
Doctor en Medicina y Medico del Hospital de la Santa Oasa de Misericofdia de Rfo
Janeiro.

En el curao de un mea, transfigurado por la mejoHa adquirida, expectorando
muy poco, absolutamente ain fiebre, sinti^aose y dedartodoee bien, m6 a convalecer
en chma de altitud. I>eq>ertaba un core de admiracidn entre coantoe le habiaa
visto al piincipio del tratamiento. Ahora, tranacumdo otro mes, ee credente la
prosperidad de su vigor fisico, por lo cual puede y debe considerane clfnica y poai-
tivamente cuiado.

(Firmados:)

Db. J. DB Olitbiba Botblho.
Db. Abthub Dantas db Qubibos.
Db. JoAQum Rut db Sant* ana.

NoTA.-^omo date personal informo con placer a este ilustnuio Congreso, que la
vispera de mi partida del Brasil este antiguo enfenno, perfectamente vi^oriisado, eano
desde ceroa de un afio antes, me telecrafiaba para desear un buen viaje y todas laa
prosperidades a quien ee, s^plin ^1, "el Salvador de su existenda."

Padente Ndmero 65. — Nifio J. A. — ^Tuberculoso de ambos vertices pulmonarea.
Tumor bianco en la articulaci6n de la rodilla derecha con deformaci6n del miemlMEo
correspondiente y synarthrose. Atrofia de los mtisculos de la piema como consecuen-
cia de eeta afecci6n.

Este enfenno fu6 presentado por una persona que se interesaba por su salud, y que
tuvo la f eliz inBpirad6n de librarlo de una intervenci6n sangrienta proyectada para el
df a siguiente, segtin me dijo cuando procurd mi opinion como espedalista. Conaenada
la operaci6n y aconsejadoe lahelioterapia y el tratamiento higidnico, etc., la fiebre, que
era constante, desaparedd, y con ella todos los sfntomas eenerales y locales de la
enfermedad, cesando los dolores que lo martirizaban y le proaucfan horribles noches de
insomnio. En la actualidad, el pequefio enfamo se halla bien nutrido y convale-
ciente. El one no podia colocar antes lapunta de los dedoe en el suelo, debido a los
dolores agudlsimos que provocaba el contacto del cuerpo duro, pudo correr velozmente
poco despu^ de un mes de tratamiento.

(Firmados:)

Dr. J. DB OuvBiBA Botblho.
Dr. Arthur Dantbs db Qubiros.
Dr. Joaquim Rut de Sant' Ana.

El tiltimo case de los que quedan relatados enderra una ensefianza digna de ser
tomada en consideraci6n por los especiaUstas y por todos los cllnicos en general, y ea
6sta: Las Uamadas impropiamente tuberculosis quirdigicas, pueden y deben ser
tratadas sin la intervencidn sangrienta, que diaminuye las probabilidades de curaci6n
y que hace que, aun cuando esta se conaiga, pierda el paciente la movilidad de su
articulaci6n.

Estoy informado de que recientes e interesantfaimos trabajos publicados en este
grande y progresista pals de los Estados Unidos de la America del Norte, adn preconiaan
la apertura de las c&psulas articulares en los tumores blancos.

Jdzgome autorizado para protestar con todas mis fuerzas contra las intervencionea
quirtiigicas en las lesiones dseas tuberculosas, pues abrir un tumor bianco ee introdudr
en el oiganismo asociadonee microbianas que antes no existian.

La belioterapia, el reposo, la cura de aire y la operaci6n del pneumo-tdrax artificial
cuando existe una lesi6n pulmonar, son un tratamiento bastante eficaz para curar, en
la gran mayoria de las voces, las tuberculosiB articulares y todas laa tuberculosis
secundarias a una lesidn pulmonar primaria.

Como nueva contribuci6n al interesante problema social y dentlfico que es asunto de
la presente Memoria, juzgo conveniente transcribir atin un editorial del Carreio da

FUBUO HB4LTH AHD WaJflOOm. 811

Mahhaf de Rio de Janeiro, conrespondiente al 4 de aeptiembre del afio que ahora ter-
mina. Dicho peri6dico, que es el diaiio de mayor circulaci6n en el Brasil, publica el
resumen de una de las sesiones de la Academia Nacional de Medicina de aquella
ciudad— eeei^n en la cual me ocup4, como muchas otras veces, del magno problema de
lacura de la tuberculoeis.
Dice el Correio da Manha:

Ocup6 una vez m^ la atencion de la Academia Nacional de Medicina el Dr. J. de
OHveira Botelho, quien presents, para el conodmiento de eea docta corporaci6n,
valioeos documentos acerca de tlaicos por 61 curadoe con el pneumo-t&rax artificial,

De entre dichoe documentos tomamoe las hojas clfnlcas sindentes, por ser dignas de
que se divulguen en provecho de la ciencia y de la humanidad.
^ Estas hojas evidendan el gran resultado producido por tal operaci6n, que el dis-
tinguido medico y compatriota nuestaro ejecuta con rara competenda.

Doe de las mencionaoas hojas se refieren a pacientes que noe son Men conocidos, de
manera que llevan ellas nuestara teetimonio, que viene asf a corroborar el del cinijano
que los ha tratado, y el de su Asistente y colaborador, Dr. Agenor de Castro, que
redstr6 estos dates clinicos.

Los documentos que vamos a transcribir son dignos de nota pNorque ellos vienen a
proyectar mucha luz sobre un asunto de vital intms para la sociedad.

He aquf los documentos a que nos rderimos:

0. v., casado, bianco, de 30 afios de edad y residente en la capital federal. Pre-
sent^ al consuJtorio del Dr. J. de Oliveira Botelho el 24 de enero de 1915.

Antecedentes hereditarios— deconoddos. Antecedentes personalesr— fu6 siempre
robusto.

Historia de la enfermedad actual.— Algunos meses antes de ir al consultorio, 8uM6 un
resfriado del cual result^ con una bronquitis que se le hizo cr6nica. Tenia toe
acompaf&ada de grande expectoraddn, y tuvo tambi^n algwnas punzadas en la r^dn
tohlcica derecha. Estaba visiblemente enflaquecido. pues lleg6 a perder 20 kild-
sramos de su peso. Declar6, adem^, sentirse muy d^Dil, tener sudores profusos por
las noches y hemotiais frecuentes. Tenia fiebre todos los dias.

Peso, 52 kilos.

C. V. ya no podia levantarse.

El dia en que imci6 su tratamiento, la temperatura eim de 38.6 centfgnuio, y la
fioroectoraddn en 24 boras era de 60 c. c.

Ezamen del esputo.— Bacilos de Koch en abundanda.

Examen clinico.— V^rtice del pulmdn derecho poco permeable: su base con profunda
infiltraci6n y zonas verdaderamente impermeables. V^rtice ael pulm6n iz^uierdo
tambi^n poco permeable. Tercio inferior con foco gencnlizado ae Infiltraciones y
sonas periectamente permeables.

Al ser operado, laa temperaturas extremas eran: 38.6 y 37.2 del centfgnuio; lo que
quiere dear que el enfermo estaba siempre con fiebre.

Despu6s de la cuarta operaci6n, laa temperaturas miixima y minima en las 24 horaa
eian 38.2 y 36.7.

Por aquel entonces la expectorad6n, debido a la compreaidn progresiva del pulmdn
por el prmmo-46rax artificial^ lleg6 hasta 120 centimeiroe ctibicos en laa 24 boras. De
ahi en adelante, la temperatura fu6 bajando gradualmente, y al fin de la sexta ope-
racidn ya no ezcedia de 37.6.

Con la s^ptima operacldn, la temperatura mAxima del padente ya no excedia de
37.3, mientrui la minima osdlaba entre 36.2 y 36.5; eso hasta completar la primeim
aerie de operadones. Dicha serie empez6 el 24 de enero y dur6 hasta ei 13 de tebrero.
tiempo durante el cual redbi6 el padente tres mil centlmetros c<ibicos (3,000 c. c.)
de dzoe. En se8:uida se retird a un clima de altitud para hacer su cura higi^nica, y
alii permanedd nasta el 16 de marzo.

Al regresar al consultorio del medico, se vl6 que estaba ya completamente aplr^ptico,
que no tenia toe ni expectoracidn y que habia ganado 14 kilos de los 20 que antea
perdiera.

Al tercer mes de convalecenda habia recuperado sua 20 kilos y habia ganado 2 y
medio mis.

El padente, restituido a su familia y a la sociedad, es hoy un hombre verdadera-
mente atl^tico.

A. L.— Portuguds, de 30 afloe presumibles, soltero. Antecedentes, ignoiados.

C(mcuxri6 al conaultorio del eq[>edalista el 13 de enero, acuaando tos, expectoraddn
abundante, aodores noctumoa y temperatura febriL

£1 ezamen dfnico y radioacdpico ha revelado infiltraddn tuberculosa bilateral
iocalisada en el vdrtice del pulmdn iaquierdo y eztendidndoae por la mayor parte
del pulmdn deracho.

312 PBOCEEDINQS SECOND PAN AMERICAN SCIENTIFIC C0NGBB88.

Movilidad reducida del lado izquierdo y miia atin del lado derecho.

£1 paciente sufrla dolores en el t6rax, delgadez extrema y ^ta de energia fHuca,
de modo que no podfa trabajar.

£1 dla 15 de enero recibi6 su primera operaci6n, y las siguientee loe dfas 17, 20,
22, 24, 26, y 28 del mismo mes y 1 de febrero, que fu6 cuando concluy6 bu pneuino-
tdrax artificial.

Su temperatura, que habfa pereietido febril hasta el dfa 7 de febrero, deeapareci6
entoncee para nunca mds volver.

£i eeputo, que habfa alcanzado a 300 c. c. en 24 horas^ tambi^n desaparecid al se-
gundo mes de tratamiento: el tiltimo examen microsc6pico ya no revelaba la exis-
tenria del bacilo de la tuberculosis.

El paciente estd completamente curado, y vive de su trabajo desde hace cerca de
un afio, y declara que estd bueno y en complete vigor, como si nunca en la vida
bubiese side tuberculoso.

Sin embargo, repiti6 su pneumo-tdrax artificial apenas un mes despu^s de habeiio con-
cluido, por no juzgar necesaria la continuaci6n del tratamiento. Al tercer mes habfa
aumentado 7 kilos en su peso; lo que acusa im aumento de 4 kilos sobre el peso m&ximo
absolute alcanzado antes en las mejores ^pocas de su vida.

M. S.— Brasilera, blanca, casada, con un hijo, y de 20 afios al parecer.

Antecedentes hereditarios, positivoo. Todos bus hermanoo nan muerto tubercu-
loses.

La enferma conciUTi6 al consultorio del medico con tos intensa, fiebre, hemotiaia,
demacraci6n, proiimda anemia, y deprimida en su estado moral por tener la convic-
ci6n de que le sucederfa a ella lo mismo que a la totalidad de sua hermanos, aireba-
tadoe todos por la tuberculosis.

£1 examen clfnico y el iadioBc6mco acusaron la presenda de una tuberculosiB
bilateral, m^ intensa ael lado derecno.

£1 examen del esputo tu6 positive.

La paciente, antes de enfermar, peeaba 50 kilos, peso que ripidamente decay6 a
42, seetin se vi6 el dfa en que fu6 al consultorio del Dr. Oliveira Botelho.

£1 dfa 8 de febrero le fue practicada su primera operaci6n de pneumo-tArax artificial:
el dfa 9 la segunda: el term6metro marco en esta ocasidn una temperatura de 38 gra-
des. £1 dfa 11 recibi6 la tercera; en este dfa su temperatura baj6 a 37.5.

Despu^ de la tercera operaci6n la fiebre desaparedo completamente, para no volver
a presentarse.

£l esputo, que era de 30 c. c, fu^ disminuyendo ripidamente hasta su desapariddn
total y completa, aun antes de conduir sus operaciones de pneumo-tArax artuJUial,

Al concluirlas, la paciente pesaba 47 kilos: asf, pues, habfa aumentado 5 kilos en
poco mis de un mes.

La padente volvi6 una vez apenas para renovar su pneumo-tdrax artificial, habiendo
interrumpido entonces su tratamiento por juzgarse a si misma enteramente fuerte y
bien dispuesta.

M. S., diez meses despues de convaledente, continuaba en extreme bien— como
si nunca hubiera estado enferma.

C. S.— Brasilero, bianco, soltero, de 22 afios de edad, estudiante de la Facultad de
Medicina de Kfo Janeiro.

Su enfermedad empez6 por sucesivas hemotisis, que duraion, con altematlTas, echo
meses seguidos.

Cuando fu^ a la clfnica dd Dr. Oliveira Botelho, d padente tenia tos intensa,
expectoraci6n, fiebre, sudores nocturnes, hemotisis, dolores toricicos y disminuddn
considerable de peso. £xaminado por uno de nuestros mis distinguidos dfnicos,
Profesor ilustre de la Facultad de Medicina de la capital del Brasil, redbi6 el diag-
n6stico de una tuberculosis avanzada.

£1 examen microsc6pico del eeputo fui podtivo.

£1 examen df nice y el radiosc6pico revelaron una invadon tuberculosa bilateral, mis
intensa del lado derecho que dd iz<iuierdo.

£1 dfa 19 de julio se le hizo la primera operaci6n, y con ella perdi6 por complete y
para siempre la fiebre.

La expectoraci6n, que era de 25 c. c. en las 24 horas, fui gradualmente disminuyendo
hasta 23, 22, 18, 14, 8, 6, 5, 4 y 0.

Complete su pneiano-tdrax artifidal, el futuro Doctor fui a convalecer a un dima de
altitud, de donde r^greed un mes despu^ manteniendo la misma cura dfnica con-
8M[uida.

£1 padente no trajo de su viaje las notas diaiias de costumbre iMura ser rcsistradas en
su hoja dinica, por dedarar que no tenia mis fiebre, ni tos, ni expectoradiSi y sentirse
perfectamente oien. Al segundo mes de tratamiento habfa readquirido su peso
normal.

PUBLIO HEALTH AND MEDICINE. 313

Lo ezpueeto comprueba la afleveraci6n por mf hecha al iniciar este estudio, y es que
la tuberculosis es uoa enfermedad pronta y fdcilmente curable en la mayoria de las
veces. Repito ahora un axioq^a que acostumbro recordar a mis compafleroe de labor
profesional, dentro de mi pais; y es que, salvo ezcepciones, no se curan hoy apenas los
tuberculoses, cuando no quieren, no pueden o no saben tratarse.

Los m6dicos alemanes dirigidos por el sabio Profesor Brauer, ban modificado el
pnewno-tdrax artificial no sangriento, por la operaci6n a ddo ahierto con resecci6n de
una o m^ costillas.

Mi experiencia me pone en condiciones de poder aseverar que la modificaci6n
del ilustre Brauer y bus disclpulos, modifica en sentido adverse el m^todo del pneumo'
i&rax artificial^ transformando una operaci6n r&pida, simple e incruenta, en una opera-
ci6n demorada, que demanda cloroformo, que mutila y que exige efuai6n de sangre.

Es de mi deber condenar absolutamente la modificaci6n del gran Brauer en la pr&c-
tica del pneamo-tdrax artificial^ prdctica que yo he ejercido en Europa y en America
sin ningdn accidente quirtirgico que lamentar.

No quiero conduir esta Memoria dedicada por mf al tratamiento de la tuberculosis
por el m^todo de Forlanini, sin abordar un problema que est6 aun hoy muy contro-
vertido en denda. Es el siguiente:

iLoM tubereulwoM pueden curat la tuberculon$f

Me creo en condidones de poder contestar con la m&s rigurosa predsi6n y exactitad
a la pregunta que acabo de formular.

Las tuberculinas s61o deben ser empleadas en los tuberculoses, y no en los tlsicos.
Ellas pueden curar al tuberculoso, pero agravan al tfsico. Al tuberculoeo-tisico s61o se
le pueden dar las tuberculinas asodadas al suero de su propia sangre, el cual le permite
tolerarlas y mejorar con ellas. Aconsejo a los espedalistas que acaso me hacen d
honor de escuchar, que no empleen nunca las tuberculinas en un tlsico, a menos que —
como acabo de indicarlo — ^las asoden al suero del mismo padente.

La cuesti6n de la tuberculina que veba elegiise la reputo asunto de escasa impor-
tancia: cualquiera tuberculina sirve desde que sea preparada con caldo de cultuia fil-
trado, sin haber sufrido la acd6n del calor.

Se comprende que dicho caldo debe ser muy dilufdo, en las proporciones que indica
la experiencia y que constan en todos los tratados que se refieren a esta materia.

De que la tuberculina puede curar al tuberculoso, yo puedo dar mi testimonioi
porque tengo experiencia de un crecido ntimero de estos enfermos que se haUaban en
el primer perfodo de su enfermedad, y a quienes yo devolvf al goce perfecto de su salud
mediante d use exdusivo de las tuberculinas.

A este respecto yo soy ed^tico, pues miro las cosas de la denda con la serenidad de
un hombre de estudio y de trabajo, y no con un parti prie que se apasiona por un m6todo
determinado.

Supongo haber puesto mi modesta experiencia al servido de esta &se del problema
del tratamiento de los tuberculosos, problema que adn se encuentra, como dije haoa
poco, en el perfodo de las controversias.

Ha tenido el honor de hablar a los sefiores miembros del Congreso dentffico, d m^co
que primero oper6 tfsicos en Bdlgica, en Espafia, en Mexico y en el Brasil.

iPuedan mis estudios y mi experiencia servir a los espedalistas, en el combate que
todos emprendemos contra la enfermedad que mia ataca y destruye al g6nero humanol

Dr. AoBAMONTE. I present the following resolution for action:

The Second Pan American Congress, conscious of the irreparable loss suffered by the
recent death of one of the most eminent workers in the field of etiology and preventive
medicine, a pioneer in bacteriological investigation in America, resolves to express its
profound condolence to the family of the late Gen. Gecvge M. Sternberg, and to the
Oayemment of the United States, in whose Army his counsel and his labors were so
fruitful.

814 PB00EEDIKG8 SECOND PAN AMEBIOAN 80IBNTIFI0 C0NGBB88.

C!ol. HoFF. I move that we depart from our usual custom of refer-
ring this resolution to the committee on resolutions, but that it be
passed by the section.

Dr. EoBEB. Mr. CSiairman, I desire to express unusual gratification
that this resolution emanated from one of our Latin American col-
leagues, who rendered himself most distinguished service in connec-
tion with the yellow-feyer campaign. It is certainly one of the most
beautiful tributes that can possibly be paid to our departed friend
and colleague that a man who is preeminent in the pioneer work in
yellow fever, a man who has faced the dangers of several epidemics
and who fell himself a victim in a yellow fever epidemic, should be
the author of this beautiful tribute, and I move, therefore, that the
resolution be adopted by a standing vote.

AoBAMONTE. I thank you, sir, for your reference to myself and
indorse every word that you said otherwise.

Seconded and imanimously approved.

Dr. RoDBfouES DoBiA. I move that a recess of ten minutes be
taken in honor of the resolution just passed.

Seconded and approved.

Dr. Agramqktb. It wiU be so stated in the records of the session.

Recess of 10 minutes.

On reconvening, Dr. Agramonte called the session to order and
asked for the reading of the following paper on ** Housing of wage
earners,'' by Mr. Lawrence Veiller:

HOUSING OF WAGE EARNERS.

By LAWRENCE VEILLER,
Direetor of National ffounng AsgoeiaHon, New York Citjf,

My topic is the housiiig of the wage earner. The housing jiroblem, I auppoae,
really originated with the cave dweller. It is as old as civilization. I was interested
to see the other day that they came across some tenement houses that had been occu-
pied by the cliff dwelloB in one part of this large country, and we know that the
early Greeks and Romans had very serious housing problems. I suppose really the
most difficult problem of this nature ever encountered was that encountered by Noah,
where there was very serious congestion of population, if only for a short time. I was
interested to leam not long ago that the nearest approach to the peculiar problems of
congestion that we have in New York was to be fou^d, not in England or France of the
seventeenth century, or even of the thirteenth or fourteenth, but in Rome in Nero's
time. If we read the accounts of Petronius and other Roman writers, we find that
they describe conditions almost exactly similar to conditions that exist in New York
to-day; that they too adopted legal regulation as do we to-day. They even fixed the
height of buildings, as we do in New York.

The point of these remarks is to show you that the housing problem is really a uni-
versal one and exists where the house exists, wherever man exists. It is something
inflicted upon us by civilization and therefore something that we can remedy, whidi
makes it all the more hopeful

PUBUO HBALTH AND MBDIdNB. 315

I take it that in this topic the words "wage earner" are taken in their commonly
accepted meaning. O! course, we are all wage earners, except those of us who live on
others, and the brain worker is as much a wage earner as the man who works with his
hands, to which thecommon acceptation of the word confines its meaning. That is a
somewhat Umited meaning, because in our housing efforts we find we must provide
for the policeman, who does not earn his living with his hands but with his brains.
Similarly we must take into consideration letter carriers and men in somewhat the
•emideiical class. I assume therefore that we are to tak» the subject broadly, mean-
ing by wage earners what is usually understood.

Housing is particularly a city problem, yet it is really a universal problem. We
encounter the same problems even on the prairies of America that we find in some of
the most congested parts of our cities. I know of one case whero thero was the evil of
room overcrowding in a cabin from idiich the nearest habitation was a mile away,
and yet in it there were found 13 people living in one room. That was certainly not
due to economic causes. There was no ovefcrowding of the land in that case. Sothat
the problem is not entirely a city problem. With the growth of cities in the last
century, with the development of the factory system, with the greatly increased free-
dom of transportation, with all that has resulted in bringing large numbers of our rural
population into towns and cities, the housing problem has become more acute in
cities, certainly in this country, and we have had to take notice of it and try and
devise means to overcome the worst evils.

I shall speak only of conditions of which I have had personal knowledge during
my 20 years' career as a housing retomer. I have no knowledge of the conditions
which exist in your South American and Cential American countries, but I say
without fear of contradiction that I have not the least doubt that you have down
there the housing evils, the overcrowding, the lack of ventilation,— all the housing
problems that we have here in the United States. It is a question of degree. I have
no doubt that you have dark rooms in your houses in South America, that 3rou have
inadequate ventilation, that you have room overcrowding, that you have land con-
gestion in some of your large cities, that you have the taking in of lodgers, that you
have bad drainage, that you have the evil of the vault, even underground living
quarters. I have not the least doubt that all of these conditions with which we are
so familiar in the United States we can find in Cential Imd South America.

Of course, there are differences of kind just as there are in different parts of the
United States. Climate plays an important part. We recognise ihnU even hare in
the United States. When we get up in the northern part of this country, near the
Canadian line, we find it very necessary that houses should be built to keep out the
cold and when we get down into the Southern States we find it very necessary that
houses should be built with a view to keeping out the heat, and, of course, in your
Latin American cities that problem is more important than keeping out the cold.

Looking at the housing question in a broad way, we see that it is not merely a dty
problem— 4t is a country-wide problem, a nation-wide problem— because there is no
country in the worid where they do not have housing problems so long as they have
houses. Out in the Philippine Islands I was interested to learn a lew years ago that
they had great tenement houses such as we have here in our large dtiss and that they
had duplicated there practically all of the conditions that we have in our Eastern States.
Of course the details of the problems vary in different localities, but the fundamentals
are the same.

In this problem of housing we must consider first questions of sanitation— adequate
lig^t, proper ventilation, pmpet drainage, modem sanitary plumbing, freedom from
dampness. We must not allow the house or its environs to create nuisances or to
foster the development and spread of fly-borne disease. We have learned a great
deal in the last generation about disease, and it has a very dose and intimate relataoo
and bearing upon housing. Take the great question of ventilation, for instance.

316 PROCEEDINGS SECOND PAN AMBBICAN SCIENTIPIO CONGBBSS.

We have had to reconstruct completely everything that we learned 20 yean ago about
ventilation in the light of the diBCOveries that have been made in the last 10 yeus.
WTien some of us went to school and college, we were taught about carbon dioxide,
cubic feet of air space, and almost all our statutes that bear on ventilation have to do
with the amount of cubic feet of air space in the room. In the very interesting scien-
tific experiments that have been carried on in recent years in Germany, England,
and other coim tries we have learned .that the vital factors in the question of ventila-
tion do not bear on the number of cubic feet of space nor the chemical content of the
air nor the amount of carbon dioxide and oxygen anything like so much as on the
movement of air, low temperature, and not too great an amount of dampness. These
discoveries have completely revolutionized the question of ventilation. We find
in the light of our new knowledge that we must insure free movement of air; cir-
culation of air b of greater importance than anything else in the question of ven-
tilation. And yet most buildings are not constructed from that point of view. This
room, for instance, and many others in laige buildings have windows along only one
side. I see that we have in the comer here a window, and I will have to withdraw my
remarks concerning this room, although they stand as regard a great many of our
hotels. We even think it good practice architecturally to constract inaide bath-
rooms in many of the large hotels, where there is no opportunity for circulatum of
air and where the air is kept at a high temperature by the vapors, by the hot-air
pipes, and there we have all the worst conditions present. That is due to the fatct
that the modem architect has to learn his profession all over again.

It is like the doctor who has been out of his medical school for 15 years and is not
quite in touch with the latest thought. You all remember Dr. Richard Cabot. He
is one of our great physicians in Massachusetts, a very human man. Some years
ago he developed a very useful field of work. He had a class in the Harvard Medical
School ditfing the summer for medical practitioners who had been 15 years out of the
medical schools, with the idea of bringing them up to the latest discoveries, and he
took this class down to a great tuberculosis sanitarium in the neighborhood of Boston
where they treat the disease in its early stages. There he gave each doctor a patient
and said: "Now, go into the examining room, take your patient, and go over him;
each of these men has tuberculosiB in the early stages; find it." He said the doctors
would be gone something like half an hour, and then he would begin to hear pufis and
pants, then he heard grunts and groans and remonstrances. Finally the physician
would come out, and his report would be: "This man may have tuberculosis, but I
don't know it and I can't find it; he has what I would call a healthy chest." In
other words, it was a new disease to that practitioner.

Well, so it is with the science of ventilation. It b a new science to the avenge
architect and builder, and he has to leam it all over again.

Taking up another point, the question of fly-bome disease: I do not need to enlarge
upon the discoveries of recent years to you gentlemen who have come from the south-
em Republics. You know much more about fly-bome disease than we do, because
that is the point on which the great emphasis has been laid in your work of sanitation
during recent years. Here in the United States we still have the fiy. We have places
where human excreta is deposited in vaults and cesspools so that flies breed and later
come into intimate connection with the food supply of our homes, and we all know,
who are fftmiiiar with the conditions of the large cities of America, that these vaults
exist by thousands, and we know that the flies go direct from these vaults to crawl over
the faces of infants and poison and infect them; that they also crawl over the food
supplies in the kitchens and m the little neighborhood grocery stores. One dty that
I know has 22,000 such vaults existing. It is an intolerable condition. We must
therefore provide for the prompt, adequate, and sanitary removal of human wastes and
not allow them to be stored and accumulated in places where they may cause great

PUBUO HEALTH AND MEDIOINE. 817

danger to the health of the occupants near by and to the whole community. For we
can not segregate the fly, he mil insist, no matter though we tell him it is bad form,
in going from the quarters of the poor into those of the rich.

We must consider the housing problem from the economic as well as from the sani-
tary point of view. Houses must pay, they must attract the investor. We can not
confiscate property. There must be an inducement to build houses, for if some one
does not build there will be no place for the people to dwell. We have many towns
in the United States now where there is a house famine. I know of one great manufac-
turing town in Connecticut where men are sleeping in the poorhouse where paupers
go^ respectable mechanics, men earning good wages, yet sleeping in the poorhouse
and in the railroad depots because there are not enough places in the town to house
them. That is due to the fact that there has been a great increase of population owing
to the large war orders these manufou^turers have received. We must not discourage
the investor. On the other hand, we must not allow imscrupulous landlords to take
undue profits and to exploit the poor and the wage earner. There must be a fair
return for the money. On the other hand, there must be a fair return to the tenant
for what he pays, he must be given decent living quarters at prices that are within
his income, and this expenditure must bear a certain relation to the income of the
family. Here in the United States, based not on scientific but on practical experience,
we have a saying that the workingman ought not to spend more than one-fourth of his
income for rent. Some say not more than one-fifth. And on the whole, that is about
what he does spend. There is no economic law involved in it, but we know that
when he does spend more than that bad economic conditions result.

I want to point out some fallacies in connection with this problem. There is nothing
easier than to hypnotize people by a saying, an epigram, a proverb, and one of the
epigrams which has done harm is that the working man should own his own home.
We theorize about it and say that it makes him more conservative, helps him to save,
etc. Now, it may be a very bad thing for the community if the working man owns
his own home. In the first place, we must analyze \^ hat that o^-nership is. Nine
times out of ten it is not real ownership; he only owns a small equity, the house is
mortgaged, and he is land poor and house poor. In order to pay off his loan and
acquire the real possession of his hoiise in his own lifetime, be very often starves his
family, makes them suffer all sorts of social discomforts, stints their food supply, does
not clothe them properly, in order to satisfy this ambition to own a house. Here in
this city of Washington, where we are holding our conference and in the neighboring
city of Baltimore, and in many other cities, you will find miles of houses ''owned'*
by the inhabitants. How do they own them? They pay $25 down and they own a
house and property worth about $2,000, and they keep on paying this sum for years
and years, hoping that some day they will come into possession. It is a bad thing for
these men to be encouraged to own their houses, because they are not of the soda
class that has the capacity for ownership.

And, on the other hand, it is a bad thing for the community, because where you
have a large class of property owners of very small rseources, you have a community
that is all the time voting down improvements that call for any expenditure, whether
it be for sewers or any other most important need. We have seen that worked out in
many cities, where improvements vital to the health of the community are either
voted down or postponed for many years, simply because the mass of the property
owners are men of very small means and their votes are respected in oar American
communities.

In connection with our housing work, we must consider a new science that has
arism among us, that of dty planning or dty building, which vitally affects the
matter. We must consider the proper subdivision of property and such questions
as what is the best size of a lot on which to place a house, because every bouse has to
rest on some kind of land. How shall we divide up our land to get the best results

818 PROCEEDIKQS SECOND PAN AMBBIOAK 80IENTIFI0 OONQBBSS.

for the wage earner? Here in the United States until very recently it has bem by
hit and min. Men have divided property as they thoug}it best, and the way they
thoug}it best was usually the most minute division that would give them the largest
return for their money, the smallest lot on which they could get their house. We
have had very bad subdivisions in most American cities, lots 25 to 30 feet in width,
100 to 200 feet in depth.

Those familiar wlUi housing conditions have come to know in recent yean that the
too-narrow lot is a bad thing, and that the too-deep lot is a bad thing, and that the
nearw to the square lot we can get the better. Let me enlarge a little. If you want
a house about 20 feet wide or even a little wider, and your lot is only 25 feet wide and
we have what we are all very fond of in America for all classes ol dtiiens, vis, the
detached house, the house with land on all sides of it— if, I say, your house ib 20 feet
wide and the lot is 25 feet wide, and you want a yard on each side, your yard can be
but 2i feet wide or a little less, and this results in long, damp, narrow pockets between
buildingB, little sluiceways that become dumping grounds for all kinds of refuse and
are dark, damp, and objectionable. That is the main objection to the narrow lot. It
results in not sufficient space between buildings. The main objection to the deep lot
is that you are providing more land than the working man can aff wd to pay for. That
is a consideration which, I think, has not always hem borne in mind by housing
students, the fact that there is a limit to the amount of land that a working man can
afiford to pay for.

When we provide a house for the wage earner of four rooms or five or six rooms, it
is usually all that he can afford to pay for; but we all say that he must have unlimited
land, a wide and generous garden. Let us give him a generous garden if he can afford
to pay for it. If he can not, we are doing him an injury, not a service, when we pro-
vide him with a generous garden. So that the deep lot as api^ied to wage earners'
buildings is a bad idea and the shallower we can get our lot within certain limits the
better it is.

There are many important phases of city planning that have relation to this housing
problem. We have done another foolish thing in the United States, we have as %
rule made our streets too wide. There seems to prevail an idea that the wider we can
get our streets the better. As applied to main traffic thoroughfares, that is good, but
as iq)plied to our residential streets it is faulty and worse than faulty; because every
street we make costs money and the wider we make it the more it costs to build it,
to upkeep it; and the abutting cffmm has to pay this cost. Though it may be dii*
guised he has to pay it.

So we have to consider carefully the question of wide streets and also the great
question of radial streets, such as we have here in Washington, which enable people
to get quickly from the place where they live to where they work. That matter is
very greatly assisted by a fan-shaped plan for a city. Moflt of our cities have what
we call a gridiron plan, a rectangular plan, which greatly congests traffic, and the
resulting conditions are such as we have in great cities like New York, where we have
great congesUon and where we have had to build up in the air in tall tenement houses,
partly because we have had no proper sjrstem of transit in sections of the city where
the working man can live within his means.

Next we need to consider the establishment of residential districts apart from
industries and the building of what are known as garden suburbs. These have been
developed very successfully in recent years in Qreat Britain and Germany, vis,
the development of the residential section apart from the noisy city streets, with
gardens, trees, open spaces, and charming architectural treatment.

Lastly, we have to approach this great problem from the point of view of its being
a social question. And under that we have to conskler race, customs, and habits.
Here in the United States at least we are not a homogeneous people; we have every
race and every nation of the worid living in our cities. That has a very important
bearing on housing conditions. For instance, we find room overcrowdiog only among

PUBUO HBALTH AND idBDIOINB. 319

certain races in the United Stfttee. The Italians want to live out of doors a great deal;
most of the Latin races do. The Northern races who come hefe do not want to live
out of doors, and we have to provide very different conditions when we are providing
for the Latin races from what we do for the Northern races. We must consider ques-
tions of recreation, gardens, playgrounds, parks, small squares in connection with the
homes of the wage earner, and, finally, we have to consider from the social point of
view the effect that bad housing conditions have on crime, pauperism, and disease.

It is perfectly simple to make mi^ and show how we have a greater degree of crime
and of sickness in the most crowded quarters. It has been shown again and again.

And finally we must consider the effect of bad housing upon citizenship. In a
democratic country like America where the people rule it is of vital importance that
we do not allow the living conditions of the class which is least able to care for itself
to be so degraded that it is going to result in a degraded dtisenship. We have
had some startling warnings of what mi^t come from this in the United States
recently. In a little Massachusetts town in New England, a town of about 80,000
people or less, two years ago we saw the workers in that town parade with red flags,
the badge of anarchy, on which were written, "No Qod, no law," parading the streets
of that staid New England town, the town of Lawrence, Mass. And we found later
that the workers of that town were living under conditions not fit for animals. So
too, not long ago in Paterson, N. J., in Little Falls, N. Y., similar disorder has occurre^i
and careful investigation has shown that in each case ^e foreigners in those places
were living in housing conditions unfit for animals.

Ladies and gentlemen, this ia a very large problem, and as you see, an interesting
one, one that touches upon every phase of human thought and endeavor. It is quite
impossible for me to discuss all of its phases in this meeting. All that I have sought
to do was to play the overture, as it were, to see if I could not touch on one or two of the
main points to stimulate thought, to give you an idea of the many problems with which
we are called upon to deal.

Dr. Agbamonte. The paper is now open for discussion.

Dr. KoBEB. I had hoped that one of our Pan American colleagues
would begin the discussion, which is certainly of very great interest
to an. I have been interested in the housing movement in the city
of Washington and it has been, perhaps, one of the most enjoyable
pieces of work which I have hdped to carry on in the line of social
work. I have always felt that the sanitary home was imdoubtedly
one of the greatest problems in the work of sanitation. As has been
pointed out, the heiedth and the morals of the people are intimately
connected with the housing conditions, and just as soon as we provide
sanitary homes, particularly for our least resotirceful people, we may
accomplish wonderful reductions, not only in the so-called ''house
diseases," of which tuberculosis is a typical example, but also in the
prevention of immorality and crime.

There remains absolutely nothing that I can add to the very
instructive paper of Mr. Veiller. I might mention that the Sage
Foundation has recognized the importance of the housing move-
ment in relation to all that has been pointed out and has actuaHy
carried on a very effective campaign, national in character, for the
promotion of sanitary homes. Mr. Veiller is, fortunately, the director
of that movement, and it is to be hoped that similar attempts wiU
be made elsewhere. We have a company in the city of Washington
that has invested probably a million and a half doUars in houses

320 PEOCEEDINGS SECOND PAN AMEBIOAN SOIENTIFIO CONGBESS.

for wage earners, and it is gratifying to be able to say to you that
we are renting three rooms and bath at as low a rent as $7 per month,
which I think is unexcelled in the records of the housing movement
in the United States. At the same time this company has been able
to pay dividends of 6 per cent to stockholders from the very incep-
tion of the movement and has accumidated reserve fxmds amply
large to guard against any physical deterioration of those houses.
To those who are interested I will be especially glad at least to refer
them to my friends, so that they may be taken for a personal inspec-
tion of those houses.

On the whole, I consider it a very important sanitary and social
problem, and at least one of the movements where the community
at large may well consider themselves their brothers' keepers by
kindly human sympathy, especially where it does not involve
charity. The fact that we can pay 5 per cent and yet do good seems
to me to commend it to all those who have the slightest human
sympathy.

Dr. GuTTEBAS. I suppose that most of you think that the housing
conditions in a tropical country ought to be very easily attended to,
owing to the fact that there is a great deal of light and ventilation.
You see there is no necessity for closing up on accoimt of the warm
weather. The problem, it would seem, ought to be an easy one. I
do not know whether it impresses in that way those who really know
about the subject. I see the gentleman says no.

But really the gentleman is right, even from my point of view.
In the Tropics they do build houses to make good use of these nat-
ural favorable conditions, big doors, big windows. People ought to
be healthy. Now you ask, why is it that we have tuberculosis in
Cuba? We have tuberculosis there about as much as you have in
your northern cities, no more and no less. Why, with these open
doors and windows and plenty of light ? Because the people do not
open them. They build them, and they do not open them. What
are we going to do with them ? They build these big windows, these
big doors, and they shut them up, and thoy like to hve closed up.

I have asked myself sometimes, is this a natural outcome of certain
truly .tropical conditions? Is it the result of experience due to
malaria? It is characteristic of the Spanish races, I believe, and
probably the Portuguese and Iberian races, to shut themselves up;
and I have asked myself, in connection with another entirely distinct
problem from this, whether this might not have accoimted to a cer-
tain extent for the success of the Iberian races in founding and estab-
lishing the race in the Tropics. The Iberian is really the only successful
white race to implant in large measure a population in the Tropics.
He shuts himself up at night particulariy; he is afraid of the night
air. Did he not keep away the mosquito by that? Did he not save
himself from malaria, and did not that make it possible for bJTn to

PXJBLIO HBALTH AND MEDIOIKE. 321

do what the English have not done, what the French have not
done, namely, to estabUsh successfiil colonies in the Tropics ?

Dr. William F. Snow. As I have been listening to the discussion
of this subject by men who have been world famous in the fight
against yellow fever, I have thought of the inspiration I received in
Habana in following some of Dr. Guiteras' house inspectors during
the battle against yellow fever. I never had a more definite impres-
sion of the value of house-to-house conference by tactful men, look-
ing for mosquitoes, and explaining why this shoidd be so and why
that shoidd be so. I came away from Habana feeling that it would
be a fortunate thing for some American cities if we could just have
their report, at least, of yellow fever cases, so that we might institute
such work.

Dr. Agramonte. May I call upon Dr. Jackson to present some of
his experiences in this connection? I understand he has had some
valuable experience.

Dr. Jaokson. I do not know that I can add anything to this very
interesting discussion except perhaps to remark that in my experi-
ences abroad, in the Phihppines and recently in the Balkans, I have
noted the inclination on the part of the house dweller to close his
house at night regardless of whether he be Spanish or Turkish or
FiUpino. It seems to be an almost universal tendency, in my
observation, for the house dweUer to close up as much as possible
his house at night; and recently, in Serbia, we were all very much
impressed ^with the disposition of the Serbian, even in the cidtured
and inteUigent portion of the popidation. In some instances the
medical men close up their hospitals, close up their sick rooms, to
such an extent that it was necessary even at times to actually
remove the windows in order to provide, under the extremely con-
gested conditions, the necessary and proper ventilation.

Another fact that occmred to me just now in connection with
housing, is that in our recent plague campaign in Manila we were
able to substantiate and corroborate the findings of the investigators
who worked shortly before us in Java. We had housing of the rat
in our bamboo rafters and roof supports, especially the rafters of the
tropical house,|and while we have not at the present time, I am glad
to say, as|f arjas I know, plague or even rat plague in the American
cities, we havejconditions in our older houses, less modem houses,
which are very similar to those conditions which obtain in the
tropical^^houses of the Philippines and of Java. If we should have
the misfortune to have a spreading through some of om* larger cities
of rat plague, we would have to meet that question of house con-
struction, and it seems to me that in connection with architecture
and house building that that possibihty, even though remote, should
be taken into account.

322 PBOOEEDINOS SEOOITD PAN AMEBIOAN 80IBNTIFIC CONGRESS.

Mr. Veillbb. Just verj briefly, Mr. Chairman, I would like to re-
spond, especially to Dr. Guiteras's words. He said, How are you
going to get the people to open their windows when you have given
them the windows ? The chairman says, very properly, ' 'by educa-
tion." Dr. Snow has already described what Dr. Guiteras was
doing in Habana. As he says, they were after yellow fever, but as
they went along they were teaching the people. Now, the gentleman
is absolutely right. This habit of closing the windows is not con-
fined to the Iberian races. I won't limit it at all. It is universal.
We find some of our wealthiest and best educated people who never
open their windows day or night. In the great palatial houses of
the rich on Fifth Avenue, in New York, there are windows that are
never opened — they are afraid of soiling the curtains. But there is
this great, basic ignorance on the part of the people and the fear of
night air. Of course, it is inherited from the days when night air
was very dangerous on account of the mosquito. We are educating
tiie people in the United States, educating the children in the schools
with primers on tuberculosis. It is part of their regular course of
study, and the children in some of the large cities know a great deal
more about fresh air and sanitation than many of us, and we are now
educating them in regard to cleanliness, etc., in New York City.
They have made a play out of a health primer. Now, if you can
make a play out of a health primer, you are 'Agoing some,'' as we say
in America. However, there must first be windows in the houses
before we can ask people to open them, and the first problem is the
building of the houses. We must first have the windows, the ade-
quate ventilation, then there must be the campaign of education.

Dr. Agbamonte. This completes our program. The session is
adjourned, with the reading by tide of the following papers:

Influencia de la habitaci6n en la lucha contra la tuberculosis, by
Juan Monteverde.

La inspecci6n m6dica en las escuelas ptiblicas de Centre America,
by Dr. Louis Schapiro.

LA INFLUENCU DE LA HABrTAClON EN LA LUCHA CONTRA LA
TUBERCULOSIS.

Pot JUAN MONTBVEEDB,
Pro/e»or de Ingenieria Saniiaria de la FaeuUad de MaUmMcoM de Montevideo,

Entre las enfennedades qae atacan a la humanldad, la que produce mis estragos, la
m&i implacable y la que ofrece mis dificultades para combatiila, es la tuberculoeis.

La medidna, con el aiudlio de la ImctauAogfa^ ha detenninado con precisi6n las
causas de casi todas las enfennedades infecdosas, y las vacunas y saeros que ha descu-
bierto y aplicado con ^xito, inmunisan o ctnan a un elevado porcentaje de enfennos ;

PUBLIC HEALTH AND MEDIdNB. 328

pero hasta ahont reaiste a todo tratamiento eficas la m&B temible y la mis difandida
de todas las enfermedades trasmisibles, la que por si sola mata mis que todas las otns
reunidas, la que ha destnildo mis vidas que todas las g^uerns que registra la historia:
la tuberculoeiB 8ig:ue su fdnebre y tiiunfal marcha por el mundo, sin xespetar climas,
ni razas, edades, ni condiciones sodales.

Se conoce perfectamente el microbio especffico de la tuberculosis, las condkiones
lavorables para su desanollo y sus efectos destructores sobre los ^ganos que ataca, pero
no se sabe como desalojarlo de sus posidones o por lo menos hacerlo inofensi\-o; eztr^
madamente reaistente a la acci6n de los deainfectantes, muy virul«ito en determinadas
condiciones, difundido cual ningdn otro, es un formidable enemigo, tanto mis peli-
groso, cuanto generalmente no se sospecha su ezistencia, y s61o se apredan sus efectos
cuando ha hecho presa de sus vfctimas, las que sacrifica implacabkmente.

Se conocen, sin embargo, dos medios poderosos para combatir con ^to el bacilo
tuberculoso: el aire puro y la luz solar, Ma sobre todo.

La luz solar, como destructor del bacilo tuberculoso, no tiene desinfectantes que le
iguale en sus electos: es el anna que aiempre tenemos a mano, y de ef ecto mis podetoso
para defendemos del mortifero bacilo.

£1 sol, que es la fuente de la vida en el mundo, es tambidn el protector mis eficai
contra los mortales ataques del insaciable enemigo, que, si bien pequefio en dimension
nes, es el mis formidable para la humanidad por sus efectos destructores.

£1 bacilo tuberculoso tiene extraordinaria resistenda, y en sitios htoedos y oscuros
puede consen ar su virulenda durante meses; ha sido sometido a temperatura de 100
grades, durante tres horas, en estufas de aire, sin baber sido destrufdo, y durante
meses puede vivir en hielo y bajo la nieve: la putrefecd^n tampoco lo deBtruye,
puesto que, babi^ndose entemdo putmones tuberculoses, se verified al cabo de seis
meses que el bacilo conservaba toda su virulenda.

£1 doctor Grancher, en un informe sobre la profilaxls de la tuberculosis se expresa
en estos t^rminos: ''S61olosesputosolasBupuradonesbadliaressonpeligrosos. £sti
demostrado que esos esputos, desecados, depositindoee en forma de polvo sobre las
paredes de la habitad6n del tMco, sobre los muebles y sobre el piso, conservan mucho
tiempo su virulenda, durante meses, y atin durante alios. Y en cambio se ha demos*
trade que la luz solar destruye ripidamente, en algunas horas, el bacilo de Koch, lo
mismo que la luz difusa, aunque menos ripidamente. Tambi^n esti demostrado que
el medio de contagio mis temible es el contacto dlrecto, tal como se produce en la vida
en comtin, y que principalmente se contrae la tuberculosis por las vlas respiratorias.*'

£1 eminente Brouardel declaraba en 1900, ante la Gomisidn de la Tuberculosis de
Pariis, que la habitad6n insalubre, la que evidentemente es hdmeda y tiene insuficiente
luz natural, constituye un medio en el cual se deearrolla fidlmente la tuberculosis.

£1 doctor Lef^ re, mis explfdtamente, decla en 1905, en un articulo del " Journal '*
de Paris: "La luz es el gran enemigo de los microbios, prindpalmente del bacilo
tuberculoso: iete, despu^ de haber sido convenientemente asoleado, pierde su vitali-
dad, y no se desarrolla o se desarrolla mal, cuando se le cultiva."

Si un tuberculoso eecupe en una habitaddn, la contamina: si es clara, si, sobre todo,
redbe directamente el sol durante algunas horas, los badlos pierden poco a poco su
virulenda y el peligro disminuye. Si, por lo contrario, la habitad6n es oscura,
htfaneda, si no esti sufidentemente aireada, los mortiferos microbios pueden con-
servarse casi indefinidamente y ocasionar tantas victimas como locatarios pasen por
esa habitad6n.

£1 peligro de infecd6n tuberculosa aumenta sobremanera, si en las haUtadones
vi^en aglomeradas las personas, puesto que la viciaci6n del aire sehace mis inteuMy
resulta mis fntimo el contacto.

Las familias que, por sus eecasos recursos, se v«i obligadas a vivir aglomendas en
habitadones insufidentes, pagan un elevado tribute a la anemia, a la mortalidad
68486— 17— VOL ix 22

324 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

inboitU, y muy espedalmente a la tuberculosis: asf lo demuestran con toda evidenda
las estadisticas de todos los patees y los registros sanitarios de las habitadones.

En Berlin, de 1903 a 1906, considerando exclusivamente los tuberculosos muertos
en SUB viviendas, el 70 por ciento correspondid a los hogares que s61o disponlan de una
o dos habitaciones; el 20 por ciento a los que vivfan en tres; y el 10 por ciento a los que
vivfan mis holgadamente, en m&B de tres piezas.

Segdn datos de Friedrich, presentados en 1905 al Congreso de la Tuberculosis, en
Budapest, sobre 451 tuberculosos, el 70 por ciento eran de familias que ^ ivian aglome-
radas en habitaciones insalubres, verdaderos focos de tuberculosis.

El cuadro que expongo referente a Viena, contiene datos muy sugestivos, que tomo
de una monograffa sobre el saneamiento de esa ciudad en 1900.

Con toda claiidad se desprende de este cuadro, que a doble densidad de poblaci6n
de las viviendas, corresponde un aumento de 50 por ciento en el coeficiente de mortali-
dad general y de la infantil, y de 100 por ciento en el de la tuberculoflis.

Viena 1900 — Mortalidad media por tuberculosis en reladdn con el nikmero de habUanUs

de las habitaciones.

Tdrmlno medio de habltantos por 100 habftadones.

DeTOaiao.
DeiaOalSO
lOsdolM..

Mortalidad

Kortalldad

en el primer

general

aftopor
lOOniflos

I or 1,000

habitantes.

nacidos

convida.

14 28

10.3

18.00

ao.9

22.96

25.S

MortaUdad

tubercokMa

por 1,000

habltantea.

24.68
32.2
46.3

II.

La influencia de la insufidente ventilaci6n sobre el deeanollo de la tuberculosis esti
demostrada con toda evidencia por los datos de los casilleros sanitarios; de Mos
resulta, in^ ariablemente, que las familias necesitadas, que tienen que vivir aglome-
radas en ambientes que no tienen la capacidad neceearia, son las victimas preferidas
de la tuberculosis; los efectos del aire viciado, en la noche sobre todo, cuando la
ven tilaci6n es casi nula durante siete u ocho boras, se hacen sentir a la larga, primero en
la sangre, que va empobred^ndoee en gl6bulos rojos, y despu^ en el organismo entero,
que va debilitindose gradualmente y haci^ndose menos resistente al ataque de las
enfermedades, de la tuberculosis sobre todo, cuyo badlo se encuentra enonnemente
dilundido en las aglomeradones urbanas.

£1 organismo tiene defensas naturales que destruyen el bacilo tuberculoso, pero,
para que el organismo resista, es neceeario que sea sano, y no puede serlo el que no es
nutrido p<ff una sangre bien oxigenada.

Relacionando Marie Davy la mortalidad por tuberculosii de las casas de Paris con
el ntim^x) de sus puertas y ventanas, en 1905, dedujo la siguiente conclu8i6n: que a
menor n6mero de puertas y ventanas corresponde mayor mortalidad por tuberculosis,
llegando a tal punto la influencia de aqu^Uas, o sea del aire y de la lu£ solar, que a
doble ntoero de tales aberturas corresponde la tercera parte de cases de muerte
tuberculosa.

El siguiente estado es un restimen que he hecho de los datos mis interesantes de
Marie Davy:
Mortalidad tuberculosa por mil:

1^. Casas cuyo n6mero de puertas y ventanas no excede de dos por habitante, 6.
2^. Casas que tienen de dos a tres puertas y ventanas por habitante, 4.36.
3^. Casas que tienen mis de tres puertas y ventanas por habitante, 2.2.

En Alemania y en Francia se hicieron estadisticas sobre la mortalidad tuberculosa,
en relaci6n con la elevaci6n de los pisos de las viviendas sobre el suelo: invariable-

PUBLIO HEALTH AND MEDIOINB.

825

mente resultd que en 1m casas de varioe pisoe la mortalidad por tuberculosis era mayor
en loe pisoe infeiiores, que reciben menos aire y menoe sol que los superiores; sin
embaigo, hay que exceptuar las boardillas, que dieron mayor mortalidad tuberculosa
que los pisos inferiores.

Esta contradicci6n de los resultados revelados por la est&distica en los diversos pisos,
en cuanto a la mortalidad por tuberculosis, se explica, porque en las hoardillas viven
siempre familias pobree, en condiciones poco favorables a la salud, por bus ocupaciones,
por BU alimentaci6n y por el regimen normal de su a ida.

III.

De lo expuesto, resulta con toda e\ idencia que las causas primordlales de la insalu-
bridad de las habitaciones son la insuficiencia de la lu£ solar, el confinamiento del
aire, y la aglomeracidn de sus moradores: los r^istros o casilleros sanitarios de las
casas, despu^ de 20 afios de observ aciones, concordantes al respecto, no dejan la
menor duda, y permiten afirmar, de un modo absoluto, que el desarroUo alarmante
de la tuberculosis se debe precisamente, y en primer t^rmino, a esos factores de insalu-
bridad de las habitaciones.

Nada mia convincente, nada mis decisi\ o en £a\ or de la exactitud de esa afirma-
ci6n, puede citarse, que los resultados de las observaciones del director del registro
sanitario de las casas de Paris, durante m&a de 20 afios.

Juillerat public6 en un pequefio libro, la ozganisacidn de ese casUlero sanitario, que
estd bajo su direcci6n desde su fundacidn, con los resultados de sus observaciones y
estudios sobre la causa de la insalnbridad de las habitaciones y de su influencia.

Tomando Juillerat los 10 primeros afios de sub observaciones (1894-1904), estudia
seis agrupadones de casas, 1,600 en conjunto, con 60,000 habitantes, situados en dife*
rentes circunscripciones de Paris: result6 que el 70 por dento de esas casas habfan
tenido mortalidad por tuberculosis, que habla bastante cantidad de'ellas que podian
consideraise con infecci6n permanente tuberculosa, llegando algunas a dar un coefi-
ciente de mortalidad por tuberculosis hasta dies voces mayor que el medio de la
ciudad, de por si bastante elevado.

En el siguiente cuadro aparecen extractados los datos mis interesantes del estudio
de Juillerat sobre las indicadas 1,600 casas de Paris:

Orapoe

NAiiMro

decuM

aitudladM.

Nthnero
de casas
atacadas
portu-
baronlosis.

XiMrtospor

tuberoolosis

por 1,000

habitantoi.

Mnertospor

enlioteies,

oasasamoa-

bladas

por 1,000

l£bitaiit«8.

Mnsrtospoc
otiasaD-

fennedadaa

infeociosas
par 1,000

lukMtuitas.

281
80
106
600

182
818

PorelefUo.
86

12.47
0.68

10.40
0.46
7.10
8.28

21.74
18.68
22.00
81.16
12.06
19.70

LOl
1.61
2.00
1.72
2.24
2.24

Los ndmeros de ese cuadro hablan con nUui elocuencia que las palabras: v^ase el
eecaso ntoero de casas indemnes, compirese los estragos de la tuberculosis en relaci6n
con los que causan todas las otnys enformedades infecciosas reunidas, y dfgase despu^,
■i los medioe hasta ahora empleados son sufidentes para combatir un flagelo de tal
magnitod.

Advierte Juillerat que las cifras del cuadro estin por debajo de la realidad.

"La declaraci6n de la tuberculosis," dice, "no es obligatoria, y, por otra parte, en
los medios especiales en que e^ olucionamos, un gran ntimero de defunciones tubercu-
loaas, se r^gistran con otras designaciones: pulmonias, bronquitis, etc."

826 PBOCEEDIKGS SECOND PAN AMBBIOAN 80IBNTIFI0 GONGBBSS.

IV.

Una fio despu^ Juillerat extendi6 bus observadones a todas las casas de Paris, esta-
diando la distribuci6]i de la tuberculosis en los 80,000 edificios de la gran capital, en
un periodo de once afioe (1894-1905).

De los dates del registro sanitario, resultd que, durante ese periodo de once alios, el
50 por ciento de las casas de Paris, tuvieron defunciones por tuberculosis, pasando de
100,000 las defunciones denunciadas como tales en ese periodo de tiempo.

Para mejor estudiar la influMicla de la habitaci6n sobre el desarrollo de la tubercu-
losis, Juillerat dividi6 en tres grupos las casas que tuvieron defunddn tuberculosa.

En el l** grupo incluy6 las casas cuya mortalidad por tuberculosis fu6 inferior a 5
por casa, en el periodo de 2 alios: considerd eeas casas anno no infectadas.

£1 SQgundo grupo comprendia las casas que hab&n tenido de 5 a 9 dehmdones
por tuberculosis en los once alios. Estas casas se presnmfon infectadas permanente-
mente y con muchas probabilidades de que se convertieraa en focos de tuberculosb.

Finalmente formaban el tercer grupo, las casas que tuvieron mib de 10 defun-
ciones por tuberculosis en el periodo considerado. En la gran mayorfo de los casos
se trataban de focos perfectamente caracterisados, y Juillerat las con8ider6 como casM
netamente tuberculoeas.

Particularigando los datos del segundo y tercer grupo de las casas, expongo en el
siguiente cuadro las cifras de mils inter^, publicadas por Juillerat.

PanioDO 1894-1905.— IforfoUciMf amuU por tMbtreuUm$ m vertss eosot de ParU por
1,000 kabitanUif 9«g^ JuUUrat,

de
pnnde.

4,4tt

toUlde

tssliipor

Sefiindo grapo de OMM.

8aO,S76
Terotr trapo de I

loe^aoD

lao

Detan-

dopes

tubenii-

7.5a

9.88

Noc^.— Bn lea casas del terotr gmpo las hotaka j casas
tubercnloals tuA 19.26 por mlL

anwieWadas la mortalidad media anual por

Siendo de 4.95 la mortalidad anual por tuberculosis en Paris (1894-1905), resulta
que el segundo y tercer grupo de casas consideradas por Juillerat, dieron respectiva-
mente 50 por ciento y 100 por ciento de aumento sobre el coefidente medio.

"Con ras6n, pues," dice Juillerat, refiri^dose al coefidente de 7.52 por mil, corres-
pondiente al segundo grupo, "esta mcnrtalidad es formidable, si se la compara a la
media de la dudad, pero es poca cosa, si se considera el tercer grupo aisladamente.''

De las observadones y estudios de Juillerat, que someramente he dado a conocer,
dedujo diversas condusiones, y de dlas meracen ser conocidas, por su importanda,
las siguientes:

P. Las causas de la mortalidad por tubercnlodt no son Isa mismas que origiaam
la mortalidad por las demis enfermedades iaf ecdosts. La mortalidad tubercnilosa
depende, pues, de una o de varias causas diferentes de las que predden la apaiidte
y la evoluddn de las otras enf ermedades oontagiosta.

2°. Las casas de devada mortalidad tubermiksa parecen tener una acddn sobre
las casas vecinas. En cad todos los casos, las casas contiguas a una casa foco, pre-
sentan defundones de tuberculosisi atin eaicontr^mdose aquellas casas en favoimbles
condidonee de higiene.

PUBLIC HBALTH AND MEDIOIITB. 327

3^. Hay que buacar en la cant miama la causa o las causae de la penistenda de la
tuberculosis: esas causas no son ezteiioies, existen en el propio edificio.

4^. Tbdos los grupos de casas, y todas las casas esfeudiadas que se revelaion como
loco de tuberculosis, presentan las mismas caracterlsticas: calles angoetas, patios
insuflclentes drcundados por edificios elevados, o disposiciones constructivas que no
permiten elacceso delsol en los locales habitados. Ensuma, faltade yentilaci6n y de
■d en las viviendas: de sol espedalmente.

''£n resumen," dice Juilleiat, ''podemoe formular el resultado de nuestia encuesta,
didendo: la tuberculosis es ante todo la enfennedad de la oscundad."

VI.

Resulta, de lo ezpuesto por los higienistas que he dtado, que son conoddas las
causas que prindpalmente favorecen el desanoUo de la tuberculosis: esas causas
podemos eliminarias, pues son defectos de construed^ o de disposiddn de nuestras
casas y de nuestras dudades, defectos que podemos evitar o por lo menos atenuar
considerablemente.

La acci6n mancomunada, inteligente y perseverante del m6dico, del ingeniero y
del arquitecto puede y debe ser de las m^ eficacee en la lucha contra la tuberculosis.

£1 medico, empleando la profilaxia directa, trata de eliminar las causas que debili-
tan el organismo y de hacerlo refractaiio a la tuberculosis: el ingeniero y el arquitecto
complementan la acd6n del m6dico mediante una profilaxia indirecta, inmunizando
el medio en que vivimos, had^ndolo inapropiado para la vida y el desarroUo del bacilo
tuberculoeo.

£s prindpalmente la acd6n del arquitecto la que m^ eficazmente puede hacerse
sentir en la lucha contra la tuberculosis, dando a las viviendas el aire puro y el sol que
deben tener para ser sanas, hadendo comprender a los propietarios los graves defec-
tos que resultan para las casas al redudr demasiado las dimensiones de los patios y al
usar inmoderadamente las daraboyas o vidrieras para cubrirlos.

£s necesaiio que el arquitecto se d^ cuenta de que su misuSn al proyectar una casa,
no es solamente de haceiia artlstica, sine que ante todo debe hacerla sana: que no es
l^gico destinar las habitadones de m^ capaddad, las mia aireadas, las mis favored-
das por el sol, para redbir viaitas algunos diss del mes, en perjuido de los dormi-
tonoB donde pasamos la tercera parte de nuestra vida; que no es radonal gastar el
dinero con exceso en vanas decoradones, para escatimarlo en los servidos mis funda-
mentales de la higiene de la casa.

Y como no &ltan propietarios que sacrifican las condidones de salubridad de la
casa a las ideas de lucro y de 06tentaci6n, toca a las autoridades ptiblicas imponer
leyes, r^lamentos y ordenansas que impidan construir y habitar casas que puedan
alectar la salud de sus mondcxes.

VII.

Pero el pioblema mis diffdl en la lucha contra la tuberculosis esti en las habita-
dones de las familias de escasos recursos, a quienes la necesidad obliga a vivir en
ambientes de insufidente capaddad, en esas casas llamadas de renta, con patios ra-
qufticos, de habitadones sin sol y de escasfaima ventilad6n: el dia que la rotad^ de
inquilinos Ue ve a una de esas casas un tuberculoso, seri indefectiblemente contaminaoa,
y ofrecerd a sus ulteiiores movadores los mismos peligros que las casas tuberculosas de
Pwrfs, sefialadas por Juillerat.

XJno de los grandes males que debe extirpane con toda uxgenda, porque dafia flslca
y moralmente a una parte de la sodedad, es la casa de vedndad, lo que Uamamos
coQventillo. No puede daise habitaddn que mis est^ en oposid^n con las convenien-
das de la higiene sodal.

328 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

Existe en el conventdllo, en mayor escala que en la habitaddn individual insalubre,
el mortal pellgro de la aglomeracidn y del contagio, no 86I0 por la habitaci6n en sf
misma, sine tambi^n por loe vecinoe de la misma comunidad que est^ en continuo
contacto en el mismo patio, lavan las ropas en la misma pileta y utilizan los mlsmos
excusadoe: habiendo un enfermo tuberculoso, ^c6mo puede evitarse el contagio en
tan desfavorables condidones de vida? iC6mo pueden observarse las prescripdonee
de la hlgiene para evitar las multiples causas do contaminaci6n? iC6mo evitar,
prdcticamente, que el badlo tuberculoso, en un medio tan favorable para desarroUo,
no ataque a personas que por las condidones de su vida normal estdn predispuestas
a ser atacadas?

Puede afirmarse que el problema de la habitad6n sana y barata es el m^ impor-
tante, el de mayor trascendenda, el m^ iu:gente de reeolver, entre los que tienen
planteados loe Gobiemoede los pueblos dvilizados: el abaratamiento y la mejora de
la alimentad6n y de la liabitaci6n son los puntos fundamentales de la cue8ti6n social.

La reducd6n de los horarios de trabajo y la mejora de los jomales, en las actuates
condidones econ6micas, puede deciise que ban alcanzado su Ifmite, sin que por eso
las claaes necesitadas hayan obtenido el relative bienestar y la protecd6n eficas
a que tienen derecho contra la enfermedad.

La Sodedad tiene el deber de proteger la salud y la vida de los que trabajan por
ella en las condidones mds desfavorables, impuestas por el modo de ser y por las for-
mas de actividad que esta misma sociedad ha creado: por deber, y hasta por egoismo,
debe otorgar esa protecd6n a los necesitados, para evitar los pellgros de diveiBos
6rdene6 que, al negarla o descuidarla, ocasionarla a su propia existencia.

Como muy bien lo expres6 el sefior Mabilleau, en una conferenda sobre las casacr
populares, es predsco proteger la salud del pueblo desde su misma cuna, poniendo
a su alcance los medios para vivir una existencia sana, eliminando las causas de en-
fermedad y de degeneraddn.

Es precisamente la tuberculosis la enfermedad que diezma a los que por no tener
fortuna viven aglomerados en habitadones que minan su salud, agotan sus eneigfas
y son causantes de miserias, de enfermedades y de dolores para millares de familias.

Ciertamente que es complicada la solud6n del problema de la casa sana y barata,
y que es diffcil extirpar en poco tiempo tantas viviendas insalubres como taenen
las dudades: hay que luchar contra la ignoranda de muchos propietarios; pero si Hon
cruzamos de brazos, limit&ndonos a deplorar el mal, este ser& cada vez mayor y mis
diffcil de remediar. Es necesario obrar con la actividad y la decisi6n que exigen los
altos intereses sociales comprometidos.

VIII.

Las leyes no protegen sufidentemente contra el mal social de las habitadones
insalubres quizd por un concepto demasiado absoluto del derecho de propiedad y
seguramente por no apredar en toda su importanda las causas de aquel mal y sua
enormes perjuidoe para la sodedad.

"Desgradadamente," decfa Lefrevre en 1905, "la ley no permite publicar los
dates, tan informativoe como alarmantes, de muchas de las casas inscritas en el Casillero
Sanitario. Un propietario invocando el articulo 1382 del C6digo Civil franc^, podrfa
Teclamar dafioe y perjuidos al que denimdara la insalubrldad del inmueble de su pro-
piedad, y con raz6n podrfa temerse que los jueces aplicando la letra de la ley con-
•denaran al denimdante, sin apreciar el fin que persiguiera, al hacer la denuncia."

"Para obrar s^tin las leyes de la humanidad,'' dice Juillerat, "para defender la
-vida humana contra una explotaci6n abusiva e impfa, necesimos una ley especial,
iormal, que autorice la divuigad6n de los dates del casillero sanitario a toda peraona
interesada."

PUBLIC HEALTH AND MEDICINE. 329

Atin m^ cree Juillerat, que debe hacerae. Opina que cuando una caaa preeente
durante varioe afioe seguidoe una mortalidad an(»rmal, y que el piopietaiio se haya
moBtndo refractaiio a toda mejora higi^nica, pueda autorizar el juez la colocaci6n
de un tablero en la puerta de ese inmueble en que figuren las causae de insalubridad,
y ponga por lo tanto en guardia, a cualquier interesado en alquilarlo, de los peligroe
a que se expondrfa viviendo en 41.

En ningtin pals dvilizado las leyes permiten construir edifidos que no ofrezcan
las debidas condiciones de eetabilidad: si eeto lo exige la seguridad pliblica, si adem^
ha sido necesario reglamentar severamente las condidones del agua de allmentad6n,
y los desagUes de las aguas servidas y materias fecales, i por qu^ no ha de exigiise
tambi^n por causa de salud pdblica que todas las habitadones tengan el aire puro
y la luz solar que higi^nicamente son tan importantes como los servidos indicados 7

Acabo de referirme a uno de los problemas de higiene de la habitaddn que m^
preocupan a las autoridadee munidpales y a los higienistas, problema que adn no
ha side resuclto prdcUcamente en forma satisfactoria; la ventilad6n y la iluminad6n
solar directa de las habitadones en los barrios densamente pobladoe, preeenta seiias
dificultadcs: las reglamentadoncs vigentcs no Uenan el fin a que se aspira en cuanto
a dotar ampliamente a las habitadones de tan primordiales elementos sanitarios: la
gran divisidn de los terrenes urbanos, bus dimensionee, su agrupad6n en las manzanaa
uisuales de las dudades amerlcanas, los tipos de casas comunes, la valorizad6n alcan-
zada por los terrenes son factorcs opuestoe a la buena ventilad6n e iluminaddn solar
de las habitadones: habrd que llegar a la expropiad6n de los terrenes demasiado pe-
quenoe, o dictar leycs que obliguen a reunir los patios de dos o m^ casas contiguas,
cuando sea necesario, para obtener un espado libre sufidente, en reladdn con la
altura de la edificad6n circundante, para la buena ventilad6n e iluminaci6n solar
de las habitadones.

Es de urgenda resolver el problema indicado, puee en todas las grandee dudades
americanas, se estdn construyendo casas de varioe pisos, con patios insuficientes que
dan por resultado graves defectos de ventilaci6n, abastedmiento de aire impure y
eecasisima luz natural. Son esas casas — de diffcil modificaddn, por su dispodd^n, y
de no menos diffcil expropiaddn, por su elevado predo — ^las que aumentar&n la
mortalidad infantil y debilitar&n el organismo de sus habitantes, las que mis ade-
lante se infectardn permanentemente por la tuberculosis, constituyendo los feces
pellgroeos a que se refiere Juillerat.

IX.

Condunones sometidas a la wnsideraddn de la aeccidn VIII del Congreso Oientifioo Pan"

Afnericano.

1®. Los palses americanoe deben crear recursos de importanda, e idear medioe
pr&cticoe, que est^ en relad6n con el esfuerzo a realizarse, para dar alojamiento
sano y econ6mico a las famllias necesitadas.

2®. Debe difundirse por medio de la ensefianza, jwr conferendas, por peri6dicos
y por publicadones gratuitas ampliamente distribufdas, los conocimientos y los
preceptoe sobre la higiene de la alimentad6n, del trabajo y de la habitaci6n: debe
darse a conocer prindpalmente, las circunstancias que favorecen el desarrollo y el
contagio de la .tuberculosis.

3^. Debe regulamentarse con urgenda 1^ obligaddn de dotar de patios amplios a
las casas, para que todas sus habitadones redban el aire puro y la luz solar directa
que exige la hii^ene.

880 PB00BEDIN08 BBOOKB PAN AMEBIOAK SOIBIfrriFIO 00NGBB88.

LA INSPECaON MfiDICA EN LAS E9CUELAS PtBUCitS DECENTSO AMt-
BICA— NECESIDAD Y POSIBILIDAD DE ESTABLECERLA EN VISTA DE
LAS OONDiaONES EXISTENTES EN COSTA UC A.

PorLOmS SOHAPIRO,
Dirtetor m Ooita Riea de la CaminSn IrUemaeUmal de 8<midad de la Fundaei6n RoeU-

feller.

Nuestro propdaito al fonnular este trabajo, ha aido el de promover la di8cu8i6n con
respecto a laf onna y mejor manera de establecer y aostener el servicdo de Inflpecci6n
M^ca en las eecuelas pdblicas de Oentro AmMca.

La In8pecci6n M^ca Eacolar ha pasado ya el perfodo de ensayos, y los trabajoe
realizados en eete sentido en loe Estadoe Unidoe y en Europa nos demuestran clara-
mente el indiscntible provecho que aquella in8tituci6n reporta, no 86I0 por loe inme-
diatos resultados que se advierten en el mejoramiento de la salud de cada nno de loa
alumnoe, aino tambi6n por las favoiables consecuencias que derivan en el futuro
las localidades y pafses en donde se encuentre organizada de manera eficiente, en lo
que se reladona con la salud pdbUca.

Numerosas estadlsticas recogidas en los Estados Unidos de America, han permitido
establecer el tanto por dento de las condiciones anormales existentes entre los alumnos
matriculados en las escuelas de aquella naci6n, y no es aventurado juzgar que esas
mismas condiciones se encuentran en los pafses de Centre y Sud America, en donde
una investigacidn acerca de este asunto acaso nos revelaria un tanto por ciento m^
elevado que el que acusan los aiguientes datos:

Entre los 330,179 alumnos examinados en la ciudad de Nueva York en el aflo de
1914, el 69.5 por ciento de los mlsmos neceeitaron el concurso del m^ico para ser
tratados de distintas enfermedades, las cuales se distribuyen en la siguiente pro-
porci6n:

EnfeniMdades.

Tanto
o£ato.

Bnfennedades.

Tanto
o£ato.

4.0

8.4

9.0

11.0

0.25

Imperfeccioiies de la ylsta

AnoJci^ii inoomDMa

Kn^rmftdadw Mrvfoaas

RwplracKSii nasal defeottiofla

Alteradonfls de la dentadura

69.0

Hll^itp^fla d4^ Im nmlgdabiff

(Por regia geoacal pnade oonslderane qoe eita ditlma anfmnedad provooa el deaamllo de otne oondl-
dones patoldglcas entre kM atomnoe aCectados.)

Los datos nmn^ricos que el Cuerpo Midico Eecolar de Montevideo conaigna en su
inlorme de 1914, establecen de un mode evidente que la existencia del servido de
Inspeccidn M^ca en las escuelas piiblicas de estos paises es indispensable. £1
nflmero de alumnos examinados por aquel cueipo fu^ de 7,568, en tanto que el de las
enfermedades encontradas entre los mismos ascendi6 a 11,174, las cuales se distribuyen
en las proporciones que se detallan a continuacidn:

Enfermedadee.

Tanto
dSato.

Enfermedades.

•

Tanto

CMOtO.

Debilldad general, anemia 7 adenopa-

tfaS. ...........rTTT.rTTr»,»-T-TT

13.0

4.6
64.0
1.7

17.5

Kn^rmedades de la garganta

34.8

Enformedades oatlneas 7 del enero
oabeUudo..

Enfermedades palmonaree

Enfennedades ^el sistema droolatorlo..

Atrsflo mental

10.9
.4

Enfermedades de kM dientee y de la boca.
EnfMniAdAdm de loe oMoa.

PUBLIC HBALTH AKD ICSDIOIKB.

881

Dtuante el perfodo compreiidido Mitre 1909 a 1913» el Guerpo Medico Esodar de la
ciudad de Nueva York ha logrado reducir el tanto por ciento de divenaa enlermedades
en las dguientea cantidades:

TMtoporelHrto.

EirfamiedMlM.

BnlQOO.

BI11913.

Dtteran-

ctode
manM.

1S.1

ia.7

32.0

8.6
8.9
11.8

4.6

Rfspinickfii mnl fktfeftuoM ..... ... xx....t. . ..

9 $

HIpWtrn Aft tU^ Im amlgdafaM

10.7

Lo6 caaofl de anemia y laquitiamo aaf como lo6 retraaados ffsica y mentalmente que
hemes observado en Costa Rica, tienen su origen en la uncinaria y otros par^tos in-
testinales. £1 81.7 por ciento de los alumnos que asisten a las eacuelaa ruialee
eetdn infectados con la uncinariaii$t en tanto que apenas un 12 por ciento de alum-
nos de las escuelas urbanas se encuentran en aquella condici6n. Es digno de notarae
que el 96 por ciento de estos dltifios padecen, en cambio, de asdUides lombricoides
y tricoc^falos y que entre los 5,092 alumnos examinados en dos de las ciudades
m&B importantes de Costa Rica, el 4.9 por ciento revelaron la presencia de tenia, de
las especies solium y soffinata. Entre las diferentes condiciones sanitarias que hemes
advertido en los pafses tropicales, y subtropicales, ninguna a nuestro juicio, es toAb
peligrosa que la uocinariasis, por la forma casi imperceptible pero segura con que
mina las eneiglas ffsicas y mentales deun pueblo, y estimamos por esta ras6n, que uno
de los deberes primordiales de los mMicos encargados de la in8pecci6n escolar es el de
restrlngir y eliminar esta clase de enfermedades insidiosas asf como el de hacer desa-
parecer las infecciones parasitarias.

Las enfermedades contagiosas pueden ser evitadas entre la poblaci6n escolar, siempre
que el maestro o el medico inspector adviertan en tiempo oportuno la presencia de
algtin case; de esta manera no sdlo se logrard reducir al minimum el peligro de que
aquellas se propaguen, aino que, a la vez, se Ubra a los habitantes de dolencias peli-
grosas y acaso de la muerte, en la inteligencia, naturalmente, de que las medidas
profiUcticas que cada case requiere sean aplicadas en la forma que la ciencia aconseja,
tal, por ejemplo, las epidemias de virudas que tan s61o pueden ser detenidas por
medio de la vacuna. Los maestros que est&n destinados a servir en los distritos a
donde no alcanza la acci6n de los medicos, deberian recibir una preparaci6n tunica
que les permitiera reconocer los primeros sfntomas de las enfermedades contagiosas
mds comunes y tomar, llegado el memento, las medidas preventivas que fueren ne-
cesarias. En estos cases es preferible pecar por ezceso de desconfianza, eliminando
desde el principio cualquier case sospechoso que se presente entre los escolares y no
esperar a que la enfermedad est^ declarada, con lo cual no se hace otra cosa que expo-
nerlos innecesariamente a un contagio.

En la inspeccidn sanitaria de las escuelas pt&blicas deberfa estar comprendida la
vigilancia de la higLene y limpieza de los edificios escolares, la cual se dejarla eventual-
mente al cuidado de los funcionarios de cada escuela, pero bajo la direcci6n del medico
inspector. Asimismo, es necesario que el Director de la Inspecci6n M^dica pueda
intervenir en la construcci6n de edificios escolares para que disponga lo conveniente
con respecto a las condiciones de alumbrado, ventilaci6n, mobilario, etc., de los*
locales, asf como a la instalaci6n de excusados, baflos y campos de juegoe.

Las escuelas normales deberian incorporar al plan de estudios por el cual se rigen,
un curso complete que comprenda el tratamiento de la higiene personal y escolar, el
conocimiento de los defectos f faicos que puedan advertirse f&cilmente y los primeros
sfntomas de las enfermedades contagiosas. De esta manera los maestros estarfan en

332 PBOCEEDnrGS SBOOm> pah AMERICAV BCIEJTlglO G09<

aptitnd de ocnpane de estoe asaiitos e» loe cans en qne ae difictttte cosaegnir d ccm-
C1IIB0 del ni^dk» y podHiui, a U Tes, ayndar eficmsmente il Cocrpo de M^^^
tores, coando por exceeo de tnbajo no pndienn hacerlo eiloe mimoe en todoe km
difltriloe.

Durante d citno lectivo loe medicos inspectores darfan doe confcrenciaB, par lo
menoe, a loe maeBtroe de an respectiYa proYincia, sobre aanntos que ae rrianonen c<m
la higiene piibbca, pero anbordinadoa a laa espedalea condicionea y neceadades de
cada locaHdad.

Loe maeatroe d^>erfan dedkao* una daae por armana en cada grado» al doaarroDo
de laa enaefianzaa rdadvaa a la higiene personal, y el reanmen de loa pnntoe tratadoa
en eataa leccionea durante un mea, aerfan objeto de una conf erenda a la cual ae invi-
tarfa a loa padrea de loa alumnoa. De eate modo, la escuela ae pondria en laa mia
lavorablea condicionea para que con el traacurao dd tionpo fuera conaiderada como
el centro cfvico a cuyo cargo eetaria la conaervacidn del bieneatar ffsico y moral del
pueblo. Loa elementoe para eataa conferendas deberiLn aer anministradoe por el
Centro Directivo, a fin de que loa puntoe que ae traten aean cientificamente exactoe.

Eatoa aervicioB deben eatar bajo el control de un cuerpo de m^dicoa y de enfo*-
meraa a quienea incumbe la tarea de practicar eximenea y preacribir los tratamientoa
neceaarioe, la oiganizaci^ ideal aerla ^aa; pero, aerfa poeible eatablecerla en loe dia-
tritoe ruralea?

En Coeta Rica iinicamente loe grandee centroa de pobladdn aprovechan loe aer-
vicioa de loe m^dicoa quienea dedican gran parte de au tiempo al cumplimiento de
eate deber, mientraa que en el campo ea caai impoaible obtener el mismo resultado.
Esta Bituaci6n merece aer conaiderada, porque actualmente el trabajo de clasificar a
loa alumnoa de laa eacuelaa ruralea por sua delectoe visiblea y, en algunoe caaoa, la
condicidn de los mismoe, esti al cuidado de loa maeatroa que hu^can reeibido previamenU
las instruecUmeM adecuadiu para realizar aquella labor.

El prop^to fundamental de la inapecddn m^dica, ea el de producir resultadoa
tangibles y deciaivos en la mejora duradera de la salud, investigando cuidadoeamente
]a<4 enfermedades y defectos de los alumnos e instruyendo a los hogares para que est^n
en aptitad de combatirlos; este servicio social puede estar al cuidado de maestroe
competentes que hayan reeibido la necesaria instniccidn, en el caso de que no pueda
contarse con los servicios de enfermeras profesionales.

Para que una oiganizaci6n de eeta claae sea factible y capaz, al miamo tiempo, de
producir excelentes resultados, recomendariamoa la adopci6n de las siguientee bases:

El medico director serd directamente responsable ante las autoridadea por la or-
ganizfKd^n y efidenda del trabajo.

Habrd en cada provincia un m^ico inspector con reaidencia en la reapectiva ca-
pital; loe inapectorea tendr^ a su cargo el trabajo que fuere necesario en las eacuelaa
de la provincia en donde sirvan, cifi^dose a las instrucciones que al efecto formule
el director. Deber^ visitar cada eecuela por lo menos una vez al mes y acudir a
cualquier llamamiento que se les haga en caso de epidemia.

Loa doctorea deber&n eatar bien pagadoa, en raz6n de que por fuerza ban de dedicar
todo 8u tiempo al cumplimiento de sus obligaciones de inspector eecolar. Tampoco
podrdn ser removidos a consecuencia de cambios polfticos.

Un dispensario central ser4 mantenido en cada capital de provincia para el uso
exclusivo de los alumnos, y siempre que fuere posible se pondrdn a disposicidn de
los mismos los servicios de un competente dentista.

De acuerdo con laa instruccionea que reciba, el director de cada eecuela, aseaorado
por los macstxos, haria los exdmenes para determinar los defectos visibles de los alum-
nos y para eliminar los que se encuentren en condici6n normal. De este modo se
evitarla al m^ico un considerable e innecesario trabajo, y podrla dedicar la mayor
parte de su tiempo a todos aquelloe que necesitaren su concurso.

PVBUO HBALTH AND MBDIOIKB.

333

Contemplado el problema bajo el aspecto econ6mico, declaramoe que el esfuerzo
en conservar y mejorar la salud de las futuras generaciones, juatifica ampliamente
la inveraidn de los fondoe pliblicoe.

lUpAbUca d« Costa Rica. Secretarla de Instrttcdte PAbllea.

In8pbcci6n Santtabia Escolar.

inpormb del mab8tro.

Escuala DIstrito Cantdn Provlnda .

Nombre del alumno Sexo Edad al oomensar los estudtos — ; edad al terminar los estudtos —

HI8TORIA ACADtMICA DEL ALtnCNO.

OiBdo.

Cursado

en el afio

de-

En la

escuela

de-

Aprovecha-
miento E. B.
R. D. mD.

ConducU

mR. R.I.

mD.

Asistenda

mR.R.I.

ml. A.

t rtr lo deuciente en

de- j

ANTECKDENTE8 SANITAIUOS DKL ALUMNO.

;Ha padecido de—

81-No.

Afio.

xHa padeddo de—

81-No.

Afio.

SarampMn

Difteria

Escarlatlna

Tosferina

MfilKria

Anquilostomiaids

Vacunado. . . .{^^}En qu« afio . .. Re8Ultado{{J^- } Aspect© de la vacuna {a^S^ vi8lble}*^y

excusado en la casar SI-No.

COMDiadN DE 8ALUD DEL ALX7MMO.

Asimtos de InyestlgackSn.

fialud

E-B-M

NatrleMn

E-B-M

Voi

C-O- Af

1....

Dolor de cabeia

p-int

Vista

.. . B-D-Mal

OMo

F-TUMft] , , ,

DIentes

B-Mal

Labtopartido

SINo

""I*"""

Paladar hendido

81-No

....|....

Catarros frecuentes

Sl-No

Resjjlra por la boca ...

... SI-No

Baile de San Vlto

SI-No

Pedio. vivos (ptojos)

SI-No

Aiso en m persona , .

E-B-R-D-mD..

Taitamndet

5.4.^2.1

Epilepsia

fU4-a-2.1

C01fDia6N MENTAL DEL ALVMNO.

Cnalldades y deCectos Abs. Atr. Nonn. Res. Pusll.

Aotivldad fceneral Est. Per. At Ner. mNer.

Inteleotualldad Pmd. Ked. Ind. Imp. mimp.

Bxpresidn del senttanlento Am. Sns. At At. 8omb. Rud.

Vobrntftd Hnr. VoL Pfrm. Flex. Inest.

Observadones.

334 PROCEEDINGS SECOND PAN AMBBICAN SCIENTIFIC 00NGBE88.

In8pkooi6n Sanitaria Esooiab— Contintn.
coNinadir dk. hoqas.

Oflolo del padrt: ..
Olloio d« la madre:

En el 0880 do quo algono do loe pediMl ,

Idol mlumiio hubiore fiaUoddo. indS-l

qooso on lo podblo, l8 onfannodiMl qnof ..
-^^dolMloelfntmto ...J..

orjgjndc

lIodioodoTlda Ri. Ao. M. P. mP.

Condoota on ol hogar E. B. R. D. mD,

Cnltnra del hogar B. B. R. D. mD,

il;:

OBOBTAaOlflS DK. XAXSTBO.

OlMorvaelonos.

NOTA.— La oqatraloncia do 188 al»oyktiira8 88 onooontm on ol fblkio do liiotroool^^

; DK. MtDICO.

AaontoB do dtfttamfitii

Asnntot do diotanun.

Edadaparento

Edad intolectoal (lf«t. Bl-

DOt).

Poroontfje do sangre

Estado do nutricion

Tonstlltis hlportx^flca

Adenoldes

Rospiraddn na8al deleo-

tuosa

Caries dental

Plorrea

Miopia: olodorecho

Miopia: ojolsquierdo

Hlpennetropla

ConJantMtb folkmlar

Otros defBCtos do los ojoa....

Andlddn dofBCtuosa

Ortop^:

Columm^vortolnal

Tronoo

Eztremldado8

OlAndulas UnlAtloas Infttfta-

das

Enfermedados:

Mentales

Nervlosas

Dolpolmdn

. Deloorasdn

Dolapiel

UmBYXNadN dk. MtDtCO BSCOLAB.

El oUdloo dobo anotar por ordon do fochas, los tratamientos qoe haya preooripto para ol alumno as! oomo
kM consojoo sanitarios dados al mismo, en forma Indlvidoal. Anotooe tambUn la yaeonaoldn.

Fooha.

Motlvodolalntorvon-
oldn.

Tratamlento prosorito.

NombiodolmMloo.

Infloonda do la oondJddn sanitaria del alnmno

Aflos.

en loo ostudios.

19...

W...

19...

rontaglnsa ...

Progreooonl

a ooooola*

OB8IBTAaONX8 DK MtDICO.

NofA.— El MMloo Esoolar omploarA ol signo O para Indkar que ol alumno estioxonto do las onlmnod.4l88
o dofoctoo anotados on la Usta anterior; on oaso oontrarlo dobori osar ol signo X, siempfs qno ol oontonldo
do la frase lo oonsienta.

JOINT SESSION OF SUBSECTION B OF SECTION Vm AND THE
AMERICAN STATISTICAL ASSOCUTION.

Raleigh Hotel,
Thursday momingf December SO, 1916.

Chairmen, Sam L. Rooebs and E. Dana Duband.

The session was called to order at 10 o'clock by Chairman Rogers

The Chaibman. Gentlemen, may I call your attention to the
matter of the reading of the papers and their discussion? What is
your pleasure as to discussion ? I will entertain a motion in regard
to this matter.

Dr. Wnxoox. Mr. Chairman, in view of the number of the papers
on the program, and the comparatively short time available, I move
that discussion of the several papers be postponed until after the
papers are presented.

The motion received a second and was carried.

The Chairman. According to the program, the meeting was to
open at 10 o'clock. We are a little late. I congratulate the body
upon the fullness of the program, as indicated by the papers filed
with the secretary.

We have with us the president of the American Statistical Asso-
ciation, Dr. Durand. It is my pleasure to yield the chair to him.

Dr. Durand thereupon took the chair.

The Chairman. It gives me great pleasure to have the honor of
presiding at this session of the joint meeting between the Pan Amer-
ican Scientific Congress and the American Statistical Association.
Certainly it is an extremely important field that we have to cover
this morning, and it was most agreeable to the officers of the Amer-
ican Statistical Association to be invited to join with this great con-
gress in the preparation of this program. Because of the very
limited time which we have for a rather long program, I will not
impose on you with any more remarks, but will call for the first
paper on the program, ''The nature and significance of the changes
in the birth and death rates in recent years," by Prof. Walter F.
Willcox, of Cornell University.

Dr. Willcox. Before I begin my paper, I want to say a word or

two about these two diagrams which I shall have to refer to. The

diagram showing death rates for New York City from 1804 to 1913,

and for Massachusetts from 1849 to 1913, is indicative of the way in

which the death rates have changed in the two regions of the United

States for which we have sufficient records to make them typicaL

llie other diagram shows the birth rates of Berlin from 1800 to 1909,

and of England and Wales from 1838 to 1910.

S86

336 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONGRESS.

THE NATURE AND SIGNIFICANCE OF THE CHANGES IN THE BIBTH AND
DEATH RATES IN RECENT YEARS.

By WALTER F. WILLCOX,
Frofunar of Economics and Statisties, ComeU Univernty.

Certain important changes in death rates are revealed by a diagram showing annual
death rates for a populous area through a long series of years. The American districts
best satisfying these two conditions are Massachusetts, for which the death rate since
1849 is known, and the old New York City, for which the death rates run back now
through more than a century.

.,!;!Jt:h:!£ik!^:..^.!ni;i;

This diagram illustrates what a laiger body of evidence would confirm, that the
perceptible and steady decline in the death rate is a relatively recent phenomenon.
In order to test the <x>rrectness of this inference, the average death rate has been com-
puted for each decade and the ratio found between that rate and the rate in the
preceding 10 years taken as 100. The results are as follows:

Date.

Death rate in-

Ratio of rate to that ia
preceding decade- 100.

New York
City.

Massachu-
setts.

New York
City.

Maasacfau-
setts.

1804-180e

as. 3

24.7
26.8
29.8
30.3
35.6
81.7
27.6
26.8
23.1
19.0
15.3

1810-1819

94.2
104.2
115.7
101.6
117.7
89.0
87.2
97.1
86.0
82.3
80.6

1820-1829

1830-1839

1840-1849

1860-1850

18.0
19.4
19.7
18.6
19.1
16.0
16.5

1800-1809

107.8

1870-1879

101.6

1880-1889

99.6

1890-1809

97.1

1900-1909

84.0

1910-1913

96.7

These figures show that the decennial death rate in New York City rose for the 40
years following 1810-1819, but has been falling since the Civil War and is now mndi
lower than ever before. In Massachusetts the rate rose until about 1880 and has been
faUing since that date, but at a slower rate than in New York. Decennial rates for at
least two decades have been obtained in 27 European countries, and in every one the
rate for 1901-1910 was lower than for any previous decade. This evidence shows that
the decrease of the rate is well-nigh universal in Europe. A few exceptions to the rule,
howev^, are found in other parts of the world, namely, Ontario, Canada, Connecticut,
Michigan, Vermont, Oiile, Jamaica, Japan, and C^lon. But in some of these the
rates at earlier decades were incredibly low and the apparent increase was probably
due, in part at least, to more complete returns of deaths in the later years.

FUBLIO. HBALTH AND MEDIOIKE. 337

The diagram also suggests that the annual fluctuations begftn to decrease at about
the same time that the rates began to fall. To judge whether this is a general or only
a local change, conditions in the 23 countries of Europe ^ for which the rates as far
back as 1870 are known have been examined. The average annual variation has been
determined. Naturally the successive years between whidi the greatest variation
occurred were the years of transition from peace to war or vice versa. Thus, the
greatest changes occurred between 1871 and 1872 and between 1870 and 1871. The
war of 1876 exerted a less noteworthy influence. On the whole, the annual fluctua-
tions have decreased, but the change is less obvious and uninterrupted than students
of individual cities or countries mig^t expect.

Both the steady decrease in the death rate and the slow reduction in the annual
fluctuations mark and measure man's progressive emancipation from physical ills of
disease or famine, which are closely dependent upon climate and season, and we mig^t
have thought, before August, 1914, from the political ills of war and revolution.

In New York State between 1894 and 1909 there was a marked decrease in mortality
during July and August as compared with the average for the entire year. I believe
no similar studies have been made for other States. In default of other evidence we
may conclude that one factor in the diminishing death rate has been an increased con-
trol of deaths in summer. If this should iMove to be a general fact, it would i^obably
be connected with the success of efforts to reduce infant mortality. The hot months
are especially dangerous to infants, while the cold months are especially dangerous
to the aged.

Age influences the death rate more powerfully than any other physiological factor.
Most people know that the death rate is lowest at the age of puberty and very mudi
higher at the beginning and end of life. But the amount of difference is not com-
monly realized. In New York State boy babies under 1 year of age suffer from a
death rate 65 times that of boys of 10 to 14. The death rate of nonogenarians rises to
169 times that of the youth.

It would be a natural expectation of one who is told that the death rate is rapidly
ftdling that the gains had been distributed somewhat evenly up and down the scale
of years. But this anticipation is not borne out by the facts. Even in a hurried sur-
vey like this two points, the possible Increase of infant mortality and the possible
increase of mentality among the aged, call for mention.

High medical authority in England alleged neariy 10 years ago that infant mortality
is stationary or increasing, and this conclusion won some acceptance in the United
States. Fortunately the figures proved to be susceptible of another explanation.
But into that question there is now no need to go, since even in England and on the
face of the figures infant mortality has decreased since 1900. Indeed among the 19
countries of Europe for which statistics are at hand there is not one in whidi infant
mortality has shown no decrease since the beginning of the twentieth century. In
the United States the r^lstration of births is still very defective and there are no
laige population groups for which we know the true infant mentality, that b, the num-
ber of children dying in the first year of life to each thousand living births. Our best
substitute for this figure is the ratio between the deaths under 1 year of age and the
living children under 1. In the registration States of 1900, com|»ising 26.3 per cent
of the country's population, this ratio fell from 162.4 p^ 1,000 in 1900 to 141.7 in 1910,
indicating that infant mortality fell about one-eighth in the decade.

When we turn to the other end of life, the indications of our American figures are
less gratifying. In the registration States of 1900 the death rate decreased between
1900 and 1910 for every age period below 55 and increased at nearly every age period
above 55. On this point our experience is apparentiy at variance with that of Europe.
The latter indicates that before 1900 the fall in the death rate as a rule extended to
all ages and was especially great at ages between 5 and 53, but that for ages above

I For this puHMse tlM thTM divisions of Oraa Britain and btlaod a^
Bmpin hmy ban traatad asoountriss.

388 PBOCEEDINGS BEOOKD PAN AMBBIOAN 80IBNTIFI0 CONGRESS.

55 it WM oU^^t or in some countries absent.^ The English life tables pablished in
1915 and speaking for a more recent period show that at every age above 5 3rean
the mcNrtality in 1901-1910 was ksB than that in 1891-1900 and that the mortalityin
1910-1912 was less than that in 1901-1910.*

The apparent increase of mortaHtj at hi^ ages in onr regislation States, in oppoa-
tion to the general trend in other countries, invites and should be given nuure carrful
and thorough analysis than it has thus far received or than I have been able to give it
for this paper. Although it appears in both sexes, it does not show itself among
women until the age of (M) is reached, while among men over 45 the death rate in 1 910
exceeded that in 1900. It appears also among the three dasses of native white, for-
eign-bom white, and colored, eariiest among the cdored with whom the increase
appears in each sex at every age above 30, latest among the foreign-bom whites with
whom the increase does not appear in either sex until the age of 60 and then fcft females
appears only for the 10-year age period 60 to 69. It appears in a prevailingly agricul-
tural State like Vermont at an earlier age and more definitely than it does in a pre-
vailin^y industrial State like Massachusetts or Rhode Island. In a recent reference
to this change, based mainly upon the figures for Massachusetts and New Jersey
between 1880 and 1910, three possible causes were mentioned, ''the amalgamation of
the various races that constitute our population," "lack of adaptation to our rapidly
developing civilization," and ''some unknown biologic influence,*' and a preference
for the second was indicated.' Thus far no evidence has been produced, I bdieve,
showing that the increase is greatest where amalgamation of races is probably affecting
the largest proportion of the population or where the lack of adaptation to a developing
civilization is greatest.

An influence upon mortality which the United States is in a more favorable position
to investigate is that of race. Under this term I do not include those residents in the
United States who or whose progenitors were bom in a certain country or spoke a
certain language, like the Scandinavians or the French Canadians. At some future
time we may be able to investigate the death rate of groups like those, although the
present position and sluggish development of American vital statistics make one f esr
that the facts nuiy become inaccessible before the country is ready to study them. I
refer here to the two great races of white and Negro, whidi include between them
more than 99 per cent of our population. The registration States of 1900 contained in
that year 19,544,821 whites and 388,198 Negroes and many more in 1910, groups large
enough and residing in States widdy enough scattered to make the changes in their
death rates between 1900 and 1910 somewhat representative of the changes in the
whole country.

The death rate of whites in these States fell from 17.0 in 1900 to 15.5 in 1910, a de-
crease of 1.5 per 1,000, or 8.8 per cent of the initial rate. Meantime the death rate of
Negroes in the same States fell from 25.6 in 1900 to 25.0 in 1910, a decrease of 0.6 per
1,000, or 2.3 per cent. These figures show that the fall in the death rate during the
decade was more than twice as great among whites as among Negroes. Stating the
same change in another way, the death rate among Negroes in these States exceeded
that among whites by 51 per cent in 1900 and 61 per cent in 1910.

But to compare the two races in this way and stop without noting whether significant
differences exist between the age and sex composition of the two groups mig^t easily
lead us into error. Thus among the whites 50.5 per cent, but among the Negroes only
48.3 per cent were male. As the female death rate is regularly lower than the male,
the tme difference between the death rate of the races would probably be greater than
the foregoing figures indicate. Even more important is the fact that of the whites
21.5 per cent but of the Negroes only 16.1 per cent are either children under 5 or
aged 55+ and have the hij^ death rate characteristic of infancy and old age.

> lUroh. 8Uttotiqii» Intorn. do Mouvim^nt d» la PopulatUm, VoL I, pp. 4a-4» and 460.

* R«K. Qm^ SoppkoMiit to75th Ann. R«p., Pk I, Life T»bleB,p. 90.

• FlilitfftndFifk,HowtoUve,p.2B2. See also UwlnsU-ConrlB In N«w Yofk TkiMt,
ptomeol, Dm. 11,191s.

PUBLIC HEALTH AND MEDIOIHB. 339

Probably the beet way to measure the effect of these differences in sex and age
composition is to compute standardized death rates for each race. When the death
rates of each race for a given sex and age are applied to the population of the same sex
and age in a standard million distributed as in the registration States of 1900, the
standardized death rate in 1910 is found to be 15.5 for whites and 27.5 for Negroes,
showing that the corrected death rate of Negroes exceeds that of whites by 12.0 per
1,000, or 77 per cent. The corresponding standardized death rates in 1900 were 16.9
for whites and 29.0 for Negroes, showing a fall during the decade of 1.4 per 1,000 for
whites and 1.5 per 1,000 for Negroes. But in 1900 the standardized Negro death rate
exceeded that of the whites by 72 per cent as compared with 77 per cent in 1910.
The standardized death rate among female Negroes exceeds that among female whites
by 61 per cent in 1900 and by 72 per cent in 1910, while the difference among males
was 69 per cent in 1900 and 84 per cent in 1910, showing that the difference between
the males of the two races is greater and increasing more rapidly than among the
females. The death rate of each race is falling, but the gap separating the two races
has seemingly grown wider. Before the Civil War, according to what evidence we
have, the death rate of Negroes exceeded that of whites by 29.8 per cent of the lower
rate, and in 1890 the difference was 56.5 per cent. These earlier rates are not strictly
comparable with each other or with those for 1900 and 1910, partly because they speak
for different areas, neither of which agrees with the registration States of 1900, and
X)artly because in them no attempt has been made to allow for differences in the age
and sex composition of the two races or for changes in these respects. The general
conclusions, however, that the death rate of each race has fallen by approximately the
same amount and that the ratio by which the Negro rate exceeds the white has been
rising, seem to be supported by evidence enough to make them deserve acceptance.

Still another influence upon mortality which has been recently investigated is that
of marital condition. Eturopean figures indicated long ago that the mortality of hus-
bands is much less than that of bachelors or widowers of the same age and the conclu-
sion is now corroborated by figures for New York State. No doubt this difference is
largely due to the selective process by which the men who marry are, on the average,
at the time of marriage more healthy and vigorous than men of the same age who do
not marry. Evidence that direct benefits to health accrue from married life is found
in the death rate of widowers, which is much higher than that of husbands, in the
death rate of Catholic celibate clergy, which is higher than that of Protestant clergy,
most of whom are married, and in the death rate of all males during the years at which
marriage is most common. The normal and usual course of mortality in each sex is
for a slow but steady increase to begin just after the minimum is reached in the early
teens, and to continue with accelerating rapidity to the end of life. To this course
there is no significant exception among women, but among men in several countries
the increase is checked or even turned into a dight decrease tcft a longer or shorter
period between the ages of 20 and 35 when marriage is most common. The probable
explanation is that the normal increase of mortality during these years is nearly or
quite neutralized by the steady transfer of many men from the less healthy bachelor
state to the more healthy married state. The explanation finds some support in the
fact that during these years the death rate of bachelors treated separately rises steadily
with age. On the whole, the evidence justifies the inference that marriage exerts a
directly beneficial influence on men's health and prospects of longevity. For wives
the facts are less favorable. In New York the death rate of wives between 20 and 29 is
greater than that of single women at the same age period. The difference is slight and
part of it no doubt is due to the fact that wives 20 to 29 years of age are, on the average,
more than two years older than spinsters belonging to the same age group. But as
less than half the difference can be thus explained, it seems clear that in New York,
as in most other areas in which the facts have been determined, during the early years
of married life wives have a higher death rate than spinsters and probable that the
difference is largely due to the dangers attending childbirth, especially among primi-
68486— 17— VOL DC a

340 PBOCEEDIKQS SECOND PAN AMEBIOAN SOIENTIFIO CONGRESS.

parae. But though the mortality of wives 20 to 29 yean old is greater than that of
spinsters or husbsuids it is less than that of bachelors.

There are no American birth rates which extend over a long series of years and may
be trusted as accurate. In default of evidence from this country I have used in the
diagram the birth rates for England and Wales since 1838 and for Berlin since the
beginning of the last century. The diagram shows that the birth rate was probably
at its maTJmum about 1875 and has decreased almost steadily since that date, that
the decrease in England has been about one-third and in Berlin about one-half of the
maximum amount, that the variations both from year to year and through longer
periods were greater in the city than in the entire State, that the decrease since 1876
has been almost uninterrupted, that there was a marked depression in both areas in
1890, and that Berlin had a much more notable depression in 1871. If in the other
diagram we had used the death rates for Berlin, high points on that curve would have
been revealed in 1871 and 1890 when the birth rates were low.

As a rule influences which tend to increase deaths tend also to decrease births, and
influences which tend to decrease deaths tend to increase births. This appears even
in the rhythm of each day, Italian figures apparently showing that deaths are most
frequent and births least frequent in the afternoon. There is also a yearly as well as a
daily rhythm traceable in the figures, but in this case the reciprocal relationship is
between conceptions as mirrored in the births nine months later and deaths. There is

Bivtk "RAteS-Bwlm. 1100- 1101, En^ivvl «rui V1«ltS, itM-Wi^

11^: jfi

I - ^1

rK\^^

■ ■'■ ' ■

-. : :: _'

VjikA-?"^-

^^ . • '

■ - 1 -r.i
1

^ '1 „ .. .

■'.-. .:

some evidence that during the late spring and early summer and again during the late
fall the death rate is low and the conception rate high. There is some evidence, like-
wise, that during the late winter and ^e late summer the death rate is high and the
conception rate low. This reciprocal relationship between births, or conceptions, and
deaths appears also in the case of any great social calamity. As a war or a pestilence
raises the death rate, so likewise it depresses the birth rate, and in estimating the social
effect of either it is of the first importance to consider not only the deaths it has caused
but also the births it has prevented. For example, in Massachusetts between 1860
and 1864 the death rate rose from 18.7 to 22.8, an increase of 4.1 per 1,000, and the birth
rate fell from 29.3 to 24.2, a decrease of 5.1 per 1,000. In Sweden continuous and
trustworthy records of births and deaths have been maintained without a break since
1749, a longer period than in any other country. The year 1773 was marked by the
heaviest death rate of this century and two-thirds, and during that year the birth rate
was also lower than in any year before or since . The most universal and fatal epidemic
which has afflicted civilized countries of recent years was probably the first of the recent
visitations of influenza, which spread over Europe and America in the winter of 1889-
1890 and caused in New York State about 5,000 deaths. Wherever the births were
reported and published by months one finds, nine months after the influenza epidemic
was at its height, a marked shortage of births. There were at least 200,000 fewer births
in Europe in 1890 than the average annual number for the preceding five-year period.

FUBLIO HBALTH AND MEDIOIKB. 341

Now the most marked change in the birthrate during the last hall century, a change
revealed by a comparieon of the two diagrams, has been the gradual decline and almost
complete cUsappearance of this reciprocal reUtionship between births and deaths and
the appearance in its place of a tendency for births and deaths to change in the same
way rather than in opposite ways. Before proceeding to consider the causes, let me
set forth the facts a little more fully.

1. The birth rate and death rate now remain approximately the same in any given
country during any few years. The sharp annual variations which characterized these
rates and which are still traceable in the statistics of undeveloped countries are dis-
appearing.

2. The tendency of both death rates and birth rates is to undergo large and important
modifications in longer periods of time. The sharp up or down movements in both
curves connected with such causes as war, pestilence, €ft famine, on the one hand, or
bountiful harvests and cheap food, on the other, are being succeeded by a steady pro-
gressive downward movement in the death rate and the birth rate.

Begarding the birth rate in the United States we know practically nothing. But in
default of this information I have found an available substitute by comparing the
number of children under 5 years of age at the date of each census with the number of
women 16 to 44 years of age at the same census. The results are given in the following
table, in which the figures before 1850 are estimated from such data regarding sex and
age as the earlier censuses afford.

Number o/ehiidrm tmder 5 yean of age to lyOOO wmen 16 to 44^ yean of age.

1800 976

1810 976

1820 928

1830 877

1840 835

1850 699

1860 714

1870 649

1880 635

1890 554

1900 541

^ 1910 508

During the 60 years 1850 to 1910 the number of children to 1,000 women of child-
bearing age decreased in the United States by 191, or an average of 32 in each
decade. There are only about seven-tenths as large a proportion of children in the
United States now as there were in 1850. If we assume that the change will continue
in the direction in which it has been moving ever since 1860 and at this average rate
ol 32 in a decade, the number of children under 5 in the country to each 1,000 women
16 to 44 will be as follows:

1920 476

1930 444

1940 412

1950 380

2000 220

2050 60

2060 28

2070 0

The figures indicate that, if changes like those which have been in progress in the
United States since 1850 should continue unchecked for a century and a half, there
would be no children left. Let me not be understood as predicting a continuance oi
the movement for any long period in the future. But often the best method of bring-

1 In order to reduce the error of the estimates in the earlier decades to a mhiimum, ages 16 to 44 were choeea
instead of 16 to 40, the more usoal limits.

342 PBOOEEDIKGS SECOND PAN AMEBIOAN SOIENTIFIO C0NGBE88.

ing home to ouraelves the vast sweep and significance of the changes revealed by
statistics is to project them into the future and see whither they lead . No doubt social
movements do not occur along straight lines. On the contrary sharp inflections in the
curves of social change are frequent. But it is one of the main duties of statistics to
point out the trend of the stream along which society is moving and thus perhaps to
arouse a desire for a change.

This tendency to a decline in the birth rate is in nowise confined to the United
States. On the contrary the movement in most European countries has been in the
same direction. In 24 European countries, all, except Ireland, Portugal , and Bulgaria,
for which the records are at hand, the birth rate 1901-1910 was lower than in the preced*
ing decade and in nearly all of them it was lower than in any earlier decade.

In considering the causes of tlus great change, let me refer first to the position of
Herbert Spencer. He has argued that the various organs of the body compete with
each other for nourishment and growth, that the surplus not required by the individual
is all that can be devoted to the continuance of the race, that no other system makes
demands upon the body as heavy as those of the nervous system, that civilization and
education are steadily increasing this drain and decreasing the surplus. He finds,
therefore, a natural and inevitable connection of a physiological kind between an
advancing civilization and a decreasing birth rate. Some students of American
statistics have sou^t to find support for this position in our fragmentary and elusive
material. I can not go further with the question this morning than to express my
judgment that these efforts have not been successful and that there is no conclusive
evidence, statistical or otherwise, in support of Spencer's contention. While ad-
mitting the heavy and increasing demands upon the nervous system made by modem
conditions, I would point out that the decreased death rate and the decrease of sick-
ness by which it is probably attended mean an increase of human vitality and so of the
surplus to be drawn upon. Whether the increased expenditure on the nervous system
equals or exceeds this increased surplus no one has even tried to prove. Until that is
done I believe the Spencerian theory must be deemed only a theory.

Nor can we admit, as others have argued, that the decreased birth rate in civilized
countries is due either to the growing abuse of alcohol or to the spread of vena«al
disease. Such arguments have come mainly from special students of these social
evils and such students often lose the sense of proportion and find a relief from every
social ill in the one reform on which their eyes are riveted.

Walker explained the decrease in the American birth rate by the menace to the
American standard of life fron^ the influx of swarms of immigrants accustomed to che^>
food and clothing and bad housing and to the effect of this menace upon the birth rate
primarily of the native stock and ultimately of the entire population. This explanar
tion is improbable, because the decrease as we have se^i began as early as 1810, whan
immigration was an unimportant influence, and has been matched in Australia,
where it must be due to other causes than that assigned by Walker, since Australia
has had no great influx of immigrants.

Turning from these inadequate explanations, the true reason for the fall in the birth
rate is that in modem times, mainly within the last half century, births and the birth
rate have come under the control of human will and choice in a sense and to a degree
never before true. Our leading American authority. Dr. John Shaw Billings, put it as
follows: "The most important factor in the change is the deliberate and voluntary
avoidance or prevention of child bearing on the part of a steadily increasing number
of married people who prefer to have but few children.'' Before this change began
the birth of a child was, to be sure, the result of normal physiological processes, but
in the vast majority of cases the birth itself did not indicate a deliberate preference
for that result on the part of both or either of the parents. There is not a sin^e one
among the experts who denies that this is the great underlying cause of the modem
decline in the birth rate of all civilized countries.

In considering this change may I first suggest that some such change was an almost
necessary consequence of the great decline in the death rate? That is, if the death
rate in Europe had declined as rapidly as it has and the birth rate had not declined »

FUBLIO HSALTH AND MEDIOIKB. 343

the peculation of that continent would now be increasing even faster than the wealth
or the food supply. The standard of living would be sinking and we would probably
soon relapse into our former ill state. It is the decline in the birth rate, and only that,
which has enabled mankind to grip and hold fast the advantages promised by the
decline in the death rate.

But there is a very important difference between the two changes. It is probably
to the interest of society in the long run that each individual should be given a chance
to live out his life to old age, and social effort directed to that end is beneficial both
to the individual and to society. Thus far the interests of the two coincide. For
this reason the two have cooperated and are cooperating effectively to reduce the
death rate. But in the matter of the birth rate there is a lack of adjustment between
the interests of society and those of the individual. Society is deeply concerned
that enough children ahould be bom to secure its own permanence and a reasonable
increase and that those children should have the highest promise of service. The
individual is deeply concerned not to compromise his own future by assuming responsi-
bility for wife and family without the prospect of being able to maintain them in
accordance with his standard of living. The individual may often see for himself or
herself, therefore, a balance of advantage in abstinence from or postponement of mar-
riage, in a childless marriage, or a small family, while society from its point of view
might conceive it to be most important that a given endowment of much social worth
ahould be perpetuated.

If there were time it would be easy to show that a low and diminishing birth rate
IB especially charactenstic of many strains of population, like college graduates of
both sexes and the native American stock of the New England States, stocks perhaps
better endowed than the average population with hereditary qualities the perpetua-
tion of which is socially desirable.

While persons engaged in grappling with public health problems should interest
themselveB in the various changes I have briefly outlined, the main question which
my figures raise is this: How shall the desirable natural increase of the population be
secured and at the same time the quality of the peculation be maintained or improved
by securing at least a normal ot average and, if possible, a more than normal birth rate
and natural increase in the strains of populatkm which are of the best stock and there-
fore likely to transmit qualities of greatest social worth?

In this difficult field a few general principles may be stated dogmatically, which I
would be glad to explain and defend, if there were time.

1. The death rate can not be expected to fall much below where it now stands in
healthy districts.

2. Thete is no such natural limit to a fall in the birth rate.

3. The spread in the volitional control of the birth rate is a change against which,
even if we believe it undesirable, it is hopeless to struggle.

4. Legal regulations of marriage in the effort to diminish the number of births of
diseased or otherwise undesirable children seem likely, unless accompanied by segre-
gation, to do m(»:e harm than good.

5. llie social service rendered by parents who have hereditary qualities <^ great
▼alue and make heavy sacrifices in other directions in order to rear families of normal
dse or larger is likely in future to be much better appreciated and requited.

6. Persons interested in maintaining the numbers and improving the quality of the
population should aim not merely or mainly at a continued reduction of the general
death rate but also at the gradual education of public opinion toward a readjustmen t
of the birth rate in various classes which will enable society to gain from its best strains
more than it can do under present conditions.

The Chaibman. The next paper will be on the subject of "The
potential influence of vital statistics on the conservation of human
life/' by Dr. W. S. Rankin, secretary of the State Board of Health of
North Carolina.

844 PBOOBBDINQS 8E00NP PAK AMBKEOAN 80IBNTIFIC C0NGBE88.

THE POTENTIAL INFLUENCE OF VITAL STATISTICS ON THE CONSER-
YATION OF HUMAN UFE.

By W. S. RANKIN,
Secretary North Carolina State Board o/HeaJUh,

Statistical practice, like all Gaul, diviaa est in tree partes: Fint, the collection of
statistics; second, the tabulation of statistics, which includes, of coune, the proper
classification; and thiid, and finally and most important (in that it is the end to
which statistical collection and tabulation are directed), the application of yital
statistics to public thought.

Unfortunately, most of our experience in statistical practice, and most of the litera-
ture on statistiod practice, has to do with either the collection or tabulation of statis-
tics, and little so &r has been said and less has been done with the application of
statistical ftbcts to public thought. Thorough collection of vital statistics and abso-
lute accuracy in statistical tabulation aro worthless if the statistics aro not made a
part of public thought. It is to this phase of statistical practice, or the application of
vital statistics to public thought, that I shall address myself briefly. Applied vital
statistics serve four important uses: First, vital statistics supply tlfb human con-
servationist with

THB 8UB8TAN0B OF HIS FAITH.

Back of all great movements, such as the consovation movement, tbero is a doc-
trine; back of all doctrines thero is a creed; back of all creeds tbero is a faith, and it
is the &ith that is the germ of the movement. Now vital statistics furnish the health
officer, and through him the public mind, with the substance of the &ith that is essen-
tial to initiative and progress in human conservation— -vital statistics furnish the
tangible and incontrovertible evidence of the fttr-reaching possibilities of health work.
In the appeal to legislative bodies or any organized group for a greater investment ol
funds or effort in human conservation, the bedrock on which the health officer must
stand, the trench from which he can not be driven by his opponents, is the numefooi
facts confirmatory of each other, all telling the same story, of which the following
chart will serve as a type of many charts with the same meaning:

General death rate of the United Statee registration area, 189(hl91S.

Year.

"r^

RatoiMT
IfioST

1880

8,588,000
19,660,440
80,706,618
34,006,606
68 843 806
63,290,164

10.8

1890

10.6

1900

17.6

1905

16.0

1910

l&O

1913

14.1

Let him who is to appeal to the public to take a practical interest in health wofk
romember that the proof of the pudding is in the eating, and the proof of the possi*
bilitiee of human cdnservation, the argument that the doubter and the reactionary
can not face or distort, is the actual figures, the vital statistics of the last 25 yeaa.
The second and third practical uses to which I wish to direct your attention are—

THB PULL AMD VUBH. OF VITAL 8TATI8TI08*

Human naturo, individually and collectively, moves in response to two powsrfol
forces— one a puU, an appeal, an ideal, and the other a push, a criticism, a shame.
So in moving a social organism toward a higgler conservation of human life, idietfaer
the social mganism be a small or large town, or dty, or a county, or a Stele, vitd

FUBUO HBALTH AND liBDIOIinfi. 845

otatiBticB may be used in these two powerful ways— es a via a fronte or a via a teigo,
depending upon whether the social organism to which the statistics are applied is
healthy or unhealthy, as shown by an analysis of their death rate.

The pull of vital statistics may be applied through one healthy town, or a healthy
county, or a healthy township or community, to many towns, and counties, and town-
ships, both healthy and unhealthy. Note that we said through, not to, one healthy
town, etc.—the idea being to focus public attention on the healthy social group, not
for the sake of that group, but for the sake of those whose attention is directed to it.
The method is as follows: The State registrar of vital statistics notices from his local
statistical returns that a certain county, or a certain town, or a certain township in his
State has the lowest general death rate of any town, or county, or township in the
State; he notices again the county, town, or township in his State that has the lowest
tuberculosis death rate; the social group that has the lowest typhoid death rate; the
social group that has the lowest contagious-disease death rate; the social group that
has the lowest death rate from diarrheal diseases of infants. He calls the attention
of the local authorities of such a social group to their apparently commendable health
showing; notifies them that if they can prove to him that their returns are complete
as indicated by their records and probably later by his inspector, he will issue a laige
official certificate, to be hung in the public offices of the town or county, giving due
credit for the remarkable health conditions obtaining for the past year. Such a health
certificate will be made a part of the State health exhibit, and prominent mention of
the health showing of their town, county, or community will be made in the bulletin
and other health publications. This practical use of statistics, this holding up hekm
the public of the statistical ideal, this public commendation, serves to get the officials
interested in the complete collection of the statistics through a realisation, by the local
authorities, of the practical value of vital statistics; moreover, this vital statistical
pull always makes friends for the statistical authorities, whereas the vital statistical
push, the shove, which I confess, somewhat to my embanassment, that I have had
more extensive experience with, occasionally begets enemies. If, therefore, I shall
treat more fuUy of the vis a teigo, the pushing power of vital statistics, than the pulling
power of vital statistics, I warn you that it is not because I think more of the former
than of the latter, but for the reason that I have had more experience in the applica-
tion of vital statistics as a shove or a push or a whip to a sick social oiganism.

The pudi of vital statistics may be applied to any unhealthy town or county o
other social group. Notice here tiie use of the preposition "to" in contradistinction
to the use of the preposition ''through," in referring to the application of the pull
of vital statistics. Where we can use a social group as an ideal, where we can com-
mend a social group on its health conditions, we can do so publicly, calling the atten-
tion of a whole State or group of counties to the favorable condition, and so in using
vital statistics as a pull, we apply the pull ''through" some particularly healthy
social group to all those social groups that may be influenced by the holding up of
such an id^. But in applying the pudi, the shove, the criticism of statistics to any
unhealthy town, or county, or township, the following rule should be observed: The
unfavorable facts, the critical figures, diould be given, in so far as it is possible to
circumscribe them only to the social group concerned. These unfavorable facts (the
push) should be applied to the sick social oiganism or group in a public meeting,
composed of representative citizens of the group affected, or applied to that group
through local publication. If the local group to which the vital statistical vis a teigo
is applied can not be influenced by the local application, then it may be well to con-
sider and often to use the facts in a public way, in stimulating unresponsive local
pride with public criticism.

Most sick social groups or organisms are unconscious of their vital conditions. To
illustrate: Go into any city or town with high general and hl^ special death rates;
in short, an unhealthy town or city, select five or a dozen representative citizens of

346 PBOCEEDINGS SECOND PAN AMEBICAN BCIENTIFIC C0NQBES8.

that town or city, go to the telephone and call them, and ask them the following
questiona in the order given: "T^iat is your opinion of the health conditions of this
place? How many people died here last year?" They will all answer the first
question without a moment's hesitation— healthy; they will all hesitate in their
answer to the second question, for two reasons; first, they will not have any idea of
the number of deaths for the preceding year; and, second, they will see the relation
of the two questions and be embarrassed from their ready answer to the first question,
and (to them) their unsatis^tory answer to the second question. I did this experi-
ment in a city whose vital conditions are shown in patient Z, charts 2 and 3. I called
up five citizens of that city; they all answered the first question without the slightest
hesitation — ''healthy''; they all hesitated and demurred in their answer to the
second question, and their answers were as follows: Three out of five said the total
number of deaths was 60, evidently reaching such uniformity by estimating about
five deaths per month; one said the number of deaths in the city was 100 a year; and
the fifth, that there were about 300 deaths per year. As a matter of fact, tiiere were
506 deaths, but 72 deaths less than the sum of the guesses. The restoration of con-
sciousness, the push, the force of the truth as seen in statistical fact, restored con*
sciousnesB in that particular city and started important sanitary reform that has not
yet exhausted its momentum.

Another interesting example: I was called in consultation by a board of aldennen
and board of county commissioners to consider and advise with them regarding the
e£fect on a town's health of a small pool of water, covering, I suppose, a half acre of
ground, and situated right over the municipal boundary line. After looking over
the pond in the morning and making a general sanitary survey of the town, I walked
over to the local r^istrar's office to see how many people were dying and from' what
they were dying. At 5 o'clock I consulted with the board of aldermen, several phy-
sicians, and health officers and others. I called their attention to the fact that the
small collection of water was but one very small item for consideration in their health
situation; that malaria had caused very few deaths in their town, and it was doubtful
if the pond had very much to do with their malaria, as there were so many other
breeding places for mosquitoes; that with a little ditching and kerosene oil (I went
into details) the pond could be dismissed as a health menace; that whereas the pond
was of little consequence, othor conditions of health in their town were of grave con-
sequence; that, taking statistics from their own official, they had a death rate of 27.5
per thousand, which meant 12.5 people out of every thousand of their population
died in excess of the average death rate that obtained throughout the United States;
that for 4,000 population this meant an anniial unnecessary loss of 50 lives to their
town; that even if they had a death rate of 15, some of the 15 would be from prevent-
able diseases, and, therefore, the 50 lives lost must necessarily be regarded as excessive
preventable deaths; that their records showed a death rate from tuberculoBis of 317
per 100,000, instead of the average of 167; that their records showed a death rate from
typhoid of seven and one-half times the average; that during the last winter their
town had had its share of deaths from measles for 60 years; that this last fact meant
one of two things — either an extremely malignant epidemic, the improbable explana-
tion, or Inefficient quarantine, the probable explanation; that they were most incon-
sistent in having required a railroad that passed through the town to build an over-
head bridge, at a cost of $18,000, because during 10 years the railroad had killed, at
a crossing, as many as 10 people; that the interest on the original investment of the
railroad, and the wear and tear of the bridge, would amount to at least $1,500 per
year, which they were forcing the railroad to spend to prevent one needless death;
that while they were requiring the railroad to spend $1,500 to prevent one death,
they, the aldermen, were spending only $150 to prevent 50 deaths. Again, there
was a restoration of local simitary consciousness and definite sanitary reform started.

FUBUO HBALTH AND MEDICIN£. 347

MAKING HBALTH OFFI0BR8 BFFIOIBNT.

ThiB IB the fourth practical use that the public should be given through vital 8ta-
tistics. Certainly every health officer must stand squarely on this platform: Health
work that is worthy of the name means the prevention of disease; the prevention of
disease means the prevention of deaths or the consequences of disease; the preven-
tion of deaths means one of two things — either the retention of an average death rate
or the reduction of a high death rate. Applied vital statistics, therefore, furnish the
only sure check the people can have on their health officer, the only means by which
they can discriminate between the true and the counterfeit. If a health officer has
been employed for some time, say, from two to four years, and can show no influence
on the death rates of his jurisdiction, it is time to make li change in the health office.
On the other hand, the health officer whose administration has been coincident with
a definite decline in the death rate of his jurisdiction, should find in vital statistics
the strongest insurance for the permanency of his work. In short, vital statistics are
the means by which the first law of nature, the survival of the fittest, should be, and
will be in time, applied by the public to health officers, with the result that the
inefficient man will be eliminated, the efficient retained, and the standard among
health workers will be automatically raised, as the people are taught the practical
use of vital statistics.

The Cratrman. One could well wish that such an eloquent presen-
tation could be made not merely to those who already know, but to
the masses of our people who so often are indifferent on the subject.
Those who live in this advanced eastern community, where vital sta-
tistics are properly recorded, scarcely realize the shame which some
of us feel for tiie communities in which we live and in which no ade-
quate records are kept.

The next paper, The relation of sickness reports to health
administration, is by Dr. John W. Trask, Assistant Surgeon Oeneral,
United States Public Health Service.

THE RELATION OF SICKNESS REPORTS TO HEALTH ADMINISTRATION.

By JOHN W; TRASK,
Ai9itUmt Surgeon Oeneral, United States Public HeaUh Service,

Whenever a sincere attempt is made to rid a municipality or locality <^ cholera,
plague, or yeUow fever, the first measure that is determined upon is to have aU cases
promptly reported to the health authorities. It is realized that when these diseases
•re present the authorities responsible for their control must know when, where, and
under what conditions cases are occurring. This is necesnry that fod of infection
may be traced and removed and the formation of new fod prevented. What is true
of these three diseases is true of every other disease, with but few unimportant
exceptions.

The effective control of disease depends largely upcm the use of information
obtained through the reported cases. Adequate notification shows the conditions of
occurrence, the relative prevalence, and the varying distribution of the notifiable di»-
easos. Without this knowledge attempts at their control are to varying degrees inef-
lective and the practicable i^otection of the health of the community is impossible.

848 PBOOEEDINQS SECOND PAN AMBBIOAN SOIBKTIFIO CONGBBSB.

Not 80 very many yean ago the duties of the health officer were simple and related
entirely to the control of certain diseases associated with popular dread. However,
as knowledge of the causes of disease and their means of spread has been acquired the
responsibilities of the health department have rapidly increased. At the present time
in all advanced communities the health department is properly considered the guar-
dian of the community's health in so far as health can be conserved by the prevention
or control of disease.

The preventable or controllable diseases may properly be considered to be those
of which something is known of the cause or means of spread. In fact, they might be
limited to those of which sufficient is known of the cause or means of spread to make
their control practicable. Given this knowledge, the first and essentaid step in their
prevention or control is the seeming of information of the occurrence and location of
the factors that produce the disease and of the foci from which cases are developing.
Of the communicable diseases a knowledge of the existence and location of cases is
necessary, as each such case constitutes a focus from which the disease may spread.
Of the diseases that are preventable, but not communicable, a knowledge of the
occurrence of cases and of conditions under which they are occurring is necessary,
as it shows the existence of factors or agencies which produce these diseases. Tbis
knowledge can be obtained only when the occurrence of cases is made known to
some autiiority; in other words, when cases are reported. Any attempt at the pre-
vention of disease must neceesarOy at beet be incomplete and in large measure a
makeshift unless it is based upon a knowledge of the occurrence and prevalence of
the disease. To so great an extent is this true that it may be said in all fairness that
the health department is able to control disease only in im)portion to the completeness
and exactness of its knowledge of the occurrence of cases.

Only with full information of existing cases can the health department work effec-
tively and direct its efforts at prophylaxis against the disease itself. Without such
information it must work with uncertainty and without the lig^t and guidance given
by knowledge of existing conditions. Without this information its attempts at the
control of disease must be of a general nature, occasionally effective — ^more often not—
for it is working in the darkness, in ignorance of the location and prevalence of that
which it is attempting to control. In the absence of notification there may be present
hundreds of cases of typhoid fever, scarlet fever, or even smallpox, in a locality without
the health department being aware that the disease is even present.

Tuberculosis is a communicable infectious disease. With the exception of the
relatively small proportion of cases of the bovine type contracted through the use of
milk from diseased cows, each case is contracted directly or indirectly from some
preexisting human case. This is true regardless of the effect in lowering the resist-
ance that may be caused by conditions of bad housing, underfeeding, overworking,
and dissipation. All tubercle bacilli come originally from cases of tuberculosis.
Without tubercle bacilli there would be no tuberculosis. To control this disease in
even a small measure it is necessary that each active case be known to the health
department, so that it may ascertain that the patient is not unnecessarily exposing
others to infection. Tuberculosis is usually chronic in nature, and those infected may
remain for months or years foci from which the infection will spread to others. To
control this disease the health department needs to make sure that the sick understand
how to conduct themselves so that others may not be infected. It should also make
sure that those associated with the sick understand how to protect themselves from
the disease. There are other reasons why the health department should know of all
cases of tuberculosis, one of which is that it may prevent those so affected from engag-
ing in certain occupations in which they would be especially apt to spread the disease.

Typhoid fever is another good example of a disease of which the health department
needs to know of the occurrence of cases if the community is to be protected. Every
typhoid fever patient has potential possibilities for harm to the community through
the contamination of water, milk, or other food supply, and at times through the

FUBUO HBALTH AND MEDIOINB. 849

medium of fliee. A knowledge of all c&aes in the community is neceseary for the
protection of others, for each case is a focus from which, imder suitable or perhaps
unsuitable conditions, an outbreak may arise. Whenever there are a number of
cases of this disease in a locality, there are usually some one or more sources from
which it is being spread, and it is only when cases are being reported that the health
department can ascertain their relationship to each other or their common source of
infection, when such exists. It is only through the reporting of cases that outbreaks
due to infected milk, which are especially common in this coimtry, or that infected
water supplies, which, unfortunately also, are all too common, can be recognized
and proper remedies applied, or that typhoid carriers can be traced and controlled
to the extent that control is possible.

Still another disease which may be used as an illustration of the direct bearing
of the notification of cases upon its control is scarlet fever. The need for the notifica-
tion of cases of this disease is universally imderstood and expected. Like the other
infectious diseases, every case of scarlet fever comes from some preexisting case.
No community would expect, and no health department would attempt to control
this disease in the absence of the notification of cases that were occurring.

A long list of other diseases might be named which would be immediately accepted
as impossible to control without a knowledge of the location and whereabouts of
cases. There are also many other diseases, however, in which the need for the report-
ing of cases has not generally been appreciated, but in which the necessity is just as
great if they are to be prevented. The necessity for notification exists in all pre-
ventable diseases. The tiu^tors which cause them and the conditions contributing to
their spread may be different, the measures necessary to control them may vary, but the
knowledge of the occurrence of cases given by notification is essential in all for their
successful control. The health department can not prevent the spread of disease
of the existence of which in the community it has no knowledge.

As regards the practical problem of the control of disease as it is met in public health
administration, cases of the communicable diseases may be divided into four groups:
First, the well-marked cases; second, the mild, concealed cases; third, the mild, unrec-
ognized cases, and fourth, the well, or apparently well, carriers. In order to prevent
the spread of a communicable disease in a community, control of all four groups is
necessary. The first group — ^that is, the well marked cases — are usually reported if
the disease is one of those the notification of which is required by law. The cases
of this group have monopolized practically all of the attention of health departments
in the past. They are the cases which have usually been more or less effectively
isolated or quarantined, as the case may be. But attention to this group alone will
not prove effective in the control of a communicable disease, for the well-marked cases
of tbis group usually come less into contact with others of the community than do
the cases of the other groups. The severe cases are apt to be confined to their beds
and to come in contact only with members of the household, while the mild cases
may be about and mingling with many persons in the household and outside. The
well-marked severer cases of a disease are therefore likely to be less potent Actors in the
spread of infection than are the mild cases. It is as important, if not more so, that the
mild cases be reported to the health department as it is that the severer cases be
reported.

As regards the third group — ^the mild, unrecognized cases— these of course will not be
reported. Neither wiU the members of the fourth group — ^the carriers— be reported,
except occasionally. This is mainly because, like those of the third group, they will
not be recognized . However, the notification of the cases in the first two groups should
enable an efficiently oiganized and well equipped health department to discover
most of those in the other two groups by a careful study of the conditions under which
the reported cases have occurred. To find the imrecognized cases and carriers which
are spreading the communicable diseases— in fact, to which their spread is laigely

360 PEOCEEDINGS SECOND PAK AMEBICAN SCIBNTIFIO CONGBESS.

due under present-day conditions in the average community — ia an important duty^
of the health department. The accomplishment of this requires a knowledge of the
causes of disease and the means by which they are spread, combined with intelligence
and watchfulness, and will be possible in proportion to the completeness with which
the recognized cases are reported.

The statements made so far relate to what a health department must know of the
prevalence of disease within its jurisdiction if its administration is to be succesBfuI
in the light of present-day standards. However, the health department must have,
in addition, a knowledge of the prevalence of disease outside of its jurisdiction if
it Is to attain to the highest efficiency. It must have a knowledge of the prevalence
of the communicable diseases in the neighboring communities, and not only in the
communities which are its neighbors by contiguity and geographic proximity, but
in the communities as well which are its neighbors because of the commercial and
social association brought about by the travel and commerce made possible through
the development of rapid transportation. Chicago to-day is a closer neighbcv of
New York City than was Philadelphia a century ago, and Rio de Janeiro is closer
to Washington than were New Orleans and Richmond. A health department must
know of the prevalence of disease in the contiguous districts and in nearby cities
that it may know of the possibility of the introduction of disease from these con-
tiguous districts or near-by cities. It must also know of the prevalence of disease
in the communities and localities with which it is connected by transportation facili-
ties and to and from which individuals are constantly traveling. In localities well
supplied with transportation facilities the prevalence of the communicable diseases
in every city or community with which they are directly <xt indirectly associated
has an important bearing upon the protection of the health of the population of the
localities.

In the United States, with the responsibility for the immediate control of pre*
ventable diseases vested in the several State governments, and with the resulting
State departments of health, it is necessary, if these State departments of health
are to be something more than a figurehead, that they diall have knowledge as
nearly ciurent as possible of the prevalence of the controllable diseases throughout
their respective jurisdictions. Otherwise, the control of these diseases is impossible.
But, further, as in the case of the local health agencies, so also with State, provincial,
or other similar health departments; if they are to attain a reasonable standard of
efficiency, information must be at hand of the existence, prevalence, and geographic
distribution of communicable diseases in surrounding States, Provinces, or districta(
and the idea can be extended to the logical conclusion that efficiency in public
health administration and the control of the controllable diseases requires, under
the existing conditions of rapid transportation and the intermingling of peoples,
information regarding the world prevalence of at least the more communicable dis-
eases. Such a knowledge of the world prevalence and distribution of disease Is
certainly essential to the maintenance of international quarantine.

A discussion of sickness reports without dwelling for a moment upon the relation
of the practicing physician to the subject would be quite incomplete. The reports
of the occurrence of case** of diseases originate with the practicing physician. He
is the only one in the community who comes into contact with the sick and knows
where cases are occurring. This he does because of the very nature of his vocation.
Sickness reports must therefore depend upon the physician, and they will be com-
plete and satisfactory to the extent to which the physician cooperates in the matter.
Furthermore, inasmuch as the control of disease and the protection of the welfare
of a community depend upon the information furnished to the authorities by the
reports of cases made by the physicians, in those localities where the law makes
certain diseases notifiable, the physician who does not report the cases which he
recognizes is not only not obeying the laws of his community but must be olsMed

PUBLIC HEALTH AND MEDICINE. 351

as ignorant or unmoral, for the immediate result of his action or neglect is to place
a serious handicap upon the health department in its efforts to prevent the spread
of disease and protect the community. A physician who shows sach indifference
to the common good and general welfare as to fail to report the cases of the commun-
icable diseases in his practice when these are required to oe reported may make
great claims of following a humanitarian vocation, or may attempt to conceal his
true character beneath a cloak of medical ethics, but the only response on the part
of intelligent people will be an amused C3niicism.

A summary of the uses of morbidity reports in public health administration may
be briefly stated to be as follows:

1. In the communicable diseases morbidity reports show the occurrence of cases
which constitute foci from which the disease may spread to others, as in scarlet fever,
typhoid fever, tuberculosis, or yellow fever, and make it possible to find the pre-
viously imrecognized cases and to take proper precautions to protect the family of the
patient, his associates, or the community at laige.

2. In some diseases morbidity reports make it possible to see that the sick receive
proper treatment, as in ophthalmia neonatorum, diphtheria, and, in certain cities,
tuberculosis. The reporting of cases of ophthalmia in the newborn makes it possible
to save the sight of some infants who would otherwise not receive adequate treatment
until after much damage had been done. In diphtheria the health department can be
of service in furnishing antitoxin. Some cities furnish hospital or other relief to con-
sumptives who would otherwise be without proper treatment.

3 . In diseases that are not communicable, such as those due to occupation or environ-
'ment, reported cases show the location of conditions which are causing illness or

injury. This makes it possible to remedy the faulty conditions, so that others may not
be similarly injured.

4. In certain diseases, of which the cause or means of spread is unknown, morbidity
reports show their geographic distribution and varying prevalence and the conditions
under which cases occur. This information has great potential value in attempts to
ascertain their causes and means of spread.

5. Reports of the occurrence of disease are necessary to show the need of certain
sanitary measures or works and to control and check the efficiency of such measures or
works when put into operation. In pulmonary tuberculosb such reports show the
number of consumptives in the community and the need of sanatoria. In malaria
they show the prevalence of the disease, the need for drainage and other antimosquito
work, the efficiency of such work when in operation, and when a change in the pro-
phylactic measures is needed or additional ones are necessary. In typhoid fever
they show faults In the water supply, or in the control of the production and distribu-
tion of milk, or in the disposal of excreta in special localities.

6. Morbidity reports when recorded over a period of time and properly compiled
become a record of the past occurrence of disease. They show the relative prevalence
of disease from year to year and under varying conditions. They show the effect of the
introduction of public-health measures and of sanitary works. They give a history of
diseases not obtainable in their absence.

In conclusion it is believed that it may be conservatively stated that the knowledge
given by the notification of the preventable and controllable diseases is the only
satis^tory foundation upon which can be established the control of disease and the
work of a health department, be that health department local, provincial, or national.

The Chaibman. We shall now have the pleasxire of listening to a
paper by one of the honored delegates from another country to this
congress, Dr. Julio Etchepare of Uruguay. This paper seems to show
a very complete system of reporting contagious diseases in force in
our sister country of Uruguay.

352 PROCEEDIKOS 8E00ND PAK AMEBIOAK SOIEKTIFIO 00KGBE88.

This paper will be followed by one entitled "Vital statistics in
relation to life insiurance/' prepared by Dr. Lotus I. Dublin, statis-
tician. Metropolitan life Insurance Co.

n^FORMES REFEBENTES A LA MORBOSIDAD mFECTO-CONTAGIOSA—
DISPOSIOIONES T PROCEDIMIENTOS ADOPTADOS POR LA ADMINISU
TRAOION SANITARLk PARA SU OBTENaON.

Pop JULIO ETCHEPARE,
Montevideo, Uruguay.

La Administracidn Sanitaria terrestre y maritiina de la Beptiblica eetd a caigo del
Consejo Nacional de Higiene, que ee la autoridad superior en materia de higiene
pdblica, en las condiciones que determina la ley de su creaci6n.

Entre los importantes y diversos cometidos que dicha ley ha confiado a esa Corpora-
ddn, figura el de dictar todos los r^lamentos, ordenanzas y disposiciones que con-
sidere necesarias para evitar la invasidn y propagaci6n de cualquier enfermedad
infecto-contagioBa.

El Consejo ha dictado una ordenanza estableciendo que la dedaroidAn de los casos
de enfermedades inf ecto-contagioeas, ee ohUgaJtona^ en todo el territoiio de la Repd-
blica, para el midico que viaite con car^ter profesional, a enfermos atacados de las
lef eridas alecdones.

La ndmina de las enfermedades inf ecto-contagiosas, cuya declaracidn es obligatoria»
es la siguiente:

Fiebre amarilla, c61era (Asidtico o Lidiano), peste bub6nica, beri-beri, tifus exante-
mitico, viruela, varioloide, varicela, escarlatina, sarampidn, difteria, fiebre tiloideay
tos convulsa, eriaipela, fiebres puerperales, tuberculosis pulmonar, y laringea, lepra^
meningitis cerebro-espinal epiddmica, p(irpura hemorrdgica, adenitis de causa des-
conocida, tracoma.

Las declaraciones se extienden en hoja impresa talonaria cuyo modelo, aprobado
por el Consejo Nacional, se envla adjunta a la presente.

Los medicos tienen que hacer la declaracidn expresada, dentro de las 24 horas de
la comprobacidn de la enfermedad, excepto para los cases de c61era, peste, fiebre
amarilla, difteria y viruela, o ^'sospechosos'' de tales enfermedades, que debedoi ser
declarados inmediatamente.

Sin perjuicio de lasuperintendencia que corresponde al Consejo Nacional de Higiene,
el servicio de profilaxis de enfermedades infecto-contagiosas en el Departamento de
la capital, est& a cargo de la Direcci6n de Salubridad, Repartici6n Mimicipal.

Las declaraciones de los medicos pueden entr^garse en varias oficinas encaigadas de
iecibirlas,dependientes de la municipalidad (Lispeccidn de salubridad, Casa de
desinfecci6n, Comisiones auxiliares de la junta econ6mico-administrativa).

En los Departamentos de campafia se remiten las declaraciones respectivas, con
arreglo al siguiente procedimiento:

(a) Los medicos radicados en las capitales rurales, tienen que remitir las declara-
ciones a la Ofidna del Medico del Servicio Pdblico Departamental correepondiente,
aun cuando los enfermos estuvieren domiciliados en pueblos, villas, o distritos rurales.

En estoe dltimos cases, el jefe de familia o de casa, debe entregar sin p^rdida de
tiempo a la Comisi6n de higiene local, un duplicado de la declaracidn que seri llenado
por el medico con la advertencia **dupli4xida.** En case de no existir Comisi6n de
higiene, se entregard a la Comisi6n auxiliar (municipal), de la localidad y si no eetuvie-
ra esta (iltima constitufda, al Comisario de policia. Esta declaracidn "duplicada,''
debe ser trasmitida oportunamente, al Mddico del Servicio P<iblico.

PUBLIO HEALTH AKD MBDIOINB« 358

(5) Si el mMico declarante tuviera su domicilio en un ''pueblo/' villa o distaito
rural, debe entregar la dedaraa&a 4nioa, a la Comlfii6n de Higiene local. Si 4eta no
existiera, a la Comifiddn auziliar (municipal) de la localidad y ai esta tiltuna no estu-
viera constituida, al Comisario de policla de la seccidn respectiva, quienee la trasmi-
tiiin, edn demora, por el digano correspondiente, al Medico del Servicio Pdblico del
Departamento.

Las GomiaioneB de higiene que ban ddo constituidaa en loe pueblos de importancia
de los Departamentos, como auxUiares y correeponsales de loe Medicos del Servicio
PdbUco, tienen entre bus atribuciones, la de informar o comunicar aemanalmenU, al
Medico del Servicio Ptiblico del Departamento, las novedadee sanitarias que ocurran
en BUS jurisdicciones y de inmediatOf el primer oato de loi enfertnedades epidhnicas,

Loe Medicos del SOTvicio Ptiblico, son funcionarios que dependen de las jefaturaa
poUticas y de policia y reciben tambi^, 6rdenes e instruccionee del Consejo Nacional
de Higiene.

Los deberes y atribuciones de esoe medicos, son loe que tenfan anteriormente, por
una parte, los inspectores departamentalee de higiene y por otra, los medicos de
policfa y de guardia de ctoel. Son empleadoe amovibles, nombrados directamente
por el Poder Ejecutivo y deben residir en las capitales departamentalee de campafia,
coireepondiendo uno a cada Departamento.

Los MMicos del Servicio PtibUco estdn obligados a trasmitir $emanalmerite, al
Consejo Nacional de Higiene los dates sobre enfermedades infecto-contagioeas, ain
perjuicio de comimicar, de inmedUitOy por telegrama, la aparici6n del primer caso
infecto-contagioso.

Deben remitir tambi^, al mismo Consejo, mensudlmentef dentro de los cinco prime-
ros df as siguientee al mee venddo, una inf ormaddn sanitaria de sus respectivos Departa-
mentos, utUizando al efecto, formukaios impreeoe, aprobados por dicho Consejo.

Debmi asimismo informar anudlmente, id Consejo y en cases espedales, cuando
^ete lo solicite, sobre el estado sanitario del Departamento (capital, pueblo, centre
de poblaci6n y secciones ruialee).

Los MMicos del Servicio Pdblico estdn obligados a desempefiar las comisionee
sanitarias que dentro de cualquier punto del Departamento les encargue el Consejo
Nacional de Higiene y deben in/ormar a ^ste, dentro del mis breve tannine, acerca
del resultado de dicha comisi6n.

En el Departamento de la Capital, segdn lo hemes dicho, el servicio de profilaxis
de las enfermedades infecto-contagioeas, est& encomendado a la Direcci6n de Salu*
bridad, que es tma repartici6n mimicipal. Pues bien, diariamenU, por intermedio
de una de las oficinas de su dependencia (Casa de Deeinfecci6n ''Doctor Honor6"),
se remite al Consejo Nacional de Higiene, ima infonnacl6n detallada de todas las
declaradones de enf ^medades Inf ecto-contagiosas, ocurridas en Montevideo, Departa-
mento de la Capital.

El inspector de Sanidad terrestre, funcionario medico, de la dependencia del
Consejo Nacional de Higiene, tiene tambito, entre sus diversos cometidos, trasladarse
a cualquier punto de la Repdblica, siempre que el consejo lo conaidere oportimo,
informando seguidamente acerca de la misi6n que ha deeempefiado.

Entre otras de las comisiones que se le conffan, se cuentan las que se relacionan
con la aparici6n y desarroUo de determinadas enfermedades traeminbleiy estableciendo
su naturaleza, procedencia, medios adoptados para combatirlas y dem^ dates ilustra*
tivos, dlgnos de mencidn.

Los capitanes de los buques surtos en el puerto, estdn obligados a denunciar a la
Inspecci6n de Sanidad Marftima (ofidna dependiente del Consejo Nacional de
Higiene), la aparicidn de cualquier caso de enfermedad que ocurra a bordo.

La susodicha inspecci6n, debe dar conocimiento a la Direcddn de Salubridad
(municipaUdad), de los enfermos infecto-contagiosos que hayan desembarcado o
deben desembarcar de los buques surtos en el puerto.

854 PBOCEEDINOS SECOND PAN AMEBIOAN BOIENTIFIO 00NQBE8S.

Trat&ndoee de buques que proceden de puertos extranjeros, los informee relativos
a las enfermedadee ocurridas a bordo, son obtenidos por los M^cos de Sanidad
(Inspecci6n de Sanidad Marf tima), llen^dose al efectx), las formalidades consignadas
en las disposiciones pertlnentes.

Los mMicoe aludidos dan cuenta del resultado de su visita al Inspector de Sanidad
Marftima y ^te por escilto, al Presidente del Consejo NacionaJ de Higiene.

La sanidad militar comunica al Consejo NacionaJ de Higiene, los casos de enferme-
dadee infecto-contagiosas que ocurren en la armada y en los campamentos.

Los medicos de los establecimientoe dependientes de la asistenda pdblica nacional,
hacen la declaraci6n de enfermedadee infecto-contagiosas, a la direcci6n respectiva,
y ^ta debe transmitirla, sin demora, a la oficina habilitada para recibirla, segtin se
trate del Departamento de la Capital o de los de campafia.

Los m^cos de los establecimientoe de ensefianza oficial, de las dLrceles y de los
cuarteles, hacen la declaraci6n antedicha, en la oficina correspondiente habilitada
para recibirla.

Los datos relacionados con la morbotidad y mortalidad in/eeUheorUagiosa en la Re-
pMlioUy recogidos y ordenados por la Oficina de Estadistica del Consejo Nacional de
Higiene, se publican en una Memoria anual^ presentada a la corporaci6n por el presi-
dente de la misma.

Ademis, en el Boletfn del Consejo Nacional de Higiene se publica mentualmerUe,
algunos cuadros estadisticos relacionados tambi^n con la morbosidad y mortalidad
infecto-contagiosa, en la Repdblica.

Modelo del formulario para la declaraci6n de enfermedadee infecto-contagiosas,
adoptado por el Consejo Nacional de Higiene.

Nombre del enfenno . .

I>omicilio

Enfermedad

Fecha de la dennncia..

Tal6n Correspondiente a la hoja del formulario.

Nombre del mMioo. . ..

DECLABAa6N DE KMRBMKDAD IlffKCTO-OOMTAOIOSAS.

Enfermedad ......•.••

Nombre del enfermo. . . - -- -

Edad

... Nadonalidad Kfttado

Profesltfn . ...

Rma

Domlclllo

Dat09 up^daUt para la virutHa,

EsTaeonadof Hatenidoyiroelaanterioniientef

Antes 0 despote de vaounadof •

Cu&ntas cicatrices de vacuna prosenta? »•

De coanto tiempo data la tUtlma vaconaoldnf

FUbre puerperal,
QaA partera la ha aslstldoT

Daloe generaUe,
Orlgen del contagio (probable o positivo)

Fieonenta algnna etonela, taller o rednto de aglomeraoidn de personasT..

OhaervaeUmee generalee.

Fecha..
Firma.

1 Inspeoclto de Salabrldad-Casa de Deslnteoeion o Comislones AuzlliarBs de la Junta E. Admlniftn-
tlva (Montevideo).
Para los Departamentot de OampaAa ytense los p4rrafos anterlores.

PUBUO HEALTH AND MBDIOINB. 866

VITAL STATISTICS IN BELATION TO LIFE INSURANCE.

By LOUIS I. DUBLIN,
Statistician, Metropolitan Life Insurance Co,, New York, N, Y.

Life insurance companiee provide protection against the economic losses resulting
from death. Consequently they must have, as guides for making their premium
rates, the facts as to the mortality of their possible membership . The data of mortality
must be analyzed for each year of age and for such distinctions as color, sex, and the
general economic and social condition of the insured. This is the basis of the life
insurance companies' interest in vital statistics, and, just as they have been dependent
on this science for their safety and growth, so they have been, in turn, a very potent
influence in its progress. In England, where modem life insurance first took definite
form, and where it has attained the widest extension, vital statistics has likewise
found its highest development. In other countries of Europe we find, with the growth
of insurance systems, a simultaneous advancement of vital statistics to serve the ends
of insurance and of other social activities.

The history of vital statistics and of life insurance in America likewise points to a
most intimate and profitable interrelation. One need only recall contributions so
basically important as the reports of Elizur Wright, 1859-1867, who, as first commis-
sioner of insurance in Massachusetts, gave direction to the evolution of insurance
mortality experience; the American Experience Table of Mortality, first published in
its present form by Sheppard Romans, of the Mutual Life Insurance Co., in 1868; the
report of Levi Meech, 1881, covering the mortality experience of 30 American life
companies for geographic divisions of the country and for certain of the more important
causes of death; and the report of E. J. Marsh, of the Mutual Life Insurance Co., 1896,
which continued further the analysis, by causes, of the mortality of persons insured
under the '*old line" plan. For many years the reports of the Actuarial Society of
America have been replete with valuable material for the statistidal investigator.
Mention should be made of the specialized mortality investigation of 1904 by this
society, and more recently of the report made in conjunction with the Association of
Life Insurance Medical Directors under the title, ** Medico-actuarial mortality investi-
gation.'' These volumes have thrown a flood of light on the mortality of large groups
of our population as influenced by sex, by occupation, by physique, by conjugal condi-
tion, and by habits of life; they constitute most important contributions to the vital
statistics of this country.

It is obviously impossible to treat fully the historical side of our subject^ or even to
mention the names of the many men now active in the field of insurance, who, during
the last two decades, have played important parts in the development of statistical
science in this coimtry. This paper will rather discuss m broad, general terms the
more important activities of the life companies in the statistical field, and the manner
in which their work supplements that of the Federal, State, and municipal bureaus.
Incidentally, I shall point out how their field of activity may be still further extended
to their own profit and to that of the community.

The life insurance companies possess excellent vital statistics. These statistics
limit themselves for the most part to a consideration of death; although, as we shall see
later, some of the companies have valuable data on the occurrence of sickness and
accidents. At the beginning of this year 250 life companies operating m the United
States had upon their books about 40,000,000 policies. These policies, which con-
stitute the so-called *'in force," are classified by age, sex, and color of the insured.
These facts correspond to the population data of the States, but they have the advan-
tage that every policy is accounted for. The figures are kept currently correct, and
there can be no serious errors resulting from either annual estimates or inaccurate
enumeration. Against these '*in force" figures are placed annually the figures of
68436— 17— VOL ix 24

356 PBOCBEDIKOS »B001<n> PAK AMEBIOAK 80IENTIFI0 00NGBB88.

claim payments on deaths. In 1914 over $222,000,000 were paid by the life insurance
companies as death benefit on more than 450,000 claims. The claims are tabulated,
like the ym force/' by age, sex, and color of the deceased. From these tabulations
mortality rates are computed for the various classes of the insured population. These
rates constitute the chief sources from which premium tables are finally prepared.

Perhaps the most interesting insurance vital statistics are those in the hands of the
so-called industrial companies. These companies include under their protection a
large proportion of the total population; the three largest operating in America together
cover about 20,000,000 men, women, and children. They not only prepare such figures
as have been referred to above, but in addition study their experience intensively
for such facts as cause of death and occupation of the deceased. Their tabulations
are in every essential respect similar to those found in the mortality reports issued
annually by the Division of Vital Statistics of the Census Bureau. A reproduction of
a typical run sheet from the statistical ofiice of one of the companies is submitted here-
with (Table I), showing what facts with reference to deaths are available, i. e., the
number of deaths specified for each cause by sex, by color, and by age period. Tables
giving the rates per 100,000 for the principal causes of death by corresponding sub*
divisions of sex, color, and age are likewise available for calendar years.

The figures obtained in this way by the industrial companies are a valuable measure
of the health standards and conditions of the great mass of the American working-
classes. Furthermore, the companies prepare their data for the States and the more
important cities in which they operate. Their figures, accordingly, cover the regis-
tration as well as the non-registration States. It is of interest to record the fact that the
Metropolitan Ldfe Insurance Co. is now engaged in putting at the disposal of the health
authorities of the States and the large cities figures giving the mortality experience of
the policyholders in the respective localities. There is thus made available for large
areas of the country the only existing measure of the death rate, since for a number of
States there are neither Federal nor reliable State mortality figures. For the States
where rates are published these insurance figures will serve as valuable checks on the
accuracy and completeness of the death registration. The utility of such comparisons
will grow as the cooperation of the insiurance organizations with the Federal and State
statistical departments becomes more intimate.

In addition to these general mortality tabulations many contributions to specialized
problems of vital statistics are being made by the statistical ofilces of the life insurance
organizations. Hunter, of the New York Life, in addition to his valuable contribu-
tions to the medico-actuarial reports, has more recently devoted his attention to the
effects of alcohol on mortality. Hoffman, of the Prudential, has long studied the
incidence of tuberculosis in the dusty trades, the prevalence of industrial accidents,
and, indeed, the effects of occupational stress in its various forms. His work has been
invaluable as a basis for enlightened labor legislation. He is now making important
contributions to the statistics of cancer. Frankel and the writer, of the Metropolitan,
have issued a number of studies on such subjects as infant mortality, industrial and
school hygiene, and the sequels of the acute infections. The statistical method has
been followed in the handling of these problems, but the emphasis has usually been
on the social ends to be attained.

The companies concern themselves particularly with the accuracy and complete-
ness of the returns which they receive, and which form the basis of their tabulations.
Thus the Metropolitan Life makes special inquiry into the detailed facta of the c8L\iBe
of death, whenever the statement of cause given is vague, or where there is likelihood
that other conditions than those named have played a part in causing death. Ov^
10,000 letters are sent by this organization to physicians annually, asking them to
give more complete or more precise statements of cause of death. The work has been
carried on for a period of four years, and has resulted in educating physicians in the
requirements of good technical procedure for the completion of death certificates. This

PUBUO HBALTH AND MBDIOINB« 357

can have only a good effect on Federal, State, and municipal vital statiBtics. Physi-
cians who learn through such letters that statierticianB are interested, for example, in
recording the acute infectious diseases, rather than the terminal pneumonias, show
the result of their better understanding in the certificates which they subsequently
send to governmental offices. It will be of interest to know that such inquiries have
resulted in a marked increase of satisfactory assignments, and in a corresponding
decrease of vague and indefinite ones. Thus the registration of '* syphilis'' was
increased in the four years 1911, 1912, 1913, and 1914 from 1,322 to 2,350 deaths through
this inquiry method; the death rate from this cause was correspondingly increased by
78 per cent. On the other hand, ''paralysis without specified cause" was reduced
from 3,340 assignments before, to 2,090 after inquiry, a reduction of 37 per cent in the
rate. "Fractures, cause not specified,'' were reduced from 1,484 assignments to 545,
a reduction of 63 per cent. In each one of these causes, and in many others, the death
rate was radically changed.^ Much more confidence may be given to cause of death
statistics prepared on this basis, and, conversely, we must put much less weight on
returns which have not been subjected to such scrutiny.

i*'Th« improvMiMot of statirtlot tbroofl^ wqipteinentary inqnirta to pli78iaUiif,"bj Louii L Dablin
and Sdwln W. Kopf ; Qovtwlj PubUeatioos of the Amirioui 8t«tlrtlcal Aasodatkui, June, 1916.

358 PB00BEDIKO8 SBOOND PAN AMBBIOAK SOIEKTIFIO OOKaBESS.

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The life compamee are also active in pepolarizing the use of the graphic method.
Bogiimuig with the Columbian Exposition at Chicago, in 1893, and contmning down
to the two Panama expositions which have just closed in Caliloniia, insurance com-
panies have participated in congresses and expositions, both national and interna-
tional, where they have set forth by means of charts, pictorial representations, and
models, the facts of their own mortality experience, as well as the corresponding
returns obtained by governmental offices. In recent years the companies doing a
casualty business lutve exhibited graphically the effects of preventive measures on
the reduction of accidents. As the number of offices participating in this form of
statistical exposition has increased, the technical standards of graphic prosantation
have been correspondingly developed. The participatian of the insurance companies
will undoubtedly stimulate the movement for the standardization of graphic methods.

Much may be expected for the standardization and improvement of insurance vital
statistics from a movement which is now being perfected by the laigest American
industrial companies. These organizations propose to prepare annually a joint mor-
tality experience showing the number of deaths incurred, distributjdd by cause, by
color, by sex, and by age p^ods. The companies have agreed to follow international
standard practice with reference to the assignment of causes of death and to other
details of tabulation. The results will be farreaching, for these companies embrace
in their membership nearly 20,000,000 men, women, and children, both white and
black, engaged in all occupations and distributed over every State of the Union.
On the combined basb the statistics will be more valuable than those of any indL
vidual company. There will thus be created a nation-wide registration area for
insured members of the industrial classes, which, if it does not include every person
in the communities, covers many more States than the Federal registration area, sSL
embraces a sufficiently large number of persons in each State to give a fairly good
picture of the sanitary conditions that prevail there. It is not possible at this time
even to estimate the benefits that will accrue from this arrangement, not only for
insurance statistics but also for official vital statistics in America.

An increasingly large number of companies are devoting themselves to the writing
of sickness and accident insurance. The statistics which they compile are of great
value in showing the prevalence of the various diseases, their duration, and the
economic losses which they involve. These data cover a large proportion of the
occupied groups, and will be highly serviceable to legislators and others who are
interested in advancing the welfare of the working classes. The Metropolitan life
Insurance Co. has inaugurated an extensive visiting nurse service for the sick among
its policyholders. Cloee to 200,000 cases are treated each year. The records for these
cases are especially complete, and analyses are made of them each year for the diseases
and conditions treated, the color, sex, and age of the patients, and such additional
facts as the duration of the treatment and the condition of the patients <m discharge.
Part of this morbidity experience has already been published.^ Table II, taken from
this publication, is submitted as an example of the tabulations which are prepared.

Receatly the same organization, under the direction of Dr. Lee K. Frankel, its
sixth vice president, has completed sickness surveys in the cities of Rochester, N. Y.,
and Trenton, N. J. A considerable proportion of the population was reached in
both instances, and a body of substantial facts was obtained.* The tabulations give
the number of cases and the rates of sickness found in these cities, by sex and by
age, and indicate also the extent of the disability which the sickness involved. No
figures as extensive as these have been prepared in this country since the fickness
survey given by Billings in connection with the 1880 census. It is hoped that the
same plan will be extended in due time to other communities.

I See "Standards in visiting nune work," by Lee K. Frankel; Metropolitan Life Insoranoe Co., New
York, 1915.

t "Community sickness survey of Rochester, N. Y., September, 1015," by Lee K. Frankel and Louis
I. Dublin; Public Health RepOTts, Washingtoh, D. C, Feb. 35, 191A. Since this was writtoi the com-
pany has mada other sickness surveys In Boston ("A Sickness Survey of Boston, Man.," by Lee K.
Frankel and Louis I. Dublin; Metropolitan Life Insurance Co., New York, 1915), North Carolina ("A
Bieknsas Survey of North Carolina," by Lee K. Frankal and Louis L Dublin; PubUo Health Bapcfts,
Washington, D. C, Oct. 18, 1916), Wast VirglnlA and Feiu^yhrania, Kanm Oty, Naw Ortoam, aCo.

PUBUO HEALTH AXTD MEDIODrB.

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The life insuranoe companies, collectively, as represented by the Assodatioii of
Life Insurance Ftesidents, have for years helped to improve the status of vital statis-
tics in this country. They have united their efforts with those of the Federal Gtovem-
ment and of other interested bodies, urging upon the States the adoption of the model
vital statiiticB law prepared by the Federal Bureau of the Census. The assodation
has distributed a large number of pamphlets on this subject, has appealed directly
to many legislative bodies, and has held pubUc sessions on the value of vital statistics,
giving the movement wide publicity. One company has during the last few years
made it a practice to ask its large field force, including the agents and medical exam-
iners, to further local vital statistics legLslation. When a model vital statistics bill
has been under consideration in any one State, hundreds of letters firom these insur-
ance men have reached the legislators, urging them to support such approved legis-
lation. This method has been followed with success in South Carolina, North Caro-
lina, Georgia, and Florida during the last two years. In other States, such as Kansas,
Midiigan, and Massachusetts, the same procedure was carried out either for the en-
actment of a model vital statistics biU or for the improvement of an existing law.
The same company has distributed to physicians, legislat(»B, members of women's
dubs, and other groups whose aid mig^t be useful, thousands of pamplets on the value
of good vital statistics. The more recent growth of the registration area has certainly
been furthered by the active cooperation of the life insurance companies.

The registration of births is another brandi of vital statistics which has been ma-
terially aided by the life insurance companies. For this purpose one organizatioii
prepared for the use of its large agency f(»*ce 200,000 mailing cards, addressed to the
health officers or registrars of the States. It was required that the agents distribute
the cards in the homes of policyholders where there had been a recent birth, or where
a birth was expected. The mother was directed to fill in the name and date of birth
of the child and her own name and address, and then to mail the card. As an induce-
ment to the mother to send the card, it called on the health officer to send literature
on child hygiene. The plan proved of assistance to health departments, giving them
at least a partial dieck on delinquent physicians and midwives, and helping them
to register births which otherwise would have escaped official registration. This
fact was brought out clearly in a recent communication received from the registrar
of a New England State which has always prided itself on good registration. During
a single month 45 birth reports were received on these TttM'Hng cards. It was found
on examination that 16 had not been previously reported by the physician or midwife
in charge. The letter also stated that the system led to more prompt returns than
could have been obtained through the usual practice.'

The life insurance companies seek further opportunities to serve American vital
statistics. They wish to cooperate more and more with Federal, State, and munidpal
bureaus. They have, I believe, proved their interest and effectiveness in this field.
They are, moreover, in the best sense of the word, social institutions intensely inter-
ested in the life and health of the people. The growth of their life conservation work
is creating a healthy demand for vital statistics in every important locality. The force
of this demand will inevitably increase the supply of good statistics, and will result
in the extension of the registration area and in the improvement of the character of
the returns. They desire, therefore, to help in every possible way to extend the regis-
tration area. The companies, in addition, have well-equipped statistical offices
capable of carr3ring on investigations of interest to the State. They are ready toput
these at the disposal of official bodies to assist in studies of social value. Great and
lasting good has already come out of the interest of life insurance companies in vital
statistics, and there is every reason to believe that the future wiU bring an even
greater measure of benefits.

1 See "The present statu of birth registration in Amerioan cities," by Louis I. Dablin; Quarterly
PabUoations of the American Statistical AssocUtlon, March 1917, pp. 543^548.

PUBUO HB^LTH AND MBDIOINB. 866

The Chairman. The last paper of the morning session, ''Statistics
of infant mortality," is by Mr. Lewis Meriam, now of the Bureau of
Mimicipal Research, New York City, but whose recent connection
with the Children's Bureau lends special interest to his paper on this
topic.

INFANT MOBTALFTT STATISTICS.

By LEWIS MERIAM,
Bureau of Municipal Retearcht New York, N. Y.

In the coune of the three years that I served as assistant chief of the Federal Chil-
dren's Bureau, I gave most of the small amount of time that was free from administra-
tive duties to problems concerning the statistics of infant mortality. Most of these
problems involved the minutse of the special investigations of infant mortality which
the bureau is conducting, but a few of them had, from the point of view of the statis-
tician, a broader aspect and were of more general application. The more important of
these larger problems I have selected for special discussion in this paper.

At a meeting of the American Statistical Association held in New York a year or
two ago, Mr. Henry Bruere urged upon the statisticians the importance of evolving
what he was pleased to call * * the one statistic. ' ' In infant mortality studies ' * the one
statistic " IB unquestionably the infant mortality rate, the number of infant deaths per
1,000 infants bom alive. The indiscriminate use of this one statistic, based upon
the defective number of births registered has been termed, not inappropriately, the
great American infant mortality fallacy. In the United States our birth records are
incomplete. We have examples of almost all the different degrees of incompleteness.
Thanks to a great cooperative effort, engineered largely by that master registrar,
Dr. Cressy L. Wilbur, to whom the people of this country owe far more than they are
ever likely to realize or repay, we are in possession of reasonably accurate facts regard-
ing the number of deaths of infants occurring among about two-thirds of our population.
The less important matter of birth registration has not yet been pressed so effectively,
and the number of births as registered is in most localities a gross understatement.
We are, however, frequently confronted with the work of the rough and ready statis-
tician, who, for propaganda work, divides the practically complete niunber of infant
deaths by the very incomplete number of births secured from the registration records,
thereby deriving an infant mortality rate that is shocking.

To illustrate the variations in tiie apparent infant mortality rate produced by
variations in the degree of completeness in birth registration, we may take the case
of a hypothetical community having each year a true infant mortality rate of 100 per
1,000 births. In its early days, when it was in the Illinois class, it registered perhaps
every other birth, 500 out of the 1,000, and it had an apparent infant mortality rate
of 200. The model registration law was introduced, and the number registered
increased to 750 out of the 1,000, and the apparent infant mortality rate fell to 133.3
per 1,000. The office practice of the registers was perfected and 850 out of 1 ,000 were
registered, giving an apparent rate of about 117. Finally a few physicians were prose-
cuted for their failure to register births, and 980 out of the 1,000 were registered. The
apparent rate became approximately the true rate, 100.2 instead of 100. To make our
illustration complete, we must assume that in the early days a milk station had been
established and that at the close of the latest year it circulated a nicely printed little
brochure in which the marked decrease in the infant mortality rate from 200 to 100
was presented most attractively in a beautifully colored diagram and was attributed
entirely to the striking success of the policy of milk distribution and other infant
welfare work.

866 PB00EEDING8 SECOND PAN AMEBICAN SOIEHTIFIO 00HGBE8S.

Such an illustration is, perhaps, unfair because it allows nothing for the good effect
which the infant welfare work, if intelligently directed, would undoubtedly have
produced. The point is that even some of the very best departments of child hygiene
and some of the best infant welfare associations have perhaps, unwittingly, greatly
overstated the effects produced by their work. They are possibly misleading the
general public into a belief that they have already demonstrated that along their path
lies the final solution of the infant mortality problem. When one considers the almost
universal decline in the birth rate and the almost universal fall in the infant mortality
rate, one becomes anxious to know to what extent a relationship exists between the
two, and one fears lest the possible extent of such a relationship be lost dght of in ui
endeavor to attribute all the decline in infant mortality to milk stations, clinics, and
similar agencies. When one reads Dr. Whitridge Williams's valuable contribution to
the general knowledge of the subject, in which he brings out the magnitude of the
relationship between syphilis and stillbirths and deaths in the early months of life,
one does not want it explained away as being peculiar to Baltimore with its relatively
large proportion of negroes, until similar studies have been made in hospitals which
receive the least promising whites in some of our large northern cities. The Federal
Children's Bureau ought ultimately to give us, for the United States, information re-
garding the relationship between infant mortality and certain economic and social con-
ditions, such things as housing, father's earnings, and mother's work. It is also gath-
ering data regarding the reproductive history of the mothers, so that ultimately, it is
to be hoped, we shall have some accurate information regarding the size of family and
infant mortsJity so tabulated as to permit of differentiating the well-to-do from the less
fortunate. The public must not get the idea that the solution of the infant mortality
problem is simple. It is extremely complex. A high infant mortality rate is an
alarming symptom of a dangerous disease. The disease, not the symptom, must be
treated, if fundamental progress is to be made.

The fallacious use of an apparent infant mortality, that has perhaps resulted in
some popular misunderstandings of the nature of the i^oblem, is also frequently
encoimtered in tables purporting to show the relative standing of cities in respect
to infant m<»rtality, or the changes in this standing that have taken place in a given
period . Any such table at the present day is, to say the least, of distinctly questionable
value.

When the Children's Bureau chose infant mortality as the first subject for its special
investigations, it seemed to me imperative that we should bring t<^ther the existing
statistical data on the subject so that we might have them as a guide in selecting the
communities which we were to study. For the reasons that I have already indicated,
this material could not be analyzed through the use of the registered births as a basis
for computing infant mortality rates. Two substitutes, or perhaps better two uses
of the same substitute naturally suggested themselves; (a) the number of children
under 1 as reported by the census of 1910, and (&) this number increased by an allow-
ance for the children who were bom in the census year but died before the census day.
I used both. For arriving at the second, in view of the well known fact that the
number of children under 1 is an understatement of the actual number, I attempted
no nice calculation, but simply added to the number of infants imder 1 as reported
by the census, the total deaths of infants under 1 that occurred in the census year.
It was of course an extremely crude {Nrocedure, but I was encouraged in this course
by discovering that for the States in the provisional birth registration area, as estab-
lished by Census Bureau in 1909, the total number of births as thus estimated was
very close to the total number registered. For individual States in this area I found,
however, considerable differences between the two. Such evidence as I had lead
me to two conclusions: First, that my estimates were on the whole imderstatemente
of the true number of births; second, that for the purpose of comparing one State with
another or one city with another, I had as good a measure as is at present available,
crude and unsatisfactory as it was.

PUBLIC HEALTH AND MEDICINE. 367

For the piirposee in view an annual average number of infant deaths in the five-
year x)eriod of which 1910 was the middle year seemed the best figure, because it
represented average conditions, whereas if 1910 alone had been used it would have
represented extreme conditions, for 1910 was a year of excessive infant mortality.
When data for all five years were not available 1910 was taken, with one year on
either side if the figures were to be had. By proceeding in this way figures for about
twenty States were secured through the use of census mortality statistics. No State
figures for deaths were used. Similarly figures for cities and counties in this death
registration area were prepared.

Far be it from me to claim for such figures any nice degree of precision. At best
they were crude, but nothing better was available. Used with due allowances fxa
their crudity they were at least suggestive.

When the 20 States were ranked according to this crude infant mortality rate, all
the States with high infant mortality rates were found to lie east of the Alleghenies
Those with markedly low infant mortality rates were west of the MisrisRippi. No
typical Southern State was included in the tabulation because of the absence of data.
Maryland was the only State included that had a considerable proportion of n^^ro
population.

The fact that, roughly speaking, infant mortality declines as one moves westward,
naturally suggested a relationship between infant mortality and urban concentration.
The ranking of the 20 States according to infant mortality was therefore contrasted
with their ranking according to the proportion of the population living in commimities
of 2,500 or over, that is the proportion urban according to the definition employed
in the Federal census of population. It was not quite a perfect agreement. In the
case of four States the differences were conspicuous. New Hampshire and Maryland
had higher infant mortality rates than the degree of urbanization in their population
would seem to warrant, whereas the reverse was true in the case of California and
Washington. If the negroes were eliminated from the Maryland figures, that State
came more nearly into place. The peculiarities of climate in Washington and Cali-
fornia seemed to explain the exceptions in the case of these States. The case of New
Hampshire has not yet been explained. For the remaining 16 States the similarity
between the two rankings was extraordinary and I believe clearly demonstrated
a close relationship between the two phenomena.

The next question which arose was whether any direct relationship could be traced
between the infant mortality rate and the size of the community. In this tabulation
the definition of rural adopted for mortality statistics had to be used, namely, that
any place having lees than 10,000 inhabitants is rural. Several classes of cities were
distinguished, and the data were arranged by States. One general rule appeared.
In every State, with the single not very marked exception of Utah, the infant mw-
tality rate was lower in the rural communities than it was in any class of cities. The
differences seemed too great to be attributed in any considerable degree to differences
in the efficiency in death registration. As between cities of different sizes no definite
rule appeared. Baltimore was conspicuous among the large cities for a higher rate,
as were the industrial cities of New England.

That the infant mortality rate in the rural districts is lower than that in cities,
or in other words that the baby living in the coimtry districts has a better chance of
survivorship than the baby living in the cities is of course no surprise to statisticians
who have long been familiar with the fact that in a given State the rural death rates
are generally lower than the urban. The fact, nevertheless, needs special emphasis
at this time. Into the popular propaganda literature on the subject of infant mortality
are creeping all sorts of statements tending to indicate that the condition of the rural
infant is desperate — far worse than that of the city baby. Froin such actual data
as I have been able to find, I should be inclined to say that the infants in the rural
districts of northern and western United States aie faring very well; perhaps not

868 PBOOEEDINGS SECOND PAN AMEBIOAN SOIENTIFIO 00NQBE88*

as well 98 those in New Zealand, but if we had better birth records we might even
be able to find some sections of the country which fully equal New Zealand's fine
record. Those who would urge extensive infant welfare work in rural districts must
take for their argument not the excessive infant mortality rate in rural districts but
rather the fact that in this country three babies out of five live in communities of less
than 2,500 people or in distinctly rural districts.

The question should perhaps be raised as to whether the law of diminishing return
is not operative in infant-welfare work; whether it is not entirely probable that in a
community with a high infant-mortality rate a relatively large number of infants
can be saved with comparatively little effc^, whereas in a community with a low
infant-mortality rate similar effort will have comparatively sli^t effect. The ques-
tion is one of some practical importance, as it should be considered in determining
whether in the national campaign for the prevention of infant mortality the major
effort should be concentrated on the communities with markedly high infant-mortal-
ity rates or whether it should be q;>read broadly over the whole country. In one
case the campaign can be highly specialized to meet local conditions; in the other it
must be kept fairly general in the effc^ to make it universally applicable, and in the
latter case it will run the danger of much publicity and little actual accompliahment.

Special attention should be called to one point regarding the industrial dties east
of the AUeghenies, toward which a national campaign would be first directed if espe-
cially sore points were selected for attack. One of the factors which undoubtedly
in a large measure explains their high rates operates to increase the difficulty of bring-
ing about improvement from within— namely, the &K:t that, as contrasted with com-
mercial dties, the proportion of their population falling in the lowest income clannos
is probably very large and the proportion equipped for leadership in improving local
conditions is comparatively small. It is frequently a case of absentee ownership.
That a very large proportion of the population falls in the lowest income group would
probably explain in part why the infant-mortality rate is so high, whereas the small
population equipped for leadership would perhaps explain why more progress has
not been made toward the reduction of the rates in such communities.

The erroneous idea that the infant-mortality rates are higher in rural oommunities
than in dties can, I think, be traced to a very interesting report that was submitted
to Gov. Sulzer, of New York, in 1913 by a commission appointed to investigate public-
health administratbn in that State. The report showed that in New York the crude
general death rate had been falling more rapidly in the communities having 8,000
or more persons than in the smaller towns and rural districts, and that of late years
the urban rate had been sli^tly lower than the rural. In the report was a warning
from Dr. Walter F. Wilcox that the comparison was perhaps somewhat misleading,
as it might be due to differences between the two classes of communities in respect
to the age distribution of their population and to improvements in death registration
in the rural communities. Standardization of the rates for age and sex would, in all
probability, have largely, if not entirely, removed the difference in favor of the
urban communities in the latest years. If the law of diminiflhing return operates
in health work, the commimities with the higher death rates will, as a rule, show a
more n^d improvement than those with the lower rates. Be that as it may, these
broad general condusions of the commission, based on facts regarding crude death
rates mainly derived from the use of estimated populations, were apparentiy taken
by some persons as synonymous with frightful conditions among intots in rural
districts not only in New York but in the country as a whole. More exact data were
disregarded, and now frequentiy one encounters bread statements tending to show,
if followed to a logical condusion, that if a country mother wants to improve her
chances of raising her baby she should move to a hesdthful dty shun.

These statements are, of course, based on facts relating to the North and West.
Little information is available conceming conditions in the South Atlantic and

FUBLIO HBALTH k£lD MEDIOINB. 869

South Central States, and we know practically nothing regarding intot mortality
among the great body of Negroes living under what may be called the more usual
environment of the race in this country, a southern agricultural community.

R^;arding the Negroes dwelling in the larger cities within the death-registration
States and in certain cities outside of these States, some infonnation can be secured
from the census reports on mortality statistics. The infant-mortality rates for Negroes,
figured in the way I have described, are markedly hi^, in some cases about twice as
hig^ as the rates for the whites. To some extent this difference may be exaggerated,
because the number of children under 1 as reported by the census may be lees com-
plete for the Negroes than for the whites, which of course would operate to make
the apparent rate higher for the Negroes than for the whites; but such an explanation
can account for but a small part of the great difference, and it may be safely stated
as a general rule that the infant mortality among dty Negroes is excessive.

To contrast the dty Negro with the country Negro would indeed be interesting if
we only had the data relating to the South. To a limited extent for the North one
can make a comparison by contrasting the figures for the large dties with those for
the balance of the State lying outside of those dties, though of course the Negroes
in the balance of the State may be mainly dty Negroes, but anyway they are at least
smaller-dty Negroes. Such a comparison shows that the Negroes are at a great disad-
vantage in the very laige dties. As compared with the whites, the Negroes are at a
disadvantage in both classes of communities, but the differences between the two
races are mudi greater in the larger dties than in the smaller dties and country dia-
tricts. The condusion one would draw is that the conditions surrounding the life
of the Negroes in large dties deserve special investigation. Those interested in the
condition of the Negroes may indeed look forward with special interest to the resiflt
of the Children's Bureau's investigation now being conducted in Baltimore, througji
which facts regarding the social and economic conditions surrounding a large body of
Negro babies (it is to be hoped, at least a thousand) will be secured. Supplemented
by data regarding health and physical condition which have already been published,
and by additional data which can doubtless be secured, the report should constitute
a valuable addition to existing knowledge. I may say in general that I suggested
and recommended the selection of Baltimore because, judged by existing statistical
data, it seemed to offer in many respects a unique field for investigations sudi as those
the Children's Biireau is conducting, and I believe the final report should be the most
valuable the bureau has published in this field.

After one has attempted to knock the props from imder the present use of the
apparent infant mortality rate based on registered births as a measure of the move-
ment in in&nt mortality ov^ a series of past years, one may reasonably be expected
to be asked for some substitute. One can not, of course, make bricks without straw,
but I found of some interest rates based on the number of infants under 1 esti-
mated according to the arithmetical method, using the infants under 1 as reported
at the census of 1900 and 1910 as the fundamental data. This method was applied
only to those States which were in the death registration area in 1900. The resulting
rates fluctuated from year to year, and ciuioualy the two census years, 1900 and 1910,
were both years of high in^t mortality. The general tendency of the rate was,
however, downward, and each high year seemed a little lower than its predecessor.
The English experience has been similar. If the rates be divided into two classes,
rates from diarrhea and enteritis and rates for other causes, it becomes apparent that
most of the fluctuations from year to year are due to variations in the number of
deaths from diarrhea and enteritis. The fluctuations were sufllciently great to make
one feel the necessity of calling attention once again to the grave danger that lies in
attempting to measure the success of any intot welfare campaign by a comparison
of the in&mt mortality rates over a small number of years. Success is probably to be

870 PBOOEEDINOB SECOND PAK AMBBICAK SOIBNTIFIO 00NGBE8&

proved by showing a low infant mortality rate for years having abnormally hot sommers
and other conditions fatvorable to the development of dianiieal diseases.

Throughout my work with infant mortality statistics I have been impressed with
their potential value as an instrument of fair precision for locating areas of social and
economic pressure. They should be of peculiar value for this purpose, for under an
adequate S3rBtem of biith registration properly administered the infant mortality
rate would be derived each year from an accurate base, whereas crude death rates,
except in census years, have to be based on estimated population, and the more
significant standardized death rates and special death rates when based on estimated
population are of doubtful value, especially in cities which are largely afifected by
immigration.

In conclusion, therefore, I would like to suggest that this congress adopt suitable
resolutions advocating the establishment of adequate systems of birth registration
throughout the Western Hemisphere. It is a matter of deep regret that a statistical
study of infant mortality in this country at the present time must be incomplete and
must be based largely on entirely unsatisfactory data.

The Chaibman. We have a limited amount of time which can be
devoted to a general discussion of these papers, and shall take them
up in the order in which they were presented. Is there any dis-
cussion of the paper by Dr. Willcox on birth and death rates ? The
subject is one of vast importance, and there may be those here who
would like to take part in the discussion of it. Dr. Willcox's eru-
* dHion on the subject is such that most of us can not add to his
facts or conclusions.

Is there any discussion on the paper of Dr. Rankin with regard to
the influence of vital statistics upon the conservation of human life f
I feel sure no one would think of criticizing his line of argument, but
some perhaps would Uke to emphasize it. Dr. Wilbur, we shall be
pleased to have you say something upon this subject.

Dr. WiLBUB. Mr. President, I shall be very glad, if not trespassing
upon the time of others, to say a few words with reference to the papers
of Dr. Rankin and of Dr. TVask. Before beginning I should like to
express my appreciation of the very great value of Mr. Meriam's
paper and to ask that this association adopt his suggestion, i. e.,
to pass some resolution that may go before the congress for
adoption, emphasizing the necessity of registration of births as a
basis for the study of infant mortality. I have in my pocket some
resolutions adopted by the American Association for the Study and
Prevention of Infant Mortality, in Philadelphia, on November 12,
which I have had printed on the back of a letter to physicians in
regard to the enforcement of the New York law. These resolutions,
which urge each State and mimicipality to pass laws requiring the
filing of birth certificates within five days after the date of birth and
to enforce the penalty for failure to comply therewith, are as follows:

Whereas the maj(»ity of the deaths of infants occur during the first few weeks of
life; and

Whereas efforts to reduce infant ni(»rtality depend largely for success upon bringing
the child und^ proper supervision and care as early as possible; and

PX7BLI0 HBALTH AND MBDIQIKB.

871

Whereas a prompt reporting of births is therefore essential as a basis for succeerful
efforts to reduce infant mortality: Therefore

Be it resolvedf That the American Association for the Study and Prevention of
Infant Mortality urge each State and municipality to pass laws providing for the
reporting of births within five days, at the most, from their occurrence, and furth^
providing adequate penalty for ftdliure to observe this law.

Mr. Meriam's paper may be considered somewhat academic. It
did not propose a practical method of obtaining sickness statistics.
I think I can tell you how in a few years we can get sickness statis-
tics in the United States — simply by the enforcement of law. Now,
the present condition of the United States may be represented in this
way [writing on blackboard]:

Time card^ New York State Department of Health.

stations.

Tialn 1, vital statistics.i

Tiain3,
morbidify
statistics.

NoDenforoement of law (rotten records, inaccurate statistics, de-
fective public health service).*

Enforcement of law (complete and correct records, accurate sta-
tistics, efficient public health service).

Leave Jan. 1,1016...
Arrive Mar. 81, 1016.

Apr. 1,1010
Jmie 30,1010

1 Vital statistics carries births and deaths. Morbidity statistics (of course equally "viUl sUtistlcs")
handled by Division of (Communicable Diseases.
t Empire State Express.

The paper of Dr. Rankin was intensely practical, and I know
of no one in this coimtry, and certainly not in the South, who
is doing better work for the extension of the registration of vital
statistics and the enforcement of law, or who makes better use of
the facts already obtained from the law of his State (North Carolina).
I think if we had a dozen Dr. Rankins scattered through the country
we should have better vital statistics very soon.

Dr. Trask's paper was an excellent one. For practical public
health purposes sickness statistics are more valuable than mortality
statistics. They are of more practical use to health oflSlcers in
enabling them to know where diseases prevail before deaths occur.
Mortality statistics are necessarily later. Besides, ratios of fatality
between sickness and deaths are essential to the knowledge of disease.

What we want is enforcement of law, and that means accurate,
correct and complete l^al records. It means accurate vital statisticB,
and it means efficient public-health service.

The way to get from this point to this point [indicating] may be
compared to the establishment of railroad service between two places.
We need a raiht)ad first — a roadbed, a track and proper bridges;
in other words, we need law — a sound basis of law. Then we must
have OTU* trains; and each train may represent a special law, e. g.,
a vital statistics law.

68436— 17— VOL IX-

-25

872 PBOCEEDINOB SEOOND PAN AMEBIOAK SOIBKTIFIO 00HGBB88.

We will consider this the train-dispatcher's board. We will have
train No. 1, vital statistics, and that should start at a certain time,
say January 1, I should say if you start that out on a proper track,
and if it is a well-constructed train, it can reach its destination within
three months, say by March 31. Then we can send out another
train, say train No. 3 G>ocause they are going in the same direction
and so both have odd nmnbers), morbidity statistics. You can
start that out on April 1, and in three months that train should reach
its destination under perfect enforcement of law. And that we are
doing in the State of New York imder the direction of Chief Train
Dispatcher, Dr. Hermann M. Biggs. We are enforchig absolutely
our vital-statistics law. As soon as I report that that is completely
in force and that no birth or death can occur in the State, outside
the city of New York, and fail to be roistered without prompt
punishment, then Dr. Biggs will start his morbidity train and it
will go through on schedule time.

I have in my pocket a letter I received this morning from my

stenographer. Mr. Lappin brought it down to me. Here is an

example (reading):

Dbobmbbr 28, 1915.

Dbab Dr. WniBUB: Am pleased to advise that yesterday mormng we mailed to
52 midwlves letters 6 and 7, there being, respectively, to licensed midwives 36 and to
unlicensed midwives 16. The entry of September undertakers in the register will
be completed this afternoon, and we will b^;in to-morrow morning the preparation
of letters to be sent to undertakers.

You may be interested to know that out of 17 letters received from ph3rBician8,
in reply to the "N. G." letters sent out on December 23, 13 appear to be quite surprised
that you did not take it for granted from their previous letter of explanation that they
would plead guilty and have now requested that the minimum fine in their cases
be recommended to the district attorney.

Have also received letters from* district attorneys advising of the following con-
victions and payment of $5 fines: Columbia County, 1 case; Erie County, 3 convicted,

2 paid fine, and 1 (Dr. T ) sentence suspended; Onondaga County, 8 (out of 9)

paid fine, and 1 (Dr. M ), stated by district attorney, we can assume will do

likewise.

Am inclosing letter and check for $5 in the case of Dr. 8 , of B . A«

this is in reply to an "N. G." letter, did not know whether 1 should hold check until
3rour return cnt return to the physician, as the minimum fine of $5 was not recommended

.n the ''N. G." cases.

With respect to the case of Dr. T I may say that this is

the first suspended sentence we have had; and we shall, of course,
investigate and find out if there is any reason for nullifying the law
in this case.

I sent out for September 300 letters to physicians, each by regis-
tered mai], and every physician repUed. Formerly about 20 per
cent refused to acknowledge our letters. Out of the 300, 100 im-
mediately replied in substantially these words: ''I will plead guilty

PUBLIC HEALTH AIH) MEDICINE. 373

and pay my fine." Wherever they did not say they would plead
guilty I marked them "N. G." — ^not guilty; the others were *'P.G." —
plead guilty.

Only two physicians out of the 300 said they would "fight."
One wanted us to bring suit at once. I am not going to do that.
We will go back over his record and we will check up his past
behavior before we bring suit.

With respect to the others, we are taking up only the cases ad-
mitting the violation allied in our letter. Quite a number, perhaps
10 or 15, said that our statement was in error because they had, in
fact, filed their certificates in time. Our statement was based on a
certified copy of the original return. It may be that the physicians
were right. In some cases the local r^istrars wrote in and said that
the physicians were correct and that they (the local registrars) had
failed to enter the date of filing as the certificates came in, but had
waited until the end of the month and perhaps had forgotten the
exact dates. In such a case we notify the physician that his ex-
planation is satisfactory and enter suit at once against the local
r^istrar for violation of law and disr^ard of the instructions of the
department. We ask only for the minimum fine for the first offense,
S5; for the second it is $10 to SIOO. If they plead guilty we ask for
the minimum fine; but if they elect to go in and fight, we fight. The
law is working perfectly. It is the easiest way; I do not know why
it has not been tried before. It is the model law recommended by
the Bureau of the Census, and it works perfectly.

I shall be able to study the statistics next year because I shall not
have to waste so much time enforcing the law. The department is
under obligation to enforce the law; so is the district attorney; and
if the district attorney does not do it, he is subject to the penalty of
the law also. The attorney general and the governor will aid if
necessary. The law is law in New York, and will be enforced.

That is the way in which every State north of the Ohio River and
east of the Mississippi, and some States of the West and South, can
have accurate vital statistics within three months if they will enforce
their laws. The problem is more difficult in the South. They can
not do it in three months, but if they will follow the method of Dr.
Rankin they can do it in time.

The Chaibican. I regret to say that the authorities of the hotel
must have the room in order that they may prepare for the luncheon
at 12.30.

Mr. Lappin. May I have five minutes-f

The Chaibman. I am afraid we can not spare you even that much
time.

874 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

COOPERATION BY THE BUREAU OF THE CENSUS WITH STATE AUTHORI-
TIES IN SECURING THE ENACTMENT OF ADEQUATE LAWS FOR THE
REGISTRATION OF BIRTHS AND DEATHS.

By RICHARD C. LAPPIN.

The Bureau of the Census of the Department of Commerce is the only Federal
bureau which collects, compiles, and publishes statistics of births, deaths, marriages,
and divorces.

The slow progress made prior to 1900 in the enactment of effective laws for the regis-
tration of births and deaths was due principally to the fact that there was then no
Federal office in continuous existence to cooperate actively with the States in secur-
ing such legislation.

One of the first steps taken by the Bureau of the Census, after its permanent organ-
ization in 1902, was the adoption, in cooperation with the American Public Health
Association, of a set of principles for effective registration and the drafting of a model
bill for the consideration of State legislatures. The position of the Bureau of the Cen-
sus and the approval of Congress in the movement for better vital statistics are shown
by the following joint resolution:

JOINT RESOLUTION REQUESTING STATE AUTHORITIES TO COOPERATE WITH CENSUS
OFFICE IN SBCURINO A UNIFORM SYSTEM OF BIRTH AND DEATH REGISTRATION.

Whereas the registration of births and deaths at the time of their occurrence fur-
nishes official record information of much value to individuals; and

Whereas the registration of deaths, with information upon certain points, is essential
to the progress of medical and sanitarv science in preventing and restricting disease
and in devising and appl}ring remedial agencies; and

Whereas all of the principal countries of the civilized world recognize the necessity
for such registration and enforce the same by general laws; and

Whereas registration in the United States is now confined to a few States as a whole,
and the larger cities, under local laws and ordinances which differ widely in their
requirements J and

Whereas it is most important that registration should be conducted under laws that
will insure a practical imiformity in the character and amount of information availa-
ble from the records; and

Whereas the American Public Health Association and the United States Bureau
of the Census are now cooperating in an effort to extend the benefits of registration
and to promote its efficiency by indicating the essential requirements of legislative
enactments designed to secure the proper registration of all deaths and births and the
collection of accurate vital statistics, to be presented to the attention of the legislative
authorities in nonregistration States, with the suggestion that such legislation be
adopted: Now, therefore,

Resolved by the Senate and HouBe of Representativei of the United States of Anurica in
Congress assembled^ That the Senate and House of Representatives of the United
States hereby express approval of this movement and request the favorable consid-
eration and action of the State authorities, to the end thftt the United States may
attain a complete and uniform system of registration.

Approved February 11, 1903.

This resolution has been of great service in bringing to the attention of State execu-
tives and legislators the importance of birth and death registration, which, under our
governmental system, must be carried on through the operation of State laws. Up
to the time the Bureau of the Census was made permanent no concerted effort had
been made to secure satisfactory legislation, each State having acted independently,
with the result that many ineffective laws had been placed on the statute books.

About 12 years ago a special committee representing the American Public Health
Association and the Bureau of the Census undertook to discourage the ill-advised
efforts that were being made to enact inadequate laws; and it also endeavored to
hasten the extension of adequate r^stration by defining the principles that should
govern the formulation of an effective law. Drafts of bills were prepared in accord-
ance with these principles— first for death registration only, then for registration of

PUBLIC HEALTH ANJ> MEDICINE. 375

both births and deaths. These drafts of bills were published in pamphlet form and
widely distributed by the Bureau of the Census, and formed the basis of the model
bill reported by the council on health and public instruction of the American Medical
Association.

The principle of the law is very clear and may be expressed in the following manner:
Effective registration requires the prompt filing of certificates of births and deaths
(with the absolutely necessary check of the compulsory burial permit in the case of
the latter) with the local registrar (not a county registrar) of a small and explicitly
defined primary registration district and the prompt monthly forwarding of the origi-
nal certificates directly by the local registrar (not to or through any county ofiScial)
to the State registrar, who thus can exert direct control and supervision over the
local registrars and can secure uniform and effective enforcement of the law in all parts
of the State by means of the penalties provided therein, when necessary.

A draft of the model bill is published in a pamphlet entitled ''Why Should Births
and Deaths be Registered/* which has been extensively distributed by Dr. Fred-
erick R. Green, secretary of the council.

The model bill also im)vide8 for standard birth and death certificates. Until the
standard death certificate was adopted no two States in the coimtry had uniform
blanks. At the present time the standard certificate of birth is used by States con-
taining approximately 85 per cent, and the standard certificate of death by States
containing 93 per cent, of the population of the United States.

The outlook for better vital statistics is more promising at the present time than
ever before. In the last ten years the Bureau of the Census has cooperated in securing
the enactment of the model bill into law in Pennsylvania, Ohio, Missouri, Kentucky,
Virginia, North Carolina, Arkansas, Mississippi, Tennessee, Georgia, South Carolina,
Florida, and Illinois. The States of Pennsylvania, Ohio, Missouri, Kentucky, and
Virginia, and the North Carolina municipalities of 1,000 or over in 1910, are now in-
cluded in the registration area for deaths; and it is hoped that the enforcement of the
law in the other States named will soon have reached such a d^;ree of effectiveness as
to entitle them to admission also.

Before adequate registration of births and deaths can be secured amendments or
new laws will be necessary in the States of Alabama, Arizona, Nevada, New Mexico,
Oklahoma, South Dakota, Texas, and West Virginia. In addition, amendments to
the present laws for the registration of births are needed in the States of Colorado,
Indiana, and Louisiana.

The Director of the Census is in correspondence with the State health oflScials of
Oklahoma, Texas, and West Virginia, and it is hoped that the legislatures of these
States, at their next regular sessions in January, 1917, will enact the model law for the
registration of births and deaths.

I am pleased to be able to say that the director has established a temporary regis-
tration area for births, consisting of the States of Maine, New Hampshire, Vermont,
Massachusetts, Rhode Island, Connecticut, New York, Pennsylvania, Michigan, and
Minnesota, and the District of Coliunbia, and that registration therein has been imder
way during the present calendar year. While this area represents barely 10 per cent
of the land area of the United States, it has a population of approximately 31,150,000,
or about 31 per cent of the total for the country. The permanent birth r^istration
area will be organized for 1916, and will include only such States as enforce their laws.

In conclusion, I take this opportunity to say, there is no doubt, in my opinion, that
to Dr. Cressy L.Wilbur, more than to any other one person, credit is due for the progress
made in vital-statistics legislation during the past 15 years. Dr. Wilbur, now director
of the division of vital statistics of the New York State Department of Health, was for
many years chief statistician for vital statistics in the Bureau of the Census and is
now associated with the bureau as expert special agent.

376 PROOEEDIKGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

The Chairman. You are thinking of weeding out some of them ?

Mr. Lappin. We hope not.

Dr. GuiLPOY. Mr. Chairman, I suggest with respect to the train
simile employed by Dr. Wilbur that we have a transcontinental
express. For the first section, the section on vital statistics and
sickness, the chief dispatcher should be Dr. Blue, with Dr. Trask as
conductor and probably Dr. Kerr as engineer. In regard to the
section on mortality statistics, I suggest that we have for the chief
train dispatcher Director Rogers, with Dr. Rankin as engineer and
Mr. Lappin probably as conductor. My third suggestion is that
in New York, where we have the Empire State express, we might
have as chief dispatcher Dr. Biggs, with Dr. Wilbur as conductor and
probably some other member of the staflf as engineer. I might say
that the Empire State express starts in New York, and a good many
good things come out of it. We claim Dr. Biggs for his services.

Dr. Wilbur. We appreciate the great gain the State has received
through Dr. Biggs, and New York City is trying to catch up. Tlieir
limit is ten days for filing birth certificates instead of five; and they
are prosecuting cases on the second offense and not on every offense.

I>. Fulton. I move that we continue the discussion at the after-
noon session.

Adjournment at 12.30 o'clock.

JOINT SESSION OF SUBSECTION D OF SECTION Vm AND
THE AMERICAN CIVIC ASSOOATION.'

WiLLABD Hotel,
Thursday morning, December SO, 1916.

Chairmen, Siirg. Gen. William C. Bbaistbd and J. Horace

MoFabland.

The session was called to order at 10.30 o'clock by Chairman Mc-
Farland.

The chairman of Section VIII, Gen. Gorgas, expressed the pleasure
of the congress in being able to hold this joint session with the Ameri-
can Civic Association. The presiding chairman, Gen. Braisted,
announced the general subject of the papers of the joint session,
^'Town and City Planning," and introduced the writers whose papers
follow in the order of presentation.

TOWN AND Cmr PLANNING.

By F. L. OLMSTED.

The subject asugned to me is the very broad one of ''Town and dty planning,"
limited only by the fact that the paper is to be presented before the public-health
section of this congress.

The subject involves so many matters which, if treated from a technical standpoint,
would be more in place in other sections of the congress as to suggest a broad and non-
technical treatment. And althou^ I intend to emphasize certain aspects of special
interest to sanitarians rather than to skim over the whole field covered by my title, I
feel bound to begin by indicating, in the most condensed form, the scope and func*
tions of city planning as a whole.

By dty planning is meant the exercise of a deliberate and far-sighted control on
behaif of the people of a city over the development of their physical environment
considered as a whole. It differs from the intelligent planning of individual features
of that physical environm^t— fluch as a sewer, a street railway, a park, a public
building, a private building — by the emphasis which it throws upcm the dose inter-
ralation of all the elements that go to make up the physical dty and upon the fact
that predictable changes in any of those elements, whether the changes are to be
deliberate and intentional or merely the natural consequence of growth, are apt to
have an important bearing upon the wisdom of proposed changes in other elements
of the dty, even though the latter may at first sight seem to be practically independent.

For example, it is generaUy recognized as important, before entering upon a large
investment in the construction of sewers, to estimate the probable growth of the pop-
ulation for some years to come and to design the mains and other parts of the sewerage
system of a size and in a location economically adapted for meeting the needs thus

> TlMTt WM no >t«iiogrAp]ilo rtport of thli SMtloB.

877

878 PB00EEDIN6S SECOND PAN AMEBIGAN SGIENTIFIG OONGBESS.

f orecaat. It is not so generally recognized that when roads are being laid out for the
convenience of landowners in a hilly suburban district beyond the present reach ci
a city sewer system, the manner in which those roads are fitted to the hills and valleys
may greatly influence the cost and the efficiency of the sewer system which must later
be designed and built to meet the needs of that district. The peculiarities of the
street plan may easily make the cost of sewers so high as to postpone their construction
for many years after they are urgently needed for the public health.

Those who are most immediately and actively concerned in the laying out of streets
in suburban districts are apt to be the landowners who have tracts which they wish
to subdivide in lots for sale, frequently isolated or outlying tracts subdivided long in
advance of conditions which would justify the cost of building a sewer system for the
drainage area in which they are situated. These people do not worry about the
remote question of sewers or what it will cost somebody to build them bye and bye.

And the engineers in charge of the design and construction of the city's sewers are
too seldom in a position to see that the street plan in such outlying districts is reasonably
adjusted to the future drainage requirements. In the first place they are apt to be so
busy with immediately necessary sewer construction and design that it seems to
them like a waste of time to be working up plans for something so remote as the sewers
for a distant suburban subdivision, which may be wholly speculative and which is
unlikely for a great many years to have enough inhabitants to justify the construction
of sewers. In the second place, even if they think it desirable to make preliminary
sewerage plans for outlying districts very far in advance of probable construction,
they are apt to be deter^d by the lack of funds for the requisite surveys. In the third
place, even if they have an opinion as to how the streets ought to be laid out in order
to provide for an economical and efficient future sewer system, they are unable, in
most cases, to exert any effective control over the location oi the streets.

We may thus have a district in which the streets are planned with great skill to
serve precisely the purpose for which they were designed, namely, facilitating the
sale of vacant suburban lots at a good profit; and we may later on have sewers planned
for construction in those streets with great skill and economy considering the fact
that the streets are where they happen to be; and yet we may have a combined result
that is distinctly inefficient and costly.

If dty planning means anything distinctive, if it means anything more than the
mere summation of all the planning that is done for all the physical features which
go to make up a city, it is distinguished by insistence on two points.

The first point is that in every part of all this planning — whether done upon private
initiative or upon public initiative, whether imdertaken by a city plan commissioner
by people who approach their several tasks from very specialized points of view,
such as those of an illuminating engineer, a street-railway engineer, a hospital super-
intendent, or a builder of tenement houses— due consideration shaU always be given
to the point of view which takes in the city as one great organic unit and which judges
all plans by the test of whether they make toward the best attainable results for the
entire community.

Oity planning insists that in the design of every feature of the physical city due
consideration should always be given to this point of view. This is not to say that it
should be the only consideration or even the dominant consideration in every case.
It is not to say that the planning of everything that goes to make up the dty ought
to be done commimistically and by public authorities, for I believe that the best
results are to be obtained not by supplanting but by encouraging and stimulating
individual initiative in the planning and execution of improvements. I mean only
that dty planning endeavors to prevent the point of view of the dty as a unit from
being wholly ignored in the planning of anything that affects the dty and endeavors
to secure for this point of view a reasonable and proper degree of influence in controlling
each dedflion.

PUBLIC HEALTH AND MEDICINE. 379

The second point follows as a corollary from the first. It is that dty planning,
regarding everything from the point of view of the dty as a whole, wliich has a life
of indefinite duration, is bound to emphasize the need for a longer 1 >ok ahead than
is usually felt to be worth while in particularistic planning, whether the latter is done
in the interest of an individual or for the sake of a single limited aspect of community
interests.

We are still groping as to the means by which these dty planning ideals can best
be made effective. But it is clear that they fall into two groups. One deals in per-
suasion and education, seeking to implant in all who control important elements of
the physical dty a voluntary regard for dty planning ideals, which means a desire
to cooperate with others who are planning from different points of view. The other
group deals in compulsion, fixing by legal means certain general limitations and
requirements, Hke those of building laws, to which all must make their fragmentary
plannings conform, and establishing an administrative agency with the specific duty
of initiating general plans and of correlating partial plans made by others, and with
the discretionary power of bringing pressure to bear for the modification of these
partial plans where necessary to weld them into a reasonably harmonious and effective
whole.

To sum up, dty planning stands for our growing appreciation of a dty's oiganic
unity and of the profound and inexorable manner in which the future of this great
organic unit is controlled by the actions and omissions of to-day. It stands for the
consdousness that anything we dedde to do or leave undone in the complex organism
of a dty may have consequences wholly foreign to the motives immediately con-
trolling the dedflion but seriously affecting the wel&tfe of the future dty, and it stands
for the growing sense of social responsibility for estimating thee^ remoter consequences
and giving them due wdght in reaching every decision.

The field of city planning is thus seen to be far too broad and complex for any one
man or any one profession to cover it. To speak of a specialist or expert in dty plan-
ning is, in any exact sense, a contradiction of terms. It is like speaking of a doctor as
a specialist in the practice of all branches of medicine and surgery. One for whom
such a claim is made is set down by intelligent men as a quack.

After speaking thus I need not say that I do not pose hetoie you as one who is expert
in this whole great field of dty planning. I am here discussing this broad subject
because, while working in my own particular angle of municipal affairs, where I do
claim to be expert, I have become deeply impressed with the practical importance of
bringing about a better correlation of my own woric and every other branch of work
affecting the physical dty, and of the value of the city planning ideal for bringing
about this practical correlation.

City planning is not only all-indusive as to technical subject matter but as a task
and i»x>blem it is unending. As long as a city is alive and growing, unforeseen c<mdi-
tions will arise to upset the calculations of any plan, and except in purely academic
discussions planning and replanning are constantly intermingled.

We live in a world of existing cities, which inherit the errors of the past along with
its enormous accomplishments. City planning must, therefore, concern itself largely
with replacements, alterations, and enlaigements required in order to adapt what has
already been done to conditions which have newly arisen or which are clearly foreseen
as about to arise . But its most characteristic and most important sphere is in avoiding
future mistakes. It is identical in spirit with preventive medicine. I shall dwell,
therefore, chiefiy upon the application of its prindples at the most effective place and
time, namely, in the outskirts of a city while the conditions are still highly flexible.

As a matter of convenience in the analysis of dty planning problems, it is customary
to speak of all the lands comprising a dty as divided broadly into three classes: First,
those devoted primarily to the means of circulation, such as streets, railways, water-
ways, and everj'thing supplementary thereto; second, all public and quasi-public

380 PBOOEEDINGS SEOOND PAN AMBBIOAN 80IENTIFI0 00NGBE8&

lands and buildings not primarily devoted to the means of circulation; and third, all
other lands and buildings, over which a unified public control can be exerted only to
a limited extent since they are in private ownership. A large part of the city planning
which most intimately affects the health of the people is concerned with this limited
and indirect control over what is done and left undone on private land; for of all the
physical environment of an urban population their dwellings and their working places
affect them more constantly and intimately than anything else. The deliberate
pfablic control of building and other operations on private land, as exerted through
building codes, tenement-house laws, and other regulations and administrative activ-
ities, constitute a most essential chapter of city planning which is ordinarily ccmsidered
quite separately from the first main division of the subject above mentioned, vis,
the lands devoted primarily to the means of circulation.

All of the well-recognized means of circulation— the network of railway tracks, the
ramifying sewer system, the ubiquitous water pipes and electric wires, the very road-
ways of the street— are so obviously and so absolutely dependent for their value upon
the fact that they are linked together into large continuous systems, that in considering
them one does not have to argue for the applicability to them of the unified city-
planning point of view. Whether well planned or ill planned, they are single con-
tinuous systems interrelated in all their parts; from the smallest alley and court to the
largest thoroughfare; from the smallest house drain to the largest trunk sewer or filtra-
tion plant. The only question is how best to apply the unified city planning ideal
to the actual detailed planning of the several parts of these various great systems of
circulation. But when we turn to the consideration of public control over all sorts of
operations conducted on private property, whether that control is exerdsed as a health
measure or otherwise, it is less obvious that we are dealing with the several parts of one
great mechanism which can not properly function if its parts are not ^ffoperly related.

For our present purpose I propose to consider the means of circulation, those com-
plex webs which bind together all parts of a city, somewhat more broadly than is
usual, following their ramifications without stopping at the somewhat arbitrary line
which separatee privately owned land from that directly under the control ol the pob-
lie. And I propose to reach those ramifications quickly by giving only the most
cursory consideration to the main trunk lines of the various systems of circulation.

A very important function of preventive city planning is to keep the proper routes
for these main trunk lines free from obstructive occupation by buildings or otherwise.
The legal and admiaistrative methods of keeping the chosen routes free from such
obstructive occupation pending their ultimate development, and the devices for
financing the cost involved in this process and distributing its burden so as to make
it bearable, o£fer an important and interesting field of study; ^ and the technical
problems involved in wisely determining the location of routes to be reserved tot the
trunk lines of every type of circulation are of the most absOTbing and complicated
sort. But the principle is perfectly dear.

For example: In any region over which an urban development is likely to extend
we can safely predict that there will be need of some form of public conveyanoee
comparable with our present-day street railways and motor busses, running over
regular routes upon certain streets, to and from which streets the people who live
and work on other streets will walk. The routes used by these public conveyanoss
will be important thoroughfares. The same reasons which cause their selectkn
for this purpose, such as directness of line between important points, good grades,
etc., will concentrate other kinds of vehicular traffic upon them. We know by experi^
ence that vehicular trunk lines of this type ought to have roadways wide enough for
two lines of moving vehides in each direction and for vehicles standing at the cmby
and that the streets should have a width between buildings of not less than about
84 feet at 25 meters. It appears to be a foct also that in most dties there is a i

I See "GeriTlog oat the olty plan," by FlaTel Shnrtleff.

PXTBLIO HEALTH AND MEDIOINB. 881

diflinclination on the part of the people to walk, r^ularly» much more than a quarter
of a mile to reach such a transportation route, and that the community when fully
developed can and will pay for transportation routes sufficiently frequent to avoid
mach longer walking. Therefore we can lay it down as a genend rule that in the
development of a city plan steps shoiild be taken to keep open routes suitable for
such vehiciilar trunk lines not less than about 25 meters wide, not much more than
about half a mile or 800 meters distant from each other, and upon good grades and
direct lines. This does not mean to embark upon the construction of numerous
street railways or wide roadways for wheeled traffic before their need and the economic
justification for them have arrived, but merely to insure that the spaces which will
be required for them in the future shall not be blocked by permanent obstructions.

I can only suggest the problems of selecting and reserving adequate locations for
t3rpes of circulation that have more exacting requirements as to gradient or otherwise,
such as rapid-transit routes and general railway routes free from grade croesings of
street traffic, together with the terminals of the same; such as channels for the dischaige
of storm water and main trunk sewers; such as channels and terminals for water-
borne commerce, etc. In every case the principle is equally dear, that in so far as
intelligent foresight can feirly predict the reasonable requirements of the future as to
such trunk lines of circulation, steps ought to be taken to prevent needless obstructions
from arising athwart the lines.

It is hardly necessary to point out that in contributing to the adequacy and efficiency
of all the trunk lines of circulation, dty planning contributes directly or indirectly
to the public health. But it is where lo<»l branches of the various means of circulation
come in direct contact with the dwelling places and working places that their plan-
ning most intimately affects the health of the people.

The branch pipes and wires which C9nvey sewage, water, gas, electridty for light
and power, telephone service, etc., to and from the abutting property, and which
play so large a part in making dty life worth living, require such a limited space
and are so flexible that locations adequate for these purposes are normally secured
without special effort as an inddent of laying out streets wide enough for the supposed
requirements of convenient travel on the sur&k^e to and from the abutting properties.
But the width of local streets and their proximity to each other, as determined by
these considerations, are frequently insuffident to give proper access to all the abutting
property for two other commodities which are positively essential to the continued
maintenance of public health. I refer to fresh air and daylight.

Almost invariably in the development of towns the first great improvement dictated
by regard for the public health is a common water supply, because the continued use
of individual wells on the several lots is made insanitary by the manner in which all
the surrounding lots are used. The next great improvement dictated by regard tar
the public health is normally a sewerage system because the same lurban density
makes it impossible otherwise for the individual to dispose of the water-borne waste
originating on his property without imperiling the health of his neighbors as well
as of his own household. But sunlight and air are necessities of healthful life no less
than a supply of good water and the removal of putreedble waste; and as a dty grows
in size and intensity of use the natural supply of these commodities to every lot is
diminished in quantity and impaired in quality in a manner precisely analagous to
the impairment of the water supply drawn from the back-yard pump.

High walls that shut out the sun and obstruct the movement of air, chimneys that
belch black smoke, congestion of buildings on the land, of rooms in the buildings
and of people in the rooms, apart from any other drawback they may have, are inju-
rious to health primarily because they interfere with the quantity and quality of air
and daylight in the dwellings and working places of the people. The effect on public
health is slower and less striking than from the pollution of local water supplies.
Tuberculosis and general debility are not as swift as typhoid. Therefore, and because

382 PROCEEDINGS SECOND PAN AMERICAN SOIENTIPIO CONGRESS.

of difficulties to be considered below, the world is slower to grapple firmly with the
problem of insuring an air supply and a light supply really adequate in quantity and
quality for the health of lurban populations than it has been in dealing with the prob-
lems of water supply and sewerage. But like those problems it is mainly a mattw of
the proper means of circulation — of providing adequate means of access for the com-
modities in question to reach the places where they are needed.

As compared with the water and sewerage problems, the great practical difficulty
in the way of handling the problem of light and air supply lies in the fact that the
latter commodities can not be conveyed in the requisite quantities through long and
crooked pipes of moderate size, as water and sewage can be. On .the other hand we
do not have to spend money in making air-tight and light-tight channels for the circu-
lation of those commodities, after the manner in which we have to make water pipes
and sewers water-tight. All we have to do is to avoid blocking up the necessary
space by buildings of our own creation. And to prevent the erectiim of such obstruc-
tions in the wrong places is the great function of preventive city planning.

Fortunately it is only under circumstance hitherto exceptional that the width of
local streets as determined by regard for surface traffic is grossly deficient for the proper
access of light and air to windows abutting on the sUeet. It is probably safe to say
that by far the greater part of the total mileage of streets in the cities of the United
States have a width greater than is necessary to give adequate access for light and air
to the lower stories of the buildings which now front upon them. That does not help
the case of the minority of streets which are flanked by buildings too tall for the width
of the open space; nor does it mean that there is as yet any general safeguard against
the erection of new buildings on the happier streets, now in the majority, to a height
that woiild cut off light and air from their opposite neighbors to an imhealthful and
unreasonable degree. It means only that the field is open for preventive dty plan-
ning to forestall such imhealthful developments.

The means most frequently employed to that end is a general regulation limiting
the height of buildings in relation to the width of the streets on which they front;
or still better in relation to the distance from the opposite side of the street, thus
permitting buildings to be taller where they are more distant from the opposite build-
ings. But because of the fact that property values and uses are genendly adjusted
to very crowded and undesirable conditions in the central part of a city, it is seldom
practicable to enact a general regulation of this sort which is applicable uniformly
throughout the city without permitting everywhere conditions which are plainly
undesirable for the public health and, indeed, much worse than those generally pre-
vailing at the present time. It is, therefore, plainly desirable to divide the dty into
Eones of differing conditions, in each of which should be established as good a limiting
ratio as can be secured between the height of buildings and their distance from the
opposite side of the street.

But if we are to face squarely the problem of providing means of circulation by
which daylight and air may reach all the places where they are needed for the health
of the public, and may reach them in quantity and quality as satisfactory as those of
our present water supplies, we have only scratched the sur&ice of the problem by
insuring proper light and air for windows facing on the streets.

Water pipes and soil pipes of a size sufficient to meet the needs of ordinary buildings
are small, relatively inexpensive, and extremely flexible as to locaticm. Their
introduction to exactly the points in every building where they are most needed for
deanliness, comfort, and health occupies very little valuable space and invdves
only a very moderate expense, yet it requires much legislaticm and much effort on
the part of building inspectors, health officers, and others to get these two systems
properly installed in buildings after the dty has brought them to the lot line.

When it comes to circulating air through restricted channels, the size of channels
necessary for o£betting friction and maintaining an effective circulation is astonish-

PUBLIC HEALTH AND MEDICINE. 383

ingly great. The early attempts at artificial ventilation, like the attempts still often
made by those without scientific knowledge of the subject, were ridiciilous in their
futility because of the inadequate size of the ventilating ducts, usually several hundred
per cent or even a few thousand per cent too small to provide the circulation expected
of them. They were merely the expression of a newly awakened sense that ventilation
was desirable; not a practicable means of attaining the desired result. And simi-
larly the clauses which have been introduced into our building codes, tenement-
house laws, and the like, requiring certain minimum sizes of yards and coiuts and light
shafts, are in many cases little more than the indication of a pious wish that daylight
and fresh air might be abundantly admitted to the buildings; as thoiigh one were to
say ''on accoimt of its importance for maintaining health, food shoiild be eaten at
regular intervals — as frequently as once a week."

It is one of the aims of city planning to secure for every room in every new building
as much fresh air and daylight as is needed for thoroughly healthful living and working
conditions. One of the chief means to that end must be to enforce the existence of
open spaces for the circulation of light and air, of adequate dimensions and suitably
distributed in relation to the future building masses. We can not as yet say to what
extent this will be accomplished by laws or regulations prescribing in general terms
what spaces shall be kept open on all lots for light and air, which is the method attempt-
ed in the tenement-house laws with which we seek to prevent the repetition of some
of the worst evils of congested building; and to what extent it will be accomplished
by laying out upon the city map, in connection with the open spaces which we call
''streets," and between them, certain other open spaces specifically defined by build-
ing lines and adapted to the local conditions of every block, which is a method more
laigely employed by German city planners. The latter method recognizes more
clearly that these other open spaces serve essentially the same function as the streets
so to as concerns the circulation of light and air.

From the large point of view of city planning the distinction between the spaces we
call streets and those we call private yards or coiuts is no sharper than the distinction
between main thoroughfares and local streets. Here in Washington the more or less
garden-like yards to be seen in front of most of the dwelling houses, while improved and
maintained by the householders, are legally a part of the streets. Only the central
portion of the legal street width being needed for traffic, that portion alone is so used.
The remainder is kept open for the circulation of light and air and for the contingen-
cies of future traffic; and in the meantime is loaned, as it were, to the abutting house-
holders for use in a manner not inconsistent with those public purposes. The plan
of Washington may Mrly be criticised in that it reserved such very ample open
spaces in front of the buildings for light and air and future contingencies, while leaving
the determination of the spaces for light and air and other purposes in the interior
of the large blocks wholly to private initiative without any city planning at all. The
result in many cases has been the creation of dark and ill-ventilated rooms and other
evils. There is no apparent reason why spaces of a size and distribution really ade-
quate to bring light and air to every inhabited room of every building shoiild not have
been reserved in the interior of every block, in private use but subject to city control
and available for other uses if needed, in substantially the same status as the front
dooryards. And if this coidd have been done in Washington it can be done in any one
of the suburban areas springing into growth around all oiur cities to-day.

It is an interesting fact that in Latin countries, as contrasted with those of northern
Europe and especially as contrasted with the United States and Canada, there is more
apt to be a direct connection for vehicular traffic from the streets to the courts and other
interior open spaces, and those interior spaces are more generally used for the loading
and unloading of vehicles and for the temporary storage of standing vehicles, thus
relieving the streets to a considerable extent from usee which may greatly impede the
flow of moving traffic. By closing the courts and yards and other interior spaces off
from the street, so that they can not be used by vehicles, as we generally do in the

384 PEOOEEDINGS SECOND PAN AMBKICAN SCIENTIPIC CONGBBSS.

citiee of this country, we not only compel the obstruction of the streetB by standing
vehicles but tend to make all the other open spaces useless except for light and air,
and thus increase the economic pressure against which we must struggle in trying to
keep these spaces laige enough to avoid dark, ill-ventilated buildings.

The rapidly and enormously increasing use of automobiles has recently made the
problem of street obstruction by standing vehicles a serious one, even with compara-
tively wide streets. The problem is especially acute in the business portions of the
middle western cities of this coimtry, notably Cleveland and Detroit. Is it unieaBon-
able to look forward in our dty phms to the definite exclusion of this outdoor garage
business from the streets, and to the systematic reservation of interior courts, yards,
and passages, in addition to the streets, so laige and so well distributed as to be ample
for the storage of vehicles while loading, unloading, or waiting, and for the admission
of really adequate light and air to the adjacent and inclosing buildings?

The widths and the distance apart of local streets are made to vary in different parte
of a dty plan in accordance with the expected uses of the land; laige manu&ictuiing
plants, for example, requiring a greater distance between streets than rows of small
houses. Expectations of use are sometimes deceived and changes of street plan are
made necessary, if no more than the dosing of certain sheets to enlaige the block
sizes for laige industrial plants, or the reverse process of subdividing original laige
blocks by supplementary streets, as in the many instances of the ' 'half " streets here in
Washington.

The plans for open spaces within each block must be even more variable. For
storage warehouses of certain kinds such spaces are useless and Likely to be highly
objectionable, as also for large btdldings of a type dependent on the use of elaborate
artifidal lighting and ventilating systems, notably tiieaters; and for factory build-
ings of many sorts greater width is needed between open spaces than in the cam of
dwellings. The theory of d.y planning is to provide as well as possible for each of
these different classed in different localities; to provide blocks suitable for storage
warehouses where the entire space may be covered many stories deep from street to
street; to provide blocks, at the other extreme, where a detached dwelling house can
be built in a garden with definite aseimince that no neighboring lot can be so buiH
upon as to impair the general airiness and open character of the locality. And jusi
as local s>reet plans may require change when errors of judgment are shown to have
been made, so to an even greater d^:ree are plans for the interior open ^^ paces of a
block liable to change if, after proper public hearings in any given case, it is apparent
that a change will permit the block to be more effectively and appropriately used
and if the interests of those who have built in reliance upon the original plan are duly
protected.

It has taken longer than I expected to set forth this characteristic city planning
conception of the open coiu-ts and yards on private lots as not mere unused remnants
of building land but integral parts of the dty's complex system of circulation. So
long that I can but touch on one other aspect of the matter, that of public facilities
for recreation, especially for outdoor recreation. I can not speak of the very different
functions that need to be performed by different parts of a public park and recreation
system, and the corresponding special requirements to be met in the selection of park
lands. Because of their perishable and irreplaceable character, occasional landscapes
of peculiar natiuul beauty are worth preserving for their future value in offering a
much needed quiet refreshment to tired dty people. But whether opportunities
exist for preserving such natural parks or not, it is fundamental in any good dty
planning to secure in connection with the layout of streets a series of paro and play-
grounds of such size and distribution that every man, woman, and child in the district
will be able to reach a suitable place of outdoor recreation within reasonable walking
distance of home. The reservation of these local recreation grounds and the associated
sites for schools and other local public services are as mudi a part of the dty plan
as the basic systems of circulation themselves.

PUBUO HEALTH AND MEDICINE. 385

THE HUMAN SIDE OF CITY PLANNING.

By J. HORACE McFARLAND,
President American Civic Asiociationf Earrisburgf Pa,

The title of this address at first seems to be anomalous. All modem city planning
has to do with living humanity. I Have heard of no present efforts to revise the
plans of Pompeii or Babylon, or of old Petra, in eastern Syria.

But what I have in mind to present briefly is that intensely human relation of dty
planning which has most to do, I believe, with the completest hiunan happiness and
efficiency.

80 feur as it has yet been set forth, city planning obviously relates to communities
of some size. Primarily it has been considered for the laiger communities only, and
there exists a dearth of suggestion and available information for the improvement
of the far more numerous communities having less than 50,000 population.

For the purpose of this address, however, I want to consider that all of the United
States is one commimity, and that it deserves as a whole thou^tful consideration io
respect to health, happiness and efficiency.

Notwithstanding the predominance of cities in consideration of population, the
larger portion of our American citizenship lives outside the oiganized commimities;
or did when the census of 1910 was taken. It occasionally seems rather incongruous
that the 41 per cent tail included in the population of all the oiganized commimitie0
in the United States should so violently wag the 59 per cent dog nuiking up the re-
mainder of our vast population.

What we have heard this morning as to the painful defidendee in rural sanitation
and as to the absolute folsity of the old idea that it was more healthful to live in the
country, makes the proposition I am to bring forward all the more important, if we
take into consideration the whole of the United States.

The thought I wish to set before you is the direct economic relation of recreation as
a factor in individual, in community, and in national effidency. I shall use a fonnula
which is not my own, having &een proposed several yean ago by a v^y able and acute
observer, Mr. George A. Parker, of Hartford, Conn.

Recreation in the sense I wish to discuss is by Mr. Pttrker construed as induding
all the time of every human being within the considered territory not actually used
in eating, sleeping, and working. If any one will reflect upon this statement, he will
realize that out of each 24 hours an appreciable amount is spent otherwise than in
eating, sleeping, and working. He will also realize that not only is time spent but
money is spent in these hours not devoted to the actual necessities of life.

I believe th^e has not in general been a broadly considered thought of this recrea-
ti<mal expenditure in its relation to our national prosperity. Yet we have given a
great deal of time, much effort, and have made vast expenditures to take care of the
results of unwholesome and ineffident recreation. Every jail, every hospital, every
innne asylum is a direct agency for caring for misapplied recreational endeavor, and
our extensive and well-arranged cemeteries are the final deposiUNiee for wasted human
beings, the lives of many of whom have been shortened through ineffident recreati<mal
provision.

We have, it is true, attacked unconsdously the problem of providing for recreational
time. We have churches, libraries, theaters. Young Men's Christian Assodationa,
Young Women's Christian Associations; we have saloons, "movies," brothels, dance
halls, and the like; we have some parks, some playgrounds, and yet fewer recrea-
tional centers.

All of the agendes just mentioned relate directly to the recreational time and re-
creational expenditure of our people. The schools are not induded, for they are

386 PBOOEEDINOS SECOND PAN AMEBIOAN SGIBNTIFIO C0NGBEB8.

workBhops. They might also be recreational centers of great importance, and are
likely to be as we come to realize their value as community centers. The churches
likewise, it is hoped, will reach a greater efficiency in dealing with the problem of
human recreation.

It is trite to say that in a democratic and Christian civilization there is absOTbed the
entire economic loss resulting from unwise recreation. Each of us pays, directly or
indirectly, for all human deficiency; for the results of all avoidable illness. As
Grov. Brumbaugh, of Pennsylvania, has recently succinctly phrased it:

We have reduced the hours of work, but we have made no provision for the increased
hours of leisure thus provided. The wron^ against society are committed by. our
people not in their hours of work but in their hours of leisure, and the responsibility
lies not wholly with the people who perform these unfortunate acts, but with the peo-
ple who have not been wise enough to see that the fundamental business of the com-
munity at large is to see to it that it becomes increasingly easy for the people to do
right and increasingly hard for them to do wrong.

Now let us grasp, if we can, the application of the Parker formula to the whole
population of the United States. Extended investigation proved to Mr. Parker that
each individual in the ordinary community spent five hours of each day in doing
something else than eating, sleeping, and working. He discovered, *too, that the aver-
age recreational expenditure for this time could be estimated at 2 cents per hour
per person.

I have submitted this formula to many thoughtful persons, and have found a dis-
position to consider that it is too conservative rather than too radical. It may there-
fore be safely applied to the consideration of the situation in the United States.

Counting on a round 92,000,000 as the population of continental United States in
1910, it will be observed that a recreational expenditure of five hours per person per
day gives us in all a total daily recreation time of 460,000,000 hours. This is an
almost inconceivable amount of time, and it is scarcely less incomprehensible to
reduce it to years and to say that the daily recreational time-use of continental United
States amounts to 52,511 years, every moment of which is used every day either
in making the individual and the Nation more efficient or less efficient, better or wone,
richer or poorer.

Applying the money fetctor to the calculation, it appears that there is expended
for recreation each day approximately $9,200,000. If any one cares to check the
ascertained expenditures for churches and saloons, for moving pictures, theaters,
and all other previously mentioned factors included in the competition for the recrea-
tional time of our people, he will find a disposition to believe that the sum stated is
far toosmaU.

Mr. Parker's idea was that a ccnnmunity which aimed at reasonable efficiency for
its people and which was devoted to. keeping them happily at work under comfort-
able conditions, rather than to promoting the means of wooing them from productive
work and of sustaining them in deficiency in jails, hospitals, and the Hke, would en-
deavor to control one hour of the recreational time of each individual, with its col-
lateral expenditure, each day. This for continental United States would mean the
taking care each day of 10,502 years of recreatioDal time, and involve the wise
expenditure of $1,840,000 each day.

In order to get in mind the seriousness of the problem and the absolute inadequacy
of our present recreational facilities, good and bad, let us consider the working houn
of the existing agencies. Churches are open an average of 10 hours per week, while
saloons operate approximately 108 hours per week, and theaters and movies 60 hours
per week. Organizations like the Young Men's Christian Association are assumed
to do business 105 hours per week. The jails, hospitals, and cemeteries in general
are always open, and their efficiency is therefore 168 hours per week each. It will
be seen, alas, that we are thus providing only for keeping open with efficiency the re*
repair shops and the junk heaps of humanityl

PUBLIC HEALTH AND MEDICINE. 887

Parks and playgrounds under favorable conditions seldom do service more than 60
hours per week, and the country over, under the present inadequate view of the sub-
ject, do not serve the people an average of more than 35 weeks per year.

I realize that these figures, in so far as they have related to the Nation's recreational
usage and expenditure, are incomprehensible. In order that we may get a view
that is comprehensible, I reduce the application of the factors so as to apply them
to a city of 50,000 inhabitants. In such a city the recreational expenditure is 29
years per day, at a cost of $5,000 per day, 6f which sum considerably more than 80
per cent is exi>ended for those forms of recreation which reduce the economic effi-
ciency of the individtial.

There is not time to enter into any complete consideration of this subject. I do
no more than set the factors before you as including the human side not only of city
planning, but as well of Nation planning. When we come to look at it, in the whole,
we are sure to realize thai national security, national prosperity, and national effi-
ciency relate intimately to the provision by the Nation, and by the States and com-
munities making up the Nation, of facilities for wholesome recreation. As we
consider the definite increase in recreational time due to the shortening of hours of
labor, we are faced with the increasing seriousness of the problem. As we further
realize the tremendous competition for this recreational time and recreational
expenditure o£fered commercially by the forces of evil, deficiency, and disorder, the
duty of the community is the more plainly brought into the limelight. It will need
not only many more parks of all sorts, includi^ especially the national parks and the
State parks, to attract whole families for relatively extended recreational visits, bat
as well ample playgrotmds, school community centers, well-managed and upbuilding
amusement fadlitiee of all sorts.

It used to be a truism that all work and no play made Jack a dull boy. We might
now paraphrase it and get much nearer the truth in saying that less work and poor
play make Jack a bad boy. We have every reason of patriotism, of self-interest, of
Christianity and of a desire for national efficiency to uige the thoughtful considera-
tion of this awe-inspiring problem of national recreation, or of the human side of
Nation planning.

THE EFFECT OF LAND SUBDIVISION UPON HOUSING AND PUBUC

HEALTH.

By JOHN NOLEN,
Fellow Amerioan Soddy Lmtdfcape ArehUecU, Cambridge^ Mau.

City land from the point of view of land subdivision may be put into three main
dassee— namely, land for industrial use, land for retail and wholesale business, and
land for residential purposes. The principal field of land subdivision, however,
the class which concerns at least two-thirds of all city land, is residential property.
In fact, when land subdivision is spoken of, it is ordinarily assumed that it refers
to the la3ring out of land for dwellings. The evils of undesirable and imintelligent
land subdivision in the case of residential property are also more apparent and more
in the public eye than in the case of industrial and business property.

There is a widespread feeling abroad and to some extent in this country that dty
planning has thought more of streets, of civic centers, of parks and playgrounds, and
of other subjects, than it has of land subdivision, housing, and public health.
Foreign town planners are constantly asking, ''Why is housing not given more atten*
tion by dty planners in the United States?''
68436— 17— VOL IX 26

888 PBOCEEDINGS SECOND PAK AMEBIOAK SOIENTIFIO CONGRESS.

There is much to be said, however, in answer to this question. There are reasons
why land subdivision and housing have not been given more attention by city
phmners in this country. Some of the more important are the following:

1. On account of the Federal Constitution, which provides that private property
can not be taken except for public use, and with due process of law and just
compensation, and on account of the conservatism of our courts in interpreting the
Constitution and the law, it is always very difficult and often very costly to regulate
land subdivision and housing by public authority.

2. The rights and limitations of American municipalities have been such that 8i>
far as land subdivision controls — that is, location, width, etc., of streets, the width
and depth of lots, and the location, density, and spacing of buildings, except tene-
ment houses; all these features have been beyond public authority or else have often
been laigely determined before the outljdng sections havQ been included within the
city boundaries; on the other hand, there has practically been no effective control
of such matters by rural or county governments.

3. Public opinion generally was not, and in fact is not yet favorable to the strict
public regulation and control of the laying out of residential neighborhoods. It is,
indeed, very difficult to make an advance, even in sanitary requirements, in measures
for the reduction of fire hazard, in the reasonable protection of light and air, adminis-
trative regulations which might naturally be expected to receive attention in advance
of broad city planning. In an address last month before the American Public Health
Association, Dr. William T. Sedgwick recounted the victories of municipal sanitary
engineering in recent years, but at the same time pointed out many flagrant failures
in American sanitation. There is a widespread feeling that public health matters
should have first attention. Thus, the obstacles to regulating and controlling land
subdivision are greatly increased in this country by the '^Laissez-^dre" doctrine, by
what is known as the rights of individual property, and by the strength of vested
interests.

4. Until recently, aside from a few laige cities, and other important but never-
theless exceptional developments, the characteristic housing in American towns and
cities has seemed relatively good, so far as the subdivision of the land and city plan-
ning could affect it one way or another. The actual lots as built upon have been,
usually, from 20 to 40 feet in width, and 100 feet or more in depth, with a density
of eight or ten houses, or less, to the acre, the standard of the best English garden
city development.

5. The disinclination of private capital, except in the case of a few employers for
their own employes, to respond to invitations and opportunities to invest in housing
schemes on the limited dividend principle, yielding only the normal business interest
on invested funds of, say, 5 or 6 per cent, ia anoliier reason why housing and land
subdivision have not apparently been given more attention in this country by land-
scape architects and town and city planners. Cooperation or copartnership in housing
schemes, as in other matters, has not yet succeeded in the United States as it has in
Europe.

To avoid misapprehension, however, it should be added that every one of these
reasons has recently been losing its strength. Largely through the energetic and well
directed efforts of the National Housing Association, the public is becoming more and
more aware of the need and advantages of a somewhat radical change with regard to
all of them. It is also becoming convinced that much of the housing in the United
States that seems good is not good, and that large lot sizes do not necessarily result
in safe, sanitary and pleasant homes.

One hesitates and is naturally timid in attempting to discuss land subdivision and
its effect upon housing, because so little reliable data of any considerable extent
exist on the subject. Much laying out of land has been done, but the merit of <me
scheme as against another has not been tested. To give a basis for conclusions and to

PXJBLIO HBALTH AND MEDIOINB. 389

guide future action in this matter, the executive committee of the National Conference
on City Planning recently determined to make a systematic compilation of facts and
of well digested opinion in regard to the most effective and satisfactory units of land
subdivision for various purposes and under various conditions in American cities.
The instructions to this committee are, broadly, to gather and digest any information
likely to be of practical assistance to those responsible for maintaining and improv-
ing the quality of land subdivision plans. It is the intention to gather the essential
facts about the more important types of subdivision plans which have been tested
in actual use in the United States, and which have proved their advantages or dis-
advantages to the developer, to the owners and occupants, and to the general public
An effort will be made to concentrate the study mainly upon a limited number of
selected urban districts, representing large, small, and middle sized cities, some flat,
some hilly, located in different sections of the country. The investigation wiU seek
to discover the physical results, the sociological results, and the financial results of
the various types. The more important points outlined for study are, depth of lot,
width of lot, width and improvement of streets, and building or other restrictions.

The first results of this committee's investigation are now available, the local com-
mittees from the following municipalities having reported: Berkeley, Cal., Boston,
Mass.; Bridgeport, Conn.; Brookline, Mass.; Chicago, 111.; Cleveland, Ohio; Detroit,
Mich., Kansas City, Mo.; LouisviUe, Ky.; New York City, Newark, N. J.; Phila-
delphia, Pa.; Syracuse, N. Y.; Washington, D. C.

The gist of the conclusions deduced by the local reporter as summarized in the
committee's preliminary report may be stated as follows:

1. Lot size.

(a) Philadelphia is in a class by itself, with lot sizes averaging 15 by 60 feet.
(6) New England, based largely on returns from Boston and Brookline, is irregular,
but the tendency is toward lots from 40 to 60 feet in width, by 92 to 100 feet in depth.

(d) Middle and Western States have had larger lot sizes, with later tendencies
toward reduction in both dimensions.

2. Lot sise change tendencies.

(a) The general tendency shows a reduction in depth except in New York, Newark,
and Chicago, the former put at 100 feet and the latter at 125 feet, respectively. These
depths have been maintained as a standard for New York and Newark for 100 yean,
and for Chicago for 40 years.

(6) Cities which had lots deeper than 100 feet show a tendency to revise to that
figure.

(e) New England, with its irregular lot sizes, shows a tendency below 100 feet for
depth.

(<f) Philadelphia shows tendency to smallest possible lot dimensions.
(e) With the exception of Philadelphia, the lot widths in all cities tend down to
about 30 feet, while lots wider than 20 feet are recommended everywhere.

3. Effect of lot size on type of development.

(a) The lot area seems to be the original determining factor. Deep lots are made
narrow, and narrow lots lead to narrow buildings, usually undesirable for residence
or business. Deep lots, even down to 70 feet or 80 feet, tend toward having rear build-
ings, often residences. These conditions lead toward congestion and low values.

(6) Except in Philadelphia, the lot aze has generally influenced the building size
and the niunber of buildings per lot. In Philadelphia the desire for the single family
house has developed the small size of lot.

4. Effect of lot and incidental building size on real estate values,

(a) Where growth is active, either in number of residences or conversion to other
uses, the existing lot and building size is of little moment. Where conversion is
slower the larger plots are worth more, because more easily converted.

390 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

(&) Established poor occupancy tends to depress or at least restrain increase of
values, through natural depreciation and the shift of classes of occupants, depending
upon the condition of the dwelling.

5. Effect of restrictions on conditions.

Legal restrictions as to per cent of lot which may be covered, the shape and mze ol
courts, and location of buildings on lots must be added to conditioning lot sizes, if
best results are to be obtained.

6. Standard dimensions.

(a) The results of the investigation so far seem to show that standards are exceedingly
desirable.

(b) A lot depth of 100 to 125 feet is the apparent aim of best standardized conditicmfl
and of present tendencies. There is considerable data and opinion to justify even
shallower depths for certain classes of dwellings.

The problem of land subdivision, we believe, is largely public regulation, control,
and restriction. In fairness to all concerned, what shoidd the real estate operattnr
be allowed to do in tMs very important matter of dividing up and selling his property,
cutting up land upon which people are to dwell for ages to come, changing agricultund
acres wholesale into a form from which they can be changed again, if at all, only at
great cost?

The principle of restrictions in the subdivision and iise of land is well undorsteod
in the United States and very frequently applied. In fact, it is so well understood
and 80 highly valued that it is most often applied in a surprisingly thoroughgoing way
by the real estate operator in his own interest. The restrictions placed upon the
purchaser in the conve3rance of the property often include a long list of kinds of
business which are classified as nuisances and which may not be established or main-
tained upon the property; regulation as to stables and garages; fences and walls; set
back of buildings from streets and from lot lines; minimum cost of bmldings; easements
and rights of way for public utilities; and in some cases the approval of plans and
specifications, including nature, shape, kind, height, material, color scheme, and
location of buildings, and the grading plans of the plot to be built upon. These
restrictions or conditions are often placed for a period of 25 yean or more, with the
right of renewal, subject to the assent of the owners. But, after all, can we depend
entirely upon the knowledge, skill, and motive of the owner or operator to subdivide
the land and place the restrictions? At best his action is uncertain; it is applied
only in spots, often spasmodically, and even when most ''public spirited,'' as we oay,
it is not always intelligent. Again, his chief motive must be profit. He can not
reasonably be expected to have consistent and permanent concern for the results of
his methods upon the future occupants of the property, nor upon the general public*
Then, may we not add, he does not always know what is best; and if he did, not
owning or controlling all the property of the city of town, or even a large percentage
of it, he would not be able to make his knowledge effective. Fiuthermore, he has
only the power of a private citizen.

In land subdivision, therefore, we must rely more and more on the right and neces-
sity of the public to regulate private property with due regard to all the interests
affected. In its final form this means the zone system of building districts; that is,
the division of the city into areas each devoted primarily to industry, to business,
and to residences. There might probably be further subdivisions of the residential
districts into zones for different classes of dwellings, separating especially apartment
houses and tenements from single ^rnily houses. In defining these building zones
consideration should be given both to the rights of the commtmity and the rights
of private property owners. In the long run, these interests will prove to be more
nearly identiotd than they are generally believed to be, and one of the best reasons
for districting a city is that it makes general real estate values in all sections higher

PUBLIC HEALTH AND MEDICINE. 391

and more stable. The fixing of the boundaries for the various districts is as important
as it is difficult. These boundaries should be determined not only by present con-
ditions, but by a careful forecasting of the probable future conditions. In general,
the i^evailing opinion on this subject is that many of the areas should be relatively
small, and they should be subject to change periodically, with changing conditions.
Districts should be established in such a way as to help industrial, business, and resi-
dential interests; that is, effort should be made to provide each district with the best
possible kcilities for its purposes. In other words, the zoning or districting of a city
in connection with land subdivision should help all kinds of buildings by discrim-
inatingly limiting them to those districts in which they naturally belong, and by
providing a first-rate development in each district for the various types of buildings.
Each district or subdistrict will thus have its appropriate restrictions so as to safe-
guard it. The points of greatest importance will be depth of lot, percentage of lot
allowed to be covered, or density per acre, and the height of buildings.

Some authorities hold that the housing question is primarily a question of land
values. They claim that the value of a lot is dependent on the revenue from it, and
that if building laws and local usage permit overbuilding on a lot, the buyer must pay
more for the land, even though he intends to build only a small house. In o^er
words, where the value of a lot is high as a result of building laws, the owner of the
land must build compactly or lose money. Thus the density permitted and the value
of the lot react on each other. If this view is sound, it follows that the proper regula-
tion of the laying out and occupancy of the land can do much to improve housing con-
ditions. Furthermore, some American writers hold that the rent payer's mim'tniifyi
outlay for house rent becomes an important ^tor in determining wages. Therefore,
should not the minimum standards of housing be a home that meets the requirements
of safety, health, convenience, privacy, and that degree of agreeablenees which is con-
sidered essential? Of course these minimum standards, we believe, would prove
advantageous not only to the workingman and his employer, but eventually to the
land owning class also. The greatest burden of the present system, however, creating
automatically as it does excessive congestion and slums, falls finally on the com-
munity.

In conclusion it should be said that there are, of coujrse, technical problems in-
volved in every land subdivision, and their solution requires skill and experience.
Furthermore, Uiese problems of land subdivision are related to still wider and more
difficult technical problems of city planning, city building, city maintenance, and
city administration, all requiring still greater skill, knowledge, and experience.

Land subdivision, as the term is used by architects, landscape architects, and engi-
neers, determines the location and width of streets, roads, alleys, and other open
spaces; the definition of building districts; the location, depth and length of blocks;
liie location of lot lines; the height of buildings; and other physical features. When
the subdivision is made upon the initiative of the real-estate operator, and sometimes
when it is made upon the initiative of public authority, it det^mines also building
lines, restrictions, and conditions of development. Muiy examples could readily be
given of what is done, and how it is done. Thus it would seem that land subdivision,
detennining so many matters in the physical lay-out of the city, has a very direct and
important effect upon health and housing, perhaps greater and more permanent than
any other single influence.

BIBLIOQR/IPHT.

Adams, Thomas. Town Planning and Housing Reform in Canada. Conservation

of Life, January, 1915, pp. 52-56.
Rep(»rt on the Planning of Greater Vancouver. Conservation of Life, January,

1915, pp. 57-60.
Albany Home Building Co. History and Development. Albany, N. Y., 1912.
Aronovici, Carol. Constructive Housing Reform. National Municipal Review, ii,

no. 2, 1913 (uid other publications).

392 PBOCEEDINOS SEOOND PAN AMEBIOAK 8CIBNTIFI0 CONGBESS.

Aronoyid. Carol. Suburban Development. Annals of the American Academy of

Political and Social Science, li, whole no. 140, January. 1914, pp. 234-238.
Atkinson, William. The Orientation of Buildings or rlanning for Sunlight. New
•^ York, 1912. 139 pp.
Baumeister, Reinhard. Bauordnung und Wohnungsfrage. Stftdtbauliche Vortrage,

Heft III, 1911.
Billerica (Maas.) Garden Suburb. Prospectus and other Forms.
Boston Dwelling House Co. Woodboume.
Brookline (Mass.) Education Society Town Improvement Committee. The Wooden

Apartment House Question in Brookline. 1915.
Conference Committee. Best Methods of Land Subdivision. Ftoceedings of Seventh

National Conference on City Planning, 1915, pp. 247-273.
Crawford, A. W. The Interrelation of Housing and City Planning. Annals of the

American Academy of Political and Social Science, U, whole no. 140, January,

1914, pp. 162-171.
Culpin, Ewart G. Garden City Movement Up-to-Date. The Garden Cities and

Town Planning Association, London, 1913.
Cutting, H. C. Land Values. Richmond, California.
Departmental Committee appointed by the Local Government Board for Ireland to

Inquire into the Housing Conditions of the Working Classes in the City of Dublin.

Report. Dublin, 1 914 j 42 pp.
Ford, James. The Housmg Problem. Harvard University, Cambridge, Mass., 191L

Some Fundamentals of Housing Reform. The American City, May, 1913.

George, Henry. Progress and Poverty. Doubleday, Page A Co.
Goodyear Tire and Rubber Co. Goodyear Heights, Akron, Ohio. 1913.
Haldeman, B. A. Control of Municipal Development by the Zone Syatem and Its

Application in the United States. American City, vii, September, 1912, pp.

222-225.
Howe, Frederic C. The City the Hope of Democracy. Chape. XVII and XVIII.

Chas. Scribner's Sons, 1909.
The Modem City and Its Problems. Chaps. XIX, XXII and XXIII. Chas.

Scribner's Sons, 1915.
Hurd, Richard M. Principles of Land Values. The Record and Guide, New York,

1903.
Ihlder, John. What Good Housing Means. American Journal of Public Health, iv,

no. 1, September, 1913 (and other publications).
Kober, George M. Histonr and Development of the Housing Movement in the city

of Washington, D. C. Washington Sanitary Improvement Company, 1907.
Lewis, N . P. The Planning of Undeveloped City Areas. American City, iii, Septem-
ber, 1910, pp. 137-140.
Marcus Hook, Ta. Garden Cities.
Muller, Alfred F. Myers Park, Charlotte, N. C. The Wildwood Magazine, Fort

Wayne, Ind., Spring, 1915.
National Conference on City Planning. Report of Committee on City Planning

Study. Chicago, 1913.

Report of Committee on Land Suodivisions. Detroit, 1915.

National Conference on Housing. Housing Problems in America. Proceedings,

1911-Hlate.
New York City Heights of Buildings Commission. Report of Board of Estimate and

Apportionment. 1913.
Nichols. J. C. Real Estate Subdivisions: The Best Way of Handling Them. Ameri-
can (Svic Association, Washington, D. C, November, 1912.
Nolen, John. The Factory and the Home. Proceedings of the National Housing

Association, Philadelphia. 1912.
Fiarrish, Helen L. One Million People in Small Houses. National Housing Associa-
tion Publications, Februajy, 1913.
Penticost, George F., Jr. The Economic Development of Building Estates. The

Architectural Record, April, 1909.
Roland Park, Baltimore, Md., A Representative American Suburb. House and

Garden, April, 1903.
Roland Park Co. A Book of Pictures in Roland Park, Baltimore, Md. March and

June, 1911.
Sage Foundation Homes Companv. Forest Hills Gardens. New York, 1911.
Salem, Mass. (City of). Municipal Bulletin No. 4, January, 1915, containing the pro-
posed housing ordinance.
Standard Buildings, Inc. The Industrial Village. New York Cit^.
Toronto Housing Co., Limited. Bettor Housing in Canada, "The Ontario Plan."

1913.

PUBLIO HEALTH AND MBDIOINB. 898

Unwin, Raymond. Nothing Gained by OvercrowdingI Garden Cities and Town

Planning Association, London, 1912.
Town Planning in Relation to Land Values. Town Planning Review, Jiily,

1914.
Veiller, Lawrence. Buildings in Relation to Street and Site. Proceedings of the

National Conference on City Planning, Philadelphia, May, 1911.

Housing Reform: a Handbook for Practical Use in American Cities. New

York, 1910. 213 pp.

A Housing Programme. National Housing Association Publications, June.*

1912.

Walpole, Mass. Plan To-day for Tomorrow 1914.
Weller, Charles Frederick. Neglected Neighbors. Philadelphia, 1909. 342 pp,

RURAL HYGIENE.

By J. N. HURTY,
Indiana State Health Commieeioner,

In 1901, when riding in a country in a southern Indiana county, I stopped at %
farmer's house which was falling into decay, with the yard Uttered and untidy, and
chickens and pigs much in evidence. I knocked on the door and in response heard
a weak female voice hardly audible say, "Come in." I entered and found in a bed
in the room into which the outer door opened, a woman too sick to rise. I can
never forget the appealing look in her pale face. ''Are you alone?" I asked. A
dight side movement of the head was the sign which constituted an affirmative
answer. ''I am a doctor," I said, "and can I help you?" She feebly replied "Yes."
Her temperature was 104.5, her tongue heavily coated, her pulse rapid and greatly
disturbed. These and other sjrmptoms and a few questions told plainly the disease
was typhoid fever. And she alone. A doctor had been to see her a few days before,
two days she thought, and her husband had gone to town for some medicines and
flour. He had left in the morning sometime and it was now 2.30 p. m. She probably
had been alone for five hours. The poor creature was at times delirious and the bed
soiled by involuntary stools. My driver, upon direction, quickly brought a woman
neighbor living about one-half mile away, and together we bathed the sufferer and
changed the bed. The husband, a true brother of the clod, and reeking with tobacco^
arrived about 5 o'clock. The trip to town could easily have been made in 90 minutes.
He said he had left at 9 in the morning. The patient died the following day.

This incident set me to studying rural hygiene, and for 14 years the subject has been
constantly before me. In that time I have witnessed two other typhoid deaths in
farm houses, and I have seen several scores of cases. Of consumption I have seen
two deaths, and of cases long ago lost the count. I learned long since that insanitary
housing with insanitary surroundings were not less frequent in the country than in
large cities. All of these and still other facts led me to want to do something, if possi-
ble, to bring relief. In making my studies of rural hygiene I have visited every one
of the 92 counties of Indiana, and some of them two, three, and even five times. I
have taken long country rides in every county, have analyzed samples of water from
wells in every county, and have carefully noted the maladies which were found.
Dyspepsia and malnutrition are frequent on the farm, consumption is continually
in evidence, and typhoid fever is more prevalent than in our cities. Rheumatisin
is found among the majority of farmers, skin diseases are not rare, and the district
country schools continually flame forth with diphtheria, scarlet fever, and other
infectious diseases.

Of course, all this occurs to a greater degree in cities, but it is of the country we q>eak
at this time. Rural hygiene is the theme.

394 PBOCEEDINGS SECOND PAN AMEBIOAN SCIENTIFIC CONOBESS.

While rural hygiene has not been entirely neglected, it certainly has not had the
attention which has been accorded to municipal hygiene. This is accounted for by
the fact that rural morbidity and mortality rates have heretofore been less than
municipal rates, but now, that the tables are turning in this respect, attention is drawn
to the need of improved country hygiene.

Hoffman shows that typhoid is a rural disease, in the sense that it prevails more
extensively in the country than in cities, pointing to po<»rer sanitation. In Indiana
(for which State I speak almost entirely in this paper) the typhoid rate, fonnerly
higher in the cities, is now higher in the country. The death rates, calculated upon
the statistics of the last 10 years, shows the typhoid rate for the whole State to be
29.5 per 100,000— for the cities 27.5 and for the country 31.5. The total death rates
are: State, 13.2 per 1,000; dtiee, 14.9; country, 11.9 Pulmonary tuberculosis makes a
showing which is interesting and significant: State rate, 132.1 per 100,000; dtiee,
154.2 ; country, 128.6. The abundance of pure air in the country, the supposed abund-
ance of pure, plain food, and the supposed existence of quite all antitubercular
conditions would lead to the condusion that tuberculosis of the lungs should be
almost nonexistent in rural districts, yet we find it not unmarkably less abundant
than in the dties with their congested conditions, with their smoke and dust laden
air. The testimony of one hundred rural physicians who were interviewed was
unanimous that *' stomach trouble, malnutrition, rheumatism, and constipation
were generally prevalent among farmers. ' ' We find that while the country morbidity
and mortality rates are lower than in the cities, the city rates are decreasing, while
the rural rates are stationary or very slightly increasing. It is assumed the dty
rates decrease because of bett^ sanitary conditions, which grow better continually.
A like decrease would also occur in the country if like improvements in sanitation
were instituted. Insanitation is as glaringly apparent in many country areas as in
the poorer or slum districts of dties. In fact, most country homes are insanitary;
only a minor proportion reaching the state which might fairly be called sanitary. The
average farmer and his family do not i>ay the attention to personal hygiene which is
necessary for good health. Bathing facilities, other than those of the crudest character,
are usually absent. Indeed, even the moderately appointed bathroom on the fann
is vary rare.

In early days, when carpentry was crude and the big open fireplace was the
method of heating and cooking, farmhouse ventilation was good; but in these days
of better carpentry and air-tight stoves ventilation is very bad. At this time it is
the procedure on most farms when fall arrives to light the fire in the air-tight stove,
dose and list the windows and doors, and from this time on until late spring the
only fresh air admitted finds entrance when the single door used for entrance and
exit is opened to go out and in. Excreta disposal on the farm is almost always by
privies, which are frequently old and dilsqpidated, open to flies, rats, chickens, and
hogs, and more or less noisome. On account of such bad provisions, it is no wonder
that bowels are neglected, and chronic constipation with its serious train of ills appears
as a well-nigh universal rural ailment. The insanitary privy too is largely the
source of the typhdd fever and diarrheal diseases which plague the farmer. The
near-by bam with its almost omnipresent huge manure pile, with its enormous
fly-fare^ding possibilities, is potential for ill health and disease.

The following editorial from the Indianapolis News of December 17, 1915, very
strikingly presents the farm-manure situation.

RURAL SANrrART CONDITIONS.

A farmer's wife, Mrs. Mary Doane Shelby, living somewhere in the Ozark regi<xi,
writes an open letter in the Independent to the Secretary of the Department of
Agriculture. It is a belated response to the department's request for suggesdoiis
from farmers' wives regarding improvements in farm life. Mrs. Shelby's letter deals

PUBUC HEALTH AND MEDICINE. 395

particularly with conditioDs in her own neighborhood, but she writes also of con-
ditions to be found on farms elsewhere — everywhere, in fact, from one end of the
country to the other.

She says, for instance, ^'that the Government does not give the country woman
the protection which the city woman receives and which she should have.'* She
continues, with proof:

On a neighboring farm, where the bams are not far from the house, there is a large
pile of stable manure. It has been standing there for weeks. My neighbor's wife
knows why she has so many flies; she also knows the menace to health. Her
husband Icnows too. Your information has reached them. But it seems that at
the present time there is no available field for this fertilizer; no man and team to
haul it; some time it will be attended to; just now ** he ** is busy with other work.
The city man would be prevented by law from thus jeopardizing the health of those
around him. The farmer is permitted to dally with the situation. Why could
there not be rural health departments to insure sanitary conditions? The farmer
and his wife are said to be national assets. Why not protect them? The forest has
its rangers; conservation of forces would suggest a uke protection for farm folk.
Another neighbor is permitted to let the drainage from his farm buildings pollute his
water supply. Why not have building restrictions for the farm?

Education, instruction in the laws of health and preaching of the doctrines of sani-
tation are not enough. Mrs. Shelby makes this clear. People in cities know that
cleanUneBs is the beet safeguard against sickness, but, if it were not for stringent laws,
inspection under municipal authority and enforcement of the laws by order of the
boards of health, cleanliness would not come to exist. The farmer is told what to do,
and why it should be done, but the periormance is left in his own hands. There is
point, therefore, to Mrs. Shelby 's recommendation. Indeed, in all the correspondence
from farmers' wives published by the department, there has been no simpler or saner
suggestion.

When we come to the farm water supply it is found so frequently to be polluted
that the presumption of impurity is forced until purity is proven. A dug well in a
city or town should be under suspicion from the first, and if analysis proves it to be
pure, this condition for even a day can not be assumed, for near by is certain to be one
or more vaults more or less filled with human excreta threatening pollution. Any
day or hour liquids from these stores of filth may find their way into the dug well,
and also into the shallow driven well. In the country dug wells may be considered
innocent until proven guilty, but this is dangerous, for the large majority are found
upon analysb to be polluted . Deep driven or bored wells usually supply pure water —
that is, free from organic matter but usually overladen with mineral matter. The
shallow-driven well is not liable to suriace pollution, but on other accounts is as likely
to supply polluted water as the shallow-dug well. It is undoubtedly true that farm
water supplies are all too frequently bad, and much of the stomach and bowel disorders
among rural dwellers is due to polluted water.

Slop and garbage disposal at country houses has been found to be usually insanitary.
Not infrequently kitchen slops are thrown upon the ground near the kitchen door,
forming a soggy and sodden area, which is soiur, unsightly, stinking, and in summer-
time black with flies. Of 278 farmers* houses inspected only 12 had covered metal
garbage cans. Leaky wooden buckets and barrels, nail kegs, cracked stoneware
crocks, or Uke receptacles, were found in use, uncovered, with contents oozing out
onto the surrounding ground, bad smelling, and supporting swarms of flies.

Medicine taking, especially of patent medicines, is prevalent on the farm, equally
as prevalent as in the cities. Medicine fakers, with gaudy wagons covered with
absurd statements of cure, go through rural regions selling great quantities of medi-
dnee. They offer and find ready sale for "Dyspepsia cure,** ** Spring medicine,**
"Blood purifier,** "Winter tonic,** "Cough cure,** "Eye relief,*' "Earache cure,*'
"Diarrhea cure,** "Female cure,** "Eczema cure,** and so on, until the damnable

396 PB00EEDING8 SECOND PAN AMEBICAN SOIENTIFIO C0NQBBS8.

list becomes a veritable plague. These so-called medicines are truly an assault upon
health of such serious magnitude as to call for statutory prohibition.

There are abundant facts and much strong argument for believing that the whole-
sale taking of medicines and drugs by the American people constitutes their greatest
offense against health. No other people have such a per capita record for drug swal-
lowing as Americans, and this, too, when it is obvious that he who doctors himself has
a fool for a doctor.

Sanitary betterment is sorely needed in rural districts. The farmer needs to learn
he must surely suffer if he neglects to dispose of his household sewage in a sanitary
way. The almost ubiquitious manure pile offending sight and smell and producing
flies and fever must be abolished. He must learn that clear water is not always
pure, and must supply his family with water which is unquestionably wholesome.
He must learn to dispose of slops and garbage in a sanitary way; he must ventilate
thoroughly; he must provide bathing facilities; he must stop taking medicines by
wholesale; and last, but not least, he must learn food values and better preparation
of foods, for it is true a man is what he eats, how he eats it, and how much he eats.

Rvral sanitary survey of nine counties of Indiana — Bartholomew, Boone, Daviess, Mar-
shall, Montgomery, Scott, Union, Ohio, Blackford,

•

Number of homes surveyed 9, 163

Highest score 90

Lowest score 24

Ayerage
score

for each
point.

Site 76

Sanitary condition of premises 61

House 72

Cellar 8

Ventilation 60

Water supply 29

Sewage disposal 17

Bam, barnyard, pigpens, chicken coops 39

Disposal of manure 11

Health 81

Average 46.4

The above table shows form of score card used and also shows the average results.
As stated, the standard adopted was 76 per cent and to fall below this means insanitary.
The average is below standard.

Indiana death rate for decade ending with 1914.

Death late,
1,000.

Typhoid

pate,
100,000.

Tabereok).
alt rate,
loo/xn.

State

Percent,
13.4
14.9
1L9

PerctfU,
20.5
27.5
SI. 5

Percent.
1814

Urban ...............*. ...^.

144. S

RSaLv::;;:::::::;:::;:;:::::;:::;:::::;;;:;:::::;::::;:;::::::;::

12&6

»L4

>10.4

1 More in rural.

> More in urban.

PUBUO HEALTH AND MEDICINE. 397

IndianaJStatb^Boabd op Health Rural Sanitary Survey.

score sheet.

Date

County

Township

Town

Name

Poet office

SCORE.

1. Site of house

2. Sanitary condition of premises

3. House

4. CeUar

6. Ventilation

6. Water supply

7. Sewage disposal

8. Bam, bamg^, pigpen, coops

9. Disposal of manure

10. Health

Average

Births in last two years?

Remarks

, Inspector.

SANITARY FARM SURVEYS.

Total number of surveys 278

Pot
cent.

Frame houses, 192 69.06

Brick houses, 84 30.21

Stone houses, 2 71

More or less bad repair, 188 67.62

In good or passable condition, 90 32. 37

Flat on the ground, unventilated beneath, 173 62. 23

Raised up 18 inches or more and ventilated beneath, 105 37. 76

Dry, well-ventilated cellars, 64 23.02

Without cellars or simply an excavation under part of house, usually damp

and dirty, 214 76.98

Small one-window bedrooms, 278 * 100

Heated by air-tight stoves or base burners, 221 79. 6

Heated by furnaces, 57 20.5

Slops thrown on ground at or near the kitchen door or into leaky receptacles,

214 76.98

Slops cared for carefully, 64 23.02

Sewage disposal by outdoor privies, 278 100

Nimiber of foul open-to-flies privies, 221 79. 5

Well built, well kept privies, 57 20.5

1 Erery one of the 278 houses h«d one or more small one-window bedrooms, and only oocaslonally did I
find large airy bedrooms. Not infrequently as many as four persons slept in a small one-window room
frequently two or more slept in the sitting room, and in 10 Instaooes people slept in the Idtdien. This
In only a few instances was caused by poverty. In most instances it was plainly due to ignorance and
penuriousnesB.

398 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONOBESS.

Dug wells and so-called springs, 159 57. 19

Driven wells, 119 42.80

Supplied with baths and running water, 11 3.9

Bams and barnyards within 150 feet of house, 207 74. 46

Unsanitary bams and barnyards, 224 80. 57

Used patent medidnes, 278 100

Kitchens and oooHn^.— All the kitchens in the 278 houses surveyed were inspected
as to equipment, order, and cleanliness. Number of passably equipped kitchens, 56,
or 20.14 per cent. Number of kitchens in good order and really clean, 256, or 88 per
cent.

Only in 37 instances could the cooking be fully inspected, and in 22, or 69 per cent,
it was distinctly bad. In these the bread was not well baked. It contained live
yeast cells and the starch was not changed by thorough baking to the soluble form,
nd hence it was difficult of digestion and provocative of gastric trouble. The frying
pan was too much in evidence. Potatoes and string beans swimming in grease were
on the table frequently, and frequently the meats were fried hard and were stringy
and juiceless.

The jams, jellies, fruit butters, and pumpkin pie were invaribly good. Biscuits
were usually heavy and yellow with soda. Bolls were very large (too large) and like
the bread usually contained live yeast cells and were not sufficiently baked.

Statistics of nine counties of Indiana.

Counties.

Popolation.

Increase

(+)or

decrease

(-).

Percent.

School ennmera-
tinL

Decrease.

Percent
decrease.

1900

1010

1900

1910

Bartholomew

Boone.

M,i»4
20,321
20,747
25,119
29,388
8,307
6,748
4,724
17,212

24,813
24,673
27^747
24,176
29,296

f'2S
6,260

4 320

16,045

+ 219
-1,648
-2,167

- 344

- 92
+ 419

- 488

- 395
-1,168

+0.9

-6.3

-7.2

-3.8

-3

-7

-8

-6

7,152
7^866
9,986
8,192
8,353
2,764
1,612
1,325
5,381

6,849 303
6,835 1,090
9,136 849
7,061 ' 1,111
7,373 1 980
2,408 ! 266
1,372 240
9821 343
4,502 1 875
1

4.2

Daviess

9.2

Mftrffh<fl1 , ,

18.6

IConteomery

1L7

soottf^^r?..:..:.:.:

Union

Ohio

2.5

Blackford

Birth, deathj and disease rates.

Counties.

Birth

ijorf.

Death

^^
1,000.

Consomp- Typhoid
tion rate, rate,
100,000. 100,000.

III

State
death
rate.

State to- State

berculosis typhoid

rate. < rata.

Bartholomew . ■

21.0
18.3
23.3
18.6
2a4
18.2
18.5
16.2
24.5

12.5
12.8
12.4
12.6
18.2
12.6
12.4
12.2
12.0

204.7
108.1
185.0
109.1
186.8
194.8
111.7
69.3
99.7

42.3
32.5
49.0
2a8
27.0
22.9
16.9

Boone

Daviess

MwTPh*^" r- -

22.2

13.2

145.8 36.5

liontgoPMfY

sootTv!:^.::.::":

Union

Ohio

Blackford

12.4

r ••

PUBLIC HEALTH AND MEDICINE. 399

SUMMARY.

Sanitary aurvey of 9,753 farmhouBes. The average score per cent was 45.4; re-
quired to pass as sanitary, 75. Highest score, 90 per cent; lowest, 24 per cent.

Number of houses which by the test could be counted as sanitary, 241, or 2.6 per
cent.

The prevailing '^stomach trouble" among farmers, which surely frequently comes
from poor food, tells plainly that the farmer's dietary is frequently poor.

The open and usually noisome privy, the frequently polluted well, the manure and
the flies, make plain why typhoid prevails upon the farm to a degr^ greater than in
the cities. Consumption should be practically absent from rural homes, and it will
depart when the farmer opens his Jidndows and gets rid of his stomach trouble.

The firmer needs to be better informed of the conditions productive of health,
and, as said by the farmer's wife who was quoted, he should be compelled by law to
build hygienically and keep his farm clean, if he does not voluntarily do it.

I append tables which gave data of the sanitary study of 9,431 farmhouses; 273
were surveyed by myself, the remainder by two trained inspectors.

Adjournment.

JOINT SESSION OF SUBSECTION B OF SECTION Vm AND
THE AMERICAN STATISTICAL ASSOCUTION,

Raleigh Hotel,
Thursday afternoon, December SO, 1916,

Chairman, Joseph A. Hill.

The session was called to order at 2.30 o'clock by the chairman.

The Chairman. The first paper on the program this afternoon is
presented by Dr. Cressy L. Wilbur, director of the division of vital
statistics, New York State Department of Health, and is entitled
''The Federal registration service of the United States: Its devel-
opment, problems, and defects."

Dr. WiLBUB. Mr. Chairman, ladies and gentlemen, I take up in
the general paper on the subject the relation of the census to vital
statistics. At the time the paper was handed in, November 1, the
Federal registration area for births had not been established. I may
say that there are some very valuable tables in the appendix to this
paper, prepared by the Bureau of the Census, which show the actual
results of registration and the condition of vital statistics in the
various States of the Union since the first registration area was
organized.

THE FEDERAL REGISTRATION SERVICE OF THE UNITED STATES: ITS
DEVELOPMENT, PROBLEMS, AND DEFECTS.^

By CRESSY L. WILBUR,
Director of Vital Statistics, StaU Department of Health, Albany, N. Y,

The Chairman. Is there any discussion of Dr. Wilbur's paper ?
Dr. J. N. HuRTY. You showed a slide. Dr. Wilbur, indicating that
Indiana was without an adequate birth-registration law. We have a

1 Dr. Wilbur's paper has been published as a separate bulletin under the same title by the Burean of
the Census, Department of Commerce, Washington, Oovernment Printing OfRoe, 191ft.
The table o( contents is as follows:

Page.

Introduction 7

Relation of the Census to vital statistics 7

Extension of the registration area for deaths 9

Growth of registration area for deaths: 1880 to 1915 (cartograms) 10,11

Population, land area, and death rates of the registration area: 1880 to 1914 (table) 12

Growth of registration area for deaths: 1880 to 1914 (diagram) It

Adequacy of birth and death registration laws: 1915 (cartograms) 10

Useof standard birth and death certificates: 1915 (cartograms) 10

400

PUBLIC HEALTH AND MEDICINE. 401

better law than the model. A physician who does not report his birth
in 36 hours can not collect his fee. It comes right home. Further-
more, we are getting a better birth rate than New York.

Dr. WiLBUB. What proportion of your doctors report their births
in 36 hours?

Dr. HuRTY. All that are reported come in that way.

Dr. Wilbur. What proportion report within the limit set by law ?

Dr. HuRTY. I can not teU you, because _the vital statistics are not
directly managed by me. We had a baby show in Indianapolis,
where 300 babies were shown, and we found that only 5 had not been
reported — and one doctor failed to do that. He paid a fine on each
individual case. We prosecuted him on each one separately. The
prosecutor wanted to take them all in a bunch, but we insisted on
one at a time. I do not know the total amount, but those prose-
cutions are being brought all the time. Now that the Director of
the Census wants the exact information, we will gather all that.
The doctors are reporting in a grumbling way, and some are trying
to get the State board of health abolished because of this enforcement.

You said we did not have an adequate law. If there is any trouble,
it is with the executive officers of tie State and not with the law.

Dr. Wilbur. You may remember that a few years ago, when I
was chief statistician for vital statistics in the Bureau of the Census,
we held a consultation in r^ard to the Indiana law. We agreed,

Footnote— Contiiiiied. Page.

TlM registration area for births 17

The Model Law 19

Necessary provisioiis for registration 21

United States standard birtli and death certificates 91

The standard osrtifloate o( death (reduced feosimlle) M

Instrootlons on standard certificate of death (redaced faoiimlle) M

The standard certificate of birth (reduced facsimile) 25

The workof the Federal and state registration servloes 26

Items returned to the Bureau of the Census on mortality schedules or transcripts: 1860 to

1»1« (table) »

lldrtality card used by the Bureau of the Census: 1914 (reduced &csimlle) 22

Problems and defects of the present system of vital statistics 28

When and how will the United States obtain complete registration of vital statistlcsr 87

Resolution by Congress 41

B4sDm« a

Oflldal publications on vital statistics In the United States 49

▲ppnrDicu.

AmMMX L—Orowth of registration area, population inohided, by divisions and States: 1880 to

1916 64

AmNDix 2A.— Deaths and death rates from registration sources, by divisions and States: 1900

to 1914 06

ArpiKOix 2B.~I>eaths and death rates from registration and nonregistration sources (the latter

very incomplete), by divisions and States: 1880 to 1900 70

AmMMX 8.~6frths (eocoiuslve of stillbirths) and blrtu rates, according to data available (very

faMomplete), by divisions and States: 1880tol910 72

AmifDU 4.~The Model Law: "A biU to provide for the registration of all births and deaths tai

the Stateof " n

402 PBOGEEDINGS SECOND PAN AMEBICAN SCIENTIFIC C0NGBE88.

I believe, at that time that it required amendments in order to
bring it into conformity with the model law. Your law required
births to be registered in 36 hours. You have not foimd out how
many doctors file their certificates in 36 hours, have you ?

Dr. HuBTY. No.

Dr. WiLBUB. In the State of New York we have coimted the cer-
tificates for May, 1915, and know just how many doctors complied
with the law. We foimd 20 per cent did not; and I will guarantee
that in Indiana at least 20 per cent, and very likely 50 per cent, register
after the l^al Umit set by your law. I beUeve, therefore, that your
law is being violated right along in possibly 50 per cent of the cases.

Dr. HuBTY. Oh, no; I guess it is about 30 per cent.

Dr. WiLBUB. You are guessing and I am guessing. You are per-
mitting violations right along. But you make a guess, based on a
baby show where only five babies in that particular instance were
not registered.

Dr. HuBTY. We asked the school teachers to aid us in finding to
what extent births were not registered. We promised them $1 for
every birth that had not been registered. We took 10 townships,
and it cost us only $8.

Another thing brought great returns — our Indiana Mother's Baby
Book. Every mother in Indiana gets it as a present from the State
when her baby is bom and a letter from the governor congratulating
her. That has been published all over the State, and it is astonishing
how many mothers will write in for the present and disclose the fact
that the baby has not been registered, whereupon we send her a
blank to be filled out before she gets the present and the letter.
This costs about $6,000 a year, but it pays.

Dr. WiLBUB. I want to say that Dr. Hurty's baby book is the
finest one that I know of. Dr. Williams, deputy commissioner of
New York, took a copy of it to the governor in a recent budget
hearing, with the plea Uiat an effort be made to get something like
that in New York.

Dr. GuiLPOY. I have enjoyed the Uterary treat which Dr. Wilbur has
furnished us, and I must say that if I were of a literary turn of mind
nothing woidd suit me better than to create a big policeman in the
vicinity of that pond so that I might compel Massachusetts and Indi-
ana and their sister States to take the plunge. We took it in 1910.
Before that we had tried for many years to place the administra-
tion on record as making an effort to obtain full and accurate reg-
istration of births, but it was not imtil 1910 that we succeeded in
obtaining a commissioner who gave the registrar carte blanche to
obtain complete registration of births. Within the first two years of
his administration we prosecuted 312 physicians and midwives.
Three hundred of these were physicians and 12 were midwives, and

PUBLIC HEALTH AND MEDIOINB. 408

each and every one of them was fined. From that day on I thmk
in the city of New York we hare had an accurate registration of all
births.

We made a test by getting names of a large number of children
and tumiog them in to the registration office, where comparisons
were made with the birth indices. It was found that Mfmhattan
was roistering 99 and a fraction per cent of its births; the Bronx,
100 per cent; Brooklyn, 96 and a fraction. So, for all practical pur-
poses, we have in the city of New York at the present day very
accurate registration of births.

We welcome Dr. Wilbur to the field of New York with open arms.
We are cooperating with him as strongly as possible — ^much more
so than imder the previous State administration. He wiU be as
successful there as he was in the Federal Census Bureau.

The Celiibman. I think this discussion is doing very much to
vitalize vital statistics. As the Director of the Census, the chairman
of the subsection, is now present, I will ask him to take the chair.

Director Rogers thereupon took the chair.

Dr. WiLLOOX. In view of the fact that we have a program of six
papers, only one of which has been presented and discussed, I should
like to propose that the discussion of the other papers be postponed
until all have been presented.

THE INCroENCE OF THE DIFFERENT CAUSES OF MOHTALirY IN PROVI-
DENCE DURING 55 YEARS, 1856 TO 1910.

By CHARLES V. CHAPIN,
SuperinUnderU of HeaUk, Providence, R. I.

I ought first of all to apologize for presenting to a meeting of statisticians merely a
series of guesses. The only excuse for so doing is to indicate the uncertainty of many
of the data of mortality statistics and to call attention to the dangers awaiting one who
attempts to base conclusions on uncorrected death rates.

This study ought to be of value because, during the period named, the registra-
tion of dealhs has been practically complete, and because, during this time, there
have been only two registrars, with the same clerk working for many years under each.
This practically eliminates the personal equation so far 88 tabulation is concerned
and has rendered it possible to correct most of the changes in tabulation and to make
allowance for others.

That during the last 60 years there have been very great changes in the causes
of deaths as certified by physicians which do not at all indicate corresponding changes
in the incidence of disease is well known. These changes are due to many causes,
chief among which are the better education of physicians, better methods of diagnosis,
and increased knowledge of pathology and causation. That physicians' certificates
have shown a progressive tendency to greater accuracy in stating the causes of death
no one will deny.

If one considers the change which has taken place in the incidence of any particular
cause, as, for instance, the decrease in infantile convulsions, the thought at once
68436— 17— VOL ix 27

404 PBOCBEDINGS SBOOKD FAK AMEBIOAN SCIENTIFIC C0NGBE8S.

suggeetB itself that this change is not wholly, if at all, real, but that it is due largely to
physicians now certifying death as due to the underlying cause of the conyulaions,
while in former years they failed to mention the real disease, but only the conYulaions
which were its terminal manifestation.

It is comparatively easy, and is a common practice, when considering such a change
in mortality from a given cause, to say that the decrease, or increase, is due to a transfer
to, or from other causes. Such an assumption can often be substantiated by good and
siifficient evidence. It is, however, easy to assume too much when claiming such a
transfer for any particular cause, especially when the assumption is made with the ob>
ject of proving some point in pathology or epidemiology . Thus one might assume that
the decrease in convulsions is due to a transfer to scarlet fever and enteritis and the de-
crease in pulmonary tuberculosis to a transfer to pneumonia and bronchitis. If, how-
ever, the changes are critically considered in connection with other diseases, these par-
ticular assimiptions seem to be unwarranted. It has seemed to me that the chances of
error in estimating and locating the changes and transfers would be very much les-
sened if they should all be considered together. By considering all the suggested
changes in the statement of the causes of death, and estimating them quantitatively,
the chance of an erroneous assumption is very much lessened, for the total increase, or
decrease, of the c<»Tected causes must equal the total increase, or decrease, which
actually occurred, and because of this check the chance of making wild guesses is
certainly diminished.

For the purpose of making such a study, some years ago I prepared a table showing
the apparent increase, or decrease, in the different causes of death between the decades
1856 to 1865 and 1896 to 1905, and I have recently, for the purposes of this meeting,
prepared another table showing the changes between the decade 1896 to 1905 and the
5-year period 1906 to 1910.

The tables referred to are to be found appended to the paper.

I then proceeded to discuss changes in nomenclature and to make certain transfers
from one cause to another so as to make the nomenclature of the first decade corre-
spond as nearly as might be with present day usage. Such transfers must depend
diiefly on the judgment of the one making them, and my attempt was at the time
considered merely tentative, and I have since concluded to modify it somewhat. The
table shown is the amended form.

We will now consider the different causes and try to determine what transfers should
be made to make the nomenclature of the physicians of 50 years ago correspond with
the conclusions of the pathology and etiology of the present.

There have probably been almost no deaths in Providence from malaria, but since
the disease became mildly endemic in 1881 cases of both fatal and nonfatal disease due
to other causes have been attributed to this. A perhaps fair estimate is that of the ap-
parent increase, 2.06 has been really a transfer from phthisis, 2 from imknown and
0.41 from anemia.

Dii^theria showed an apparent slight increase between the first and last decades,
but it is almost certain that the very great decrease in croup is really a decrease in
diphtheria and so, also, is perhaps 1.5 of the tonsilitis and pharyngitiB included in
diseases of the mouth, etc. On the other hand the apparent increase in laryngitis ia
almost certainly due to the effort to avoid the restrictive measures which are applied
in cases of diphtheria. If these causes are grouped as diphtheria the result shows a
substantial decrease of 46.77.

As there was probably no epidemic influenza during the first decade the increase of
23.12 is doubtiess real and there is good reason to believe that it should be increased
by at least 5 deaths per 100,000 attributed to bronchitis and by 13 from pneumonia.
If this is true, and it is not unlikely that the figures ought to be even larger, the death
rate from influenza in the decade 1896-1905 should be 41.12 instead of 23.12.

PUBUO HEALTH AND MEDICINE. 405

The apparent increase in septicemia is doubtless due to the better diagnosis of cases
of hidden origin. It is not unlikely that 1.58 is a transfer from tuberculosis and 2 from
tjrphoid fever.

The tuberculous infections, other than phthisis, have approximately increased 40.26,
but it is probable that the whole of the 10.24 decrease in scrofula and that 55.53 in
hydrocephalis should be credited to tuberculosis. The description of hydrocephalus
given by the older physicians indicates that it was probably a tuberculous menin-
gitis, and the age distribution of the deaths lends color to this view. In the seventies
it is almost certain that some cerebrospinal meningitis was reported as hydrocephalus,
but this error probably does not appear to any extent in the decades under considera-
tion. Of late years the term hydrocephalus has been used almost exclusively to
designate congenital defect. It is probable, also, that 1.55 of the decrease in abscesses
represents a decrease in tuberculosis. It is also thought by many that a very appre-
ciable amount of tuberculosis was formerly diagnosed as typhoid fever, and perhaps 3
of the decrease in that disease really represents a decrease in tuberculosis. It is prob-
able also that a part of the decrease in diseases of the brain is due to transfer to tuber-
culocds, perhaps 7.12. If these various changes are considered together we have
instead of an increase in nonpulmonary tuberculosis a decrease of 35.60. This is
very much less than the decrease in pulmonary tuberculosis, but here again it is not
impossible that a certain amount of the latter, which I have not ventured to estimate,
may in recent years have been returned as generalized tuberculosis, while in former
years it would have been reported as pulmonary.

That syphilis has really increased is not unlikely.

The question of the reality of the increase in ihe mortality from cancer has been
much discussed, but no certain conclusions have been arrived at. The fact that the
more easily recognized cancer of the breast has increased very little suggests that the
apparent increase in other forms of cancer is also to some extent unreal. The diffi-
culty is to find the cause or causes under which obscure cancer mig^t formerly have
been returned. The unknown deaths could have included only a few cancers as
there has been little decrease in the unknown at cancer ages. Perhaps 2 per 100,000
may have been derived from this source. The same is true of old age, and perhaps 3
may be assumed as a transfer from this cause. Intestinal cancer may formerly have
be«[i returned as dysentery or diarrhea, and the decrease in these diseases at cancer
ages may warrant a transfer of 5 and perhaps 10 may have been transferred from diseases
of the stomach. It is likely that 5 may formerly have been reported as liver disease.
Combining all these there is still left an increase in cancer mortality of 26.34, which it
is difficult to explain as unreal.

DoubtleflB a Ittge part ai the increase in diabetes is due to the recognition that this
disease is often the cause of gangrene of the extremities and the decrease of 3.71 in
gangrene and skin diseases should be transferred to diabetes and perhaps 2 from old
age and 2 from unknown.

Other general diseases have increased 1.57, about 1 of which is real and due to
increase in lead poisoning and drug habits and the rest is pertiaps a transfer of 0.27
from the unknown to Addison's disease and 0.30 from goiter (diseases of mouth, etc.)
to exophthalmic goiter.

The increase of 8.17 in deaths from cerebrospinal meningitis doubtless really rep*
resents the focto fairly well. A study of hydrocephalus and inflammation of the
brain renders it almost certain that between 1866 and 1880 many cases of the epi-
demic disease were concealed under the last named titles, but there is no evidence
of the existence of the disease during the first decade of registration.

The death rate from cerebral hemorrhage has shown a substantial increase, which I
believe to be real. The tendency in recent yean has been to attribute to heart
disease, embolism, or thrombosis, or to kidney disease, sudden deaths which for-

406 PBOOEEDIKGS SECOND PAN AMBSIOAN SCIENTIFIC C0NQBB88.

merly would have been returned as due to apoplexy. On the otlier hand, it »
unlikely that better diagnoos has transferred much, if anytliing, to this cause, so that
I am inclined to think that the increase is even greater than the figures indicate.

The small increase in tetanus is probably real.

The increase in diseases of the nervous system conflistB chiefly in diseases of tiia
spinal cord and, perhaps to the extent of 4, may be a transfer from paralysis. The
remaining 3.11 may well be a real increase.

Deaths from diseases of the heart have shown a marked increase, a part of whidi
may be due to a transfer htan cerebral hemonhsge, though I have not so indicated in
the table. There can be little doubt that there has been a omsiderable tnmsfer from
dropsy and more htan old age and unknown.

There is still left under old age a decrease of 13.91, which must represent transfer
merely, 15 under dropsy and 28.35 under unknown, which also are not real. I think
it not unlikely that 20 out of the total 57.26 decrease in these titles, chiefly in dropsy,
might properly be transferred to heart disease, thus reducing the apparent increase
of the latter to 57.97, and making it somewhat moce than for cerebral hemorrhage.
As stated above, a small transfer from the latter would make the increase of the two
about equal.

The increase in arterial disease is confined to arterio sderoais, and I have assumed
that of the total increase of 5.90, 3.90 repree^ts a transfer from old age and 2 from
phthisis.

Embolism and thromboeis have shown a decided increase, a part of which may be
real and part due to transfer from heart disease and i^plexy. Both of the latter
causes have increased very markedly, and it is likely that any real increase in embolism
and thromboeis is due to the same causes.

The increase in diseases of the larynx should be added to diphtheria.

The apparent increase in bronchitis and pneumonia is very marked, and it is often
assumed to be real, but it can not be whdly so. There is doubtless much confusion
between bronchitis and pneumonia, as the differential diagnosis is often not made in
infants and young children. Whether a death in a young child will be reported as
bronchitis, or imeumonia, depends very much on the fashion of the hour or the knowl-
edge of the individual making the repart There has undoubtedly in Providence,
at least, in recent years been a tendency to prefer pneumonia, so that a part of the
decrease in bronchitis in the last few years hu probably been due to a transferance
to pneumonia. The differential diagnosis of bronchitis, bronchopneumonia, and
lobar pneumonia has been so uncertain that for the extremes of life it would probably
be useful to consider them all together. But in this connection only the cases reported
as bronchitis, whether capillary or otherwise, are considered.

There has apparently been a very great increase in the mortality from brondatis,
from 11.5 per 100,000 living in the first decade of registration to 60.4 in the last decade,
an increase of 48.9. The maximum, however, was not attained in the last decade»
but in the 5-year period, 1886-1890. In order to examine this increase more doseiy
it is desirable to note the changes in the age distribution of the disease. Thou|^
it would perhaps be better to consider these diseases together, they will be taken
up separately.

The prevalence of both bronchitis and pneumonia is affected to a marked extent by
the presence of influenza, and I think it hi^y probable that at least 5 of the inoease
in the former is due to this cause and should be tzansferred. Among old people it is
probable that there has been a considerable transfer from old age, say, 10, and among
infants and children a transfer of perhaps 6 from diseases of the brain and 10 from
convulsions. The latter transfers may seem too large to s<«ie, but I leel very sure
that they are not. There has been much discussion as to the transfer from phthisis
to bronchitis and vice versa. Doubtless there has been some in both directions, and
after having held various opinions I am now inclined to think that for the decades
under consideratian the transfers balance.

PUBUO HEALTH AND MEDICINE. 407

On pneumonia influenza appeara to have a more marked effect than on bronchitie,
and we may assume a transfer of 18. I would assume transfer of 14 from brain disease
and 10 from convulsions, with perhaps 6 from old age. There has perhaps been a
transfer from phthisis of 5 due to a desire, in recent years, to conceal tuberculosis.
The apparent decrease of 0.58 in pleurisy is also probably due to a transfer to pneu-
monia.

The increase in other respiratory diseases is due partly to the more accurate diag-
nosis (A gangrene of lungs and emphysema, and in so fttr may represent a transfer from
phthisis, bronchitis, or pneumonia, but is chiefly due to the inclusion of pulmonary
hemorrhage, as required by the international classification, so that perhaps 2 of this
increase ought to be carried over to phthiab.

Diseases of the stomach have shown a very considerable apparent increase, but it
18 highly probable that none of this is real. Teething has now practically disappeared
from death returns, as the deaths formerly attributed to it are recognized as due to
gastro-intestinal infections or perhaps meningitis. It is here assumed that all of this
decrease in teething should properly be credited to diseases of the stomach. So,
also, perhaps 10 of the decrease in convulsions and 5 of infantile debility represent
a transfer to disorders of the stomach, which in recent years have been recognized
as the underlying cause of the convulsions, or the debility. There has probably
also been a transfer of at least 6 from diseases of the brain and 5 from unknown. On
the other hand, there has probably been a transfer of perhaps 10 to cancer. Thus
instead of an increase in diseases of the stomach there is probably a decrease of 11.89.

For the present purpose hernia and intestinal disease may well be considered
together. The joint increase has been 24.09. The principal intestinal diseases are
Tarious forms of bbstruction and appendicitis. The increase of 24.09 is almost entirely
confined to hernia and appendicitis, especially the latter, and in the case of appendi-
citis is confined to the last 20 years. It is assumed, and particularly by surgeons,
that this increase is apparent only and is due to a transfer from other causes. It is
alkged that deaths from appendicitis were formerly returned as inflammation of
the bowels, or colic, but this is certainly not so in Providence. Nearly all of the
comparatively few deaths so returned were of young children, not of the appendicitis
age. The only other titles showing a decrease from which the appendicitis and hernia
increase could be derived are peritonitis and unknown. In peritonitis the decrease
10 only 6.24, and doubtiess a part of this should be credited to diseases of females,
leaving 4 for intestinal diseases. Perhaps 8 may be taken from unknown. The total
increase of intestinal disease is then 17.09, which, so far as can be seen, is real.

Diseases of the liver have shown an increase of 2.92. It is probable that there has
been a progressive shifting of dropsy to diseases of the liver and from the latter to
cancer, and it is perhaps not unfair to assume that liver disease as a cause of death
has remained stationary, or perhi^ more of the decrease of dropsy and some of un-
known should be transferred to this cause.

Disease of the kidneys show an increase of 115.68, consisting almost exclusively
of nephritis, or Bright's disease, a larger increase than is found imder any other title.
That a considerable part of this represents merely a transfer from other causes no one
will doubt. Fifty years ago the diagnosis of chronic nephritis was not readily made
by the average practitioner, and the recognition of this condition has increased during
the succeeding years. When we look about for tities imder which it might formerly
have been reported we see that there remains a decrease of 87.26 in the combined
titles of old age, dropsy, and unknown. If the whole of this represents a transfer to
diflcftsos of the kidneys, the increase of the latter would be reduced to 78.37, still
leaving it greater than for any other titie. There seems to be no doubt that disoaoos
of the arteries, as indicated by cerebral hemorrhage, diseases of the heart, and of the
kidneys, have shown a remarkable increase. As they are pathologically related, it is
perhaps not surprising that they show a somewhat correlated increase.

408 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIO CONGRESS.

TJrinary disease, coTuristing chiefly of calculi and disease of the bladder and pros-
tate gland, has shown an apparent increase of 6.77, periiaps 1 of which may, owing
to better diagnosis, be a transfer from the unknown. It is difficult to explain the
remainder of the increase as other than real.

Diseases of females also have increased by 6.95. A part of this, say 2, may be ex-
plained as a transfer from the unknown and perhaps 2.24 from peritonitis and 0.69
from tumors, leaving 2.02 as real.

Puerperal fever may well be combined with childbirth, the resultant being a net
decrease of 1.84, which is doubtless real.

I have been unable to obtain any satisfoctory explanation of the apparent increase
in deaths from disease of the bones and joints comprised in the title diseases of loco-
motion.

The increase in malformations is probably real. Most malformations are merely
the persistence of fetal conditions, and with the increase in premature births it is
but natural that some should be attributed to such conditions.

There has apparently been a very laige increase in premature births, which I believe
is largely real in the sense that it is due chiefly to the greater care used by physicians
in distinguishing between stillbirths and living births. There has jHrobably been a
transfer of about 5 from debility to premature birth.

There is no reason to doubt that suicide, insolation, and homicide have increased
as the figures indicate.

Accidents also have doubtless really increased, thou^ oi the total 23.30, about 5 if
due to the inclusion of accidents at birth as formerly required by the International
Classification, and should be transferred to debility.

A number of changes in the causes showing a decrease have already been refened
to. Typhoid fever has probably decreased a little less than appean, owing to a
transfer to sepsis and tuberculosis. The decrease in smallpox is doubtless real.
Scarlet fever has diminished slightly more than the figures eAiow, owing to transfer
from dropsy. Measles and pertussis show decrease, but, owing to their periodicity,
10-year periods are too small for their proper study. Probably there has been a greater
decrease than is shown by the figures, as doubtless deaths are now properly reported
which formerly would have been attributed to pneumonia or bronchitiB. We may
perhaps assimie the decrease in erysipelas to be real.

Phthisis has apparently decreased more than any other disease. That most of it is
real seems likely, though perhaps 16 to 25 per cent of it may be due to the increasiiig
number of deatJis of Providence people outside of the city. The apparent decrease
in scrofula, tumors, and anemia is doubtless due to transfer to other causes. It is
probable that alcoholism has shown a real decrease. The decrease in the next two
titles also probably represents transfers and the same is true of convulsions. The
decrease in insanity on the other hand is real and depends upon the increasing num-
ber of deaths in the State hospital outside the city limits. This is also true for epilepsy.
Most of the decrease in hemorrhage is probably in that form of hemorrhage caused by
pulmonary tuberculosis and might well be combined with the latter title. The de-
crease in pleurisy and in diseases of the mouth has been shown to be probably a
transfer.

Diarrheal diseases have shown a very marked decrease which is probably mostly
real. This group must be considered in connection with diseases of the stomach.
In infants many deaths are due to gaetro-intestinal disturbance and whether the
death will be reported as due to gastric indigestion, or diarrhea, or enteritis, has, to a
considerable extent, depended on the fashion of the hour, or the personal views of the
physician . There is no doubt that the group of diseases here referred to has decreased
very decidedly.

The decrease in infantile debibty, teething, old age, dropsy, and imknown causes
has doubtless been due almost entirely to better diagnosis.

PUBUO HEALTH AND MEDICINE.

409

The principal points to be noticed after this attempt to allow for changes in diag-
nosis are that the degenerative diseases of advjtnced life, cerebral hemorrhage, heart
disease, and kidney disease have shown a very marked increase. Cancer has shown
an increase but not nearly as great as at first appears. Pneumonia and bronchitis
have really increased very little, their apparent increase being due almost entirely
to influenza.

The great decreases are seen to be in the infectious diseases, typhoid fever, scarlet
fever, diphtheria, tuberculosis, and gastro-inteetinal infections.

Another chart has been jn^pared to show the changes between the 10-year period,
1896-1906, and the 5-year period, 1906-1910.

It will be noticed that cancer is still increasing, that cerebral hemorrhage and
diseases of the heart and of the arteries, are also increasing. The only reason \diy
kidney disease shows no increase is probably because a better pathology and diagnosis
refer back to circulatory changes. The increase in premature birth is still due
largely to more care in registration. The increase under ''unknown" indicates a
lessened tendency to guess. The increase in measles is the result of the usual peri-
odicity of the disease. The increase in scarlet fever mortality was due to a par-
ticularly virulent strain of that disease.

Typhoid fever and diphtheria continue to decrease and the decrease in pulmonary
and other forms of tuberculosis and in gastro-intestinal diseases is still phenomenal.
Influenza is disappearing and as a consequence the combined m(»tality of bronchitis
and pneumonia is diminishing at a very similar rate. Malaria, croup, scrofula,
teething, and dropsy have become nearly obsolete as causes of death and old age and
convulsions are far less frequentiy used to conceal careless diagnosLs.

Mortality in

Providence, by causes— Changes in rates per 100,000 living between 1856-
1865 oni 1896-1905.

No.

Disease.

Increase

kSI&o

Clailsfloatian
No.

Disease.

Decrease
livlnf.

U»lAllA...,

4.47

.97

88.12

8.68
4a 26

Z67
4X03

9.68

1.67
.84

8.17

6X21

.78

7.11
77.97

6.90

6.79

1.84

48L90

61.86

.46

X94
28.92

8.99
20.10

X92
116.63

6.77

6.96
.87

8.83

6.00
88.94

6.77

4.0

28.30

1.27

48.80

9-1

Diphtheria.

Vsrioia.

7.64

InfiuensA.

Rnb«ll#.....x

.14

tSSSSuS^T!'.*::::-

ffoATlA^nii

118.88

96 to 84.

Pertussis.

8.20

flyphnt". /.....

0-2

Croup ,

48.08

80 to 46

C^oer

5:::;:;::;:

Ery«pelas

8.64

DJabetee

Other general diseases. . .
Rheoiniatism.

Cerebral hemorrhage —
Tetanus.

piSiBiT...:.:;::.:::::::

169.81

lto66

Scrofula.

laM

47,48

Tumors

.69

«ll2

g'"

60'toTOL'.'.*.'.
66

AlAAhnlfimi

.41

S4-1

las?

Brain diseases.

82.19

62 to 76

Other nervoos diseases. .

Heart

Diseases of arteries, etc..
Embidism and throm-
bosis.

Paralysis.

7.89

77 to 80.

S:**:::::::

TnflNiJty

9.86

81 to 86

Ponvulsions. ..............

8&84

82..............

69 :...,

Epilepsy. ,,

L78

8w68

Diseases of larynx.

Bronchitis.....

89,100,102..

184 to 187...
142

picSri8y!T;::::::::;:;;::

.68

Diseases of mouth, phar-
ynx and esophagus

Dforrheal diseases

«'.•'•»:::;::::

Pnenmcnia.

4.04

Asthma.

Diseases of respiratory

organs

Diseases of stomadi.

H«mi<^

78.19

87,96,98,99

Peritonitis

6.21

Childbirth.

171

108,104

OAngrene

.81

10? ;:

144

148,146

160-1

161,162,168.

Abscess.

1.66

107,109,118

110 to 114... .

Intestinal diseases.

Diseases of liver

Skin diseases.

8.40

66.58

119 to 121

Diseases of kidney..:.::.

Urinary diseases.

Diseases of females

Pwrperal fever

Inhntile'debUity

»:»

122 to 126.

Teething

20.81

127 to 182.

164

Old age.

8&81

187

177

21.78

146 to 149

Diseases of looomotioQ...
lialformatioos

179

Unknown.

46.62

160-1-2

Total

Ifi^l

Premature birth

826.60

is^ioua

Suidde.

Excess of decrsase over
IncTsano

66LS7

169

Insolatioa.

168.164 to 176...

Aoddent

176-3 . .

Homicide.

174.88

Total

66L27

410 PEOCBEDINGS SECOND PAN AMERICAN SCIENTEFIO CONOBESS.

Mortality in Providence, by causes, after certain hypothetiocd changes, 185$-18S5 and

\89&-1905.

Increase.

Decrease.

Disease.

Rate.

Disease.

Rate.

Tnflpenm, , . . , . , , , , ,

41.12
2.57

17.03
1.97
1.00
.84
g.17

52.21

.78

3.11

67.97
6.79

17.90

3.27

.46

.94

17.09
2.92

78.37
5.77
2.02
8.33
5.00

28.94
5.77
4.00

18.30
1.27

Typhoid Itover

43.80

Byphflf<r , ,, ,

Variola

7.54

C^oer

Rubella

.14

Diabetes

Srnrly^tlna „.,.,

115.10

Other general diseases

Dir'h1h(>rte,.

46.77

Rheumatism

P(*r'i]'^ia*^^.*

8.20

Er'-.'sicHilas ,

8.64

Cerebral liemorrhageT

pii«iii;^is.......

Tph'i^rnJJosls

158.75

Tetanus T.

35.60

Othnr Tiflrvous diseases . ....

AJi-.iTirtlisra ..»,.

10.37

Heart disease

Pn-ilvsis

3.89

Embolism and thrombosis

In 'Lriftv **.*.*- ^

0.86

Bronchitis

CC'Ei^ntgiofis

8.84

Pneumonia ,,

E;'ii'."P5v.....

Hi'^'iorrliaec

1.78

Asthma

8 53

Other respiratory diseases

Di:'f i-'^":; m montll, etc

2.24

HemiaT!: ?..?!!!!t...::::::::::::::

Dfii^li.^.'v of ':l0!n^1Ch

Dhr-r-i'rtl i.1fwLV>'S

CLilubirtb

11.89

Diseases of liver

73.19

Diseases of kidney

1.84

Urinary diseases

Infantile debility

6.32

Diseases of females

Total

Diseases of locomotion

MalformiUions

Suicide

Insolation

Accident

Homicide

Total

388.41

562.74

388.41

174.33

Mortality in Providence, by

Changes in rates per 100,000 living between 189S-J905
and 190$-1910.

Disease.

Increase

iflSfooo

living.

Disease.

Decrease

1(£^
Uvlng.

Rubella

11.08

10.79

.06

.79

17.99

2.86

.19

8.46

2.83

8.99

10.39

22.12

U.43

2.77

7.70

.53

11.24

1.40

.51

.84

1.78

.87

2.17

.06

13.02

6.83

8.39

2.29

Typhoid Ibver

6.69

Scarlatina

ifiSSS..:™:::::::::::::::::::::::::::

8.73

Erysipelas

Variola

.45

Syphilis

Pertussis

8.60

Cancer

Diphtheria.

11.16

Diabetes

Croup

5.92

Ai^mi^fm^ lukemia..

Tnflnenca. ,,,

14.92

Ai«A>»oH?»n . . . . .

■Punilent septicemia.^.

.94

Other genAral diseases

Phthisis .'

6&14

Cerabf^qolnftl meningitis r

Tuberculosis

6.18

nAi«brA|>ATnorrhnff<^r..

.28

Diseases of heart..:.

Tumors

4.78

Diseases of arteries, etc

Rheiirri Atism ....... r .................. .

2.51

Embolism

Diseases of brain

19.06

Paralysb

4.21

Diseases of mouth

Injianlty

.87

Hernia

Epilep^

LOO

Other diseases of digestive organs

Convulsions

6.65

Urinary diseases... T .".

Tetanus.

.25

Diseases of females

Othnr nervous dfa^wses ..................

.10

Childbirth

H^fimorrhage . r

2.97

Skin diseases

Diseases of larynx.

1.72

Diseases of locomotion

25.88

Hydrocephalus

Pleurisy

.74

Pramatuie birth

Asthma

Suicide

Diseases of respiratorv orvana.

AccidaDts

Diseases of stomach

9.M

HomidcS:::. ;.:.:...:::::

Diarrheal diseases

40.16

PUBUO HEALTH AND MEDICINE.

411

Mortality in Providence^ by causee — Changes in rates per 100,000 living between 1896-1905
and 1905-1910— Continued.

Dlswse.

Increase

Disease.

Decrease

loolooo

liYtDS.

Unknown

4.21

Diseases of Intestines

0.27

Diseases of liver

1.57

Peritonitis

5.01

Kidney diseases

.09

Puerperal fever

.98

0<vi^rene ... . .

.21

.70

Malformations

2.04

Infen tile debility

4.77

Twthfrig

1.81

Old age

21.13

Insolation

8.65

Dropsy

.70

Total

Tatal

101.09

270.09

Total increase

161.09

Net increase

115.60

VITAL STATISTICS IN CITIES.

By WILLIAM H. GUILFOY,
Registrar of Records, New York City,

Aa far as I have been able to dlscoyer or unearth there was no effort made in our
earliest days to collect statistics of this nature. It is true that isolated records of mar-
riages and births were made here and there by some of the churches and officials.
Dr. Wilbur has discovered what he claims to be the first record of a birth of a slave
child made in New York State at the town of Smithtown, Long Island, in 1797.

It was not imtil the middle of the last century that the importance of the tabulation
of births, deaths, and marriages was realized, and that efforts were made to present in
tabular form and with appropriate comment the statistics of a few of the larger cities.

The earliest table of mortolity that I know of or have been able to discover is a
printed table issued in the year 1854, which showed the mortality of the city of New
York from the beginning of the century— 1804 to 1853, inclusive. Apparently it
was a recapitulation of previous tables issued in the early part of the century. It
gave the individual causes of death by yean for the half century and an added recapitu-
lation giving the deaths from all causes by 13 age groups.

The three large cities of Boston, Providence, and New Y(Hrk were the first to pub-
lish statistical tables reflecting the fecimdity, the mating, and the mortality of these
communities.

The city registrar of Providence, Dr. E. M. Snow, issued his first report in 1855,
which contained tables showing the birthplace of brides and grooms and their ages,
the births occurring in the dty by wards and by nativities of the parents, the deaths
by sex, condition, nativity, montiis, wards, ages, and causes of deaths; in connection
with these tables he wrote upon their most striking phases and according to his li^ts,
Intelligently and convincingly.

In 1849 the city registrar of Boston was requested to file births, marriages, and deaths
and in 1872 he publfahed for eadi year from 1849 to 1872 one table of births, one of
marriages, and six of deaths.

In 1853 the city inspector of the city of New York, as he was then called, pub-
lished over 110 pages of statistical and reading matter bearing upon the mortality

412 PB0CEEDIN6S SECOND PAN AMEBICAK SdEKTEFIG G0NGBE8S.

fecundity, and maniagee of the community. During that year the text was faiily
good and took up more space than the tables.

The most noteworthy features of the tables published in these early reports was
the incorporation of ^at we might call the fundamental factors in statistical mor-
tality work. All mortality tables were constructed with the end in view of showing
deaths by cause, sex, age, locality, and nativity. If we tiun to the repwts of 1914
we find that the tables therein include these necessary adjuncts to a proper appre-
ciation of the community's welfare.

Tables showing births by wards and nativities, and marriages by ages and birth-
places of bride and groom, were printed, and these essentiaLs have been continued
in the reports of the present time. The classification adopted in the preparation
of mortality tables was in most instances and for many, many succeeding years,
the simple one of the alphabetical arrangement, with the exception of that employed
by the city inspectcnr in New York, who published tables showing the causes ci
death arranged on a mixed etiological and anatomical basis. It is only within recent
years that the alphabetical arrangement of causes of death has been superseded in
many cities and States by the mofe scientific international classification.

In 1866 the metropolitan board of health of New York and Brooklyn was organized
and appointed Dr. Eli^a Harris as its register of vital statistics. The appointment
was a fortunate one for the dty and the cause, as Dr. Harris was one of the foremost,
eloquent and literary w(^kers in public-health movements. His analysis of death
and birth returns and his articles on all the sanitary questions of his day are to be
found in the eariy reports of the department and are models of diction and thought
that might well be studied in these days of loose expression and hasty, ill-considered
conclusions.

Along in the eariy sixties Philadelphia awoke and began by the publication of two
small tables of mortality by sex, age and ward, one table of births and three of marriages,
the latter showing ages, general nativity and the denomination reporting same. If I
may be allowed to digress, for a moment in order tb give an idea of the sanitary prob-
lems confronting the health officers of those days, I will mention some of the topics
discussed. The comment on vital statistics was never very extendve unless there
was present an epidemic of Astatic cholera, typhus fever, or smallpox. In years free
from these causes or of diminished severity, the eariy reports contained discussions
of burial grounds, street cleaning, drains and sewers, cellar tenements, privy wells,
slaughter houses, bone boiling, odors from gas houses, etc., that is, anything that
offended the sense of smell and of vision came in for a lashing and scoring. To-day,
while we may have eye-sores and noeenKH^, in much less abundance it is true, the
work of the health officer is of a thing apart from the foregoing list.

In passing it is wOTthy of note that according to the report of Philadelphia of 1860,
there was appropriated the sum of $32,000 for public health purposes of which $6,000
was tiuned back into the city treasury. Fifty dollars were allowed for brandy, wine,
and ale for use in the quarantine hospitals and only two dollars were spent. One
wonders at the moderation, financial and bibulous, in these early days. Cincinnati
published its first annual report in 1868, which contained in addition to the usual
invective against nuisances a few tables on mortality by cause, age, color, sex, and
wards with two pages of comment. St. Louis in the same year printed one table
showing deaths by cause, age, and color. Chicago, in 1867, put into effect laws similar
to those passed in 1866 in the city of New York, and in that year printed four tables
of deaths, one of births and one graph showing mortality from chief causes by months.
Washington, D. C, in 1872, printed two tables on births and two on deaths. Freak
table — ^Baltimore printed l^ pages of decedents over 70 years of age. Abroad,
Berlin published in 1874 its first statistical yearbook, containing seven pages of vital
statistics, the greater part of the volume being devoted to the consida»tion d the

PUBUC HEALTH AND MEDICINE. 413

other activitiefl of the dty. In reality, this yearbook was a contmuation of annual
report called "Berlin and its Development," beginning in 1867.

In the report of 1880 the seven pages of 1874 had grown to 84 pages devoted to tables
of births, marriages, and deaths, including life and insurance tables. Paris in the
same year printed 164 pages of text and tables.

In the cities of our own country we find that the improvement in number and qual-
ity of the statistics presented was exceedingly slow and gradual, accompanied by
entire lapses in some of the cities. In New York there were no reports printed during
the years 1881 to 1888, inclusive, because it was deemed extravagant to issue reports
which nobody read.

The tabulations presented in the various yearly reports of a large number of the
principal cities are undoubtedly of better quality and of greater quantity than in
the early years mentioned. Statistics of population are given, death rates printed,
age groups have been increased, special attention given to infant mortality and
to mortality over 45 years of age; occasionally life tables are published; specific
causes of death, as diphtheria, tuberculosis, and cancer, have received close statistical
attention. Much remains to be done, however; occupational mortality has not been
carefully studied, standardization of rates are avoided by city officials, and above
all there is a woeful deficiency in statistical analysis.

Public health is purchasable, we are told, and so is vital statistics; lack of money
is the defense interposed when criticism of quantity and quality of text and table is
offered, and with much truth. Commercial institutions do not suffer from this
affliction; if it is good business for them to spend considerable money in statistical
investigations of morbidity and mortality why should those who hold the city's purse
strings look askance at similar attempt to obtain the wherewithal to conduct extensive
and intensive studies of the health of the community? There is one feature of sta-
tistical work that New York has gone into this year, and that is the division of the
city into so-called sanitary areas, or health districts, and the preparation of tables
showing death rates from certain prominent causes, at different age groups— espe-
cially under one year — and of different nationalities in these 40-acre tracts as recom^
mended by two different committees of statisticians whose aid was asked and freely
given during the past five years.

MORBIDITY STATISTICfl.

On a smaller scale the morbidity in these districts is receiving consideration, a
health census having been taken in one of the districts— in August of this year, and
another is to be taken in February of 1916.

This is the b^^inning of one of the most important phases of preventive medicine—
i. e., to get into close contact with the citizen and his ills. How the experiment
will turn out only time can tell.

Slides were used in showing the great trend toward publicity of the work being
done by health departments.

Cities showing no text in reports:

Weekly-
Amsterdam, Holland.
Cairo, Egypt.

Monthly-
Concord, N. H.
Detroit. Mich.
Oakland, Cal.
St. Paul, Minn.
Salt Lake City.
Cities showing text and tables:

Weekly, Chicago, 111.

Weekly, Cincinnati, Ohio.

414 PROCEEDINGS SECOND PAN AMEBICAN SCrBNTIFIC C0N0BB8S.

Cities showing text and tables—Continued.

Monthly, Harrieburg, Pa.

Monthly, New Haven, Conn.

Monthly, New London, Conn.

Monthly, Seattle, Wash.

Monthly, Bulletin, Toronto, Canada.

Monthly report, Toronto, Canada.

Weekly Bulletin New York City, department of health. 14,000.

Monthly Bulletin, New York City, department of health, 14,000.

School Health News, New York City, department <d health, 24,000.

Chronicles. New York City, department of health, 85,000.

Other publications (reports for libraries).
States showing text and taoles:

Florida.

New Hampshire.

New Jersey.

New York.

North Carolina.

Viiginia.

I might mention that New York City has b^gun in a small way to gather morbidity
statistics on a 40-acre tract of about 30,000 people. We sent 80 policemen there in
the month of August and tried to obtain a census of illness in that particular dis-
trict. The results were rather disappointing, but we are determined to take it again
in February, under other conditions, by having the nurses of the department take
that census.

There is one more question I should like to touch upon before I dose, and that is
the great change which has come over the weekly and monthly reports made by the
various cities of the Union. I have prepared some slides which will show how,
even in the present day, in some cities, mere statistical tables are published, with
little or no text, but how a large majority of the cities, and even the States, are now
furnishing text along with the tables in order to show what the community needs.

Dr. Oxdlfoy here gave an exhibition of lantern slides, showing pages
from the reports and bidletins pubhshed by various cities. In the
course of his remarks in reference to these slides, he said, in part:

Those whose reports give text include Chicago; Cincinnati; HarriBburg, Pa., the
residence of our esteemed State registrar; New Haven, Conn.; Seattle, Wash.; the
city of Toronto, Canada (they publish an excellent weekly bulletin). The same
for the city of New York; we print 14,000 of the weekly jbulletiiis in New York City
and they are sent to every physician in the city and to every school principal, and
to all public officials. Of the monthly bulletins, 14,000 are printed and sent to the
same people. The articles in the mcmthly bulletin are of a little higher order than
those in the weekly, and a little longer. One month was devoted to diphtheria and
another month to malaria.

Of the School Health News we publish 25,000, and are endeavoring to put them
into the hands of every teacher in the public-school system.

This is the Chronicle: The second, third, and fourth pages are all the same text.
The front page contains local matters of interest, and they are distributed by means
of local neighborhood associations in those portions of the city where we think they
will do the most good. One such locality is around Fifty-ninth Street; another is
in the neighborhood of Eightieth Street; another on the lower East Side, where there
are many Russian Jews; another, the old village of Qreenwich, where tJie American
population is still in existence.

PUBLIC HEALTH AND MEDICINE. 415

DESARROLLO DE LA ESTADlSTICA DEMOGRlFICA EN LA ISLA DE

CUBA.

Por JORGE LE-ROY Y CASSA,
Steretario de la Academia de Oiencias de la Habana.

El gobiemo de mi pals se ha servido invitanne para que contaibuya con mi esfuerzo
al 6xlto de nuestra repreaentaddn ante el Segundo Congreso Cientffico Panameiicano.

Se me 8efial6 como tema, imo de loe consignadoB en el programa del Congreso, que
dice: desarrollo de las estadlsticas demogr^cas en los paises panamericanos; pero
teniendo en cuenta la brevedad del tiempo de que puedo disponer y la magnitud
del tema, asi como las dificultades de proporcionarme los dates necesarios para desen-
volverlo, he optado por tratar solamente imo de los capftulos de que debe componerse
aqu61, y con tal motive no me ocupar6 m^s que del Desarrollo de la estadistica demo-
gr&fica en la isla de Cuba. De esa manera no incurrir6 en omisiones que serlan lamen*
tables, dada la importancia de los paises de que se trata, cuyos representantes, estoy
seguro, se ocupar&n en damos a conocer la marcha seguida por la estadistica en sus
respectivas naciones, y podr4 a mi vez dedicar mayor extensi6n al tema que me
propongo desarrollar.

Mtiltiples son los factores que determinan la prosperidad de im pueblo, pero uno
de los m^ importantes es, sin duda alguna, su buen estado sanitario, pues de ^1 de-
pende el aumento de la poblaci6n y ^ste trae consigo la riqueza y el bienestar que se
deeprende de las diversas actividades de sus ciudadanos, ora se las considere desde el
punto de vista agricola, ora del industrial, ora del comerdal o ya desde el m^s elevado
de las ciendas y de las artes.

Mi pais ha aumentado su poblaci6n a partir del censo realizado al terminar la sobe-
ranfa vaiias veces secular (1899), en casi un mill6n de habltantes, debi^dose este
incremento en su mayor parte al exceso de los nacimientos sobre las muertes, y en
otra parte a la inmigraddn que no temiendo ya a la terrible fiebre amarilla, ni a las
viruelas, ni al paludismo, encuentra medios de subsistencia m^ f^ciles que los que
le indujeran a abandonar su pais de origen. Si se tiene en cuenta que ese aumento
se ha realizado en el corto perfodo de tres lustres, se comprenderd sin grandes esfuerzoe
la magnitud e importancia del mismo.

La estadistica es la ciencia de las comparaciones; por ella es por la que los gobiemos
conocen las necesidades de sus gobemados, y por ella tambi6n los hombres dirigen
0US actividades en determinado sentido, buscando en los distintos medios la conse-
cuci6n de sus ideales. Ella les muestra los recursos de que dispone cada pals, su
desenvolvimiento, los medios de subsistencia y de trabajo, asl como las dificultadee
con que han de luchar para veneer en la batalla de la vida. Cuando est^ bien hechaa,
muestran al observador las ventajas y los inconvenientes que ofrece cualquiera de las
orientaciones que se intente seguir; por eso desde la mia remota antigQedad todos
los pueblos han hecho sus estadlsticas, aimque s61o desde el pasado siglo puede afir-
marse que eeta ciencia ha side considerada en su verdadero aspecto; y aun hoy dla se
tropieza con multiples obst&culos que dificultan su aplicaci6n, no siendo de los meno-
res la ignorancia que se tiene por muchos que se imaginan que es una ciencia baladf ,
al alcance de cualquiera, porque no le dedican toda la atenci6n y el eetudio que su
importancia reclama.

No es ^sta la oportunidad de hacer ima incursi6n por el campo de la histoiia general
de la estadistica y por eso no me referir^ al empadronamiento de los hebreos, ejecutado
por Mois^ en el Sinai; ni a la estadistica de los vastos dominies del Em])erador Yao,
ejecutada m^ de dos mil afios antes de nuestra era; ni a los registros que de todas sus
poblaciones Uevaban los persas, anotando el ntimero y clase de los habitantes, sua
circunstancias, bus fortunas, los terrenes que cultivaban, ya en propiedad, ya en
usufructo, etc., ni a las operaciones catastrales ejecutadas por los egipcioe para conocer

416 PROCEEDINGS SECOND PAN AMEBICAN SCIBNTIFIO C0NGBE88.

lo6 Ifm ites de las propiedades boiradas por las inundaciones del Nilo; ni a los cuadro
trazados por las democr&ticas institucioneB de la Grecia, que al decir de Jenofonte ser^
vfan para peear y comparar las fuerzas de la Repdblica; ni al perfeccionamiento
aportado por los romanos, formando las relaoiones m^ minuciosas sobre la poblaci6n
de BUB extensos dominios, clasLficada por edades, sexos y condiciones, sobre medicidn
y repartici6n de terrenes a prop6sito para el cultivo, sobre el estado y adelanto de
las artes m^ necesarias, sobre la riqueza individual, inix>osici6n de tributes y su
distribuci6n, sobre gastos y recursos del Estado y sobre cuantos asuntos se sujetan a la
inve6tigaci6n y a los c&lciilos matemdticos.

Tampoco he de referirme al eclipse que sufrieron los estudios estadfsticos despu^ de
la desmembraci6n del imperio romano y en la ^poca del feudalismo, salvadoe en parte
por los ^abes, que al apoderarse de la peninsula ibMca encaigaron a bus sabioB la con-
fecci6n de laestadisticadeBusprecioBas conquistas; nihede relatarlas aplicaciones de
eBta denda hedias por las reptiblicas italianas, que en los estados venedanoB y floren-
tinos durante los siglos XIY y XV levantaban mmuciosoe censoe de pobladdn, del
movimiento comercial y politico, dignos de figurar al lado de nuestros modemos traba-
jos; pero si he de referirme a dates importantes de los dos pueblos, prindpales de nues-
tro continente americano, por que las civilizadones encontradas por losconquistadc^ee
en el imperio azteca y en el de los incas del Per6, evidencian con cuanto inters Be
llevaban estas operaciones en ambos pueblos del norte y del sur de este grandiose hemis-
ferio ocddental.

Segdn refiere el historiador Herrera, el emperador Moctezuma tenia den grandes
dudades, capitales de otras tantas provindas, con bu correspondiente guamici6n y
gobemadores e intendentes, que redbf an los tributes y conocf an perfectamente, afiade
Hem&n Cort^, el estado rentistico del imperio, que habfa trazado, con otras muchas
noticias, en registros pintados.

En el imperio de los Incas, se llevaba un registro de todos los nacimientos y defun-
ciones que ocurrian en toda la extensi6n del pais, y cada aflo se enviaba al gobiemo
del Guzco un censo de toda la poblaci6n por medio de los quiptu, curiosa invend6n
que consistfa en una cuerda come de 2 pies de largo, compuesta de hilos de diferentes
colores fuertemente retorcidos y entrelazados, de la cual salf a una multitud de hilos
m&s pequefios en forma de franja. Los hilos eran de diversoe colores, y habia entre
ellos muchos nudos: efectivamente la palabra quipu significa nude. Los colores
representaban objetos tangibles; asi, por ejemplo, bUmco^ significaba pZota, y amariUo,
oro, Tambi^ indicaban algunas voces ideas abstractas; asi bianco^ querfa decir pat
y rojo, guerra. Pero los quipus se usaban prindpalmente para dilculos aritm^ticos.
Los nudos Servian de ntimeros y se podian combinar de manera que repreeentasen cual-
quier cantidad que se quisiera. Por medio de ellos hacian bus c&lculos con mucha
rapidez, y los prlmeros espafLoles que fueron a aquel pals atestdguan la exactitud de
^stos.

En cadadistrito habla empleadosa quienes Uamaban quipiuximayoi o eomervadores
de los quiptu cuya obligaci6n consistla en dar notidas al gobiemo sobre varies asuntos
importantes; imo eetaba encaigado de las rentas y daba parte al gobiemo de la can-
tidad de materias primeras que se distribulan entre los trabajadores, la calidad y can-
tidad de los tejidos que con ellos se hacian, y la suma de provisiones de diferente dase
entregada a los almacenes reales. Otro enviaba eetadlstica de los nacimientos y
defunciones, de los casamientos, del ntimero de los que se hallaban en estado de
servir en el ej^ito y otros pormenores de esta clase relatives a la poblad6n del leino.
Estos informes se remitlan anualmente a la capital donde se sometlan a la inspecddn
de otros empleados que entendlan el arte de descifrar estos misterioeos escritos. Asl
adquirla el gobiemo una vasta coleccidn de dates estadlsticos preciosos; y las cuerdas
de variadoB colores reunidas y cuidadosamente conservadas, constitulan lo que bien
podemos llamar archives nadonales.^

I Pnfoott Historla de 1a oonqulsta del Pertk, Madrid, 1861, p. 19 y 84.

PXJBUC HEALTH AND MEDICINE. 417

Cuba no puede remontane, en el teneno de la estadMica, no ya al perfodo pre
colombino, como el de los pueblos que acabamoe de citar, ni a(in al perfodo de la con-
quiflta, pues los primeros dates que sobre su poblaci6n existen los consign^ en el trabajo
que lei ante el Tercer Gongreso MMico Nadonal, celebrado en la Habana en didembre
de 1914. Sin embaigo, no figura en estas materias en tiltimo lugar, pues los trabajos
que dar^ a conocer en seguida, muestran que se ha ocupado de estas materias mudio
antes que otros palses americanos y aun que muchos de los del viejo continente.

Para hacer mSm met^dica mi exposicidn dividir6 el desanoUo de la estadfstica demo-
gr&fica de mi paiiB en ties grandes perfodos, a saber: desde el iiltimo terdo del siglo
XVIII hasta la mitad del siglo XIX; desde esta fecha hasta los comienzos del siglo
XX; y desde la inauguraddn de la reptiblica en 1902 hasta nuestios dias. En todos
ellos pueden sefialarBe los progresos obtenidos por los nombres de las contadas personas
que de estas materias se han ocupado; no separ&ndonos en ^sto de lo que ocuzre en los
dem^ pafses, pues si bien los gobiemoshan contribuido a esos progresos, m^ha aide por
las condidonee personales de los hombros que han estado al frente de tales servidos,
quienes a su competencia profesional han unido los sentimientos del mto elevado y
verdadero patriotiamo.

£1 primer perfodo, que bien pudidramos llamar * *embrionario, " se inida poco despu^
de la devoluddn de la Habana, hecha por Inglaterra a la corona de Espafia como
reeultado del Tratado de Versailles. Fu^ en esa 6poca cuando realmente se conoci6
por la antigua metr6poli la importancla de su posesidn ultramaiina, y cuando Cuba
pas6 de la condid6n de factorfa a la de colonia productiva.

La llegada de D. Felipe de Fonsdeviela, Marqu^ de la Torre, a esta iala, inicia una
serie de reformas altamente benefidosas, entre las cuales una de las principales fu^
el levantamiento del primer censo de pobladdn, cosa desconodda aqul segtin se
desprende del siguiente pdrrafo que transcribe del historiador Pezuela:

aQu^ mucho que se ignorase todavfa el ndmero general de predios rdsticos y de sus
habitantes, si el euarismo exacto de los vedndarios de los pueblos y de la misma capital
era desconoddo? En el gobiemo de la Habana y en ef de Santiago no existia m^
documentad6n estadfstica que la ref erente a las f ortalezas, soldados y cafiones. Seguf a
la grande Antilla entonces a manera de caos de confusidn desentrafiable.^

Ese primer censo, levantado a costa de grandes esfuerzos dd Marqu^ de la Torre,
se termind en 1774 y arroja una poblacidn de 171,620 habitantes distribufdos seg6n
sexos, razas y condiciones de libres y esclavos.

Despu6s de este censo, d documento mis antiguo que he podido consultar es un
extracto de la gufa de forasteros en la Habana, para d afio 1781, publicada en las Me-
morias de la Sociedad Patri6tica de la Habana p<Hr ima comisidn permanente de su
seno, el afio 1842 (t. XTV, pp. 109-110) y en d que se bace constar que " D. Jacobo de
la Pezuela le hizo ver al autor esa obra" que seguramente bi6 la prim era de su clase
que se imprimid en la Habana, y por supuesto queda desmentido el concepto de
cuantoshan atribuf do al benem^rito gobemador D. Luis de las Gasas su establecimiento
d afio 1793. Esta Gufa se imprimi6 en la ofidna de la Capitanfa General, a cargo de
D. Francisco Seguf, calle de la Obra-pfa, ostent&ndose en ella adn los resabios de la
edad en el bello arte de Gutenberg; empero, nos atrevemos a decir que para su tiempo,
la ejecuci6n y encuademacidn lujosa con las annas reales sobre-doradas en las tapas
es m^ que regular y digna de celebrarse. Siendo tal vez esta Gufa la dnica que se
encuentra en d pafs, la hemes extractado en la parte mia esendal, y hoy la ofrecemos
como un testimonio autdntico que recuerde a las presentee generadones los ilustres
compatriotas que figuraron en aquella remota 6poca, cuyamemoria nos es grata y apre-
dable en todos respectos. El ndmero de buques que entraron y salieron en este
puerto el afio de 1780; las notas parroquiales que sefialan los bautismos, matrimonios

iPesoeb. Hittork <le 1a Ida de Cote, Madrid, 1878, t. m, p. 96.

418 PBOOEEDINOS BEGOND PAN AMEBIOAN SGIBNTIFIO CONGRESS.

y entioTOS de aquel afio; la noticia de algunoe productOB de nuestia agricultaia; la
idea geogr&fica, histdrica y poUtica de la iala y ciudad de la Hahana con que concluye,
todo intereaa, todo sirve para hacer comparacioneB y un prdijo examen de lo que
^ramoi entonoeB y de lo que bcbooob hoy.

He hecho esta cita en toda bu extensidii, pc^ue ella revela la existeucia de ese
importante documento, que a peear de mis reiteradas investigacioneB bibliogiificaB
no he podido conocer en su original, con el que se deemiente la leyenda muy gene-
ralmente aceptada de que fu6 D. Luis de las OaaaB, el que primero public6 las mendo-
nadas Gufas de ForaBteroB, cuando en realldad deBde Iob tiempoB de D. Juan M.
Cagigal tuvimoB OBa intereeante noticia de nueBtra vida colectiva.

£1 documento eBtadlBtico que Bigue a 6ete en antiguedad ee iin cuadro de la pobla-
ddn de la Habana y bub anabaleB, la Salud, JeeCa Maria y Job^, Horcdn, Oerro, San
Ldzaro, Jbb^b del Monte y R^la, claaificada por blancoB, pardoB y mcvenoB &i bub
condicioneB de libree y eBclavoB, aacado del ceneo eBpafiol ejecutado por el Excmo.
Sr. Oonde de Floridablanca en el afio 1787, y que conservo entre mis papeloB, copiado
de un documento que pertenecid al iluBtre educador Jo86 Oomelio Diaz. Al dofBO
tiene una nota que dice: ''Diario del Gobiemo de la Habana, 30 marzo 1817."

La creaci6n de la ''Real Sociedad Econdmica de AmigoB del Pals,*' durante el go-
biemo del inolvidable D. Luis de laB Caaas, trajo consigo multitud de ben^ficas
institucioneB, entre laB cuales la fundaci6n del Papel peri6dico y la pubHcaci6n del
Calendario Manual y Gufa de Forasteroe de la Isla de Cuba, desde 1793 dan a
conocer Iob datos demogr&ficos de la ciudad de la Habana y ademis el movimiento
de enfermos en sub dlstintoB hospitales y asilos.

En el afio 1792 public6 una hoja del "Padr6n general de los habitadores de la iala
de Cuba, formado en el mes de didembre de 1792, de orden del Excmo. Sr. D. Luis
de las Casas y Aragorri, Gobemador de la Habana y Capitin General en dicha Isla,
sin comprender en 61 laB tropas veteranas, marina, preeidiarioB, ni eBclavos del Rey,
espres^doae el ndmero de los templos, hospitales, colegios y hadendas de campo."
Este padr6n estd clasificado en hombres y mujeres y ambos sexoe se refieren a Iob
individuoB blancos, mulatos libres, mulatos esclavos, negroe libres y negros esclavoB
Begdn los pueblos y partidos de cada jurisdicci6n. Las hadendas de campo com-
prenden: ingenios de azticar, hatos, corrales, potreros, sitios, estancias y vegas.

La publicad6n de este documento me parece bastante para dirimir las contiendas
susdtadas por Humboldt, Pezuela, Behm y Wagner sobre la fecha de este censo,
refiri^ndolas al afio de 1791 o al de 1792.

Sigui6se trabajando con actividad en aquella fecha de verdadero eeplendor para la
historia de Cuba, pues el incansable trabajador, Sr. Antonio L6pez Prieto pubUc6 *
un cuadro de los ^'Nacimieutos y Defundones en la Isla de Cuba durante el afio
contado desde el 1^ de septiembre de 1792 a fin de octubre de 1793, segtin datos torna-
dos de un antiguo manuscrito." Los nacimientos y las defundones est&n clasificadoB
segdn blancos y de color, en las dudades, villas y pueblos; slendo su resumen como
Bigue: Nadmientos — ^Blancos, 5,829; de color, 6,046; defundones — ^Blancos, 3,534;
de color, 4,844.

Con el siglo XIX surge en la historia de Cuba im hombre de inolvidable memoria, el
Obispo Dr. Juan Jos6 Diaz de Espada y Landa, el que introdujo con D. Tom^ Romay
la vacuna, antes que llegara la comisi6n enviada por Carlos I Va cargo del Dr. Francisco
X. de Balmis; el que proscribid los enterramientos de los cad&veres en las igleeias,
creando los cementerios fuera de poblado; el que intervino directa y personalmoite
en todo aqudlo que representase cultura y progreso para este pais, tuvo su parte en el
desenvolvimiento de nuestra estadfstica, pues al realizar la visita pastoral de su
entonces extensa di<5cesi8 (se extendfa hasta el Camagtley) se hizo acompafiar del
Dr. Justo V^lez, quien redact6 la nota delosbautismos, matrimonios y entieiroB de laB
distintas parroquias visitadas.

1 Boletfn Ofidal de Hacienda y Estadlstloa de la Iila de Cuba, Habaoit, 15 de febrero de 188S, p. 84.

PUBLIC HEALTH AND MEDICINE. 419

£1 ilustre ayuntamiento de la Habana reali£6 en 1810 un Padr6n de la ciudad, segtUn
Be desprende de la lectura del intereeante tzabajo redactado por el Jovellanoe cubano,
que lleva por tftulo: ** Representaddn de la Ciudad de la Habana & las Cortes, el 20 de
Julio de 1811, con motivo de las proposkiones hechas por D. Joe^ Miguel QuridiAlcocer
y D. Agustln de ArgQeUes, sobre el tr&fico y esclavitud de loe negros; extendida por el
alf^ez mayor de la Ciudad, D. Frandsco de Arango, por encaigo del ayuntamiento,
consulado y sociedad patiidtica de la Habana. " En los documentos que acompafian
a esa representaci6n, expedidos por el secretario del consulado, 8r. Antcmio del
Valle, el 20 de julio de 1811, se encuentran varios cuadros de la poblaci6n, dasificada
por sexos, edades, razas y condici6n civil, y su comparaci6n con el empadronamiento
hecho en 1791.*

En el afio 1817 se lleva a cabo el levantamiento de im nuevo censo de pobladdn,
publicado con el nombre de ''Estado General de la poblaci6n de la Isla de Cuba, dis-
puesto de orden del Excmo. Sr. Teniente-general Don Joe^ de Cienfuegos, gobemadcw
de su Provincia y Capitania general, de acuerdo con el Sr. Don. Al^andro Ramires,
Bui>erintendente general subdelegado de la Real Hacienda de ella, y coiresponde al
alio de 1817. En la parte inferior de esta hoja se lee: "ComisidndeEstadlBticadela
Habana, 10 de diciembre de 1819. Juan Miguel Calvo. Por Arazoza y Soler." '

En septiembre de 1826 se publica en Paris, el Essai politique sur Tile de
Cuba, por Alexandre de Humboldt, obra la m&s intereeante en lo que se refiere a nuetro
pals, y en su artlculo ''Poblaci6n," presenta numerosoe cuadros estadlsticos, que
discute con sobra de competencia y profundidad de razones; y al analizar las dife-
rencias que se advierten entre las cifras de loe distintos documentos que estudia,
escribe esto que traducimos:

^C<Smo admirarse de las contradicciones parciales de los cuadros de la poblacidn,
levantados en America, cuando se recueroa las dificultades que se ban tenido que
veneer en el centro de la civilizaci6n europea, en Inglaterra y en Francia. cada vee
que se ha emprendido la gran operaci6n de un empadronamiento general? *

Loe llmites de este trabajo no me permiten examinar debidamente esta obra; pero
no puedo menos de hacer constar que ella es la primera manifestaci6n cientlfica reali-
zada en Cuba sobre eetadlstica, y que no puede escribiise nada sobre eetas importantes
materias sin consultarla.

La semilla sembrada por el Bar6n de Humboldt germin6 en f ^rtil suelo, pues en 1827
fu^ publicado el '^Cuadro estadlstico de la siempre fiel Isla de Cuba, correspondiente
al afio 1827. Formado por una comisi6n de gefes y oficiales, de orden y hajo la direc-
ci6n del excelentleimo sefior capita general Don Frandsco Dionisio Vives; precedido
de ima descripci6n hist6rica, flsica, geogrdfica, y acompafiada de cuantas notas son con-
ducentes para la ilustraci^n del cuadro. Habana, Oficina de las viudas de Arazoza y
8oler, impreeoras del Grobiemo y Capitania general por S. M., 1829." Este censo, elabo-
rado con paciencia y laboriosidad durante varios afios por ima comisidn que recorri6 la
islay obtuvo los datos directamente en cada localidad mered6 dd histoiiador Pezuela
el siguiente juicio:

. . . d censo o cuadro estadlstico de 1827 fu6 d trabajo m&a completo e importante
que hasta entonces se hubieee publicado sobre una isla que mal podui ser adnunistrada
con acierto antes de ser completamente conodda. No fu^ como los anteriores \m simple
resumen de poblad6n, fu^ la primera descripd6n que se conociese de la riqueza
pdblica de Cuba clasifidmdola por productoe, aepartamentoe y jurisdicdones; fu6, &i
fin, la primera demostrad6n de una verdad tanto m&s derta y liaonjera, cuanto oue
ningun error num^rico ni ninguna espede falsa result^ de loe cfatos con que salid a lus
acompafiada. *

I Obns del Bxomo. 8r. D. Frandsoo de Antngo y ParraAo, Hsbenft, U88» t. II, p. 175-900.

• TreUee, BIbUognflaoabeoadelilgloXIX, Metentae, 1911, 1. 1, p. 158.

* Op. cit., 1. 1, p. 141.

« Pesnela, Diodonirio Oeogiifloo, Setadtotioo, Histdrioo de la Isk de Cute, ICedrld, 1866, 1. 1^, p. SM.

68436— 17— VOL. ix ^28

420 PEOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIO OONGBESS.

£1 mismo Vhes, hizo levantar el afio 1828 el '^Genso de la dempre fidelisima ciudad
de la Habana, capital de la siempre fiel Isla de Cuba. Fonnado de orden del Exmo.,
Sr. Don Francisco Dionido Yives, actual Preeidente, Gobernador y Capit&n general
de ella; por el Teniente Coronel de Infanterla, Capitan del Real Cuerpo de Ingenieros
Don Manuel Pastor. Habana, Imprenta del Gobiemo y Capitania General por S. M.
Enero de 1829.''

El discutido escritor, D. Ram6n de la Sagra, public6 en la Habana en el afio de
1831 su Historia econdmico-polftica y estadistica de la isla de Cuba o sea de bus pro-
greeos en la poblacion, la agricultural el comercio y las rentas y en la introducci6n
(p. VII) hace constar que ''el trabajo que presento en esta obra, s61o es completo en
cuanto a la Habana, mas puede servir como de prontuario para extenderlo a toda
la Isla.''

He aqui el fndice del capitulo I. Poblaci6n:

Articulo 1^. Sus progresos en diversas ^pocas. Relaci6n entre las castas en las
ciudades y en loe campos.

Art. 2^. Proporciones entre los sexoe.

Art. 3^. Relaciones entre los nacidos y los muertos. Movimiento anual de la
poblaci6n.

Art. 4*^. Matrimonios. Obsen aciones y comparaciones estadfsticaB sobre la ciudad
de la Habana en el quinquenio de 1825 a 1829: (1) Xacidos. (2) raz<Sn entre los nacidos
legftimos e ilegftimoe. (3) nadmientos por meses. (4) muertos, (5) mortandad por
sexos, (6) mortandad p6r edades, (7) mortandad de la nifiez, (8) Mortandad re8pecti\ a
a los nifios legltimos e ilegftimoe, (9) relacidn entre los nacidos y los muertos, (10)
matrimonios.

Este mismo autor publicd dos afios deepu^, con motive de la terrible epidemia
de c61era que diezm6 a la Habana las ''Tablas necrol^cas del c61era-morbus en la
ciudad de la Habana y sus arrabales foimadas a excitacion del Ecmo. Sefior Inten-
dente de Ej^ito, Conde de Villanueva, por Don Ram6n de la Sagra, Habana,
Imprenta del Gobiemo, Capitania general y Real Sociedad Patridtica por S. M. 1833."
Es una curiosa serie de cuadros formados ''extractando de las cartas, oficios y partidas
de muertes, las circunstancias del sexo, casta, condiddn, pals de naturaleza, estado
y edad de cada uno de los fallecidos durante la existencia acti\ a del c61era en esta
ciudad desde el 26 de febrero hasta el 20 de abril." Adem^ del examen de dichos
documentos en las iglesias, hizo el de los asientos de entradas y salidas en los hospi-
tales reales de S. Ambrosio, y de San Juan de Dios, en la sala militar de ^ste y en
los proviaionales establecidos para indigentes en el Real Arsenal y en el campo de
Marte. Asimismo anot6 114 muertos de cuarteles, fortalezas y el pont6n de la marina;
y afiadi6 al final de los restimenee 704 defunciones para completar los 7,549 bdlecidos
que ofrece en su trabajo con loe 8,253 que se determinan como enterrados en los
cementerios.

Estas Tablas fueron examinadas por el insigne publicista Jos4 Antonio Saco en
el ndmero IX de su peri6dico la Revista Bimestre Cubana examen que se reprodujo
en sus papeles,^ de cuya obra tomamos este juicio: "Es inn^;able que su autor ha
tenido gran padencia y laboriosidad en su formad6n; pero tambi^n lo es, que el
resultado no ha correepondido a sus intendones, pues por donde quiera que se abra
el cuademo que vamos a revisar, se encontrar&n observaciones inexactas y c^culos
errdneos."

Otras valiosas contribudones sobre aquella terrible epidemia public6 tambi6n
Saco y una descripd6n completa de ella existe en el primer peri6dico de medidna
de la Habana — el Repertorio M^co Habanero— debida a la pluma del inolvidable
Dr. NicoUs J. Gutierrez y del Dr. Agustln Encinoso de A'breu.

En los peri^dicos de aquelloe tiempos se publicaban notidas sobre el estado de los
enfermos de los hoepitales y de las enfermedades que contribulan a producir la mor-

iColeoddn de papelee oientifioos, hlst^rloos, poUtioos y de otros ramos sobre la isla da Cuba y% pubU-
eados, ya Inedltoe, por Don Joed Antonio Saoo, Paris, 1858, t. II, p. 335^343.

PUBLIC HEALTH AND MEDICINE. 421

bilidad de la poblaci6n; pero es neceeario llegar al afio de 1838 para encontrar en
La Cartera Cubana, revista del Dr. Vicente Antonio de Castro, una seccidn dedicada
especialmente a dar cuenta del estado de las enfermedades reinantes en cada mes, en
eeta capital. Al morir aquel peri6dico y fundar el Dr. Gutierrez el Repertorio M^co
Habanero, ee siguid tan buena costumbre, pudiendo asf formamoe idea, aunque muy
imperfecta, por las bases de clasificaci6n no6ol6gica adoptadas-correspondientes a los
conocimientos de la 6poca — de las dolencias que contribulan a nuestra morbilidad
y mortaUdad.

En 1^ de julio de 1840 el principe de Anglona orden6 se levantase un nuevo censo,
lo que fu4 aprobado por el rey de Espafia en no^ iembre del mismo afio, public&ndose
en el siguiente el ''Resiunen del censo de poblaci6n de la isla de Cuba a fin del afio
de 1841, fonnado de orden del Ecmo. Sr. Capitdn general de la misma por una comisidn
de Gefes y Oficiales nombrada especialmente para veriiicarlo precedida de una adver-
tencia preliminar y notas justificativas del director de la comisi6n. Habana. Im-
prenta del Gobiemo por S. M., 1842. *' El contenido de eeta obra puede apreciarse
por su indice que copio a continuaci6n:

Advertencia preliminar del Director de la Comision. Notas ju8tificati\ as. Censo
General de la Isla de Cuba. Estado de comparaci6n entre los censos de 1827 y 1841,
V razdn en que se ha verificado el aimiento de la poblaci6n. Estado por edades de
los habitantee de la Isla de Cuba, y razdn que guardan entre sf. Estado de las pro-
porciones en que se encuentran ambos sexos. Fechas a que se refieren los censos
particulares de las diversas jurisdicciones de la Isla de Cuba. Estado de la poblaci6n
de la ciudad de la Habana a fin de 1841. Resimien de los partidos de la Isla de Cuba
a fin de 1841, con expreei6n del ndmero de sus habitantes por clases y sexos, tanto en

Soblaciones como en ingenios, cafetales y fincas rurales existentes. Tabla al&ib^tica
e las poblaciones segtin el mayor ntimero de sus habitantes fijos. Tabla alfob^tica
de las poblaciones de la Isla de Cuba.

Este censo arroj6 una poblaci6n de 1,007,624 habitantes, estudiados en los departa-
mentos: occidental, central y oriental, por sexos, razas, condicidn ci^il y edades,
aiendo la divisidn de 4etas de 1 a 15 afios, de 16 a 60 y de m^ de 60 afioe.

Desde esa ^poca comienza a d&rsele a la estadlstica demogr&fica mayor importancia,
como lo demuestra el siguiente decreto, dictando reglas para la formaci6n de la
estadlstica mortuoria:

Gobiemo y Capitanla Greneral de la Isla de Cuba. Habi^dome manif estado la Jimta
Superior de Sanidad en consecuencia del acuerdo tenido en 16 de diciembre Ultimo
la conveniencia que resultarla a la ciencia y a la administraci6n pdbUca de adoptar
algunas medidas para facilitar la formaci6n de la estadlstica de la mortalidad, de
cuyo trabajo ha empezado a ocuparse, he dispuesto con consulta del sefior aseeor
general primero, que para llevar a cabo el objeto propuesto se observen los artfculos
fliguientes:

1*. Que todos los facultativos den una certificaci6n en papel simple, expreeiva de
la enfermedad o accidente aue hubiere producido la muerte del cuerpo que se tratase
de sepultar, sin exigir por ella derecho alguno.

2^. Que los ptoocoe no libren la papeleta que se da para que el cadiver sea admitido
en el cementerio, sin que se les presente dicn& certificaci6n, la cual tendr^ obUgaci6n
de recoger y remitir con las dem^ del mes el dia primero del siguiente a la secretarla
de la junta de sanidad.

$<*. Que los hospitales lleven un libro dondese haga la anotacidn correspondiente,
y del cuaJ sacar&n a fin del mes la certificaci6n general que deber^ tambi^ remitir
a la secretarla de la jimta.

4^, Que respecto de aquellas personas que por vivir absolutamente solas o sin recursos,
vinieren a encontrarse muertas, sin que tal vez las hubiese asistido facultative alguno,
eeri obli^i6n del primero que Uamare el comisario o pedtoeo el extender dicha
certificaci6n segiin su leal entender.

5^. y tiltimo. Que en los casos de muerte, en que interviene la autoridad, por haber
side causada casualmente o de mano airada, haran los pedtoeos la oportuna expreei6n
en el ofido que pasaren al p&rroco para dar sepultura al cadiver, remiti^ndole por
duplicado, a fin de que queoindoee con uno, envien el otro a la secretarfa de la jimta
con las c^tificaciones del mes.

422 PEOOEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONGBESS.

Y para que tenga esta detenninaci6n su mds puntual cumplimiento, ademis de
comunicarse a quienes correeponde, ins^rteBe en el Diario de esta dudad para cono-
cimlento del publico.'' Habana y enero 22 de 1843. Valdes, Francisco Gamica,
secretario (Bando de Gobemaci6n aprobado por S. M. Habana, 3* edici6n).^

D. Pedro Tellez Gir6n, Principe de Anglona, hizo levantar el censo de 1841; el
Teniente General D. Ger6nimo Vald^ dict6 la medida que acabo de txanscribir.
AmboB prepararon la ejecuci6n del siguiente trabajo debido al Dr. Angel J. Cowley,
catedrdtico de nuestra Universidad de la Habana, auxiliado por el Dr. Simdn de IO0
Rfos, que Ueva por titulo: ''Ensayo estadlstico medico de la mortalidad de la DL6ceBi8
de la Habana durante el afio de 1843, formado por el Dr. A. J. Cowley, secretario de
la junta de sanidad de la Isla de Cuba y mandado imprimir con acuerdo y aprobacidn
de la misma junta. Habana. Imprenta del Gobiemo y Capitanfa General, 1845."

Como resultado de las Reales 6rdene6 de 22 de didembre de 1842 y de 20 de mano
de 1844 se form6 la Comisi6n de Estadistica, que en Cuba se ocupaba de esos asuntoe.
Presidida por el Brigadier Juan Herrera Ddvila, hasta que fu6 nombrado gobemador
de la ciudad de Trinidad y del Departamento del Centro, y luego por el de la misma
clase, Juan Rodriguez de la Torre, lley6 a cabo los trabajos de un nuevo censo, hecho
a fines de 1846, y publicado con el titulo de ''Cuadro estadlstico de la siempre fiel
Isla de Cuba, correspondiente al afio 1846, formado bajo la direcci6n y protecci6n dd
Exmo. Sr. Gobemador y Capit&n General Don Leopoldo O'Donnell por una Comisidn
de Ofidales y Empleados particulares. Habana, Imprenta del Gobiemo y Capitanla
General por S. M., 1847."

Este censo, mucho mis complete que los anteriores, calificado por Vald^ Domlngues
de ''valiosa publicaci6n, '' arroja un c6mputo de 898,752 habitantes solamente, cuando
el anterior del afio 1841 elevaba la cifra a 1,007,624, lo que revela una disminucidn
de 108,872 habitantes en el quinquenio que separa ambas enumeraciones. Pezuela
explica esta disminuci6n diciendo: "La paz que reinaba en todas partes, el recono-
cimicnto por Espafia de la independencla de casi todos los Estados de Arnica que se
hablan emancipado de su dependencia y varias medidas represivas de la trata de
Africa, lejos de detenninar ningtin aumento en la poblaci6n general del pals cuando en
1846 apareci6 el tiltimo censo publicado, influyeron naturalmente en su disminucidn.
Y con tanto mds motive habiendo afiigido al pals durante el quinquenio de 1841 il
citado afio, prolongadas secas y desastrosos huracanes que destmyeron en el territorio
occidental la mayor parte de las siembras.'

Si se examinan las cifras del cuadro de los bautismos y entierros registrados en el
obispado de la Habana y en el arzobispado de Santiago de Cuba en el quinquenio de
1842 a 1846 se encontrar&n los primeros representados por 161,349 y los segundos i>or
109,218, lo que revela un aumento vegetative de 52,131 habitantes, que se compagina
mal con la dlsminucidn antes sefialada; y a pesar de la impugnacidn de las razones de
Pezuela por Thrasher,' creo con DeUtsch, que esta diferencia "se debe al hecho de habei
dejado de enumerar muchos esclavos en 1846 '^ y a que habi^ndoee impuesto en 1844
una contribuci6n por cabeza de los criados de mano, es decir, los esclavos que preetabin
sus servicios en las poblaciones y en los domicilios de los amos, temiendo la extensidn
de esta medida a la poblad6n rural, se ocultasen numerosos Individ uos de la raza de
color, donde se observ6 la mayor disminuci6n anotada.

Con esto queda terminado el primer perlodo en que he dividido el estudio del
desarroUo de la estadistica demogr&fica en Cuba, al que he dado una extensi6n quizas
algo mayor de la que me propusiera; pero lo he hecho precisamente porque los primerof
pasos son los mds diflciles y como cuesta mucho trabajo compulsar las fuentee onginales,
agotadas muchas de ellas, me he preocupado en citar las de informaddn para demot-

1 LeglslacMii sobre oementerios con U memoria, nglamanto 7 tartlh del de Colon, por el Dr. D. Amlxtwio
Oons&les del Valle, Habana, 1898, p. 57-^.
s Pesuela, Diooionario, etc., t. IV, p. 240.
• Infonne sobre el Censo de Cuba, 1890, Washington, 1900, p. 727.

PUBUO HEALTH AND MEDICINE. 423

tna lo que aqul se trabaj6 por loe distintOB elementoe que integiaban eete paSe, y al
mismo tiempo para combatir la err6nea creencia soetenida por algunos escritoreB que,
am profundizar las materias, pretenden que Cuba carece de pasado y que todo lo que
tenemoB se lo debemoe a la 6poca presente.

£1 segundo perfodo, que bien podemos llamar de crecimiento, comprende, como
bice notar antes, toda la seg:unda mitad del siglo XIX, y durante ^1 toma la estadistica
demogrdfica mayores proporciones y fija mejor los derroteros que sefiala la dencia a
eetoe estudios.

La divisidn territorial d^ la isla en tres departamentos: oriental, central y occidental^
soetenida desde 1821, se reduce a b61o dos departamentos, asimilados a las dos di6ce6i8
entonces existentes y teniendo como limites a Puerto Principe y Nuevltas.

Otro factor de Importancia de esa ^poca es la introduccidn de individuos de las razas
china y yucateca, contribuyendo a modificar las condicionee ^tnicas de nuestros habi-
tantes y a importar con sus costumbres enf ermedades aqul no padecidas anterlor-
mente.

La primera produccidn de eete periodo es la obra de Job6 G. de Arboleya, ''Manual
de la Isla de Cuba. Compendio de su historia, geografla, estadistica y administracidn.
Habana, 1852,'' llena de interesantes noticias relacionadas con los asuntos en que nos
ocupamos.

Slguele en orden cronoldgico la notable obra dedicada "A la estudiosa juventud
m^dica de la Isla de Cuba," por el Dr. Ram6n Pifia y Pefiuela, que Ueva por tftulo
''Topografla m^ca de la Isla de Cuba,'' impresa en la Habana en 1855, y que com-
prende importantes cuadros demogr&ficoe de las poblaciones civil y militar de la isla, en
loe aflos 1853 y 1854, eetudiando bus enfermedades principales en cada jurisdicci6n.

Otra obra donde se encuentran numeroeoe datos es la que Felix Erenchun public6
con el nombre de ' ' Anales de la Isla de Cuba. Diccionario administrativo, econ6mico»
estadlstico y legislative, por Don Felix Erenchim (oidor de la Beal Audienda Pre-
toria]}, afio de 1855. Habana, Imprenta dd Tiempo, calle de Cuba No. 110, 1856."
El tomo 1^ comprende las letras A-C, y d 2^ las D-V. El alio 1856 lo trata igualmente
en otros dos tomoB, en d dltimo de los cuales hace constar que termina la obra el 8 de
mayo de 1863, lamentando ''la temprana muerte dd infatigable D. Ilam6n Pifia,
cuya sentida p4rdida se ha dejado sentir muy notablemente en la segunda mitad del
presente diccionario."

El discutido Sagra, a quien encontramoe antes (1831), deepu^s de haber impreso su
gran obra de 1842, da a luz otra llamada "Cuba en 1860 o sea Cuadro de sus adelantos
6D la poblaci6n, la agricultura, d comerdo y las rentas ptiblicas. Suplemento a la
primera parte de la historia polftica y natural de la Isla de Cuba, por D. Ram6n de la
Sagra, Paris, en la libreria de B. Hachette y Co., MDCCCLXII," en la que rectifica,
amplia y reproduce cuadroe estadlsticos, curvas demogr^cas y meteorol(3gica8 y
otra serie de datos absolutamente necesarios para todo el que quiera conocer nuestros
problemas demogr&ficoe.

En 1861 se levanta un censo ofidal de la pobladdn, que bo resume en el libro:
"NotidsB estadisticas de la Isla de Cuba, en 1862. Dispuestas y publicadas por el
Centro de Estadistica conforme a 6rdenee e instnicdoneB del Excelentlsimo Sefior
Intendente de Hadenda, Conde Armild^z de Tdedo, Habana, Imprenta del Gobiemo,
Capitania General y Red Hacienda por & M., 1864." La Introducci6n est& firmada
por el Jefe inmediato dd Centro de Estadistica, Jos^ de Frfas. Trae luego los cuadroe
resdmenes dd censo levantado en la noche dd 14 al 15 de marzo do 1861 y enseguida
los numeroBOS datos del afio 1862.

En 1863 se publicd en Madrid, imprenta ddestablecimientodeMellado, el grandiose
"Dicdonario geogr&fico, estadistico, hist^Srico de la Isla de Cuba, por Don Jacobo de la>
Pezuela" en cuatro tomos, de los cuales loe tree primeros Bon impreeos en esa casa y
en d afio dtado, y d cuarto, en la imprenta dd Banco Industrial y Mercantil, tambi^
en Ifadrid, pero en d afio 1866. Esta obca, de m^to excepdonal, contiene datos

424 PBOOEEDINGS SECOND PAK AMEBIOAK BCIEKXIFIO 00KGBE8S.

estadlsticoB de valor inapredable, y es una de las fuenteB de infonnaci6n mSm preciofla
para cuanto a Cuba se refiera.

La hmdacidn en mayo de 1861 de la Academia de Cienclas M^cas, Fisicas y Nato-
rales de la Habana, agrupando en su seno las grandee energies de los intelectuales de
Cuba, abre ancho cauce por donde coireHLn en breve raudales de investigacionee en
el terreno demogrifico, a cuya cabeza ha de colocarse un nombre inolvidable, el del
Dr. Ambrofflo Gonzdlez del Valle y Cafiizo, que durante laigos afios mantuvo enhiesto
el pabell6n glorioso de la estadistica m^dica.

Precedi^nle, no obstante, en la miama Academia otros trabajadores entre los que
citar^: las notas presentadas en la sesidn del 27 de abril de 1862 por el Dr. Fernando
Vald^B y Aguirre * y el Sr. Andr^ Poey * y la memoria presentada al (jobiemo por el
Sr. Frandsco Matias Ruiz sobre las "Causas que contribuyen al aumento de la mot-
tandad de la raza de color y a los medics de remediarlas'' y remitida por aquel a la
Academia para que le informase sobre dicha memoria en 9 de noviembre de 1862.
En 8 de marzo del aiguiente afio, el Dr. Fernando Vald^ y Aguirre emiti6 el infbrme
solicitado* en el sentido de que dicho trabajo '^cree no debe ser aceptado por el
Gobiemo.**

Al final de las entregas de septiembre de 1864 y de marzo de 1865 del tomo I de los
Anales de la Academia, aparecen unos cuadros del ''Movimiento sanitario de la Isla
de Cuba, Primer semestre de 1864/' y con igual tftulo el Segundo Semestre del propio
afio, en los cuales se estudia, por meses, en la Habana y en toda la Isla, en sus departa-
mentos occidental y oriental, el estado especial de fiebre amarilla; el estado que
comprende todos los enf ermos y fallecidos, ya en los cases, ya en las defuncionee, con
la proporci6n entre el ntimero de fallecidos y el ntimero de habltantes por cada 100,000.

Con esto Uegamos ya a los trabajos del Dr. Ambrosio Gonzalez del Valle. Los
primeros fueron de orden puramente meteorol6gicos, tornados en el Observatorio del
Colegio de Bel^n, dirigido entonces por el sabio Padre Vifies^; pero desde el 30 de
junio de 1867* presenta la "Tabla mortuoria del primer semestre de 1867" y eetudia
en las razas, blancos y de color, las edades de adultos y pirvulos en cada uno de los
meses, y afiade un reeumen de la "Mortalidad del 61 time quinquenio 1862-1866";
y la del Segundo semestre del mismo afLo, haciendo oportunas manifestaciones acerca
de la epidemia del c61era asidtico que se declar6 en eeta ciudad en octubre de ese afio.

Siguen a esta tabla los '*Detalles estadfsticos meteorol6gicos de la Habana en el afio
1868 " con los nacidos y muertos clasificados por los meses del afio y la relaci6n de los
caddveres sepultados en los distintos cementerios de la ciudad; las "Inhumadones
verificadas en los Cementerios de la Habana en 1868, con distinci6n de sexos y condi-
clones, adultos y pdrvulos.^" La "Mortalidad de la Habana en el primer semestre
de 1869" y las ^'Tablas Obituarias de la Habana con dates importantes correspon-
dientes al s^undo semestre de 1869.^ " Desde eete trabajo, consagra Gonzalez del
Valle el nombre de Tablas Obituarias cuyos semestres primero y segundo del afio
1870 publica en los Anales* y desde 1871 lo hace ademis en foUetos anualee hasta el

1 Datos para la estadistica de la flebre amarilla en la Habana, El Estlmalo, Habana, mayo 1862, 1. 1,
p. 187-189; Anales, etc., t. XLIX, p. 100-105.

> Curvas de Invadidos y folleddos de la flebre amarilla en la Habana, EI Estfmulo, Habana, mayo ISO,
1. 1, p. 171-173; Anales, t. XLIX, p. 105-100.

* Causas que contribuyen a la disminucidn de los esclavos en Cuba y medlos de destnilrlas, Trab^los de
la Comisidn de Medidna Legal e Hlgiene PAbllca de la Academia de Cienclas MMicas, Ffsicas y Natuiate
de la Habana, 1873, t. II, p. 8-23.

4 Climatologla, Anales, etc., t. II, p. 343-344; Meteorologia, Anales, t. Ill, p. 324-325; Climatologfa de la
Habana en 1867, Anales, etc., t. IV, p. 360-371.

ft Tabla mortuoria del primer semestre de 1867, Anales, etc., t. IV, p. 136, y Tabla mortuoria del Segondo
semestre de 1867, Anales, etc., t. IV, p. 411-112.

• Anales, etc., t. V, p. 377-378; 442; 466-467.
» Anales, etc., t. VI, p. 77-78; 252-254.

» Anales, etc., t. VII, p. 157-158, 567-672.

PUBLIC HEALTH AND MEDICINE. 425

de 1882, acompafiando a lo6 datos aanitario-demogr&ficos, cada vez mis completos y
mejor ordenados, tktilee e interesantee inveetigaciones relacionadas con el asuBto.

Al analizar las correspondientee al alio 1877, el Dr. Eduardo F. Pld, decfa .... este
como el de los afios anteiiores constitaye un trabajo estadfstico de una importanda,
que hace honor a su ilostrado autor, tan competente en la materia y el dnico que en
la ac tualidad cultiva en Cuba esta clase de estudios, * * y mis adelante agrega' ' : " Ahora
bien, nadie deeconoce, ni negarse puede la gran ventaja que presta una buena esta-
distica mMica, ni las muchas dificultades que para lograrlo es neceeario veneer,
exigi^ndose para ello la escrupulosidad, la paciencia y la constancla de que tantas
pruebas lleva dadas el autor de este opdsculo, i por qu^, puee, la junta de sanidad no
crea en su seno una seccidn de estad(stica dotada del personal y fondos suficientes,
para r^^ularizar y hacer extensivo a toda la Isla, eetudios tan titiles e importantes
como los iniciados por el Dr. Valle ? * "

Si fuese a citar cada uno de los trabajos del Dr. A. Q. del Valle, necesitarfa Uenar
muchas p^inas, por consiguiente me limitary a reproducir lo que eecribi6 hace afios
uno de sus bi^grafos, el Dr. Antonio Gons&lez Curquejo al referirse a este gran
dem6grafo:

Las aficiones estadfeticas del Dr. Valle se manifestaron hace cerca de treinta afios
con la publicaci6n de sus observaciones climatol6gicas que recogfa en el Observatorio
de Bel6n, donde anotaba las oscilaciones barom^tricas, el movimiento del term6me-
tro, la tensidn del vapor de agua, la m&xlma y minima de la humedad y evaporaci<Sn;
asf como la cantidad de agua caida y las direcdones de los vientoe. Dichos estudios
que continu6 durante algtln tiempo fu6 relacion&ndolos con la etiologla de las enfer-
medades reinantes en cada estaci6n y con la mortalidad de la ciudad de la Habana.
Hay que tener en cuenta las ideas dominantes hace 40 afios' sobre la influencia que
en la producci6n de las enfermedades tenfan la electricidad, el magnetismo y los
demds agentes atmosf^ricos, para comprender la preferencia que daba a aquelloe estu-
dios:

La aparici6n del c61era en el afio de 1867, enardeci6 el celo del Dr. Valle y com-

Srendiendo que eran los ndmeros los que dnicamentepod(an demostrar el incremento
e la epidemia, y el peligro que corrut la poblaci6n si no se ponfa coto a su progreso,
comenz6 a formar cuadros de las invasionee y defunciones por barrios llainando la
atenci6n sobre aquellos que eran m^ azotados, a fin de oue pudieran removerse las
causas de insalubridad. Son meritorios los trabajos que durante el afio de 1868 pre-
sent6 a la Real Academia de Ciencias relatives al c6lera. en cuyo afio fallecieron de
esa enferfaiedad 3,277 individuos. al^nos de cuyos trabajos se refieren a la Cdrcel, en
la c^ue tenisL intervenci6n en calidaa de Concejal del Ayimtamiento.

Siguiendo el curso de las estadfsticas necrol<3^cas del Dr. Valle se nota un pn^reso
constante, pues al principle se limitaban a dividir los fallecidos por razas. estaciones
y edadee. Mds adelante estudia las entermedadee productoras de la muerte; asf como
los enterramientos que por aquel entonces se hacian en distintos cementeiios: para
ocuparse despu^ de los nacimientos y establecer la proporci6n entre la natalidad y la
mortalidad de los individuos.

Fu6 asunto de la atenci6n del Dr. Valle la procedencia de los fallecidos, eegdn
fuesen de los hospitales o de las diferentee parroquias de la ciudad, dividi^^ndoloe
por sexos, llamanao la atenci6n en los trabajos posteriores sobre aquellas enfermeda-
des que como la viruela, la fiebre amarilla, la tuberculosis y las afecciones inteeti-
nalee son las que m^ diezman la poblaci6n.

/ Adem^ de las estadlsticas generales hizo el Dr. Valle estadisticas parciales como
por ejemplo las de los Hospitales de Caridad de la ciudad. En una nota por demis
mteresante que public6 en 1870 hace notar la ventaja alcanzada en el de San Felipe y
Santiago, despues de su traslaci6n de las calles de Aguiar y Empedrado, a los altos
de la (^rcel. Oigamos suspalabras: ^'Obs^rvase que tanto en el afio 1859 que estuvo
el Hospital dentro de la ciudad como en un quinquenio recogido en aquel antiguo
local, hecha comparaci6n de los afios posteriores al 59 y los transcurridos en los altos
de la cdjcel, desae 1861, la mortandaa ha disminuido en m^ de 8 por riento por la
situaci6n del lu^ y la ventilaci6n mis sana que por cierto no tenia antes en el con-
vento hospitalario de San Juan de Dios. iCuanta Iecci6n para demostrar que la mor-

1 Crdnlca MMioo-Qoin^aioft de la Habana, 1878 t. IV, p. 82-86.
< Esto M aseribia en 1802.

426 PBOCEEDIKOS SECOND PAN AMEBICAN 80IENTIFIC GOKQBBSS.

tandad del Hospital de San Felipe y Rantiago vendria a la menor dlra poeible edifidb-
dolo con las condiciones que impone la ciencia con prudbas indeclinables!'' Afor-
tunadamente los deseos v vaticimos del Dr. Valle se ban cumplido satis&urtoriamente
y el Hospital de San Felipe y Santiago, hoy llamado Nuestra Sefiora de las Mercedes
cuenta en la actualidad con edifido propio, montado en las mejores condiciones
hin^nicas y con una admini8traci6n y aaistenda m^icas recomendables.

Otro ejemplo de esas estadlsticas parciales es la relativa a los fetos, anclanos, y
gemelos muertos y la que ee refiere a Guanabacoa.

Para comprender el m^rito que tienen los trabajos demogr^cos del Dr. Valle hay
que tener presente que los hizo por cuenta propia, luchando con todo g6nero de con-
trariedades, sin apoyo oficial de ningdn g^nero y teniendo que emplear los recuTBos
de BU bolaillo v de su prestigio personal para lograr datos y noticias, en una 6poca en
que se carcecut de regjstro civil y no poca parte de los profesores m^cos expedlan
certificados de defunci6n faltos de datos y sobrados de defectoe.'

Gene

asf: '*B^]gica solidta los modestimmos trabajos •
Valle (D. Ambrosio) con plausible perseverancia publica periodicamente; los Estados
Unidos estiman esos trabajos, piden notas al laboiioso acad^mico y hasta le envfan
planillas ad hoc para fadlitarle su tarea; la prensa de Madrid da cuenta de ellos, los
jwm y recomienda y lamenta aue el Dr. Valle no tenga imitadores en la Peninsula;
ei Gobiemo de la Isia tambi6n los valoriza, los pide a esta Acadeinia y al acad^mico
en particular, y adem^s los declara oficialmente dtiles, comprendiendo los fecundos
resiutados a que conduce la fisiologla de los pueblos estudiaoa al trav^ de las dfras;
fecundos para la ciencia, que por este medio encuentra la soluci6n de numerosos
problemas en que ee traducen padedmientos sociales; fecundos tambi^ para la
adininistraci6n pdblica que, sin esas cifras. o desconoce dertas necesidades que
afllgen a bus administrados, o si las ve ignora las fuentes de donde emanan, diri^endo
al azar bus esfuerzos, que se agotan sin alcanzar el origen del mal, que en su soRdtud
dega no encuentra.'

En la Beei6n celebrada por nuestra Academia el 10 de noyiembre de 1878 preeent6
Finlay un trabajo de higiene pdblica, titulado ''Clima de la Isla de Cuba' en el que
deepu^ de algunas consideraciones fayorables a nuestro clima y de yarios inte-
resantes cuadros estadfsticos, demostrando lo infundado de ciertos conceptos que se
encuentran en algunos autores nadonales y de ahf reproduddos en tratados de higiene
que gozan de autoiidad en el extranjero. Sefiala la corta mortandad que fuera de la
Habana ofrece la raza blanca en la isla de Cuba; la menor de ^sta comparada con la
de color; la eleyada de la raza asi^ca en la Habana; las condiciones meteoroldgicas
que colocan a nuestro clima en posiddn muy yentajosa relativamente a las demis
antillas; que a pesar de yarios factoree, que sefiala, la mortandad de la Habana es
inferior a la de algunas dudades de Europa, en particular Madrid, Barcelona, Viena,
etc.; y pide que en el censp que se efectu6 el 31 de didembre de 1877 se dasifique
la poblad6n no tan s61o por razas y condidones, sine tambi^n por edades y naturali-
dades ''como dnico fundamento dentffico en que debe basarse el estudio de la inmigra-
diSn blanca y de color en la Jala de Cuba, que tan justamente preocupa a los
nombres penodores del pals."

Como continuad6n de este trabajo public6 un escrito sobre la "Apologia del clima
de Cuba" en didembre de ese mismo afio, en el que, refuta con datos estadisticos
los calificatiyos de insane y mortlfero aplicados a nuestro dima. Presenta las con-
didones meteoroldgicas que le permiten asegurar: "que en manera alguna debe
asimilarse el clima de la Habana al de los palses tropicales m^ dUidos y htimedos; "
estudia la salubridad del dima de Cuba, la aclimatad6n del europeo en Cuba, y
la diffcil propagad6n de la raza de cdor en la Isla de Cuba, conduyendo: P, Que el
dima de la isla de Cuba debe considerarse como uno de los m^ saludables del mundo
para la raza blanca; 2?, que el inmigrante bianco es verdad que ha de contar con el

■El Dr. D. Ambrodo Ckms&les d«l Valle, por el Dr. Antonio Qonz&lez Curquejo. Repertorio VMico
Fmnaotetioo de 1* Habana, novlembre de 1893, aflo HI, p. 363-372. •

•NeoetidaddeunabtienaEfltadbtloaMMlcaenlalsladeCuba. Condidones que debe llenar. ICoddn
elevada al Oobiemo General, por el Dr. Vicente B. Vald^ Anales, etc., t. XVI, p. 150-161.

tAnalef, etc, t. XV, p. 961-378.

PUBLIC HEALTH AND MEDICINE. 427

tributo que nueetras p^Bunas condidoiies higi^nicas le obligan a pagar, por una sola
vez, a la fiebie amarilla si viene a residir en la Habana o en otras pobladones del
litcnral; peio que, paeado eee peligro cuyas pioporciones estd en sus manos disminuir,
ae encuentra aqul con mayores probabilidades de vida al menos hasta los 60 afios,
que las que hubiera tenido en su pals natal; 3^, que la raza de color con dificultad
ae sostiene en la isla de Cuba y probablemente, iria en disminuci6n sin su cruza-
miento con las lazas europeas.

Este trabajo lo refut6 el Dr. Juan Espada y entonces Finlay contestd con otio,
continuaci6n del que he sefialado, con el tftulo: ''Contestacidn a las 'Breves Obser-
vaciones' del Dr. D. Juan Espada" y que public6 en la misma revista m^ca que el
anterior.'

En la sesidn siguiente a la en que Finlay preeent6 su primer trabajo aniba men-
cionado, el Sr. Marcos de Jesds Melero ley6 una ''Reseiia estadistica acerca de la
mortalidad en la Isla de Cuba" ' en la que, despu^ de comparar los nacidos y los
muertos, blancos y de color en los censos de 1827, 1846 y 1861, y de demostrar que
"los ntimeros vienen en abono de que el dima de Cuba no es lo mortffero que se pre-
tende hacerlo aparecer para los europeos" pide la creacidn de una Comifil6n per-
manente de estadlstica m6dica, a lo que accede el presidente de la Academia, Dr.
Gutierrez, nombrindose para formarla al Dr. Ambrosio Gonzdlez del Valle, como
Presidente, a los Sres. Melero, Finlay y Reyes, como Vocales y al Dr. Vicente Benito
Yald^, como Secretario; presentando acto seguido el de la Corporaci6n, Dr. Antonio
Mestre, la propuesta del nombramiento de acad^mico de m6rito, la m^s alta distincidn
que confiere la academia, a fovor del Dr. (jonz^ez del Valle, paia premiar asf la
importancia y utilidad de bus trabajos; honor que m^s tarde le fu^ conferido.

Al mismo tiempo que esto ocurrla en nuestra Academia de Ciencias, el presidente
de la Comisi6n Central de Estadlstica de la Isla, Sr. Mariano Cancio Villamil, pedla
a la corporaci6n (30 noviembre 1878) que, para cumplir los deberes impuestos por el
decreto de su fundaci6n, fecha 18 de septiembre del mismo afio, le remita peri6dica-
mente cuantos datos sobre mortalidad y estado sanitario en las diferentes localidades de
la isla se compilan por la misma, ''con el fin,'' decla, "de poder en su dla establecer
las comparacionee, las observaciones y los estudios a que conducen todoe los datos
estadlsticos en sus aplicaciones prdcticas con relaci6n a la poblacidn, la topografla
del pals, su extension y clima.''

La Academia contest6 en 27 de marzo del siguiente afio pidiendo: 1^, abrir en los
juzgados municipales un r^:istro andlogo al civil quo rige en Espafia, acomodado al
fin con que lo indic6; 2^, adoptar en esta isla la comprobaci6n de defunciones con
arr^lo a la R. 0. de 19 de noviembre de 1872, que contiene la instrucciiSn para su
observancia; 3®, crear comisiones locales de higiene y estadlstica sanitaria y m^ica,
encaigadas de coleccionar y apreciar las notidas y elementos que encontrarlan en
aquel registro y en otras fuentes que se pondrlan a su disposicidn para los fines de su
creaci6n; y 4®, disponer que los establecimientos del Estado y los de los particulares, asf
como los profesores medicos, envlen a la autoridad correspondiente los partes y datos
que son menester para la formaci6n de esta Estadlstica.'* '

Este informe, favorablemente acogido por la junta superior de sanidad, fu6 sometido
al consejo de administraci6n, quien hizo reparos legales que motivaron volviese todo
el expediente a la Academia y en otro informe emitido en 11 de enero de 1880, despu^
de discutir las modificadones propuestas por los dos organismos antes dtados, formula
24 artlculos de un reglamento quo debe servir para registrar losnacimientos, los matri-
moniol y las defundones, siendo lo mis importante de ellos la uniformidad a que se
Bometen los certificadoe de esta tiltima clase, con lo que se facilita el trabajo eetadlstico

1 Oaoeta MMloa do la Habana, didembre 1878, y marso de 1870.

< AnateB, etc., t. XV, p. 287-295.

sAiiale8,t.XVI,p.848.

428 PBOCEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NGBE88.

y Be garantiza ademis el que personas extrafias a la profeei6n den certificados de tanta
trascendencia, oponi^ndose igualmente a la ocultaci6n de muchoe crfmenes.^

Todo parece conspirar en aquellos tiempos al mejor deeenvolvimiento de la esta-
dlstica. Con la paz que termin6 la guerra de los diez afios suige la neceeidad de encau-
zar la vida en el sentido del progreeo y del orden administrativo, y el Gobiemo se
preocupa de satdsfacer estas neceeidadee. Buena prueba de ello ee el siguiente decreto
del gobemador general D. Ram6n Blanco, expedido en 30 de junio de 1879 ' en el
cual entre otras cosas se dice lo siguiente:

Era, pues de todo punto forzoeo acomcter la colosal empresa de hacer de una vee
una buena estadfstica. Con gran conocimiento de la materia y con todos los medios
necesarioe se emprendieron en octubre del dltimo afio pasado loe trabajos al efecto;
y grande ha eido el celo deeple^ado, ya por la junta de personas notables puestas a
su frente; ya por los funcionanos encargados de la ejecuci6n de los trabaioeen esta
capital y en las provincias. Se ha tropezado, sin embargo, con dificultades por el
pronto inauperables y el 6xito no ha correspondido a las previsiones, no habi&idose
podido conseguir hasta la fecha que los particulares llenen con regularidad las pla-
nillas de sus declaraciones y que los Ayuntamientos las recojan y remitan: s61o de doe
municipioe, y no muy importantes por cierto, se han recibido aquellos datos, y tales
ban venido, que a la simple primera vista revelan su inexactitud y su completa inuti-
lidad.

Entre la parte dispositiva de dicho decreto merecen citarae los siguientes articulos:

1^, Se suprimen temporalmente desde 1° de julio pr6ximo las oficinas creadas en
esta capital y en las provincias, para auxiliar a las comisiones permanentes de estar
distica, en virtud del artlculo 7** del Real Decreto de 18 de septiembre de 1878.

2^. En lugar de las oficinas suprimidas, se crea en la Direcci6n General una Secci6n
que se llamard de "Estadlstica preparatoria, " cuyo objeto es reunir, rectificar y clasi-
ficar los datos existentes sobre la estadfstica de la poblaci6n, de la industria y de la
riqueza de esta isla, y procurar la adquisici6n de todos los necesarioe para poder, eai
su dla, por medio de un procedimiento r&pido, y con sujeci6n al Decreto citado,
formar el censo de pobladdn y el padr6n general de la riqueza. Esta secci6n se haHL
cargo de los archivoe de todas las oficinas del ramo y organizaii un '^ Archivo Especial
de Estadfstica."

3°. Las comisionee honorfficas nombradas en virtud de lo dispuesto en el decreto
arriba citado subsistir^n como cuerpos consultivos, a que rectirrird la administracidn
en todos las casos dudosos hasta tanto que preparadoe los trabajos por la Secci6n, se
restablezca en todo su vigor el mismo Decreto. "

La Real Orden de 23 de noviembre de 1881 dispuso la ''conveniencia de que fund&n-
doee en la R. 0. de 4 de octubre dltimo, ordene a D. Antonio L6pez Prieto con uigenda
la confecci6n de un proyecto para organizar con amplitud en eea Isla, de manera que
responda a esta verdadera necesidad, pues sin una estadfstica perfecta, ee casi impoeible
el conocimiento de la riqueza imponible, ni la base para una administraci6n correcta
y prudente. " '

El nombramiento de este distinguido funcionario, muy poco conoddo a pesar de sua
importantes trabajos demogr&ficos, marca una fecha de verdadero incremento en loe
estudios de esa fndole. Supo imprimirle al Boletfn que dirigfa un sello de seriedad
notable, y public6 datoe de importancla capital para todoe los que quieran laborar
en ese campo fecundo de fructfferas ensefianzas. Con el tftulo gen^rico de '^Estudioe
estadfstico-demogrdficos" di6 a conocer importantes documentoe entre loe cuales
sefialar^ por su importancia los cuadroe de loe **Nacimientoe y muertoe por razas &i
la Isla de Cuba en los a£ioe 1793, 1827, 1842, 1843, 1844, 1845, 1846, 1853, 1862 y 1879. "
y los siguientes, todoe ellos del afio 1879: "Nacimientos de hijos legftimos e il^timos
por sexos y razas; id., de los bautizados en la Isla de Cuba; id, por provincias; muertoe

1 Estadlstlca MMlca y Sanitaria en esta Isla. Instnioclones reglamentarias, por el Dr. Vicente B. yaI<Mf,
Anales. etc., t. XVI, p. 343-355.
s Boletin Oflcial de Hacienda de la Isla de Cuba, Habana, 10 de enero de 1881, aflo I, p. 8-6.
t Boletin Oflcial de Hadenda de la Isla de Cuba, Habana, dioiembre de 1881, aflo I, p. 473.

PUBLIC HEALTH AND MEDICINE. 429

per razas y por provinclas; nacimientos y nacidoe muertos y expueetoe o abandonadoe
en parajee ptiblicos, por provinclas, sexoe y razas; no nacidoe pero sf bautizadoe;
nacimientoe por estaciones, sexoe, razae y provincias; muertoe por eetadonee, sexoe,
razas y provincias; y defuncionee por enfermedadee y provincias, clasificadas aquellas
por orden alfab^tico, con los resdmenes de blancos, pardoe libree y eeclavoe, morenoe
libres y eeclavoe, y varones y hembras. '

Asimismo di6 a conocer el ''Cuadro de fiebre amarilla en el Hoepital Militar de la
Habana, por meees, deede 1874 hasta 1881*' eetudiando loe caeoe y loe muertoe.'
Public6 igualmente sus ''Estudioe sobre Poblaci6n" en 1881, y refiri^ndose a elloe
eecribfa en enero de 1882, nueetro insigne bibli6grafo Antonio Bachlller y Moralee '
lo eiguiente: ''El jete de la Secci6n de Estadfstica, laborioso cuanto ilustiado, amigo
nueetro, D. Antonio L6pez Prieto, ha oiganizado y se ban dado a luz, bellamente
impreeoe en La Propaganda Literaria, unoe eetadoe que ba considerado como Estudloe
0obre Poblaci6n, de que ee un deber que ee ocupe el i)eriodismo aunque no sea mis
que para marcar con piedra blanca este dfa fausto en que se dedica eea publicaci6n
a las neceeidades de todo "psia civilizado.'' Analiza y comenta loe bechoe reveladoe
por las cifras en esos estados, y en otro lu gar del artfculo dice: "No debemoe concluir
sin bablar de los Estudios demogr&ficos correspondientes a 1879, que tambi^n ha
publicado oficialmente la Administracidn de Hacienda en La Propaganda Literaria,
como los Estudios posterioree a que henios consagrado merecida atenci6n."

''El Sr. L6pez I^eto ha acompaflado una intereeante introducci6n en que se leen
estas palabras: 'Blen puede decirse, Excelentfsimo Seflor, que por primera vez en
Cuba, extend iendo los estudios a toda la isla, se levanta el velo que hasta ahora ha
ocultado graves males sociales, que urge remediar, y la Secci6n de Estadfstica Pre-
paratoria, inspirada en altoe sentimientos de patriotismo, ha considerado como uno
de sus principales deberes no ocultar por mis tiempo el cuadro doloroeo que bajo el
punto de vista moral preeenta la poblaci6n en el movimiento de su deearroUo, punto
tan digno de la ilustrada atenci6n del Gobiemo. ' Si en lugar de consignar que por
primera vez se levanta el velo se hubiera dicho oficialmente, o se confirma oficialmente
eetarlamos de completo acuerdo, como lo estamos, no ahora, sino hace muchisimo
tiempo, en la realidad del cuadro que ofrece Cuba en su abigarrada, insignificante
para su extensi6n, maleada por sus antecedentes, poblaci6n cubana. "

Los Estudios sobre Poblaci6n, de L6pez Prieto, dieron motive a nueetro erudite
publidsta Dr. Jos^ Varela Zequeira, para leer en la sesidn del 6 de febrero de 1882,
ante la Sociedad Antropoldgica de la Isla de Cuba, un intereeante trabajo que lleva por
titulo, ''Eetudioe eetadlsticoe/' y por eubtftulo, ''El desnivel de loe sexos en la Isla
de Cuba," * en el que, despu^ de estudiar los febctores que ban contribufdo a este mal
y de muiifestar que: "En el presente case Ian cifras estadisticas anotadas confirman
que en la Isla de Cuba el desnivel de los sexoe es un peligro cierto y evidente que nos
lleva a pensar en el s^quito de calamidades que arrastra consigo toda infracci6n o dese-
quiUbrio en las leyee sociales/' concluye proponiendo como tinico remedio a tamafio
mal: "... la inmigraci6n por familias de nueetra raza; no la importaci6n de colonos
asiiticos, proyecto que ban acariciado nuevamente eepfritus obcecados y polfticoe de
ocasi6n.**

Public6 el Sr. L6pez Prieto otra serie ae trabajoe intereeantee eobre eetadlstica— ya
que no he de hablar de los histdricos, literarios, etc., entre loe que dtar^ el "Cuadro
8in6ptico de loe principalee censoe de la Isla de Cuba, deede 1768 a 1879, con el reeumen
de BUS rentas generales en loe afioe que se consignan, " ' el 27 de diciembre de 1880;
"Las aduanas de Cuba, 1864-1881" del libro in^to "Ensayoe de Eetadlstica comer-

1 Boletfn Oflcial do Hacieiid* de 1* Isla de Cuba, 30 JaUo 1881, aAo I.

t Boletfn, etc, de Cnba, 30 abrU 1883, aflo n, frente a la p. 100.

> Estadistioa de Cuba, Estudios sobre la pobladdn, Revlsta de Cuba, Habana, enero 1883, t. XI, p. 00—74.

« Revtota de Cuba. Habana. felmro 1883, t. XI. p. 143-147

» Revtota de Cuba, Habana, mano 1883, t. XI, p. 386.

430 PBOCEEDINGS SECOND PAN AMEBICAN SOIENTEFIC OOKQBESS.

dal de la Isla de Cuba,'' cuadro firmado el 5 de abiil do 1882' y en julio de eee miamo
afio, la propia revista da cuenta de la publicaci6ii reciente de la ^'EetadiBtica de Sub-
flistencias,'' eerie de eetadoe demoetrativos del consumo de cames en la lala de Cuba
en el afio de 1880; y afiade este triste comentario: '* Ee el dltdmo trabajo de la sede de
laudables ensayoe que recomiendan la actividad de un centio digno de oiganizaddn
mis amplia y completa. Tenemoe entendido que el infonne rasonado del Sr. Ldpes
Prieto para dotar a esta isla de una verdadera ofidna central de Estadlstica, ei no del
todo iniructuoeo, ha side desatendido en su parte mia sustancial y provechoea para ei
pais. No se desaliente el Sr. L<5pez Prieto, persevere en sub eetudios, e insista en so
prop<5eito de salvar nueetra rudimentaria estadfstica del error en que la ha sumido una
absurda centralizaci6n administrativa.' Probablemente, serla ^te su dltimo trabajo
eetadistico, pues fallecid el 8 de abril de 1883.

Un hecho de suma trascendencia sefiala los comienzos del afio 1884: la promulgarirtn
del real decreto, fecha 8 de enero de 1884, implantando en Cuba y Puerto Rico la ley
provisional del registro civil de 17 de junio de 1870. En su art£culo 2^ se dice: '*La
citada ley empezari a regir el dfa 1^ de septiembre del coniente alio,'' (1884). Por
Real Orden de 6 de noviembre del mismo afio, aprob6 S. M. el ** Reglamento para la
ejecuci6n de la ley del registro civil" y se puso en vigor en 5 de diciembre oguienta
Por dichas disposidonee se estatuye que los nacimientos, los matrimonios y las defun-
dones se inscriban en el registro que llevar^ los juzgados munidpales, cesando por
tanto los registros parroquiales, encargados hasta entonces, de las inscripdones de
dichos actos. La cread6n de los mendonados registros determina la fuente de ortgen
de todas las ulteriores investigadones estadisticas.

El alejamiento de bus habituales labores del Dr. Ambrosio Gonz^es del Valle y la
muerte del Sr. L6pez Prieto constituyen, a pesar de la cread6n del registro dvil, un
retroceso en la hermosa via que venlan recorriendo nuestros estudios dempgr&ficos.
Buena prueba de ello la hallamos en la siguiente notida tomada de la Cr6nica Medico-
Quirtiigica de la Habana, monumento levantado por el Dr. Juan Santos Femioidez a
la gloria de nuestra medicina, pues bus colunmas enderran cuanto se refiere a la cultura
profesional de Cuba. Al dar cuenta de la sesidn celebrada por la junta provincial de
eanidad el 24 de noviembre de 1886 se consigna:

Despu^ de la lectura y aprobad6n del acta de la sesidn anterior, el secretaiio di6
cuenta de la comisi6n que, compuesta del Sefior Gobemador Civil y los Dies. D. Luis
Cowley y Santos FernMidez, vi8it6 al Excelentlsinio Sefior Gobernador General y le
hizo preeente la necesidad de organizar la estadfstica m^ca.

El Gobemador General convino en que sin estadlstica m6dica no era j^ble satis-
focer las necesidades a ciencia fija, de la higiene, la que sobre todo, necesitaba de eUa
como base de bus estudios, y reconoci6 que serfa yergonzoeo para el gobiemo de la iala,
en SUB relacionee intemacionales, no poder suministrar los dates eetadlsticoe que con
altos fines pueden pecUr los gobiemos extranjeros y nuestra misma metr6poli. El
General CaUeja prometi6 dictar 6rdenee oportunas y en^rgicas a fin de gue de los jua-
gadoB munidpales se remitiesen los dates necesarios, ya que el dero se mega a suminis-
trarlos.'

Poco resultado se obtendrfa de tan levantadoe propdsitos y halagadoras promesast
cuando en marzo de 1888 el Dr. Santos Femimdez escribid el siguiente editorial en so
ya dtada Crdnica:

Nueetra secd6n de estadfstica: Es de todos sabido que lo defectuoeo de la estadfstica
en la Penfnsula y^ la carencia de ella en esta Isla, constituye la fuente de muchoe de
nuestros males; sin estadfstica no es posible dar un paso, cualquiera que sea la esfera
en que se gire, en una palabra, no es posible gobemar; m&s como no es, ni ha sido
nunca nueetro prop^sito, salimos de los If mites profesionales, nos referiremos hoy
exclusivamente a nuestra estadfstica m^dica, en la cual estd comprendida, no s61o la
mortal! dad, sine todo cuanto hace relad6n a los nadmientos, matrimonios, etc.; por

1 Revista de Cuba, Habana, abril 1882, t. XI, p. 381.

t Revista de Cuba, Habana, jnlio 18S2, t. XII, p. 91-«2.

* Crdnioa VMloo^nirfkrgioa de la Habana, enero 1887, t. XIII, p. 2IMK).

PUBLIC HEALTH AND MBDICnSTE. 431

la influencia que loe estudioe demogrdficos pudieran tener en nuestra noeologfa y en
el planteamiento de loe preceptos de la Higiene.

La Cr6nica, desde su fundaci6n, ha prestado preferente atenci6n a la estadistica;
basta reconrer sua pdginas para convencerse de esta verdad: de todas partes de la Isla
hemos allegado datos, y nuestro inaigne corredactor el Dr. D. Ambrosio Gonzalez del
Yalle lleva la mejor parte de la glona que cupiera a la publicaci6n en esta obra alta-
mente civilizadora.

El Dr. Gonzdlez del Yalle ha empleado gran parte de su vida en este g^nero de
estudios aue continu6 con una enviaiable perseverancia en la Or6nica hasta que sua
achaques le obligaron a abandonar, a su pesar, tan meritoria empreea.

Faltoe 3ra del poderoeo concurso de nuestro eminente corredactor, forzoso noe era
llenar el vaclo oue su obligada inacci6n habfa provocado, y a este propiSsito recurrimos,
como siempre nemos hecno, a la inidativa individual. No debemos conformamos
con pedir a loe Gobiemos instituciones titilee y provechoeas; es necesario que se las
demos hechas y comba tamos la r6mora de aquellos, con nuestra propia actividad.
Nadie resiste a la evidencia de los hechoe reales, y la necesidad de una estadistica
demogr^ca ee una verdad que se impone as! como se palpar&n sus ventajosos resulta-
doe una vez que se establezca, siquiera sea rudimentanaj pues no se nos oculta que la
obra no es de un dia y que demanda un trabajo sin Ifmites.

La Or6nica no ha retrocedido jam^ ante los grandes obstdculos, porque le alienta
la fe m& pura y el amor desinteresado de la patna. Se ha impuesto el deber de velar
por los intereses de la cienda y de la profesion m6dica y no escatimard la ocasidn ni el
momento de sacrificar en su obsequio el repoeo y la calma siempre ambicionadoe; si
en cambio de ello brUla para nuestra cienda, menospredada m^B all& de nuestras
fronteras, un dia de gloria o un triunfo merecido.

Nuestra secci6n de estadistica demc^rifica empezard bien pronto a fundonar bajo
la direcci6n de nuestro ilustrado corredactor el Dr. D. Vicente de la Guardia, que ha
dado pruebas de su competencia, en su trabajo sobre la Fiebre Tifoidea y en otros que
no es del caso enumerar.

La Cr6nica facilitar& al Dr. la Guardia cuantos recursos demande, en la medida de
BUS fuerzas. y no dudamos que nuestra estadistica demogrdfica, continuad6n de la
otra iniciaaa por el Dr. Gonz&lez del Yalle. serd un elemento m^ de estudio entre
noeotroe v por lo menoe servird de emulacion para obra de mayoree propordonee de
parte de los Gbbiemos y las corporaciones popuiares.'

He preferido copiar fntegro este artfculo porque fija el nombramiento del Dr.
Vicente de la Guardia y porque demueetra una vez mis que la estadistica progresa por
el esfuerzo personal de los hombres que la dirigen, a pesar de las trabas de que se la
rodee. Sirvi6 de latigazo a las dormidas actividades de los gobemantes y para las
tristes confeeionee que se hacen en la circular dictada por el gobemador dvil de la
provincia de la Habana en 12 de abril de 1888, de donde copiamoe este pdrrafo:

Mas, sin embargo, vanoe y est^riles han sido los esfuerzos de este gobiemo de Pro-
vincia para lograr ver realizados los prop6sitos que le animaron a dictar dicha circular
(la de 2^ didembre, 1887, disponienao aue las juntas litoralee y territorialee remitieran
cada 15 dias a la tVovincial, eetadoe ae la mortandad acaecida en la quincena, con
expreei6n de las causas de las muertes), puesto que la junta provincial de sanidad se
ha visto en la imposibilidad de poder ilevar a cabo tan importante servido, debido a
que por las Juntas subaltemas del ramo no le han focilitado los dates necesarios al
decto, sin embain) del intimo convencimiento que tiene este gobiemo de que ella
siempre deseosa de responder a loe fines de su constitud6n, no se ha parado en los
medios de realizar este miportantidmo servido, que vi6 sin duda como uno de sus pre-
ferentes objetoe, y en obsequio dcd cual tiene hecho m&s de un esfuerzo para alcanzar
de su resolud6n,el privilegiado resultado a que se presta una buena Estadistica Sanitaria
y Mortuoria.'

Una terrible epidemia de viruelas asolaba a la Habana en el afio de 1887, y ella le
Birvi6 al Dr. la Guardia para iniciar sus interesantes trabajos demogrdficoe. En el
ndmero correepondiente a septiembre del mendonado a£Lo de 1887, de la Cr6nica,'
public6 bajo el epigrafe: ''Demografia del Estado relativa a los individuos falleddos
de viruela desde el P de enero de este afio hasta el 31 de agoeto" estudiados por
barrios, razas, sexos y edades; consignando al final esta ^'Nota. E^tos cuadros esta-

iCrdnloaMddioo^ulrdrgica do la Habana, mano, 1888, t. XIV, p. 133-184.
tCrdnlca Mddioo-Qolrtrgica de la Habana, Junio, 1888, t. XIV, p. 3U-3U.
* Crdnica HMic(M)uirtirKica do la Habana, 1887, t . Xm, p. 532-^35.

432 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONQBESS.

dlsticos forman parte de un trabajo, en preparaci6n, sobre la actual epidemia de
viruelas, que oportunamente serd publicado en este peiiddico/' Dicho trabajo lo
public6 mis tarde en los Anales de la Acadenxia ^ y en hojas sueltaa tituladas: ''Esta-
dfstdca demogr^co-sanitaria de la ciudad de la Habana. — ^Epidemia de viruelas 1887-
1888 por el Dr. V. de la Guardia," y comprende la relaci6n de losindividuoe fallecidos
en cada barrio, desde el mes de mayo de 1887 hasta el de septiembre de 1888, con un
resumen por razas, sexos y las edades de menos y mis de 10 afLos.

Con el mismo tftulo gen^rico de '*Estadfstica demogrifico-sanitaria de la ciudad de
la Habana" public6 la de los meses y afios correspondientes a 1888, 1889, 1890, 1891,
y 1892 en la Cr6nica, en los Anales y en El Progreso M^co, y en la Cr6nica ' el
"Estado comparativo de Mortalidad, Fiebre amarilla y Viruelas, durante los afioe
que se expresan" (1887, 1888 y 1889), haciendo la comparaci6n por meses en el Hos-
pital Militar y en la Poblaci6n Civil, para cada una de las enfermedades estudiadas.

En la segunda sesi6n (16 enero 1890) celebrada por el Primer Congreso M6dico
Regional de la Isla de Cuba, present6 el Dr. La Guardia unas "Consideraciones demo-
grdficas relativas a la ciudad de la Habana, a£Lo 1889,'' en el que estudift: las enferme-
dades clasificadas por razas en los doce meses del afLo; la mortalidad con relaci6n a la
edad, dividiendo 6stas asf : hasta un afLo, de 1 a 5 afLos, de 5 a 10, y desde esta dltima
hasta los 100, en periodos decenales y otro de m4s de 100 afilos; las defunciones por
estado civil, en los sexos y las razas; por nacionaUdades; el promedio de la vida; los
nacimientos; los nacidos muertos y muertos en el parto; las proporciones de nacidos
y muertos, de mortalidad y nataUdad por cada 1,000 habitantes y la mortalidad y
natalidad diarias en cada mes del a£Lo; las defunciones ocurridas en la ciudad de la
Habana durante los anos de 1887, 1888 y 1889; la criminaUdad en los mismos; el
cuadro comparativo de fiebre amarilla y viruelas, a que antes aludf ; el boletfn meteo-
rol6gico de cada mes de ese afio, tomado del Observatoiio del Colegio de Bel6n; la
mortalidad (nacidos muertos excluidos) y natalidad, por meses y en relaci6n con el
estado meteorol6gico; el movimiento de pasajeros del puerto de la Habana, durante
el afLo 1889 (entradas y salidas) y el resumen del afio. Como se ve por el resumen
anterior este trabajo sefiala un positivo progreso en nuestros estudios demogrdficos,
seguidos luego por el autor con verdadero interns.'

En ese mismo Congreso M^co se presentaron otros trabajos estadfsticoe, con los
siguientes tftulos: ''Estadistica Demogr^ca de la Ciudad de C^denas, durante un
perfodo de seis afios" (1884-1889), por el Dr. M^ndez;^ ''Resefia topoghkfica y eet»-
dlstica demogr&fica de Santiago de las Vegas,'' por el Dr. Eligio M. Palma;' ''La esta-
dfstica de la fiebre amarilla, por el Dr. Rafoel Weiss;"* "Apuntes estadfsticos para
servir al estudio del t^tanos infantil," por el Dr. Rudesindo Garcia Rijo (de Sancti
Spfritus);^ ''Del tratamiento del hidrocele por el dcido f6nico diluido. Estadfstica
Resultados," por el Dr. Ignado Plasencia;' "La cirugfa abdominal en Cuba. Esta-
dfstica y resultados, por el Dr. Avelino Barrena;",' y la "Estadfstica M6dica de una
localidad de Vuelta-Abajo; " del que hay un extracto en la (3r6nica M6dic<>-Qui-
rdrgica de la Habana, al dar cuenta de los trabajos del expresado Congreso; '^ y aparece
luego publicado en el afio 1891 con los cuadros demogr&ficos correspondientes a Caba-
fias, S. Diego de Ntifiez, Bahfa-Honda, Las Pozas y La Mulata.*^

1 Anales de la Real AcademJa de Clendas ICMlcas, Flslcas y Natnrake de la Habana, 1888, t. XXV, p. 196.
« Crdnlca, etc., 1889, t. XV, p. 260.

• Primer Congreso VMico Regional de la Iila de Caba,oelebrado en la Habana en enero de 1800^ Habana,
Imprenta de A. Alvarei y 0, 1890, p. 29-^.

• Idem, p. 6»-76.
» Idem, p. 78-83.

• Idem, p. 101-109.
T Idem, p. 167-176.

• Idem, p. 43{M53.

• Idem, p. 517-626.

10 Crdnfca, etc., t. XVI, p. 91,
u Idem, t. XVII, p. 197-210.

PUBLIC HEALTH AND MEDICINE. 433

El Dr. Vicente de la Quardia public6 mia tarde en la segunda ^poca de El Progreeo
M6dico un trabajo sobre '^La mortalidad en la Habana'' * en el mee de octubre de 1899
y otro en diciembre con el mismo tftulo;^ con el mismo escribid otro el Dr. Manuel
Dellfn, en noviembre ' y despu^s en junio de 1900 el Dr. la Guardia volvi6 a tratar el
asunto, titulando su trabajo de ignal modo que los anteriores; * publicando finalmente en
noviembre siguiente ''Algunas consideradones relativas a la ciudad de la Habana"*
en el que entre otros muchos asuntoe importantes presenta un cuadro de la * ' Mortalidad
general y mortalidad de fiebre amarilla civiles y militaree/' deede enero de 1888 hasta
octubre de 1900. Con posterioridad a este trabajo, ha dedicado sua actividades al
Centro General de Vacuna, cuya direcci6n desempeila y que en Boletines sucesivos
ha dado a conocer la marcha de tan importante centro.

Desde el mes de marzo de 1891, aparece el Dr. Manuel Delffn firmando los estados
que, eobre la ''Demograffa de la Habana,'' sigui6 publicando la Cr6nica M^dico-
Quirtirgica hast^ concluir el mee de julio de 1895. La guerra de independencia,
iniciada el 24 de febrerode eee afLo, trajoconsigo la paralizaci6n de laestadfsticade
nuestra tirbe, pues nada progreea como ella con la paz, pero nada sufre tanto con la
guerra como la estadistica. Antes de Uegar al reetablecimiento de esta importante
fanci6n de gobiemo, tenemos varies trabajos importantes que sefialar, como contribu-
dones particulares a la demografia, pues si Men en el afio 1877 y en el de 1887 se levan-
taion doe censos de poblaci6n, ^toe Qst&n comprendidos en los generalee de Espafia, y
forman uno de los capf tulos de los mismos. No obstante, dar6 la indicaci6n biblio-
gr&fica de uno y otro, para que tan importantes documentos no queden sin la debida
menci6n. El primero dice: '^Censo de la poblaci6n de Espafia, segdn el empadrona-
miento hecho en 31 de diciembre de 1877. For la Direcci6n General del Institute
Geogr&fico y Estadistico. Madrid, 1883. Imprenta de la Direcci6n General del
Institute Geogrifico y Estadistico." El s^^u^do dice: ''Censo de la poblaci6n de
Espafia, segtin el empadronamiento hecho en 31 de diciembre de 1887, per la Direcci6n
General del Institute Geogrifico y Estadistico. Madrid, 1891.''

Entre las contribuciones particulares, la m^ antigua que he encontrado en las
columnas de la Cr6nica consiste en dos cuadros del ''Estado de los nacimientos y bau-
tizoe efectuados en la Provincia de Pinar del Rio, durante el mes de enero de 1879" *
y el ''Estado general de las defunciones ocurridas en la Provincia de Pinar del Rfo
durante el mes de enero de 1879.'' ^

Aparece luego la ''Estadistica de defunciones en Cienfuegos en el segundo semestre
de 1880," per el Dr. Sinesio Lapeyra* y los Estados de las defunciones y de los naci-
mientos de la villa de Cienfuegos deede enero de 1881 hasta agosto de 1885.' En esa

iBlProgresoMMioo^Habftiia, 1800, t. IX, p. 112-115. .

« Id. id., t. IX, p. 23a-236.
» Id. Id., t. IX, p. 174-176.
« Id. id., t.X, p. 20(^214.

• Revlsta do MediciDa Tropica], Habana, noviembre, 1000, 1. 1, p. 65-73.

• 7 7 Crdnica ICMico-QuirArgica de la Habana, t. V, p. 284 y 332.

• Crdnica, etc., t. VII, p. 110-113.

•CrOnioa, etc., t. VII; Ene., p. 232; Feb., p. 283; ICar., p. 268; Abr., p. 276; Hay, p. 277; Jan., p. 326;
1« semestre de 1881, p. 327; JaL, p. 864; Ag., p. 410; Sep., p. 478; Oct., p. 525; Nov., p. 576; t. VIIl: Die.,
p. 20; 2« semestre 1881, p. 87; Resumen necroldgioo de Cienfoegos en 1881, p. 89-01; Afio 1882; E., p.
126; F., p. 145; M., p. 201; Ab., p. 284; If., p. 844; J., p. 345; Resomen del 1« smestie, p. S7»^73; J., p.
427; A., p. 486; S., p. 534; O., p. 600; t. IX: N., p. 70; D., p. 86-87; 2* semestre, p. 178-180; Afio 1883: E.,
p. 181-182; F.,p.l88; M.,p.255; A., p. 306; lC,p.S46; J.,p.891.402; l««8emestr., p. 450-451; J.,405; A., p.
406; 8., p. 560; O.,p.606; t.X: N.,p.44; D.,p.83; 2o semestre, p. 246-248; Afio 1884: E.,p.l20; F.,p.2Ql;
M., p. 245; A., p. 285; M., p. 338; J., p. 300; J., p. 440; A., p. 407; 8., p. 534; 1« semestn, p. 535-536; O., p.
574; N., p.575; t. XI: D.,p.73;2« semestre, p. 74-76; ReflezioDesaoeroa de la estadistica de Cienfuegos en el
qninqneniode 1880 a 1884, p. 121-132; Afio 1885: E.,p.l70; F.,p.200; M.,p.283; A.,p.310; lC.,p.375; J.,p.
483; 1« semestre, p. 434-435; J., p. 488; A., p. 527. Faltan los meses de Sep. y Oct. y oomiensa el Dr. Pema
«nelt.XII: N.,p.38; D.,p.88; Afio 1886: E.,p.l87; llar.,p.436; t.XIII: Ab.,p.48; Afio 1887: E.,p.l55;
F., p. 106; y ya no vnehre a baber nada hasta el t. XV, queen la p. 360-370 aparaoe la estadistica de enero,
fobrero y marso de 1889. En el t. XVII, p. 60-41, apareoe laPemografla Estado neoroldgioo de la olodad
de Cienfuegos, durante el afio 1880, pero sin Anna alguna que lo garantJce.

434 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

^poca falleci6 el Dr. Lape3rra siendo sustitafdo en la publicaci6n de IO0 cuadios <
dfsticos por el Dr. Luis Pema de Salom6; pero este compafiero oiniti6 los pertenedentes
a Beptiembre y octabre, comenzando sa labor en noviranbre de 1885, 7 lleg6 con maicada
irregularidad hasta el alio 1889; Men ee verdad que sub8an6 faltas eecribiendo en 189S
un foUeto sobre "Nacimientos y defonciones habidoe en la ciudad de Cienfaegos
durante la d^ada que empieza en enero de 1880 y termina en didembre de 1889,"
trabajo que le valid su ingreso como acad^mico corresponsal de nueetara Academia de
Ciencias, a virtud del inlorme emitido por el Dr. Vicente de la Guardia.^

Entre las otras estadfsticas de pequefias localidadee citar6: la ''Mortalidad de la
Villa de Manzanillo en 1880, Begin loe partes parroquiales; por el Dr. A. G«. del
Valle;" » la Mortalidad de la Villa de (Juanabacoa en 1880," por el mismo;* los
" Apuntes para la topograffa m6dica del pueblo de Candelaria," por el Dr. Luis Vald^
de la Puente, seguidoe de loe estadoe semestrales de las defunciones y nacimientos
ocurridos en dicho pueblo, deede el primer semestre de 1883 hasta el terminado en
didembre de 1886; ^ los ^'Apuntes para la topograffa m6dica de Macurijes," por el
Dr. Juan Brunet, secretario de la Jimta Local de Sanidad de dicho lugar, acompafiadoe
del "Estado de las defunciones ocurridas en el partido de Macurijes y causae que la
ban determinado durante el afio de 1883" • y continuado luego con el del afio 1884; •
los ''Estados de los nacimientos y defundones del tannine munidpal de Marianao,"
eetudiadoe por el Dr. Enrique Morado desde el primer semestre de 1886 basta tennitaar
el primer semestre de 1889 ' y continuada la publicad6n de esos dates demogr&ficoe
por el Dr. Manuel TJnanue, quien en 1893, siendo secretario de la Junta Local de
Sanidad de ese munidpio escribi6 unos "Apuntes sobre Estadistica del T^rmino
Munidpal de Marianao;" * la publicada por el Dr. Rudesindo Garcia Rijo con el
tf tulo- " Estado de las defundones habidas en la poblad6n de Sancti-Spfritus, durante
el primer trimestre de 1887"* en que divide el estudio de las edades en: menores de
1 afio, de 1 a 5, de 5 a 12, de 12 a 20, por decenios hasta los 70 y de ahf en adelante
por quinquenios hasta Uegar a los 100 afios, y de 100 en adelante; la del Dr. Job6
Ramos Aineyda, "Estado demoetrativo de las defundones ocurridas en el tannine
munidpal del Cano, clasificadas por razas, sexos y edades," asi como el de los nad-
mientos inscritos en el registro civil, durante el primer semestre del afio 1888 **• durante
el tercer trimestre " y durante el cuarto trimestre del mismo afio; " el ''Estado de los
nacimientos y defunciones del t^rmino munidpal de Guanabo en el afio 1889," publi*
cado por el Dr. Sebastian Gonzdlez Arango; " el Dr. Fernando M6ndez Oapote con-
tinu6 el trabajo presentado al Primer Congreso Medico Regional, dando a conocer la
"Estadistica demogrdfica de la dudad de Cdrdenas'' en los doe semestres del afio
1890 ^^ publicando m^ tarde el Dr. Luis Ros la del afio 1893 >' y la del afio 1894. **
^ La dudad de Matanzas ha tenido varies cultivadores de la demografia, pues desde
el estudio sobre el "Censo de pobIaci6n de la Provinda de Matanzas, por Manud

I Anales, etc., t. XXX, p. 544-648.
« Anales, etc., t. XVII, p. 403.
» Anales, etc., t. XVII, p. 404.

• Crdnica, t. X, p. 19-22; 84; 889; t. XI, p. 284; 528; t. XII, p. 183; 437; t. XHI, p. 200.

• Crdnlca, t. X, p. 265-269.

• Cr6nlca, t. XI, p. 484.

Cr6nlca, t. XII, p. 438; t. XHI, p. 42; 104; 166; 157; 199; 257; t. XIV, p. 61; 193; 306; 648; t. XV, p.
547; 659.

• Crdnlca, t. XVI, p. 233; 824; 446; t. XVII, p. 228; 428; 896; t. XVHI p. 62.

• CrtnJcB, t. Xin, p. 471.
»«Cr<5nlca,t.XIV,p.629.
iiCr6iilca,t.XIV,p.649.
i»Cr<5nlca,t. XV,p.368.
i» Crdnlca, t. XVI, p. 232.

u Revista de Clendas MMioas, Habana, t. V, p. 268-269 y t. VI, p. 115.
» Rerlsta de denclas MMlcas, Habazia, t. IX, p. 26-27.
u Revista de Cienoias ICMScas, Habana. t. X, p. 262.

PUBLIC HEALTH AND MEDIOIKB. 435

Yillanova/' ' lae estadfstlcas fragmentarias del Dr. Eduardo Diaz ' de loe afios 1887 y
1891 y la completa del afio 1893,' la tambi6n fragmentaria de loe Dre. Enrique y
Olaudio Fortdn, que abrazan las defunciones solo del primer semestre de 1890^
hasta el complete eetudio leldo en el Centre M6dieo Farmac^utico de Matanzas per el
Dr. Jorge Trelles, con el tftulo de **Conflideraciones sobre la Demograffa de Matanzas
en el quinquenio de 1888 a 1892'' ^ siempre se ban ocupado lo6 matancero8 de esta
importante rama de la medicina; habiendo lefdo en el Centro antes citado, el Dr.
Eduardo Diaz una memoria que redacts con el incansable bibli6grafo Sr. Carlos M.-
Trelles, sobre la ''Demografia de la provincia de Matanzas en 1894," que segdn afirma
este tiltimo no lleg6 a imprimirse; y en el mismo afio y en el propio Centro, el Dr.
Juan Guiteras otro sobre ''La fiebre amarilla considerada como enfermedad de la
infancia en los focos antillanos." ^

Como estudios demogrdficos de pequefias locaUdades deben citarse el trabajo sobre
"La higiene en las cdrceles y en los presidios" ^ del Dr. Andres Valdespino, en el que
public6 el ''Estado de los enfermos y muertos habidos en el presidio de esta ciudad
(Habana) durante el quinquenio de 1880 a 84; y el movimiento de enfermos ocurrido
en el antiguo Hospital de San Felipe y Santiago durante los afios 1879,' 1880,* 1881,*' y
en el actual de Nuestra SefLora de las Mercedes durante el afio 1886 por el Dr. Emiliano
Ntifiez " y el '' Informe sobre la administraci6n y gobiemo de la Real Casa de Bene-
ficencia y Matemidad (Habana) en el afio econ6mico de 1885 a 1886, por su Director
Administrador, Comelio C. Coppinger" del cual los Anales de la Academia repro-
dujeron los m^B importantes dates estadisticos. "

En cuanto a las contribuciones dedicadas a estudiar enfermedades o accidentes espe-
ciales tambi^n son dignas de anotarse, entre otras, los ''Dates estadisticos de los sordo-
mudos y ciegos existentes en la Isla de Cuba" por el Dr. Luis Biosca, publicados el
afio 1881 ; la " Epidemia de fiebre tiloidea en el tannine municipal de los Palacios " por
el*Dr. Manuel Delfin, con la estadlstica de los cases por ^1 asistidos *'; el magistral
discurso leido por Dr. Vicente de la Guardia el 27 de junio de 1886 con motive de su
ingreso en la Academia de Ciencias, que titul6 " Algunas consideraciones relativas a la
fiebre tifoidea en la Habana" ^* en el que estudia esta dolencia desde el afio 1856 en
cuanto a los individuos muertos de la enfermedad; las "Notas relativas al suicidio en
la circunscripci6n de la Habana," por el Dr. Tomis Plasencia*' y el del mismo profesor
relatando las "Defunciones ocasionadas por el rayo en la Isla de Cuba" desde el mes
de Julio de 1885 basta 1892 *'; el estudio sobre "El muermo en la Habana" del Dr. Juan
B. Fuentes " en el que trae la estadfstica de los enfermos de muermo ingresados en el
hospital Mercedes desde enero de 1890 hasta fines de septiembre de 1893; y el que le
airvi6 al Dr. Manuel P^rez Beato para ingresar en la Sociedad de Estudios Clf nicos de
la Habana, en noviembre de 1894, presentando la "Estadlstica de la mortalidad por

1 RevistA Cubuia, Habana, 1888, t. Vni, p. 458-404, 6S2^SS.

• CrteSca, t. XIV, p. 62, laO; t. XVn, p. aOQ, 418, 604.
cRavista de Ctendas ICMkaa, t. IX, p. 27-28.

• Revista de Cfendas liMicas, t. V, p. 287.

• Crdoica, t. XIX, p. 307-ei7, 342-848, 880-888, 400-107.

• Crdniea, t. XX, p. 267-266, oon oinoo dfagramas.
7 Cnbiica, t. XI, p. 860-874.

• Anales, etc., t. XVU, p. 206-804.

• Anales, etc, t. XVUI, p. 71-100.
10 Anales, etc., t. XIX, p. 248-272.

u Anales, etc., t. XXIV, p. 10&-204, 322-826 y t. XXV, p. 828-834, 670-676^ 6«1-6I9, 717-726.

f Anales, etc., t. XXIII, p. 866-850.

i* Cronlca, 1885, t. XI, p. 866-867.

H C^Onica, 1886, t. XII, p. 306-818, 381-887, 410-127, 461-478, 618-682, 606-406.

1* Anales, t. XXn, p. 400-i20.

u Anales, t. XXX, p. 280-237.

n Revista de ciencias mftlloas, t. VIII, p. 217-221.

68436— 17— VOL ix 29

436 PBOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIO GONQBESS.

fiebre puerperal." * trabajo que motiv6 intereeanlee consideracionee del Dr. Rafael
WeifiB sobre *'La mortalidad en la fiebre puerperal." •

Lob servicios sanitarios del municipio de la Habana no dejaron de realizar tambi6n
BUS trabajoB estadfsticoB. Buena prueba de ello son los datoB publicados en todos loe
peri6dieoB profesionaleB y en algunoB folletos entre Iob que citar^: la ^'Memoria del
Bervicio Sanitario Municipal durante el afio de 1889 presentada al Excelentisioio
Ayuntamiento por el Dr. D. Julio de Zdfiiga, subinspector del cuerpo, Habana, 1890/'
• y la ''Memoria del estado sanitario de la ciudad de la Habana durante el quinquenio
de 1890 a 1894, redactada por el Dr. Antonio Ruiz y Rodriguez, secretario de la Juntft
Municipal de Sanidad, Habana, 1896," que contiene 12 cuadroB correepondientes a loe
mefies y uno de resumen del quinquenio por enfermedadeB y razas.

Como cuestiones de orden general existen: las ^'ConsideracioneB sobre la poblaci6ii
de la Isla de Cuba, segdn el censo de 31 de diciembre de 1887," por Comelio C. Cop-
pinger ' y las *' Reflexiones sociol^gicas sobre las causas de mortalidad en la Habana,"
hechas por el Dr. Diego Tamayo^ en lasesidn soleome de la academla el 19 de mayo de
1893.

Algunos otroB trabajos existen desperdigados en las colecciones de nuestros peri6dicoe
cientificos, sobre viruelas, sobre fiebre amarilla, sobre rabia, etc., pero como son limi-
tadoB a determinadas circunstancias, no los cito para no prolongar demasiado este
eetudio.

Por la relaci6n de trabajos que hasta aquf he presentado puede colegirse con f acilidad
que, Bi bien hubo profesores que dedicaron sus esfuerzos a dar a conocer determinados
aspectoB de los graves problemas sanitarios, aqu^Uos carecfan de ef ectividad porque se
estrellaban contra la indolencia y la apatia de los gobemados y ante la ignorancia y la
falta de eetabilidad de los gobemantes. Las cifras, con su muda elocuencia, no
despertaban las energlas de los primeros, y a los segundos con venia que no se presentasen
agrupadas de manera que pusieran de manifiesto las p^simas condiciones en que aqui
viviamos. En apoyo de esta afirmaci6n, v^ase lo que escribfa el Dr. Juan SantoB
Femdndez en enero de 1893, uno de los aflos de mayor actividad estadfstica: '* Ahora
bien, si para cualquier pais todas las cuestiones que se relacionan con la higiene y
descansan en la estadfstica demogrdfica tienen una importancia capital, para nosotros
que nada hemos hecho todavfa, rigurosamente hablando, en higiene tropical, no tiene
Umites. Estd por resolver el vital problema de la aclimataciiSn de los europeos en los
pafses cdlidos, porque de otro modo nuestra poblaci6n no 861o permanecerfa estacionada
sino que lejos de alcanzar la cifra mdxima de ocho a diez millonee que nos correeponde,
retrogradard como estd sucediendo y lo hemon senalado mds de una vez en las columnas
dela"Cr6nica."

Un pais como la Isla de Cuba, formado de un conglomerado especial de divCTsas
procedencias, no ha emprendido tampoco el estudio de la i>rediB]X)eici6n de lae div^^
sas razas humanas con relaci6n a las distintas materias infecciosas; por mds que
el tema se ha indicado, por mds que en el campo de las teorlas las corporaciones nan
ventilado el asunto, ae nin^tln modo han podido sacarse consecuencias pricticasi
de las cuales puedan deducirse bases fundamentales para el movimiento inmifpra-
torio de las razas que pueblan nuestro territorio y este estudio como cualquiera
otro de higiene ptibhca no puede ni siquiera esbozarse, si para ello no se concursan
como primer dato los que resultan de la eetadistica demognifica.'

El Dr. Delffn, por su parte, al estudiar la ''Estadlstica Demogrdfica del afio 1892,"
escribfa:

El constante anhelo de los (jobiemos es el saneamiento de los centres de poblacidn,
porque cstdn convencidos de que el comercio, la agricvjtura y todos los elementoe

1 Archtvos de la Sociedad de Estudios CllnJcos de la Habana, t. VI, p. 284.

s Archivos de la Sociedad de Estudios CUnioos de la Habana, t. VI, p. 2Q0-304.

s Kevista Cubana, Habana, mayo 1891, t. XIII, p. 453-473.

< Anales, &, t. XXX, p. 4J-58.

- I'rdnJca, etc., t. XIX, p. 43.

PUBUO HBALTH AND MEDIOIKB. 437

Sie contribuyen a la riqueza y prosperidad de las naciones se afianza, cuando por
trdfico no corre peligro la vida de los que acuden a nuestroe puertos, de los que
•e amparan bajo nuestro clima.

La Isla de Cuba, que por su temperatura, por su atmdsfera, por su suelo y por todo
lo que constituye el clima, es uno de los piafses mds sanoe del mundo, ha llegado a
hacerae temible por la incuria de su adinii)iBtraci6n pdblica, que tiene en el m^
lamentable abanaono toda medida sanitaria que sirva para disminuir la mortalidad
y aumentar la natalidad.

Estudia loe multiples factores que conspiran contra la salud del pueblo y agrega:

Solamente con tantoe elementos destructores podr& concebirse el que en un afio
una cludad de 200,000 habitantes arroj6 6,963 defunciones, es decir, 34.81 por cada
mil habitantoe, y solo asi podrd concebirse que ese contingente lo den especialmente
las enfermedades infecciosas; poraue ^tas son las que dependen de la faJta de hi^ene
pdblica y privada; de eeas 6,963 aefunciones corresponden 5,381 a los alectos infec-
cioBoe. . . .

Al analizar los elementos ^tnicos dice:

En las razas negra y mestiza se ve que perece extraordinario ntimero de hembras
miM que de varones, por la dificultad que encuentran para la subsistencia, por los
trabajos a que se deoican y por la falta de bigiene a que la odiosa esclavitud los
acoetumbhS.

Luego afiade:

Si la mortalidad es horrorosa, si horripilan bus altas cifras al que se detiene a meditar
acerca de las causas ^ue la producen. no menor tristeza ban de causamos las que
ie refieren a la natalidad. . . . Mucnas son las causas que contribuyen a que la
natalidad de las razas ne«;ra y mestiza sea cada dla menor. En esta misma esta-
dlstica se ve que es grandisimo el ntimero de hembras negras y mestizas que fallece
anualmente, a mds de la manera de vivir f uera de toda bigiene racional y de las priva-
dones a que se ven sometidas por su escasa cultura moml y material. Sin embar^
creemos que es grande el n6mero de nifios de ajnbas razas (negros y mestizos) que deja
de inscribirse y es de desear que se ponga coto a este incumplinuento de la ley, pues
Bfif no solo se dificulta la exactitud de Ss estadfsticas, sino que en el porvenir resul-
tardn dificultades de otros 6rdenes no menos importantes.'

Sobre este problema que planteaba el Dr. Delfin en 1893 vengo insistiendo hace
t^fioB en las estadisticas que no ya de la Habana, sino de la Reptiblica entera vengo
publicando desde que se cre6 ese servicio nacional.

Hubo un hombre que vi6 con claridad meridiana uno de los factores fundamentales
de nueetra Idgubre lista mortuoria; y no s61o lo vi6 sino que anunci6 cuil era la causa
y la manera de combatirla. El genio inmortal de Finlay, evidenciando el medio
de transminidn de la fiebre amarilla por el mosquito dom^tico— el Culex mosquito,
eomo le Uamaba— sefial6 una de las causas que contribufan a presentar a Cuba como
ima sucivsal de tA Cairo; pero su tiempo no habia llegado, y el fatalismo musul-
min que imperaba en todas las esferas, por una parte, y por la otra el desd^
que acompaf^ generalmente a las concepciones geniales, Mzo que bus doctrinas no
fueran escuchadas, a pesar de la tenacidad con que las sosten^ dentro y fuera de
Cuba, y asf se perdieron muchos afios, y, lo que es mds triste, muchas vidas sacri-
ficadas en aras de la ignorancia y de la vanidosa pretensi6n de los que consideraban
*1 descubrimiento que luego pasm6 al mundo como extravagancias de un car^ter
ilusionista.

Vino la guerra de independencia, y con la reconcentraci6n de loe habitantes nurales
«n zonas urbanas no preparadas para subvenir a las necesidades de los en ellas re-
dufdoB, poco falt6 para que Weyler consiguiese el objeto que se propuso al dictar
ten b^bara medida: la total destruccidn del pueblo cubano.

La mortalidad de la Habana, que como he demoBtrado en otro lugar' tuvo como
promedio durante todo el siglo XIX la cifra de 36.76 por cada mil habitantes, alcanz6

* Crdnica, etc., t. XIX, p. 60-75.

* Estudios sobre la mortalidad de la Habana durante el Siglo XIX y los comienxos del actual, por el Dr-
Jorge Le Boy y CassA, 28 marao 1913, Anales, etc., t. XLIX, p. 862-877.

438 PEOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONGRESS.

en lo8 aftoB de 1896, 1897 y 1898 las eepantoeas de 50.98, 77.34 y 89.19, reepectiva-
mente; esta tiltima la mds alta que jam^ se conociera en nueetra urbe, cuando
a los horroree de la guerra de independencia se afiadieron los del bloqueo del puerto
de la Habana y de loe demds de la isla por la escuadra americana en su guerra contis
Espaiia.

Toda acci6n trae deepu^ su reacci6n y &ta vino para la salud de Cuba con la inters
venci6n americana, comenzada en 1^ de enero de 1899. El primer jefe de aanidad, lo
fu4 el Major John G. Davis que en el terrene estadlstico public6 la ''StatisticB of
Births, Marriages, Deaths, Immigration and Yellow Fever from 1890 to 1899," y
una hojita "Report of Vital Statistics of Havana for the year 1899.*'

En el curioeo y muy escaso libro ** Annual report for fiscal year ended June 30, 1899,
from December 22, 1898, William Ludlow, Brigadier General, U. S. V., Commanding
Department of Havana and Military Governor of the City of Havana, Cuba, " se en-
cuentra el inf orme presentado por el entonces Jefe de Sanidad Davis hasta el 30 de junio
de 1899 y en 6\ hay varios cuadroe estadlsticos interesantes, sobre todo en lo referente
al censo realizado en la Habana y sus suburbioe y a las cifras de las muertes generales
y por fiebre amarilla en cada uno de los meses de los afioe de 1890 a 1899.

Sin estadfstica no hay gobiemo poeible, pero sin censo tampoco es posible ninguna
estadfstica verdadera. Penetrado de esta idea el gobiemo interventor se preocup6
del levantamiento de un censo general de poblaci6n y, en efecto, el 17 de agosto de
1899, el Presidente de los Estados Unidoe William McEinley expidi6 una prodama
al pueblo de Cuba en la que hacfa constar que : * ' Como un paso preliminar en el cumpli-
miento de este deber (el establecimiento de un sistema eficaz de gobiemo propio) he
dispueeto que se forme un censo del pueblo de Cuba y he nombrado para loe cargos de
enumeradores e inspectores, a competentes y deeinteresados ciudanos de Cuba."
El 19 del mismo agosto, el Secretario de la Guerra Elihu Root, disponla:

1®, Por orden del Presidente se efectuard un censo de la poblaci6n, de loe productos
agrfcolas y del estado de la educaci6n de Cuba, el dfa 16 de octubre y se completarft
el dfa 30 de noviembre de 1899^ o con anterioridad a esta fecha; 2^, Se nombra al
Teniente Colonel J. P. Sanger, inspector-general, director del censo, con oficina en
Washington; 3^, Se nombra al Sr. Victor H. Olmsted, subdirector del censo, con
oficina en la ciudad de Santa Clara, Cuba, y queda encai^gado, bajo la direcci6n del
director del censo, de reunir loe dates que esta orden requiere y cmnplir las disposido-
nes que en lo future pueden expedirse; 4^^, loe siguientes dudadanos de Cuba cuvoa
nombres aparecen a continuadon, propuestos por el Crobemador Militar de Cuba,

Suedan por la presente nombrados inspectores del censo: (1) Pedro Pequefio, provinda
e Pinar del Rio; (2} Manual Rasco, de la Habana; (3) Claudio Dumas, de Matanzas;
(4) Juan Bautista Jmaenez, de Santa Clara: (5) Agusnn H. Agilero, de Puerto Prin-
cipe; y (6) Sabds Meneees, de Santiago de Cuba.

En la carta dirigida por Sanger al Secretario Root en 25 de agosto de 1900, remi-
ti6ndole el censo hace constar las dificultades con que se tropezaba ''puesto que durante
muchos afLos los habitantes estaban acostumbrados a considerar como una miams
cosa d censo, la impoeici6n de contribuciones y el servido militar obligatorio, hada
d cual siempre habfan tenido una natural y marcada aversidn'' y tambi6n dice que:

Por m^ que es posible que se hayan cometido algunoe errores en la obra, y acaao
se hayan cometido algunas omisiones. no debe olvidarae que ^ta es la primera tenta-
tiva que los cubanos nan hecho paia levantar un censo y que las dificultades con que
necesariamente se tropezaron han side numerosas, serias y no fddles de veneer. Pero
sean cuales fueren los defectos que tensa, es la opini6n del pueblo de Cuba y de loe
encuadradoree expertos y peritos estaofsticoe que han tomado parte en la oIh« de
compilar y analizar laa cifras, que llevan el sello de un trabajo hecho con condenda,
que el censo se tom6 rdpidamente y con mayor exactitud de lo que podia hab^se
eeperado, y que en esU particular puede compararse ventajosamente con cualquier censo
de los Estados Unidos.^

Este censo arToj6 la dfra de 1,572,797 habitantes, que comparados con d 1,631,687
del Ultimo censo levantado por Espafia en 1887 revda una pdrdida mayor de 100,000

1 Lo flacrtto «a baitardilla es del tutor.

PUBLIC HEALTH AND MEDICINE. 439

habitantee. A pesar de las objeciones que pudieran preeentarse acerca de la 6poca
en que fu6 realizado, poco propicia por las condiciones en que se encontraba el pais
al concluir su glorioea epopeya de la independencia, y por el dilatado tiempo en que
88 enunier6 la poblaci6n, es el mejor documento de esta especie que se ha realizado
en Cuba, tanto antes de su elaboraci<5n, cuanto comparindolo con el que ocho afios
mds tarde se llev6 a cabo bajo la administraci6n provisional de la Repdblica de Cuba.
Su discusi6n puede verse en el artfculo publicado por el Sr. Carlos M. Trelles con el
tftulo "El censo de Cuba de 1899. " »

El le\-antamiento del censo de Cuba era un paso fundamental en el terrene de la
estadlstica; pero quedaba por dar otro de no menor trascendencia en el terrene demo-
gr&fico: la uniformidad de las clasificaciones nosol6gicas, y 69te estaba resen ado a un
hombre a quien todos los cubanos recordaremos siempre con respeto y carifio, pues a
BUS dotes de superior cultura y firmeza de cardcter unla la correcci6n mds exquisita
en todos sus actos. No es necesario decir que me refiero al Dr. William C. Gorgas.

Desde febrero de 1900 aparecen los Reports of Vital Statistics de la Habana, firmados
por ^1, y las hojas sueltas en que mensualmente se publicaban fueron mejorando de
manera notable hasta que en abril de 1901 se com irtieron en ^ erdaderos foUetos. En
su ''Report for the year 1900 " ya Introdujo una mejora de que enseguida me ocupar^:
la adopci6n de la nomenclatura intemacional de enfermedades y causas de muerte,
mia conocida generalmente con el nombre de Bertillon. En las eetadisticas de la
Habana, publicadas durante el primer afio del gobiemo inten enter se usaba la nomen-
clatura alfab^tica para la clasificacldn de las causas de muerte, habiendo retrogradado
en esto a arios afios; pero Gorgas acept6 las decisiones del Congreso Intemacional cele-
brado en Paris del 18 al 21 de agosto de 1900 y con la autoridad militar de que gozaba
la impuso a los m^icoe del distrito sanitario de la Habana, segdn se comprueba con el
preeente a^ iso publicado en la Gaceta Oficial del 20 de julio de ese mismo afio:

Oficina del Departamento de Sanidad de la Habana; Habana, Cuba, julio 16 de
1901: De orden del Comandante del Departamento. se avisa por eete medio a los
sefiores medicos de los municipios de la Habana, Rc^ia y Guanabacoa, que desde esta
fecha extenderdn las certificaciones de defunci6n de acuerdo con la clasificacidn de
Bertillon, a cuyo efecto los sefiores jueces municipales no admitirdn dichos certificados,
d no est&n de conformidad con la referida clasiiicacidn. La oficina de Sanidad pro-
verb de ejemplares del citado m^todo de Bertillon a todos los sefiores medicos que la
Sidan. W. C. Gorgas, Cirujano Comandante del Ej^ito de los Estados Unidos, Jefe
e Sanidad.

Por el departamento se pro\ey6 a todos los m^cos y a los jueces municipales de un
f olleto, sin fecha ni lugar de impresidn con este tftulo ' * Sistema intemacional de nomen-
clatura de enfermedades y de causas de defunci6n (clasificacidn de Bertillon) adoptado
por el Octavo Congreso Intemacional de Higiene y Demografia, Paris, 18-21 de agosto,
1900 " de 32 p^iginas, y una suelta con la '' Nomenclatura de las causas de muerte intra-
uterina" en el que se presenta traducida al castellano la nomenclatura acordada por
las naciones adscrltas a ese Congreso.

Xuestro dem6grafo Dr. Ambrosio Gonz&lez del Valle eecribia en 1869:
La primera operaci6n de la estadlstica es recoger y reducir a ntimeros los hechos.
Esta numeracidn iene a ser una necesidad cientlfica porque parece oirse en los hechos
el lenguaje de la experiencia, y sin ella lo pasado se hundirla en el ol\ ido y la ol>ser\ a-
ci6n tendrla que empezar de nue^ o cada dia, y la ciencia y el arte se reducirlan al tra-
bajo Improbo de Slsifo.

Nuestros esfuerzos particulares no serlan nunca suiicientes para estudiar com-
pletamente la salubridad de la Habana y de sus EBta})lecimientoe pdblicos, si nuestros
comprofesores no coadyu\ aran a la formacion de la Estadlstica medica. o mejor dicho
de la Xosolc^la estadlstica que traiga a una misma clasifl caci6n normal de generos las
variadas nomenclaturas especiales, que si son propias para los cursos de la facultad o de
trabajos piuramente did^ticos, no lo son asf para el prop6aito a que aludimos. Los
m^icos ingleses adoptando aquella cla^ e ofrecen quiz^ a estas horas la mejor estadls-
tica m^ica. El asiento de las lesiones y la nocion de causa prestan una buena base
noeol6gica. Asl podrdn apreciarse indicaciones muy \ aliosas.^ '

t Cuba y Am^rioi, Habana, 1901, afio V. p. 285.W7, 413-423. « Analea, ete., t. VI, p. 293.

440 PBOGEEDINQS SEOOND PAIT AMEBICAIT SdEimFIO C0K0BE88.

En abril de 1880 public6 en la CitSnica ^ un ''Modelo para la estadistica noeol^ca 7
de mortalidad, basado en la noci6n de cauaalidad y dtio de las ledonee, en ' ista de lot
trabajoB del sabio estadistico de Londree, Dr. William Farr. Dicha claaificaci6A
comprendfa doe gnipos hindamentalee, enfermedadee generales y enfermedadei
locales; en el primero incluye las zim6tica8 o infecdoeaa, las ^ irulentas, las toxico-
h^micas o en^ enenamientoe, las alteradones de la sangre no definidas y las diat6-
sicas o constitucionales; en el segundo las del sirtema ner ioso, del aparato circula-
torio, del aparato respiratorio, del aparato digestif o y del aparato g^nito-urinario;
luego hay otro gnipo constituldo por las enfermedadee y defunciones por del ilidad 7
deformaciones y un Ultimo por las muertes ^ iolentas, entre las que comprende: las
accidentales, suicidio, homicidio e infanticidio. En realidad muy poca diferenda se
ad ierte con la actual clasificaddn, sobre todo teniendo en cuenta el estado de la
medidna en aquella 6poca.

La multiforme actuaci6n sanitaria del hoy General Crorgas, demandaria un volumen
entero, ad que me concretar^ a condensarla en estas breves palabras : Gre<S la Sanidad &k
Cuba y como no quiero pecar de exagerado, me limitary a copiar sub propias palabras
escritas el 15 de febrero de 1902, al remitir al Jefe de Estado Mayor, del Departaments
de Cuba, el resumen de las E^stadisticas Demogr&ficas del aflo 1901 dice asi:

Probablemente este ee el dltimo informe anual hecho per im Oficial del Ej^rcito de
los Estados Unidos a su Superior Mill tar, el Gobemador de la Isla, as! es que yo eep&Q
se me disimule si seiialo a^gunas de las diferencias sanitarias entre el '^pasado" y el
"preaente."

" El Ej^rcito se hizo cargo del Departamento de Sanidad, cuando las muertes alcan-
zaban la cifra de 21 ,252 por aflo; lo entrega con una mortaiidad de 5,720 por afio. Se
hizo cargo con la viruela end^mica durante muchos afios; la deja sin aue haya ocurride
un solo caso en el transcurso de 18 meses. Se hizo caigo cuando la fiebre amarilla
tenfa dos siglos de endemicidad, siendo un enemigo implacable para todo extranjero
que llegaba a los Hmites de la Habana, al que no podfa escapar y de cuyos ataques
61 bien sabia que de cuatro personas una tenia que sucumbir. EncontnS a la Habana
temida como una cosa sucia y mirada con recelo por todos sub vecinos de los Estados
Unidos que estimaban peligrosa el tocarla o atm mi^, el aproximarse a cualqiiier cosa
que ella nubie*^ tocado; todo esto con innumerables p^rdidas financieras tan to para
ellacomo para los Estados Unidos; la dejadespu^ deim estudio detenido de la fiebre
amarilla por sus Oficiales, no obstante el grin peligro a que se exponfan habiende
fallecido varios de ellos dc dicha enfermeaad al hacer las investigaciones. Ha pro-
bado el hecho de qtie la fiebre amarilla solamente es transmitida por cierta especie
del mosquito, descubrimiento aue en su potencia por ^var la vida humana sole
puede ser excedido por el gran descubrimiento de Jenner y a medida aue el tiempe
transcurra se colocard entre la clase de los bienes otoi^gados a la humanioad.'

He transcrito lo anterior de su Ultimo informe anual, voy a dar a conocer lo que
e8cribi6 el 6 de mayo de 1902, al remitir las Estadfsticas demogrdficas correspondientes
al mes de abril de dicho afio. dice:

Este es el ultimo informe mensual de las Estadfsticas Demogr&ficas que se hsiim
para el Gobemador Militar y ea tambi^n mi tiltimo mes como Oficial de Sanidad de la
ciudad de la Habana. De?eo, en consecuencia, invitar la atenci6n del Gobemador
Militar har'ia un paralelo entre el estado que existfa en abril de 189H, justamente el
anterior a la ocupaci6n americana, y las que existen en abril de 1902, tiltimo del
r^men americano.

El numero de muertes en la ciudad de la Habana, durante el mes de abril de 1898,
fueron de 1399, dando una mortaiidad de 71.88. En abril de 1902 ocurrieron 491
muertes dando una proporri6n por mil de 21.77. En abril de 1898 se r^ietraron 49
fallecinaientos por paludismo; en el de este afto ocurrieron 8 muertes. Ni cases ni
muertes sobrev-inieron en abril de 1902 a causa de fiebre amarilla o viruela: dos cn-
fermedades que, durante algunas generaciones, estuvieron entre el rango de las prin-
cipales causae de muertes.

I Cronlca, etc., VI, p. »0-242.

s Informe demogriflco de la ciudad de la Habana presentado al brigadier general Leonardo Wood, U. 8. A^
Oobernador Militar. afio de 1901, p. 9.

PUBLIC HEALTH AND MEDICINE. 441

Como Bon de gran importancia los pdrrafos que dedica a estas dos enfermedades
tambi^n me permitir^ el transcribirlos:

Nuestra faena sobre el mosquito comenz6 el 4 de febrero de 1901, y como la Habana
jam^ se vi6 antes libre de fiebre amarUla^ creo que es razonable deducir de las cifras
citadas, que estd ahora enteramente extirpada; y estimando que solamente es pro-
pagada por el mosquito, no creo que surja de nuevo, a menos que sea introducida del
exterior.

La ciudad contintia adn libre de virucla; no hemos tenido nins^dn caso desde julio
de 1900 y contiamos en que no ocurra a menos que se introduzca de patses extranjeroe.
En ^stos siempre hav peliirro, pues nnestro Intlmo comercio con los Estados Unidos,
nos expone a infecciones de aquellas fuentes en cualquier memento. El dnico caso

3ue ha habido en la Habana deede hace tiempo fu6 uno que apareci6 tree dfas despu^
e la lle^:ada del enfermo que procedia de New York. Afortunadamente se descu-
bri6 en tiempo oportuno el caso, el cual se envi6 al Hospital Las Animas, habiendo
eecapado asl aparentemente de aquella fuente de infecci6n.

El volumen IV del Informe del General Wood, que contiene los del Jefe de Sanidad,
del Cirujano en Jefe del Departamento y del Superintendente del Departamento de
Caridad, es una colecci6n de documentos estadfsticos que serd siempre consultado con
provecho por los que quieran conocer aquel momento histdrico en que un gobemante
de feliz recordacidn, el Dr. Leonard Wood que antes que militar era mMico, y unos
hombres como Goigas, como Kean, como Ross, como Furbush, etc., nos. ensefiaron a
hacer sanidad y prepararon el advenimionto de la Reptiblica, inaugurada bajo loe
mejores auspidos el 20 de mayo de 1902.

Con esto termino el segundo perfodo en que he dividide el estudio del desarroUo de la
6Btad{stica demogrdfica en Culf>a, y creo que esti plenamente justificado el tftulo de
crecimiento con que le he denominado, pues las contribuciones que he dado a conocer
J otras que he omitido, como, por ejemplo, todas las estadlsticas quirtirgicas, abonan
perfectamente tal denominaci6n.

Apeeardelas valiosas contribuciones prestadas por los autoros que he sefialado y a
peear tambi^n de las disposiciones gubemamentales tendientes a obtener una estadis-
tica demogr&fica general de Cuba, prevista y deseada por el Dr. Gonz&lez del Valle al
terminar en 15 de abril de 1885 sus Tablas Obituarias, no pudo ll^i;ar8e a ello ni en la
^poca colonial ni aun durante la intervenci^n americana. Estdbale reservado eee
beneficio a la Reptiblica, y a mi la satisfaccidn de haberlo implantado y desarrollado,
hasta llevarla a la forma que ahora tiene.

El tercero de los peHodosen que hedividido el desarrollode laestadisticaenCuba,
comienza con la instauracidn de la Reptiblica, y como es el actual, en el que he tomado
ana activa participaci6n, me abstengo de darle nombre alguno, dejando 6sto a los
que me sucedan.

La primera ley sanitaria cubana fue redactada por el gobiemo interventor en las
poetrimerias de su mando, como si quisiera dejar a nuestro pueblo organizado en eete
terrene de manera tal, que pudiera s^^ir fdcilmente realizando las obras que, con
admirablee resultados, implant6 durante su mando. En efecto, la Orden Militar
No. 159 del Cuartel General del Departamento de Cuba, firmada por el General Wood,
el 17 de mayo de 1902, imific6 loe diverooe servicioe en un solo organismo que, creado
con el nombre de '*Junta Superior de Sanidad de la Isla de Cuba/' tenia bajo su
|urLsdicci6n cuanto a sanidad se referfa.

Los articulos de esa orden que hacen referenda a nuestro asunto son: el inciso (j)
de la secci6n 2* que dice:

Tendrd poder (la Junta Superior de Sanidad) para pedir a las autoridades corres-
pondientes, datos respecto de las estadfsticas demognlficaB de la Isla, en lo que se
refiere a los nacimientoe, defunciones, matrimonios. enfermedades v epidemias; y
a su vez emitird a este efcto, los informee que le pidiere la autoriridaa Superior de la
Isla; V el inciso (g) de la secci6n 3* que tambi^n aice* Hard mensualmente (el Jefe de
Sanidad) un informe por escrito para la jimta, de estadfsticas demogrdficas de la
Isla; asf como un informe anual, tan pronto sea poaible despu^ del 30 de junio de
eada afio. En dlchos informes se hara menci6n de las conaiciones sani tanas de la

442 PBOCEEDINGS SEOOND PAK AMERIOAK SCIEITTIFIO CONGBBSS.

Isla en general, del trabajo llevado a cabo por la junta, y sns empleados y aeentes
durante loe doce meses tranflcurridos, incluyendo tambi^n un estado de tooAs laa
cantidadee recibidas y pages hechos durante eete perlodo.

Se nombr6 jefe de sanidad de la Isla de Cuba al Dr. Carlos J. Finlay, quien por minis-
terio de esa misma ley era el Presidente, a la vez que Ofidal Ejecutivo de la Junta
Superior de Sanidad, y bajo su gobiemo y direcci6n estaban las Juntas Locales, crea-
das por dicha orden para cada municipio de la Reptiblica.

Pi^ticamente no se puso en vigor hasta el 2 de enero de 1903, en que por decreto
presidencial No. 1, fueron nombrados las personas que debfan constituir la Junta
Superior de Sanidad. Se disponfa, ademis, en ese decreto que la jiinta actuara
como una dependencia de la Secretarla de Gobemaci6n. En 26 de marzo la junta
6ancion6 el reglamento redactado por una comisi6n de su seno, formada por los Dres.
Juan Santos Femindez, Jos^ A. del Cueto, Juan Guiteras y Enrique B. Bamet, secre-
tario de la jiinta, cuyo r^lamento fu6 sancionado por el Secretario de Gobemacidn
en 1° de junio de 1903. En el articulo 22 de dicho r^lamento figuran los cuatro
negociados en que se dividfa la oficina, y uno de ellos era el de ''Estadistica."

Pocos dfas despu^ de creada la junta superior de sanidad, era yo designado (fe-
brero 1903) como jefe de estadlstica general de la Isla, cargo al que me llev6 Finlay
por los trabajos que sobre esos asuntos habla presentado en la Sociedad de Estudios
Clfnicos de la Habana en 1899 ' en el tercer Congreso M^co Panamericano, cele-
brado en esta capital del 4 al 7 de febrero de 1901 *; en el Congreso Sanitario Int^-
nacional, celebrado en la Habana del 15 al 20 de febrero de 1902 *; y en la misma
Sociedad de Estudios Cllnicos el 20 de abril de 1902*, utilizando dates que tenfa
como medico del Hospital de San Francisco de Paula y como secretario de la Co-
misi6n de Fiebre Amarilla, cargo este liltimo que desempefi^ hasta el 1^ de julio de
1902.

En la carta de 1** de febrero de 1903, en que el Dr. Carlos J. Finlay ronitia al Secre-
tario de Gobemaci6n la estadlstica del mes de enero de la Habana, hace constar:

La Jimta Superior de Sanidad de la Isla de Cuba se encuentra, pues, ya en el des-
empeflo de las importantisimas tareas a ella encomendadas, aunque todavia de mode
incomplete, ya por la brevedad del tiempo transcurrido desde su constituci6n, yi
por no naber podido aun organizar sus oficinas ni nombrado el personal correspondiente.
1^0 obstante esto, el informe sanitario y demmprifico presentado a esa SecretaHa hasta
ahora por el Departamento de Sanidad de la Kabana exclusivamente, pero incluyendo
ademds de la capital las poblaciones de Chianabacoa y Marianao, se publicara este
ntimero como 6rgano de la Jimta Superior, en combinaci6n con el Departamento de
la Habana, y se ir& extendiendo sucesivamente su clrculo de accion a todas las
poblaciones de la Isla, a medida aue vayan aportdndose dates de las respectivas
juntas locales de sanidad, organizadas tambi^n conforme a las preecripciones de la
Orden No. 159.

Tambi^n sefLala otra circunstaacia digna de menci6n y es haber acordado la junta
solicitar del Gobiemo, que por el Seilor Secretario de Estado y Justida se disponga
que, para que los iueces mumcipales expidan los correspondientes permisos de entenra-
miento, sea condici6n precisa que las certificaciones de defunci6n vayan perviamente
intervenidas por el Departamento de Sanidad, a cuyo fin se estableceri en sus oficinas
un negociado al efecto^ara evitar que sufra dilaci6n ni entorpecimiento alj^uno tan
importante servicio. Unicamente de esta manera podr& lograrse que recai^ sobre
quien corresponda cualauier responsabilidad en la muerte o en el diagn^stico tulao
consignado en una certincaci6n.

1 Gk^ntrlbucidn al estadlo de la Fiebre amariUa en la Habana. Estadlstica del Hospital de mulefes de
S. Francisco de Paula desde I'dejnliode 1883 a 15 demanode 1899. Archiros delaSoc.de Estndioenini-
008 de la Habana, t. IX, p. 49^65; Crdnica, t. XXV, p. 81-«7.

* Estadlstica de 25 aAos de fiebre amarilla (1* enero 1876 a 31 diciembre 1900), tercer Congreso MMioo Pan
Americano, t. II, p. 1012-1041. foUeto.

* Estadlstica de fiebre amarilla. Congreso Sanitario Intemacional, 19 febrero 1902, Revista de IfedldDa
Tropical, Habana, 1. 1, p. 73-83, folleto.

< Estadlstica de fiebre amarilla. Desaparicidn de dicha enfermedad en la dodad de la Habana demoe-
tiada por los datos de la misma. Archiyos de la Soo. de Est. Clin, de la Habana, t. XI, p. 277-320, y foUeCo.

PUBLIC HEALTH AND MEDICINE. 443

Hasta marzo de 1904 no pudo organizarse el servicio de la estadistica demogr^ca
tal como yo lo habfa concebido y habia merecido la aprobaci6n del Dr. Finlay, quien
Hzo constar lo siguiente en la carta de remisi6n de la estadf stica del nios de enero de
ese afio, al Secretario de Gobernaci6n:

Un retraao notable expenmenta la publicacidn del primer Inf onne Mensual Sanitario
y Demogr&fico de eete afio (1904) con motivo de los inconvenientes que es precise
yencer para reunir los dates necesarios a la realizacidn del plan a que hice referenda
en la carta de remiBi6n de marzo del a&o pr6ximo pasado y, sobre todo, para formar un
cuadro en que la mortalidad por cada causa especial y correspondiente a cada uno
de los munlcipios de la Repdbuca pudiese ser apreciada a simple vista y debidamente
clasificada por edades, sexos y razas. Dos obst^culos se ban opuesto para que la solu-
ci6n del asunto no sea sine temporal y aproximada. Uno de ellos, es debido a las
dificultades que se les presenta a las «runtas Locales de Sanidad (principalmente en
la provincia de Santiago de Cuba) para la recolecci6n y el envio de los dates estadfsticos
que les correspondan, y consiste el otro en el hecho de que la noblacidn de 1,572,797
habitantes consignada en el censo de octubre de 1899 para la Isla, se encontraba
entonces distribulda entre 132 ayiintamientos, cuando el ntimero de ^tos ha side
posteriormente reducido a 82, mediante la incorporaci6n a los municipios vecinos de
106 barrios mds pr6ximos pertenecientes a los ayuntamientos suprimidos. Ademds,
no ban side camoiados los nombres de los t^rminos municipales as! expansionados, por
lo cual su poblaci6n actual reeulta, en muchos cases, considerablemente mayor al
compararla con la establecida en el Censo de 1899.

Los informes mensuales sanitario-demogrdficos del afio 1903 carecfan de uniformi-
dad, excepto para la Habana, pues las Juntas Locales remitfan dates incompletes y
mal preparados, por la ignorancia que tenfan acerca de las pr4cticas estadfsticas.

Mi primer cuidado fu^ trazar cuadros en los que, usando la clasificaci6n detallada
de la nomenclatura de Bertillon, pudiera apreciarse todo el movimiento de las defun-
dones ocurridas en cada locaHdad, segiin grupos de edades de los fallecidos, compuestos
de las siguientes divisiones: de 0 a 1 afio, de 1 a 5, de 5 a 20, de 20 a 40, de 40 a 60 y
de mia de 60 afios; en otros cuadros presentaba esas mismas defunciones clasificadas
siempre por enfermedades, desde los puntos de vista de las razas y de los sexos; y
en un cuadro resumen daba a conocer la poblaci6n del dltimo censo (1899) y la actual
estimada; los matrimonies, estudiados por razas y sexos; los nacimientos, divididos en
legitimes e ilegitimos, con las mismas subdivisiones de razas y sexos; los nacidos-
muertos, con la misma clasificaci6n de los nacimientos; las defunciones por razas y
sexos; y las ganancias o p^rdidas respectivas en cada uno de los municipios de la
Repdblica.

En 10 de septiembre de 1904 se le pas6 a los jueces municipales, encargados del
registro dvil, una circular dici^ndoles:

La Junta Superior de Sanidad ha tenido a bien acordar se suplique a Ud. remita a
la misma los auplicados de las certificaciones de defunci6n at dia sieuiente de ser
inscritas en el Registro Civil de ese Juzgado, teniendo la precauci6n unicamente de
imprimirle a cada uno el sello del mismo y el ntimero de orden correlative a la inscrip-
ci6n, a fin de evitar cualquier posible extravfo, especificando cuando falte algun
ntimero la causa que motive la falta, en el escrito de remi8i6n.

Como por esta Junta se proveerd de certificados impresos a todos los sefiores facultati-
yes de la Repiibica, ru^,^ole no acepte nin^dn certificado que no est^ extendido en los
impresos de referencia. del que se le' acompafia un ejemplar para su conocimiento.

Kespecto a la estadistica de matrimonies, nacimientos y nacidos muertos, se le
incluyen doce ejemplares a fin de que se sirva remitir dentro de los cinco primeros
dfas de cada mes el resumen de las inscripciones verificadas en el anterior, conforme
a los dates que en el mismo se piden.

Estos datos son los que se ban sefialado en el cuadro resumen a que acabo de referirme.

En ese mismo dfa se public<5 el primer ^'Informe Bianual Sanitario y Demogr&fico
de la Repdblica de Cuba (Afios 1902 y 1903), '* en el que el Dr. Finlay hizo constar
que: **En la provincia de Santiago de Cuba s61o 6 de los 16 municipios que constituyen
la provincia han enviado los partes requeridos. Tan pronto como se redban estoa
datos se publicari un Suplemento que incluird la totalidad de las defunciones en

444 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC 00NGBES8.

dicha provincia oriental, asf como un resumen para toda la Repdblica, con cla8ificaci6n
por sexos y razas. " Efectivamente hasta el 12 de abril de 1905 no pudo publicarae
ese Suplemento, y en ^1 se subsanan las faltas cometidas por loe jnzgados que oportuna-
mente no remitieron sua estados.

Sigui^ronse publicando lo6 informes mensuales y anuales de 1904 y 1905 con las
mismas clasificaclones de edades antes sefialadas; pero deede el afio 1906, en los men-
Buales se alter6, bien a mi pesar, la divisi6n de las edades, reduci^ndola a loe gnipot
de 0 a 1 afio, de 1 a 5 aflos y de 5 en adelante; y deede 190S se adopt6 tambi^ para
los anuales, hasta que en 1910 se adopt6 la clasificaci6n acordada en el 61timo Congreeo
de Paris (1909) para la revisi6n de la nomenclatiura de enfermedades y cauaas de
muerte.

El afio 1905 sefUllase por doe hechoe trascendentee en el terrene de la estadistica: la
publicaci6n del '^ Manual de Prdctica Sanitaria,' ' publicado bajo la direcci6n del Dr.
Enrique B. Bamet, jefe ejecutivo del Departamento de Sanidad de la Habana, en el
que escribf el capftulo Estadfstica Demogr&fica y la ce]ebraci6n del Primer Congreeo
M^ico Nacional, uno de cuyoe acuerdoe fu6 la aprobaci6n, por unanimidad, de la
moci6n que present^ para que se solicitase de los poderes pdblicos la elaboracida
de un nuevo censo, que sirva de base para todas las operaciones de la Kepdblica.
En ese Congreeo fu( designado para deeempefiar con los Dres. La Guardia y Delffn
la ponencia del tema oficial de la Secci6n IV, "Estadfstica Sanitaria de Cuba."
Tambi^n presents otro trabajo sobre la ''Contribuci6n al eetudio de la mortalidad
producida por el t^tanoe en la Repdblica de Cuba" estudiando el quinquenio 1900-
1904 en la totalidad del territorio nacional y en la Habana deede 1871.

Los votes formulados por aqu61 Congreeo tuvieron su realizaci6n en el afio 1907 en
que se hizo el ^T^nso de la Reptiblica de Cuba bajo la admini8tracl6n provisional de
los Estados Unidos." De la proclama del Gobemador Provisional, fecha 6 de septiem-
bre de 1907, se deduce que en 8 de mayo se dict6 el decreto No. 520 disponiendo ee
levantase el censo; que el lunes 30 de septiembie comenzarla la enumeraci6n, la que
deberfa estar terminada para el 14 de noviembre (45 dfas) y sobre todo esta afirmacidn
que 1e qidta todo el valor a la obra emprendida, firmada por el Gobemador Provisional
Charles E. Magoon: ^'Se repite la advertencia de que si bien el censo tieno el car^cter
general de un censo de poblaci6n, es sobre todo un censo electoral, y que deberA
prestarse la mayor atenci6n a que las tablas que se entreguen contengan tod os los
dates necesarios para poder formar una lista rigurosamente exacta de las personas que
tengan derecho electoral." *

I^ anterior dec]araci6n oficial, mueetra bien a las claras que eete fu^ un censo
politico, y como tal Ueno de inexactitudes y aun erroree de sumas, y con la misma
falta que advertf al tratar del de 1899, de haber side realizado en un largo perfodo de
tiempo.

Si este documento estadfstico merece serias censuras, en cambio s61o alabanzas
merecen las Ordenanzas Sanitarias para el regimen de los Ayuntamientos de la Kep6-
blica, puestas en vigor por los decretos presidenciales ntimeros 17 y 53,de 12 de enero
y 17 de febrero de 1906. De estas Ordenanzas, que constituyen en realidad nuestra
ley sanitaria, los artfculos que hacen relaci6n*con los asuntos demogrdficoe son los
marcados con los ndmeros 527 y 615, que textualmente dicen:

Art. 527. I^as certificadones de defunci6n serdn extendidas por duplicado y ajusta-
das a las Instruccionee oontenidas en las planillas impresas, conforme a un modelo
uniforme, distribuidas gratuitamente por la junta superior de sanidad entre todos
los medicos en ejercicio. Es obligatono el uso de la Nomenclatura intemacional de
Bertillon. El juzgado municipal respective conservard una de las certificaclones y
remitird la otra al jele superior de sanidad, en un t<^rmino que no exceda de cinco
dfas.

1 Censo de la Reptiblica de Cuba bajo la adminlstrBcidn provisional de loi Estados Unidoe, 1907.
Director Victor H. Olmsted, Oficina (sic) del Censo de los Estados Unidos, Washington, 1006, p. 563.

PUBLIC HEALTH AND BffEDICINE. 445

Art. 615. Iam jueces munlcipales de la Repdbllca c]uedaD oblisados a remitir a la
junta superior de sanidad, en la tonna y perfodoe de tiempo Que ma seflale, los datoe
relativoe a nacimientos, matrimonioe y defimciooee, con el nn de hacer las publica-
ciones de estadfsticas demogrdficas.

Las instruccionee a que se refiere el artfculo 527, esUoi impresas en las cubiertaa
de los cuademoB de los certificados de defunci6n, y dicen as(: 1^, Loe profeeores medi-
cos expedirdn por dupllcado estos certificados, para entregar en los juzgados muni-
cipales a los efectos del registro civil; 2^, la direcci6n de sanidad proporcioua gratis
estos certificados, asf como ejemplares de la clasificacidn de Bertillon a los medicos
que est^n registrados y lo soliciten del jefe local de sanidad; 3^, escrfbase con letra
bien legible y con tinta firme; 4*^, cuando se ignore algdn dato, conslgnese ignorado;
pero no se deje ningdn particular sin contestaci6n; 5*^, escrfbanse los nombres completos
del iallecido. No ser^ admitldas las iniciales. Si es casado o viudo, d^nse tambl^n
los nombres del c6nyuge; 6*^, los datos de la primera columna deben obtenerse del
cabeza de Camilla o de algdn all^:ado o amigo responsable, consigndndose siempre
todos los datos exigidoe y no contundiendo la naturalidad con la nacionalidad; 7®,
conslgnese la clase de casa, si es particular, de hu^spedes, hotel, de vecindad, estable-
cimiento, etc.; 8<^, si el cad&ver es de un reci^n nacido sin nombre, d^ el de los
padres; 9®, si la muerte ha orurrido en un hospital, asilo, etc., d^ solo el de ^e al
consignar el lugar del fallecimiento; 10^, fli la enfermedad fu^ adquirida fuera de la
localidad, hiigase constar en la primera columna el lugar en que se contrajo; 11*,
para determinar la causa directa y la causa indirecta de la muerte, consdltense las
re^as para resolver las dudas a este respecto que se encuentran al final de la clasifi-
caci6n de Bertillon; 12^, las defunciones de individuos que no hayan cumplido 24
boraB de nacidos, se extendeiin en los impresos espedales para fetos, y no en ^stos.

En las nuevas ordenanzas sanitarias, promulgadas por el decreto presidencial No.
674, de 6 de julio de 1914, el antiguo artfculo 527 forma parte del actual 264, y el 615
•e reproduce ahora con el No. 329, sustituy^ndose en ambos la designad^n '* Junta
Superior de Sanidad" por ''Direcci6n de Sanidad.''

En diciembre de 1907 present^ al entonces Jefe de Sanidad de la Isla, Dr. Carlos J.
Finlay, \m informe sobre la necesidad de implantar varias reformas en los servidos
estadfaticos, relacionados con la recolecci6n de datos, sobre todo en lo referente a los
matrimonies, nacimientos y nacidos muertos, a fin de que resultasen una verdad las
cifras representativas de los mismos, pues la carencia de datos primaries no me permi-
tfa rectificar loe errores y las omisiones cometidos por los oiganismoe colectores, ni
establecer estudios transcendentales sobre esos interesantes problemas, por cuanto
solo recibla las cifras indicativas de los sexos y razas, de la legitimidad o il^ltimidad
de los seres que venlan al mimdo o de los que cambiaban de estado; en ese informe
le propuse la adopci6n de los modelos que acompafio al final de este trabajo, en los
cuales se podrd apreciar el caudal de datos utilizables para toda class de investiga-
donee demogr&ficas.

Finlay, que dedic6 siempre preferente atenci6n a esta clase de estudios, aprob6 las
reformas propueetas y someti6 el informe a la Junta Superior de Sanidad, quien apro-
bando lo informado por su letrado, pas6 el expediente al consul tor sanitario. Dr. J. R.
Kean, para que lo elevase al gobemador provisional; pero en las oficinas de tan alto
fundonario desapared6 todo lo actuado, sin resolver nada sobre el asunto.

Al reinstalarse nuestro propio gobiemo, me apresur^ a plantear de nuevo el pro-
blema, y esta vez con tan buen resultado que ahora fundona en toda la Repdblica el
■istema por mi propuesto, de boletines unipersonales para cada una de las divisiones
del movimiento de la poblad6n; y si bien es verdad que todavia no ha rendido todos
los frutos que e8t4 llamado a dar, espero que en breve se podr&n cosechar ^tos, pues
sefialado el mal, f&cil es remediarlo.

Tiempo es ya de presentar la manera como fundona este servido, que ha mereddo
celebradones de propios y extraftos, y que reviste excepdonal interim por las estre-

446 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

chas reladones que nos Hgan con los Eetados Unidoe, intereeados, despu^ de noso-
txo6, en que se conserve nuestro buen estado sanitario.

ConvencidoB desde los prlmeros momentoe de la neceaidad de centralizar loe servi-
cioe para evitar los mtiltiples errores que se van cometiendo por cada uno de los oiga-
nismoB recolectores, implant6 el envio, por cada registro, del duplicado de la certi-
ficaci6n que loe facidtativoe expiden al fallecer un individuo, y para suplir la ialta
de este documento en loe lugares donde no hubiese medico que pudiera extender el
certificado, dispuse la remisi6n de una copia del acta de insciipci6n en los libros del
r^;istro civil.

Esos certificados, que Uevan el ndmero de orden correlativo de su inscripci6n, y
loe sellos de las Jefaturas locales de sanidad y de los Juzgados Municipalee respect! vob,
con el fin de garantizar su autenticidad y evitar posiblee extravios de los boletines uni-
personales, son clasificados por mf desde el punto de vista del ntimero de la nomencl*-
tura a que debe atribuirse la muerte en cada case, y si &lta algtin date se pide en el
acto al lugar de origen. Llenos estos requisites, son inscritos en libroe especialee, para
cada aiio y cada una de las seis provincias en que se divide la Reptlblica, y donde en
forma de columnas estdn registrados todos y cada uno de los dates fundamentales que
contienen dichoe certificadoe.

Con estos libros se obtiene la ventaja de no volver a tocar el documento originaly
que se archiva convenientemente, y de poJier con rapidez analizar los distintos ele-
mentoB que encierran loe mencionados boletines. De estos libros se extraen loe datos
que se publican mensual y anualmente, segdn se dispone en el artlculo 285 de la Ley
del Poder Ejecutivo que textualmente dice: ''Adem^ del informe anual prevenido
por esta ley, el Secretario de Sanidad y Beneficencia publicard, tan pronto como sea posi-
ble despu^ de la terminaci6n de cada alio natural, un informe de la Estadlistica sani-
taiia y demogr&fica de la Rep(iblica. Tambi^n publicaril un informe mensual esta-
dfetico sanitario."

En impresos ad hoc y sirvi^ndose de Upices de varios colores, se reducen a cifiras
loe datos suministrados por las certificaciones de defunci6n, relatives a la causa de la
muerte, a la edad del fallecido, al sexo y a la raza, estudiado todo esto en cada una de
las 112 jefaturas locales de Sanidad, que corresponden a su vez a los ayuntamientos
de cada provincia.

Para tener un medio de comprobar cuaJquiera omiBi6n o cualquier error, los jefes
locales remiten a su vez imoe estados de las defunciones que ban registrado antes de
ser inscritas en el r^istro civil, y por otra parte envian, cada decena, otro estado
demoetrativo del movimiento de las enfermedades de declaraci6n obligatoria, con d
resultado obtenido sea que hayan terminado por la muerte o por la curaci6n.

En cuanto a loe matrimonioB, nacimientos y nacido-muertos, todavfa no se ha
podido publicar todo lo que arroja el andlisis de loe datos suministrados por los bole-
tines unipersonales, sujetos a las mismas prdcticas quese sigue^ con los de las defimdo-
nes, debido a la falta del personal competente que hace afios vengo demandando para
cumplir esas importantcs funciones. El dfa que ^to se consiga ee podrd Uegar a una
perfecci6n que atin estd muy distante de tener este servicio en lo que se refiere a eetos
puntos concretes.

En ** Sanidad y Beneficencia," Boletfn Oficial de la Secretarfa del ramo, que susti-
tuy6 a los antiguo6 Informes mensualee eanitario-demogrdficoe de la Reptiblica de
Cuba, se ha continuado la publicaci6n de las estadieticas de que d( cuenta al hablar
de aquellos; al propio tiempo ban aparecido en sus columnas otra serie de trabajoe
estadfsticos, que no menciono especialmente por hacerlo en la bibliograffa que doy
a conocer al final de este estudio, limitada dnicamente a lo que ha visto la luz pt^blic*
en los afios transcurridos del Biglo actual. Por ella podrd apreciarse cuil ha side la
labor de cada uno de los que de estas materias se ban ocupado en esta Repdblica.

De la exposici6n realizada en cada perlodo de los tres en que he dividido eete estudio
puede deducirse que Cuba no ha dejado de contribuir, con las luces de bus hijos las

PUBLIC HEALTH AND MEDICINE. • 447

mis de las veces, con el eefuerzo de lo6 extranjeros en no p.ocas ocadones, al progreeo
de la eetadffitica y al de la demograf fa, y que ocupa una ventajosa poeici6n en el con-
cierto de lo6 pafsee panamericanos. Si este trabajo tiene, como toda obra humana,
SUB defectos, que soy el primero en reconocer, muestra a su vez la labor cumplida, y
ensefia la que falta por realizar, la cual espero que en no lejano dfa hard que brille
Cuba con resplandores tan vivos como los que irradia la eetrella que refulge en el
rojo tridngulo de nuestra bandera.

BIBUOOBAFLl BSTADiSTICA DBL 8I0L0 XX.

1901.

1. Goigas. Report of vital statistics of Havana for the year 1900. s. a. La carta
de remi8i6n de este informe estd firmada por W. G. Goigas, major and surgeon, U. S. A.,
chief sanitary officer, January 17, 1901. Esti publicado en la Habana y todo en
ingl^.

2. Le Roy. Estadlstica de 25 afios de fiebre amarilla. Trabajo presentado al Tercer
Congreso Medico Panamericano, celebrado en la Habana, 4 febreio 1901. Actas de
las sesiones y memorias presentadas, t. II, p. 1012-1041; y folleto.

3. Santos Fernandez. Las enfermedades de los ojos en los negros y mulatos.
Trabajo leldo en el XI 11. Congreso Medico Intemacional, celebrado en Paris del
2 al 9 agosto 1900. Cr6nica M6dico-Quirtirgica de la Habana, septiembre 1901, t.
XXVII, p. 385-405. Presenta 9 cuadros estadlsticos de los enfermos de los ojos por
^ asistidos desde 1875 hasta 1899.

4. Le Roy. Los medicos y el censo. Revista de la Asociacidn M^co-Farmac^u-
tica de la Isla de Cuba, 1. 1, p. 644-645.

_ 1902.

5. €roigas. Informe demogr&fico de la ciudad de la Habana presentado al Bri-
gadier General Leonard Wood, U. S. A., Gobemador Militar. Aflo de 1901. Las
cartas de remisi6n (ingl^ y castellano) eetdn fechadas en la Habana el 15 de febrero
de 1902. Todos los cuadros estadfsticos tienen sus leyendas en los dos idiomas.

6. Le Roy. Estadfstica de fiebre amarilla. Trabajo presentado al Congreso Sani-
tario Intemacional, celebrado en la Habana en febrero 1902. Revista de Medicina
Tropical, t. Ill, p. 73-83; y folleto.

7. Ruiz Casab^. Difteria en Cuba. Influencia del suero. Mortalidad. Trabajo
presentado al Congreseo Sanitario Intemacional. Cr6nica, etc., t. XXVIII, p. 117-127.

8. Duefias. Necesidad de la creaci6n de un hospital de niflos en la Habana como
medio de contribuir, entre otras cosas, al saneamiento de la ciudad. Trabajo pre-
sentado al Congreso Sanitario Intemacional. Cr6nica, etc., t. XXVIII, p. 127-131,
137-144.

9. Le Roy. Estadfstica de fiebre amarilla. Desaparicidn de dicha enfermedad en
la ciudad de la Habana, demostrada por los dates de la misma. Trabajo presentado
a la Sociedad de Estudios Clinicos de la Habana el 20 abril 1902. Archives de la
Soc. de Est. Clin, de la Habana, t. XI, p. 277-320; y folleto.

10. Le Roy. Un afio complete sin fiebre amarilla en la Habana; comunicaci6n
a la Academia de Ciencias M^dicas, Flsicas y Naturales de la Habana, el 28 septiembre
1902. Anales de la Academia, etc., t. XXXIX, p. 153-156; Rev. de la Asoc. Med.
Farm, de la Isla de Cuba, t. Ill, p. 59-62.

1903.

11. Finlay. Informe sanitario y demogr&fico del tannine municipal de la Habana
correspondiente al afio 1902 y presentado al Secretario de Gobemacidn Sr. Eduardo
Yero Budu^n por el Dr. Carlos J. Finlay, Jefe de Sanidad de la Isla de Cuba, 1903.
La carta de remisi6n esti fechada el 1^ enero 1903 y e8t4 publicada, asf como la
leyenda de los cuadros, 'en castellano e ingl6e.

448 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC 00NGBES8.

12. Iribarren. Repdblica de Cuba. Secretarfa de Hacienda. Estadfstica Gene-
ral. Movimietito de poblaci6n. Aflos 1900 y 1901. Habana, Imp. La Habanera,
1903. Ouadios de matrimonios, nacimientos y defunciones, publicadoe por Miguel
Iribarren, jefe de laeeccidn.

13. Iribarren. Ig:ual titulo que el anterior, para el afio 1902. Imp. La Propagan-
dista, 1903. Igualee cuadros y los resdmenes de 1901 y 1902.

14. Iribarren. Repdblica de Cuba. Secretarla de EUcienda. Estadfstica Gene-
ral. Matrimonies, Nacimientos y Defunciones inscritos en el Registro del E^stado
Civil de la Repdblica en el afio 1903, con un resumen comparativo, por Provincias, de
los nacimientos y defunciones, y aumento de la poblaci6n en los afios de 1900 a 1903,
inclusive.

15. Schweyer. Cuadros demostrativos de la disminuci6n de la mortalidad de
Matanzas (enero 1898 a abril 1903), por meses, en la ciudad y el t^rmino municipal.
Presentados en la Segunda Conferencia Nacional de Beneficencia y Correcci6n de la
Isla de Cuba, celebrada en Santa Clara, 25 mayo 1903. Memoria Oficial, p. 129-130.

16. Fuentes. Conaideraciones generales sobre la profilaxia de la tuberctdosis.
Presentadas a la Segunda Conferencia, etc., Memoria Oficial, p. 315-323. Tiene un
cuadro estadlstico que demuestra el movimiento del dispensario especial para enfer-
mos del pecho, creado y sostenido por el Departamento de Sanidad de la Habana,
durante los 16 meses transcurridos desde 14 febrero 1902 hasta 20 mayo 1903.

17. Acosta. La rabia y el tratamiento de Pasteur en la Habana. CnSnica, etc., t.
XXIX, p. 328-329. Estadfstica de los inoculados en el Laboratorio de la Cr6nica
MMico-Quirdrgica de la Habana, desde su fundacidn en 1887 hasta el afio 1902.

18. Le Roy. S^^undo aniversario de la extincidn de la fiebre amarilla en la Isla
de Cuba. Comumcaci6n a la Academia de Ciencias, 27 septiembre 1903. Analee, t.
XL, p. 149-153; CnSnica, t. XXIX, p. 343-346; y folleto.

1904.

19. Santos Femdndez. La conjuntivitis granulosa en Cuba. Cr6nica, t. XXX, p.
41-47. Tiene tres cuadros estadfsticos que abrazan un perfodo comprendido entre lo8
afios 1875 y 1903.

20. Finlay. Informe bianual sanitario y demogrdfico de la Repdblica de Cuba
presentado al Secretario de Gobemaci6n Interino Dr. Leopoldo Cancio y Luna, por el
Dr. Carlos J. Finlay, Jefe de Sanidad de la Isla de Cuba y presidente de la junta
superior. Afios de 1902 y 1903. Habana, 1904. La carta de remi8i6n estd f echada en
10 septiembre 1904 y estd publicada tambi6n en ingl^. Los cuadros todos en cas-
tellano.

21. Le Roy. Tercer aniversario de la erradicaci6n de la fiebre amarilla de la
Habana. Comunicaci6n a la Academia el 14 octubre 1904. Anales, t. XLI, p. 170-
177; Revista de Medicina y Cirugfa de la Habana, t. IX, p. 584r-589; y folleto.

1905.

22. Santos Femdndez. Los ciegos y sordo-mudos en Cuba. Trabajo presentado a
la Cuarta Conferencia Nacional de Beneficencia y Correcci6n de la Isla de Cuba, cele-
brada en Camagfiey en abril de 1905. Memoria Oficial, p. 61-72. Tiene 6 cuadros
y uno de resumen de los existentes a dltimos de 1880, con expresi6n del pueblo de sa
residencia, edad, estado de su instrucci6n, clasee y causas de su desgracia.

23. Finlay. Suplemento y nota adicional al Informe bianual Sanitario y Demo-
grdfico de la Repdblica de Cuba. Afios de 1902 y 1903 presentado al Secretario de
Gobemaci6n Dr. Fernando Freyre de Andrade por el Dr. Carlos J. Finlay, Jefe de
Sanidad de la Isla de Cuba y Presidente de la Junta Superior. Abril 1905. Este
suplemento es la rectificaci6n, completando los datos, de la Provincia de Santiago de
Cuba. Contiene, ademds, el resumen de las defunciones ocurridas en cada una de las
Provincias de la Repdblica durante los aflop 1 902 y 1903, clasifi^^adas por enfermedadop,

PUBUO HEALTH AND MEDICn?E. 449

86X08, y razas. En el infonne bianual, antes anotado, se public6 tambi^n el informe
de la nabai)^ correepondiente al afio 1903.

24. Departamento de SanidM. Informe anual sanitario y demogr&fico del t^rmino
municipal de la Habana. AHo 1904. Habana, 1905. Este informe no tiene fecha ni
firma; pero esti hecho bajo la direcci6n del Dr. Finlay.

25. Finlay. Importancia de ciertos factores s^undarioe en el deearroUo de la
tuberculosis pulmonar y en la mortalidad producida por la misma. Ck>municaci6n a
la Academia, 23 junio 1905. Anales, t. XLII, p. 62-75. Es la ampliaci6n de la nota
preliminar preeentada al Primer Congteao Medico Nacional, celebrado en mayo de 1905.

26. Le Roy. Ck>ntribuci6n al estudio de la mortalidad producida por el t^tanos en
la Reptiblica de Cuba, Trabajo presentado al Primer Ck>ngreBo M6dico Nacional.
Actas y Trabajos, p. 384-391; y folleto, reproducido de la Revista M^dica Cubana.

27. Le Roy. Estadfstica sanitaria de Cuba. Ponencia del tema oficial del mismo
tftulo, en el Gongreso expresado. Actas y Trabajos, p. 427-434; Rev. M6d. Cubana,
t. VIII, p. 3-13.

28. Le Roy. Estadistica sanitaria. Capitulo del Manual de Pr^tica Sanitaria, p.
993-1014, editado por el Departamento de Sanidad, bajo la direccidn del Dr. Enrique
B. Bamet, Habana, 1905.

29. Le Roy. Cuarto aniversario de la erradicaci6n de la fiebre amarilla en la
Habana. Comunicaci6n a la Academia el 29 sepUembre 1905. Anales, t. XLII,
p. 133-143; y foUeto.

1906.

30. Finlay. Informe anual sanitario y demogr&fico de la Reptiblica de Cuba. Afio
1904, Habana, 1906. La carta de remisi6n est& firmada en la Habana el 10 de marzo
de 1906. Publicada en castellano e ingl^. Este informe contiene, adem^, el del
t^nnino municipal de la Habana correspondiente al afio' 1904.

31. Junta Local de Sanidad. Informe anual sanitario y demogr&fico del t^rmino
municipal de la Habana. Afio 1905. Habana, 1906. Contiene los datos estadisticoe
flin comentarios de ninguna especie, y estd publicado bajo la direccidn del jefe local
de sanidad de la Habana. Dr. J. A. L6pez del Valle, aunque sin fecha, ni firma.

1907.

32. Finlay. Infonne anual sanitario y demogrdfico de la Reptiblica de Cuba (bajo
la Admini8trac]6n Provisional de los Estadoe Unidos). Afio 1905. Habana, 1907.
La carta de remisidn estd firmada en la Habana el 25 de enero de 1907. Publicada en
castellano y en ingl^. Contiene tambi^ el del t^imino municipal de la Habana
correspondiente a 1905.

33. Junta Local de Sanidad. Infonne anual sanitario y demogr&fico del t^rmino
municipal de la Habana. Afio 1906. V^ase la nota del tftulo nflmero 31.

34. Le-Roy. Nota ampliatdva al trabajo del Dr. Enrique B. Bamet (aobre mor-
talidad infantil), preeentada a la Sexta Conferencia Nacional de Beneficenda y
Gorreccidn de la Isla de Cuba, celebrada en Cienfuegoe el 31 de manco. Memoria
Oficial, p. 121-124.

35. Valdee. Objeto y fines de las sociedadee protectoras de la infancia. Sexta
Conferencia Nadonal de Beneficenda y Correcddn de la Isla de Cuba, celebrada en
Cienfuegoe el 1^ abril 1907. Memoria Oficial, p. 189-194. Preeento la estadistica de
la mortalidad infantil, de 0 a 1 afio ocurrida en la dudad de la Habana, capital de la
Rep6blica de Cuba, durante el quinquenio de 1901 a 1905.

36. Le-Roy. Suicidio por el fuego. Nota preeentada a la Sexta Conferencia Na-
donal de Beneficenda y Correcd6n de la Isla de Cuba, celebrada en Cienfuegoe el
l"" abril 1907. Memoria Oficial, p. 219-224.

37. Tamayo. El Dispensario Tamayo. Lo que ee en la actualidad y lo que puede
ser en el porvenir. Tntbajo presentado a la Sexta Conferencia Nadonal de Bene-

450 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

ficenda y CoiTecci6n de la lela de Cuba, celebrada en Cienfuegoe el 1^ abzil 1907.
Memoria Ofidal, p. 245-256.

38. Le-Roy. Quo tendimus? Estudio m^ico-legjld sobre el suiddio en Cuba
durante el quinquenio de 1902-1906. Memoria laureada con el Premio de Medicina
Legal Doctor Antonio de G6rdon y de Acoeta en el concuroo de 1907, por la Academia
de Ciencias M6dicas, Flsicas y Naturales de la Habana. Anales, etc., t. XLIY,
p. 38-63; Rev. M6d. Cubana, t. XI, p. 129-149; y foUeto.

39. Finlay. Atmospheric temperature as an essential factor in the propagatifm of
yellow fever. XIV. International Congress for Hygiene and Demography, Berlin,
23-29 September, 1907; y en los Trabajoe SelectOB del Dr. Carlos J. Finlay. Habana,
1912, p. 551-671.

40. Finlay. Inlorme anual sanitario y demogr&fico de la Reptiblica de Cuba (bajo
la Administraci6n Provisional de los Estados Unidos) preeentado al Crobemador Pro-
visional de Cuba Hon. C. E. Magoon por el Dr. Carlos J. Finlay, Jefe de Sanidad de
la Repdblica y Presidente de la Junta Nacional (con la aprobaci6n del consultor
sanitario del Departamento). Afio 1906. Habana, 1907. La carta de remiBi6n est^
fechada en la Habana a 7 noviembre 1907. Este infonne contiene: el del t^nnino
municipal de la Habana para el afio 1906; el de los realizados por el Laboratorio de la
Isla de Cuba durante el afio 1906; en sus secclones de bacteriolpgia, qulmica genenl,
qulmica legal y epizootias.

41. Ferrer. La oftalmo reacci6n a la tuberculina de Calmette. Trabajo pnaeah
tado a la Academia el 8 noviembre 1907. Anales, t. XLIV, p. 484-492. Es la
experiencia personal del autor en 100 casos por ^1 investigados.

1908.

42. L6pez. Inlorme sanitario y demogr^co del tannine municipal de la Habana
preeentado al Jefe Superior de Sanidad Dr. Carlos J. Finlay, por el Dr. J. A. L6pef
del Valle, jefe local de sanidad de la Habana (con la aprobacidn del consultor sani-
tario del Departamento). Afio 1907. Habana, 1908. Este es el primer informe
anual de la Habana precedido de consideraciones especiales sobre la nueva oiganisa-
ci6n sanitaria, implantada por el Decreto No. 894 del Gobiemo Provisional, nacionali-
sando los servicios de este ramo de la Administraci6n. Estd fechado en la Habana
a 31 de diciembre de 1908.

43. Valdes. Mortalidad infantil, sus causas, medios para prevenirlas y combatirlaa.
Trabajo preeentado a la S^ptima Conferencia Nacional de Beneficenda y Correccida
de la Isla de Cuba, celebrada en C^oxienas en abril 1908. Memoria Ofidal, p. 99-116.
Presenta cuadros estadlsticos de la mortalidad infantil en la Habana, en los mfks
1901 a 1906, clasificada por enfermedades, edades, razas y sexos.

44. Santos Femdndez. La profilaxis del tracoma en Cuba basada en la vigilanda
de los inmigrantes y de las escuelas ptiblicas. S^ptima Conferencia Nacional de
Beneficencia y 0>rrecci6n de la Isla de Cuba, Memoria Oficial, p. 319-329. Acom-
pafia la estadlstica de los casos de tracoma asistidoe en la cUnica de enfermedades
de los ojos del Dr. Juan Santos Femdndez desde abril de 1875 hasta marzo de 1908.

45. Le-Roy. Algo sobre demograf la. Trabajo preeentado a la S^ptdma Conferencia
Nacional de Beneficencia y Correcci6n de la Isla de Cuba, celebrada en la ciudad de
Cardenas y leldo por su autor en el teatro Otero en la sesi6n del 20 de abril de 1906.
Memoria Oficial, p. 397-403; Rev. de Med. y Cir. de la Habana, t. XIII, p. 201-206;
y folleto.

46. Finlay. Informe anual sanitario y demogrdfico de la Reptiblica de Cuba (bajo
la Administraci6n Provisional de los Estados Unidos) preeentado al Gobemador Pit>-
vidonal de Cuba Hon. C. E. Magoon por el Dr. Carlos J. Finlay, Jefe de sanidad de la
Repdblica y Presidente de la Junta Nacional (con la aprobaci<Sn del consultor sanitario
del Departamento). Afio 1907. Habana, 1908. Este informe, el Ultimo de ks
anuales firmado por el Dr. Finlay, Ueva fecha 22 de octubre de 1908, y contiene.

PUBLIC HEALTH AND *MEDICIKE. 451

ademds de las estadlBticas de la Repdblica durante el afio 1907, lo6 infonnes presen-
tadoe por el Servicio de Cuarentenaa y por el Laboratorio Nacional, correspondientes
al afio de referenda.

En el afio 1903 se public6 mensualmente el Inlorme mensual sanitario y demogr^co
de la Repdblica de Cuba, pero sin uniformidad en lo que se refiere a loe ayuntamientos,
ezcepto para el de la Habana, a causa de empezar a oiganizarse loe servidoe estadls-
tkoe al prindpio de aquel afio.

Desde el de 1904 hasta el de 1908, amboe indusive, se publicaron cada mes, ya de
manera uniforme, los tiabajoe estadlsticos de la Reptiblica y de la Habana, con el
mismo tltulo antes citado. En ellos se publicaron los datos de poblad6n (la del
censo y la estimada), matrimonios, nacimi^itos, naddoe-muertoe y defunciones, en
cada uno de los municipios de la naci6n; dichos trabajoe iban precedidos, cada mes,
de una carta en la que Finlay hacia las consideraciones que le sugeria la oportunidad
de loe hechos de que se daba cuenta en la estadlsUca.

Desde 1909 esos trabajos se ban segtddo publicando en Sanidad y Beneficencia,
Boletin Oficial de la Secretarla, creada en esa fecha, al restaurarse el Gobiemo propio.

1909.

47. Ferrer. Estadfstica del Cuerpo de Artilleria.. Rev. M6d. Cubana, enero 1909;
t. XIV, p. 13-20, y foUeto.

48. L6pez. Inlorme anual sanitario y demogr^co del t^rmino munidpal de la
Habana presentado al Jefe Intenno de Sanidad Dr. Enrique B. Bamet, por el Dr. J. A,
Ldpez del Valle, jefe local de sanidad de la Habana (con la aprobaddn del consultor
sanitario del departamento). Afio de 1908. Habana, 1909. La carta que precede a
este inlorme lleva fecha 16 enero 1909. En eee mes tambidn se pubUc6 el dltimo
informe mensual en la forma usada en los afios anterioree.

49. Fosalba. El problema de la poblad6n en Cuba. Trabajo presentado a la
Academia de Ciendas M^dicas, FMcas y Naturalee de la Habana, d 16 abril 1909.
Analea, etc., t. XLV, p. 693-751; Sanidad y Beneficencia, t. I, p. 430-556, aquf en
castellano, ingl^ y franco.

50. Guiteras. Notas sobre la fiebre amarilla y la tuberculosis en Cuba durante lo8
dltimoe afios. Sanidad y Beneficencia, t. I, p. 17-29. Acompafia un cuadro de loB
cases de fiebre amarilla ocunidos en la Beptiblica deede la reintroducddn del mal, en
octubre 1905, hasta enero 1909.

51. Duque. Al Medical Record. La amenasa cubana. Sanidad y Beneficencia, t.
I, p. 341-352, en castellano, ingl^ y franc^. Editorial desvanedendo errdneos
conceptos publicados por el p^i6dico de Nueva York, y dtando cifiras de la mortalidad
comparada de 1908 y 1909.

52. Duque. Cuba, Sanidad y Beneficencia, t. II, p. 11^137, en castellano, ingl^
y franc^. Editorial dando a conocer el estado sanitario de Cuba, con un cuadro oom-
parativo de los nacimientos, defundones, con su tanto por mil, e inmigraddn en el
primer semestre de los afios 1908 y 1909.

53. Le-Roy. Notas sobre estadfstica profesional. Sanidad y Beneficencia, t. II,
p. 232-236.

54. Le-Roy. Estadfstica demogr&fico-sanitaria. Importantesreformas. Sanidad y
BeBeficenda, t. II, p. 472-479.

55. Arteaga. Contribud6n al eetudio de la funddn menstrual en las cubanas resi-
dentes en la dudad de la Habana. Trabajo presentado a la Academia el 29 didembre
1909. Anales, etc., t. XLVI, p. 344-357.

56. Le-Roy. Apuntes sobre las fundones sexuales en la mujer cubana. Comuni-
caddn a la academia el 29 didembre 1909. Anales, etc., t. XLVI, p. 358-369; Rev.
de Med. y Cir. de la Habana, t. XV, p. 78-86.

0843e— 17— VOL IX 30

452 PB0CEEDIK6S SEOOND^AK AMEBIOAN 8CIENTIFI0 CONGRESS.

1910.

57. Guiteraa. £1 problema de la tuberculosis. Sanidad y Beneficencia, t. Ill,
p. 1-13. Refutaci6n de errores publlcadoe por el peri6dico La Discu8i6n.

58. Le-Roy. Paludismo en Cuba. Estudio demogr&fico. Trabajo presentado a la
Academla el 10 marzo 1910. Anales, etc., t. XL VI, p. 490-494; Sanidad y Benefi-
cencia, t. Ill, p. 129-134.

59. Ferrer. Apuntes sobre la raci6n alimenticia del obrero cubano, por el Dr.
Horacio Ferrer. Anales, t. XLVII, p. 41-98. Memoria preniiada por la Academia de
Ciencias M6dicas, Fisicas y Naturales de la Habana en el concurso de 1910.

60. Guiteras. Carta de remisidn (del informe anual de 1908). Sanidad y Benefi-
cencia, t. Ill, p. 518-537, en castellano, ingl^ y francds. Estd fecbada en 30 de mayo
de 1910 y se ocupa especialmente de fiebre amarilla, cdncer, tuberculosis y del alcantar
rillado. Con tree cuadros estadlsticos: del cdnccr en Cuba, por razas, sexos y localizft>
ci6n en los afioe de 1902 a 1908, ambos inclusive; comparativo de la poblaci6n corree-
pondiente a las idades de 30 a mds de 100 aflos, por perfodos de cinco en clnco, segtin
los censos de 1899 y 1907; y de la poblaci6n total y ndmero de defunciones por tubef^
culosis pulmonar con sus proporciones en Ice afios de 1900 a 1908.

61. Le-Roy. Estadfstlca demogrdfico-sanitaria del afio 1908. Sanidad y Benefi-
cencia, t. Ill, p. 538-569. Va precedida de la carta de remisidn eecrita en castellano,
ingl^ y franco, fecbada en mayo 1910.

62. Ramos. La Homicidtura en Cuba. Sanidad y Beneficiencia, t. IV, p. 13-43|
52-74, 83-104, en castellano, ingl^ y franc^; y folleto. Este trabajo tiene once
cuadros estadlsticos y estd precedido de un artfculo titulado Homicultura, del Dr.
Eusebio Hemdndez y de otro del Dr. Manuel Varona Suarez, secretario de sanidad,
llamando la atenci6n de los medicos y de todoe los que entre noeotroe se interesen por el
perfeccionamiento de la niflez.

63. Gmteras. Carta de remisi6n (del informe anual de 1909) Sanidad y Benefl-
cencia, t. IV, p. 150-156, en castellano, ingl^ y franc^. Estd fecbada en julio de
1910 y acompafia un cuadro de las defunciones por fiebre amarilla en la ciudad de la
Habana, durante los afios que se citan (1890-1909).

64. Le-Roy. Informe anual sanitario y demogr&fico de la Reptiblica de Cuba.
Afio 1909. Con dates estadlsticos del decenio 1900-1909 presentado al sefior director de
sanidad por el Dr. Jorge Le Roy y Cassi, jefe de estadlstica. Sanidad y Beneficenciai
t. IV, p. 157-192. La carta de remisi6n lleva fecba 22 de julio de 1910, y estd piiblicada
en ingl^, franc^ y castellano.

1911.

65. Mufioz. Etiologla y profilaxis de la fiebre tifoidea en la Habana. Sanidad y
Beneficencia, t. V, p. 577-614. Preeenta cuadros estadlsticos comparativoe de la
tifoidea en las 6pocas anterior y posterior al abastedmiento de agua por el Canal
de Albear.

66. L6pez. La fiebre tifoidea en la Habana. Sanidad y Beneficencia, t.VI, p.
530-568; en castellano y en ingl^. Presenta cuadros estadfeticos de las defuncionet
por esta enfermedad desde 1872, y de las invaaiones y defunciones deede enero de VM
hasta noviembre de 1911.

67. Le-Roy. Estadlstica sanitaria y demogr&fica de la Reptiblica. Afio 1910.
Sanidad y Beneficencia, t. VI, p. 58(M20. La carta de remisi6n de este infofme
anual lleva fecha agosto de 1911 y estd publicada en castellano, ingl^ y franco.

68. Le-Roy. Consideradones sobre estadlstica. Trabajo leldo ante la Amevican
Public Health Association, en su reuni6n celebrada en la Habana el 8 diciembre 1911.
Rev. de Med. y Cir. de la Habana, t. XVI, p. 684-688. Este mismo trabajose pubUcd
en ingl^ con el tltulo '*The international classification of causes of sickness'' en el
6xgano oficial de la asodacidn, American Journal of Public Health, t. II, p. 28-29.

PUBLIC HEALTH AND MEDICINE. 453

1912.

69. Abad. Aumento de la poblaci6n cubana. Sanidad y Beneficencia, t. Vll,
p. 740-745. Se reproducen tree artfculos publicados por el Sr. Luis V. de Abad en
el Diario de la Marina, Habana, los diiis 10, 26 y 28 de julio de 1912, el primero con
el tftulo arriba indicado; el aegundo con el de La poblaci6n y el pon enir de Cuba y
el tercero con el marcado **Sobre la poblaci6n de Cuba."

70. Guiteras. El estado sanitario de Cuba. Rev. de Med. y Cir. de la Habana,
t. XVI. p. 443-446. Replica alRepreeentante en el Congreso de los Estados Unidoe,
Mr. George E. Foes.

71. Le-Roy. Progreso sanitario de Cuba demostrado por datos estadfsticos. Tra-
bajo presentado a la American Public Health Association, en la reuni6n celel rada
en Wellington en septiembre 1912, por el Dr, Jorge Le Roy y Cassd, jefe de estadfs tica
de la direccL6n de sanidad, ^ icepresldente de la Secci6n de Estadfstica de dicha asocia-
ci6n. Rev. de Med. y Cir. de la Habana, t. XVII, p. 557-568; Sanidad y Bene-
ficencia, t. VIII, p. 499-518, aquf en castellano, ingl^ y francos y; y en el Ameri-
can Journal of Public Health, t. Ill, p. 255-262, con el tftulo de Sanitary improve-
ment in Cuba as demonstrated by statistical data.

72. Le-Roy. Estadfstica sanitaria y demogr^fica de la Rep6blica. Afio 1911.
Sanidad y Beneficencia, t. VIII, p. 549-596. La carta de remisi6n de eete informe
anual lleva fecha 1^ de diciembre de 1912 y estd publicada en castellano, ingl^ y
franco.

73. Guiteras. Endemicidad de la fiebre amarilla. Sanidad y Beneficencia, t.
VIII, p. 617-709, en castellano y en ingl^. Reproduce un tral ajo publicado en 1888
con este tftulo: "Obsenacionee sobre la historia natural de las epidemias de fiebre
amarilla, fundadas en el estudio de la estadfstica de la mortalidad en la ciudad de
Key West, con indicaciones sobre la necesidad de un estudio continuado de esta
afecci6n, por el Gobiemo de los Estadoe Unidoe, por Juan Guiteras, M. D., Passed
AssiBtant Surgeon U. S. Marine Hospital Ser ice. Traducci6n del Annual Report
•f the Super ising Surgeon General of the Marine Hospital Ser ice of the United
States for the year 1888. Se encuentran numeros cuadrosoe y gr&ficos muy intere-
santee.

1913.

74. Le-Roy. Estudios sobre la mortalidad en la Habana durante el siglo XIX y
los comienzoe del actual. Tral ajo presentado a la Academia en 28 marzo 1913.
Anales, t. XLIX, p. 852-877; y foUeto.

75. Oafiizares. La estadfstica en nuestra administraci6n, por Manuel V. Cafiizares,
Habana. Afio 1913. Imp. La Propagandista, 26 p^inas. Es una tesis uni ersitaria,
presentada en diciembre 1911, para obtener el tftulo de doctor en derecho pdblico,
aegtin hace constar el autor en la Ad ertencia que la precede fechada el 14 a1 ril de
1913. Estudia estas cuatro cuestiones: ^Qu6 es Administraci6n7 ^Qu^ es Estadfs-
tica? La Estadfstica y la Administraci6n, y La Estadfstica en nuestra Administra-
ci6n. Refiri6ndo8e a las de Sanidad dice: '' Justo es, sin embargo, consignar que las
eetadfsticas de este Departamento, asf las generales de que se acaba de hacer menci6n,
como las locales del t^rmino de la Habana, formadas ^stas por la jefatura local de sani-
dad, son, acaso, lo mejor que tenemos por su esmerada confecci6n, en punto a
eetadfstica"(p. 23).

76. Bamet. Consideraciones sobre el estado sanitario de Cuba, discurso lefdo por
el Dr. Etuique B. Bamet en la sesi6n solemne de la Academia el 28 de mayo de 1913.
Anales, t. L., p. 34-43.

77. Le-Roy. Estadfstica Sanitaria y Demogrdfica de la Repdblica. Afio 1912.
Sanidad y Beneficencia, t. X, p. 1-57. La carta de remisidn de este informe anual
esti fechada el 15 de mayo de 1913 y publicada en castellano, ingl^ y franc66.

78. Guiteras. Estudios demogr^cos. Aclimataci6n de la raza blanca en los triSpi-
COB. Trabajo presentado a la Academia el 27 junio 1913, Anales, t. L, p. 98-118;

454 PBOCEEDIKOS SEOOKB PAN AMERIGAl!^ 8GIEKTIFIC C0K6BESS.

Samdad y Beneficencia, t. X, p. 284-305, aqui en castellano y en ingl^. Consdlteee
la di8CiiBi6n de este trabajo en la Academia por loe Dies. Carloe de la Tone, Joige
Le-Boy y Joan Santos Fernandez, Anales, t. L., p 9^97.

79. Barr^i^. Estndios m^dico-legales. El suicidio en la Habana en el afio de
1912, por el Dr. Antonio Barrens, Be\ . M^. Cubana, t. XXII, p. 315-341; y foUeto.

80. Le-Roy. La Sanidad en Cuba, sus progreeoe. Cuba Contempor^Lnea, t. Ill,
p. 46-63; Sanidad y Beneficencia, t. X, p. 218-283, aqul en castellano, ingl^ y fianc^
Parte de este trabajo aparece publicado con el titulo "Public Health" en la obia
editada en Londres, '' XX Century impresions of Cuba,'* London, p. 137-142.

81. Villuendas. Algunos estudios sobre fiebre amarilla, poi el Dr. Flcvendo
Villuendas, Sanidad y Beneficencia, t. X, p. 116-179. Preeenta estadisticas de la
Habana, de la Isla de Cuba y de la de Puerto Rico.

82. Ferrer. Resultados de la inspeccidn ocular de 9,000 nifioe en la provincia de
Pinar del Rfo, por el Dr. Horacio Ferrer, Rev. de Med. y Cir. de la Habana, t. XVIII,
p. 461-474; Sanidad y Beneficencia, t. X, p. 306-325. Acompafia trece cuadios
estadfsticos.

83. Guiteras. La mortalidad en la pro. incia de Matanzas. Sanidad y Beneficen-
cia, t. X, p. 326-330. Estudia la mortalidad general y la producida por la tubercu-
losis pulmonar, la enteritis infantil, la tifoidea y el paludismo.

84. Guiteras. Sobre mortalidad infantil. Sanidad y Beneficencia, t. X, p. 429-
445. Tiene un cuadro de las ''Defundones de menos de 1 afio de edad por 1,000
nadmientos'' estudiados en los afios comprendidos desde el de 1888 hasta el de 1912.

85. Garcia Rivera. Estudio de los <n1genes y desarroUo de la fiebre tifoidea en
Pinar del Rfo. Sanidad y Beneficencia, t. X, p. 624-644. Con interesantes gr^cas
y cartogramas.

86. Guiteras. Mortalidad de nifios en la Reptiblica. Sanidad y Beneficencia,
t. X, p. 657-691, en castellano y en ingl^. Informe presentado al Sr. Secretaiio de
Sanidad y Beneficencia por el Dr. Juan Guiteras, Director de Sanidad con num^osH
grdficas y cuadros demoetrativos.

1914.

87. Le-Roy. La difteria en Cuba, Notas estadisticas. Trabajo presentado a la
Academia el 26 enero 1914. Anales, etc., t. L, p. 864-869; Rev. de Med. y Cir. de
la Habana, t. XVIII, p. 68-72.

88. Garcia Rivera. Estudio sobre los orfgenes y desairoUo de la fiebre tifoidea
en Vifiales. Sanidad y Beneficencia, t. XI, p. 157-207. Con interesantes grAficM
y cartogramas.

89. Le-Roy. La mortalidad infantil en Cuba. Notas demogr&Qcas. Trabajo [Hes-
entado a la Academia el 27 marzo 1914. Anales, t. L, p. 1024-1052; La Reforma Social,
Habana, t. I, p. 313-338; y en folleto. V^ase la discusi6n que provoc6 eete trabajo
en la Academia. Anales, t. L, p. 1018-1020. Larevista *' Vida Nueva" public6
parte de este trabajo en el t. VI, p. 128-134.

90. Le-Roy. Estadistica Sanitaria y Demogrdfica de la Repdblica. Afio 1913.
Sanidad y Beneficencia, t. XIII, p. 477-531. La carta de remisi6n de este infoime
anual Ueva fecha 20 abril de 1914, y esti publicada en castellano, ingl^ y francos.

91. Fosalba. La mortinatalidad y la mortalidad in&mtil en la Repdblica de Cuba,
por Rafael J. Fosalba. Estudio bio-social laureado por la Academia de Ciendas
M^icas, Ffsicas y Naturales de la Habana con el premio de la Academia en el con-
curso de 1914. Anales, t. LI, p. 88-445; Sanidad y Beneficencia, t. XI, p. 659-735,
t. XII, p. 60-146, 353-470 y en dos libros reimpresos de ambos peri6dicoe. Eete
trabajo, el mejor que sobre eeta materia se ha escrito en Cuba, va acompafiado de 49
cuadros estadfeticos fuera del texto y de 27 gr&ficas demostrativas.

92. Garcia Rivera. La mortalidad infantil en Pinar del Rfo. Etiologia y pro-
filaxis. Sanidad y Beneficencia, t. XI, p. 403-449. Con interesantes grdficas de-
mostrativas.

PUBLIC HEALTH AND MEDICINE. 455

93. Sdnchez de Fuentes. Mortalidad infantil en Cuba, sus causae, distribuci^n
geogrdfica, medidas profil&cticas que deben adoptane. Trabajo presentado al 3^
Oongreso M^ico Nacional, en opci6n del premio del Primer Congreso. Sanidad y
Beneficencia, t. XIII, p. 211-307. IluBtracionee de grabadoe, gr&ficas y cartogramas.

94. Le-Roy. La eetadlstica y la prensa m^dica. Trabajo preeentado al Segundo
Congreeo de la Prensa M^ica celebrado en la Habana en noviembre de 1914. Rev.
de Med. y Cir. de la Habana, t. XX, p. 334-340; Vida Nueva, t. vi, p. 267-270.

95. El incremento del cincer en Cuba. Trabajo preeentado al Tercer Congreso
M6dico Nacional celebrado en la Habana en diciembre de 1914. La Reforma Social,
t. Ill, p. 334-340; Vida Nuev**, t. VII, p. 2-7.

96. Le-Roy. Estadfstica sanitaria de Cuba. Estudio de su poblaci6n. Ponenciv
del tema ofidal del mismo tftulo, designado por el Tercer Congreso Medico Nacional,
celebrado en la Habana del 1^ al 6 de diciembre de 1914. Actas y Trabajos, 1. 1, p.
225-254. Sanidad y Beneficencia, t. XIII, p. 57fr-595.

97. Ramos. Mortalidad in&ntil en Cuba, sus causas, distribuci6n geogrdfica y
medidas profil&cticas que deben realizarse, por el Dr. Domingo F. Ramos. Sanidad
y Beneficencia, t. XIV, p. 113-189. Este interesante trabajo fu6 presentado en
opci6n al premio de la Academia en el concurso de 1914, mereciendo ser tomado en
consideracidn. Lo ilustran numerosas grdficas y cartogramas.

98. Anuario Estadfstico de la Reptiblica de Cuba, formado principalmente con
datoe lacilitados por las oficinas del gobiemo o contenidos en publicaciones oficiales.
Director: Orestes Fenara. Redactores: Joige Le-Roy, Antonio J. de Arazoza,
Joe^ P6rez Arocha, Fernando Ortiz. Secretario de redacci6n: Luis Marino P^z.
Afio I, 1914. Habana, Imp. El Siglo XX, de Aurelio Miranda, 1915, en 4^, con 191
p^iginas. Esta obra, la primera de su clase publicada en Cuba, es debida al esfuerzo
personal.

Adem^ de las contribuciones estadfstico demogrMco-sanitarias arriba enumeradas,
y de Sanidad y Beneficencia, Boletin Oficial de la Secretarla del ramo, que ha seguido
publicando los informes mensuales y anuales, sanitario demogrdficos, asi como otra
aerie de estadfsticas parciales, deben sefialarse las siguientes publicaciones, donde
06 encontrar&n datoe sobre las materias propias de cada centre.

Boletfn oficial del Departamento de Beneficencia de la Isla de Cuba. 1901-1908.

Boletfn de la Liga contra la tuberculosis en Cuba. 1902 hasta el presente.

Boletines del Centre General de Vacuna, del 1 al 9, por el Dr. Vicente de la Guardia.
1901-1908.

Boletin m^ico municipal, fundado en 5 octubre 1913 por el Dr. Joe6 A. Clark, y
dirigido por (X con la colaboraci6n del Dr. F. Llano.

Informe del Laboratorio de la Isla de Cuba, por el Dr. Manuel Masforroll. 1902-
1905.

Las memoriae del extinguido servicio de higiene especial, por el Dr. Ram6n Maria
Alfonso. Las de los Hospitales, Nuestra Sefiora de las Mercedes, No. 1, Dementes,
San L^lzaro y de la Casa de Beneficencia y Matemidad, por los respectivos directoree.

Los folletoe de la Secretaria de Gobemaci6n, donde se publican los datos de la
Direcci6n del Censo de Poblaci6n, y alteraciones de los municipios en lo refe rente a
sus respectivos territories y habitantes.

Los de la Secretaria de Hacienda, en lo que se refiere a movimiento de pasajeros
y a la inmigraci6n.

La Memoria de Estadfstica Judicial. Quinquenio del 1909 al 1913, que acaba de
dar a luz la Secretaria de Justicia. En este mismo orden de la estadfstica moral,
las Memorias del Tribunal Supremo de Justicia y de las Audiendas, con las de los
Fiscales respectivos.

Las publicaciones de la Secretaria de Instruccidn Ptiblica y Bellas Artes en lo
que a instrucci6n y eRcuelas se refieran.

456 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC 00NQBES8.

Las de la SecretaHa de Agricultura, Comercio y Trabajo, en lo que hace reladdn
con las epizootlas y con los servicios meteorol<5gico6 y climatol<5gicos.

Ocupan lugar muy sefialado en eeta dltima cuestidn las Observaciones magn^ticas
y meteorol<5gicas que anualmente publica el Observatorio del Colegio de Bel^n.

Por dltimo, deede abril de 1914 ha comenzado a publicarae ''La Reforma Social "
revista que dedica buena parte de sus columnas a estudios estadisticos de indole
diveraa.

CINCO A!}0S de DEMOGRAFiA URUGUATA.

Por JOAQUtN DE SALTERAIN,

VicepresidenU del Consejo Nacional de Eetadistica del Uruguay.

DEiiooRAFiA DEL Ubuouat, 190^1913.

poblaci6n.

(a) El movimiento habido en la poblaci6n del Uruguay, durante el espacio de tiempo,
comprendido entre los afioe 1909 y 1913, inclusives entramboe, se deduce de loi
fligiuentes guarismoe.

El dltimo Censo general efectuado el 12 de octubre de 1908, di6 un total de 1,042,686
habitantes: 861,464 nacionales y 181,222 extranjeros. En 31 de diciembre de 1908
ese total se elev6 a la suma de 1,054,190 habitantes.

Adicionando, ahora, el aumento migratorio y el producido por el crecimiento
vegetative, tenemoe, al finalizar el ano de 1913, la cantidad de 1,293,838 habitantes:
Vale decir, 251, 152 habitantes mds que los que demo6tr6 el Censo de 1908. El aumento
medio anual, por consecuencia, resulta igual a la suma de 50,230 habitantes.

^De qu6 cantidades fueron partfcipes, respectivamente, las poblaciones de los
departamentos del Interior y del departamento de Montevideo, capital del EstadoT

He aqui los dates demostrativos:

Poblaol<)n— (^enso de 1908).
Poblaci<3n— calculada en—

81 de diciembre, 1909. . . .

31 de diciembre, 1910....

Side diciembre, 1911....

31 de diciembre, 1912....

81 de diciembre, 1913 ... .

Interior.

741,174

774,183
803,705
839,385
877,426
919,833

Monte-
video.

313, Olf

321,234
339,888
338,351
855,017
374,001

Relativamente pues a las sumas obtenidas, segdn el Censo de 1908, los departa-
mentos del Interior han aumentado su poblaci6n de 1909 a 1913 en la cantidad de
178,659 habitantes, equlvalentes a un promedio anual de 35,731. Montevideo, en
tanto, y durante el mismo periodo aiunent6 el ndmero de sus pobladores ^i 60,989
m^ que los que contara en 1908, equivaliendo ese total a un prcHnedio anual de 12,197
de aumento.

Estudiando, parcialmente, la influencia que han ejercido los fac tores esenclalee
que contribuyen al incremento de la pobIaci6n, obtenemos los resultados siguientes:

Aumento,
migratorio.

Proporcidn,
pordento.

Crecimiento
vegetativo.

ProxMccfan,
por oiento.

1009

32,307
18,774
23,167
32,279
36,454

29.49
16.56
19.67
26.19
28.17

20,414
19,412
20,978
22,426
24,941

18.6)

1910

17 13

1911

17 81

1912

18.19
19.37

1913

142,981

34.09

108,171

18.21

PtTBIJO HEALTH AND MEDICINE.

457

(h) Si, dejando de lado loe movimientoe migratorioe, por considerarloe de inter^
relativo para el higienista, concretamos, imoe momentoe, nuestra atenci6n al estudio
de loe factoree que intervienen dlrectamente en el crecimiento vegetativo, vale declr,
la marcha de loe nacimlentos y el desenvolvimiento de la mortalidad, observamos:
E^ lo relativo a loe nacimientoe una elevaci6n abeoluta gradual de favorable aignificado.

Con el fin de apreciarla mejor, consideremoe la natalidad total en loe dltimoe 15 afloe
7 tenemoe:

Nacimlentos.

1899 30.719

1900 30.589

1901 31.703

1902 31.526

1903 32.600

Total 157.137

Promedio anual 31.427

1904 (guerra civil) 26. 984

1905 33.700

1906 32.578

1907 33.657

Naolmieiitot.
1908 35.520

Total 162.439

Promedio anual 32. 487

1909 35.663

1910 35.927

1911 37.530

1912 39.171

1913 40.315

Total 188.606

Promedio anual 37. 721

(c) El coeficiente medio de la natalidad, durante el tiltimo quinquenio, reeult6 igual a
SI. 78 por mil. Gonsiderando, a eu vez y como en el caeo de loe nacimientoe, el nCimero
abeoluto de lae dehincionee, durante loe iUtimoe 15 afioe, tenemoe:

Defuncionas.

1899 11.449

1900 12.878

1901 12.504

1902 13.439

1903 13.673

Total 63.943

Promedio anual 12. 788

1904 (guerra civil) 11.515

1905 13.612

1906 15.083

1907 15.561

1908.

DefnncIonM.
.... 14.421

Total 70.192

Promedio anual 14. 038

1909 15.249

1910 16.515

1911 16.552

1912 16.745

1913 15.374

Total 80.435

Promedio anual 16.087

£1 coeficiente medio de la mortalidad, durante el iUtimo quinquenio, reeult6
igual a 13.55 por mil.

(d) Para apreciar mejor el deeenvolvimiento de la poblaci6n del Uruguay, durante
loe (iltimoB cinco afioe, consider^moela parcialmente, por Departamentoe y compara-
doe el principio, con el final del perfodo aefialado, en eee caeo tenemoe:

Departamento.. \ ^^^

Pobladdn
en 1018.

Departamentos.

Poblact6n
en 1000.

Poblad^n
en 1018.

FlOTM 17,238

RfoNeero 23.276

21,161
81,007
85,151
86,284
36,806
42,851
42,503
40,503
57,146
50,600
52,704

Florida

47,558
48,400
48,666
48,787
53,800
58,007
01,556
821,224

55,483
55,678
60,175
55,285
61,470
71,513
104,801

San Joed

Artlgas...:*, ; 28,n0

TralntavTras 30.318

Salto

TacnarembO.

Malfl^iiAdo 80. A8R

MIniui. .,

Rocha 86;023

Rivera 87,146

Colonia

Canelonei

Soriano 41,617

Payiandd 42,148

Durasno 44,268

Cerro Larco 46.404

Montevideo

874,005

1,005,407

1,303,888

458 PBOGEEDINGS SECOND PAN AMERICAN SCIENTIFIC C0NGBES8.

Lo8 anterioree goariflmos demueetran im aumentx) de podtiva aigiiificaci^ en el
perfodo estudiado, en cada uno de loe diez y nueve departamentoe, en que ee halla
dividida la Reptiblica. Eae aumento, bien yidble por cierto, absolutamente pro-
poidonal para la mayorfa de loe Departamentos, alter6 el orden de importancia
num^ca que ocupaban en el aflo de 1909, en algunos pocos de loe refeiidoe.

IMPORTANOIA DE LOS DBPARTAMBNT08 SEOI^N SU POBLACI6n.

J^ 7909.— Montevideo, Canelones, Colonia, Minaa, Tacuaremb6, Salto, San Joed,
Florida, Cerro Laigo, Durazno, Paysandd, Soriano, Rivera, Rocha, Maldonado, Treinta
y Tree, Artigas, R(o N^;ro, Flores.

£n 191^.^— Montevideo, Canelones, Colonia, Minas, Salto, Paysandti, San Jos6,
Florida, Tacuaremb6, Cerro Largo, Durazno, Soriano, Rivera, Rocha, Maldonado,
Treinta y Tres, Artigas, Rfo N^;ro, Flores.

(«) Los coeficientes demogrdficos, m&ximos y minimos, parciahnente considerados,
en los Departamentos, fueron:

NATALIDAD.

Coeficientes mdximos. ^TremtA y tres, 1912, 41.26; Rivera, 1912, 38.84; Colonia,

1910, 37.96.

Coeficientes mintmot.^Rfo N^;ro, 1913, 25.60; Rfo Negro, 1912, 27.03; Rfo Negro,

1911, 27.07.

ORXOZMIBNTO VSOBTATIVO.

Coeficientes mdximos.—TTeantA y Tres, 1912, 29.43; Florida, 1913, 28.10; Canelones,
1909, 26.90.

CoefieierUes minimos.— l£onteyideOf 1910, 10.07; Montevideo, 1912, 10.45; Monte-
video, 1911, 11.80.

1CORTALIDAD.

Coeficientes nufximot.— Rivera, 1911, 20.12; Montevideo, 1910, 18.67; Artigas, 1909,
18.45.

Coeficientes minimos,— B,io Negro, 1913, 7.89; Florida, 1913, 8.19; OEUielones, 1913,
8.55.

INFECTO OONTAOIOSAS.

Coeficientes mdrtmos.— Montevideo, 1910, 22.73; Montevideo, 1909, 19.22; Monte-
video, 1911, 18.25.

Coeficientes minimos,— MsldoDBdo, 1909, 2.77; Rivera, 1912, 4.78; Rfo Negro, 1913,
5.55.

REPI^BLICA O. DEL URUOUAT.

PoblaeiSn, naamientos, matrimonios, defundones y propordoneSf por Departamentos,

Departamentos.

1009

ArtlMS

Candoiies

Cerro Largo

Colonia ,

DuraEno

Flores ,

Florida

Maldonado

Minas

Montevideo.....

Paysandti ,

Rio Negro

Rivera ,

Rooha

Salto

Pobla-
cidn.

28,710
0t,55fl

17,233

53,399
3^1,224

;tfi,023

Naci-

mien-

tos.

929
3,320
1,522
2,906
1,524

592
1,666

973
1,770
9,363
1,416

726
1,168
1,355
1,524

Pro-
porcidn,

cJento.

Matrl-
monlos.

Pro-
porcidn,

por
ciento.

32.34
36.32
82.79
37.97
34.42
34.35
35.03
31.80
38.14
29.14
33.99
31.14
81.44
37.61
31.82

124
706
207
373
216

87
291
193
295
2,299
222

92
196
177
215

4.31
7.71
4.46
6.42
4.87
5.04
6.11
6.30
5.52
7.15
5.26
3.96
5.24
4.91
4.41

Defon-
ciones.

Pro-
I)orcidn,

por
ciento.

530
863
788
660
552
246
511
324
595
6,466
543
287
596
386
758

Crecsl- ' Pro.
miento pordda.
vegeta-, por
tfvo. .ciento.

18.45 I
9.42
15.79 !
11.36 I
12.46
14.27
10.74
10.59
11.14 I
17.01 '
12.88 '
10.18 ,
16.04
10. n I
15.47

399

2,463

789

1,546

973

346

1,155

649

1,176

8,897

878

488

672

960

771

18.80
36w90
17.00
96.61
21.96
2a 07
34.26
31.21
22.00
12.13
20Ln
90.96
15.89
36.89
15.84

PUBUC HEALTH AND MEDICINE.
REPIJbLICA O. del URUGUAY-ContliHia.

459

Pohladdn, nacimientOBf matrimonioSy defunciones y proporciones, por Depitrtament

Contintia.

Departamentos.

1909

San Josd

Soriano

TacuaiemlM3

TreintayTres...

Total.

1910

Arttois

Caneiones

CeiTO Largo

Colonia

Duramo

Floras

Florida

lialdonado

Minas

Honto video

Paysandt^

Rio Negro

Rivera

Rocha

Salto

San Joe^

Soriano

Tacuarembd —
TreintayTres..

Total.

1911

Artigas

Caneiones

Cerro Largo

Colonia

Durasno

Flores

Florida

Maldonado

Minas

Montevideo

PaysandA

Rio Negro

Rivera

Rocha

Salto

San Jose

Soriano

Tacuarembd —
Treinta y Tres..

Total.

Artigas.
Caneiones...
Cerro Largo.

Colonia

Dnrazno

Flores

Florida

Maldonado..

1912.

Pobla-
cidn.

48,400
41,617
48,787
30,318

1,096,407

29,622
94,521
47,645
60,442
45,028
18,080
49,229
31,818
55,097
329,888
45,127
25,452
38,227
37,483
51,002
50,034
42,758
50,104
31,436

1,133,593

31,380
97,719
49,307
63,732
47,253
19,030
51,202
33,168
67,036
338,353
48,419
27,622
39,413
39,038
54,159
61,785
44,720
51,505
32,897

Montevideo

PaysandA

Rio Negro

Rivera

Rocha

Salto

San Jos^

Soriano

Taouarembd

Treinta y Tree.

1,177,738

33,470
100,981
51,025
67, 151
48,871
20,131
53,158
34,704
59,229
355,017
52,038
29,631
41,030
40,705
56,875
63,698
46,910
63,169
34,650

Total 1,232,448

Naci-
mien-
tos.

Pro-
porcldn,

por
ciento,

1,664
1,372
1,555
1,013

35,663

962
3,479
1,321
2,294
1,444

588
1,732
1,069
1,806
9,486
1,387

689
1,093
1,362
1,545
1,740
1,398
1,517
1,015

35,927

997
3,484
1,624
2,168
1,693

552
1,902
1,091
1,940
9,824
1,365

748
1,339
1,323
1,608
1,?37
1,407
1,631
1,207

Matri-
monioe.

34.38
32.96
31.87
33.41

32.65

Pro-
porddn,

por
ciento

366
211
181
141

6,591

32.47
36.80
27.72
37.96
3L64
32.62
36.18
33.59
32.77
28.75
30.73
27.07
28.59
36.33
30.29
34.77
32.69
30.27
32.28

31.68

31.77
35.66
32.93
33.86
33.71
29.00
37.14
32.89
34.01
29.08
28.19
27.07
33.97
33.89
29.69
33.54
31.46
31.66
36.69

37,630 31.86

1,034
3,657 '
1,681
2,340
1,601

621
1,840 '
1,092
2,040
10,049
1,462

801
1,694
1,381
1,723
1,712
1,614
1,090
1,480

114
769
196
319
223
76
294
218
340
2,496
172
110
174
177
201
392
195
209
143

6,818

124
785
281
334
211

81
286
204
304
2,581
186

86
209
227
208
322
173
210
156

6,967

7.56
6.07
3.71
4.66

6.01

3.84
8.13
4.11
6.27
4.88
4.20
5.97
6.85
6.17
7.66
3.81
4.32
4.55
4.72
3.94
7.83
4.66
4.17
4.54

6.01

3.95
8.03
5.69
6.24
4.46
4.25
5.56
6.16
6.32
7.62
3.84
3.11
6.30
6.81
3.84
6.21
3.86
4.07
4.74

6.91

39,171 31.78

3.76
8.07
6.68
6.80
8.74
4.81
6.07
6.28
6.26
7.94
4.03
3.00
6.46
6.70
4.66
6.57
4.60
4.90
4.09

6.11

Defun-
ciones.

Pro-
porcidn,

yor
ciento.

585
613
697
369

15,249

639
1,024
590
860
593
250
565
348
617
6,162
552
221
621
412
783
615
747
709
407

16,616

543
926
606
711
606
242
569
381
641
5,829
698
286
793
406
788
626
641
870

16,652

12.08
14.72
14.28
11.84

13.92

18.19
10.83
12.38
14.22
12.99
13.82
11.47
10.93
11.19
18.67
12.23
8.68
13.62
10.99
15.35
12.29
17.47
14.16
12.94

14.66

17.80
9.47
12.29
11.16
12.86
12.71
11.11
11.48
1L23
17.22
14.41
10.35
20.12
10.46
14.54
12.08
14.33
16.89
11.73

14.05

459 I
1,029 I
688 I
698 I
717
254
627
367 I
681
6,836 ,
646
263

447 !
799 I
533 I
528 <
759;
410

13.71
10.19
13.48
10.82
14.67
12.61
11.79
10.57

9.80
17.84
10.47

8.87
17.30
10.98
14.04

9.92
11.25
14.27
11.88

16,746 ! 13.68

Creci-
miento
vegeta-
tive.

1,079
759
858
664

20,414

423

2,455

731

1,434

851

338

1,167

721

1,189

3,324

835

468

572

950

762

1,125

651

806

608

19,412

454
2,658
1,018
1,447
986
310
1,333

1,299
3,995
667
462
546
915
820
1,111
766
761
821

20,978

675

2,628
993

1,647
884
367

1,222
725

1,459

3,n3
917
538
884
934
924

1,179
986
931

1,020

Pro.

porcldn

por
ciento.

22.29
18.23
17.68
2L67

18.68

14.27
26.97
16.34
23.72
18.65
18.69
23.70
22.66
21.68
10.07
18.50
18.38
14.96
25.34
14.94
22.48
16.22
16.12
19.34

17.12

14.46
26.17
20.64
22.70
20.84
16.29
26.08
21.40
22.77
1L80
13.77
16.72
13.85
23.43
15.14
21.45
17.12
14.77
24.95

17.81

17.17
25.03
19.46
24.62
18.06
18.23
22.98
20.89
24.63
10.46
17.62
18.16
21.54
22.94
16.24
2L96
21.01
17.61
29.48

22,426! 18.19

460 PROCEEDINGS SECOND PAN AMERICAN SCIENTinO CONGRESS.
REPUBI.ICA O. DEL URUGUAY— ContlnAa.

Pohlaci&n, nacimientoSy Tnatrivionios, defuncUmes y proporcianes, par Departamentoi—

Continda.

Departamentos.

1918.

Art leas

Caneiones

Cerro i/argo....

Colonla....^

Duraxno

Floras

Florida

Haldonado

Hinas

Montevideo

Paysandd

Rio Negro

Rivera

Rocha

Salto

San Jo94

Soriano

Tacuarembtf . . .
Trelntay Tres.

Total

Pobla-
ddn.

.161
:>91
,794
, 12
J190
, S61
32

.03

:»51

.175

jl73

, -93

, •.!85

,L»4

1,293,838

Naci-
mien-
toe.

Pro-
porcidn,

por
ciento.

1,101
3,587
1,757
2,359
1,652

571
2,012
1,126
2,046
10,422
1,536

817
1,436
1,404
1,778
1,749
1,590
2,050
1,322

40,315

Matri-
monloa.

28.76
34.36
33.28
32.98
32.59
26.98
86.29
31.01
33.27
27.86
26.87
25.60
33.78
33.15
29.54
31.41
32.06
37.06
36.43

31.16

152
630
286
877
225

96
297
218
257
2,756
184

95
397
240
260
286
243
262
169

7,3

Pro-
porddn,, Defnn-

por i clones,
ciento.

4.82

6.03

5.41

5.27

4.43

4.53

5.35

6.00

4.18

7.36

8.21

2.97

6.98

5.66

4.32

5.13 I

4.89

4.73

4.65

445
893

549
257
454

314
512
5,824
581
252
679
474
744
490
547
650
404

5.66 15,374

Pro-

porci6ii,

por

liento.

12.65
8.55
13.88
8.73
10.83
12.14
8.19
8.64
8.32
15.67
10.16
7.89
15.97
11.19
12.36
8.80
11.02
11.75
11.13

Creci-

miento

vegeta-

tivo.

Pio-
porckSiif

por
ciento I

656

2,694

1,077

1,734

1,103

314

1,558

812

1,534

4,596

955

565

757

930

1,034

1,259

1,043

1,400

918

11.88 24,941

18.66
25.80
20l40
24.34
31.75
14.88
38.10
22.36
34.95
12.29
16.71
17.70
17.81
21.95
17.18
32.61
31.08
35.33
35.39

19.27

P0BLACI6N, NACnCIENTOS, MATRIM0NI08 DEFUNCI0NE8 Y PR0P0RCI0NE8, QUIN-

QUENIO 1909-1913.

1909

1,095,407
1,133,593
1,177,738
1,232,443
1,293,838

35,663
35,927
37,530
39,171
40,315

32.55
31.68
31.86
31.78
31.16

6,591
6,818
6,967
7,541
7,330

6.01
6.01
5.91
6.11
5.66

15,249
16,515
16,552
16,745
16,374

13.92 20,414
14.56 19,412
14.05 i 20,978
18.58 ' 22,426
11.88 1 24,941

18.61

1910

17.12

1911

17.81

1912

18.19

1913

19.27

Total

188,606

31.78

35,247

5.94

80,435

13.65 !l08,171

18.38

PXTBUO HKALTH AND MEDICINE.

461

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464 PROCEEDINGS SECOND PAN AMEKIOAN SCIENTIFIO CONQBE88.

THE ACCURACY AND COMPLETENESS OP COMPILED VITAL STATISTICS
IN THE UNITED STATES.

By JOHN S. FULTON,
Secretary State Board of Health of Maryland,

For the compiled vital statistics of the United States it can not be said that they
are complete and accurate. For the annual publications of the United States Census
Bureau on mortality statistics I am boimd to say that they are the most int^-esting
statistics of the kind that I know of. For the broader uses of such statistics they are
quite reliable, exceedingly well presented, and not often much delayed in publica-
tion. The population statistics are better than the mortality statistics, and it can
be claimed for the population statistics that they are for practical purposes complete
and accurate. Not much help is furnished by the 49 sovereign States to the Census
Bureau in the matter of correcting or testing the estimates of population for inter-
censal years. Very few States undertake a census of population, and it is not sur-
prising that census estimates of local populations for intercensal years are occasionally
in significant error.

The census statements of mortality are based on transcripts of the mortality records
furnished by the States and the cities in the registration area. The so-called regis-
tration area is that part of the United States which is believed to record 90 per cent
or more of its current mortality by means of a death certificate of standard form and
contents under a State law which conforms to the essential provisions of a "Model"
form framed by the Census Bureau. Transcripts of local records are regularly sent
to the Census Bureau and these with the population figures supplied by the Census
Bureau are the materials of the census publications on mortality. Not until 1907,
nine years ago, did the registration area for deaths include as large a proportion as
half of population of the United States. At this moment it includes more than 65
per cent of the population of the country; but 60 per cent of the country's area iB
yet outside the res^istration area. The area comprises the District of Columbia, 20
States, part of another, and 42 cities in nonregistration States.

It can not yet be said confidently that the registration area will be larger each
successive year. Now and then a State drops out of the area.

Manifestly the condition of admission is not such as to assure completeness of
mortality returns. Ninety per cent of completeness can be achieved and maintained
in more ways than one. A State having several large cities where registration laws
have been effectively operated for many years can be admitted to the registration
area in spite of considerable defect of registration in its rural counties and can continue
in the registration area without much effort to improve the registration in the rural
parts of the State. It is reasonable to assume that a State newly admitted to the
registration area will be registering 90 per cent of the mortality in rural counties aft^
about 10 years.

Among the States outside the registration area are three deserving special men-
tion. Delaware, a small State and one of the oldest, was in the r^:istration area
as long as 1890, but has been a nonregistration State for about 20 years. The three
neighboring States are all in the registration area, but Delaware shows no sign of
amending her ways in the matter of mortality registration.

Illinois, in contact with five registration States, has never been a r^;istration State.
Illinois is the home of the American Medical Association, the richest and most powerful
medical association in the world.

Alabama is a nonregistration State. All of the public-health functions of the State
of Alabama were conferred more than 30 years ago upon the organized medical pro-
fession, the State Medical Society becoming an official body. "Mortuary Statistics"
were published in the early years, but when Jerome Cochran died registration could
not survive.

PUBUC HEALTH AND MEDICINE. 465

I mention these two States, Illinois and Alabama, for the encouragement of those
who believe that the sanitary destinies of a people may be left very largely to the
good will and intelligence of the medical profession.

In 1912, Dr. Cressy L. Wilbur, posted the States of South Carolina, Georgia, and
Arkansas as three Southern States offering least encouragement to hope that they
might become registration States. South Carolina is perhaps in a fair way now, having
had two years' experience with an unsatisfactory law. If I should have to pick the
eventual tailenders on present indications I should select Geoigia, with Delaware
the only likely competitor.

The principal obstacle to the progress of mortality registration in the United States
is the battered, stupid, unconquerable delusion that local conditions necessitate
radical differences in legislation on every subject. It is all but useless to point out
the causes of failure. Each State seems resolved on achieving success in registration
by repeating all the blimders previously repeated and again previously repeated in
other States. Only lately the State of Kentucky has become a registration State
in record time, recording both births and deaths as no State has done in anything
like so short a time. Perhaps Kentucky has quelled the home-rule hoodoo.

In using the census mortality figures one must be mindful of certain caution marks,
not too conspicuously printed by the Census Bureau. Deaths are always charged
against the locality named of the death certificate. The Census Bureau takes no
heed of item No. 18, which enables the local registrar to clear his mortality account
of deaths of nonresidents. The census officials do not redistribute deaths to the places
where the decedents were coimted among the living.

This tends to swell the apparent mortality of cities, but cities in general know how
to take care of themselves. It is possible, indeed, that the reluctance of city officials
to settle the question of a man's residence by the same criteria, whether he is living
or dead, is one of the Census Bureau's reasons for ignoring item No. 18 of the death
certificate. In recent years, however, the tendency of local registrars to shrink the
numerator and swell the denominator of the death rate formula has not been so
frequently observed.

Counties where large institutions housing numbers of nonresidents are located are
distinguished by an asterisk in the mortality reports. I am sure that some cities
supporting such institutions outside their limits add the deaths occurring there to
the intradty mortality account, but the same deaths are regularly charged by the
Census Bureau to the places where they actually occurred.

Areas in which the registration of deaths is believed to fall below the required 90
per cent of completeness are indicated by a dagger. In a report for 1913 this mark
distinguishes 94 counties in 10 registration States. I wonder if any State registrar has
ever disputed the justice of this stigma. For myself, I never had that hardihood.
Whenever the sign of the dagger has been printed against a Maryland county, the
implication has been to my mind only too true, and I can say that other daggers
might have been awarded without fear of contradiction.

The death rates published by the Census Bureau are crude rates. Occasionally
there are limited tables of corrected rates. We are not very heedful in this country
of the illusions which may be wrought by crude death rates. In the matter of age
distribution enormous differences are foimd in the populations of American States
and cities. This one item of age distribution is sufficiently variable to make com-
parisons of mortality rates between States and cities very misleading.

Remarkable differences in sex proportions are also foimd in this country, and these
are likely to deceive the unwary.

The distinction of race is a deep-cutting distinction in parts of the United States.
For States having a considerable Negro population the Census Bureau gives separate
statements for colored and white mortality.

466 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

The Census Bureau gives no account of stillbiTths and does not receive from regis-
trars full accounts of mortality of infants prematurely bom, although the bureau
desires all such records. In the returns of the Census Bureau there is probably a
considerable defect of infant mortality in the first week of life.

The Census Bureau does not r^^larly account for mortality according to occupa-
tion. The mortality report for 1908 devoted a good deal of space to this subject, but
I have never regretted the lack of such statistics in other volimies. It is very difficulty
and at present impossible, I think, to make a classification of occupations which
would satisfy those who are interested in occupational hygiene without exceeding
the liberal dimensions of Federal publication . The regional variations of employm^it
in this country are very great, and their statistical study seems to me beyond what
may be reasonably asked of the Census Bureau.

Many of us know what sacrifices were made to establish the schedule which is now
known as the international classification of causes of death. The classification ct
mortality by occupation is more difficult. The Census Bureau would probably fail
in an effort to account regularly for mortality according to occupation . On a skillfully-
abridged schedule the Census Bureau could furnish a useful annuiU statement of
occupational mortality; but the more detailed accounting should be done by local
governments according to their local requirements. Failure ought to result every
time the Federal Government tries to do for the States, or for any State, what the
States should do for themselves.

At one time it seemed possible that States and cities might attempt to evade their
own responsibility and depend upon the Census Bureau for the study of local mortality.
There are yet alive some hygienists who speak of vital statistics as *' sanitary book-
keeping," and where this view prevails it is not likely that the local statisticB, if
done elsewhere, could be done worse.

I am convinced that it is better to have the work done badly by local officials than
to have it done as well as the Census Bureau can do it. I am not aware that the
Census Bureau does any such work at this time, but such substitution of functions is
a very questionable public service and likely in the long run to do more harm than
good, especially where such assistance is furnished to health authorities. Wherever
a quantitative knowledge of population, births, deaths, and sickness is lacking; where
there is no zest for continuous study of current morbidity and mortality; there they
do not know, nor judge, but guess what has happened, what is happening, what will
happen. Hygienic undertakings, without numerical criteria, are mere adventures of
little hoya in little boats, better not out after dark.

It will be seen that the caution signs, and the reservations, necessary to be observed
when using the census mortality figures, are nearly all due to the vagaries of local
registration in the States and cities of the United States, and the Census Bureau in
setting up a fairly stout barrier around the registration area protects itself against
very defective returns.

When the accepted material of the census reports is considered in its entirety, it
is found to be free from very significant error. The standard tabulations are all in
excellent form and as complete in detail as a reasonable man can desire.

Populations, deaths, and death rates are given for white and colored, by States,
with distinction between urban and rural areas, the urban division being drawn at a
population of 10,000.

Total mortality is accounted for, by locality, and by age, for the first four years of
age, and by quinquennial age periods from 5 to 100.

Causes of death by sex and age, for the registration area, are tabulated by on^e
years to 5 years of age, and by five-year periods thereafter.

Causes of death by locality are completely tabulated for 26 causes, by days of age
for six days, by weeks for three weeks, by months for three months, and by two months
to the end of the first year.

PUBLIC HEALTH AND MBDIOHTB. 467

£iS^teeQ causes of death are tabulated by calendar months, separately, for States,
for cities of 100,000 or over, and for rural areas, with distinction of race for 4 States
and 21 cities.

Thirty-one causes of death are tabulated by subdivisioiM of the regfistiation area
down to and including counties.

Mortality figures and rates are sometimes (not regularly) given by single years of
life. We had such a table in the r^wrt of 1906, giving populaticm by single years of
age in 1900, and deaths with distinctions of sex and race, by single years to the age
of 125. For 1014 we shall have such a table by single years of life to the age of 24.

Since 1906 the Census Bureau has given a table showing average ages and median
ages at death for separate causes. The first such table gave only a few causes, but
in the 1913 report we find the average and median ages for three 8ucce«ive yean
and for each of the 189 titles of the international classification, with distinction of
sex. The calculation of these figures is quite laborious. For many id the titles the
figures are of no apparent utility. For twenty odd causes of death these figures are
very important. Among these we find a few causes of infant mortality for whidi the
median age or the average age, or both, can not be calculated becaose the divisions
of age are not fine enough. For all of the preventable diseases, statements of the
average age and median age are necessary.

The editorial treatment of the census mortality is always good and interesting.
The year's experience with the more important causes of mortality is regularly dis-
cussed, and there are always summaries of the mortality experience of several boo-
cessive yeara or comparisons of quinquennial periods.

Special studies appear from time to time, such as that on tuberculosM appearing in
the 1907 report, and such as we shall have on cancer in the 1915 report.

BIBTH REGISTRATION.

So much for population and mortality, the first two great categories in vital sta-
tistics. About registration of births, in the United States, wo know almost enoim^ to
bo ashamed of ourselves. In another year we shall know how much ashamed we ought
to be, for the Census Bureau has recently defined a r^glstcatian area for births, com-
prising the six New England States— New Y(urk, New Jersey, Pennsjdvania, Micld-
gan, Ifinnesota, and Kentucky. As recently as 1912, Wilbur said at the International
Congress on Hygiene and Demography, ''Pennsylvania is to-day the only State in
which a registration law for births has been thorou^^ily enforodd on a State-wide
basis." Obviously we have no approved criteria f(ur the admission of a State to a
provisional registration area for births. The criteria adopted are: first, the existence
of a law having approximately the merit of the so-called ''Model bill " framed by the
Census Bureau; second, the law must be regularly enforced by the prosecution of
violations; third, the recorded births during the year must exceed by a reasonable
proportion the estimated population under 1 year of age.

I am quite sure that the registration area for births will be increased in the second
year of its existence, if none of the States drop out at the end of the first year. The
registration in Maryland during the past year more than satisfies the requirements
of the "provisional" area.

It is only within the last six or eight years that a few of the most advanced
American cities learned to figure the death rate of infancy as a ratio of the dead under
1 year of age to the number of children bom aUve during the year. It is doubtful if
these latios are more accurate than those based on the estimated population under 1
year of age, but at least we are on the way to a better measure of infantile mortality.

The increased interest in birth registration in the United States, together with the
very active study of infant mortality, has brought to lig^t the interesting problem of
antenatal mortality, and created some demand for the registration and statistical study
of stillbirths. In one State any product of conception recognisable as such when

6848^—17— VOL a 81

468 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

delivered must be registered as a birth whether living or dead. There is no
arbitrary division of the period of utero-gestation to bar the registration of ante-
natal mortality, and considerable information is accumulating about comparatively
early miscarriages. It was a little surprising to find that New York City has been
registering stillbirths for some years, without regard to the period ci utero-ge8tation«
and it begins to appear possible that registration of births in the United States, thoo^
very late in arriving, may have some new and interesting features.

MORBIDITY REGISTRATION.

Fifty years ago, a country having reliable population counts and good mOTtality
registration was well started in vital statistics. In these days to have statistics of
births and deaths is to be up with the procession. But to be somewhere in the advance
it is necessary to have good morbidity registration. All of the States in the regis-
tration area for deaths have notification laws for the more important among the infec-
tious diseases.

These laws, however, are not well operated in all the States. The laws diff^ in
their character as much as in their operation. The United States Public Health
Service has framed what is known as a "model bill " for the notification of communica-
ble diseases, and a standard notification card has been adopted, with the approval of
the conference of State and Territorial boards of health. Hiis card and the model
bill name thirty notifiable diseases. The influence of the bill and the card has been
considerable, but much of the recent improvement in notification is due to ^e iBd
that the United States Public Health Service is able toprint notification cards with the
postal frank, bearing the address df any State health officer who has been designated a
collaborating epidemiologist to the United States Public Health Service. These cards
are furnished in large numbers in some States where they are distributed to physidans
and subsequently bring in reports to the collaborating epidemiologiBt. In this process
the local health officer may be wholly ignored or he may be wholly dependent upon
the central health officer, the collaborating epidemiologiBt, for official information
concerning preventable sickness in his own jurisdiction. Such an arrangement is in
ccmflict with sound theory and sound practice, but where no theory or practice exists,
no harm is done, and a surprising amount of information has been thus obtained from
territory in which there was previously no means of information nor any appreciable
desire to be informed.

For many years the United States Public Health Service has been publishing in-
f (ffmation about the prevalence ci the more important communicable diseases in the
American States and in foreign countries. Within the past 8 or 10 years this work has
been greatly improved and expanded. During the three years ended with I9I4 the
service published in its weekly reports the accounts of current morbidity furnished
by 31 States. Each year the service has tabulated these morbidity figures, by States
and by cities of 100,000 or greater population, with attack rates and fatality rates, for
18 communicable diseases.

With this experience of three consecutive years before us we contemplate, for the
first time, the possibility of defining a registration area for mcvbidity. In looking
for rational criteria the first thing that strikes us is the circumstance that the Ikt of
notifiable diseases varies from State to State. Next it is observed that some States
are quite successful with the notification of twoor three diseases, while failingunequiv-
ocally in the registration of other diseases. To distinguish fairly among the States
we should take that experience which is common to all the States; that is to say, the
notifiable diseases which occur most regularly in all the States, in sufficient number
to cause a significant mortality every year. Four acute infections satisfy this condi-
tion— ^typhoid fever, scarlet fever; measles, and diphtheria.

Examining the experience of 31 States for 1912, 1913, and 1914 we find that the
fatality of these diseases has declined from year to year, showing that notification is

PUBLIC HEALTH AND MEDIOINE. 469

more effective each year. The sicknesB from typhoid, scarlet fever, measles, and
diphtheria recorded in the three years amounts to 1,026, 528 cases, and the fatality
was 5.95 per cent. If we divided the 31 States into two groups one above and the
other below this mark, 5.95, we should distinguish the group of States best entitled
at this time to be admitted into a provisional registration area for morbidity. They
would be 14 in number, and by name as follows: Connecticut, District of Columbia,
Idaho, Kansas, Maryland, Massachusetts, MiBsissippi, Utah, Vermont, and Wash-
ington. Three of the States named are not now included in the registration area for
deaths — ^Idaho, Mississippi, and South Dakota. States which can not determine a
general mortality rate can certainly not be depended on for the fatality rate of four
causes of death. These three States should not be included in a registration area for
morbidity. The situation of several well established registration States, with re-
spect to morbidity is quite disappointing. Maine and New Hampshire are not in-
cluded, because they do not furnish morbidity returns to the United States Public
Health Service.

In four ci the older registration States, Rhode Island, New Jersey, Pennsylvania, and
Indiana, the notification of infectious diseases is shown to be defective by fatality
rates well in excess of the average rate for 31 States. Six younger States in the mor-
tality registration area, California, Colorado, Minnesota, Wisconsin, Kentucky, and
Virginia, show large defect in the registration of sickness.

Consideiing the group of 15 superior States it is interesting to note that Utah, a
vary young registration State is unequivocally best of all in the registration of sick-
nesB. Within four or five years Utah has brought the notification of infectious dis-
eases to a better status than Massadiusetts, the oldest registration State, has been
able to achieve in half a century. Some part, not all, of this superiority of Utah, i»
probably due to a provision of the notification law, which punishes a delinquent
physician by revoking his license to practice.

Morbidity registration can never be complete. Only that part of current mor-
bidity which declares itself to the diagnostic sense of physicians can be r^^istered.
It may be assumed that three-fourths of the sickness from notifiable diseases come9
under medical observation in these days, and that the proporti<ni will increase.
This part of current morbidity can be registered within a few days of its inception,,
and will be registered from the moment that health authcnities begin to exact pen-
alties for notification delinquencies.

The three tables following show the results during the three years 1912-1914.

Table I shows the morbidity of cities from four causes for each of the three year».
It will be seen that the morbidity registration of cities is better than that of the States
in which they are situated. Such is the general rule in the registration of mortality^
and we can derive a caution c<mceming morbidity regiBtrati<ni. If the admission
ci States to the registration area for deaths were conditioned on evidence that th^
mortality records exceed 90 per cent of deaths occurring, some States would be ex-
cluded. The mcnrtality registration of cities is required to give some States a tatal
registration better than 90 per cent.

That mortality registration is better in cities is only a general rule. In excep-
tional cases one finds that both births and sickness are better registered in smaUer
towns and in the country districts than in large cities. This emphasises the need of
caution with respect to divisions of the registration area, and it shows that a fatality
test, to be effective, should be made more stringent every two or three years.

Table II shows the experience of all States for each of the three years.

Table III shows the experience of each of the States with each of the four diseases,.
for all the time (three years).

It is seen that New Jersey does not register measles. The probability is that if measle»
were as well registered as the other three diseases, the fatality figuve would have been^
under 6.96. It also suggests that there might be some advantage in using a single:
disease, typhoid fever, as a general test of efficiency of registration.

470 PBOOEEDINOS SECOND PAN AMEBIOAK SOIEKTIFIO OOKQBB88.

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472 PBOGEEDINGS SEOOND PAN AMEBIOAN 8GIENTIFI0 C0NGBES8.

I have spoken of the three essential divisions of vital statistics, births, deaths, and
morbidity. Of the census population figures, I have spoken no criticism. Tlie popu-
lation basis is as sound and as accurate as the Federal Government can make it, and
when we have erected on this excellent foundation, successful registration of births, of
(deaths, and of communicable diBeases, we shall have established a first tripos of vital
statistics.

I hand you a summary of three years' experience in morbidity registration for 31
States, asking you not to refer to this summary in criticism of a paper which I expect to
publish in about three months, which will considerably extend the figures here shown.
These figures are perfectly sound and they show that the States concerned are register-
ing each year a larger proportion of their current morbidity.

Dr. WiLBUB. Mr. Chairman, may I make a correction in what ^p-
pears to be a Ubel by the speaker on a Federal State? I imderstood
him to say that in his judgment the three States Delaware, Georgia,
;and Alabama had be^i the most backward States and would be the last
to have accurate r^istration of vital statistics.

Dr. Fulton. I said I would bet on Georgia being tail-ender.

Dr. WiLBUB. And the next ?

Dr. Fulton. Delaware.

Dr. WttBUB. And the next?

Dr. Fulton. I have no third.

Dr. Wdlbub. I have here very fortunately a letter which was
addressed to me at Albany by Dr. A. E. Frantz, secretaiy of the
State Board of Health of Delaware, on an entirely different subject.
I sent him a little pubUc comfort card, and he wrote expressing his
approval, and added, without any question on my part:

The birth, death, marriage, morbidity and mortality registration in Delawve is now
-almost perfect. I believe that with our system, we have in Delaware the fullest regis-
tration of births, deaths, and marriages of any State in the United States. Of coufse
^e are small, but if we were a hundred times as large, it would simply mean one hun-
dred times the work.

The Chaibman. I beUeve that ends the program for the day. We
liave at least 30 minutes in which we can have a discussion of any
subject that the congress sees proper to take up. Shall we take it up
by number, or have you some other method ?

A Mbmbeb. Is the meeting open for general discussion, or merdy
for discussion of the papers presented ?

The Chaibman. I think the meeting is open for discussion in refer-
ence to the subjects we have before us. Dr. Hurty, have you some-
thing to say ?

A Mbmbeb. Mr. Chairman, in the hope that I may help Dr. Hurty
out, I move that we spend a few minutes in discussion directly or
indirectly connected with the subjects treated in the papers.

The Chaibman. The motion is made that the meeting be oi>en for
discussion of the subjects presented in the papers read, or of matters
directly or remotely connected with them. Is there a second ?

The motion received a second and was carried.

PUBUO HEALTH AND MEDICINE. 478

The Same Mbmbsb. I should Uke to ask a question that has a
direct bearing on the reporting of morbidity. I am interested in the
ways for the prevention of general paralysis of the insane, which we
know is caused by syphilis. I should like to ask the speaker whether
in laws requiring the reporting of morbidity he would think it prac-
ticable to require the reporting of cases of syphilis.

Dr. Fulton. Propositions to report syphihs and the other venereal
diseases are very frequently made, and the people who make them
r^ularly encounter a reluctance on the part of health officers to
extend the requirements of morbidity registration. The business of
registering sickness has now advanced so far that we do not write
our laws with special reference to cholera, plague, and other diseases
which appear once in a generation, but with special reference to
diseases always present — ^typhoid fever, diphtheria, measles, malaria,
etc. Now, we have some thirty-odd communicable diseases, acutely
dangerous, which we must handle. There is a proposition to record
occupational diseases, to record cancer, and to renter cases of vene-
real disease. With respect to the venereal diseases in question I
should say that the nature of those diseases is such, or the opinion in
which they are held by society is such, as to bring them under that
one legal restraint to sickness rc^tration, the protected professional
communication. I do not know whether that barrier can be broken
down with respect to syphilis and gonorrhea. It might, but it has
not been completely broken down with respect to such diseases as
diphtheria and typhoid fever, and when it comes to a study of gen-
eral paralysis of the insane, desirable as it is to renter syphilis, it
will probably be a good many years before syphilis and gonorrhea are
commonly included among the notifiable diseases. The public atti-
tude toward these two diseases in America is such that they would
be considered privileged information, not to be placed at the com-
mand of health authorities.

Mr. J. M. Gillette. I should like to ask the gentleman who has just
spoken how generally physicians refuse to report on venereal diseases.

Dr. Fulton. I do not know. I have no experience.

Mr. Gillette. I happen to be on the board of health of my city
as a member of the city council. Our physicians have absolutely
refused to report such cases, saying that where professional privacy
is invaded they draw the line. We can not get a report. I was
wondering how widespread that condition is.

Dr. HuRTT. I should like to say that New York City requires that
the births shall be reported within 10 days after their .occurrence and
New York State 5 days. In Pennsylvania it is [addressing Dr. Batt]
5 days?

Dr. Batt. Ten days.

Dr. HuBTT. Indiana requires 36 hours, or the doctor's or midwife's
fee becomes illegal. Dr. Wilbur says that 36 hours is unreasonable.

474 PROOEEDINQS SEOOITD PAN AKBBIOAK 8CIBKTIFIC OONOBE88.

I should like to know why. If it is going to be reported at all — and
it does not take more than three to five minntes — why shouldn't it
be done immediately) That law in Indiana was put on the books
by lawyers. It was originally written five days, but the lawyers and
two ex-judges in the legislature said that if births were to be reported
they should be reported immediately and not wait five days. Now,
Dr. Wilbur says it is unreasonable. I should like very much to hear
why.

Dr. Wilbur. In theory it may not be tmreasonable, but with
respect to practical enforcement of law I think it is. I do not think
a law should have a provision that one can not expect to see enforced
in each and every case. Now, it seems to me that in the country,
especially where the means of communicatk>n are sometimes not
good, where the physician or midwife may be some distance from the
registrar, and there may be storms, etc., to cause delay, it may be
difficult to m^ke out a certificate of Inrth and file it with the local
registrar in 36 hours. Of course they might drop it in the post-office
box, but that is not sufficient in New Yoric. We have had experience
with it in New York. Some people induced the administration some
years ago to adopt a 36-hour limit, bui it was not observed; there
were thousands and thousands of cases of violation. Where physi-
cians don't file in 36 hours there may be many reasonable excuses.
I have nothing against the 36-hour limit in a city, or 24 hours; in
fact, perhaps it might be desirable for many purposes to require im-
mediate notification of birth within 12 hours on a postal card, to be
followed up later by full registration, say, within 6 days. But the
point is, you should not make the limit so low that a reasonable pro-
portion of the people woxdd not support it.

AjK)ther thing, Dr. Hurty, I believe that not half of your hiribs
are actually registered in 36 hours. You may think that 90 per cent
of the births are registered in 36 hours. If you have made an actual
coimt, and have the data to show that, I shall accept your state-
ment; but without that I don't believe 50 per cent are registered in
that time.

I have made a study of it ia New York. Our limit is five days.
One month there were 1,600 reports made over 5 days after the
births had occurred; and our physicians know just as much about
the law as they do in Indiana. The only diHerence is that in New
York they don't lose the compensation, which amounts to vety
little anyway. I beUeve, if you will make a comparison for a single
month of the dates of filing and dates of birth on the certificates in
Indiana, you will certainly find that over 25 per cent, and very likely
40 or 50 per cent, file later than 36 hours or even later than 6 days.

Dr. HuKTY. I do not think the point has been made yet that
reporting within 36 hours is unreasonable. There have been some
assertions that it is not popular with the people, but our newspaper

PUBLIC HKiLLTH AKD MEDIOINE. 475

comments and our correspondents have been very favorable toward
it. And the question is always asked: ''K you are going to report,
why not immediately?'' The only objection in regard to it is that
the mother is not always prepared to name the child. The answer is,
''Send it in anyhow and we will get the name afterwards by cor-
respondence." We sent out last year something like 4,000 letters
to mothers, every one of them being exhorted to tell other women
about Uiis matter of registration, and to state that they don't have
to pay the doctors if they don^t register the births they attend within
3d hoxirs; and it has made a great deal of talk. I don't see the unrea-
sonableness of it.

Dr. TjTiLBUB. It is not imreasonable if you will show that you are
getting 00 per cent regist^ed in 36 hours. If you can do tiiat, we
might try to get our New York law amended.

Dr. HuBTY. Perhaps that is too strong a statement, but let me
tell you the basis of it. For 3 consecutive months every county
that returned a birth rate below 20 was ''combed." We sent letters
to all the trustees of the rural counties and to the accredited school
teachers that we have had accredited to us by the county 8iq>erin-
tendents, sajdng: "Search your county and we will give you a dollar
for each birth that has not been reported.^' I think there w^e 7
or 8 counties combed in that way for 3 successive months, and we
found that we were getting 90 per cent of all the births accord-
ing to that method of checking up. The school teachers, who
are Uving on possibly $35 or $40 a month, are glad to get the
opportunity to earn $5; it coimts big with them. But they didn't
send them in. They said they had searched for them but didn't
find them.

In Indiana we have over 450 centraUzed schools. They have given
up the district schools and the pupils are carried to one central
sdioolhouse. Eiight miUion dollars worth of those centralised school-
houses were built in Indiana in the last five years, and in those
townships we have an admirable chance to learn of births which have
occurred, for a teacher has only to ask the pupils, "Do you know of
any baby being born in your neighborhood ? " Upon that basis — ^it is
a good one, I know — ^we are getUng 90 per cent of the births.

And then out of the 300 babies in the baby show at Indianapolis
only 5 were not reported and those all by the same doctor; that is
rather extraordinary.

Another basis is provided by the new^aper chppings of all births
and deatJis, which we get from the cUpping bureau. We have them
all checked up by a derk engaged in doing nothing else than that.

I admit the basis is not broad, not perfectly sound to make whole-
sale deductions from, but it is something; and I really think that we
are getting 90 per cent of them.

476 PBOCEEDINGS SECOim PAN AMBBIOAN SOIEKTIFIO CONOBE88.

Dr. Fulton. One word more. I should not be sorry to lose a bet
on Delaware. I should be a cheerful loser for the sake of adding
another State to the registration area. I did not make a third choice.
If I had, it would have been Alabama, and perhaps Alabama would
have been my second choice for tail-end position. But Georgia is the
best bet. In making the choice between Alabama and Georgia for
last place, the real tailender, it is something like this: The situation
in Alabama will soon be solved; in a short time and in the course of
nature that situation will solve itself. Alabama, in my opinion,
won't be the tailender. In Georgia it is a sort of illness that
may never be fatal — something like the hookworm. The remarks
of Dr. Wilbur, myself, and others may stimulate Georgia,
Alabama, and Delaware to get out of the rut which they are
undoubtedly in.

I was sorry we could not continue the discussion this morning
about the enforcement of registration laws for deaths and for infec-
tious diseases. Dr. Wilbur is going to start his morbidity train about
the 1st of April. I don't know what his January train will teadi
him concerning registration of births, but for th^ registration of
both births and infectious diseases and for prosecutions I will prophesy
this: That before Dr. Wilbur has had a year's experience he will
begin to look with some disfavor on pleas of guilty and fines willingiy
paid. We have in Ifaryland a long Ust of pleas of guilty. In sudi
cases there is no effect of example. The physician does not tell his
most intimate friend about it, and there has been practically no pub-
licity.

I have been wishing for more than two years that the newspapers
would watch the magistrates' courts and say something about the
judgments so frequently entered against physicians. It isfi't our
business to spread news of that sort, but I doubt whether it is wise
of us to be as reticent as we are. I advise Dr. Wilbur to have a
fight. He has indicated that he is going to choose his method of
flighting, and he is very wise in doing that. We had a little fight in
the city of Baltimore recently. Within the last six months a physi-
cian chose to fight and went to the grand jury. An indictment
resulted. A notable jump in the registration of births ensued,
though the judgment of the court was in favor of the physician.

The Chaikman. I beheve this finishes the work of this subsection
of Section VIII. As chairman of that subsection, I give you my
hearty thanks for making the program so interesting and so valuable.
I am sure that the men of science will appreciate your contribution
to scientific knowledge, and that the public will feel the good of your
work in their lives and health and happiness. I am very much
obUged to you.

Thereupon, at 4:50 o'clock, the meeting adjourned.

GENERAL SESSION OF SECTION VHI.

New Ebbitt Hotel,
Thursday afternoon, December SO, 1915.

Chairman, George M. Kobeb.

The session was called to order at 1.30 o'clock by the chairman.

The Chaibbcan. The first paper on the program deals with the
medical and social problems of venereal diseases and is by Dr.
Edward L. Eeyes, jr., of New York City. This paper will be read
by Dr. William F. Snow.

PROPHYLAXIS OF VENEREAL DISEASES.
By EDWARD L. KEYBS, Ja.

A generation ago the attitude of society toward the venereal peril was traditional
and simple. In Anglo-Saxon countrieB the topic was taboo— nothing was done. In
Gennany, France, and certain Scandinavian uid Latin countries the reglementation
of prostitution was depended upon to insure regular and frequent medical examina-
tion of prostitutes, and their treatment if they were found diseased.

FhHn such small and totally inadequate beginnings the campaign against venereal
disease has spread, until it ramifies into almost every comer of the social organisation.
The civilian is now almost as interested in the topic as the military man has always
been. These diseases, which only a few years ago could not even obtain admission
to our hospitals are now recognized and combated in our charitable institutions and
prisons. Society is striving to perfect some plan whereby youth may be fortified to
resist its passion, and matrimony may be protected against befoulment by ignorance
or vice. Discussion of this once tabooed topic is heard from the pulpit as well as in
the legislative chamber.

So complete a campaign, comprising educational, medical, legal, penal, social,
and military elements, can only be summarized in the ensuing paragraphs. It may
be considered under three heads: (1) The attack upon commercialized vice; (2) the
attack upon venereal disease; (3) sex education.

COMMERCIALIZED VICE.

Prostitution is the only business that is a direct and inevitable cause of venereal
disease. Previous to the twentieth century the attempt to suppress or to regulate
prostitution has been the sole attack upon venereal disease; an effort at repression
counterbalanced by a general opinion that prostitution could not be repressed. The
futility of punishment has been nowhere better illustrated than here. The mortal
penalty of medieval times proved no more deterrent than the mild imprisonment of
modem times.

Even to-day every reformer who takes up anew the problem of the disposition of
the prostitute turns instinctively to some form of repression or segregation as the only

477

478 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONORE8S.

recourse in such a hopeless fight. But serious investigation of the problem, as crya-
talized, for instance, in Abraham Flexner's ''Prostitution in Europe/' has shown the
utter futility of all attempts at segregation and suppression.

The awakening of the average individual to a realization of this fact is nowhere
better expressed than in the oft-quoted wcHrds of Mr. Carter Harrison, at the time
mayor of Chicago:

Se^nr^tion leads to protected vice and corruption of officials. I have reached the
conclusion that my ideas of the hanaikig of the vice problem have been wrong. I
have no hesitation now in subscribing to the general mdictment of the segregaticm.
plan. Its worst aspect is the corrupting influence it exercises over the entire law-
enforcing arm of tne Government. Commercialized vice is a crime, and the only
remedy is repression. The policeman who takes graft from protected vice will soon
be taking it from pickpockets and burglars. Chica]^ is through with the segregatioii
of vice. We can never entirely eliminate prostitution in any large city, but we can
drive it to cover, and we can make it unprofitable for those who would capitalize the
weaknesses of others. Segregation, it is proven, does not segregate. There was as
much scattered vice before the segregated districts were closed as there is to-day,
^en all have been closed. Chicago is making an honest effort to hold the Bodal
evil to a minimum. So far the effoix has met with almost universal ap]>roval.

The modern plan of attacking prostitution is to attack, not its unfortunate victim,
but the actual business people who profit by their act. The business itself must be
destroyed. The best agency for the destruction of prostitution as a business is not
the unaided police force. They have no special interest in this matter; they all too
readily confess the impossibility of complete success, and thus fall into acquiescence
and the taking of bribes as an inevitable consequence.

Every large community requires the activities of a permanent, independent,
privately supported and organized vice committee. Such a committee, independent
of political affiliation and of treasury support, may be depended upon to attack seri-
ously every new form in which prostitution appears. Upon the vigilance of such a
committee and its tactfulness in dealing both with the police and with the com-
munity at large, the morals of any city must depend.

Apart from unrelenting vigilance, and a tireless effort to arouse the moral sense
of the community and to keep it aroused, the best instruments for the use of such a
morals committee are, first, a vagrancy law permitting them to deal efficiently with
individual offenders, and second, a strict enforcement of the laws recently passed in
many States to punish the promotion of vice, and third, an injimction and abatement
law whereby any citizen may make a complaint against any house of ill-fame alleging
that it does harm, not to himself as an individual, but to the commimity in general.

But though the business of prostitution may thus be repressed, it doubtlees can not
be entirely swept away, and we have, not only now but in the future, to consfd^ the
care that should be taken of the im fortunate victims of this business. The rehabilita-
tion of prostitutes on any large scale is, to all intents and purposes, a Utopian scheme.
Such prostitutes as are ordinarily captured by the police are generally either too vicious
to wish to be reformed or too feeble-minded to care. Often they are both. Another
great step in advance will have been t^en when the community shall recognize that
the prostitute must be classed, either as a victim, feeble-minded or otherwise incom-
petent, who must be properly cared for, or as a criminal preying upon society, who
must be dealt with accordingly. The view that the prostitute is a criminal is net
new. But the means of dealing with this criminal in any way other than the futile
one of fining her or locking her up foar a few days in a prison has yet to be faBy
developed.

Much temporary good may also be done by examining the blood of all proetitotss
for gonorrhea and syphilis, and confining them in institutions until treatment siiall
have rendered them, temporarily at least, no longer a source of infection, pttyvided
administrative measures to this end can be developed without involving recognitioo
or toleration of their practices.

PUBLIC HEALTH AND MEDICINE. 479

THE CONTROL OF TENBRBAL DISEASE.

The direct attack upon venereal disease consisted under the older dispensation
simply in the effort of individual physicians at obtaining a cure of individual patients
afflicted with venereal disease. Modem social science sees in the problem a threefold
one: The attempt must be made to prevent the individual from seeking out oppor-
tunities for acquiring venereal disease. If such opportunity has occurred, he must be
given some preventive treatment calculated to forestall the development of venereal
disease, and finally if the venereal disease has developed in him he must be properly
treated, and the community properly protected from contagion. The first problem
(that of preventing the occasions of infection) is the problem of sex education and of
repressing prostitution. The others (the personal prevention of infection, the treat-
ment of infection, and the protection of the community from infected persons) con-
stitute the medical problem here to be discussed. This medical problem has to be
handled by the individual physician, by the health board, by the hospital and clinic,
by the authorities of the military and naval services, and other organizations poesessing
control over large bodies of employees, and by the churches.

The individual physician, to whom a patient applies for a safeguard within a few
houre of sexual contact, will recognize that certain local treatments are calculated
to prevent infection. It may not be amiss to note, however, that individual cases have
^ proven that even the most careful and immediate application of these remedies does
not absolutely guarantee against subsequent development of either gonorrhea or
•yphihs.

The present range of health board activities in the attempt to control venereal disease
in the United States may be summed up under three heads: The prosecution of quacks;
the so-called advisory clinics, and the registration of venereal disease.

The sudden cutting of! of the supply of salvarsan, due to the present conditions of
war on the continent of Europe, has resulted in a very difficult situation which has
led at least one health ofiicer to proclaim that the Govenunent should take over the
manufacture of this drug and supply it free to all those who need it. Doubtless the
suggestion will not yet be acted upon.

The part played by the clinic and the hospital in the treatment of venereal disease
is also being developed. In the past the following curious contradictory situation
has existed in many of the cities of the United States: The regulations of most of the
hospitals prohibited the admission of infectious diseases, including therein the vene-
real diseases. Thus all men were effectively excluded . But inasmuch as the internal
complications of gonorrhea in women, such as pyosalpinx, formed a large part of the
operative material of the gynecologist no one ever thought of prohibiting the admission
o( such cases to any hospital. In many instances, indeed, the women themselves were
unaware that they were suffering from a venereal disease. A broader knowledge of
the infectiousness of venereal disease Is, however, changing the hospital's point of
view. It is recognized, for instance, that the syphilitic, however disfigured by
eruption, is no more of a danger to attendants and other patients in a hospital than is
a patient suffering from tuberculosis or typhoid fever. On the other hand, the abso-
lutely uncontrollable contagiousness of gonorrhea in little girls imder hospital and
institution conditions has led to a rigorous quarantine against this disease in all chil-
dren's institutions, whether for the well or the sick.

Out-patient clinics may be stimulated to do efficient work in two ways: First, by
th^ cooperation of the board of health in sending patients from its advisory clinic for
treatment only to those clinics that live up to a recognized standard of excellence;
second, by a federation similar to the Association of Out-Patient Clinics conducted
under the auspices of the New York Academy of Medicine, whereby the chiefs of
clinics assemble and enact regulations for the conduct of the institutions that they
represent. The fundamental requirements for clinic efficiency are laboratory diag-
nosis (spirochaeta, gonococcus, and blood examinations), the control of cures by blood

480 PBOCEEDINOS SECOND PAN AMEBIOAK SOIEKTIFIC 0ONOBE8&

examination, and, above all, the control of patients by a social service. This last
item includes not only the posting of a letter to patients who fail to return for the
continuation of treatment, but furthermore, if they n^lect to respond to a letter, it
includes the sending of a social-service worker to visit them at their homes and inquire
why they do not pursue treatment.

One would suppose that the life of such a social worker would be beset with violence
and strife; yet, curiously enough, a little tact seems to solve aU difficulties. Just as the
board of health has foimd that if a Wassermann test is i)ositive in a married man, he
can very readily be persuaded to bring his wife and children for examination, so the
social worker finds that, not only can he persuade the careless patient to return for
further treatment, but he can also obtain access to the family of this patient and
inform them directiy of the dang^n to them.

The military services of the Nation have, by their absolute control of the opportu-
nities of the men to seek occasion for sexual intercourse, a singularly good opportunity
for employing personal prophylaxis. In certain countries of Europe military inspec-
tion of licensed brothels, together with preventive treatment of soldiera exposed to
contagion, is said in times of peace to have resulted in a very low morbidity of venefeal
disease. One notes with interest, howev^, that since the beginning of the war the
efficiency of even the Crerman military medical regulations have completely broken
down under the unusual and relaxed conditions inevitable upon field work. We are
not told to what extent venereal diseases have attacked the Gennan anny, but it is
quite evident that the staff is much alarmed by the existing condition, and since all
medical regulations have failed to produce a control of venereal disease the suggestkn
has been put forward from several official quarters that much more insistance most
be placed upon the moral campaign.

The United States Army Regulations require that a soldier who has been exposed
to infection shall report for preventive treatment. Certain Army officers also conduct
a course of instruction in sex hygiene.

Conditions are much the same in the Navy as in the Army. Failure to report
exposure to sexual contact, as disclosed by the development subsequentiy of v^iereal
disease, is made a punishable offense. Formerly a package containing a preventive
treatment was also distributed to the sailors on leaving ship. The Secretary of the
Navy has disapproved of these activities as lowering the morality of the men and has
directed that there be much greater insistance upon the moral side of the campaign.

Religion has a function in the protection of society against venereal infection quite
apart from the moral influence which it can exert in supporting the campaign of sex
hygiene, for matrimony is still almost universally regarded as a sacrament and placed
under the regulation of the various churches. The protection of matrimony against
venereal disease has long been the dream of legislators. But the difficulties sunoond-
ing the general enforcement of a medical certificate preliminary to matrimony aeem
almost insurmountable in the present state of medical knowledge. Quite apart fnm
the surmountable, economic, social, and legal difficulties involved in such a law, we
must consider the perplexities of the physician. He would divide his candidates
for licenses into two classes — ^the sheep and the goats — ^the truthful and the untruthfoL
With a true history of previous gonorrheal and syphilitic infections at his disposal, a
competent physician might be expected to arrive at a correct decision with no more
than a normal allowance of human error. But the untruthful patient may totally
deceive the physician. He may have been exposed to infection a few days before the
guaranty is given and may only develop his infections subsequent to obtaining his
certificate. If syphilitic, he may, through the intelligent use of treatment, aasare
himself of a negative Wassermann reaction and the absence of all ssnnptoms for several
months; yet neglect of treatment after marriage may leave him quite as infectiooi
as any otiier victim of the disease. On the other hand, the unfortunate possessor ol
chronic syphilis with a fixed positive reaction, though entirely free fnai contagioiie-

PUBUC HEALTH AND MBDIOINE. 481

nen, would be unable to obtain a license, since under the circumstances his story
would of course obtain no credence.

On the other hand, the assumption of the requirement for a health certificate pre-
ceding matrimony by a religious organization puts the matter on an entirely different
basis. It by no means turns all the goats into sheep, but it opens up the subject in
a confidential manner between the family and their religious adviser in a way that is
calculated to appeal to the best instincts of all concerned, and to minimize the number
of the untruthful applicants. The Episcopal Church of Chicago has already inau-
gurated this requirement, with very considerable success.

8BZ EDUCATION.

The discussion of sex education has been selected as our last topic in order that we
may insist upon it as the culmination, the quintescence, indeed, of the wh6^ prob-
lem of the control of venereal diseases. We must differ fundamentally with those
who hold that the venereal disease problem is simply a i»oblem of hygiene. What
can we hope, for instance, to achieve in the control of commercialized vice unless we
attack at ^e same time the source of 'demand as well as the source of supply. Illicit
sexual relations, whether professional or casual, will always be the most important
source of venereal infection. The great advantage of eliminating pnrfessional pros-
titution appears to us to be, not so much the saving of the prostitute, for in a large
number of cases the prostitute is a professional in aU but name before she enters a
house of ill-fame. But elimination of the prostitute means the elimination of the
professional tempters of young men to vice. The public are very slow to believe
the perfectly well-established fact that wherever a number of young men are gathered
together in colleges or other associations, there will arise in the vicinity a group of
panderers, who make their living through the seduction of these young men. Elimi-
nate these professional corrupters of youth, and you have gone very far toward mini-
mizing the number of those very men who will, in future in their turn, become
seducers of women, and pander to the vices of both sexes.

Given the impossibility of totally eliminating professional panderers and i»oeti-
tutes, the need of sex education to divert the mind of youth from sexual matters,
and to strengthen them against sexual temptation, is sufficiently obvious.

The same argument holds in reference to the prevention and treatment of venereal
disease. We have already tried to show that only good morals and honesty will pro-
tect matrimony from venereal infection. It is equally true that only good morals
will protect the individual members of the conmiunity, whether male or female,
from such infection. Personal medical prophylaxis does, it is true, notably diminish
the number of infections. Yet a long experience with the histories of men who em-
ploy personal medical i»ophylaxis has shown us that they are scarcely mote immune
from infection in the long run than their fellows who do not employ these measures.
The very assumption of safety derived from prophylactic injections engenders a
carelessness that inevitably results in infection in the end.

Certain phases of the campaign against venereal disease, notably those conducted
by the health board, may, indeed, have no direct concern with morals, and since the
moral aspect of the subject is so bristling with difficulties, we can not at aU blame
those public Officials who insist upon keeping their skirts free of it. Yet the moral
question is at the center of the whole subject, and the success or failure of this cam-
paign will largely depend upon the answer which the public gives to the question,
''Can we aspire to a single Christian standard of morality? " and to that kindred ques-
tion, '*Is there a real dominant sexual necessity in the male?" If our crusade is to
succeed we must inspire our children with the aspiration to remain sexually clean.
This aspiration we can not impart unless we ourselves are fired with enthusiasm for
this result, and place real faith in the training of the will, aided by an education
calculated to increase reverence rather than to excite curiosity, supported by re-

482 PROCEEDINGS 8BOOKD PAK AMEBIOAN SOIBKTIFIO CONGBE88.

ligion, and abetted by a daily lile that distracts the thoughts from sex. UnlesB we
believe in all this, I say, our crusade is doomed to esssntial failure.

That under proper supervision and care a dean sexual life may thus be lived with-
out any detriment to health whatever by the nonnal man we must firmly believe.
When the race loses this aspiration it loses with it all hope of chastity in women as
well as in men. It condescends to the approval of trial marriages, to the tolerance
of illegitimacy, to the Micouragement of divorce. It leaves our men worse off than
they are at fMresent, and exalts for our admiration child-bearing outside of matrimony
and barrenness within it. This way lies perdition. We can not hesitate for a mo-
ment to choose between this picture and the ^imiliar one held up to us by the Chris-
tian moralist. Let virgins, male or female . continue to suffer their arid fate. Let the
wile continue to foUow her native instinct, and risk her life for the happiness of the
generation to come. Let the husband continue to riave his fife out in faithful toil
for the support at home and family. In this scheme d existence individuals may,
indeed, falter and fail, fall sick and die. But at least they fight in ibe trendies tbiat
defend their homes; they fall in defense of the ideal. Without this Christiaa mofality
there is nothing 1^ to us but blank materialistic despair. Witii it to support us, we
at least can struggle against license and promiscoity, and hope for a higher, nobto
raee in the days to come.

aUKMART.

The campaign against venereal disease may be considered under three heads: 1. The
attack upon commercialized vice. 2. The direct attack upon venereal disease. 3. Sex
education.

Commercialized vice. — Prostitution is the great cause of venereal disease. It has risen
in spite of every penal code. Segregation seems at first sight the only solution, but
this fails, for segregation does not segregate. The best agency for the destruction of the
business of prostitution is not the police force, but a permanent, independent, privately
supported and organized vice conmiittee. Each laige city should have such a commit-
tee. They must rely on an efficient vagrancy law, and an injunction and abatement
law. The former to suppress the individual prostitute, the latter to control the owners
of houses of ill-fame. What to do with the professional after the profession has been
destroyed is not yet clear.

The control of venereal diiease.— The individual must be deterred from seeking oppor-
tunities for acquiring venereal disease. This is the problem of sex education. Once
exposed, he must be given treatment to prevent the development of possible disease,
and if disease develops, he must asjaiu be treated in order to cure himself and protect
the community. These medical problems involve, not only the individual physician,
but also the health board, the hospital and clinics, the military and naval services, and
the chim:h.

Health board activities in the United States to-day include the prosecution of
quacks, the administration of an advisory clinic that afTords a diagnosis of gonorrhea
and sjrphiHs after examination of the blood, and also advises the patients who come
to it through advertisements in the newspapers, and distribute them to physicians or
clinics. The experiment of compulsory registration of veneral diseases has been made,
but only for so brief a period that we have little information as to its efficiency.

With a better understanding of the infectiousness of venereal disease, hospitals are
more liberal in their treatment of these cases, and more stringent in their quarantine
against gonorrhea in little girls.

The out-patient clinics must be equij)ped for ldb(»ratory diagnosis, and should
attempt social service.

The Army and Navy are experimenting with personal prophylaxis, and sex educa-
tion as well.

PUBUO HEALTH Al!n> MBDIOIKE. 483

Apart from its general and educational function, the church can be of great aasistance
by requiring a prenuptial guaranty of health.

8ez education. — A belief in the possibility of masculine chastity, and an aspiration to
attain this, both in ourselves and in the succeeding generation, is absolutely essential,
not only to the success of this campaign, but also to the chastity of the race.

The Chaibhan. Before proceeding with the program I will ask Dr.
Agramonte to take the chair.

Surg. Oen. Ooboas. I move, Mr. Chairman, that the resolutions
submitted by the committee on resolutions be retained by the chair
until next Wednesday morning for consideration at one time by the
congress.

The CShaibman (Dr. Agramonte). Do I understand, (}en. Goi^gas,
that you would defer the report of the committee until Wednesday!

Sui^. Oen. GoBGAS. My idea was that our committee should report
to the chair, but that the chair hold the resolutions and not bring them
up for action until Wednesday.

Seconded and approved.

The Chaibman. We shall now listen to the reading of a paper on
''Sexual education of young men as a prophylactic measure against
venereal diseases/' by Dr. Alfredo Pirsico, Montevideo, Uruguay.

educaciOn sexual de LOS jOvenes como medio profilAotico de

LAS ENFERMEDADES VEN^REAS.

(BesumeD.)

Per ALFREDO P^RSICO,
Prcfwjr de la Universidad de MonU»^'deo, Vruguay,

El autor ha tenido en cuenta al emprender eite estudio y Uevarlo a cabo, sobre todo
el estado en que la profilaxia de las enfermedades vendreas, a cuya espedalidad viene
dedic^dose deede hace varioe afioe, se encuentra en su pais, el Uruguay. Cree fun-
dadamente que, por (le^gracia, la situaddn no es muy diatinta en los otroe paises de la
Am<^ca Latina, por lo que conffa en que 1^6 conclusionee a que arriba y las medidas
que propone pudieran hacerse extensivas a dichoe paises. £n lo que se refiere a los
Estados Unidos de Norte America, tiene conocimiento de los importantes trabajos
que, en contra de la propagacidn de las plagas ven^eas, han reaUzado y realizan, con
un tes6n digno del mis caluroso aplauso, mdltiples asociaciones en los dLversos estados
de la Uni6n, en algunos de los cuales, gracias a esos trabajos, una legislacidn sabiamente
hecha y juiciosamente aplicada ha permitido mejorar de un mode sensible el estado
sanitario en lo referente a las llamadas "enfermedades BOcial«is/'

Las medidas profiUctlcas empleadas hasta hoy contra las enfermedades ven^reas no
han dado desgradadamente un resultado muy halagQeilo dado que, de acuerdo con la
observacidn de todos cuantos se dedican a cuestiones de higiene pdblica, ya sean
medicos, corporaciones cientfficas, etc., el ntlmero de victimas de dichas enferme-
dades va en constante aumento, pudi^ndose afirmar que, por lo menos en los pafses
con los cualesmantenemoe correspondencia cientlfica activa, casi no llega ningtin hom-
bre a la edad madura sin haber contraido la m^ extendida de todas ellas, la blenorragia.
68436— 17— VOL ix 32

484 PROCEEDINGS SEOOim PAN AMEBICAK SOIENTIFIO OOKORE88.

Las publlcaclones m^dicas, tanto europeas como americanaa, asf nos lo demuestran.
En ]o8 Estadoe Unidos de Norte America se admite que contraen la blenorra;^ el 80
por ciento de loe jdvenes, entre los 18 y 30 afios, la sifills el 15 por ciento. En cuanto
al Uruguay, son muy raros los j6venes que escapan a la primera de dlchas afecciones,
pudi^ndose afinnar de ella que es la mis extendida de todas las enfermedades.

Los progresoB de la clinica en los tiltimos afios ban venido a dar dfa por dfa mis
importancia a la luretritis gonoc6xica por sus serias consecuencias, cuando no se la
cura radicalmente. Los ginec6logos hacen constar que del 60 al 70 por ciento de las
Intervenciones que practican en sus servicios, son el resultado de la infecci6n gono-
c6xica. Los oculistas estiman que la of talmia purulenta del reci^n nacido contiibuye
a la ceguera en la aterradora proporcl6n del 25 por ciento, en todos los pafses. En
cuanto a las consecuencias de la sffilis, serfa completamoito ocioso el insistir, tan
evidentes son los estragos que causa.

Ante estos hechos innegables cabe preguntar si las medidas higi^icas adoptadas
est^ en relaci6n con la importancia y gravedad del mal; si hay paraielismo en la
lucha que contra los flagelos que afligen a la humanidad se ha emprendido en los paises
civilizados, especialmente en Am^lca. Por poco que nos detengamos a examinar la
cue8ti6n vemos que la respuesta es negativa. Al lado de una propaganda activa e
inteligente, la mayor parte de las voces, contra la tuberculosis, el quiste hiditico, el
alcoholismo, propaganda que en el Uruguay ha Uegado a todos los rincones del pals en
forma de folletos explicativos, articulos en la prensa, conferencias de vulgarizacite
cientlfica nor personas competentes, carteles ilustrados repartidos con profusi6n, oise-
fianza en las escuelas ptiblicas, exposiciones de higiene, ete., se nota un abandono
inexplicable, iina deddia que no puede perdonarse en lo ref ^ente a la profilaxia de las
enfermedades sexuales. Se dirfa que hay temor en abordar franca y ampliamente un
problema de tan grande importancia y entretanto siguen llen^doee las salas de nues-
tros hospitales de atacados de dichas enfermedades, siguen en aumento las mutiladones
de infeUces mujeres condenadas para siempre a no poder llenar el papel primordial de
su vida; los ftervicios de g^ito-urinarios ateetados de sujetos que pagan bien caro
muchas veecs su ignorancia del peligro ven6reo, ignorancia de que no son culpables
puesto que nadie les ha ensefiado el en^nigo ni mucho menos los medios de com-
batlrlo.

Los jdvenes Uegados a la pubertad no reciben ni en sus casas ni en las escuelas la
m^ pequefia ensefiansa sobre higiene sexual. El tema no es Abordado nunca por los
padres, por considertoele delicado, los programas de ensefianza tanto primaria como
secundaria lo excluyen completamente, de una manera deliberada, y dejamos a
caigo de algdn compafiero '*m^ adelantado ** la tarea de abrir los ojos en tan trascen-
dental asunto al nuevo candldato a las pestes vendreas. Ahora bien, dicho improviflado
maestro, como se comprende f^ifanente es la persona menos indicada para desempefiar
ese cometido. Su superioridad consiste tinicamente, la mayor parte de las veces, en
haber ya contrafdo la enfermedad de la cual casi seguramente no se ha librado adn. A
penas conoce la existencia del peligro y ello de la manera menoe cientifica poaible.
Sin embargo, aunque tenemos la absoluta seguridad de que el adolescente concurriii
al sitio de peligro, exponi^ndose al contagio, lo dejamos sdlo, en la ignorancia mis
completa, librado a sus propias fuerzae, esperanzados en que la suerte lo protoja hasta
que llegue el memento en que pueda adquirir por medios indirectos e inc<xnpletos la
preparaci6n sahadora.

Este abandono del joven en la edad peligrosa ha dado y esti dando los tristes frutos
que x>alpamos diariamente, tanto en nuestras clfnicas hospitalarias c(Mno imvadas.
El autor cree haber side el tinico en el Uruguay que haya dado a un auditorio de ado-
lescentes conferencias sobre el peligro ven^reo, a iniciativa de la Asociaci6n Oristiana
de Jdvenes de MonteA ideo.

PUBLIO HEALTH AND MBDIOIKB. 486

La reglamentaciiSn de la proBtitaci6n, con la viaita m^ca obligatoria practicada
do8 veces por semana a las mujeree inscritas, no ha dado las resultados esperados. El
hecbo de que entre nosotros casi ningtin joven se libre del contagio, es la mejor prueba
del fracaso de dicha medida profildctica. Apuntamos el hecho, sin entrar a investigar
el porqu^ de dicho fracaso, taiea Mcil a mi juicio, pero que no cabrla en los estrechos
Ifmites de este resumen.

Mientras no se establezca la ensefiansa de la higiene sexual de un modo amplio en
los liceos de ensefianza secundaria, en los talleies y f&bricas, cuarteles, asodaciones
obreras, etc., pero como c<Mnplemento de la iniciada en la escuela, ya que deogracia-
damente no puede estableceree de un modo reglamentado y obligatorio en los hogares,
serin casi intitiles las medldas profil&cticas de nuestros consejos de higiene. Es necesa-
rio dar a cada uno de los j6venes en edad de contraer la enfermedad, la preparaci6n
suficiente para que tome €i mlsmo sus medidas i>ara evitar el contagio, para que se
defienda de por si. Debe conocer cuales son las enfermedades que f&cilmente se
transmiten en las relaciones de los sexos, cualessusfunestasconsecuencias, laimportan*
cia de una cura radical antes de contraer matrimonio y as! habremos colocado a las
plagas sexuales al nivel de las dem^ enfermedades contagioeas. Si hemes conseguido
ikJi brillantes resultados con respecto a estas tUtimas, hasta el punto que algunas han
casidesaparecido en las alanmantes f ormas epiddmicas en que se nos presentaban antes
7 ello debido en gran parte a la vulgarizaci6n de los principles de higiene, es 16gico
pretender que id4nticos o parecidos resultados obtendrfamos con la blenorragia y la
sifilis.

£1 autor propone como condusidn que se reconozca la utilidad de la educaci6n
sexual de los j6venes, incluy^ndola en los programas de ensefianza primaria y secun-
daria, como contribuddn eficas a la profilaxia de las enfermedades ven^reas.

The Chaibman. Inasmuch as there are several papers dealing with
the same subject, I will hold the discussion until the conclusion of the
reading of these various papers. For those of my hearers who do not
understand Spanish, I wiD read a rfeum^ of what Doctor P^rsico haa
just said. (R6sTun6 read.)

He presents this motion, which I shall try to translate:

That the congress pass a resolution that the usefulness of sexual
education in the young should be recognized and should form part
of the curriculum of primary and secondary education, as the most
e£Bicient means of preventing venereal disease in the young.

This resolution is before you for action.

C!ol. HoFP. Is there any regtdation in that country?

The Chaibman. Yes.

Col. HoFF. I move that the resolution be referred to the committee
on resolutions.

Seconded and approved.

The Chairman. We will now pass to the reading of the next paper,
by Dr. William F. Snow.

Dr. Wm. F. Snow. May I say in explanation of the subject matter
of this paper that it is built upon a program which is taking shape in
the American Public Health Association, that is, a practical program
of demonstration dealing with the venereal disease problem. The

486 PB00EEDING8 BEOOND PAN AMBBIOAN 80IENTIFI0 C0KQBE8S.

Abstract which has been handed to you has summarized under three
group headings certain measures which were adopted as a provisional
program by the administrative officers' section at the last meeting of
the American Public Health Association, in September, at Rochester,
N. Y. I would like also to say that this is essentially a reword-
ing of the measures recommended by a committee of the same asso-
ciation which, as you know, represents Canada, Mexico, Cuba,
and the United States, and presented in 1910 by a committee
of which our Dr. Kober was the chairman. In the past five years
there have been, as far as the United States is concerned, a great
many discussions here and there as to what we can do about this
question of venereal diseases, and my paper is an attempt to put in
writing some of the arguments which seemed to lead to these measures.
First of all, I would like to attempt to define or make a statement con-
cerning the words ''social hygiene," since in this country that name
has come into general use, but has no scientific reason, I suppoeet
for being appUed in this limitation to venereal disease and moral
prophylaxis.

PUBLIC HEALTH MEASURES IN RELATION TO VENEREAL DISEASES.

By WILLIAM F. SNOW,
Oeneral Secretary Amerioan Social Hygiene iittociafion.

Social hy^ene is an incluaive phrase covering activities of which the campaigns
-against venereal diseases and prostitution are only a part, but, necessarily, in past
years, the most prominent part. Eventually the social hygiene movement will
become recognized by the public as a constructive e£fort to promote all those condi-
tions of living, environment, and personal conduct which best protect the family
as an institution and secure a rational sex life for the individuals of each generation.

Prior to 1900, certain scientific and sociologic data were recorded in their bearing
on the reduction of syphilis and gonorrhea, but no effective public health measures
were instituted. From 1900 to 1912, existing facts were marshaled for educational
campaigns, and new facts of the highest in^>ortance were discovered. In the medical
fields there were added new observations of gonorrhea, its ravages, communicability,
and treatment, the discovery of the organism of syphilis in 1905, the development of the
Wassermann reaction in 1907, the preparation of salvarsan for the treatment of syphilis
in 1910, and in 1911 the successful experimental innoculation of syphilis and artifi-
cial cultivation of its organism. These advances made possible by 1912 a practical
campaign against venereal diseases as soon as public opinion should be developed in
support of it.

In the law-enforcement field, the records of the past twenty years show many per-
sistent and self-sacrificing efforts to utilize existing statutes and to devise new legis-
lative and administrative measures for the represssion of commedalized practicas
inimical to high standards of public morality and health. In the religious and ethical
fields likewise, notable efforts have been made to bring about recognition of the
importance of good environment and personal observance of moral living as forces in
any campaign for the ultimate eradication of venereal diseases and prostitution as

PUBUO HBALTH AND MBDIOINE. 487

great Bodal ills. The organization and extension of Bodal hygiene society campaigns,
and the promotion of similar work by numerous other national and State associations,
have now prepared the way for a serious attempt to deal effectively with this great
medical-sodal problem.

Syphilis and gonococcus infections are foremost among a group which may be design
nated social as well as individual disorders affecting people's lives in many tragic
ways, and thenefore to be attacked through social treatment as well as medical treat-
ment. It will be profitable to summarise at this point certain facts. Venereal dis-
eases are communicable infections due to identified organisms; their methods of
tnmflmission are known, and a practical laboratory and clinical technique has been
worked out icft diagnosing each of them; they are widely prevalent throughout the
world and are not limited to any race, sex, age, or condition of people; they find their
chief opportunity tot dissemination in the sex relations of infected individuals witb
other individuals who are susceptible; they are largely but not exclusively trans-
mitted through the promiscuous sex relations defined as prostitution and condemned
by society as harmful alike to the health, the morals, and the social progress of a people ;
recent methods of therapy make practicable the shortening of the period of infectivity
and improve the chances of ultimate recovery of the patient submitting to eariy and
thorough treatment; once contracted, they may run their course to practical recovery
with or without medical assistance, but under present conditions an unknown and
large percentage of those infected never completely regain their health or cease to be
ctRiers, and, therefore, are a continuous menace to society. Syphilis in its early-
stages is especially a public danger, while in its late manifestations the menace is
largely confined to the individual himself; gonorrhea on the contrary, while a public
danger at all times, is particularity damaging to the individual in its early acute devel-
opment and later becomes an insidious danger to those intimately associated with him.

With these general facts before us, the medical lines ci attack are clear: (1) We must
seek by cooperation with or control d the infected individual to prevent his infecting
others; (2) We must endeavor by education and administrative measures to enable
uninfected individuals to protect themselves against infection; (3) We must develop,,
so far as may become possible, the defenses of society calculated to prevent the recru-
descence of venereal diseases in any community "vi^ch is measurably reducing them.

The measures which have been advocated to meet this program may be grouped
as follows:

I. Management of existing cases.
II. Prophylactic measures.

III. Measures contributing to their reduction and ultimate eradication.

OBOUP I.

1. Frwfition of public heaUh kUwratory equipment for fite exandnatkm^ for evidenet
qf typkUii and gonococcuB trrfectunu.—So many State and municipal health laborato-
ries in the United States have now established this work that its practicability has
been demonstrated and its continuance assured. In 1914, the New York City Health
Department examined 59,614 specimens, 75 per cent of which were received from
private physicians. During the first seven weeks of operating the Wassermann lab-
oratory d the Massachusetts Department of Health (June-July, 1915) 1,451 spedmens,
from only fifteen institutions, were examined, and it was decided to extend the service
to private, charitable, and municipal hospitals and institutions and to patients of
private physicians. Nowhere has any serious difficulty arisen.

2. Frovition (^ ample fa/cUHiee at public expenee for diniad diagnoeii and advice m
oaeee of pouible typkiUe and gonorrhea. — ^Interesting and encouraging experiments in
this direction have been recently made. By the close of the current year, the New
York City Department of Health will have aided, throu£^ its advisory clinic more

488 PBOCEEDINGS SECOND PAN AMEBIOAN SCIENTIFIC CONGRESS.

than 3,000 new patients.' The Oregon State Board of Health operates a similar
department for diagnosis and personal advice, and in addition has develq>ed an exten-*
sive correspondence with persons in all parts of the State who write for infonnalioa.
More than 5,000 interviews and letters have been handled in the past four years, the
majority of individuals having applied alter seeing one of the 2,000 healthboard
venereal-disease placards posted throughout the State. With minor modificationa
of the general plan, a sufficient number of other health departments are now begin-
ning this work to insure its success in the United States.

3. Proviiion of adequate treatment of ambulatory caeee free of cost to those reqwing
public OBsiitance, — ^Having provided laboratory and clinical facilities and medical
advisers, it is essential to any effective administrative campaign that persons infected
with syphilis or gonorrhea be given proper treatment and supervision until they ara
returned to health and are no longer a source of danger to others. These may be
divided for practical purposes into ambulatory (those who may come to the physi-
<dan's office or the dispensary for treatment) and hospital cases. Medical opinion
has not been fully formulated as yet upon what should constitute admission into these
respective groups, but the prevalence of the diseases make it mandatory that the
ambulatory group be as laige as possible.

Of the ambulatory cases those who can pay for the services of private phyaiciaiiB
arerelatively of less danger to the community health than those who must depend upon
public assistance; but medical rec(»rds show how very frequently the physician ftils
to study his venereal cases and entirely neglects his responsibility for protection iA the
patient's family and of society. The highest efficiency of the private general prac-
titioner in the treatment of venereal infections must be sought, because with this more
than with any other group of ccmununicable diseases the practitioner can be util-
ized as the representative of the health department during the indefinite periods of
necessary surveillance.

Without attempting to estimate the percentage of venereal patients who can pay
lor their treatment and those who can not, it is known that the proportion of the latter
is high. It is also known that a certain percentage constitute a middle group oon^
prising those who can pay something; the evening pay clinic experiments have deouHi-
strated this fact. Admimstrative efficiency demands just as good treatment for the
indigent case as for the private pay case; administrative economy demands arrange-
ment for such partial payment as may be practicable. In all cases the interests
of good citizenship demand conditions under which the self-respect and privacy <A
the patient may be retained.

There are now being worked out in the United States a number of valuable experi-
ments in free and pay clinics for venereal diseases, and evidence is being collected
which demonstrates Uie need for the enforcement of standards for equipment, service,
and reqxiirements for discharge of venereal patients from genito-urinary and gyne-
cological clinics. A recent survey * to determine how many clinics in New York
were meeting the requirements of the Associated Out-Patient Clinics reported only 7
approved clinics for syphilis out of 27 and but 4 approved out of 26 clinics tot other

1 This nomber indaded men and women, 310 of whom came during the firtt six months in response to a
small paid advertisement of free confidential advice carried by the health department in some of the daily
newspapers publishing quack notices. These applicants for diagnosis and advice are told the nature of
venereal diseases, the dsuoger of improper treatment, and the neoessity for strict adherence to their phyal-
oians* orders. The danger of discontinuing treatment and the unreliability of the socalled aex dlieaBe
"specialists" are stated. The importance of oontinenoe for the sake of the individual and of society It
emphasized. If applicants who require treatment can not afford the services of a private physldaii, tiwy
are referred to a list of accredited oUnios— public and private— for proper attention.

• "A Survey of Veneceal CUnics in New York City and a StatisUoal Effldenoy Test," by B. 8.Barrii«er
and Philip S. Piatt, Social Hygiene, Vol. I, No. 8, published and reprinted by the American Sodal Hygiene
AssodaUon, 106 West 40th Street, New York City.

PUBLIO HBALTH AND MBDIOINB.

489

venereal diseasee. Many of these could with small effort meet the requirements,
but 12 were found hopelessly bad. Furthermore, in only two of the clinics was de-
tailed analysis of a year's records possible without a prohibitive amount of work.
The records of these two clinics showed ' for gonorrhea alone 9.7 per cent and 9.4 per
cent, respectively, dinnissed as cured. These figures are probably fairly typical
ci every part of the United States. Dr. Davis, of the Boston dispensary, reported
11.4 per cent of 450 gonorrheal patients as cured; Dr. Sanford, of the Lakeside Hospital
dispensary, Cleveland, reported a series in which 12 per cent were cured. Equally
unsatisfactory results have been found in studies of syphilis.

4. Provisian of adequate hospital faeUUies, free of eo$t to individuaU when neeeetary,
for eypkilis and gonorrhea caeee in all stages in which hospital care is an advantage to the
patient or a protection to the public. — In a general way what has been stated concern-
ing private treatment, pay clinic, and free clinic service for ambulatory cases applies
to similar classes of hospital cases. The hospital adds chiefly a bed and the more
complete supervision possible through discipline and its organized professional and
nursing staffs. But these additions in certain manifestations of syphilis and gonococ-
cus infection make all the difference between success and failure. Many experienced
physicians believe that the intravenous administration of such remedies as salvanan
(the treatment for syphilis frequently referred to as ''606' '), when perfcnrmed outside
the hospital, is attended with serious risk to the patient. Furthermore, such treat-
ment under the adequate supervision possible in the hospital is most likely to inhibit
the transmissibility of the disease for a considerable period or even to end its develop-
ment in early cases. The treatment of many cases of gonococcus infection is surgical
and hospital care therefore imperative; but tiiere are others frequently denied admis-
sion whose prompt recovery and return to normal living and occupation without
danger to family or fellow workmen would be greatly increased by those swvices
which can be rendered only under hospital conditions.

There are other reasons why the hospital should be studied as an important tector
in the administrative control of venereal diseasse. An investigation now being con-
ducted in New York City * has shown that of 30 general hospitals only 10 receive
recognized cases of syphilis in actively infectious stages, but once admitted on some
other diagnosis 27 give care and treatment, although only 17 provide the services of a
syphilologist. Only nine receive adult cases of gonorrh^ infection needing hospital
treatment^ and two of this number specify that only surgical cases are accepted.
Three city hospitals receive and treat active gonorrhea in little girls. Thirteen of the

Clinic A.

CllnioB.

Nomber.

Feroent

Nomber.

Percent.

Patients dismissed as onrad

35
fiO
184

•.7
19.3
71.0

67
306

9.4

fHMftftfl tifMitment Inmraved

14.2

<Hmi]Nh1 treatHMiit iinhnnrffved

70.4

What this means to the pnblio can perhaps be paralleled by the spectaoolar outbreak of smallpox which
oocorred in Montreal in 1887 when the panic«tri^en Inmates of a hospital, after ezposore to anonieoof-
nixed case, were permitted by the authorities to scatter through the dty with the result that several thou-
sand persons developed the disease and many died. Outbreaks of venereal diseases are not spectacular
or sudden nor do the causal organisms find ready opportunity to attack new yictlms except through tha
intimate relations of sexual intercourse, but their insidious spread, aided by the prolonged periods of yean
during which infected individuals may be carriers makes them far more dangerous than Mwftiipff»-^ in the
development of adequate medical and social treatment of ambulatory venereal patients we have pieeented
to health departments a concrete problem for which solution is demanded by every interest, eeonomio,
social, and moral.

t A Joint investigatioo by the Bureau of Public Health and Hygiene of the Association fbr Improving
the condition of the poor and the Committee on Publio Health of the New York Academy of liedlelne.

490 PBOCEEDINGS SEOOND PAN AMBBIOAN 8CIEKTIFI0 G0KGBE88.

30 will not receive medical CMee with known complications of syphilis or gonorrhea.
Yet during the past year 2,607 syphilis cases were treated, according to the reports of
<mly 15 of these hospitals. Again it may be inferred that these conditions are prob-
ably typical of every part of the United States.

The investigatitm referred to wiU show the need of public supervision of requirements
for discharging venereal patients from hospitals. Five hospitals require before dis-
charge of a syphilitic patient three tests, technically designated as (a) healed lesions,
(6) entire diM4[>peanaice of symptoms, (c) one negative Waasermann; 13 require
none of these. One requires for the discharge of a gonorrheic patient two tests — (a)
negative complement fizaticm, (6) negative prostatic massage (for men) or negative
cervical smear (for women); 15 require neither of these. Ten hospitals refer dis-
charged oases to social service departments for some form of follow-up observatioii.
Both patioits and public will profit by the active health department supervision of
conditioas to clinic and hoepital treatment and dischaige of v^iereal cases.

5. Eastmmon o/hoipiUU $ocial $erv%ce work <o typkUii and gonococcua infection eaae$. —
The value of social service i<x dispensary and hospital cases has been generally recog-
nised ias practically every class of diseases except the venereal. To the picmeer
activities of the Bost<Hi Diqiensary in cooperation with the Massachusetts Social
Hygiene Society, the social service of the Genito-XJrinary and Syphilology Divisions
of the Massachusetts General Hospital, and the notable efforts of a few other institu-
tions, the credit is due for the application of social service to syphilis and gonococcus
infections. No unusual methods or expenditures are involved. Experienced workm
have found it possible to obtain the sociid histories desired and to secure the interested
and intelligent cocqperation of patients in implicitly obeying instructions for their own
treatment and in bringing to the dispensary other membere of their families for diag-
nosis and advice. This work La proving that in social service we have a weapon of
very great importance in the battle against venereal diseases, and in addition a service
for helpfully dealing with the personal, moral andsodal problems inevitably involved.
This latter benefit probably outweighs the medical value of social service.

GROUP n.

1. CompuUory notification of syphilis and gonococcus infection to the health department
for proper action in protecting the public, due precautions being taken to safeguard Ae
rights and privacy ^ the individuals concerned. — ^The right of society to demand the
Immediate reporting of each case of a dangerous conununicable disease to the health
authorities for such action as may be deemed necessary for public protection is estab-
lished and enfOTced for many diseases. The notification of venereal diseases ie now
required by the laws of 11 States and a number of cities, but these laws have thus
far not been enforced to any considerable extent. Partly this may be accounted for
by the difficulties which operate against all morbidity returns, but largely it is due
to three special factors: The public has been in igncnranoe of the nature and dangers
of these diseases; the physician has believed that duty to his patient bound him to
silence; and health departments have offered no practical program for dealing effec-
tively with the problems presented by each case reported. None of these difficulties
is insurmountable.

California made venereal diseases reportable by case number in Novemb^, 1910,
for the purpose of developing a basis for correspondence with physicians upon specific
cases and the problems of public protection involved. New York City requires
reports by names and addresses of all patients in public or charity hospitals and dis-
pensaries, with the purpose of supplementing the work of the medical profeasioa in
private cases, by investigation and supervision of those under treatment in insti-
tutions which could not follow up their patients. The State of Vermont has enacted

PUBLIO HBALTH AND MBDIOINB. 491

a new law ' which requires the name, address, age, and sex of each patient and provides
payment of the physician for reporting and penalty for faUure to repc»rt.

With complete notification by physicians and full cooperation with dispensaries and
hospitals, a health department is in position intelligently to direct its work of pt(h
tecting the public from all recognized cases. Ref^^ence is made below to measures
proposed for securing Information of other cases.

The logic of compulsory notification must be recognized . The desirability of proper
data and the name of each patient being filed with the health department for identi-
fication and reference in future labomtory examinations and action regardless of
whether the patient may have changed physicians is obvious. Evidence is not lacking
to prove that cases receive the best assistance and the public receives the best pro-
tection when the physician and the health department work together in full knowledge
of who the patient is, where he lives, and how he is occupied . It seems absurd to eon-
tend that health departments can not be made just as trustworthy repositories tat
personal lustories as doctors' offices, private laboratories, and nuising staffs. In time,
it is probable that public opinion will demand that the health officer, as the repre-
sentative of the people, be taken into consultation in dealing with venereal disease
patients, just as he is now taken into the confidence of physicians dealing with tubw-
culosis, typhoid fever, and other communicable diseases, which experience has shown
the private physician may treat in g^ieral practice, provided the public interest is
safeguarded through certain supervisi<m by the health department. All the general
arguments for complete reporting of other communicable diseases apply with equal
force to the venereal diseases.

2. InstmcHon of periont exposed in meawrtsfor the protection of themselvee and their
immediate aaeodates, --To the extent made possible by notification, the most impcntant
work in prophylaxis is the instruction of the persons exposed . This implies individual
instruction in accordance with the facts for each case. This in turn demands compe-
tent, tactful, sympathetic advisers, with time available for getting the facts in each
case and using them effectively with the individual. It is in this field especially that
the advisory clinic and the social service worker are needed . It has been demonstrated
that the people will accept and evesi welcome this swvice, and that administratively
and financially it is practicable.

3 . Promotion ofeonHnenee a$ the grealeiifaetor m penonal proj^laxU. — ^Turning from
the imlblem of those known to be infected, or definitely exposed, to the unknown
majority of the population who should be protected by such prophylactic measures
as they may apply continuously themselves, or by which they may be protected
through official and community action, sexual continence must be acknowledged at
the one from which the g^featest reductiGn of veneral disoisos would result — ^provided
it could be generally enforced outside of marriage. Evidence is accumulating which
shows that the formation of public opinion in favor of continence outside of marriage
is steadily gaining ground.

In 1914 a canvas of the foremost medical and scientific men of America resulted in
360 signing the following statement: "We, the undersigned, membos of the medical
profession, testify to our belief that continence has not been shown to be detrimental
to health or virility; that there is no evidence of its being inomsistent with the highest

1 8eo8. 8 and 4 of "An act for the prevention of venereal diseases/' effective as a State law, Jane, 1016, read
as follows: ** A physJdan who knows or has reason to believe that a person whom he treats or prescribes for
Is infected with either gononiiea or syphilis shall immediately report the name, address, afs, and sex of
sncii person to the secretary of the State Board of Health, for which report he shall receive the snm of S6
cents, to be paid by the State Board of Health. A physician who CaHs to make suofa report shall be flnad
not more than S200. The State Board of Health shall make and enforce such rules and regulations for the
quarantining of cases of gonorrhea and syphUls reported to It as may be deemed necessary for the protection
ofthepobUc Said board shall not disdose the names or addresses of such persons reported or treated to
any person other than a prosecating officer or in ooort on proseoutlon under this act.**

492 PBOOEEDINGS SECOND PAN AMEBIOAN SGIENTIFIG CONQBESS.

physical, mental, and moral efiBlciency; and that it ofifers the only sure reliance for
sexual health outside of marriage."

There are a few authorities who are not prepared to subscribe to this statement
in its entirety and a few who believe that harm may be done to a percentage of men and
women through rigid enforcement of sexual continence. But without disputing the
great difficulty certain individuals may encounter in personal observance of con-
tinence, it may be successfully contended that the welfare of society as a whole, of
the family as an institution, and of the children of the next generation demands such
sacrifice as individuals may have to make in the observance of continence outside d
marriage. To the argument that man is polygamous by ancestry and his nature can
not be changed, it is reasonable to point out that no one knows what may be accom-
plished by serious effort. Until very recent years the policy of silence and toleration
of extramarital sex relations, provided no public scandal ensued, has abetted the almost
universal teaching of the so-called sex necessity for men. It is a fact that women have
very laigely been held to the observance of continence until marriage. It is a fact
that men from the beginning of history have been guided by law and public opinion in
the selection of marriage mates; it is rational to believe they will be guided in the
practice of continence when they understand its importance and know public opinion
favors it.

4. Dissemination of general information concerning syphilis and gonorrhea and their
methods of transmission. — ^All the arguments which favor the dissemination of informa-
tion regarding any disease which the individual and the public may e£fectiyely
combat apply to the dissemination of information regarding venereal diseases; but it
does not follow that the same methods should be used. Without endeavoring in this
paper to discuss the details of this important factor in prophylaxis, it may be said
that, throu^ health departments and many other agencies, the work has been well
begun. The American Social Hygiene Association ^ has established a nati(mal
clearing house for information upon all such matters, and many State and city societies
have been organized to do intensive local work.

5. Utilization of approved medical prophylacHc measures under adequate restrictions and
supervision. — ^That society is not opposed to the popularization of methods for prevent-
ing the spread of diseases by means of medical applications, or even to the furnishing
at public expense and compelling the use of medical prophylactics is amply denu>n-
strated by numerous instances. The requirement of vaccination against smallpox,
the distribution of diphtheria antitoxin, the preparation and administration of anti-
rabic treatments are concrete illustrations. The opposition to medical prophylactic
measures for venereal diseases is based primarily upon the public determination to
safeguard something it holds far more precious than health, namely, the morals of the
community. The approval accorded the use of silver nitrate preparations in pre-
ventiog gonococcus infection of babies' eyes is direct evidence that objections to the
parallel preventive treatment for syphilis and gonorriiea in adults is not baaed on
medical groimds.

Where it is possible, as in the Army and Navy, for competent officers to instruct
men individually in the nature of venereal diseases and the immediate application
of medical prophylactics in the event of exposure, some reduction in their prevalence
has been obtained; and these measures combined with rigid requirements for follow-up
preventive treatment at military quarteis have very laigely reduced them. Some of
the most experienced officers, however, believe treatment as applied by the medical
staff at the military dispensary is most e£fective, and favor the use of the prophylactic
packet only by those men who are granted more than 10 hoiu^' absence and who
can not be trusted to remain continent. This is such a small number that some
officers are opposed to any recognition of self-applied medical prophylactic ]

> Amflrioui Social Hygiene Association, 106 West Fortieth Street, New York City.

PUBUO HEALTH AND MEDICINE. 493

In dvil life the difficulties of infltructing the general public in the uses and limi-
tations of self-applied medical prophylaxis are greatly increased. The moral argu-
ments against attempting any such instruction are admittedly logical and strong,
but discarding for the moment the relations of medicine to morals, there remains
the argument that such medical prophylaxis can succeed only in a percentage of
those cases in which adequate instruction has been given and the individual has
the intelligence to apply properly the medical preparations immediately or within
a few hoius after exposure. Obviously, these requirements are not likely to be met
by the immature boys, the drink-befuddled adults, the defective girls, the average
prostitutes, who constitute the bulk of the citizens to be protected. It seems appar-
ent that medical prophylaxis can wisely be made use of only under the advice of
physicians who are fully informed of the circumstances in each case and are prepared
to observe each individual imtil the danger of infection has passed.

If personal supervision by a physician is an essential for the effective use of medical
prophylaxis, it becomes imdesirable to advocate publicly such measures for attempted
application by individuals without such supervision. The private practitioner, the
dispensary officer, and the health department staff constitute the qualified persons
for the employment of medical treatment designed to prevent the development of
venereal diseases after exposure. The avoidance of exposure constitutes the only
prophylaxis which may be wisely advocated in advance of exposure, and since there
are no practical methods by which the layman can recognize persons who are infected,
this means the practice of continence prior to marriage and selection of a marriage
mate who has neither syphilis nor gonorrhea in a communicable form. The need
for ample facilities at public expense for advisory clinics and treatment of ambu-
latory cases has been previously mentioned. These facilities should be extended
to include applicants who apply immediately after exposure, as well as those who
apply when infection has reached a well-defined stage. As in the use of a medical
prophylactic for the gonococcal infection of babies' eyes, so in the conmum venereal
infections the emphasis should be placed on popularizing the need for early and
competent advice and treatment, rather than on methods of self-medication.

GROUP ni.

For the piuposes of this paper, the measiires contributing to the reduction and
ultimate eradication of venereal diseases may be passed over with enumeration of
the principal ones which every student of the venereal-disease problem must recog-
nize to be vitally important.

1. Tlte repression of proetUtUion through law enforcement, — ^It has been amply proved
that the commercialized aspect of prostitution can be eliminated by law enf<ffcement
and maintenance of public opinion persistently against its toleration.

2. The provision of ample facilities for wholesome play and recreation^ and redvxAion
of enviromnental and social conditions which encourage extramarital sex relations. —
The maintenance of playgrounds and recreation centers for people of all ages, and
the reduction of environmental and social conditions which encourage extramarital
sex relations are powerful factors in their bearing, particularly on the lessening of
those adventures in sex relations which are in no sense to be classed as prostitution.

3. The elimination of alcoholic drinks. — Careful investigation of commercialized
prostitution in over 100 cities and towns in the United States has shown that the
sale of alcoholic drinks is as much a part of the business as the immoral practices.
Every huge employer of men knows the part played by alcohol plus prostitution
plus venereal diseases in lowering the efficiency of the company's employees. The
example of Health Commissioner Goldwater in including the attack upon alcohol
among the proper functions of the New York City Department of Health is one which
should be followed ever3rwhere.

494 PROCEEDINGS SECOND PAN AMEMCAN SCIENTIFIC CONGRESS.

4. Promotion of sex education and general standards of personal conduct which art
in keeping with high moral principles. — ^The public is convinced that sex educatioo
properly given ia a neceesity. The methods have not been hilly worked out, nor
have ways of translating knowledge into action through the observance of high moral
principles been adequately developed; but most encouraging progress has been made
in both these directions by our educators and our clergy. Many strong forces are
now at work along these lines, which are in the end to be the greatest factors in the
ultimate eradication of venereal diseases. Not the least encouraging fact is that
the whole subject of sex education, prostitution, and venereal diseases has gone
through the agony of being discovered and seems to have passed into the stage wfafife
the superficial and silly reformers and "popular" lecturers can no longer get a shud-
der out of the public by their methods of dealing with it. The old silence due to
ignorance and lack of leadership has been largely replaced by the new sil^ioe due
to realization that success can and must be achieved by serious work with the indi-
viduals of each succeeding generation, and that the leaders among these — moral,
social, economic, political — ^must be taught to see this problem in its true propcvtioee
and be prepared to do their part.

5. The encouragement of early marriage c/ter maturity has been aUaintd, and promotion
of economic and social conditions conducive thereto. — The family is the unit of social or*
ganlsation upon which our Ck>venmient hae been built up, and conservatiQn of the
family is in the last analysis the goal toward which all social endeavor tends. Every
normal being passes through the changes of adolescence and at some stage of life expe-
riences the desire for a home and parenthood. If '' government for the people, by the
people, and of the people" means anything for the individual, and if the *' InalisnaMe
right to life, liberty, and the pursuit of happiness " is to mean in the future what it has
meant in the past, every effort must be made to give each normal man and woman the
opportunity to choose for themselves wheth^ marriage shall be a part of their Hie
experiences, and to make that opportunity practicable in the sense that the reqpottsi-
biUties of marriage and parenthood may be met with dignity and due regard lor the
interests of the family and of the state.

To all of these indirect measures, which in the aggregate are so vital in limiting the
extent and duration of the venereal disease campaign, the health officer and preven-
tive medicine educator should give thought and active personal support.

An increasing number of experiments are being tried along lines not (q>ecifically
mentioned in the above presentation of the program for action reported by ^e Ameri-
can Public Health Association committee. The so-called healtii certificate for mar-
riage, or "eugenic law" at itis popularly called, is one of these. The purpose of such
laws IB to protect matrimony from communicable diseases, particularly venereal die-
eases, but the administrative basis for such a law hasnot been satisfactorily developed.
Both for the sake of the contracting parties and the children who may be bom to them,
it is important to develop some plan to meet this purpose, and the private physician
and the health department cooperating with the clergy can do a great deal in safe-
guarding marriage without any law. In foreign countries, i. e. , Denmark, Norway, and
Sweden, where laws of this character have been enacted, the basic principle has been
that individuals infected with venereal diseases must not marry without the other con-
tracting party being informed and both have been given verbal warning of the dan-
gers involved.

A second type of law designed to detect and inhibit the spread of venereal infectian
is bdng seriously tried by the State of Pennsylvania and New York, Philadelphia
and other cities. The purpose is to eliminate from the occupations connected with
the preparation and serving of foods persons with a venereal disease in communicable
form. Among 40,000 examinations ^us far reported in New York, only 3) per cent
have been "found in such a state of health as to make their employment unlawful";
and this figure includes other infectious diseases in addition to the venereal. In

PUBUG HEALTH AKD MEDICINE. 495

New York, also, applicants for peddlers' licenses have been examined for venereal
inlectioii and either refused the license or given it conditionally upon submission to
adequate treatment.

As a matter not of law but of public or business policy, many irstitutions require
phyBtcal examination of employees, including tests for venereal diseases. The United
States Army and Navy endeavor to eliminate from admission applicants with venereal
infection. Railroad and other business corporations with sick-benefit and pension
■ystems, life insurance companies, and other ozganizations similarly protect them-
eel^r^es so far as practicable by examination of candidates for employment. Certain
coUegee include observation for venereal infections as a part of the required physical
examination upon entrance, and many hospitals require information upon the diag-
nosis of each patient received, refusing admission to those with venereal diseases.

Many experiments have been made and will cortinue to be made to develop effect-
ive and safe methods for immunizing against syphilis, and especially against gonorrhea,
but none of them has reached the stage of scientific recogniton which warrants dis-
cuflsion of administrative application. The methods proposed for dealing with posi-
tive cases fall into several groups.

Treatment and simultaneous release under promise to strictly obey instructions for
protection of the public health. In these, as in other infectious diseases, according to
the intelligence of the individual and his family, and the adequacy of the medical
services provided, the case could be allowed full liberty in the community or should
be kept under close supervision by the health authorities. Obviously, there are cer*
tain occupations in which an infected person may engage without endangwing othen
through the necessary relations of business— the night watchman, for example, does
not present the same occupational problem as the barber or the waiter. Quarantine or
ether form of segregation during the entire period of danger to others is impracticable
for any but the most dangerous cases. It is probable that, as the program for ad-
ministoatively dealing with venereal diseases progresses, ways for protecting the pub-
lic will be devised without unduly limiting the liberty of any but the few who,
through special circumstances or low mentality, must be properly segregated as dan-
gerous carriers. In tuberculosis, the people have decided that it \b wise to appro-
priate immense sums for sanatoria, for treatment, for labor bureaus to place conva-
lescents in occupations which will safeguard the pubUc and benefit the patient, and
tott dispensaries to begin and end the public supervision of infected individuals.
Venereal diseases constitute an equally serious problem which the public must attack
in an equally thorough manner.

Sterilisation of infected persons has frequently been advocated to the confusion of
the public-health program, as it must be evident that artificial sterility like the in-
voluntary sterility due to gonorrhea can do nothing in the campaign for prevention,
except for the next generation, by insuring that no infected children will be bom.
The advocates of a number of measures such as this are confusing the venereal-disease
problem with the application of the principles of heredity.

Another proposal which is unwise as a health measure is tiie penalising of infected
individuals. For disciplinary purposes, as in the reduction in pay in armies and
navies during the period of illnees from venereal disease, or financial reasons as in the
barring of this class of patients from medical benefits in fraternal orders, or for other
reasons, such measures may in their narrow application seem justified. But this
whole group of procedures has little to Aow as concrete evidence of being effective
against disease or even a deterrent of immoral practices.

In conclusion it must be emphasized that the public should clearly understand that
medicine and morals have a large common ground of interest in the prevention of
syphilis and gonococcus infections. Every effort should be made to develop the
same attitude toward these diseases that is manifested toward other dangerous com-
municable infections, 1. e., one of sympathy and assistance for the individual during

496 PROOEEDINGS SECOND PAN AMEBIOAN 8CIENTIFI0 00NQBB88.

illness and recovery, and searching inquiry into the source of the infection, and the
community conditions which may have contributed to the opportunity fm inlectioii.
The social ostracism often exhibited without any endeavor constructively to deal with
the problem avails nothing either for medicine or morals. It is possible to deal
scientifically with venereal diseases and at the same time to advocate that, every
individual should know that sex relations outside of marriage not only expose him
to diseases which may prove disastrous to himself and others but will unfit him for
his highest efficiency in citizenship, marriage, and parenthood, and that society has
a right to expect each man and woman to set for younger people an example ci self-
respect and self-control in accordance with the standards of moral living which the
experience and suffering of past generations have developed.

The Chairman. There is one more paper upon this subject before
we enter upon the discussion of the various papers that have been
read. This paper is by Mr. James Bronson Reynolds, of New York.

Mr. James B. Reynolds. May I offer at the outset a word of
partial explanation regarding my subject and the method of its
treatment. It is by way, in part, of a somewhat personal explana-
tion. Dr. Snow, the preceding speaker, and myself happen to be
the executive officers of the American Social Hygiene Association, a
national organization of which ex-President Eliot of Harvard has
been the president until recently when he became honorary president,
to be succeeded by Dr. Abram W. Harris, of Northwestern University.
The unique characteristic of that association is its belief that sex
problems, in their very complicated relations, may be best considered
and handled by combining interest in the medical and the legal
aspects of those problems; and therefore in our work Dr. Siow has
represented the interest of the association on the hygienic side, and
it has been my duty to represent its interest on the legal side. It
has hence been thought proper that I present a paper to you on the
international agreements for the suppression of vice.

INTERNATIONAL AGREEMENTS IN RELATION TO THE SUPPRESSION

OF VICE.

By JAMES BRONSON REYNOLDS.

As some of you are undoubtedly aware, in July, 1902, by invitation of the Fremdi
Government, representatives of fifteen European nations and iA Brazil, including
with France, Austria, Qreat Britain, Gennany, Italy, Portugal, Russia, and Spain,
assembled in Paris to oonsider the drafting of an international treaty or agreement te
the protection of women and girls against the criminal traffic known as the Tndte des
Blanches, literally, trade in white women, and translated by the British and Americaii
Governments as the ''White Slave Traffic. " The agreement, unanimously adopted,
was ratified by 10 of these nations on May 18, 1904, and later by Austria, Belgium,
Brazil, Holland, and Portugal, and its details further elaborated by a second official
conference in Paris in April, 1910. The calling and assnnbling of these confeiences

PUBLIC HBALTH AND MEDIOINB. 497

tot Una piupoee was unique in the long record of diplomacy. As the late Senator
B^irenger of France graphically stated:

Until now, international concerts, so frequent during the last half century ♦ ♦ *
have dealt solely with political interests * * ♦ or with those of an economic char-
acter. « « « But we must go back more than a centurv * ♦ * to find another
instance of an international congress being convened for a purely hiunanitarian
purpose.

Then, not the Traite des Blanches, but the Traitedes Noirs, wa^the subject of con-
sideration. The earlier agreement, inspired by the courageous and tenacious initia-
tive of William Wilberforce, far from being the fruit of concerted action, was gradually
wrested from the different Governments in bitter negotiations often backed by the
menace of force of arms. In significant contrast, the latter conference was the expres-
sion of harmonious and unanimous accord on the part of the nations represented
whose citizens and Governments alike were convinced that an atrocious evil, too long
tolerated, had assumed such alarming prop(»rtions as to place its effective suppiession
beyond the power of individual Governments. The scheme of international coopera-
tion embodied in the treaty was framed to overcome the limitations and ineffectiveness
of separate national action.

This first international conference dealing exclusively with the subject of morals,
though relating to an ancient evil, was significant of a new point of view and of a new
point of union of the peoples and of the governments of the civilized world. The
evils with which the conference dealt were envisaged as a form of slavery to which
the victims were consigned unwillingly or by deceitful representations. Once this
feature of the commerce in human flesh was made manifest the most potential forces
of Qiganized society were arrayed against it. From the first gathering in 1902 it was
made clear that war a Toutrance against the evil was the determination of all the
nations represented. Further discussions and debates at the subsequent conference
of 1910 related chiefly to the means by which the united international will might be
accomplished.

This conference of 1910 extended its interest to another phase of criminal vice,
namely, the sale and distribution of pornographic literature. As the trade m women
was shown to have increased notably with the advance of transportation facilities, so
tiie circulation of obecene literature was found to have been grcuttly extended by the
development of the international postal service. These instrumentalities utilized
by the nations for the extension of knowledge were likewise utilized by the forces
of evil for the distribution of literary garbage. Formerly the publication and sale of
pornographic literature had been local and usually more or less hidden, but under
modem conditions the field was widely extended by the greater skill and ingenuity
exercised in advertising and circulating salacious matter. Catalogues of objection-
able publications were circulated broadcast and intermediaries between pubUshers
and readers were used to promote distribution and to protect those engaged in this
demoralizing business.

America was too little represented at these congresses of the great nations of Europe.
At the congress of 1902 N(»rth America had no delegate and of South American coun-
tries Brazil alone sent a delegate. After the ratification by the leading European
nations in 1904 of the agreement of 1902, Brazil in 1905 and the United States in 1908
gave their adhesion. Aigentina also gave its adhesion, but faUed to designate, as
the treaty requires, and as the other countries have done, any authcffity to which
infonnation or inquiries for aid should be directed . Its formal adhesion was therefore
of little value.

Before 1902 the traffic was almost wholly between Europe and South America and
between Europe and North America. Since that time evidence shows that a traffic
between North America and South America has also developed, and that if the peo-

498 PBOCEEDINGS SEOOIH) PAN AMEEICAN SCIENTIFIC CONGRESS.

pies and the governments of these contin^its entertain the same abhcnrence of this
blot upon civilization, they must consider and execute measures as comprehensive
and drastic as those adopted by the concert of the European powers above named.

Before considering the details of the international agreement, a brief review of the
circumstances leading to the conference of 1902 is desirable for the better under*-
standing of the agreement itself.

It can not be alleged that the crimes with which the treaty dealt were novel in the
liistory of mankind » They were the crimes attendant upon the age-long evil of pros-
titution. Even in their most shocking form they had been many times and every-
where repeated throug^ut history. It was therefore not the novelty of the crimes
which startled public attention. It was rather the increased public sensitivmieas
regarding them, the awakened and more intelligent public conscience of the nine-
teenth oeotury, and the discovery that the purveyors of vice were executing pHms
for international businees organisation and trade of a m<»« efficient and extensive
character than had ever previously existed.

The first notable modem protest againet the international traffic was made in Eng-
land in 1880. In the autumn of that year a memorial was presented to liord Granville,
then Secretary of State for Foreign Affairs, by an influential Briti^ committee
^'formed in London for the purpose of exposing and suppresring the (then) existhig
traffic in English, Scotch, and Irish girls for the purpose of foreign prostituticm.''
It was specifically alleged that Engli^ girls were being transported to Brussels with
the connivance of Belgian officials. A declaration by the Belgian Government that
this charge was an insult to a friendly country led to the appointment of a special
commissioner to determine the truth of the allegations of the memorial. It was
generally expected that upon investigation the chaiges would completely collapse.
To the surprise of nearly all concerned, Mrs. JosejMne Butler, one of the ablest
women whom England has prodticed, fully sustained by legal evidence the allega-
tions of herself and others. Two high officials of the city of Brussels were dismissed
from office and others resigned under the exposures of the investigation. Further
inquiry was made in England by a select committee of the House of Lords, which
recommended vigorous legislative action baeed upon its findings. The delay of the
Britirii Parliament to pass this proposed legislation incited William T. Stead, then
the editOT of the Pall Mall Gazette, to iwue in 1885 a sensational document entitled
''A Maiden Tribute to Modem Babylon," in which the extensive traffic in vice
between England and the entire Continent was described by his powerful pen. The
delayed legidation was then promptly passed.

From 1885 to 1899 it wasshoiwn again and again by able and trustworthy authoritieB
of various European nations ttM not England akme, but all Etux^ furnished the
recruiting ground for the trade in women and that this international commerce was
part of carefully matured and persistently followed plans.

In 1899, at a notable gathering of rein-esentative citizens of the leading countries of
Europe assembled in London, the results of a quarter of a century of agitation regud-
ing the miserable traffic were summarized. It was made evidoit that the subjects
for commercialized debauchery, while sometimes willing, were frequently wholly
innocent and unwilling, and that whether guilty or innocent, they became helples
victims of bmtal usage because of their transportation from their home country to
countries where they were strangers. Their exploiters reckoned their increased help-
lessness, achieved through their transportation to foreign countries, as a working prin-
ciple and a highly valuable asset of their international traffic. Rumors of the exist-
ence of international syndicates of traffickers were not confirmed, but it was conclu-
sively demonstrated that a secret telegraphic code was used by the traffickers, that
procurers were in touch with the centers of supply in Europe and the centers of distri-
bution in Asia, Africa, and America. The volume of the business was impossible of
determination, but was believed to reach yearly many thousands. Well beaten
I)aths for this ill-starred commerce were found to be established from Europe to Asia,

PUBUO HEALTH AND MBDIOUinS. 499

South Africa, North and South America. It was clearly demonBtrated that the in-
creased and improved facilities of travel, the lessened cost thereof, and the better
means of international communication, all acclaimed as products of modem progress,
facilitated and increased the shocking traffic in w<nnen.

It may be noted that the title '' white-slave traffic" is the official designation used
by the British Government in its translation of the term "Tndte des Blanches." It
has been chaiged that the term was the fabrication of sensational newspaper writers
or of sentimental philanthropists of America. The charge is evidently not founded
on fact. On the contrary, the above designation evidences that at leut one of the
high contracting parties of the European congresses. Great Britain, considered that
the trade was one involving virtual slavery, while the continental countries adh^ed
to the designation Traite des Blanches, or trade in women, a term clearly implying
that the women, as objects of barter, had no free part in the transaction.

The eminent European statesmen assembled in Paris in 1902 reviewed the revela-
tions of the congress at London and were convinced that the existing laws of the gov-
ernments of the world were inadequate to effectively cope with the evils which had
been shown to exist.

The conclusions reached by the conference were contained in nine articles, the
first three of which indicate the chief aims and methods proposed for suppressing the
traffic. They read as follows:

Abticlb I. Each of the contracting governments imdertakes to establish or desig-
nate an authority changed with the coordination of all information relating to the
pocuring of women and girls for debauchery in a foreign country; this authority shall
be empowered to correspond directly with the similar department established in each
of the other contracting states.

Abt. II. Each of the governments undertakes to exercise supervision, particu-
larly in stations, harbors of embarkation and en route, for the purpose of detecting
persons in charge of women or girls intended for debauchery. For this purpose in-
structions shall DO sent to officials or oUier qualified persons to procure, within the
limits of the laws, all information leading to the detection of traffic of a criminal nature.
The arrival of peraons appearing evidently to be the principals, accomplices, or victims
of such traffic shall be reported, in each case, to the authorities of the place of destina-
tion or to theproper diplomatic or consular agents, or to other competent authorities.

Art. m. Tlie TOvemments undertake in each case, within the limits of the laws,
to obtain the declarations of women and eirls of foreisn nationalit}r who give them-
selves to prostitution, with a view to estaolish their identity and civil status and to
ascertain who has induced them to leave their country. The information obtained
shall be communicated to the authorities of the countryof origin of the said women
or fl:irls, with a view to their eventual repatriation. The govarmients undertake,
wiudn the limits of the laws and as far as possible, to confide temporaiily and with a
view to their eventual return, the victims of criminal traffic, when they are without
resources, to public or private charitable institutions or to private individuals fur-
nishing requisite guaranties. The governments further undertake, within legal
limits, to return to the country of origin, those women or girls who so desire or who
may be claimed h'yr persons having authority over them. Repatriation shall take
place only after their identity and nationality and the place and date of their arrivid
at the frontiers have been determined. Each of the contracting parties shall facilitate
transit through its territory.

Article VII is important because it defines the terms for future adhesions to the
international agreement. Nonsignatory States may give their adhesion merely by
signifying their intention to the French Grovemment througji the appropriate diplo-
matic channel, which shall then inform all the other contracting States of such adhe-
sions. I may not improperly state that in a conversation in Paris in 1914 with the
Chief of the Bureau of Treaties of the Department of Foreign Affairs I was assured
that the adhesion of any nonsignatory State would be cordially welcomed by the
French Government. From Article I we further learn that as to procedure, aside
from the formal declaration of the fact of adhesion, the sole further action dearsd
68436— 17— VOL ix 83

500 PROCEEDINGS SBOOIfJ} PAN AJiCBBICAN SOIENTIBIO C0NGBE88.

is the selection and announcement of the authority to be chaiged with the enforce-
ment of the terms of the agreement.

The important articles of the convention adopted by the white-slave conference
of 1910 in Paris provided in Articles I and II that i^dioever, "to gratify the passions
of another/' procured a girl under age, even with her consent, or whoever procured
an adult woman by fraud or violence, for immoral purposes, should be punished
though the various acts constituting the offense were committed in different coun-
tries; and furth^ that the offenses contemplated in these articles should be extra-
ditable in accordance with conventions already existing between the high contract-
ing parties.

The purposes of the agreement of 1902 were expanded by a second conference
held in Paris in 1910, dealing also with the trade in pornographic literature. The
conference announced that ''all, equally desirous of focilitating so far as their respec-
tive laws permit the interchange of information for the purpose of the discovery and
suppression of offenses relating to obscene publications, have resolved to conclude
an agreement for that purpose." Und^ the agreement the contracting Grovemments
undertook to establish an authority chaiged .to coordinate all infonnation likely to
facilitate the suppression of offenses against their internal legislation in respect to
obscene literature.

Following the convention of 1902 France, Spain, Germany, Holland, England, and
other coimtries passed legislation, and executive orders were also issued to make the
provisions thereof more effective.

Repressive action was vigorous and effective. In France in 1909 there were 93
prosecutions of 146 defendants, with 125 convictions. Senator B^renger, in that
happy period when the nations of Europe still conceded one another's good deeds,
dechured that of all the contracting Gov^imients Germany had prosecuted the offenses
named in the international agreement with the greatest vigilance and severity. In
that cotmtry in 1907 and 1908, 28 convictions were obtained and in 1909, 32 convic-
tions; and many successful repressive measures were executed. In London in 1904
4 persons were convicted for procuration or attempted procuration; in 1912, 7 were
convicted for the same offense. In 1904, 97 convictions were recorded in London
for living on the earnings of a prostitute; in 1912, 209 convictions were reported.

Two national laws were passed in 1910 in the United States in harmony with the
international agreement. Under the law known as the white-slave act there were
76 convictions in 1911; 259 convictions in 1912; 298 convictions in 1913; and 357 con-
victions in 1914 — as you see, a continued and striking increase.

The Bureau of Immigration from 1906 to 1914 showed equally vigorous activity.
Its record of cases of rejection and deportation for immoral conduct during that period
is as follows:

Rejection and deportation of aliens.

1906

1907

1908

1909

1910

1911

1912

1913

1914

Rejected:

Prostitutes and other Immoral women

Prooufers of DrosUtutes.

80
2

134
43

823
181

816
179

253
141

120

263

192

371
253

116

380
254

Deported after entry:

Prostitutes

130

Supported by the proceeds of prostitution. .

Sexually immoral alter three years' rest-
dence

215

Such is the record of the conferences held in Europe for the suppression of the trade
in women and of the sale of obscene literature; and such have been the consequent
results of European and American legislative and executive activity. Do not the
achievements of the European nations in these matters and the limited activities and

PXJBUO HEALTH A19D MEDIOINB. 501

but partial adhesion of the American countries to the agreements ratified by the
European countries force upon our attention '*a specific American problem of inter-
national law"?

Have not these 35 years of agitation and progress in Europe deep import for America?
Do any of us of the Latin Americas and of North America wish to be the dumping
ground for the moral refuse of Europe brought to us through the vilest trade in the
world? Already it is evident that traffickers who no longer do business in Europe are
finding their way to North and South America. The careful, dispassionate, and
illuminating study of the results of prostitution in Europe recently made by Mr. Abra-
ham Plexner of New York reveals the large extent to which the market for prostitutes
continues to be international, whether or not its subjects are exploited by violence
and fraud.

In the United States we are learning in our cities the cost of commercialized vice,
its corruption of our ix)]itics, the ineffectiveness of medical inspection of prostitutes,
the ravages of venereal diseases, the industrial and social losses due thereto, and the
cost of the criminality which thrives where trade in vice is tolerated . We are asking:
Are not the science of government and the progress of humanity sufiSciently advanced
that we may successfully reduce this waste, abate this criminality, better protect the
womanhood of our country, and insure stronger and more wholesome manhood?

Already we have made vigorous effort in these directions. Over 40 of our indi-
vidual States have passed white-slave laws; more than a score of our largest cities
and three of our States have made special and elaborate investigations of the vice
problem within their respective territories. The public, stimulated by these laws
and investigations, is being informed and more intelligently guided in the considera-
tion of that vital issue once buried under an approved "conspiracy of silence." We
have learned that the problem of vice in our great cities is largely a problem of foreign
women and that these foreign prostitutes are usually in a more degraded and more
subject condition than native-bom prostitutes. We believe that the presence of this
large contingent of foreign prostitutes constitutes an especial danger to public health
and that their exploiters and associates are a direct menace to law and order.

As a prosecuting attorney in New York City, it became the duty of the writer not
only to investigate local vice conditions but also the importation and exportation of
prostitutes between North and South America, and he became aware that agents were
vigorously promoting this American traffic. Could anything be more at variance with
the modem spirit of liberty and equality in both Latin and North America, from our
new estimate of the value and digrity of hiunan life, from our modem humanitarianism,
from the care exercised by our Governments for the health of their citizens and for
the general welfare and economic efficiency of their workers, than this trade in women
still allowed to thrive between our western continents because of our lack of united
effort?

Should we not, then, as did Europe, unite our interest and our effort on securing a
special American congress, to consider the agreements and conventions relating to
the trade in women adopted in Europe, the improvement of their terms, if possible,
the devising of effective machinery for the execution of the conventions approved by
such congress, and to secure the adhesion of all American countries to the agreements
adopted? Should not such a congress of the countries of Latin America and North
America be assembled in Buenos Ayres, Rio Janeiro, or Washington to treat these
problems with deliberation and thoroughness, and with the enlightenment, broad
public interest, and intelligent progreasiveness of the twentieth century?

As Europe frankly admitted the weakness of its individual Governments to cope
adequately with the evils of this traffic, may not American governments, with equal
frankness and clearness of vision, admit the inadequacy of their own individual
efforts, and by conference and by the adoption of far-sighted measures of international

602 PB00EEDINQ8 SEC01!n> FAN AMBRTOAN BClEHTIJflO C0NGBES8.

and national action promote the health of their reqwctive nations and the moral and
social welfare of their peoples?

BIBUOOBAPHT.

International Agreement for the Suppression of the White Slave Traffic, signed in
Paris, July, 1902, ratified May 18, 1904. See U. S. S. Doc. No. 214, parts 1 and 2,
61st Gong., 2d sess.

International Convention for the Suppression of the White Slave Traffic, signed in
Paris, May, 1910, ratified August 8, 1912; and

International Agreement for the Suppression of Obscene Publications, signed in
Paris, May, 1910, ratified March 15, 1911. For the convention and agreement of 1910,
see Correspondence Respecting the International Conferences on Obscene Publications
and the "White Slave Traffic," Cd. 6547, London, 1912.

Report of Mr. T. W. Snagge, British Parliamentary Papers, No. 448, of 1881, p. 115.

Report of Select Committee of House of Lords, Britisn Parliamentary Papers, No.
334, of 1882, p. 3.

Report of International Conference held in Paris, 1902, Britiah Ptiriiamentar/
Papers, Miscellaneous, No. 3, 1905, Vol. CIII, Cd. 2667.

Report on White Slave Traffic, Scotland Yard, Ixmdon, June, 1913.

Profit de kn, No. 399, Senat, 1910, Paris.

La Traite des Blanches et le Comn:^rce de TObscdnit^ R. B6renger, Revue des deux
Mondes, July, 1910.

Prostitution in Europe, Abraham Flezner, New York, 1914.

Mr. Rbtnolds. Mr. Chairman, I wish to present a resohition
which I assume will take the customary procedure. This resolution
is in respect to the suppression of vicei tiie theme of the paper just
read.^

Col. HoFF. I move that the resolution take the usual course.

Seconded.

Dr. GuTTERAS. I would like to suggest that perhaps it might be
better if we heard some discussion with regard to these resolutions
before they are sent to the committee) in order that we may hear
what the general impression is. That will help us a great deal in
coming to a conclusion.

Seconded.

Dr. Agramonte. The motion made by Dr. Gmteras is simply to
postpone the action upon CoL Hoff's motion.

Dr. GuiTBBAS. Simply to postpone it until after the discussion of
the papers.

Dr. Agramonte. These papers are now open for discussion, and
I would like to hear some more or less spontaneous remarks before I
call upon some of the gentlemen who, I know, have had experience
in the matter. Are there any remarks on the subject) If not, I'll
call upon Dr. Vaughan of the University of Michigan.

Dr. Victor C. Vaughan. Mr. Chairman, I thank you very much
for calling upon me, but I do not think I have anything especial to
say upon this subject. It is a very broad and a very important ques-
tion, and I certainly approve of the resolution. There is nothing
that is of graver importance to our society as a whole than this

1 Article 41, p. 6 of this Toloma.

PX7BIJ0 HEALTH AND MEDIOINB. 503

subject, and I believe in the discussion of it, too. I believe that a
great deal of the harm that arises from venereal diseases is due to
the fact that we have simply shut our eyes to it and will not talk
about it. People are not educated along this line. We certainly need
a great deal of education in this coimtry, and I doubt not we need it
in other coimtries.

It has been my good fortune to be connected with a very lai^e
university for a number of years, having between 6,000 and 7,000
students in attendance. Most of these are males — about 5,000 to
6,000 of them are — and I want to say that as long as we did not give
any attention along that line, venereal diseases were very common
among the male students. I want to say, since I have been called
before you, that venereal diseases do not exist, at least among the
students in this great university, to any such extent as some people
claim. I have heard it stated by pubhc speakers that 80 per cent of
the men in this country have had gonorrhea or syphilis. It is false,
absolutely false, and there is no truth in it. If that were true we
would have been a degenerate race long ago and would have fallen
out. No doubt there is much degeneracy among us.

In this community of yoimg men I have studied the venereal
diseases very carefully. I have gone to all the doctors in the place
at the end of the year and have asked them to give me the number of
students that they have treated for venereal disease. Fifteen years
ago 20 per cent of the male students in Michigan University had
either gonorrhea or syphilis. Now that we give a system of instruc-
tion— every student in the university is compelled to attend a course
of lectures on this subject — ^there has been a gradual decrease of
venereal diseases. Last year there were 37 cases among 6,600, three
cases of syphilis and 34 of gonorrhea, and at least half of those were
contracted before they came to the university.

Col. HoFF. Were those declared cases or were they found t

Dr. Vaughan. They were cases that went to the doctor. Now,
I do not suppose that I got them all, but I do not beheve that many
go through gonorrhea or syphilis without consulting a doctor.

Col. HoFF. Our experience in the Army leads to the inference that
not all men in the Army do, and I think it is a fair inference to believe
that men in civil life do.

Dr. Vauqhan. Of course, some men may have gone somewhere
else, some may have been counted twice — that is, they may have
gone to one physician for a while and then to another physician.

Now, I believe that great good has been done by education. I know
that the time was in the University of Michigan — and I know that
it is no worse than Harvard or Yale and no better than those
schools — ^the time was when a man in a fraternity did not dare not
to go to a whore house; he was not a man unless he went to such a

504 PBOGEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

place. That was the spirit among the students. And I know now
that when a man in one of these fraternities gets venereal disease,
whether he reports it or not, his colleagues report it, and they tell
him that he can not live in the house; that he must go to a hospital
or somewhere else and stay until he is well.

For ten hundred years and longer we have used the agency of
moral punishment, the fear of some infliction to come upon us in a
future life. What good has it done? We have deemed it unwise,
ungentlemanly, unladylike, to talk about venereal disease. Now, in
our section of the country at least we turned radically around and
we do not hesitate to talk about these things, both to girls and to
boys, and I think that we have abundant evidence, not that it is
done away with entirely — no, no — ^not that the greatest good has
been accomplished, but that much good has been done.

Dr. KoBER. Before Dr. Vaughan takes his seat I should like to ask
him what the revelations have been in the depcurtment of pathology.
I understand that Dr. Warthin, of the university, has made a very
extensive and thorough investigation into the post-mort^n findings,
and found evidence of an undue prevalence of syphilis in his subjects.
If Dr. Vaughan has any information on this, it would be a very
opportune time to present it.

Dr. Vaughan. Dr. Kober's question is a question rather for a
strictly medical society than for a mixed audience. I may say that
my colleague. Dr. Warthin, and I do not agree. I want to give ail
the credit for what is done in the University of Michigan in reducing
venereal disease to Dr. Warthin; he has given these lectures and he
has instructed the students as to dangers that come from venereal
disease. He and I, however, do not agree. I lecture to the giris on
venereal disease; he lectures to the boys. He says I am immoral.
I may be and I may not. I say to the girls, ''I put myself in loco
parentis to you. Suppose that you were my daughters, and that
one of you should come to me and say that you were dead in love
with a young man whom I knew to have syphilis in the worst way
possible. Would I say that you could not marry that mani No,
I would not say so. I would say that I will find out all I can about
that man. He may have sinned ignorantly, he may be a fine fellow.
I will say to him, you can not marry my daughter until you are cored
of syphiUs; when you are well, then you may."

Dr. Warthin says that is immoral. He says that no man is ever
cured of syphiUs. I say that every man or a large percentage of
men who are properly treated for syphilis are cured. He has never
been a practitioner of medicine; I have been a practitioner of medi-
cine. I have lived long enough to see the children and grandchildren
of men and women who have had syphilis, and to see them healthy,
strong individuals. That is just the difference between us. I know

PUBLIO HEALTH AND MSDIOnnfi. 505

that syphilis is a curable disease in a large percentage of cases. He
says that it is never cured. He finds the spirochete even in appcur-
ently cured cases. No doubt he is right about that. I have no right
to question it at all. But if the spirochete is there, I do not think
it is transmissible. When I have treated a girl for syphilis, known
to be syphilis, and know to-day that that girl has healthy children
and healthy grandchildren, I am convinced, Mr. President, that
syphilis in a certain percentage of cases, at least, is a curable disease,
and I am not going to cut off a yoimg man's head because he com-
mitted a sin when he did not know any better, and especially when
that sin is the result of the strongest passion and appetite that is
implanted in man.

Mr. Albert Habtmak. May I answer the very eloquent remcurks
of Dr. Vaughan t I contend that the young man before he contracts
such a disease, or at any other time, does know better. Instruction
in general in this world is too widely diffused. There is not a country
school where passages from the Bible are not read. There is no one
who does not come at sometime imder the influence of some church,
and all the churches are against sexual intercourse outside of matri-
mony. That is true from here to San Francisco. I have not yet
foimd a religious community where those ideas that are held out to
young men are not recognized. It is only the weakness of the young
men, the failure of the yoimg men to live up to the ideak that are
held before them, that brings them into contact with the kind of
women where they contract such diseases.

And may I, furthermore, with the permission of the Chair, ask for
your indu^ence concerning a su^estion that I have to make) In
the District of Columbia here, and in other cities, there is a system in
vogue that really brings the scarlet woman, the prostitute, further
down, drags her lower and lower; instead of giving her any kind of a
lift when she does come into contact with the recognized legal authori-
ties, it pulls her still further down.

I have been a poUce reporter in Chicago on the south side. We
had always news in plenty that we could not print about these bad
girls that come before the judge on the charge of soliciting. If the
judge had a fine breakfast and was feeling good he fined her SI and
costs, and if he was not feeling good it was $10 and costs, and some-
times $25 and costs; and some girls were fined all the way up to $100
and costs. As a result of that they would go into the Home of the
Good Shepherd and those good ladies would sometimes straighten
them out. A very laige percentage of them are, no doubt, redeem-
able in these institutions. But the system of taking the money from
these girls, the wages of their sin, and bringing it into the public
treasury and using it for paving the streets and laying the dust on
the street — ^that system is wrong, it is vicious. What do you think

506 FBOOEEDINGS 8B001!n> FAN AMBBIOAK SOEBimBlO C0NGBE8S.

of any man who takes S5 or $10 from the women of the streets?
What do you think of the judge who takes $10 from themt He
does not handle it himself , he says, ''$10 and costs/' and puts it down.
I have said to the judge, ''It is a disgrace," and the judge says,
"Why, Mr. Hartman, it is the law; you can change the law if you
like." Well, I can not change the law, I am only a poor police
reporter. I went around to the political bosses and I did not get a
hearing. I got as far as the secretary. You see these men's names
in the society colimms in Chicago papers. They did not care; of
course, they did not care. They have no use for poor people.
But now to the point. There has been in New York City such an

indignation against this system. Mr. wrote very beautiful

letters on that subject. He denounced the injustice of taking this
money from these poor girls, and by agreement he suspended the
system of fining for some time, until the 1st of July, 1914. A law has
gone into effect since then that no more fines should be collected in
the city of New York. Now, this bill has been drafted for the State
of New York, and with the permission of the chair I shall read
it: "An act to amend the penal law in relation to punishment of
misdemeanor." I received a letter to-day from the commissioner of
correction in New York stating that some means will be found to
introduce it into the legislature and some very strong societies are
going to be behind it.

Section 1 of the laws of 1909 is hereby amended to read as follows: ''A person con-
victed of a crime declared to be a misdemeanor, for which no other punishment ia

hereby prescribed by these statutes, is punishable by imprisonment in the

and by a . No woman convicted of being a common prostitute or of loitering

or being in the public street or soliciting for the purpose of prostitution or of frequait-
ing or residing in a disorderly house or hotise of assignation shall be punished by fine.
This act shall take effect immediately.

This is from Prof. Barchweg, of Columbia University, and must be
right. I present it to the chair that it may go on the record.

Dr. AoBAMONTE. We would be glad to hear from Maj. Lyster.

Maj. Lysteb. I would be very glad to say a word on the recent
statistics of venereal disease in the Anny, if it is of interest to you,
with reference to the prophylaxis of venereal disease. About 1910
the Army, after vainly striving to reduce the amount of venereal
disease by having the surgeons lecture and talk to the enlisted men,
had an order issued requiring physical examination twice a month.
This examination was compulsory and especial attention was invited
by the order to the mouth and feet and incidentally in this examina-
tion to the genitaUa. The mmiber of cases per 1^000 in that year
was somewhere, as I remember it, about 174. It had been higher
than that previous to that time, before the existence of compulsory

PUBUO HBALTH AND MBDICINB. 507

examination. At the same time, following the publishing of the
experiments of Metchnikoff, an effort was made to take prophylactic
measiu*es against syphilis and incidentally against gonorrhea. A rapid
reduction in the rates for admission of venereal cases followed this
campaign of combined measures. At the same time, through instruc-
tions from the War Department, the efforts in the way of educational
campaign were redoubled. Lectures were given to the men, enter-
tainments were provided for them besides those that they had before,
and games and sports were encouraged. The introduction of the
moving picture show at posts enabled them to spend more evenings
profitably in the garrison. But some of those things had been done
before that.

The rates rapidly fell. The following year, 1911, 104 admissions
per thousand for venereal disease were recorded. Then, to 112 the
following year; 85 in 1913; in 1914, a sUght increase, to 89; and
for the first six months of this year the rate was 75 per thousand.
In five years, the amount of disease known has been cut in two.
Exactly what amoxmt was attributable to the institution of the com-
pulsory physical examination we can only estimate, but there must
have been a number of cases that were unknown and that did not
seek treatment.

The matter is treated in the Army the same as any other disease.
We have no favored nation clause for any pathological organism in
the Army. They are on the same basis and the mere fact that one
of them multiphes and finds a more favorable nidus on the genitalia
rather than anywhere else is immaterial to us. Our purpose is to
maintain the physical efficiency of the soldier; and whether we do it
by reducing the amoxmt of measles or smallpox or venereal disease,
it is all one in our effort to be scientific doctors. Nevertheless, we
are trying to make a point on the moral side and with the assistance
of the chaplains and of the societies that enable us to give moving
picture shows and other forms of entertainment, with the encourage-
ment of athletics, and aU these things are working together, we hope,
for improvement. However, we are conscious, I think more now per-
haps than before, that we are dealing with the deepest seated instinct
that the human being possesses and that we are dealing with immature
men, with yoimg men. We are not dealing with middle-aged men,
whose judgment has been formed. We are dealing mostly with
boys of 21 and 22, and it is with men of that age that the armies
of the United States have always been recruited.

We have, in studying this subject, foimd through a good many
observations, running into several thousand, that among the recruits
as they are sworn in 15 to 18 per cent have a plus or double plus
Wasserman. Now you may take that as meaning that that number

608 PBOGEEDINGB SECOND PAN AMEBIOAK 80IEKTIFIC COKOBB88.

of men have syphilis, or you may take it as meaning that they merely
have positive Wassermans, but those tests have been made by experts.
Before the recruit presents himself, before he is sworn in at the
recruiting depot, he is culled from a large number of men who are
rejected for various causes, among them venereal disease. For
50,000 recruits taken .into the Army last year, 150,000 men pre-
sented themselves. Records are not kept by the Government to
show the number rejected for venereal disease, but it is well known
that these men are cautioned before they come to the recruiting
officer that men with open lesions, with acute venereal disease, are
not accepted. So what this estimate of 15 to 18 per cent plus to
double plus Wasserman means, we are hardly prepared to say, but
I think it is a very conservative estimate of the amoimt of syphilis
that we are dealing with among this class in civil life.

Medical Inspector George A. LiUno. In my capacity as a medical
inspector of the Navy, tUs subject of venereal diseases has been
imder my investigation for over a period of 28 years. Consequently
if I can not add to your fund of information from my own collection
of facts, I may briefly offer you some conclusions at which I have
arrived.

It is a good many years now since the utilitarian side of the ques-
tion first came to the attention of the medical officers of the Navy.
The damage done by venereal diseases has had the previous atten-
tion of oiir people, and efforts have been made to reduce the inci-
dence of these diseases. These efforts were at first few and far
between and for the most part desultory, consisting of instructing
the young men in the dangers of venereal disease and the manner
in which they were propagated.

Spinning with the time when the Army b^an its crusade, the
Navy adopted a method which was thorough, comprehensive and
which seemingly attained some good results. It consisted of the
methods known to you who have studied the subject, namely, the
education of the man, the imparting to him of information on the
subject, the suggestion to him that sexual indulgence was not nec-
essary for his physical welfare, the offering of prophylaxis if he in-
dulges, and careful personal consideration of his case if he found
himself afflicted.

This method received official sanction and in most instancee
became a part of the military routine, so that it had a fair triaL As
one writer has stated, the man who failed to report exposure to a
possible venereal infection was punished. The method as it came
to my notice when I was acting in the capacity of fleet surgeon of the
North Atlantic Fleet — and we had then some 20,000 men — ^was studied

PUBIJO HEALTH AND MEDIOINB. 509

and carefully prepared statistics were kept by all the medical officers,
who were conscientious and thorough in'the discharge of this duty.
They were enthusiastic; we had conferences and discussed the sub-
ject; so that I do not think any loophole outside of the personal
equation gave chance for error.

I regret to say that for a period covering two years the statistics
which we tabulated showed practically nothing of value. There
were some months when it seemed as though the incidence of gonor-
rhea was less than it had been the month before or for some other
months; but in the end I was forced to the conclusion that prophy-
laxis was futile. I do not believe it accomplished a thing except to
make the evil conspicuous and to suggest the urgent need for some-
thing beyond. And that something is a specific cure, just as we have
a specific cure or a prevention for typhoid fever, and just as we have
a specific cure for syphilis. So before we can control this great
human problem we must have a specific cure or a preventive for
gonorrhea and the chancroid. Perhaps the next few years will show
what salvarsan has accomplished in reducing the incidence of syphilis.

I feel bewildered when I come to think of this subject as presented
by some of the other writers. The question of morak is such a big
one, because it seems so inadequate when you come to apply it to
this great dominant, overwhelming passion in human beings. I do
not know what we can do. I sometimes endeavor to form a definite
thought in my mind for my own consideration, but I have to take
refuge — ^it is an extreme view — ^I have to take refuge in the thought
suggested by one display made in nature. If we could establish
ourselves as the bees do, not neglecting the propagation of the race,
but reducing to a neuter gender the masculine sex, we would remove
not only these terrible diseases but a vast deal more of other vices.
It is a thought that is repellent to the individual, but it has its con-
sideration in the contemplation of the betterment of the race and of
mankind as well.

Dr. KoBEB. May I be permitted to express my deep apprecia-
tion of the papers presented on such vital themes, and also of the
very profitable discussion which has ensued. Five years ago, when
a committee was appointed by the American Public Health Asso-
ciation to study this problem, a committee composed of medical offi-
cers of the Army, Navy, and public health workers, we naturally
looked for statistics as to the prevalence of these diseases in civil
life. In the absence of reliable statistics we were compelled to secure
statistics from the armies and navies, not only in this country, but

610 PBOOEEDINGS SEC01<n> FAN AMBBIOAN SOIENTIFIO C0NGBES8.

also from foreign sources.^ It became our painful duty to announce
that the American Army add Navy^ as well as the armies and navies
of Great Britain, led in the imdue prevalence of these so-called vice
diseases. The admission rates were practically ten and fifteen times
greater than in the armies of nations where the subject had been
one of popular education and regulation. The Prussian and Bavarian
armies had the distinction of being the least afficted, because these
men had been subjected to personal inspection for years and, of
course, had had the benefit of education as well as of regulation.
Indeed, it has been clearly demonstrated by the remarks of Dr.
Lyster that much good has already been accomplished by education
and regulation in our own Army. The admission rates for venereal
diseases have been reduced one-half in the last five or six years, which
is, I think, the very best argument that can be presented in support
of the resolutions which have been presented, and I certainly hope
that they will receive formal adoption.
Dr. Agbamonte. Will Lieut. Col. Mxmson not speak on this subject 1
lieut. Col. MuNSON. Mr. Chairman and gentlemen, I am not pre-
pared to enter very deeply into any discussion of the subject, but
in common with most of the Army men I feel a certain resentm^it
always when the Army is featured up, as it frequently is, as more
or less of a sink of iniquity. I wish to affirm a very abiding faith in the
fact that there is less inmiorahty in the Army than there is among
the corresponding class of males in civil life. I wish to call attention
to the fact that, as Maj. Lyster has brought out, there are very
strong, potent forces at work in the Army all the time to prevent

1 Lieut CoL Jefferaon R. Kean, of tbe Medical Department of the United States Army and Sorg. Gbarle
N. Flake, United States Navy, supplied the following data:

ADMISSION SATIS PIB 1,000 OF ICBAN 8TBBNOTH.

Tear.

Syphflta.

Chan-
croids.

Gonor-
ihea.

Total

United States Army,
United States Navy.

Japanese Navy

BiKahNavy

British Army

Spanish Army

CfermanNavy

Russian Army

Austrian Army

Japanese Army

Belgian Army

"Dutch Army

Prussian Army

Bavarian Army

1900
1009
1007
1908
UOS
1907
1908
1907
1907
1907
1007
1905
1907
1907

80.45
26.49

8a77
28.23

185.77
106.11

37.46
S5.1
11.6
17.8
17.7
16.0
10.1
6.8
4.6
4.4
8.8

17.87
88.28
27.84
0.5
12.2
10.1
10.4

2.1

.97

67.16

40.7

28.4

86.4

30.2

2&1

17.1

19.99

17.00

12L2

10.9

196.90
160.40
180.75
122.40
75.8
67.8
68.8
60.1
64.8
87.6
96.1
2L6
18.7
15.1

Our committee said: "It is a lamentable fact that the United States and Orsat Brltafai, two typloal
Anglo-Saxon nations, should lead all other nations and navies in the prevmlenoe of venereal diseases. We
do not believe that oar population is less virtuous than that of foreign oountries but are inclined to the
optaiion thftt this undue prevalence is largely, if not entirely, due to the fact that tbe senttment fai these
two countries, both hi and out of the profession, is strongly agahist reoognlsing the evil and therefore has
not been made a subject of popular education. As a result of criminal ignorance and neglect on the part
of the public the admission rate for this class oTdiseases in the United States Army is on the increase
and is now 10 times greater than In countries where serious ftttsntfon has hem paid to the oonsideiatloa
of the problem.

FUBUO HEALTH AND MSDIOINB. 511

these men from going to the bad, to uplift them — to use that tenn —
to even penahze them by depriyation of their pay if they get sick;
to punish them if they do not take proper precautions, if they insist
on disobeying good advice and go where they should not go; and I
ask you to name a civil community that takes the precautions for
its young men that we take. I ask you if you can not go a long way
toward settling this venereal problem if you will go out into the high-
ways and byways of civil life and reach the young men in the way
that we do. Now, you use our statistics to ''point a moral and adorn
a tale." Very well. Please remember that it took conviction on
the part of the Army and the Navy to recognize the fact that the
evil existed and to go into it carefully to determine the evil that
existed. We have fought a good Sgjtxt; we are keeping the faith.
What are you doing 1

I r^retted very much to hear in one of the papers some remarks
about the inadequacy of the diagnostic methods in the detection of
venereal disease. In venereal disease detection is absolutely perfect.
That applies to all diagnostic measures, I think we may say with a
fair degree of accuracy. It does not mean that because a measure
is imperfect, it should not be used. I have been in an Army hospital
within three months — four months — ^in the Phihppines, and have
seen soldiers with venereal diseases detected by inspection and con-
fined until they were well, in order to remove them from being a
menace to the conmiunity. There was no objection raised to that.
Has there ever been any objection raised to the inspection of a male 1
No, I have never heard of it. I have been to a hospital for prosti-
tutes at Manila, run under the protecting wing of the Good Shepherd,
and supported by the contributions from women of easy virtue, and
have seen there at the same time 150 women with venereal diseases,
detected by the so-called imperfect methods, inadequate methods,
one-eixth of these women having open lesions of syphilis. Have
we a right to blind ourselves to the fact that we can detect a very
appreciable — call it large — ^number of venereal diseases by the inade-
quate methods of diagnosis that we have at present? Have we a
right not to detect those cases and remove them from being a menace
to the community, whether they are men or women t We hear a
great deal of objection to the examination of these women. Very
weD, what about the men t Are we to approach this subject from the
standpoint of science or sentiment t Are we to have an inequality
or are we to recognize this as an evil to be eradicated 1

I appreciate, as you do, that this is a subject in which ethics and
medicine are joined. I appreciate the ethical side. The Army is
doing the best it can from the medical side. Why do- not other
people recognize that in addition to the ethical side there is also a
medical side to the question t

512 PBOGEEDINGS SECOND PAN AMERICAK SCIENTIFIC C0NGBE88.

Dr. Veddeb. We are working in the dark and do not know how
much syphilis there is. Until we get that information, we can do
nothing with this subject in a sanitary way. Any sanitary work that
is done must be based on a knowledge of where the disease is and
how much we have to fight. That is the thing I am doing in a very
hmnble way. As far as I can, as I happen to be performing the Was*
sermann reaction, I am making surveys of as many different groups of
the population as I can in order to determine the prevalence of syphilis
in the community. At the present time the work has been confined
largely to the Army. That work has been published and I am now
extendiQg it as far as possible to the civil community. From the very
nature of the case, I can only do a very incomplete piece of work.
That work shoidd be done by every board of health in the United
States, just as the laboratory of the New York Board of Health is
doing, and just as they have started to do in Massachusetts and other
places. It is my firm conviction that it should be done by every State
laboratory in the United States. At the present time it is customary
in many laboratories to charge a fee of $5, or anything that can be
obtained, for the performance of the Wassermann reaction. Now,
there are a great many people who can not afford to pay a fee and if
the disease is to be attacked from a sanitary point of view, the sani-
tary officer should make both routine diagnostic tests and Wasser-
mann surveys of his community.

The point which I would have insisted upon, with regard to the
fact that syphihs is no higher in the Army than it is in the civil com-
mxmities, has already been ably brought out by Col. Munson, and I will
go no further into the subject. The fact remains, however, that in the
survey of accepted recruits, of 1,000 men, the percentage ran about

1 per cent higher than it did among men actually in the Army. So
that among men in the same class in civil Hfe the disease is fully as
prevalent as it is in the Army.

I just want to say one word with regard to Dr. Vaughan's figures
from Ann Arbor. I do not mean to detract from the value of edu-
cation in the slightest degree, because I agree with every word
Dr. Vaughan has said in that respect; but it seems to me he has
certainly imderestimated the prevalence of the disease among the
students. I do not know anything about Ann Arbor personally,
but I do know several other colleges very well. I recentiiy made a
survey of all the cadets at West Point, who presumably have far less
opportunities than coUege men in general and are under much stricter
discipline, and we got about 2 per cent of double plus reactions and

2 or 3 per cent more of partial reactions. So you can estimate that
approximately from 2 to 6 per cent of the cadets at West Point are
already infected. Now, I am quite sure that there ^ould be at least

PUBLIC HEALTH AND MEDICINE. 518

that many among college men, if a Wasserman reaction were made
of all the students.

I think that the form education must take to be successful must
be education that will build up character. I do not think that that
education which dwells upon the danger of venereal diseases is of any
use whatever. Men have known from time immemorial that it was
wrong to commit certain offenses; they have known from time
immemorial that if they did they were hable to become infected;
and so far as I can see, the only effect it has upon the normal male of
about 20 years or thereabouts is to incite him to further dereUctions.
He thinks that he is different from everybody else. In other words,
I beheve that education is our very strong hold, but that it must
be the kind of education which secures the man by showing him, not
a picture of hell, but something that makes character.

The main point that I want to make is that the discovery of the
prevalence of syphilis must be carried on as a part of the pubhc
health work of our sanitary officers before we can hope to do much
with the problem.

Col. HoFF. Mr. Chairman, may I ask the speaker what percentage
he foimd of Wassermans in the thousand he examined?

Dr. Veddeb. I did not bring my figures with me, and I can not
give them with positive accuracy, but I examined about a thousand
recruits fresh from civil life and they ran in the neighborhood of 17
per cent, coimting both double plus and single plus, not coimting
plus minus and negatives. They ran about one per cent less — 16
per cent — ^for the Army. It ran about 20 per cent for such institu-
tions as the prison at Fort Leavenworth and the Government hospital
for the insane. The patients at the tuberculosis hospital ran about
the same. I should judge that for the average community, among
young men of the class that enter the Army, the average would be about
20 per cent. I only foxmd about 17 per cent, but we must remember
that the men I examined had already been passed through two
physical examinations by the recruiting officers. Syphilis is par-
ticularly a class disease; that is, you find a very much higher per-
centage among certain classes of people than among others.

Among the college boys that Dr. Vaughan knows, you will not
find that percentage of syphilis. I do not suppose it will run higher
than 5 per cent. It will run up to 20 per cent in the young men
who apply for enlistment to the Army, and, of course, among prosti-
tutes, as we aU know, it will run about 75 per cent. That has been
shown by the investigations made at the Bedford Reformatory for
Girls, by Kneeland (Commercialized Prostitution in New York).

Maj. Lysteb. I would like to ask the speaker about the age of
those showing the Wasserman reaction.

514 PBOCEEDINGS SECOND PAN AMEBIOAN SCIENTIFIC CONGBESB.

Dr. Veddeb. The percentage, as we found it, increased directly
with the' age. The apparent reason for that was that in most cases
the disease was not cured and, of course, the older the man was, the
more his opportunities for infection have been. The young recruits
of 20 years or thereabouts had a lower percentage than the men of
40 or thereabouts who had been many years in the service. The
percentage rose perceptibly among all we examined, from 17 to 18
per cent up to 35 or 40 per cent, with the age of the man.

Dr. KoBEB. May I ask Dr. Vedder whether the recruits that are
accepted compare favorably both in morale and in health with the
average young man in this country ? In other words, it is not to be
inferred for a moment that the American soldier recruit is of a
lower type, both morally and physically, because they are certainly
not admitted into the ranks of the Army with evident lesions of these
diseases, and hence a great majority of the infections must be con-
tracted afterwards in civil life and not in barracks or on board ship.

Dr. Veddeb. The endeavor, of course, is to get the very best men
we can get, and the men that were accepted were a very much bet-
ter lot of men than a great many who applied and were rejected. The
acceptances are only a small part of the applicants. So, considering
the general economic condition of the men who would apply for enlist-
ment, we have the very pick of the men, and it is imquestionably
true that among the general population of that class of men it is
probably lower in the Army than in civil life; but, of course, we should
remember that the class of college men do not apply for enlistment
in the service. In that dass of men I think it is rather low

Dr. Agbamonte. I am informed that Dr. Ashbum would like to
contribute some interesting data.

Dr. AsHBUBN. I have nothing, sir, to say, except to call attention
to the fact that in Maj. Lyster's remarks, so far as I heard them, and
I think I heard them all, he omitted what, I think, was one important
factor in the reduction of venereal diseases in the Army — ^viz, the
cutting off of pay from men suffering from venereal disease. I did
not hear you mention that, Maj. Lyster, and I regard that as one
of the very important factors in bringing about a reduction of vene-
real disease. I must express myself as being in sympathy with the
gentleman from the Navy who finds himself bewildered in attempting
to deal with this problem.

Medical Director Lung. There is a very widely prevalent notion
that the sailorman is a swashbuckling, a swaggering and profane,
tobacco-chewing person, the man who figured on the stage 30 or 40
years ago and the man who did exists I am told, in the British Navy
some himdred years ago. Such sailors do not exist to-day. You

FUBLIO HEALTH AND MEDICIKB. 516

may take it from me that the sailorman of to-day is a good American
citizen; that his morals are good and his thoughts are dean; and that
he is far above the average citizen in many of his standards of decency.

Dr. Cabteb. When Dr. Lung Qpoke of the sailorman's social status
I think he meant the naval sailorman, because I am afraid for my
clientele, the merchant sailors. I will have to agree with what Dr.
Vedder has said, that the Army is decidedly above, morally, the same
class in civil life. The merchant sailor is nothing like — ^in morale,
physique, or social standards — ^what the naval sailor is. He does not
come, fits a rule, from as good a class in life.

I have been in the service about 37 years, not all the time in hos-
pitals, and I have not kept statistics continuously, but I have a very
thorough impression and some statistics. In my little hospital in
Baltimore I have treated about 2,600 merchant seamen and some from
the Coast Guard Service. I find that for the last two years 8 per
cent has been my admission rate for syphilis; for syphilis and gon-
orrhea together, 12} per cent. If I count the sequels from chancroids,
which are almost exdusively the suppurating lymphangitis, it runs to
18. These were hospital cases, but there are quite a number, especially
of gonorriiea, which were not treated in hospitals. I did not have
a chance to make up my office statistics, but you can take it that
about 20 per cent of my hospital cases are venereal diseases. Do not
understand that only 8 per cent of my clientele are syphilitic. Among
my Negro sailormen, I am sorry to say that I never ask a man over
30 whether he has had syphilis or not. I know that he has had it.
That may not mean that he is suffering from it now. He may come in
for a compound fracture or typhoid fever; but never do I fail to have it
in my mind and rarely have I failed to get a positive Wassennan from a
man of that race when I had it made. We have not made Wasser-
maos on people as they entered, but we have made Wassennans on
people of whose diagnosis we were somewhat doubtfuL If we knew a
man had syphilis, we did not have a Wasserman made. If we knew
the disease was something else, we did not have it made. By the way,
I counted parasyphilitics in that percentage, locomotor ataxia and
paresis, of which I have had a few cases.

Of the Wassermans that I have seen in very doubtful cases — ^I
quote from my statistics, which I looked over this morning — ^I find
that I have 62 per cent of them positive. That is a little unfair,
because I did not send in a Wasserman as a routine procedure. I
suspected a man might have syphilis before I sent in a Wasserman.
So much for the merchant seaman.

I want to say next that I lay a great deal of stress upon the
influence of age on the Wasserman. I believe with Dr. Vaughan
6S486— 17— VOL IX 84

516 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

that syphilis is curable. I beUeve with Dr. Warthin that syphilis is
rarely cured and not cured quickly. You have a body of a thousand
men. Let them be infected at the rate of 50 a year. Very few of
them can depend upon getting a negative Wasserman at the end of
five years, and, necessarily, the Wasserman will increase. But, con-
sidering syphilis not as a disease hurting the individual, rather as a
disease hurting the community, do not make the mistake of counting
every man with a Wasserman as being able to communicate syphilis.
That would be just as unwise as to count every man who gives a
positive reaction to a Von Pirquet as being an open case of tubercu-
losis. Arguments for the prevalence of the contagion of syphilis from
the proportion of positive Wassermans are totally and absolutely
valueless. Open syphilis is one thing and constitutional syphilis may
well be another.

Dr. AoRAMONTE. Dr. Persico desires to say a few words.

Hereupon Dr. Alfredo Persico addressed the session in Spanish.
Bis remarks were imfortunately not reported.

Dr. AoRAMONTE. May I ask you to close the discussion, Dr. Snow?

Dr. Snow. I think it would be imfortunate if those who are not
familiar with the subject were to think that the Army and Navy
statistics for venereal diseases show anything in regard to the
relative prevalence of immorality in miUtary and civil population.
I think the only reason many people turn to the Army and
Navy is because they are the only organizations whose officers pos-
sess any statistics worth anything in this matter. We have here and
there limited data on the civil population, as that assembled through
the splendid work begun by the New York Health Department. I
purposely avoided any reference to such scattered statistical data in
my paper, however, because I was endeavoring in the time allotted
to me to present a schedule of administrative measures. I think it
is rather interesting as an instance of cooperative work in attacking
this problem to note the fact that between the commissioner of
licenses of New York City and the commissioner of health there has
been an arrangement whereby all the ordinary street peddlers have
to submit to physical examination on applying for their licenses. In
that examination it was decided that a Wasserman reaction should
be made and also an examination for tuberculosis. That work has
covered, it is true, only a small number, but the average of between
8 and 10 per cent positive reactions is of interest. Some of the hos-
pitals in this country have taken up this work. For two years
Bellevue Hospital, in New York, has examined by the Wasserman
reaction all the patients who are retained in the hospital over three
days, and some very interesting figures that have not been published
are coining out of this work. May I say, parenthetically, that the

PUBLIC HEALTH AND MEDICINE. 517

surgeons have found the test a very useful prelimmary source of
information in indicating preliminary treatment prior to operation.

Col. HoFF. Have you got the statistics ?

Dr. Snow. The figures have not been published, but I may say to
this audience that their figures run between 20 and 25 per cent
positive. Somewhat similar figures have been obtained in other
hospitals in this country. I should say that 20 per cent as an average
would be a conservative statement of what is being found in the rank
and file of the civil population that come into hospitals.

Dr. Carter has already given some data of the United States Public
Health Service. Surgeon Banks, of that servicCi has, it seems to me,
given us a very valuable study of the collective material of the
marine hospitals. His figures show between 8 and 10 per cent of
the sailors infected with venereal diseases.

I think that, in the first place, it is encouraging to find not only
in the Army and the Navy, but beginning now in the civil population,
qualified people who are seriously beginning to get at the facts
upon which we must commence to build. Secondly, it is encouraging
to find that this problem is shown to be less in extent than some of
our agitators have stated it to be.

Dr. Reynolds has presented an excellent r6sum6 and I would hke to
say that these discussions are epoch making, for it is out of them that
the greatest good will come. We must begin to exchange opinions, not
criticizing, not taking anyone's word as final until we know where we
stand on the problem. I hope this resolution will be passed, because I
think it may bring about in the Americas what has been done in the last
two years by the appointment of the British Royal Commission on
Venereal Diseases. The meetings of that body with all the dignity
and prestige of a royal commission in Great Britain have given a
new aspect to this subject of venereal diseases. They have not done
anything yet but report the testimony; but all the best thought in the
Anny and the Navy and in civil and professional Ufe in Great Britain
bearing on this question has been brought out. Already some very
sane Uterature, something that is very much better than the Utera-
ture that has been circulated about this country in years past, has
made its appearance.

Col. HoFF. There is one thing that I would like to emphasize.
It is that in this discussion this afternoon great stress has been
laid upon syphilis, but very Uttle upon gonorrhea, and we all know
that we have from gonorrhea as grave and serious restilts as from
syphilis. Now taking our statistics of the Army as an evidence of
what probably exists among the people of the country, we find that
syphilis is to gonorrhea as one is to four; so that if we run along with
about 15 per cent of syphilis we have about 60 of gonorrhea.

618 PB00EEDIKQ8 SEOOHD PAUr AMEBIOAK 80IBNTIFIC 00KGBB88.

Dr. AoBAMONTE. With theae remarks by Col. Hoff I will declare
the discussion closed. I have another resolution in connection with
this matter which I have to place before you. It reads as follows:

Whereas the collection of fines as a punidiment for sexual o£fenses is unjust and
inadequate when the reform of fallen women is considered;

Whereas such collection of money earned by prostitution is not in any way giving
a start toward a decent life to outcasts; be it

Resolved, That the Second Pan American Scientific Congress recommends the
adoption of laws prohibiting judges from collecting fines from prostitutes, according to
the bill of Prof. Kirchweg, of Columbia University, New York.

What is your pleasure with respect to this resolution ?
Col. J. V. R. HoFP. I move that this resolution take the usual
course.

Seconded and approved.

The Chairman. The following paper, "Proyecto de ordinanza
reglamentaria de la prostituci6n/' by SefLor Silvestre Oliva, of
Argentina, will be read by title.

PROYECTO DE LA ORDENANZA REGLAMENTARU DE LA PROSTITUaON.

Por SILVESTRE OLIVA,
Director General de la Adminietraci&n Sanitaria y Aneteneia PMioa de Buenoe AinM^

Argentina,

La ordenanza reglamentaria de la proBtituci6n actualmente en vigencia, es a todae
luces deficiente y debe necesariamente eer reemplaaada por otra que en su eeenda
y en sue fines, encuadre dentro del concepto que sirve hdy de idea directriz en otras
partes, en materia de -este g^nero de reglamentaciones.

''La pro8tituci6n es un delito y la prostituta una delincuente; la re8tricci6n que
los poderes ptiblicos estdn obligados a imponer a su comercio, debe entoncee ser
represiva y punitoria."

Tales parecen haber sido las ideas que han inspirado nueetra ordenanza en vi%oi,
que proclama el regimen de la persecucidn pohcial y la hoepitalizacidn y encierro
carcelarios que son su conseeuencia, como medio de hacerla efectiva.

Ningtin fundamento cientlfico sustenta semejante sistema, que siendo por lo
mismo im verdadero atentado contra la libertad individual, el poder ptiblico no tiene
derecho a imponerlo sin sobrepasar las atribuciones que le asisten como entidad en-
cargada de la custodia y contralor de loe intereses y derechoe de todos y cada uno.

En efecto ^en virtud de qu^ facultades la asistenda pdblica va a imponer a una
prostituta, sobre todo si estd inscrita y sujeta por lo tanto a su vigilanda, el endeno
en una sala de hospital para someterla a un tratamiemto mMico detenninado?
^Puede acaso hacerlo con un colMco, un pestoeo o cualquier individuo afactado
de los grandes males epid^micoe sin su consentimiento?

Las restricciones que a la libertad individual imponen loe gobiemos en nombre de
los supremos intereses de la salud ptiiblica, tienen su atenuaci6n y hasta su justifi-
caci6n, cuando efectivamente reeultan provechoeos a la satisiaccidn de tan apre-
miantes aspiraciones.

> El tezto del Proyeeto do Ordenancs RegkinaiiUrla di U Prostltnoidii, oonita al fin d* Mte ettodlo.

FUBUO HBALIH AND MBDIOIKB* 519

Lft privaci6ii de la libertMi a una mujer p4blica a pretezto de encontrane enierma
de nretritia bleiiofrtfgka» no puede en manera algona realisar eea condid^n de salud
pdblica, porque no se tarata de una eniennedad grave capas de produdr una con-
flagrad^n general, como la fiebre amarilla, o el ciUera y tambite y sobre todo, porque
la curacidn de eee mal ven^reo en la mujer, es un problema sin soluck^n per el me-
mento.

Franda que es la cuna del reglamentarismo, y donde ^te cuenta con bu baluarte
nUb formidable, ha llegado a trauBformar bu vetusto hoBpital Saint Lasare en una
verdadera Bastilla, en donde las mujeree ezpfan bu abominable deUto de haberse
proBtituldo para sadar las necesidadee camalee del hombre, llenando con ello una
necoBidad Bocial, en tanto que bo detiva de exigendaB biol^gicas ineludibke.

PueB Men, en eee pafB como en otroe en que impera adn la reglam«itad6n draco-
niana ni ha mejorado la vida y coetumbreB de bub pobladonee del punto de vista de
la moral y del orden ni ha ganado tampoco la Balubridad general. La proetituddn con-
tintia siendo siempre una fuente fecunda de atentado a lae buenaa coBtumbreB, al
orden y al bienestar Banitario de la Bodedad.

OompenetradaB nueBtras autoridadee comunaloB de la exactitud de eBtoB hechoB
que traducen al fracaso de nucBtra ordenanza en vigor, reBolvi^xm bu reforma nom-
brando para cBtudiarla y proyectar la que debfa reemplasarla, una comiBidn ad hoc
de la que formaron parte entre otroB fundonarios, el secretario de higiene y obrae
ptiblicaB de la intendencia, el inspector general, el director dd diBpenaario de Balu-
bridad, el aseeor munidpal y otroB.

Dicha comifiidn di6 por terminado bu cometido presentando en loe primeroB meBes
del alio de 1912, un proyecto reglamentario de la prostitud6n que con un inf<vme
favorable del director de la asistencia ptiblica Dr. Horado G. Pifiero, bo encuentra a
estudio del Honorable ConBojo Deliberante.

Ebo proyecto, que indudablemente reune condidonee apreciablee, couBulta en
parte la tolerancia de este mal social y la oblJgaci6n de ser fiscalizado por loe poderes
p(!iblico6 por rasones de salubridad general, de moral y de orden ptiblico.

La creaci6n de una comisi^n consultiva o junta de profilazia social, que asesora a
las autoridades en las cuestiones relacionadas con la mendonada necesidad social y
la supreei6n del radio fijo para la ubicaci6n de las mancebfas, son las modificadones
Bubstandales que contiene.

Exduye ademis de la inscripci^n, a las menores de 18 afios que no podrin por lo
tanto ser prostitutas patentadas ni estar sujetas al contralor sanitario y deja subsistente
larecluBi6n hoepitalaria obligatoria y a puertas cerradas, para las mujeree que infrinjan
la disposici^n que les prohibe el comerdo carnal en case de enfermedad, tanto en Iob
lupanares como en bus propioB domidlioB.

Fuera de esas reetriccioneB, el reglamento en proyecto es un paso adelante en el
sentido de iuavizar las exageradones dd actual y de reducir a bus juatos IfndteB las
exigenciae que la autoridad estd obligada a impoiM^a la proatitncidn» en defenaa de
los altOB intereees aodalee.

Dentro del criterio de que la pro8tituci6n es una neceeidad pdblica y no un detito,
la mujer proetitulda que es bu drgano, no poede aef conaiderada una delincuente ni
represiva ni punitoria por lo mismo, la accidn que sobre ella ejerdten loe poderea
ptiblicos, para corregir su indisdplina y abusoe y defender a loa que c«n ella ticiicn
relaciones camales, de posiblee contaminadoDea.

Pensando asi ee que considero que en la nueva reglamentaddn no pueden figurar
lae diapoBidoneB restrictivaB a que he he(te refeiencia, tiltimoe reBabioe de un rigo-
fiamo fuera de tiempo, irracional y contiaproducente, en tanto que conepiia contra
loa mismoa finee a que tiene defecbo a aapiiar: a k diadplina moral, al reqguardo del
orden y a la profilaxia de las enfermedadee que comprometen la salud y d vigor del
individuo y de la raza.

Porque no hay que perder de virta que en d extranjero como entre noaotroa, el
reg^amentariimo excedvo y heroico ha conduddo aiempre al dandeetiniamo y a la

620 PB00EEDINQ8 fflSOOHD PAK AMBBICAK SClEJiTUfiO C0KGBE8&.

ocoltaddn, fuentes 8eg:ara0 7 fecnndas de loe miamoB malee que se quieren evUar.
Una ligera exporid^n sobre Iob detollee que m6a sublevan la reaJBtencia de las proetitu-
tas ezplicari la ras6n de ser de lo que afinnamoe.

La iii8cripci6n es la base del r^ilamentariamo y en ella deecansa la autoridad sani-
taria para desairollar la acci6n de profilaxia que le coiresponde desanollar, ante las
muj^res que se entregan al trdfico carnal; la mujer la resiste puesto que implica su
consagraci6n ofidal, definitiva e irrevocable de su divordo de la familia y de la so-
ciedad, la destrucddn de los lazos que a una y a otra la vinculan, el renundo a su
condid6n de ser libre y su relego a la condid6n de paria sin otra perspectiva que la
miseria y la ruina de su personalidad ffsica y moral.

La in8cripd6n es una dispo6id6n que la prostituta considera abominable, porque
la colma de trabas, la humilla y la esdaviza sin autorizarla ni ^Mnlitarle el ejerddo de
su comerdo, puesto que en el certificado que se le entrega se dedara "que la anota-
d6n en el registro especial, no debe considerarse como una indtad6n por parte de la
autoridad, al vido y al libertinaje ni un obst&culo al trabajo." Utiliza entonces
aquella dicha pr&ctica en benefido propio exdusivamente.

Por eso es que la resisten y que a pesar de los esfuenos de los inspectores,sesubs-
traen a ella un ntimero tan creddo.

La operaci6n les resulta a pura p^rdida, pues las colma de probibidones, las obliga
a la visita semanal del dispensario de salubridad, a descubrir sus enfermedades y a
retirarse obligadamente de la vida si Uegan a enfermarse.

La meretriz no inscrita que es la m^ numerosa, no pasa por semejantes extorsionee;
ejerce libremente su ofido sin exponerse a otras contingencias que a ser anotada por
fuerza y ser enclaustrada en un hospital si estuviera enferma, en el case muy pcoble-
mdtico por derto de ser deecubierta.

Mi opini6n es que debe despojirsele de su caricter obligatorio e imperativo, oono
se ha hecho ya en la misma Franda que es el baliiarte mis formidable del leglamen-
tarismo.

Podr& aigdirse que la inscripd6n voluntaria aboliril de hedio la Cormalidad, puee
no es concebible que las propias mujeres incurran en la candidez de entregarse inde-
fensas a quienes les est4 confiada la tarea de vigilarlas. Pero la ordenanza acueida
franquidas a las inscritas, que no le concede a las que no satisfttgan ese requisite y que
seguramente ha de servirles de incentive para cumplirioe.

Por lo dem^ la visita obligatoria al dispensario, la redusi6n hospitalaria forzada
y la limitaci6n tan s61o a los lupanares de la toleranda ofidal, del comerdo carnal,
constituyen las causas que inis divordan a las prostitutas de la autoridad y las que
mis las inducen a reeistir la inscripddn. Suprimidas como lo ban side en el regia-
mento que se proyecta, se habrdn eliminado una fuente perenne de diferendas entre
ellas y la autoridad sanitaria y las mujeres no tendr&n ya por que tener su anotad6n.

Ex profeso no se limita la edad dentro de la cual podri gozar la mujer del deied&o
de inscribirse, por cuanto dicha l^tad6n es contraria a la a8pirad6n, muy laudable
por derto, de extender al mayor nthnero de prostituldas los benefidos dd contralor
sanitario. En bien de la fund6n profilictica que por ese medio se persigue, convi^ie
suprimir exclusiones que a ningfin fin dtQ conducen, puesto que a pesar de ellas las
mujeres a quienes comprendan, continuar^ ejerdendo el ofido, con el agravante de
que lo har&n dandestinamente.

Es menester no olvidar que las menores de edad aportan un extraordinario contin-
gente al meretrismo, porque predsamente en ese periodo de la vida es que la mujer,
por su inexperienda o por encontrarse en pleno fioredmiento de su vitalidad sexual, se
deja sedudr 0 arrastrar al vido con maycnr facilidad, estimulada por el sinntimero de
lactores que en los grandes centroe pobladoe prindpalmente, conspiran contra su
honestidad.

PUBUC HEALTH Ain> MEDICIKB. 521

Al priyar]|M del mendonAdo derecho, no se les aparta de la vor^igine del vicio y se
les niega en cambio el amparo que solicitan al poder pfiblico en beneficio propio y de
las p^rsonas a quienes en iaz6n de su oficio entregan su cnerpo. La admini8traci6n
sanitaria al anotar una prostituta, no le confiere una credencial que la habilite para
el ejercido de la prostdtucidn; no hace sino colocarse en condidones de poder esta-
blecer sobre ella, la vigilanda que es de todo punto indispensable, para defenderla
de las enf^rmedades a que se encuentra expuesta y para que una vez enfenna, no se
convierta en vehlculo trasmisor del contagio.

El cumplimiento de ese requisito interesa entonces mis quiz& a la misma mujer
que a la autoridad, por lo que no debe eludir ningdn esfuerzo ni medio para conse-
guirlo.

£1 retrato que^xnno elemento de identificad6n se les exige en las libretas de inscrip«
d6n se consideia como una afrenta que repugna a la mujer tanto o m6s que la inscrip-
ddn y que resLste con inuaitada energla. Debe abolirse porque es una medida que
iavorece al dandestdmsmo.

La reclusi6n obUgatoria, con fines de asbtencia m^ca, en un hospital en donde las
prostitutas se encuentran sometidas a un r^;imen penitenciario, fu^ un lamentable
error que no admite disculpa.

Privar de su libertad a una mujer a pretexto de haber contrafdo una enfermedad
trasmisible, aunque para ello se invoque el vano y soconido argumento de la defensa
de la salud pdblica, es un abuse, sobre todo cuando se le hace efectiva en prostitutas
patentadas, sujetas al contralor sanitario ofidal.

Es adem&B una injusticia por cuanto se deja en libertad al autor del contagio, al
hombre que sabiendo que estd enfermo, puea en el sexo masculino las enfermedades
vendreo-sifilf ticas no escapan por lo general a la inspecd6n ocular como en la mujer,
trasmite consdentemente un mal que tan seriamente comprometerd su presente y su
futuro.

8i la acd6n de adquirir un contagio ven^reo-sifilltico es delictuosa, el hombre es
entonces el delincuente y es contra ^1 que debia ejercitar la autoridad su acci6n
punitoria, dejando a la prostituta en su deegrada, siquiera el derecho de elegir el
sitio y loB medics que sean de su agrado para reetablecer su salud.

£1 egolsmo del hombre resulta siempre fatal a la mujer; es d factor que invaria-
blemente la arrastra en d camino del deahonor y del vido y d que una vez prosti-
toida, la lleva a la ruina y a la desesperad6n, enfermdndola y abati^ndo en dla
hasta el tiltimo vestigio de sentido moral.

Quien quiera que haya podido observar el lastimoso espect^ulo que ofrece una
sala de mujeres pdblicas en recluaidn forzada y haya penetrado en muchos de los
detallee de la vida propia de un ambiente semejante, habr4 podido estimar a que
predo se obliga a expiar a esas humildes siervas de las exigendas camales de la vida,
0n falta de darividenda al dejarse contagiar padedmientos que ellas trasmitirto
a su vez a sus dientes.

Han de sentir all! ens mujeres a no dudarlo, los tristee presagioe de su obscure porve-
nir y las torturas de la impotencia para al lontar tan crueles perspectivas, ytk que la
Bodedad al desentenderse de ellap, paredera querer sentar la doctrina de que el dere-
dio a la libertad, no comprende a la mujer cuando ha cafdo en los abismoe de la
cofrupd6n.

Gonnaturalizindose con su de^gradada situaddn, concluyen al fin por perder los
tUtimos vestigioB de sus recatos de mujer para lanzarse luego degas y fren^ticas a
todoe loe extremes del libertinaje y de la depravaddn moral.

iRecogeacasod poder pdblicoalgtin beneficio deun«^gimen semejante? Ninguno
absolutamente, puesto que la mujer que se horroriza ante la perspectiva del secuestro,
se vale de todas las artimafias, hasta de las mia inverosfmiles, para eludir la visita

522 PROCEEDINGS SEOOND PAN AMEBIOAN BC^BNTIFIO 00NGBB8S.

oftcial euando 0e soepedia enlentt. Tftiicierto«sk>queafiniio, queladireocidiidel
Dispensario de Sahibridad no ha tenido hasta ahofa leparo en maniteftar, que fai
mayor parte de las enfennas que decburaa en mis consoltorios, k> ion por scnrprQaa, lo
que imi^ca que son m^ las que escapan a la inflpeccidn y ccmtindan por lo Umto
esparciendo ^ contagfio de sus enferviedades.

Nepuede en mi opinion sulMistir por mis tiempo el confinamiento de ofido y coend*
tiyo. Debe reemplaztoele por la ho^talizaci^ vduntaria en cualquiw hospital
en donde la prostituta se confunda con las demis enfennas, pero a puertas abiertas
y sin impoeiciones humillantee que resultan siempre contn^»ioduc«itea per las resis-
tendas que provocan.

La vida en comtin con las demis enfennas, debe necesaiiamente ejerc^ sobre
eUas una saludable influencia, aunque m49 no sea que por el hecho de sentizse dentio
de un ambiente que no les ee familiar y que las obliga a moderar sua impetus y a
refrenar sus inclinaci(mes. i Y cu&ntas al abandonar eeos recmtos, no llevaz:^ ya ea
su espfritu, el germen de su restauraci6n moral, que las ha de Tohrer a k familia y a
la sociedad 1

Dejemos pues a las prostitutas en libertad de acogerse a la asistcneia m6dica que
quieran procurarse, pero fuera de los sitlos de prostitucidn ya sea en hospitales, sana-
iorios o casas particulares; ofrezdonoslee todo el concurso de la reparticidn paza con-
seguir su saneamiento; fiscalicemos la eficada de los medlos que a ese fin ellas mjwnaii
se procuran y someUmoslas a una sevora vigilancia antes de restituirias a su comerdo;
pero no las condenemoe a las torturas del encierro i>olictal y del endaostramientD
hcspitalaiio, porque **la prostituci^n no es un delito y la prostituta no es una deUn-
cuente."

El Estado debe buscar por todos ks medios a su alcance a la prostituta, paza inf or-
marse de las condiciones de su salud, alejarks momentineamente de su eoraerdo si
estuvieran enfennas y obtoier su consentimiento para restablecer su inmunidad,
dejdndola, eso sf, la elecciite del sitio en que ha de haeecse electivo el tratMniento
que requiera.

La viaita gratuita en ks consultorios del Dispenssrk) de Salubridad, en los servictoe
ad hoc deloe hospitalee y Casa Central de la Asisteneia Pdblica, la asistenda dentro
de las salas hospitalarias y atin en sus mismos domidHos, son recuisoe que sin restric-
dones de ningtiin g^ero, est4 en el deber de pcmer a su disposiddn la autsddad
sanitaria.

Podria cuando m^ impcmerles una m6dica contribudite pecuniaria, por la asistenda
a domldlio, como por las yiaitas de inqpecd6n que a su pedkio les pxactiqiie en ellos
el Dispensario, cuando por diTorsas rasones no quieran acogerse a k inqperri^
gratuita que aqu^l les dispensa en sus dependendas.

En el proyecto de k comis!6n se autorisa el ^erddo de k prostitud^ en tree
categorfas distintas de locales: k habitaddn propk y {nri^ada de k mnjer, ks casas
de dtas y los lupanares.

Ejercen en los dos primeros las que podrlan Ikmarse prostitutas veigOBsaates» pues
son las que conservan atb derto grade de recato y no desesperan por lo mismo vohrer
cualquler dfa a k buena senda, reintegrindoee a k vida honesta y tranquik del
trabajo y de k familk.

No es prudente perseguir esta clase de prostituci6n que es k que menos compromete
el orden y ofende k moral; su rol debe consistir en someteria a una severa fiscatnacida
a loe ef ectos de las verificadones profikcttcas pertinentes y de garantizar su inocuidad.

El lupanar es d sitio consagrado para k prostitucidn ofidal; d fisco lo tolera, con-
dente y ampara, retribuyendo aftf k contribud6n pecuniaria que se le tiene sefiakda.
Est^ generalmente regenteadoe por una mujer con d tf tulo de tenedofs, que no ee
flino k continuad6n de k personaHdad del proxeneta de otros tieoBpoe y que como
aqud, explota en su dnico y exdudvo benefido, el comerdo canud de sus pupike.

PUBUO HBALIH AND MIDIOIirB. 62S

Yivtn eo eeot recintos con 1m apwienciM de leres \\hie§ licndo en raalidad pnauh
ncfM, esclavas blancas, de cuya lib«rtad we apodeimii con nn igual cinkmo las r^gen*
tee, por medio de un cikmulo de ardides aistemiltica y pacientemente puestoe eo
pfAetica.

Bon centros frecuentados por numerosa clientela que detpiertan por lo miflmo la
curiosidad pdblka y siMcitan la alanna y las angustias del vedndario que loe rodea.

£1 prostfbulo en su forma mds vulgar, veidadera colonla de mujeres regimentadas
bajo la omnf moda autoridad de la regente, es una entidad ab<»ninable y no es acreedota
a la tolerancia ni mucho menos al amparo de loe poderes pAblieos, porque explota y
esclaviza sin piedad a tanto ser indefeoso, mantiene el imperio del pzoxenetismo,
conspira contra la salud pdblica, atenta contra la moralidad y el orden y compromete
la tranquilidad y el bienestar de la sociedad.

£1 lupanar pequefio, de una, dos o tres mujeres, a lo mis, libremente asociadas para
explotar en su exdusivo prorecho el ofido, no tiene semejantes inconvenientes y
peligros. £1 menor ndmero de mujeres, impone como forzosa consecuencia la restric-
d6n de la dientela, como la ausenda de la regente, la limitaci6n del trabajo a las
propordones compatibles con la resistenda y voluntad de cada pupila. Las probabili-
dades de infecci^ disminuyen, la moralidad pdblica sufre menos y el pudor de las
familias no se ve expueeto a tantos ultrajes.

Otra de las reformas que se propidan es la supre8i6n del radio que hasta ahora
impera y que la experiencia se ha encaigado de demostrar, que es a todas luces incon-
Yoniente y contrario a los fines que se tuvieron en vista al establecerlo. £n efecto, la
poblad6n noct&mbula de Buenos Aires tiene su radio de acd6n en la parte m6a
c^ntrica, mientras que los prosdbulos ban sido confinados mis alia de la calle de Gallao,
desde donde tienen las mujeres que emigrar para buscar sus clientes.

£sta drcunstanda explica gse desfile constante de prostitutas, que desde la zona de
ubicad6n de los prostfbulos se obsenra, a partir de las dltimaa boras de la tarde, con la
violencia consiguiente de las sefioras y nifias que a esa bora y durante la nocbe frecuen-
tan los barrios centrales de la poblad6n.

Ademis, son muchas las mujeres que a fin de acercaise al mercado en que ejercen
su trdfico, se establecen, no obstante la prohibici6n, dentro del radio de la zona central,
entregindose a la prostituci6n clandestina con peligro evidente de la salud ptiblica.

A estas razones de orden sanitario y de moral social, debe agregane otra que es
tambi^n muy digna de tenerse en cuenta: es una raB6n de justicia y de equidad que
aconseja hacer recaer sobre toda la pobladdn y no sobre una determinada parte de ella,
los perjuicios a que la condena la existencia de las casas de tolerancia.

Sin embargo propido un radio probibitivo, dd cual serin exduidos en absoluto los
lupanares y que seri el comprendido dentro de las calles de Callao, Coirientes, Santa
F^ y Pueyrreddn. £xisten en el barrio un creddo ntimero de establedmientos de
instrucci6n primaria, secundaria y univeraitaria cuyos alumnos no se verin como hoy,
expuestos a los inconvenientes y peligros del contacto cotidiano con las mujeres
pdblicas que constantemente los recorren.

Se darfa tambiin una satisCacci6n a la vindicta ptibHca justamente alarmada, por
esa promiscuidad tan inconcebible que se observa en dertas regiones de la dudad y
en cd que nos ocupa en primer lugar, entre los temples del saber y de la virtud y los
centros de la corrupd6n y el libertinaje. Defendamos las generadones en lormad^
de la vmigine sensual, que es un deber de concienda y de patriodsmo tambi^n.

La brutalidad y el salvajismo mis repugnante imperan en mucfaoe prostfbulos de la
capital y espedalmente en los frecuentados por las clases mis inferiores de la sodedad.

La salud y la vida de tanta desgraciada coiren en ellos peligro y reclaman el amparo
de la autoridad.

Por eso es que me he permitido introducir un artf culo establedendo la reglamen-
taci6n del trabajo diario de cada mujer, que corresponderi efectuar a la asistenda
pdblica.

524 PB00EBDINQ8 SECOND PAN AMEBIOAK SODfiNlIFIO OONGBESS.

Ooincido con la comiaidn en la convenienda 7 neceddad de multiplicar loe con-
floltorioe para el tratamiento de las enfennedades de la eepedalidad en el hombre
particulamiente en aquelloe barrioe m6a concurridoe por las dasee obieras.

Existe una ordenanza que hace obligatoria la habilitaci6n de esoe servidoe en todas
las institudones hospitaluias de la asistenda ptiblica y si cumpli6ndola estiictamente
no resultaran sufidentes, serfa d caao de instalarioe en otros redntos en la seguridad
de que cuanto mayor sea su ntimero y las fadlidades que se le dispensen al pdblico,
m&B provediosa seri la acci6n curativa y profil^tica que realicen.

Un liberalismo que a primera £acie ha de parecer excedvo, inspiia este pioyecto de
reglamento y las consideradones que para fundarlo he emitido precedentemente.

MMico, pert) a la vez que mMico fundonario, no he perdido de vista que como tal,
debo reprimir mis impetus para no caer en el desempefio de mis tareas, en radicalismoe
que pudieran presentarme peiBiguiendo Utopias y acaridando quimerss.

La asistenda ptiblica no puede ni debe aparecer como reglamentarista ni abolido-
nistacl otttronce ni por sistema; debe ser una u otra cosa o ninguna de las dos exdusiva-
mente, pero tomando como base tan b61o una raz6n de bien pdblico.

£1 doctrinarismo es fatal en medicina como en higiene y cuando los fundonarios
encargadoe de aplicar esas doe ramas de las dendas naturales, fundamentan en 61 bus
actoa y procedimientos, se insintian en el deirotero de lo indertOi condenindose a
un fracaso casi seguro.

En materia de prostitucidn se debe ser ed^ctico sobre todo en un medio social como
el nuestro y en tal prindpio nos hemoe inspirado para redactar el proyecto que se
eleva.

PBOTXCTO DB ORDBNANSA. RBQLAJnBNTABIA DB LA PB08TITUCI6n.

ARTfcuLO ] . Tol^rase el ejerddo de la prostitud6n en locales aue par su indole, ubi-
cad6n y condidones satisfagan las exigencias de la moral ptjiblioi y loe preceptoe
de la hmene.

Art. 2. Cr^e una coml8i6n consultiva 0 junta de profilaxia social que se compondrd
del secretario de obras ptiblica de higiene y seguridad como presidente, director de la
asistenda ptiblica, asescw munidpal, inspector general, director del dispenssrio de
salubridad y del subsecretario de nkiene de la intaidenda como secretano.

Art. 3. rerseeuiri loe siguientes fines:

1^. Proyectar las reglamentadones generales y especiales para la aplicad6n de esta
ordenanza en los locales a que concurran o en que se alojen prostitutas y estudiar y
proponer las medidas <)ue considere convenientes al mejor regimen de la prostituddn y
de la moralidad pdbhca. de acuerdo con las facultades que confieren a la munidpali-
dad loe incises 5, 6, y 7 del artfculo 50 de la ley oig&nlca.

2^. Dictaminar en los pedidos de habilitaci6n o clausura de dichas casas y las servidaa
por camareras, asi como en las denundas ]^r ejerdcio clandestine de la prostituci6n
en aquellos casos en que le dlera intervenci6n el D. £.

Art. 4. Toda mujer que se entreeue al ejerddo de la prostituddn se inscriblrA en
un registro especial que llevar& el dispensario de salubrioad.

Art. 5. La in8cripci6n confiere a la mujer derecho a la in8pecci6n y visita m^ca
gratuitas en el dispensario de salubridad o en su propio domidlio, cuando por cir^
cimstandas especiales no le fuera posible concurrir al establedmiento.

Art. 6. La mspecddn y visita a domidlio cuando la requiera la prostituta par su
propia convenienda y comodidad, estari gravada con un impueeto de tres pesos
moneda nadonal por vez.

Art. 7. La mlsma clase de asistenda se prestard tambi^ en consultorios especiales

Sue el D. E. instalari con profusidn, los (]iue no ostentarAn ningiina levenda ni distintivo
eterminados y tendr&n sus puertas abiertas e] mayor ndmero de nana posibles.

Art. 8. Las prostitutas enfermas de blenorra^ 0 de sffilis est^ inhabilitadas para
el comercio carnal, no pudiendo reanudarlo sm la intervenddn dd dispensario de
salubridad. que deber4 comprobar en cada caso su curaddn o por lo menos su no
contagiosiaad.

Art. 9. La presencia en un lupanar de una prostituta afectada de un padedmiento
ven^reo-sifilltico, se casti^^ con su inmediata separacidn dd establedmiento,
imp(Hiidndoee a su regente una multa de 100 pesos la primera vez y clausurftndole k
casa la segunda.

PUBUO HBALTH AND MBDICnOB. 525

Art. 10. Ftok el tiiUico carnal se reconocen trea cate^orlaa diatintaa de localee:
la habitaci6n propia y privada de la mujer, las caaas de citas y loe lupanaree o caaaa
en que pennanentemente vive un determinado ntimero de prostitutas.

Art. 11. Las mujeres que ejerzan aisladamente en sua domlcilios, estar^ tambi^n
obligadas a la inscnpcidn en el dlspensario de salubridad y a redblr por lo mismo 1»
viaita m^ca reglamentana.

Art. 12. Las proetitutas de las otias dos clases de locales deber^ necesariamente
estar inscritas. no pudiendo las gerentes admitir, bajo ningtin pretexto a las aue no lo
estuvieran. La contravenci6n a esta formalidad s^ castigada con ima muita de 50
pesos la piimera vez ^ de 100 las reincidencias.

Art. 13. Los penniaos para establecer casas de tolerancia se acordar£n a61o a laa
mujeres inscritas en el dlspensario de salubridad pudiendo concederse para las casas
de citas a unas y a otras indistintamente, con tal de que ofrezcan las garantfas de
orden necesarias.

Art. 14. Los lupanares podrdn instalarse a distancias no menores de una cuadra
libre entre s(, comprendidas ambas aceras. No podriUi serio si dentro de ese radio
existiesen temples, colegios o estableclmientos de educaci6n autorizados. Las casas
de citas asf como las poeutdas se instalar&n s61o en loe parajes que elD. E. autorice.

Art. 15. Queda prohibida la habilitaci6n de lupanares dentro del radio compren-
dido por las calles Fueyrreddn, Callao, Corrientes y Santa F^.

Art. 16. Podri en cambio autorizarse mis de uno por cuadra dentro de la zona
limitada por las calles Necochea, Wenceslao Villafafie y Pedro Mendoza, cuando asf
lo juzgue con^ eniente el D. E,

Art. 17. Esta clase de permisos ser&n anuales e intransferibles y podri retirarlos
el D. J^. por rszones de higiene. moral y orden pdblico.

Art. 18. En los referidoe locales se observar&n fielmentejoe preceptos de la higiene
de la habitaci6n, pudiendo las autoridades exigirles cuantos requisites estimen nec^
sarios para el mejor cumplimiento de ese fin, como paramantener su aislamiento con
lespecto a los domicilios adyacentes.

Art. 19. Todo acto inmoral u ofensiro a las buenas costumbres o atentatorio al
orden que produzcan las prostitutas en la calle u otros lugares ptiblicos, ser& reprimido
por la policia y sujeto a las penalidades de esta ordenanza.

Art. 20. El JD. E. reglamentari por intermedio de la autoridad sanitaria las horas
de trabajo de las pupilas de los lupanares que alojen m^ de doe mujeres y fijari los
deberes y obligaciones que las gerentes tienen para con ellas.

Art. 21. Ninguna persona de sexo masculine puede intervenir en la explotaci6n
del comercio cvnal. pen^^ose con 30 dlas de arresto a la que lo haga, sin peijuicio
de la acci6n judicial que a dicho delito corresponda.

Art. 22. Ninguna mujer puede ser retenida contra su voluntad en un lupanar
cuyas puertas deben estar siempre abiertas para laa que voluntariamente quieran
abandonarlos.

Art. 23. El D. J^. prestari preferente atenci6n a la ordenanza que lo obliga a ha-
bilitar en todas las dependencias hoepltalarias de la asistencia ptibhca, consultorios de
enfermedades \en^reo-sifilfticas.

Art. 24. Prohfbese la prostituddn clandestina cual^uiera que sea el local en que
•e ejerza consider&ndose como tal, la que realizan mujeres no inscritas en el dispen-
aario de salubridad. Lm trannreaiones a esta disposicidn determinarin, la primera
vez. prove nciones de parte de las autoridades samtaiiaa y policiales y las restantea
multas que \ ariardn de 20 a 100 pesos.

Art. 25. La eliminacidn del registro especial que Uevari el dlspensario de salu-
bridad, ]m obtendr&n las prostitutas que comprueben ante la autcxidad sanitaria haber
abandonado el ejercido de la pro6tituci6n.

JOINT SESSION OF SUBSECTION C OF SECTION VHI AND
THE AMERICAN SOCIOLOGICAL ASSOCUTION.

Baleioh Hotel,
Friday mcrning, December 31, 1916.

Chairman, William C. Goegas.

The session was called to order at 9.30 o'clock by the chairman.
The Chairman. Dr. William C. Woodward, of Washington, will
present the first paper this morning.

WAYS AND AfEANS OF BRINGING MATTERS OF FUBUC HEALTH TO

SOOAL USEFULNESS.

By WILLIAM C. WOODWARD,
Eeallh Officer of the Distriel of Cohtmbia.

We can not intelligently consider the ways and means of bringing matters of public
health to social usefulness until we have arrived at an understanding as to the meaning
of the phrases ''public health" and "social usefulness/' and have restated the subject
in somewhat simpler terms.

By ''public health " must be understood the health of the community in the mass.
It includes no element of well-being or of disease that does not appear in some one
or more indi\iduals within the community. Public health is the sum. Personal
health is the unit of which that sum is made up. The difference is in bulk, not in
kind. For the phrase "public health" we may, therefore, substitute simply the
word "health."

The phrase "social usefulness'' is very difficult to define. To me it carries simply
the meaning of usefulnew to ofganized society, usefulness to the conmmnity as dis-
tinguished from usefulness merely to the indiyidual. We can best define it, possibly,
as usefulness to the race as a whole, in the long run, and sometimes without r^ard to
the peiBonal welfare or even the existence of the individual. The word "usefulness "
needs perhaps special definitioQ. Much might be written in an effort to elaborate and
define it, but all may be summed up in the i^irase, "tending to promote human
hi4>piness." "Social usefulness," as I conceive it, means, therefore, simply the
power of adding to the happiness of the human race. Beyond this, in an effort to
analyze this phrase, I can not at present go.

Upon the basis of the definitions just stated, we may restate the problem before us,
as follows: How can we make facts pertaining to health contribute to human happi-
ness? It is the problem as thus restated that I shall discuss.

In order to make facts pertaining to health contribute most largely to human happi-
ness, two things are necessary: First, to establish such facts and to correlate them, so
that we may understand their full significance and the underlying principles. Second ,
to weave those facts into the lives of the people.

The establishment and correlation of the facts pertaining to health has been pro-
ceeding for many years, and never before so rapidly or so satisfactorily as at the present
time. But if there be one thing that modem research has demonstrated, it is the
inadequacy of our knowledge concerning health. Manifestly the wider and more

526

PUBUO HEALTH AND MBDIOINB. 527

accurate our knowledge is, the better we ahall be able to apply it. The increase d
our knowledge is, therefore, the first step to be taken toward making facts concerning
health contribute most laigely to human happiness. In this connection we may well
ask whether the action now in progress toward the increase of our knowledge of health
and disease is as well organized as it should be.

The increase in our knowledge of health is dependent upon the proper correlation
of laboratory studies, clinical studies, and sociological studies. The comparative
recency of tiie development of the biological laboratory as a factor in the production
and promotion of health, the definiteness of its work in this field, and the promise of
large results have attracted to it great endowments and many of the best minds in the
medical and correlated professions. Laboratory wcnrk has, therefore, had a tendency
to outrun ^e work in the fields of clinical medicine and in the domain of sociology.
It must be admitted, howev^, that even laboratory studies could with advantage
well proceed on a scale vastly larger than our available resources will now permit.

While the conservation of laboratory resources would be important under all con-
ditions, yet in view of the inadequacy of such resources conservation becomes of
particular importance. In this field of work, in order that the race should profit
most largely &om it, there should be organized clearing houses for groups of labora-
tories so as to prevent duplication of efifort. Such agencies could easily plan the work
of the related laboratories so as to prevent such duplication. Throu^ them, pro-
vision should be made for the frequent interchange of ideas among the laboratories
working within the same area of research, so as to prevent any one from going over a
field already exhausted by some coworker. Individual workers might be prevented
from holding back the results of ^eir studies in the hope of acquiring personal fame
as the discoverera of some new facts or principles within the domain of their specialities,
personal ambition being compelled to give way to the conmion good.

It is, however, in the field of clinical and sociological studies that our knowledge
pertaining to health is most woefully lacking. As has already been stated, the develop-
ment of the laboratory has s^ved to draw men and resources away from the fields of
clinical medicine and of sociology. It is in these fields, however, that the results of
laboratory work must be applied in order to be made useful, if useful at all, and where
the influence of laboratory research on the practical affairs of life must be measured.
Moreover, it is throu^ studies at the bedside and studies of the living conditions of
men that we must find out what problems are most pressing for solution in the labora-
tory and by which we must learn many of the conditions of life that laboratory research
will never reveal.

In order to make the most from a preventive standpoint of our studies of men in
health and in disease, the clinical histories taken in the consulting room and at the
bedside, in homes, in dispensaries, and in hospitals, must be taken with the idea of
learning not merely wtBi the malady may be but with the idea of learning also what
caused it. This will require the development in the medical profession of a larger
interest in preventive medicine than it now has and the better training of medical
students and of physicians with respect to establidied facts and jmnciples, and with
respect to the prevailing hypotheses concerning etiology. It will require, too,
the supplementing of dimcal histories, as the phrase is now generally understood,
by sociological histories cdlected by social service nurses. Such histories will have to
probe as deeply into the physical past of the patient as the psychiatiiBt endeavon
now by psydianalysis to probe into the past psydiic life of the patient before him.

Post mortem examinations must be made more frequently than is at present posrible,
in Older to reveal conditions not discoverable, or at least not discorered, during life.
It is only by such examinations that a i^yridan can lean where his errors have been
made and successes adiieved, and only by such final audits of the physician's pro-
fessional accounts that he is able to conect in one case the mistakes he made in another.

528 PBOGEEDINGS SECOND PAN AMEBICAN 8GIENTIFIG G0NGBES6.

Our resources for clinical and sociological work are even more inadequate for the
field before us than are our resources for laboratory service. Needless to say, therefore,
^ere is the same need for conservation of resources in these fields that there is in the
field of laboratory service, which might well be brought about in the manner suggested
with reference to the last-named field. Coordination of the work in all three fields is
essential.

The first step to be taken to make the facts pertaining to health contribute most
largely to human happiness is to acquire those facts as speedily as possible by the
enlargement of our facilities for laboratory, clinical, and sociological studies, and by
coordinating all such agencies.

To make the facts and principles pertaining to health, after they have been estab-
lished, most effective in promoting human happiness, they must be woven into the
very lives of the people. This means that the people as individuals must be made to
know them and to feel their relations to personal well-being so definitely and intimately
as to make their knowledge a guide to personal conduct. This can be done through
education, and in no other way. It is the duty of the (Government, therefore, through
proper channels established and maintained by it for that purpose, to weave by educa-
tional methods into the lives of the people all available facts and principles pertaining
to health. There are various ways in which this can be done.

Direct educational methods in schools and in colleges present beyond question
the most accessible and the most potent channel througji which the people can be
reached. Not only is-the machinery for access in this way already well oiganized and
under the control of the Government, but it reaches the mass of the people at a time
when they are most impressionable and when the facts and principles tau^t can be
best imprinted permanently into the minds and habits of the pupils. Through the
schools and colleges, too, there is reached not only the pupils and students in attend-
ance, but through them the homes and the older generations within the community.

It is not sufficient, however, to rely solely upon school and cdlege education if the
masses are to be kept informed with respect to health matters. Some persons are not
able to attend college at all, and many attend even the graded sdiools for short periods
only. Moreover, our knowledge of matters pertaining to health is continuously
advancing, and it is impcartant to bring newly acquired facts to the attention of perscms
who have perhaps long since left any institution of learning. And finally, it is not
always a sufficient basis for individual acti<m that the individual have a knowledge
of the general principles underlying health, but he must have a knowledge of the
particular personal relations of those facts as they exist in his then immediate environ-
ment. For these reasons, popular education in school and college must be supple-
mented by the issue of bulletins concerning local conditions; by pamphlets pertaining
to particular maladies liable to be of immediate interest to individuals, as cancer,
tjrphaid fever, and other maladies; by articles in the local newspaper press, by lectures,
and by exhibits, designed to reach the classes not accessible to education by any of
the methods previously named. All of these must be organized upon a scale as
elaborate as the resources of the community permit, and in event of inadequacy of
such resources, two or more communities may unite in the execution of the work.

It is not enough, however, that the Government teach the community by written
and spoken word. It must teach by example. A government can best preach the
doctrine of pure drinking water from sources under private control when it has
provided a pure public supply. It can best preach the doctrine of clean yards and
dwellings after it has provided for clean streets and alleys and for the removal of city
refuse. It can beet preach the doctrine of clean homes and dean places of employ-
ment after it keeps its city hall, its schools, its homes, and its other public buiMings
clean. It can best preach the doctrine of light and ventilation if its public buildings
are well lighted and ventilated, and if it has laid down an adequate scheme of city
planning and of housing. It can best preach the doctrine of isolation of patients
suffering from communicable diseases after it has provided proper hospital facilities

PUBLIC HEALTH AND MBDICINE. 529

lor persons who must be isolated or quarantmed. Not that any of these things
should be neglected because of the failure of the government to set the example, but
the Government should set the example if possible.

So far nothing has been said of the enforcement of sanitary laws, the making of men
healthy by compulsion, or at least the malring of men to conform to such rules of con-
duct as to permit their neighbors to be healthy. This, of course, is necessary. It
should be looked upon, however, not primarily as a punitive procedure, but rather
an educational process; one that is intended to teach the offender that compliance
with the laws of health are as important as compliance with the laws of property; to
teach him by the penalty imposed for his misdeeds, the importance of proper conduct
in the future, and to make him serve as an example for other possible wrong-doere in
the conmiunity, to deter them from wrong doing.

The whole problem, how to make facts pertaining to health contribute most largely
to human happiness, resolves itself into two things. First, the discovery, correlation,
and analysis of the facts pertaining to health. Second, the making of a knowledge of
those facts a part of the conmion knowledge of the community. For it may safely be
assumed that a conmiunity acquainted with the laws underlying the conservation and
promotion of health will enact the necessary legislation and provide the necessary
appropriations wherewith to carry those laws into effect, and that the individuals in
the conmiunity having such knowledge, will abide by the laws of health so far as lies
within their power.

The Chaibman: The next paper in order is ''What can unofficial
effort do for public health ?" by Prof, Irving Fisher, of Yale.

WHAT CAN UNOFFICIAL EFFORT DO FOR PUBUC HEALTH?

By IRVING FISHER,
Yale Umvenity.

Never in the history of the world was there a time of so much interest in the sub-
ject of health as to-day; never a time when more effort was being made or when the
confidence of the public was greater in the latent possibilities for hygienic improve-
ment. This spirit of optimism goes back to Pasteur. Basing his confidence on his
own experiments, he fint dared to say: ** It is within the power of man to rid himself
of every parasitic disease." His successor, the late Metchnikoff, as boldly declared
that by man's natural birthright he should live beyond the century mark. Some
biologists to-day are even assuring us that there is no inherent necessity for death,
but that death is simply the result of injury, external or internal, usually due to poi*
sons of some kind, llie great Carrel has kept the cell tissue of a chicken alive outside
the body for the past three years by placing it in a proper medium, properly nourish*
ing and periodically cleansing it from the poisons which its own life processes produce
and thereby periodically rejuvenating it also. In fact, these cells can apparently be
thus rescued indefinitely from impending death. Does this experience portend that
when science can teach us how to rid ourselves of life's poisons, we human beings may
also expect correspondingly to postpone death? We have not travelled far in thk
direction. But science has akeady lit up our path far beyond the point at which we
are treading it.

The purpose of the health movement is to apply science, to the end that life may be
lengthened and health during life increased. Lengthened life means added years of
productivity for society, added years in which to provide for old age and added yeaie
of enjoyment for the individual. These years can be an addition, for the most part.

580 PBOOBEDINOS SBOOlfD PAK AKEBIOAK 8CIBKTIFIC C0K0BE88.

to early and middle life. If this be ever actually acoompliahed we shall then have,
as Metdmikoff said, a larger dassof men old in yean but young in vigor— hale, well
seasoned men, but men who will be able to apply their accumulated experience to
our most complicated problems of political and social life.

Any effort to lengthen life results at the same time in the accomplishment of the
second aim — ^increased health during life. Few realize the amount of iUnees con-
stantly in existence. It is estimated in the Report on National Vitality of the Roose-
velt Conservation Ck>mmisBion ' that there are at any one moment over 3,000,000
people seriously ill in the United States, of whidi illness at least half is unnecessuy ;
that every year over 600,000 people needlessly die; and that in cash value alone these
losses of life and working power mean a minimum yearly needless loss to the nation
of $1,500,000,000. Sir Lauder-Brunton, who is inteiested in this problem in England,
has said:

Of this I am perfectly sure, that there is room for improvement to the extent of
something like 100 per cent in all our living conditions: tnat there is room for an im-
provement of 100 p^r cent in the average duration of life; that there is room for an
improvement of 100 per cent in tiie avera^ physical capacity for work; that ihete is
room for an improvement of 100 per cent in the happiness and usefulness of the aver-
age life in the community.

Whatever value we attadi to sudi estimates, certain it is that a large maigin of pos-
sible improvement exists and should be expbited. There are several methods of
exploiting this reclaimable margin of life, but all may be roughly grouped under the
heads of official and unofficial agencies. We are all familiar with the achievements
of the official agencies and all are anxious to have these agencies strengthened. The
city and State boards of health and the United States Public Health Service have done
and are doing wonderfully effective work against infectious disease. I am enthusi-
astically desirous of seeing such work strengthened and extended. One of my fondest
hopes is that some day not only every municipality and State, but every nation will
have its department of health, ably manned and generously supported. If Gen.
Crorgas could reduce the death rate at Panama to less than half of what it was, why can
we not reduce the disease throughout this country, this continent, or the world?
If it was worth ^diile to spend money by the million at Panama to make possible an
engineering project, it is worth while for the United States to epend hundreds of
millions of dollars for the purpose of making possible the pursuit oi all our national
projects, including the simple but important business of living.

To conserve our national vitality should be an official national policy. In empha-
sising the unofficial health agencies, therefore, I am in no sense belittling the impor-
tance of official health agencies. On the contrary, strenuous unofficial effort seems
the only route to the official. The people must show some interest themselves befofe
their c^cial representatives can be expected to make much effort in their behalf.

Unofficial efforts to conserve public health include:

1. The research work of the universities and of the great foundations like the Rocke-
feller Institute for Medical Research, the Pasteur Institute of Paris, the British
Sanitary Institute of London, the Carnegie Nutrition Research Laboratory in Boetcm,
the Memorial Institute for Infectious Diseases in Chicago, the Eugenics Record Office
of Cold Springs Harbor, Long Island.

2. The training of physicians and health officers by medical schools.

3. The practice of medicine and surgery by the medical profession.

4. The service of eleemosynary institutions of all kinds^-^ospitals, sanatoria, dis-
pensaries, milk stations, clinics, and commissicms.

6. The service of sodai workers, and especially of the visiting district nurses.

1 Reprinted as Bulletin 30 of the Committee of One Hundred on National Health of the Ameiioaa
Association for the Advancement of Science, by Irving Fisher.

PUBUO HBALTH AND MEDIOINB. 581

6. The propaganda ot hygiene societies, such as the National Association for the
Stady and Prevention of Tuberculosis, the National Committee for Mental Hygiene,
the National Playground Association, the American Red Cross, tiie American Asso-
ciation tot Labor Legislation, the American Association for tiie Study and Prevention
of Infant Mortality, and the National Mouth Hygiene Association.

7. The efforts toward industrial hygiene by commercial concerns, namely the " wel-
fare work" of the department stores, of manufacturing establishments, and of life
insurance companies.

8. School hygiene.

9. Gymnastics and athletics.

10. Domestic and individual hygiene.

It is clear that the foregoing list includes a vast amount of energy directed unofil-
cially to health conservation. I belieiie that the possible unofficial field for health
work, where a financial backing or a strong commercial motive is present, is enormous
and that we may expect a large effect on the death rate therefrom. A great impulse
has come to su<^ unofficial agencies, especially to those with the commercial motive,
from the workman's compensation acts. The ^'safety first" movement is doubtless
based primarily on this legislation and the resulting desire of employers to reduce
risk of accident to save themselves the expense of compensation. Prior to such laws,
employers regarded the safety of their employees as largely the ''look out" of the
employees themselves. I hope we may soon see a similar and even greater impulse
toward the unofficial safeguarding of human life through the institution of health
insurance, a strong movement for which is now impending. The employer will then
feel that the health of his employees is of direct financial moment to himself and will
soon learn in what ways health conservati<m can be achieved. It will then Appeaa
that not only the working conditions as to ventilation, sanitation, woildng hours,
meal hours, and a living wage are important, but also that the personal habits of
living of employees are of vital concern.

All of this leads me to say that individual hygiene is, after all, the basic hygiene.
Hygiene as well as charity must begin at home. Individual hygiene is especially
important at this time because it has been so much and so long neglected. In the
United States to^y the degmerative diseases are increasing rapidly. I believe
it can be convincingly shown that the chief cause of thiB increasing degeneration is
the neglect of individual hygiene. If we continue to neglect it, the results of this
neglect will in time counteract the good effects accomplished by other forms of hygiene.

Civilization has upset the equilibrium of our natural biologic life. As animals we
instinctively ate what our bodies demanded, slept when we needed sleep, lived out
of doors, exercised because we had to forage for food; but as civilization has advanced
we have more and mc^e altered this mode of living— usually to our cost. However,
to endeavor at this late date to return to this primitive state, as has been sometimes
urged, would be impracticable and, most of us believe, undesirable. It is not neces-
sary that man should give up the good which civilization has brought Mm, but rather
he should find how to eliminate, or at any rate compensate for, the evil. Civilization
has given him houses and with them tuberculosis; he must see that they are ventilated ;
it has given him clothing and with it ddn, foot, scalp, and other diseases; he must
see that his clothing is corrected; it has given him cooking and with it dental decay;
he must see that he gets some hard and some raw foods; it has given him printing
with its eyestrain; he must provide corrective eyeglasses; it has brought division of
labor and with it misthapen and dull workmen; he must see that suitable compensa-
tion and recreation are provided. Such compensation must be a conscious and
scientific process. By unscientific compensation, however, we usui^ly do more harm
than good. Most drug habits are simply ill-considered attempts to compensate for
the wrong conditions of civilization. After a late evening we wake ourselves up with
68436— 17— VOL ix 85

532 PBOCEEDIKGS SEOOND PAN AMEBIOAK 80IEKIIFI0 C0NGBB88.

caffeine; we move our bowels with a cathartic, induce an appetite with a cocktail,
seek rest from the day's ^tigue and worries in nicotine, and put ourselves to sleep
with an opiate. In these practices we are trying in wrong ways to compensate fc^
insufficient sleep, insufficient p^istalsis, indigestion, overftitigue and insomnia evils
due to the disturbance of nature's balance between work, play, rest, and deep.

But civilization ia capable of providing real or scientific remedies for many of its
own evils. One of the most promising movements for the spread of individual hy*
giene is that evidenced in the Life Extension Institute, founded three years ago in
New York City. The fundamental idea of the institute is prevention of disease, and
its methods are medical examination to detect impairments (established or incipient)^
with practical hygienic advice for the unimpaired, or slightly impaired, individuid.
The institute affords such service to individuals, to clubs of individuals, to em-
ployers for their employees, and to insurance companies for their policyholders. It
has recently issued a volume entitled ''How to Live," which gives the composite
judgment of the hygiene reference board of the institute, a body of 93 authorities
in various departments of hygiene. The preachment of the book is compressed into
the following 15 rules:

I. Air:

1. Ventilate every room you occupy.

2. Wear light, loose, and porous clothes.

3. Seek out-of-door occupations and recreations.

4. Sleep out if you can.

5. Breathe deeply,
if. Food:

6. Avoid overeating and overweight.

7. Eat sparingly of meats and eggs.

8. Eat some hard, some bulky, some raw foods.

9. Eat slowly.

III. Poisons:

10. Evacuate thoroughly, regularly, and frequently.

11. Stand, sit, and walk erect.

12. Do not allow poisons and infections to enter the body.

13. Keep the teeth, gums, and tongue clean.

IV. Activity:

14. Work, play, rest, and sleep in moderation.

15. Keep serene.

Another contribution by the institute consists of its reports on the alarming extent
of personal impairments discovered through its examinations. Two series of examina-
tions made, one of 1,000 industrial employees of a motor manufacturing company in
Detroit and the other of 1,000 commercial employees of New York City, revealed the
following facts: *

Disease.

Commercial
employees.

Organic heart ,

Thickened arteries

Urinary ,

High or low blood pressure

Functional circulatory

Hinorurinarr

Digestive disturbances

Constipati<m

The enonnous number with thickening of arteries includes a majority of cases in
which the thickening is hardly perceptible and therefore discovered in time to be
laigely checked.

PU6LI0 HEALTH AND MEDICINE. 533

I hAve recently completed a etndy of the longevity of the Preeidents, Senaton,
and Reproeentativee in the United States. The average life of the Preeidenta after
inauguration is below the average in the country and considerably below that of
insured lives; moreover, it is steadily diminishing. Dividing the Presidents into four
consecutive groups covering four periods of about equal length, we find the average
ratio between actual after life and that "expected " (according to ''American experi-
ence table") to be 156, 84, 75, and 45 per cent. The Presidents in the last group
averaged only 9 years in Ufe after inauguration where they should have averaged 20
years. As to Congressmen, we find that, in terms of the American experience mor-
tality table, the mortality in the first two years after election was 59 per cent, in the
next eight years, 99 per cent, in the next 10 years, 107 per cent, or in terms of modem
insurance experience 79, 132, and 143 per cent, respectively. In other words,
Congressmen at first have an exceptionally low mortality and afterward an exception-
aUy higk mortality. Dividing our national history into four periods we find the same
general tendency to an increase in mortality as we found among Presidents of the
United States, althou^ not so pronounced.

The upshot of all our studies is that modem Ufe is sapping our vitality in an unpre-
cedented manner, this effect being felt by an increase in total mortality in middle
life and a great increase in the degenerative diseases. These difficulties all require
the application of individual hygiene. Without such individual and unofficial appli-
cation of health principles, the woric of our health boards can never cope with the
situation.

Such a reform in hygiene implies a change in the "mores" of society instead of the
acceptance as norms of those which now exist. Unhygienic customs and fuhions
are exceedin^y slow to yield, but they do yield in the end. The great desideratum
is the development of higjh national health ideals in individual, public, and
race hygiene (or eugenics), equal to and superior to those of Sparta and Athens. When
we build our civilisation on health, we are giving to it the surest foundation. In
short, health, both as to hygiene and eugenics, must be, as Sir Ftands Galton said,
our social religion.

Dr, George M. Kober took the chair.

The Chairkan. The next paper on the program to deal with this
topic is by Dr. Dearholt, of Wisconsin.

WHAT CAN UNOFFICIAL EFFORT DO FOR FUBUC HEALTH?

By HOYT E. DEARHOLT,
Milwaukee, Wi$.

When Prof. Ross asked me to prepare a paper for this meeting, he asked me to
consider primarily what could be done for individual or personal health. This I
attempted at first to do, but personal health is but a fraction of public health and is
very largely dependent upon the general acceptance or rejection of a popular
standard of what health consists of and how it may be secured. Personal health,
furthermore, should lie in the province of medical science, but medical science, in
turn, is dependent upon the support and patronage of the public. Two things,
therefore, constantly rose to the top— first, that correct public taste and popular
standards must be greatly stimulated, and, second, that unofficial health agencies
serve best when they conceive themselves to be hi^-grade promoters of the official
public-health agencies which will thus come into being in the future. Whether this

534 PBOOEEDINQS 8BG0ND PAN AMBBIOAN BOIBSTHFIC C0NGB£88.

will be the immediate or a remote future will depend upon whether that promotion
ifl well or poorly done.

The greatest buainesB enterprise in the country to-day is the life-aaving enterpciie.
Undeveloped though it is, it yet gives convincing proof of its value as an investment,
sure to bring huge returns to every investor— «§ it did most emphatically in Havana
and Panama. It is a big business and as such has a right to share in the comer winck,
big business has on money and men. It ought to be adequately financed and it ought
to be administered by the type of competent worken that are now handling other
big business enterprises. That it is not thus adequately financed and administered
is due to the fact that it is a comparatively new business, one in which supply and
demand are just beginning to find each other ^d between which there is as yet no
oiganized relation.

Supply there is in abundance, scientific knowledge which if utilised would, aocofd-
ing to Irving Fisher and other analysts, Increase man's ^pan of life by at least 15 years*
Demand there is assuredly, for no one is stupid enough to refuse to recQgniae the
tenacity with which humanity clings to life even under most discoungii^ coodi*
tions. On one hand we have millions of people anxious for life and health. On the
other hand we have the scientific knowledge which may be translated into terms el
life and health. But it needs to be translated, mind you, as well as transferred from
one hand to the other, and so it is especially important for us, in striving to perfect
the organization of this gigantic business, to sit down tegether and take stock.

MUST DSVBLOP ▲ MABKBT.

The first thing that the successful business man must do after he has secured a
worthy article to market is to know the field and to undeatand the public with which
he expects to deal. He must stimulate a demand for his goods. They are of no
value to him or to anyone else packed away on his shelves. The inventions of an
EdiBon or a Bell might as well have remained in their brains as in the laboratory.
It is only as they are utilised by the people that they are el real value.

There is enough scientific knowledge in existence to materially decrease the death
rate within a year but for the most part it is packed away in universities, in lab<»m-
tones, in dusty report files, and within the covers of books written for and perhaps
jread by the elect few but absolutely unintelligible to the lay mind.

To bring about a lowering of the death rate that knowledge must reach the consumer
in a form which permits and encourages its ready use by him. There are millions of
people literally dying for lack of that knowledge. Why? Because the scientists and
the people are at opposite poles. They need an electric current to bring them into
communication. They do not speak the same language. They need an interpreter,
a middleman, and this interpreter must know the 1ang^l^ge of both. He must have
something of the quality of the electrifying current, and he must never lose sig^t
of the fact that the translation of knowledge into life and health is a business propo-
sition and that he can not hope for success unless the best methods of distributioo
known to the business world are employed.

MIDDLBMAK 18 NEBDED.

It is no small task, this of the medico-sociologist, for I maintain that this job €i
bringing medical science and human need together is the job of the medico-eociologist.
Mistakes which were made when medicine and sociology were first hyphenated and
entered upon this wholesale enterprise of preventing disease and prolonging life —
mistakes of a kind which are inevitable in the early development of any enterprise —
will become fewer and fewer as the hyphen becomes shorter. Our medical men
need to be better sociologists and our sociologists better medical men. To be sue-

PUBUC HEALTH AKD MEDICIKE. 535

ceesful dutributen of health information, as a commodity, they must know the field,
learn the public with which they must deal, profit by the mistakes which have been
made, and recogtnze how much knowledge the public has and how much of falsehood
^e people must unlearn before their true health educatbn can begin. To under-
stand conditions and to meet them e£fectively, one must recognize them as the
natural and logical result of the evolution of medical and social science.

The healing art was one of the first of the arts utilized and cultivated by man. Its
practice, in a primitive form, began when the first thorn was drawn, the first bruise
was rubbed, tiie first outside assistance was given in the birth of an infant. The
development of medicine as an art and science began when man first put his powers
of reason, imagination, and observation to work and began the accumulation and
recording of his own and others' experiences in disease and health.

And, yet, while medicine is one of the oldest of the arts and sciences, it may almost
be said to be one of the youngest, for modem medicine, dating back seventy-five
years to the time when Pasteur opened up new vistas by the discovery and proof of
the germ origin of disease, is an almost complete reversal of old-school methods. This
discovery gave the scientist a new conception of disease and a new motive for his
labor. Where once he sought remedies he now seeks and finds causes with the result
that scientific medicine has developed more in the last seventy-five years than dur-
ing the entire previous history of man. I would not be understood to suggest that
Hippocrates, Galen, and hosts of other early medical scientists did not seek to learn
and understand the cause of disease, because they did most earnestly, but for the
most part they groped in the dark and their efforts brought pitiably small return
for the efforts expended. The public mind to-day, and quite naturally, is a cha-
otic mixture of the old and the new. It desires health but it has not yet awak-
ened to the importance of going to the root of things, of removing the barriers to
health. It is still seeking remedies, a ^t for which the old medical science
together with the conditions under which our entire civilization has developed is
responsible.

The hold which the patent medicine has on the purse of the general public, for
instance, is not at all unnatural when one stops to consider how largely we are a
nation of pioneers and how recent was the time when the inhabitants had to depend
for all of their needs upon the supplies they carried with them. Each section of
pur vast continent has been settled by hardy men and women. If they had not
l>een made of stem stuff, physically able to endure great hardships, they would have
stayed at the homes established by their fathers and mothers. Instead they went
forth into the wilderness. They lived under primitive conditions. They worked hard .
They went to bed early. They lived in the open. The streams were unpolluted
and houses were so far apart that a natural quarantine existed against the spread of
any contagion accidentally introduced. Manual labor served as an antidote for their
many violations of cardinal laws of personal hygiene. They were not of the type
to give much thought to minor ailments. For such medical needs as theirs an oint-
ment or salve for cuts, a linament for aching joints and muscles, and a ready-to-
serve so-called "blood purifier" or "spring tonic," the only virtue of which lay in
Ae purgative which was its main ingredient, sufficed.

As population increased and the pioneers acquired the age and leisure iar illneBs;
when the scars of early exposure and hardship began to ache, a demand for the special-
ifeed labor of physicians was created. Up to this time the highest medical skill of the
frontier community was held by the minister, the teacher, the blacksmith, or ft
neighborly old grandmother, as the case might be. Such spedal information as these
Iteople had they gained, at the best, from a volume written by some physician for
those of our early inhabitants who had need or desire to practice self-medication;
at the worst, from some pseudo-scientific, quacHsh patent-medicine circular. Always
and everywhere the search for the panacea or specific remedy continued.

536 PBOOEEDINOS SEOOin) PAN AlCEBIOAK 80IBKIIFI0 00K0BB88.

FBBLINO THEIR WAT BLINDLY.

Then came the era of proprietary medical colleges with their self-styled professon
to whom teaching was a mere incidental to their private practice and who had too
frequently founded the school for the prestige which it would give them among
prospective private patients. They often had little scientific knowledge or training.
Under their direction students who had peihaps served an apprenticeship in the
service of an older pioneer physician, taking care of the stables, milking the cows,
and performing other services for the privil^^e of gathering a few crumbs of knowledge,
took up a year or two years of didactic lectures and study. In these colleges, which
for a time overshadowed better class schools and which are happily decreasing in
number through the efforts of the medical profession, medicine was taught and
learned for the most part as a trade or a craft. Here again thought was centered on
remedies.

With pioneer physicians and pioneer patients — ^many of whom still survive and
talk with assumed authority and the self-reliance of the departed pioneer days— it
is not strange that they have contributed and still continue to contribute much stub-
bornly resistant misinformation to our present fund of popular knowledge concerning
the nature of disease and the real conditions which are responsible for health. When
we consider the sources from which additional contributions have been received, it
is not surprising that popular knowledge of medicine should be so strange and com-
plex a mixture of profound knowledge, much useful information, considerable mis-
information and an enormous amount of abject ignorance. Universities, research
laboratories, old wives' tales, quack advertisements, correct and incorrect inter-
pretations of personal experiences, superstitions, religious pseudo-philosophies
and countless other influences by which we are surrounded have each and all added
their grain to the common grist.

Nor must the scientist be too intolerant of this popular misconception for the im-
pregnation of which he is partially responsible, too resentful of a lack of Mth in a
science which up to recent years was largely speculative and in which empiricism
has played so large a part, too reluctant to recognize his own responsibility for the
foilure to disabuse the public mind of much of its misinformation and superstition
and to give it real knowledge instead.

And yet we modems must not find too ready fault with our fathers' tendency to
consider medical knowledge dangerous to but partially informed laymen, llieir
days were the days of complex hypotheses as to disease causation and the complex
prescriptions for their treatment. None realized so well as they the pitfolls that
their unstable science held for light thinkers who, when given an inch of theoty,
assumed an ell of fact.

TUBBROXTLOSIS CAMPAIGN BLAZBS NBW TRAILS.

Tuberculosis, the first of the big disease problems tackled in opening up the field
ci social medicine, has taught us many things. When the medico-sodologists started
out to save lives which the doctors by individual effort had failed to save in sufficient
numbers, they made some costly blunders. They naturally began their studies of
the disease in the thickest centers of the plague and because these centers were in
the tenement-house districts of the large cities where there were large numbers of
people huddled together in poorly ventilated and illy lighted rooms— povwty stricken
and frequently exploited by rapacious employers and ground down by avaricious
landlords— they jumped too far toward the conclusion that tuberculosis is caused
principally by these conditions; that it is almost exclusively the result of bad housing
conditions and oppressed labor. They mixed cause and effect somewhat. They
did not know, or ignored the fact, that in rural districts, where houses are so few that
one may look for miles out of the window, surrounded by sunlight and fresh air,

PUBLIC HEALTH AND MEDICIKB. 587

where there ia seldom a landlord and bread hunger ia practically unknown, tuber-
culosis exists almost if not quite as much as it does in the crowded tenement. They
failed to realise fully that ignorance is the most fundamental ingredient in the disease-
breeding conditions, and they made many other mistakes, the undoing of which still
embarrasses the antituberculosis campaign.

Tlie moce recent study of the in&mt-mortality problem shows signs ci repeating a
similar erwr, of jumping to the conclusion that babies die almost solely from the
poisoning of decayed milk sold by soulless merchants whose only thought is profitable
trade. As our studies progress, we shall find that babies die almost as readily in the
country aain the city and that the infant death rate ishig^, not because milk is decayed
and mothers are exploited in industries, though these may be contiibutary facts to
be deplored in many instances, but because back of all other causes lies the funda-
mental one that mothers and fathers do not know— that the country mother and father,
for instance, have given less thought to scientific baby culture than they have to
scientific agriculture.

lONORANCB THB CAUSE, EDUCATION THB BBMBDT.

Having, I trust given sufficient indications of my belief that ignorance is the funda-
mental cause of preventable illness and premature death, we are ready to consider
for a moment the remedy that I hold to be specific. If ignorance is the cause, educa-
tion is obviously the remedy. Education in this application is to me synonymous
with advertising and publicity, its purpose being to bring supply of knowledge and
the demand for it together. Tistributing medical knowledge is a much easier task
now than it would have been in an earlier generation, for established scientific truth
is almost foolproof and may with safety be taught to the people at large. But all that
is being taught to-day is not established truth, and this brings me to a warning that
in my estimation can not be overemphasized or repeated too often. In our dwellings
with publicity we must realize that we are handling a powerful therapeutic agent
which has infinite possibilities for evil as well as for good, and we must constantly
be on the guard against dispensing as fact anything which Is not firmly established
as fact. Otherwise, the gjiosts of exploded theories will rise to plague and hinder
us to the end of our days.

This has been true in both the antituberculosis and child welfare campaigns and
yet in spite of the errors, in spite of sensational misstatements which have been made
by zealous workers, eager to shake the public from its apparent indifference, these
two campaigns have proved one thing beyond all question — the power of publicity
in public welfare work, as a means of stimulating the people to make needed provision
for the prevention and treatment of diseases which are a social menace and as an
influence in molding personal habits to conform with the established laws of health.

MUST AOVBBTISB HBALTH WAEBS.

The better the middle man lives up to his opportunity in translating knowledge
into terms of life and health, the more succeerfully he adverUsee the wares of the
•dentists in language which the ultimate omsumer, the common people, can under-
stand, the greater will be the demand for those wares. Temand inevitably stimulates
supply and this will prove as true in social medicine, the attempt to idiolesale the
benefits of modem science to large groups of pec^le, as it has in the history of business
aince the beginning of time. In order that the constantly growing demands of these
large and constantly growing groups of pec^le may be met, the scientist must go on
inventing and discovering.

As the demand for an extension of life and an increase in health becomes better
defined and more insistently expressed, new incentives will be offered to researdi
laboratories and clinics for new discoveries in cause and cure of disease. More money

538 PBOCEEDINGS SECOND PAN AMEBICAN 80IBNTIFI0 00NGBES8.

will find its way to the purchase of equipment and the hire of bnins to increase the
supply and to refine the product of life-saving means. As this development take0
place the scientist must not be content to pack his goods away in the storehouse and
depend upon the demand to search them out. He must cooperate in every way in
this genend program of publicity and he must appreciate that the type of ability
which exploiU is as worthy of respect and renders as large service as the type of ability
that invents. Each has its place. But sddom will the two types be foimd together
in the same man.

The maker of a popular breakfast food does not content himself with its manufac-
ture nor with the hiring of a few salesmen to go out into the field. He buys page^ of
advertising in magazines of the largest circulation and he hires the beet advertising
man he can get to talk his particular breakfast food to the people in a way that makes
their breakfasts incomplete without that food. He educates people to demand his
wares, and every person thus educated becomes not <mly a customer but a sales
agent. Every request for the food at the store helps promote a sale f<x the factory*
No merchant refuses to deal in the goods which his customers want.

HEALTH BALBB STIMULATB SCIENCE.

A similarly well managed advertising or publicity campaign in wholesaling health
information, in which false statements and false assertions are recognized as poor
advertising and in which scientific truth and accuracy are not sacrificed for the sake
of a well sounding phrase or an attention arresting headline, will bring similar results,
like the storekeeper to whom the reader of the popular magazine goes for his break-
fast food, the general practitioner will have his equipment tremendously increased
by this education or stimulated demand of the people. The public, enlightened and
with its hunger aroused, will demand new things of him, better service from him. To
hold his patient, and his honorable position in society, he in turn will be stimulated
and enabled to deliver a better quality of service to his patrons. And as these patrons
grow discriminating in taste and more appreciative of real values he will be encouraged,
rather than discouraged as he now frequently is, to draw increasingly better wares from
the storehouses of scientific knowledge.

Market reports on the automobile industry to-day indicate that enormous manufac-
turing plants in which millions of dollars have been invested and which furnish employ-
ment at high wages to thousands and thousands of skilled mechanics, are unable to
meet the natiual and stimulated demand. Yet the first auto ever made was a crude
affair; the demand for it a vague impatience with the slowness, inconvenience, and
other drawbacks of our old methods of transportation . With the use of the automobile,
the demand took definite form as may be proved by consulting any office where mort-
gagee on real estate are recorded.

So it is with health. We are impatient with the restraints of spirit that are imposed
by disordered bodies. Put health on the market, advertise it as the automobile was
advertised, and that impatience will take concrete form as an unmistakable demand
for health service. With that demand will come better recognition of those who are
giving the service. But the demand must come from the people. Before it comes,
the people must read aright their impatience with present conditions and to read
aright people must be taught by those who know.

In the short time that remains, I have but brief space to consider publicity media,
the various avenues through which knowledge may reach the consumer.

VALUABLE PUBLICITY AGENCIES.

Unquestionably the newspaper still remains the most effective and &r reaching
means of spreading popular information and knowledge. Popular magazines are also
doing splendid work in this direction. Before they will fully meet our needs, how*
ever, their editors must come to see that the interests of their publication and their
own ethical standards demand that only what is established truth shall be printed.

PUBLIO HBALTH JLND ICBDIOIKS* 639

Enlightened veaden and influential advertiBen would demand no leas. Thla will lead
almoet inevitably to the employment of specially qoalified men on the staSts of newe-
papoTB, men vened in medicine and sociology and at the same time men who appre-
ciate the demands and limitations of newspaper patrons.

To-day the newspaper is being hard pushed for first place in popularity by the
movie. Here is a field of vast educational possibilities that has barely been scratched
as yet. As in the newspaper, it will be necessary that scenario writer, the producing
director, and actors be guided by an appreciation of the dramatic limitations of
scientific ^t and that the educator in turn shall also appreciate the possibilitiee and
limitations of this means of popularizing the truths he wishes to teach. That this
medium will replace the justly popular exhibits which have been employed may be
expected— and just as the most popular purveyors in illustrated lectures have heen,
forced to substitute the cinematograph for tiie stereopticon so must charts and ordinary
exhibit illustrations gradually give way to, or meet the competition of modem pho-
tography and the most exact method yet employed to visualize conditions and things
as they exist.

The spoken word has not lost its appeal and it is doubtful if good speakers with a
popular subject and skill in the use of the tools of their trade will ever fail to attract
and interest good audiences of thoughtful people. As in all fields, however, we
must be prepared to meet stiff competition.

FtoipUets, circulars, bill posting, and placarding all have their place in the exploi-
tation of other commodities and have in thb— but we must be prepared to compete
for attention with the clever literary and typographical composition, attractive
illustration and printing by means of which purely commercial concons attract
patronage. There is no more attractive businees in the world than the life-saving
business, none that has stronger selling points. It lends itself admirably to every
advertising medium tried and accepted by big business men and has endless oppor^
tunities in schools, churches, dubs, and other organizations from which busmess is
more or less succeofully excluded.

6TATB MSDIOINB TBLX UIAIMATB BOLUTION.

Sooner or later health service must be available to all, to the rich and the poor, to
the ignorant and the knowing. Ultimately, of course, this will lead to state medicine
just as surely as the volimteer fire company paved the way for the modem fire depart-
ment paid by the dty to protect propefrty without waiting to learn if the owner desires
or is willing to pay the high cost of a fire run or his prorated portion of the overhead
cost of the department. Disease prevention must ultimately come to be considered
as much a part of community enterprise as fire and police protection.

Before democrades will assume the responsibility of looking after the private health
as well as the private property of their citizens, however, the people themselves as
sovereigns must be taught. Obviously, this must be done by unofficial or vdunteer
agendes. Private enterprise must pave the way and firmly establish the demand
for health educational service before the public will take over its control.

This, then, is our task, the task to which various health associations and agende»—
some competent and some only well-intentioned — are devoting themselves. It is
an obligation which must be met by unofficial effort whose responsibility ends only
when and where official effort is ready and competent to take its place.

The Chairman. The next paper, '* Social medicine and work prob-
lems in the Argentine Republic," is by Dr. Enrique Feinmann.
The author is not here, but the paper will be presented by Dr.
Sarmiento Laspiur, of Buenos Aires. Will Dr. Guiteras please take
the chair ? After the presentation of this paper, the formal discussion
of the symposiimi topic will naturally take place.

540 PBOCEEDINGS SEGOin) PAN AMEBIOAK 80IENTIFI0 C0KGEE88.

LA MEDICINA SOCIAL T LOS PROBLEBfAS DEL TRABAJO SN LA BSPO«

BUCA ARCXNTINA.

Por ENRIQUE FEINMANN,
ProfuoT del CoUgio Nacwnal y Escuela Normal de Buenoi A%re$, Argentina,

CAPfrULO I. — ^LA CliNICA M^DICA Y LA LERISLACI6n DEL TRABAJO.

I. La medicina social inicia en nueetro amblente la evoluci6n cientifica de las
grandee cuestiones que promueven el mejoramiento obrero y popular.

Actuaknente las reclamaciones proletarias son mucho menos una aspiracidn
tendencLosa o partidista, que una preocupaci6n serena de todos los eepfritus haciA un
grado mayor de cultura y de bieneetar colectivo. Revisten este car&cter todas las
conqiUBtas pacificas del trabajo, alcanzadas hasta ahora, deede el h(»aiio fisiol^co
de ocho boras que rinde mis y gasta menos la vida humana que el borario minimo de
sol a sol de los antiguos, basta el descanso hebdomadario substituyendo como ley civil
el precepto dogmdtico y religioso.

Por otra parte, el eetudio de la vida y de los f en6menos sociales ba creado y estimula
cada vez mis, en todos los pueblos civilisados, esos sentimientos natundes de aimpatia
y de solidaridad bumana.

Sobre la diferencia de clases se sobrepone un inters mis alto de con8ervaci6n y de
defensa mutua, que nos Ueva a ver en cada existencia un factor natural de progreso
o de peligro. La orientaci6n biol^ca de todas las ciencias polftlcas consiste en
abarcar el conjunto y el detalle de estos dos f actores sociales; la det^minante bistdrica
suele ser el punto de vista jurfdico y econ6mico, en vez que, a la medicina y a la
bigiene las gulan sus propioe principioe fisioldgicos de perfeccionamiento bumano
universal e incesante.

Desde mediados del siglo pasado, parecen acentuarse en todos los paises civilizados
ambas maneras de gobiemo. En Alemania, vemos a Bismarck anticipando los
seguros obreros, con que obtiene tan f ecundos resultados para el porvenir de su gobiemo,
y deede hace poco llama la atenci6n en Inglaterra, su primer hombre de estado, Lloyd
George, que eleva la protecci6n obrera a todos los beneficioe de la legislacidn del
trabajo y de la medicina social.

Respecto a eeta dltima, nace con el determinismo cientffico modemo, sQgtln el cual
los origenes de las enfermedades son debidos a causas materiales diversas, ajenas
completamente a toda idea de fatalidad o de castigo celeste. La concepci6n determi-
nista de la patologfa viviente, ba revolucionado en gran parte la medicina y la bigiene,
dando una nueva fisonomia y finalidad a ambas ciencias elevindolas de su funcidn
exclusivamente individual y privada al rango de una funci6n eeencialmente pdblica
y social.

Al mismo tiempo el conocimiento cada vez mayor sobre la etiologfa de las enferme-
dades, indujo este otro principio trascendental para nuestra salud; que las enferme-
dades son en su mayor parte "evitables," con tal de modificar, combatir y mejorar
las condiciones en que ^stas se producen.

II. Tratindose del trabajo, la medicina social tiene una misi6n adn mis uigente que
desarrollar. Desde luego, porque el sujeto de trabajo se balla casi siempre expueeto
a diversos peligros inberentes al desempeflo de su profesidn, y ademis, porque enfermo
a voces individualmente, se convierte en foco de infecci6n para los demis.

Las enfermedades profesionales en efecto, pueden ser de indole microbiana y conta-
giosa, como la tuberculosis, la viruela, o el t^tano, que revisten, por lo general, formas
agudas y ruidosas; otras voces son intoxicaciones lentas y prolongadas, que pasan
inadvertidas. Estas dltimas, acompafian a los obreros que se exponen diariamento,
por raz6n del oficio, a la absorcidn constante de distintas substancias nocivas a la salud.
A la larga, esos venenos industriales revelan su efecto sobre el organismo, provocando
invalideces mis o menos graves, temporarias o permanentes, con incapacidad una
voces completa y otras incompleta para el trabajo, y a menudo la muerte.

PUBLIC HBALTH AND MEDIOINB. 541

Estas clapes de materias t6xica8 utilizadas por la industria moderna, son por cierto,
numerosas, entre ellas, el plomo, el mercurio, el ars^nico, el fdeforo, el eulfuro de
carbono, la bencina, el cian<3geno, los gasee irreepirables y venenosos, los virus de la
viruela, del carbunclo y del muermo, los polvos de la atm6Bfera y muchos otros que
wrfa largo mencionar.

AdemiB de estoe envenenamientxM lentxM por acci6n inmediata del agente cauaal,
liay otras afecciones ocacdonadas por ciertaa pricticas industriales que deben Ber
iguahnente consideradas como enfermedades profesionalee.

Tales son, los trastomos que produce sobre el oiganismo el ambiente de trabajo,
como son "la enfermedad de los caissons" por el aire comprimido, las altas tempe-
raturas, la humedad y ciertas afecciones como la "sordera de los forjadores/' las neu-
moconiosis y las puknonias, que atacan a los obreros expuestos a respirar ciertos
polvos y escorias, y hasta muchas alopecias y dermatosis rebeldes, provenientes de
la lus de los rayos Roentgen o de la manipulaci6n de sustancias irritantes para los
ojos, para el cabello o para la piel.

Por Ultimo, hay un grupo de enfermedades panudtarias y contagiosas, que parecen
no tener a primera vista, ninguna relaci6n con el trabajo. Sin embargo, dependen
de 61, segdn queda comprobado para la anquilostomiasis, llamada con raz6n "anemia
de los mineros," el antrax y el carbunclo, la "enfennedad de las curtiembres," el
muermo y la viruela entre los que se ocupan en la preparaci6n de los virus respectivos.

A voces las industrias insalubres no constituyen por sf mismas causas eficientes y
directas de la enfermedad, y 6nicamente son factores predisponentes, en cuanto
manlienen a los individuos en malas condiciones para resistir los contagios habituales.
En primer tannine, para la tuberculosis que hace sus mayores estragos en las pobla-
ciones de los talleree y de las f&bricas; luego en ciertos ambientes geogr&ficos como
en los del Norte y literal argentinos, la malaria o infecci6n paltidica, hacia los tr6picos
la fiebre amarilla y las disenterias, y en otros palses el edema maligno, el escorbuto
y las fiebres infecciosas.

III. Esta breve exposici6n sobre la patologfa del trabajo sugiere Idgicamente un
concepto de rieego profesional que corresponde por analogfa al que se admite en la
actual jurisprudenda para los accidentes del trabajo.

Ahora se tiende a trasladar ese criterio del "riesgo accidente o infcHrtunio" al
campo de la enfennedad, equiparando o acercando el rie^go profesional a enferme-
dad con lo cual no entendemos confundir el accidente con la enfennedad profesional,
aaimil&ndolos en una f6rmula estrecha, siiM) que deseamos extender segdn lo peimite
su naturaleza misma, de uno a otro terrene su verdadero criterio clinico y medico
legal.

Admitiendo, en principle, que la industria que produce un mal debe repararlo,
•e desprende 16gicamente su ind6mnizaci6n, expresada ya en el C6digo Civil argen-
tino, aunque en una forma poco predsa e insuficiente. De cualquier mode, la juris-
pfttdencia nacional admite la justicia reparadora en los cases de accidente agudo en
el trabajo; con lo que hemes expuesto, nadie negari que el mismo concepto merece
la enfermedad profesional, que es, en definitiva, un accidente cr6nico o subagudo del
trabajo.

Si no se admite esa analogfa del riesgo profesional infortunio, a lo c(tte seguiremos
denominando " riesgo enfermedad," se llega forzoeamente a una incongruenda muy
sensible : que la elaboraci6n de una misaui substancia podri dar o no derecho a una
indemnizaci6n, segdn resulte el mecanismo por el cual produce la herida, la enferme-
dad o la muerte.

Asf sea el case del sulfuro de carbono que se inflama repentinamente y quemaal
operario; ^te se acogeril al amparo fijado por el C6digo o por la ley, pero si se intoxica
con el mismo gas, a la larga, poco a poco, su invalides no merece la menor considera-
ci6n.

Esta desigualdad en la aplicacidn de un mismo principio, es un error evidente que
no se justlfica, pues el rieqgo enfermedad profeoonal, tiene su ocigen en la actividad

542 PBOCEEDINOS SEOOlfD PAH AMBXIOAK BdJeHTUTlO 00KGBB88,

de la vida industrial exactamente como el infortunio profesLonal; y trat&ndoee de
atenuar bus fatalee coiiBeciienciai, uno y otro deben equivalene a los efectos de la
indemmzaci6n por la integtidAd (M^inica, psfquica o dinimica del individuo.

IV. Sobre estos tres t^nninoe clinicoe de la cuesUdn, ha de rescdvene en definitiTa
nuestra primera legisladdn del trabajo. La medicina social, su concepto supeficv de
las enfermedades profesionales y el rieogo-enfennedad, ya demostrado, ban de pro-
IK»tionar los principaleB argnmentoe para la suici6n legal.

Tor abora, noe es grato comprobar que nuestro parlamento ti^:ie para sa estndio
varies proyectos de ley, entre elks de los doctores Escobar y Paiacios, que abarcaa
en toda su amplitud estos conceptos modemos del problema.

Desde su primer artfcido, el proyecto de ley del ex-diputado Alfredo L. Paladoo,
ledentemente despachado p<v la Cdmara de Diputados, expresa que los patronoa
estin obligados a indemnizar a su obr^os y empleados, cuyo salario no exceda de
8,500 pesos, por los accidentes que sufrieran por el hecho o en ocasidn del trabajo que
ejecutan por cuenta de aquellos.

Tambien serin responsables, agrega, de los dafios que se les causare en la explotaci6n
de las industries que por su naturaleza puedan detenninar enfermedades agudas a
intoxicaciones cr6nic9s.

Con eso, el legislador conf fa justamente en resolver desde luego para nuestro medio
mill6n de obreros, la amenaaa constante del infortunio, del dolor y del desampaio.

Las dfras estadfsticas serfan al efecto, de una elocuencia incuestionable. Baste
decir que sobre esa poblaci6n, la morbilidad apuntada el afio pasado, habiendo
requerido asistencia en hospital 24,678 enfermos, de los cuales 15,134 fueron varones
y 9,544 mujeres, mayores todos de 10 afios; adem^ que la mortalidad credente afio
por afio ha aseendido a 14,062 de los cuales 8,562 coiresponden a varones y 5,500 a
mujeres.

Esperemos que la vi£i6n de tantos hogares expuestos a todos los conflictos econ6mico0
y morales imaginables, imprceionen el espfritu de nuestros hombres de gobiemo.

Felizmente el momento histdrico es propicio y el ambiente no puede estar mejor
preparado para recibir de parte del estado ese testimonio superior de previBi6n soda!
que lo incori>ora al movimiento m^ simp&tico de la modema democracia.

V. Sintetizando el prop^to dfnico y m^ico social de este estudio, fcnmulamos
el proyecto de creaci6n de un servido hospitalario, destinado a la observad6n y
experimentaci6n dentffica de la materia que nos ocupa, y que proponemos, como
se verd, en la siguiente nota, elevada con fecha de 23 de marzo de 915 al Intendente,
Munidpal de la Capital, Dr. Arturo Gramajo.

"SeiJor Intbndentb: Tengoel agrado de dirigirle la'presente comunicaci6n, para
fundar brevemente por escrito, el proyecto de creaci6n de una Sala de "Clinica del
tiabajo y enfermedades profesionales, " que he tenido el honor de proponerle ver^
balmente durante nuestra entrevista, del 15 del corriente; y que ha mereddo, sa
m^ auspiciosa y favorable acogida.

El prop(5flito de la iniciativa, como recordadl el sefior intendente, es de propiciar
en nuestro ambiente, el eetudio de uno de los capftulos m^ interesantes de la medi-
cina modema, cual es el que se refiere al diagn<56tico, tratamiento y jtrofilaxia de los
accidentes y enfermedades del trabajo. Hasta ahora, no cxiste en nuestros hospitales,
ningiin servicio, destinado a ese fin. Los obreros y empleados, en general, victLinas
de una u otra manife8taci6n de sus oficios, se asisten, en diversas cHnicas dd municipio
diBpereando, entre ellas, las ensefianzas y consecuencias que su conodmiento des-
prende. El ideal en este punto, como tuve oportunidad de manitotarle, seda la
fundaciiSn de un hospital poucllnico especial, tal como exists en Mil4n, por ejemplo;
pero como en eso no se puede pensar por ahora, y hasta tanto sea posible, le proponfa
nabilitar, simplemente, un servicio ae 40 a 50 camas, en un hospital municipal, que
sin el menor g^to, pues, no aumentarla el presupuesto global del mismo, se destinara
a redbir de los dem^, los enfermos con dolencias del trabajo, acerc&ndolos a un solo
dtio de investigad6n, de experienda y de observad^n cientifica.

A este respecto, sefior intendente, creo que la pr6xima le^8lad6n nadonal de
protecci6n y previBi6n obrera, que no puede taroar en sancionarse^ siguiendo d
desenvolvimiento hist^rico de nuestras institudones polfticas, econ6micas v sodales,
no debe tomar desprevenido, al esphitu dentifico de nuestro mundo medloo. La

PUBLIO HEALTH AND MEDIOIKE. 548

jiMtida miana, que debeii intervenir, para determinar el dafio, el peijuicio o la
indemiiizaci6n que coneeponda legalmente, segtin la futura ley^ se apojrm inevita-
blemente, en la infonnaci6n dfnica para cada caso, como ee f&cil prever. For todas
eetas razonee, y. muchas otras, que de^o al esclarecido criterio del seiior intendente,
conviene que el cuerpo medico argentmo, se halle preparado para entender. en esta
nueva orientaci6n de la modema patologfa humana. La asistencia social, que
tantos progresos ha alcanzado, en el gobiemo municipal de la capital, ha de sefialar
de eeta manera, uno m&a, cuya trascendenda el seilor intendente ha sido el primero
en apreciar.

Al entregarle, tan sint^ticamente expueetoe loe principales amimentos, a favor de
la creaci6n de un servicio de ''CHnica del Trabajo y Enfermedadee Profesionales/'
que me permito augurar como la base de un futuro hospital del mismo nombre,
-ctbnpleme agradecer al sefior intendente, la autorizada aprobaci6n, que le ha dia-
penaado, quedando por mi parte, a su entera dispoeicidn, para la colaboraci6n que
pueda prestarle, todavla, la particular dedicaci6n, que profeso a esta rama de la
Jfedicina Social.

Saluda, etc.

(Finnado) Enrique Fbinmann."*

CAPfTULO n. — raOIENE SANFTARIA DEL TRABAJO.

I. La historia de la higiene obrera, es relativamente reciente y nace con los primeroe
adelantoB de la medicina social. El antiguo horario, de sol de los trabajadores, como
el salario miximo de los jomales, son ejemplos de enores fi8iol(3gicos y econ6mico8,
que se disculpan, respectivamente, en el menor nivel de aqucllas civilizacionas.

El adelanto de la Industria y de las artes, el crecimiento de todas las formas de la
producci6n humana, los perleccionamientoe en la maquinaria y de ias manufacturaa
mecinicas, en vez de libertar al hombre del yugo de la labor, como predecia Ar'6t6te]e8,
le da un nuevo amo, que ee la miquina, y un nuevo horizonte, que es el taller. •

El taller y la mdqulna, ban estrechado el campo de acci6n de los obreros modemos, y
ban creado a su actividad, mtiltiples peligros que pasaron hasta ahora inadvertidos.

£1 trabajo al aire libre de los eeclavos romanos, el de loe arteeanos en la edad media
y las profesiones libres de las primltivas manufacturaa, no se parecen en nada, a la
trepidaci6n acelerada de las jcnnadas actuales. Entonces, podian descuidarse muchas
precauciones; hoy, la menor imprevisi6n, abrevla la vida y compromete sus aptitudes
misdtiles.

La higiene, aplicada a la salud obrera, ensefia predsamente la manera de conaervar,
en las mejores condidones, el juego normal de nuestro oiganismo, en relad6n con el
medio, y, con las fundones que desairolla.

La caract^stica de nuestro mundo, es la despreocupacidn de si mismo. No hay
obrero, que se atreva a manejar un aparato, cuyo juego no conoce perfectamente, ni
hay patrdn que coofie, en manos inexpertaa, un instrumento de precisi6n. Sin
embajrgo, cada uno hace uso, de su propio mecantsmo, en cualquier nentido, y entrega
su esfuerzo a toda clase de improvisadones. El animal y la m^uina de trabajo,
m^recen todas laa atendones, que nadie i^lica a su propia existencia. Sin embaigo,
el secrete de la salud proviene de los conocimientos, sobre d fundonamiento normal
de nuestro cuerpo, de la fisiologfa hiunana.

El trabajador, ademis, complica su salud, con los peligros de la industria que ejerce,
Ignor^uklose a si mismo, se expone a todas las impnidendas; desconodendo la in-
ftuenda del medio que le rodea, no sabe evitar sus consecuencias, y llega tarda o tem-
pmno a ser su vletima.

Fat lo tanto, la fisiologfa, es la base de la higiene, aiendo ^sta a su vez, el respeto
inteligente a la primera. Las prindpales ccnqmstas del proletariado modemo, pro-
vienen de los adekntos de la fisiologfa y de la higiene obrera. El horario de echo
boras, d descanso hebdomadario, la prohibid6n al trabajo nocturne de las mujerea
y de los nifios, la pgoiecdAa legal a la matemidad y la defeosa social de la primera

> Posterionnento, el 4 de eiuro de 1017 j el 0 de Jnnlo del mismo aflo el autor noavd tat mlsma gestidn
dnrante el Ooblerno del Dr. Hlp^ltto Irigoyco, ante la Intendeiiela If nnioipal, bi AtliteDda PtSbUea y
•I CoDi^ DeUbennte de tai Coital Federal.

544 PBOCEEDINQS SBOOlfD PAK AMBBICAK 80IBNTIFI0 0ONOEE88.

infancia, no son ventajaa airaacadas por la imposicl^a de las maBas o por la hiena^
flino concesiones BucenvaB, obtenidas raiQnablemente de la aociedad y del Estado en
ppovecho de todos y de cada uno.

La higiene fisioldgica ha demostrado que los horaiios exceaivos, que la fatiga pato-
16gica, que las industriaa inaalubree, atentan contra la salud de Ion obreios, y, por 1»
tanto, contra la coii8ervaci6n del capital humano, que aquellos repreeraitan en la
colectividad a cuya liqueza contribuyen. Ei rendlmiento normal de un obrero
disminuye, en proporci6n inveraa al esfuerzo exce&ivo que se exlge a bus mdaculov
o a BUS nervios. A la sodedad le conviene nUis que se conserve treinta afios un obrero
trabajando, a raz6n de 8 boras diarlas, y no que se invallde a los 15 afios, aunque haya
trabajado el doble de doce a quince boras, como sucede todavfa. £1 Estado, por eso*
asume la protecci6n legal de su poblaci6n obrera, y le aplica las leyes de la higiene.
En el fondo, es una especulaci6n utilitaria e intereBada, para conservar la energfa
humana, siendo la forma de defender la colectividad contra el agotamiento pr^natuit>
de BUS principales fuentes de producci6n y de progreso. De todas maneras es una
erplotaci6n inteligente de nuestras capacidades, que transforma en trabajo dtil, la
actividad sin quebrantos del esfuerzo cotidiano.

II. La l^gislaci6n modema del trabajo, realisa en todos los paises modemoe de aita
civiliEaci6n, ese propMto de economia, de protecci6n y defensa de la salud obrenu
Sus leyes tienden por una parte a guardar al obrero, por otro, a \igilar el medio que
le rodea. Entre las primeras se hallan las disposiciones sobre horarios de trabajo^
en las diferentes industrias, segdn edad, sexo y los tumos del dfa y de la noche; las
indrannizaciones a los accidentes producidos en ocasiones o por causa del tiabajo, y
los seguros sobre imalidez y enfermedades profesionales. En el otro, todo lo que a»
refiere a la inspecci6n higi^nica de los locales, el resguaido de las maquinarias, y la»
precauciones con los productos que se elaboran, o con las sustancias que intervienen
en las industrias, como son el fMoro, el plomo y el ars^co.

No satisface, sin embargo, la pre\isi6n del Estado y la protecci6n ofidal, para
llenar cumplidamente, la vasta obra sanitaria que estudiamos; es precise afiadirle la
cultura de las gentes y la concienda higi^nica que contribuye a formar las clases
populares.

En el orden profesional, como en la vida ocdinaria los espfritus simples se hallan
dominados por extrafios prejuicios y ofrecen en cambio a las jnescripciones sanas la
mis obstinada resistenda.

Obs^n ese si n6 la displicenda con que se lavan las manos los obreros, pintotes,
tip6grafos y la negligenda que prestan al aseo en general, los que trabajan la tierra
entre el pol o o con sustancias t6xicas. Sin embargo, estiistemente c61ebie el enve*
nenamiento lento por el plomo entre los que manejan la pintura y los tipoe de
imprenta, quese Uama "saturnismo,'' comoasimismo las enfermedades que produoen
sobre el aparato digestif o los polvos atmosfMcos, caigados de g^rmenes de tubercu-
losis, de influenza o de pulmonfa y las infecdones del t^tano y de otras diyenas
supuraciones en las manos sudas de las gentes descuidadas.

En cambio decfamos, culti^an muchos prejuidos, siendo el mis hondo el enor
vulgar de creer al alcohol un alimento titil. El trabajador que tiene frfo bebe alcolM>l,
bebe cuando tiene calor, bebe cuando tiene hambre, y cuando le faltan las fuersas se
imagina que bebiendo ese excitante artificial las recobra.

Es una ilusidn de los sentidos que le cuesta muy caia; tan cara, que compromete
su salud, su hogar y su sangre. El decaimiento fldco y moral del alcoh61ico, acairea
la miseria y la ruina en la familia; luego su deecendeiM^ es decr^ita, degennada e
invilida, y los hijos siguen pagando con su came y su vergfienia el pecado de los
padres.

Por lo tanto, la educaci6n higi^nica del pueblo, debe acompafiar la acddn legisla-
tiva de los poderes pdblicos. La higiene del estado debe aplicarse sobre una masa cons
sdente que sepa aprovecharla, y disfrutar sus benefidos. De otro mode las mejores
tentativas se pierden, sin fruto y sin provecho. * Gada cual debe contribuir con sa

PUBLIO HBALTH AND MEDICIHB. 545

parte de buen sentido al bieneotar general. Un Bujeto con difteria, con eecarlatina o
con viraela, puede ser la causa de una epidemia en toda la poblaci6n. En el orden
moral y material el contacto existe, hay que e itarlo al punto que el mejor procedi-
miento reeulta ser, cuidarse y cuidar al ^ecino. En la colmena humana hay el
inters comtin de ser folices porque la de^grada de uno suele repercutir sobre la
suerte de los denUb. Deade un segundo punto de ^ ista un egoismo natural e inteli-
gente nos Ue. a pues a deeear el bien del pr6jimo. El Estado \ ela por la sociedad, y
Ma depende de los hombres que la fonnan; el fndice de esa relaci6n es el nLv el de
sacultura.

El progreeo de un pueblo no se aprecia tinicamente por la faz del aUabetismo, que
es sin duda su apecto nUis interesante. Saber leer y escribir, no resuelA e el problema
de la cultura popular; es la manera de Uegar a ella. La letra y la palabra son los
agentes nUis acti\os y eficaces de difusidn cultural, que sin e como fin y como mediot
de divulgacidn cientifica.

El contacto de la verdad y la ras6n con el alma de los humildes, representa una obra
de higiene moral tan intensa como fecunda. En la salud de los hombres no todas son
necesidades flsicas; hay un mundo moral que merece la pena de preocupamos.

Adelantemos el dato ^ue, para nosotros, el espiritu y la materia no son entidades
distintas y que sus fen6menos responden a una fisiologla comtin. De ahf, que las
alteraciones del espiritu repercuten sobre la materia y vice versa. El secreto de muchos
males incurables proviene de eetados divenos de enfermedad moral que pasan inad-
vertidos y por eso se {Mrolongan indefinidamente.

La salud moral es tambi^n una necesidad que debe atenderse y sobre todo entre la
gente obrera, que recibe de su fuente el m^jor estfmulo para la acci6n y el esfuerzo.
El obrero triste trabaja menos que el mismo cuando estaba alegre; el decaimiento
moral es un sintoma grave de agotamiento Hsico. Por eso, la higiene del espiritu es
tan interesante como la higiene del cuerpo para la salud obrera.

£1 principal medio de conservar ese feliz equilibrio de nuestio oiganismo, se halla
en el cuidado de su propia fisiologia. Todoe conocen la fdrmula cUsica de los tres
ochos, que todavfa discuten los empleados y patrones. Ella significa que echo horas
son para trabajar, ocho horas para dormir y echo horas para distraerse. Es dedr, las
24 horas del dla repartidas entre las tres ocupadones fundamentales de nuestra exis-
tencia. Nada m^ rasonable que eete ciclo de actividad altemada con el reposo, la
naturaleza, el mundo, la vida misma, parecen descansar para renovane. Sin embaigo
el hombre es el que m^ dificilmente se somete al regimen. Cuando la ley se lo permite
o se lo impone, se empefia de su parte en desacatarla o en infringirla a escondidas.
La renta de su mecanismo que es el trabajo, se consume junto con el capital que
es su salud. Por lo cual la ignoranda le reeulta doblemente deeCavorable porque
no le permite distraer bu bienestar y porque le abrevia el tiempo de vivirlo.

III. La familia obrera partidpa pw todas sus faces en la cueetidn que venimos
considerando. El hogar del obrero se refleja sobre su actividad en el taller y recipro-
camente su trabajo trasdende a la casa con todo el valor econ6mico y moral que se
imagina. Lo que no se ha sefialado sufidentemente, es la influencia higi^ca del
hogar sobre la salud general de los obreros.

Sin embargo, es evidente, la importanda que tienen las buenas costumbres dom^ti-
cas en la actividad normal de los hombres. En primer t^rmino porque en ese medio
desenvuelve las dos terceras partes de su existencia, luego porque de alii saca el
alidente mayor y el verdadero amor a su trabajo.

El hogar, es por lo tanto, el reparo saludable y el reCugio natural para curar todas sus
fatigas. El cansancio intelectual, loe quebrantos del espiritu, el deegaste corporal
deben aliviarse alll y disiparse antes que su propio ezceso los acumule en el otganismo.

La mujer tiene en ese sentido una responsabilidad singular y palpitante, que hace
de ella el factor m^ importante del bienestar obrero.

546 PB0CEEDING8 ISSOOND PAK AKBSIOAK SODSSTTIFIO G0KQRE8S.

Eatas consid^aciones un tanto imi^evistaB, parezcan qtiiz^ excedvafi, por el aleaace
que queremoB atribuirleB. Sin embaigo, ee una preoeupaci6n que noa acompafia de
mucho tiempo atr^, la cual da eea importancia de la colaboraci<ki femenina para la
sanidad individual y colectiva de la clase pioletaria.

Escogemofl para demostrarlo dos ejemploa entre loe tantoe que noe imprenonan cons-
tantemente. Uno de eUos se refiere a la causa primera, que suetituye el hogar por la
tabema cuando faltan en 61 la atracci6n y los encantoe de la compafioA cuidadosa y
econ6mica, que hace amable, por modeeto que sea, el rincdn comiin. Y el otro,
noB acusa, en la mala cocina casera el origen del decaimiento fisico y de la menor
resistencia fi8iol6gica en la mayor parte de los sujetoe que, por nutrirse insufidente-
mente, valen menos para el trabajo, para la toulia y para ei mismos, puee son las
prim^ras vfctimas de todas las enfermedades y en particular de la tuberculosis. Basta
ver lo que podrfa, en tal sentido, la mujer consciente de sus obligackmes de buena
ama de casa, para comprender la trascendenda higi^ca que tiene para la sociedad,
cultivar esas generadonee de j6venee capaces de atenderlas, realizando asf, entre
la tuberculosis y d tdcdiolismo, la mis intensa y fecunda obra de profilaxis social.

La peer complicad6n que puede ocurrir, por lo tanto, en los hogares obreros, es el
asalaramiento de la mujer en las industrias y aun en los oficios a domlcilio. El pro-
letariado femenino agrava la situaddn, de haber side regular anteriormente, con todoe
loe inconvenientes de la ausencia y del abandono forsoso, total o parcial, de los que-
haceres dom^sticoe, siendo su consecuenda la mala salud de los padres y de los hijoe.
Estos tiltimos, sobre todo, pagan las culpas fisiol^gicas que ciertos snores econ6micoe,
hist6ricos o sociales determinan. En algunas publicadones y conferencias anteriores,
entre ellas la titulada " La matemidad y la mujer en la legisladdn del trabajo," hemes
demostrado, como d Estado debe defends la salud de la mujer obrera para asegurar
las generadones luertes de la nad6n y, en otro, " El prablema social de la despoblad^n
infantil," presentamos el cuadro hondamente triste de la mortandad de los nifloe
de nuestro pais, para proponer los medios racionales de profilaxis contra la odf ermedad
y la muerte, que los Ueva injustamente.

Asf es, como la higiene modema viene contribuyendo al mayor nivel de la sahid
obrera. Antes que la sociologfa poll tica o la filosoffa econ6mica resuelvan la manera
de igualar a todos los hombree, la ciencia encontrard el modo de acercar a los humildea
y a los poderosos a una misma llnea de bienestar ideal. La distiibuci6n de la riquesa
entre los hombres, no resolverfa, por otra parte, el problema de la feliddad humana,
pues 6sta no depende del din^o, ni se pierde con €i. El capital de nuestra existencia
es la salud y a 611a aspiran y desean conservarla ricos y pobres. Su valor es esendal-
mente democrdttco y se halla al alcance de todos, siendo mis s^sredable la herenda
de una buena salud sin fortuna, que un legado de millones sin salud.

Un cuadro cdebre, " La visidn de un disp6pttco," nos mueetra la pintura admirable
de un viejo banquero sentado a la cabecera de la mesa, en un regio comedor, y que
ti^ie delante un plato servido, que mira con expre8i6n de angustia y muda desespera-
d6n. En d otro extreme de la tendida mesa, se dibuja la imagen de un nifio que
devora alegremente su racidn. La suerte del miserable disp6ptico no estaba en d
fondo de sua areas repletas de oro, sino en la cavidad de su estdmago Ueno de jugo
glistrico cuando era joven. Del mismo modo, nuestras deegracias mayores provienen
de las faltas higi^nicas que cometemos. Claudio Bernard, d ilustre fisidlogo francos,
decfa a propddto de los continues desarreglos en que incurrimos, que el hombre no
muere, sino que se mata. Lo cual es todavia exacto, en ras^ki de la dificultad con
que tropezamoe, para hacer llegar a todas las condencias d sentimiento de la higiene.
Es diHcil, por ejemplo, imaginar lo que ha costado y cueeta a6n la penetaracidn
raciond de algunas de las principales annas de la hi^ene ptiblica en la simpatia
popular. Londres y Paris muestran dos estatuas admirables, una dd sabio Jenner,
inoculando el suero de la vacuna en d brazo de su propio hijo, para convencer a sus
condudadanos sobre el m^rito de ese preventivo maraviUoso contra la viruela; y

PUBLIC HEALTH AND MEDIOINE. 547

la otra, que se halla en loe jardines del Instituto Pasteur, representa al abnegado
servidor del ilustre bi61ogo franc^, dejdndose inyectar por el maestro el virus de la
hidrofobia, para demostrar luego, los efectos del suero antirribico como remedio
precoz e inefable.

Asif la ciencia va avanzando en la fe de las multitudes, desalojando a su paso todoe
los prejuicios e iluminando el camino con la luz de sus verdades. El enemigo mayor
es la ignorancia, que ciega la raz6n a toda iniciativa y a todo impulse de progreso.

En el limite de nuestras legitimas aspiraciones, se halla la distribucidn igualitaria
de los beneficios de la salud. Es tan injusto nacer con la tara maldita de una herencia
patol6gica, como contraer por imprudencia de los demis, una viruela, que desfigura,
una fiebre tiloida, la difteria o la meningitis que hace sordos mudos, o una conjun-
tivitis granulosa que roba a la pupila, para siempre, la al^;rfa del sol y de la luz.

La higiene interesa a todos, y depende de cada uno. No sabemos a qui^n le
tocaWl el esputo cargado de bacilos que arroja al azar un tuberculoso que pasea su
mal y que adn puede curarse. Pero el pecho amigo, o simplemente ajeno, que lo
reepira, llevard sin querer a sus pulmonee, el germen mdrbido o mortal, y es lo que
debemos impedir, como un atentado que ofende el sentimiento m^ respetable, de
amor a la vida y del instinto de conservaci6n humana.

La clase obrera es la que m^ tiene que aprend^ de la higiene y de la profilaxia
modema. Sus mtiltiples actividades, el roce de sus organismos consigo mismo y
con el ambiente, la estrechez econ6mica y social en que desarrollan sus esfuerzos,
expone eeos mecanismos a tantos peHgros como impnidencias y deecuidoe quieran
imaginarse.

La higiene ensefia la prevision fisiol^ca y el empleo inteligente del caudal humano.
En eee sentido, la obra de cultura higi6nica que proponemos, debe llevar a todoe
los espiritus la idea de su propia competencia y el m^rito superior de la soHdaridad
social como medio de realizar en todos los pueblos el mejoramiento individual y colec-
tivo de las clases obreras.

CAPfrULO m. DBPBN8A SOCIAL DB LA SALUD.

I. Entre todos los problemas vitales de nuestra humanidad, el de la salud es, por
definici6n, el m^s importante y universal. La vida humana se desenvuelve entre doa
fen6menos extremos que la comprometen; la enfermedad y la muerte. Esta dltima
es inevitable, la otra se puede prevenir. Aai se explica que la biologla, es decir, la
ciencia de la vida, haya progresado m^ por una de sus ramas, la higiene, que ensefia
a comprenderla, que por la medicina que pretende dirigirla. El t^rmino medio de la
existencia vegetal y animal no se prolonga curando ksionee que la acortan sino opo-
ni^ndose al advenimiento de ^tas en los organismos correspondientes. £stoe son los
principios de la medicina preventLva que la ciencia modema ha incorporado reciente-
mente a la patologia, como ima de sus conquistas m^s brillantes y fecundas.

S61amente que la aplicacuSn de sus resultados requiere un medio social en cierta
manera preparado para acogerla. Entre las poblaciones de la antigUedad, que no
tenian de las epidemias y de los males contagiosos m^s que algiinaa vagas ideas de abs-
tenci6n aislamlento y las actuales que disirutan todas las ventajas de la m^ sabia
profilaxis saidtaiia, hay ima diferencia de grade en el orden ptiblico de los progresos
alcanzados, que no se mantiene en el nivel individual de los que se hallan sometidos
a ella. No es que queramos exagerar las reeistencias que se oponen todavla en muchos
cases a las prescripdonee higl^nicas fundamentales y a las mks elementales reglamen-
taciones sanitarias, pero sf a la deepreocupaddn en que vive la maycnria de las gentes
en cuanto se refiere a la salud y a los medios de conservarla. Las clases sodales
se agitan por muchas razones poll ticas, hist6ricas y econ6micas en todos los palses del
mundo, pretendiendo corregir las desigualdadee materialcs que en dl reinan injusta-
mente, pero apenas si se cuida del valor real que tiene para esas mismas conquistas la
repartici6n igual del capital bid^co, la salud que es la base de todas sus dem^ acti*
68436— 17— VOL i

548 PB0CEEDIKQ8 SBOOKD PAN ABGESBIOAK 80IENTIFI0 C0NQBB88.

vidades. Desde el punto de vista filoe6fico, el m^ elevado eegforunente, la justtda
distribuUva elemental oonsistiria en gosar los mismos derechos de vivir. La nneva
democrada de la ealud nntetisa nuestio peneamiento al respecto; antes que la Igual-
dad econdmica, que ee aparente y artificial, debemoe aspirar a la igualdad fisiol^gica,
que le antecede y la prepara naturalmente. De esta manera noe acercamos mi»
pronto al ideal comdn.

Puea bien, las gentes proceden al rev^. Ouanto se refiere al bienestar individual,
al mejonuniento ffaico y moral de sus capacidadee natnrales, al perfecdonamienta
de sus aptitudes oig&nicas, es relegado a un piano secundario de su atenci6n e inters
El ser humane vive en el desconocimLento de s( mismo. Se ignora en lo m^ esendal,
en lo que afecta su propio desarroUo, su conservaci6n y la de la espede a que per-
tenece. Por un milagro, si se nos permite la expresuSn, sobrevive a los errores con que
atenta a cada peso, a su existenda; decfa con ras6n, el ilustre fisidlogo franc^, Claudio
Bernard, que el hombre no se muere, sine que se mata. Y seguiri mat&ndose, sin
consideraci6n mientras no se ocupe de su propia m^uina, de su cuerpo, como el
obrero inteligente cmda su m^uina en el taller. Pues, en realidad ambos explotaa
el rendimiento de su mecanismo que, viviente o de precisi6n debe conocerse lo mejor
posible para mejorar su uso y evitar sus desperfectos.

En estos i»indpios de bidogla humana residen las determinantes del grave fen6meno
social que obser^unos. El privilegio de dase de las diversas aristocracias histdricas,
religiosas, polfticas y sodales, sefialadas anteriormente se prolongan en d campo
psicofisbldgico de nuestro mundo oiginico, por desigualdades m^ irritantes todavia
que representan por analogia de denominacidn otras tantas aristocracias bioldgicas.

II. Mendonemos en primer tdrmino lo que ocurre en los dominios de la herendm,
de la educad6n y de la vida intdectual, que constituyen los tres cfrculos prindpalee
de nuestra evolud6n normal y patoldgica. Desde luego, es evidente la influenda del
factor hereditario, para la formaddn dd individuo y de la espede; su trascendencia ee
infinitamente mayor que cualquier tftulo o fortuna trasmitida por via civil. Sin
embaigo, nadie piensa en ella, cuando se propone procrear, y muy pocos aciertan a
atribuirle la raz6n de tantos otros fracasos en la lucha ordinaria por la existenda. Sod
los mismos a voces que alcanzan en otro orden de conodmientos, con la manera de
obtener en las hadendas y cabafias los mejores productos vactmos y caballares,
mediante cruzas sabiamente escogidas. Esos ejemplares contrastan por su misma
perfecci6n con los propios de nuestra espede, no obstante regirse por las mismas reglaa
su refinamiento. En este punto, la tuberculosis, el alcoholismo y la avariosis, cons-
tituyen la triada m6rbida que degenera la humanidad a espaldas de la higiene. Ella
mantiene adem^ la desigualdad bioldgica de los naddos sanos y de los mal naddos,
de los que ban de soportar por endma de su cuna, de su nombre y de su riqueza la
suerte favorable o adversa de su plasma hereditaria. En definitiva, la miseria fisio-
Idgica es la dnica que ban de temer los desheredados; es la primera ley que debiera
ser pareja con todos.

En cuanto a la educaci6n pfiblica sabemos hasta donde es insnficiente todavia sa
caudal y su penetraci6n en la condencia popular. Es el problema per excelencia
de las sociedades modemas y a medida que se desenvuelve marca un paso de verdad
hacia las democracias positivas. Mientras tanto, el analfabetismo, la ignorancia y el
atraso educacional de las masas se oponen a la nivelad6n sanitaria de las gentes. Pues
la higiene es una cuesti6n de cultura. Las poblaciones instniidas son las m^ prds-
peras. Antes que el derecho politico y la Hbertad electoral hay que brindar a loe
ciudadanos los derechos de la salud. Un ilustre argentino, Bermu-dino Rivadavia, se
anticipa en derta manera a estas consideraciones cuando escribe *^que la ilustraddn
ptiblica es la base de todo sistema reglado, pues cuando la ignorancia cubre a los
habitantes de su pais, ni las autoridades pueden con 6xito promover su prosperidad,
ni ellas mismas proporcionarse las ventajas reales que eeparce el imperio de las leyes. '*
Y es as! , en efecto, con lo que a la higiene se refiere. Todas las ordenanzas, reglamen-

PUBUO HBALTH AND MENOINB. 549

tadonesy multas y prohibicioneB de orden sanitaiio fracafian lamentablemente si no
86 dirigen a eBplritus formados en el respeto racional de los mismos. No se Impone ni
86 adopta eepontdneamente ninguna di8po8ici6n que no nace y se acompafia de la
propia convicci^n; de ahf la neceeidad de fonnar la conciencia higi^nlca del pueblo
que 68 una obra cultural como la otra de fonnar la conciencia poHtica,

Solamente que la primera ee m^ trascendental y duradera. Un gran estadista ame-
ricano, Abraham Lincoln, oportunamente recordado por an distinguido educacionista
nuestro, Don Santiago Fitz Simon, en un importante trabajo sobre el ''analfabetismo
en la Rep(lblica Argentina, " coincide a este reepecto en un pirrafo muy interesante
que merece trascribirse.

*'La educaci6n de las masas desheredadas de la fortuna, dice, reclama m^ que cual-
quier otro asunto la atencidn de los poderes pdblicos. Cuando un Estado, por incuria
o por indiferencia culpable deja a una gran maea del pueblo sumida en la ignorancia,
con el andar del tiempo se veri obligado a invertir ingentes sumas en la construcci6n
de circeles para el encierro de millares de criminales perversos, y en hospicios para
albergar otros tantos millares de mendigos e insanos. Sin escuelas para todos, son
imposibles las instituciones repubHcanas e ilusorias las libertades popularee. El por-
venir de las sociedades depende puee de su cultura higi^nica; es el principio comtin
de todas las democracias. ''

III. Por dltimo observemos la importancia de la salud intelectual en el desarrollo
de las colectividades. Las causas de la decadencia de todas las civilizaciones sefialan
muy claramente la degeneraci6n de los gustos y costumbres populares. £1 espiritu,
como la materia, requiere cultivarse, pues sus desviaciones se perjudican reclproca-
mente. La higiene moral ee un capftulo relativamente modemo de la medicina
social. Desde los tiempos antiguos, la vida intelectual, las emociones artistfcas, el
culto de la belleza, fueron prerrogativas de unos pocos. El error empez6 por clasificar
las artes en artes superiores, o "bellas artes'' y en artes inferioreso '^artesindustria-
les, " expresando de eeta manera la diferencia que separa la belloza pura de las obras
que dependen de la materia. Distincidn, segtin Anatole France, ''inspirada por una
perversa metaffsica de castas;*' desigualdad que no fu6 ni mis feliz ni mis acertada que
tantas otras desigualdades introducidas sistem&ticamente entre loe hombres y que no
provienen de la natiiraleza. En realidad, la belleza toma de la materia sus medios de
6xpresi6n, y ' ' el artista es a la vez un artesano, como el artesano puede ser un artista. ' '
No hay, pues, tampoco do6 clases de artes, las ''industriales" y las ''bellas artes;' '
hay una sola, que es al mismo tiempo industria y belleza, que sirve para enaltecer la
vida, ya sea multiplicando a nuestro alrededor las bellas formas o expresando los
bellos pensamientos.

Para el punto de vista especial de nuestro estudio, el gran pensador franc^ con-
cluye, en su brillante discurso titulado ''Hada tiempos mejores,'' con el siguiente
pirrato: ''£1 artista y el artesano trabajan en la miama obra magnifica, contribuyendo
a hacemos agradable y querida la habltaci6n humana, a dar aire de gracia y de belleza
a la casa, a la ciudad, al jardin. Uno y otro se asemejan por la funci6n; son colabora*
dores. Y por conaiguiente lo mismo que se dice de los ejecutores debe decirse de los
que han de admirar sus composidones. El alma popular debe hallarse ablerta a la
contemplad6n de lo grande, de lo bello y de lo bueno, de la misma manera que lo
estin loe espfritus selectos, que forman hoy por hoy, la fnfima minorfa. La higiene
pdblica necesita eete cultlvo del espiritu para alcanzar sus m&a altos prop^tos de salud
social. En las tres foses estudiadas la nueva clencia organiza la democracia higi6nica.
Pues por encima de las leyes humanas que no reparten o que reparten mal los irutos
de la justicia, del capital, y del trabajo y antes que las conquistas electorales, que noa
dan la facultad de escogor a quien nos represente, nos mande o nos gobieme, apre-
damos el valor de las leyes naturales que deben distribuimos la capacidad biol<3gica
para habitar en iguales condiclones ese mismo mundo politico y 6con6mico y actuar
en su reino con annas equivalentes, para que en la luchia inevitable por la ezistenda,
d no triunfan todos, no haya, por lo menos, vencedores y venddos.

550 PB00EEDIN08 SECOND PAN AMEBIOAN SCIENTIFIO CONQBESEL

CAPfrULO ly. DBPBN8A SOCIAL DB LA MUJBR.

Es Mcil citar numerosas observaciones y experiencias verificadas todav^ hasta
hace poco en distintos hoepi tales y casas de matemidad, particularmente en Francia,
que demuestran hasta que punto no b61o la salud y el bienestar de la madre dependen
de su reposo oportuno, sino tamblen la importancia que tienen esas precauclones en el
desarrollo y en la vltalidad del nlfto.

Entre eetas obBervacIones no es la menos interesante el estudio sobie 732 cases de
parte, verificadas por Letomeau, en la ^'Clinique Baudeloque/' en Paris. El primer
grupo comprende 137 mujeres que protesaban una ocupaci6n fatigosa como ser criadas,
cocineras, etc., las cuales no descansaron durante su embarazo; sus criaturas marcaron
un peso medio inferior en 500 gramos a la normal, es dedr 3081 gramos; en segimdo
lugar figuran 115 obreras ocupadas en trabajos livianos (modistas, costureras, etc.) que
tampoco descansaron, tuvieron nifios de 3130 gramos mds o menos, no obstante su
desventaja respecto a las del grupo anterior, en cuanto su const! tuci6n Individual
era muy inferior en salud y robustez f(sica. Por dltimo, las del tercer grupo especial*
mente interesante para nosotros comprende todas las obreras que no obstante su
peeado traba jo habitual dieron aluz nifios deproporciones medias de3318 gramos gracias
al descanso que disfrutaron op>ortunamente durante su embarazo.

La sociedad, escribe con este motive Letomeau, "debe garantizar el reposo de U
mujer durante una parte de su embarazo. Encontrar^ el pago y la recompensa de su
acci6n en el aumento de luerza y vida en los nifios que nazcan en estas condiciones."

El Artfculo IX de nuec tra Ley No. 5291 de protecci6n al trabajo de las mujeres pareco
inspiiarse en estos principios, en su inciso 2 que dispone: '*Que las mujeres podr&n
dejar de concurrir a las 1 ibricas o a los talleres hasta los 30 dlas subsiguientes al alum-
bramiento, debiendo entretanto reeervdrseles el puesto". Pero incurre en el doble
error de dejarlo facultati ^o y adem^ insuficiente en su aplicaci6n, pues la obrera puede
obligarse a asistir hasta )1 dltimo dfa de su embarazo, al trabajo. Por otra parte, la
resoluci6n no se halla favorecida por ningdn seguro ni subsidio, de tal modo que
abandonada a sus propii b recursos, la obrera optard en el mayor ndmero de voces por
contrariar voluntariameiite y legal mente la previsi6n del Estado. En el mejor de los
casos estimulaid a obreio) y patrones a Polidarizarse en el prop6sito comtin de burlar la
ley, en provecho aparenle de ambos, pero en perjuicio definitivamente de todos y del
cuerpo social. La muje ' que trabaja necesita de su jomal para vivir, el embarazo no
alivia slno que complica las exigencias de su modesto presupuesto, en estas condiciones
la matemidad reeulta lu.a carga, casi un ^'infortunio,'* en su vida de obrera. Siendo
soltera, vale mucho m^ y a voces tanto como un var6n; el embarazo compromete sus
mejores energlas hacia ctro destine, disminuye su rendimiento en el taller, y final-
men te la invalida en absoluto para ocupar su puesto al pie de la milquina.

Esa invalidez temporaria no puede pasai indiferente ante ningtin espfritu libra
ni a la atenci6n de los hombres de goblemo. Ia funci6n biol6gica de la mujer es
muy superior a la que le asigna su puesto en una usina o en una fdbrica; su verdadera
mlsi6n es elaborar la raz:i humana, para alcanzar a trav^ de sus Infinitos perfecciona-
mientos el ideal de nuestra especie.

Por un determinisno econ6mico que contrasta singularmente con nuestra civiliza-
ci6n avanzada. la funcl<5n natural se ha desviado sin embargo, provocando la lorma
anormal de la mujer asalariada. Este fen6meno extrafio, tiene que repercutir tatal-
mente sobre la suerte comtin de todo el organismo, expuesto en esa forma a las contin-
gencias provenientes de la desarmonla y el desequilibrio social.

El problema cada vez mis serio de la mortandad infantil, es el primer sintoma de tan
grave mal. La Capital de Francia que en 1880 marcaba el 24.2 por ciento de mortandad
infantil sobre 56.052 nacimientos, es decir, 14.63 por ciento de niilos £allecidos»
en un afio antes de cumplir los 12 meses de edad, ya en la (Utima estadfstica de 1909,

PUBUO HEALTH AND ME0IOINE. 551

fevela aobre el iKimero menor de nadmientos 48.640, el 16.3 por denfto, es decir 8,997
nifioa Weddofl.

Alemania, en 1880 con una natalidad de 40,133 niflos en Berlin, fderde en un solo
afio 15,687, ee dedr el 34 por ciento; luego en 1909 habiendo aument ido los nacimien-
t06, que eon 48,640, gradas tambidn a la mayor higiene y previskm, 0OIO tiene
8,952 muertoe, es dedr, el 18.9 p<^ dento.

Nuestra eetadtetica es felizmente, menoa complicada; deede 1875 a 1906 el ndmero
de nadmientos fu6 de 694,852, sobre los cualee 91,766 murieron antes del afio, es dedr,
el 18 por dento; casi la quinta parte de la natalidad inlantil diurante 32 afios.

Segdn los tiltimos datos, correspondiendo al afio 1909, el ntkaero de mujeree en la
capital, mayores de 14 afios era de 417,595; el ntimero de nacimientos produddos fu6
de 42,402, de los cuales 1,979 nacidos muertos y 3,772, antes de los 12 meses; como se
ve todavfa un 13 por dento, que con ser una cifra alta, es mejor que la de Berlin 7
Paris.

£1 primer ^tor de esa despoblacidn siemin« amenasante, es el mal estado econ6-
mico de los progenitores y la insufidencia alimentida casi constante de la miseria
fisiol^gica que comparten con las descendendas.

En el Congreso Intemadonal de Higiene reunido en Paris en 1889 el Dr. Dumoulin,
de Bruselas present^ algunas condusiones muy interesantes al respecto. La miseria de
los padres, es como se veri el mayor enemigo de la infanda; hay una diferenda de 30
por dento entre la mortalidad de los nifios de 0 a 5 afios en las familias ricas y en las
fomilias pobres. El m&ximo de mortalidad de 60 a 80 por dento se observa en las
dudades nianufactureras; particularmente sobre los nifios cuyas madres no pueden
consagrar su tiempo al red6n naddo. Asimismo, segdn Marc d'Espine, en la prolija
''Estadisticade mortalidad comparada,'' se comprueba que en el Cant6n de Ginebra,
el 8.2 por ciento de nifios que nacen muertos, corresponden por orden de dase a la
obrera; solamente el 1 por ciento a la gente acomodada. Por tiltimo, Erfurt, com-
prueba que los nifios que mueren al mes de nacer, corresponden, por orden de clases
sodales en un 84 por ciento a los obreros; de 45 a 19 por ciento a la dase media y 20 a 17
por ciento a las familias ricas. En Buenos Aires, se comprueba que los barrios
pobres de la Boca y Bairacas tienen una mortalidad mayor que los barrios ricos del So-
corro y Gatedral Norte. La madre obrera se convierte asf poco a poco de vlctima en
^bitro de la paz social. La mujer que procrea, rateresa mis a la colectividad, que la
soltera est^ril que se agota en su trabajo, pero tiene tambi^n mucho mis derecho a la
consideracidn de los suyos para que su obra no se corrompa 0 se malgaste. Es asi que
la imprevisidn actual sobre el trabajo de las mujeres embarazadas es la mis propicia a
todos los trastomos fi8iopatol<5gico6 conoddos; desde el parto prematuro con criatura
viva, de existencia mis 0 menos precaria, hasta los nifios nacidos muertos y los abortoi
fatales para las madres. Luego la linea sin fin de los sacrifidod e imprudencias a que
obliga la incompatibOidad entre la leche del nifio y el pan de lu madre, entre su trabajo
y la lactancia regular del nifio. Sin embargo la higiene lo ha dicho todo al respecto.
Pinard invoca que los derechos de la mujer al hijo son sagrados; Mar&ui reclama para
el nifio la leche de la madre, supremo antecesor del nifio necesita para la obra de crear
un hombre, todos los recursos de la buena higiene.

La vida de los nifios depende en efecto de su alimentaci6n matema. Todas las
enfermedades gastro-intestinales tienen en esa causa su primer origen y son la prind-
pal fuente de su gran mortalidad.

A prindpios de 1860 varies distritos algodoneros de Inglatenra fueron reducidos
al paro forzoso por la guerra de secesi6n de los Estados Unidos. Se hiso mis tarde la
original comprobaci6n, que a pesar de la profunda miseria de la poblacidn la mortali-
dad de los nifios en vez de aumentar disminuy6 sensiblemente. La ras6n era muy
sencilla. Los nifios eran mejor atendidos y alimentados y redbfan el alimento de la
madre, a la que jamis aprovecharon mientras istas trabajalian. Para nosotios el prob*
lema reviste aniloga importancia. La legisladdn de 1907 reconoce la necesidad de

552 PB0CEEDIN08 SECOND PAN AMEBICAN 80IENTIFI0 00NGBS88*

proteger el tzabajo de la mu jer am cuidar como conviene de la funci6n de matemidad
a que se haUa vinculada. £1 proyecto de ley primitivo resolvia en todas sua partes la
dificil cueeti6n.

En cuanto a la fonna obligatoria es indiscutible si se quiere su verdadera eficada y
cumplimiento pero es precise completarla con la compensaci6n subsidiaiia, vale dedr,
el seguro. £1 Estado cuando pide el sacrifido anual de cada uno de sus hijos para la
defensa comtin del pais, no piensa en exigirle que durante sus servidoe se mantenga
con sus propioe recursos; serfa absurdo. La mujer, que es la madre de esos soldados
y de la cual conviene obtener que Ice produzca tan buenos como sea poaible, para la
grandeza material y moral de la patria, bien merece redbir un esfuerzo de previsidn
para que no se agote por hambre y de privadones durante algunos de los tantos setenta
dlas en su vida de labor.

Por otra parte no se extrafle ver incluido en un estudio sobre une ley de acddentea
del trabajo, la indemnizad6n al deecanso de la mujer embarazada. Entre la obrera y
la madre no hay dertamente ninguna relaci6n de causa a electo, pero sf de prindpio a
fin. La mujer que trabaja es primeramente una expresi6n econ6mica, sobre todo un
valor individual. Al trasformarse en madre, sufre un accidente bioldgico que la eleva
y adquiere en todos sen tides el concepto de un valor social. Esa continuidad es la
que el estado y la sociedad modema amparan y defienden, ambas contribuyen ea
rigor en la parte que les toca, a la vida de cada dudadano.

CAPfTULO V. DBFEN8A SOCIAL DB LA PRDfERA INFANGIA.

I. La defensa social de la primera infancia, es el problema por excelencia de todas
las civilizaciones.

Frente a las estadisticas de mortalidad y morbilidad iniantil, los pueblos menoa
impresionables se sienten intranquilos. Es un mundo de pequefiaa existencias que
se apagan, apenas ll^ados a la luz. Es el triunfo de la enfermedad y de la muerte,
sobre la m^ evitable de las causas que rigen la salud y la vida.

Felizmente, la tinica disculpa de la sociedad que consiente en tantas vfctimas, es sa
propia n^ligencia para protegerlas y salvarlas. Porque el remedio resulta, en realidad,
m&s a su alcanc; le bastard adoptar los medios de defensa adecuados, para obtener
un 6xito seguro y complete.

Desde 1875 a 1906, ban nacido en esta capital 694,816 niflos vivos. Sobre eae
n(hnero fallecieron 91,766, antes de U^ar al afio de edad, quedando sobrevivientes
603,000; de ^tos antes del segundo afio murieron 39,006, quedando sobrevivientes
564,044 criatiuras.

En los 32 afios que comprende esta interesante estadlstica de la asLstencia pdblica
de la capital hubo, por lo tanto, una mortalidad absoluta de 130,772 pequefiuelos, lo
que equivale al 18 por dento, vale decir caai una quinta parte del total. Un nifio
muerto, por cada cinco o seis, que alcanzan a vivir los dos afios de la primera edad.

II. En otras partes, la situaci6n no es mia brillante. En Italia, M. Flamini, en su
obra "Assistanza sanitaria infantile," sefiala, corrospondiendo al afio 1905, una morta-
lidad infantil que repreeenta por cada 100 defundones, 24 por dento de sujetoe que
no ban alcanzado a un afio de edad, y un 40 por ciento, si se incluyen los que no
alcanzaron a los 5 afios de edad. Hay que agregar, que estas cifras son ya de relative
mejorf a, puee en un perf odo pr6ximo anterior el porcentaje marca mia de 36 por dento
en el primer gnipo.

En cuanto a Franda, es notoria la importancia que reviste para ella el problems
de la de6poblad6n infantil. Su tentativa hacia el servido militar obligatorio de tres
afios, que coet6 la vida a Jaur^ pocos dias antes de la guerra, fu6 un sfntoma
nacional de particular gravedad. Hace varios afios, dos miembros del con-
sejo munidpal de Paris, MM. Dausset y Galli, denunciaron en el seno de la
misma, que la mortalidad en 1909 habia superado la cifra de 40,000 nifios men(»es
de un afio, o sea un 115.08 por mil, del total de nacimientos, proponiendo con tal

PUBLIC HEALTH AND MEDIOINE. 558

motivo un proyecto de mutualidad maternal, segtin el cual, todas las mujeres que
ocupan con su familia un local que redit6e menoe de 200 francos, puedan acogerse a
ella y a la protecci6n que el municipio ofrece, por igual, a la madre y a los hijos, en
alimentos, en lopas y en asistenda m^ca. An^loga Inidativa insplra, entre nosotros,
un proyecto de <Hxlenanza, presentado en 1912 al consejo dellberante de Buenos
Aires, por un miembro de esa corporaci6n, el doctor Delio Aguilar, denominado de
^'Mutualidad matema municipal,'' cuya sanci6n legal esperamos todavfa.

III. Los factores de la despoblaci6n infantil, en Europa y Am^ca, particularmente
^m 8U8 grandee centros urbanos, son prindpalmente econdmicos y sociales, otras vecee,
de orden higi6nico y moral. PodHan clasificarse, mejor reeumidos, en cuatro partes:
disminucidn de la natalldad, abortos, mortinatalidad (accidentales, criminales y
profesionalee) y mortalidad infantil, propiamente dicha.

Frente a Alemania, que tiene un superavit de 800,000 nacimientos por afio, con
relaci6n a bus pdrdidas en defunciones, y que a su exlstencia de 44 millones de habi-
tantes en 1871, ha pasado los 61 millones en su tiltima estadistica, Francia ofrece el
espect&culo de un equilibrio de poblaci6n mantenido a duras penas. En 1912, hubo
en Alemania 1,869,636 nacimientos, mientras que en Francia solamente 750,000, lo
que hace exclamar a Jacques Bertillon, prasidente de la Alianza Naciona), que
dnicamente en Francia, *'hay m^ f^retroe que cimas." Luego, presintiendo los
acontecimientos hist6rico6 de la guerra inevitable, en unos grandes carteles profusa-
mente dlfundidos, invoca el patriotlsmo de sus conciudadanos, mostrando bajo un
grueso letrero '' La Patrie est en Danger,'' como en case de lucha, contra cinco alemanes
habfan de pel ear dos eoldadoe fraucoses. ''Rien ne peuple comme les gueux," decfa
ya Diderot, y, en efecto, los pobree tienen mis hijos que los ricos. Este es el peligro
de todos los pafses de int^isa civillzaci6n en Europa, que empieza a reflejarse a
nuestro continente. De ahf la proposicidn, que nos apresuramos a adelantar, referente
a la protecci6n que merecen las clases humildes que son proHficas, por parte del estado
y las clases pudientes. A este respecto confirmamos, con Hutinel y Lesn^, que en el
detalle de las cifras absolutas, la proporci6n de nacimientos decrece tambidn en
Alemania como en Francia, desde hace 30 afioe, pero "la natalidad disminuye mucho
menoe que la mortalidad," y es gracias a esa diferencia, que el exceso de las cifras de
nacimiento se manti^QO en aumento. Es, pues, cuestidn de higiene m^ que la
fecundidad, declaran ambos espedalistas, lo que salva a la Alemania de la despobla-
dUSn.

Guillermo II lo confirma a su mode, en la ingeniosa ocurrencia que se le atribuye
de las tree K, como fdrmula que dirige al pueblo alemin: Kinder, es decir, el sfmbolo
de la familia; Kirche, la religi6n moral o la concienda; KOche, la codna, centre y
sfmbolo de la vida material que sostiene el ahna y la inteligencia.

En las clases proletcurias, los males akunbramientos, los sucesos prematures y la
mortinatalidad, son acddentes mis frecuentes de lo que se imagina, sobre todo en los
paiaes donde no existe la protecd6n legal a las mujeres obreras. En un capitulo
anterior titulado ' ' Defensa social de la mujer " estndiamos en detalle esta interesante
cuesti6n, y preferimos no extendemos sobre ella.

IV. El fen6meno social de la mortalidad infimtil,escQmtin a todos los pafses; tienen
los honores del minimum Noruega y Suecia, y el maximum le corresponds a Baviera
y Bajonia. Segdn la estadistica comparada de 1896 a 1900, la mortalidad anual por
cada mil nifios de 0 a 1 aflo, es de 96 a 100, y de 257 a 266, respectivamente. Entre
ambos extremes, Italia acusa 168, Inglaterra 156. Prusia 201, B%ica y Francia 158.

En todas partes, se compnieba una sensible disminuddn en el primer mes de la vida,
luego del segundo al tercero la observaci6n es menos favorable, del tercer mes en
adelante, hasta el aflo de edad, la mortalidad se agrava.

y. Las causas higi^nicas nUis importantes de estos fendmenos de intensa biologfa
humana, son los regfmenes de la alimentaddn infantil, la alimentaddn artificial, la
igncurancia popular, las enfermedades hereditarias y adquiridas.

554 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONGBESS.

Segdn Pinaid, cuyas referendas al respecto son de la mayor aatoridad, loe nifios
criados al biber6n sucumben a raz6ii de 300 por mil, y en deltas ^pocas calnrosas del
\eraiio hasta 600 por mil, mientras que, segtin Variot, sdlamente mueren el 37 por
mil de los que disfrutan la lactanda matema. En el mee de agosto de 1911, BudiA
vi6 morir en su clinica de Paris, 250 nifios criadoe al blber6n por 20 de loe otros. Las
infecdones gastro-intestinales, las meningitis del mismo origen, loa trastomoe de 1a
nutrid6n, loe /'Emihningstdrungen" de CEemy, que Oomby llama distrofias intes-
tinales, la atrofia, la atrepsia, son las resultantes mdrbidas ordinarias de la mala ali-
mentaddn y, por lo tanto, los &K:toree dominantes de la enfennedad y de la muerte
infantil.

En Escocia, en Sueda y en Noruega, donde la lactanda matema se halla m4i difun-
dida, la mortalidad infantil se reduce al minimum; en el Jap6n, donde la lactanda se
prolonga hasta 3 y 4 afios, con ser algo m^ ele ada, no pasa del 13 por mil. En cam-
bio las cifras se multiplican en cuanto nos acercamos a los grandes centres, donde Urn
madres delegan en el tiber^n o en la alimentad6n s61ida prematura, el r^;imen de
sus hijos. En Munich, se ha comprobado, por ejemplo, que mientras las criaturas
criadas por las madres ofredan el 15 por dento de mortalidad, las que estaban some-
tidoB a la lactanda artificial alcanzaban a la dfra increfble de 85 por dento. £s el
triunfo de los blberones infantiddas.

VI. Las cuatro causas determinantes que resumen la interpretaci6n fi8iol6gica del
fendmeno social que estudiamos, fueron sometidas en el campo de la sodologla his-
t6rica, a leyes fisioldgicas que Malthus sintetizd, a fines del siglo XVIII en su memo-
rable **Principio de poblaci6n."

A Rousseau, que de{endi6 con tanta elocuencia y tan buen 6xito, ''el derecho de los
hijos a la leche de la madre," y a los enddopedistas franceses que sostenfan con entu-
siasmo la aptitud de nuestra especie para el credmiento y el progreso incesantes, se
opuao repentinamente en Inglaterra la tesis de Th. R. Malthus, ''Ensayo sol re el
principio de poblad6n,'' apareddo el afio 1798. Consta, como se sabe, de tres propo-
siciones, que sintetizan el resto: (1®) Que la poblad6n se haya limitada por los medios
de subsistencia; (2^) que crece in- ariablemente donde crecen los medios de sub-
sistencia, a menos que algunos obst^ulos muy poderosos la detengan; y (3<*), que los
olTBt^ulos particulares y todos los que, deteniendo el poder preponderante, obliga
a la poblaci6n a reducirse al ni^ el de Iqs medios de subsistencia, pueden repartirse
entre los siguientes tres; la restricci6n moral, el a ido y la miseria. Terminaba con
la famoea f6rmula matemdtica, segtin la cual, el crecimiento de la poblaci6n sigue la
progrest6n geom^tiica, mientras que el crecimiento de la subsistencia sigue simple-
mente la progreaidn aritm^tica. Calculemos, escribe, en mil millones el ndmero de
habitantes actuales de la tierra, la raza humana creceria c<Hno los ndmeros 1, 2, 4, 8,
16, 32, 64, 128, 256, mientras que las subsistenciascrecerian como 1, 2, 3, 4, 5, 6, 7, 8, 9.
Al cabo de dos siglos la poblaci6n eetk, con relaci6n a los medios de subsistencia, como
256 es a 9, al cabo de tres siglos, como 4,094 es a 13, y, despu^ de dos mil afios, la
de^roporcion ser& inmensa, casi incalculable. De ahf que atacara las leyes de pn>-
tecci6D que permiten la ^ ida de los desh^^edados de la fortuna, que considera a los
pobres como seres intitiles a la sodedad y les negarael derecho de traer a la ^ ida ni de
ocupar ellos mismos, un sitio en el ''gran banquete de la naturalesa."

VII. Esta doctrina filosdfica, cuyo mMto ha sido diveraamente discutido, comparte
con respecto al problema de la natalidad, opiniones tan respetables como la de Plat^ y
AriBt6teles, en la antigQedad, de Montesquieu, Franklin y Arthiu* Young, en el siglo
XVIII, de Ricardo, de Stuart Mill y de Nietsche en el siglo pasado.

Con positive ^to se oponen a ella, Th<»rold Rogers, Sidgwick, Marehall y otros, que
estudian las fuerzas sociales, econ^micas, poUticas y g^ograficas que mantienen el equilf-
brio de la humanidad, y que requiwen, por el contrario, el ahono de las existencias
que llegan, unque no coincidan con el pan que, seg6n Bautista Say, debe bratar al

PUBUO HEALTH AND MEDIOIKB. 555

nacimiento de cada hombre. Al nudtusianismo despiadado del jacobiniamo precuraor,
que Babeuf critica en su "Siatema de la deipoblacidn,'' am haber evitado el primei
ensayo experimental, que fu6 la aplicaci6n de la guillotina y las matanzaa de la ^poca
del terror; y al midtuaianiamo atemperado de loe socialiBtas como Robert Owen en
Inglaterra y de Charles Fourier en su "Harmonla/' que refleja la viai6n de su ciudad
futura, se opone el buen genio de Rousseau que escribe para la Francia y para el
mundo, al cual pertanece su admirable espfritu, que no hay peor crisis para el estado
que la de los hombres.

A doe siglos de distancia, la generosa verdad se confirma, y no hay un solo pais
civilizado que no se preocupe lealmente en conservar y estimular el crecimento de su
poblaci6n. El bienestar individual no proviene de un reparto m£s o menoe discreto
de loe productoe materiales entre el menor ntimero, sino del eefuerzo de los mis al
bienestar de cada uno. La divisi6n del trabajo, el adelanto de las industrias, de la
agricultura y de las artes, han creado fuentes nuevas e inagotables para la actividad
humana. Los que estcarban, no son los red^ Uegados, que vienen a ocupar un
cubierto mds en el banquete de la naturaleza, sino los que llegan en malas condi-
ciones para disfnitarlo, por culpa o por desgracia de sus progenitores.

Las democracias modemas no despelian por ning6nmonte sus infantes decr^pitoe, ni
creen en la guerra y en las pestes como factores providenciales de depuraci6n humana.
£1 espiritu de los pueblos es mis req)etuoso con los derechos de nuestra especie, y en
vez de castigar en los hijos el defecto de los padres, prefiere adelantarse a corregirlos
para alzar su propia vida y la de todoe al mayor nivel.

VIII. He ahl el programa moral de dos ciencias que han surgido de su seno: la
'pediatrfa' y la puericultura. Une a ambas, el propdsito comdn hacia la defensa
sanitaria de la primera in&mcia.

Segdn V^lez Sarsfield, en el tftulo ''De las personas juHdicas," del CMigo Civil
aigentino vigente, abundaban en la Roma antigua los establecimientoe de beneficencias,
los hospicios para reci^n nacidos, para los hu^rfanos pobres y otros mis. Ninguno
de los establecimientoe de beneficencia existentes, agrega por su parte Savigny, el
erudite autor del "Derecho administrativo del imperio romano/' era desconocido en
aquellas ^pocas.

Pero es a principles del siglo XIX, en 1802, que fu6 fundado en Paris el modemo
hoq>ital infantil, seguido en 1827 por el primer asilo infantil y en 1844 pcnr la primera
' ' Cr^he, ' ' de la cual existen ahora 66 en la ciudad y 31 1 en el pa(s. ' ' Mientras vosotros
guardais los hijos de ellas— niice el filintropo fundador Fermin Marbeau — el trabajo
guarda la madre." Estas instituciones, en efecto, fueron destinadas a acoger, a cuidar
y dar asistencia, a los nifios menores de seis y de tres afios, reepectivamente, que no
podian ser atendidos por las madres ausentes, por su trabajo fuera de sus domicilios,
en los talleres o en fibricas.

En Italia se intents el primer curso de "pediatria" en 1815, pero no tuvo ambiente
propicio, y hasta 1882 fu^ instituido con caricter oficial en la Univeraidad de Padua,
y confirmado como citedra obligatoria por real decreto del 17 de mayo en 1905.

De la "pediatrfa,'' la ciencia m^ica del nifio, proviene y proeigue hacia la cultura
popular, la fisiologla e higlene infantil, que es la puericultura. La vulgarizaci6n de la
"pediatria," escribe Flamini, ha sido la obra mis eficaz y mis apropiada para dis-
minuir la cifra de la mortandad de los nifios, por debajo de los dos afios de edad.

IX. Las institucioneB de asistencia in&ntil son, asimismo, muy recientes. En
1863, se fund6 en Italia el primer "Hospital marine,'' destinado a la cura de loe nifios
escrofulosos y raqufticos y Gilbert, en Francia, promovid en 1875 el primer " Ambula-
torio infantil," del Havre.

En 1891 se oiganiz6, bajo la presidencia de Mme. Veil Picard, en Paris, la admirable
institucidn denominada la "Pouponni^re," cuya versi6n gentil a nuestro idioma
seria "criadero de ingelee," destinado a criar artificialmente los lactantes hu^rfanos

556 PB00EEDIK08 8E00KD PAK AMEBICAK 80IBNTIFI0 C0NGBE88.

o abandonadoe; al afio dguiente, el jproieBor Budin oiganiz^ sua primeras "Consultas
de infantes/' y en 1894 en F6camp se fundd, por iniciativa de Dufour, la popular ''€rota
de leche."

En Inglaterra, los "John Bamardo's Homes" son 82 institutos diseminadoe por todo
el reino, que amparan la nifiez abandonada. En Alemania ezisten, entre otros, la
Schutzkindeverein y la Verein f tbr inner Mission; en Suiza hay nUis de 60 *' creches "
y diversas instituciones pro infancia; asimismo en Eepaiia, en Hungria, en Dinamaica,
donde existe la "liga nacional danesa para la protecci6n de la primera infancia",
fundada en Copenhague en 1904, con la divisa, ' ' las medidas preventivas son preferibles
a cualquier cura." En Holanda existe desde 1900 la ''Nederlandsche Vereeniging
Ondenlinge Wrouwen beschenning,'' dedicada a socorrer las madres il^timas y a
la asistencia de los niflos pobres. B^lgica cuenta, entre muy numerosas e importantes
instituciones de.este g^nero, la "Escuela de puericultura" y el *'Dispensaiio del
Principe Carlos de B61gica/' fundado el afio 1905 en Bruselas, que constltuye un
dispensario modelo de puericultura y de asistencia clinica infantil.

X. Hemos resumido los orfgenes y el desenvolvimiento actual de las principalee
instituciones de protecci6n legal a la primera infancia, p<nrque nada hay m^ elocuente
que los buenos ejemplos para iniciativas de este g^nero.

Entre nosotros, felizmente, hay una parte ya realizada y otra muy importante,
redent^nente inidada. La cdtedra de "Pediatrfa'' existe en nuestra Facultad de
Medidna, desde marzo de 1883; la de Puericultura, cuya cread6n hemos promovido
a fines de 1912 y mediados del afio siguiente, ante el consejo nadonal de educaci^ y el
Mlnisterio de Instrucci6n PdbUca sucesivamente, bi6 sancionada primeramente en
la dependencia del consejo, en forma de cursos de ensayo que hemos dictado durante
el afio 1913 y luego se ban incorporado al nuevo plan de estudios de 1914, en el cuarto
afio de la enseflanza normal.

Posteriormente hemos extendido la misma iniciativa a la ensefianza secundaria
femenina, habiendo inaugurado el 12 de junio de 1914, por disposid6n del Ministro
de Justicia e Instrucd6n Pdblica, Dr. Tom^s R. Cuellen, la cdtedra de puericultura
en todas las E^uelas Profesionales de Mujeres, bajo su dependencia, en la capitaL

La beneficencia privada ofrece, por otra parte, entre nosotros, a la infancia
abandonada, institudones filantr^icas como los consultorios y aailos del ''Patronato
de la Tnfancia," el "Asilo de Exp^sitos'' y el "Asilo de Hu^rfanos;" la proteccida
pdblica se ejerce hasta ahora por acddn excluBivam^ite municipal, mediante siete
dispensarios de lactantes, repartidos por la comuna, seis institutos de puericultura^
la inspecd6n de nodrizas y la ''Qota de leche.''

Redentemente, tambi^n, el 26 de agosto de 1914, la direcd^ de la Asistenda
P6blica a caigo del Dr. Eduardo BeUUistegui, ha elevado a la intendenda munidpal,
un interesante proyecto, proponiendo la edlficad6n de un Hospital de Lactantes,
para contribuir desde un punto de vista mds ampUo de la asistencia de la madre y
al hijo, a la sohiddn de ese problema social de profilaxia aigentina. Por dltimo, en
el Departam^ito Nadonal de Higiene fundona ya, desde 1911, bajo la ilustrada direc-
d6n del Dr. A. Yidal, una secci6n de higiene infantil, que ha organizado para el
estudio permanente de nuestra infanda escolarizada y no escolarizada.

La opinidn general empieza a interesarse tambi^, por este noble impulso de
mejoramiento y de provisi6n humana. La literatura, el teatro, la dencia y el arte,
r^ejan ya entre nosotros, las primeras manifestadones de este sentimiento popular.
Son un ejemplo brillante, la comedia de tesis "El tomo libre," del Dr. Faustino A.
Trough, y la mis redente del Dr. C^sar Iglesias Paz, "La enoniga," cuya tiltima
escena parece ser un cuadro feliz de puericultura. El arte fotogrifico, pictdrico y
escultural, realizan amorosamente el encanto natural de los nifios, mientras la denda
acude a ellos para guardarlos mejor al amparo de todoe y de cada uno.

PUBLIO HEALTH AND MEDICIKE. 557

CitemoB a este reepecto, el importante estudio preeentado el 18 de octubre de 1913
al Congreso Nacional del Nifio, por el profesor Dr. Eliaeo Cant6n, que es im alegato
elocuente a favor de los ^'Refugios matemales,'* y el Dr. Sllvestre Oliva, quien en
la mlsma oportunidad reeume en una interesante comumcacl6n, su propia obra
Gomo subdirector de la Asistencla Ptiblica de la capital, y la do los Drs. Pifiero y
BeUlusteguly sobre la ''Protecci6n a la primera infancia;" y lu^o, loe nombres de
Sisto, Aguilar, Ortiz, Borruat, Palacios y otroe, que mueven en nuestro ambiente esta
corriente de modema humanidad que per8^:uimo8.

Por nuestra parte, deseamoB elevar a una funci6n de estado, la protecci6n social
de la primera Infancia. Hemes preeentado con este motive, a la consideracidn de ese
mismo primer Congreso Nacional del Niflo, verificado en Buenos Aires en octubre de
1913, y con el prop68ito de insistir sobre 61, en el pr6ximo amerlcano que se prepara
para reunirse en Tucumdn en 1916, un proyecto de ley sobre creaci6n de un " Instituto
Nacional de Matemologfa y Puericultura," que fu6 favorablemcnte despachado por
la 8ecci6n especial a que pertenecfa y aprobado en la scsi6n plenaria del mismo.

Ese proyecto puede resumirse en los siguientee propdsitos de tal eetablecimiento:
La protecci6n y la ensefianza de las madres. incluso de las solteras, tanto las que crfan
a sus hijos como las que se dedtcan a nodrizas, facilitdndoles cuantos medios se con-
flideran adecuadoe para evitar loe frecuentes descuidoe por ignorancia, que ocasiona
la muerte prematura de loe nifios. Gontribuir a la perfecta crianza de loe reci^n
nacidoB, amparando a las madres indigentes, seleccionando las nodrizas, velando por
la salud de amboe y garantizando, en lo posible, la asistencia higidnica y radonal
que reclaman. Fundar una escuela de nifleras-enfermeras, anexa a un servicio de
<ala-<nina donde las j6venes aprendan el arte de alimentar y cuidar a los nifioe
higi^icamente, y adquieran los indispensables conocimientos practices de economia
dom^tica y hospitalaria, preparaci6n de alimentos, confecci6n de ropas y otros.
Estimular por todoe los medios la lactancia matema. faciUtar el an&lisis de la lecbe
7 sus succeddneos, y el expendio del Uquido nutritive en condiciones econ6mica8 e
higi^nicas, como, asimismo, el estudio de las medidas conducentes a su abaratamiento
en favor de las clases proletarias. Organizar dos curses regulares de conferencias,
sobre puericultura y sobre matemologfa, con programas especiales. Por tiltimo,
constituur la asistencia a domicilio de la madre y de los hijos pequefios, mientras la
salud de ^tos asf lo requiera. Con este motive, preparamos en estos mementos, el
material complete de informaci6n y de estudio correspondiente, que figurar& en la
6ecci6n Argentina de la Exposici6n de 1915 en San Francisco de Califomia, eepe-
cialmente destinado por el Ministerio de In8trucci6n P6blica para mostrar esta parte
del progreso nacional.

Es probable, por tanto, que esta modesta contribuci6n al estudio de una Iegi8laci6n
argentina para la asistencia sanitaria de nuestra primera infancia, no se pierda como
hasta ahora, en el ambiente de incesantee preocupacionee en que nee desenvolvemoB.

Contamos en nueetro favor con la urgencia de un suelo inmenso que poblar, y de
una nacionalidad naciente que reclaman el esfuerzo del ndmero y de la calidad,
para afirmar la virtud hist6rica de una raza y de un gran pueblo.

CAPfTULO VI. — LA PBBVIBldN SOCIAL ANTB LA OUBRRA. (*)

I. La guerra como el trabajo tiene sus obreros y sus vfctimas. Por singular coinci*
denda, la m^uina de preciai6n se maneja con Igual destreza para levantar el progreso de
cien pueblos, que para deetruir en algunos meses la civilizaci6n de veinte siglos. Noa
reserva a este respectolahistoria de la tremenda tragedia continental, la nUis nutrida
e impresionante informaci6n. Mientras tanto, observemos sobre el inmenso teatro
de los acontecimientos una nueva faz que sus fen6menos revisten. Y no es que con-
venga insistir demaslado en la comparaci6n entre el peligro de las prof esiones, por
insalubres y mortif eras que sean, con los de la industria de la guerra; porque el oficio
de combatiente es expuesto por encima de toda ponderaci6n. Pero cntre amboa

1 El prwente capftulo Morito el 14 de mayo de 1916. te ba oonflrmtdo pifrmunente, mas adelante,
eegdn poode verae m el aiUciilo del Profeeor Geaset, Jefe del Centro Neuroldgloo de la XVa RegMn UU
lltar, titulado " Paiooneuroals de la foerra " poblloado en enero de 1910.

558 PB0GEEDIN63 SECOND PAN AMERICAN SCIENTIFIC CONGBESS.

ezLste una similitud de principio que merece i»reocupar la atencidn de todoe, y ea
particular de loe hombres de estudio y de gobiemo, a quienee atrae mia de cercft
cuanto Be refiere a la protecci6n social de loe intereses humanos.

Reconoce la legislaci6n universal, en t^nninos m^ o menoe andlogos, el derecho de
los individuoe a ser protegidos e indemnizados de loe riesgos profesionales; con id^tica>
juBtida en tiempoe de paz que en tiempoe de guerra. La sociedad defiende bus obre*
ros y la patrla bus soldados.

Solamente que, en comparaci6n con loe otros, el problema resulta infinitamente mis
sencillo entre los primeros, no obstante su propia complexidad; desde que a medida
que aumentan las probabilidades del dafio se hace m&s dificil el diagndstico de bub
mdltiples variedades. Ya en otro capltulo de la legislaci6n obrera hemos demostrado
la injuBticia legal que se establece en algunoe palses, y entre nosotros, amparanda
tinicamente las consecuencias del trabajo patoldgico — los accidentes — ^y abandonando
a su suerte el infortunio normal del trabajo, que constituye el grupo de las enierme-
dades profesionales. Pero en el vasto campo de los accidentes de la guerra, el criteria
clinico se impresiona por situacionee m^ interesantes, todavia, de verdad m^ca y
de equidad social.

Pwque entre los dos llmites aparentes de la actividad humana, la muerte definitiva
3 la vida fisioldglca, hay diversos grados de existencia biol6gica, que una desgracia
de guerra afecta de distintas man eras. En los partes necrol6gicos de batalla son
muertoe todos los que eet&n, pero no son sobrovivientes todos los que faltan en elloa.

No nos referimos, como se comprende, al mundo de heridos. de incapacee, de tullidos
y de inv&lidos ffsicos, que sou las vlctimas diarias de la campaila cruenta; ^sos est^
descontados en la imaginaci6n popular y en los c^lculoe estrat^icos de los comandoa
militares, que lanzan en cada acci6n tantos millares de pecbos humanos al fu^o
enemigo. Las p6rdidas finales parecen computarse luego en dos categorfas: de los
muertos y de loe heridos. Entre los dos quedan los prisioneros, y aquellos que nos
ocupan, quienes no han merecido hasta ahora el honor de contarse para la c1asificaci6n.
Desde luego. porque no parecen heridos ni se les Uora entre los muertos, y ademiis,
porque bus males no se miden por ninguna leBi6n.

Jja crisis de Europa, de su civilizaci6n y de su ciencia, ha llegado precisamente
cuando los sabios se preparaban a penetrar el misterio de uno de los capltulos m^
diffciles de la medicina modema. Las enfermedades humanas han ido cediendo
poco a poco el secreto de su origen, de su evoluci6n y de su terap^utica; en todas se
ha descubierto una causa material, viviente o no, de ambiente, o constitucional.
S6\o un grupo ha conservado su indep^idencia de todo factor anat6mico visible;
c<mBtituye actualmente el g6nero de las ^'neuroeis.''

Entre las fatigas de los talleree, no es dificil ver producirse sobre los organlsmos
debilitados, mal nutridos o extenuados, distintas manifestaciones neuropdticas: pero
en la vida de cuartel, en el *'surm^age" de las trincheras o durante las emocionea
de las batallas, el hecho clinico suele determinarse con particular frecuencia.

Los trastomos del sistema ner\ ioso son tan graves como cualquiera otro de la econo-
mia animal. No se adA ertfan ellos antiguamente, porque no se comprobaba ninguna
alteraci6n org^nica. La misma palabra era desconocida, hasta el siglo XVII I, cuando
fu^ empleada por el m6dico escoc^, Gullen. Luego se cay6 en el extremo de atribuir
a las ''neurosis" todas las enfermedades de loe nenios, de la mente y del espfrita;
desde el t6tano al Bonambulismo, desde el delirio pasajero de las pasiones, a la corea, a
ciertas fiebres y hasta la ataxia locomotriz y la pardlisis general. Fu6 en 1851, que
Saudras en su tratado especial, Axenfeld en 1863 y Huchard en 1883, definieron acerta-
damente el car^ter de las neurosis, que quedan reducidas a seis tipos: el estado ner-
vioso, la corea, la eclampsia, la epilepsia, la catalepsia y la histeria. El cardcter comtin
a todas, segdn Raymond, en 1897, es que son afecdonee del sistema nervioeo "sin
lesi6n orginica apredable," por nuestros procedimientos de investigaci6n. De afaf a
disimular su existencia, en loe cases vulg^ures, no hay m^ que un paso; y es lo que

PUBLIO HEALTH AND MEDICINE. 559

flucede actualmente. Es cierto que el concepto anterior puede ampltarse con este
otro, segdn el cual, las neuroais son enf^medades ner iosas con ''lesiones ignoradas/'
m&B bien que enfennedades sin lesionee; pero el espfritu m^ico se halla poco dia-
puesto a tomar en serio fendmenos sin fondo a isible o palpable, y apenas le m^recen
alguna atenci6n.

II. La guerra deepertar^ muchas neurosis latentes y detenninard eficientemente la
producci6n de tantas otras. Un gran tanto por ciento de sob re i ientes \ol er&n a
8U8 hogares con el cuerpo intacto, pero con el alma herida de muerte. Y no es que el
h^roe que pierda un brazo o una piema merezcaeetimarse menoe por eeo; pero el pobre
neiur6tico en qui6n nadie sospechard una contribuci6n de sangre, es acreedor a una
mayor gratitud de sus conciudadanos. La penfii6n y la medalla bien ganada que luce
el pnmero, corresponde tambi^n, en buena ley, al segundo; y es lo que no sucede
todavfa.

Ya en 1871 y 1872, a rafz de la guerra franco-alemana, Charcot obser aba en sa
c6\e} re clfnica de la Salpetri^ la descendencia tarada de una infinidad de nifioe que
Uevaban la herencia neuropdtrica de los defensores de Paris; los ilamaba ''les enfants
du si^e. ' ' Los asilos y manicomios f ueron el dnico ref ugio de esos hijos de valientes;
de los infortunados "hijos del sitio."

Serd mda propicia aun la guerra actual en manifestaciones de este g^nero. El bata-
llar incesante y tremendo, la incertidiunl re de la ictorla, el cuadro Irutal de la muerte
a cada paso, las pri^ aciones, el ham} re o el frlo en las trincheras y durante las largas
marchas, son moti os ^stos de extenuaci6n que predlsponen a toda clase de dese-
quilil rios del sistema ner ioso que pueden ir desde los simples delirios emoti os a las
formas agudas y delirantes de agotamiento, a la con! usi6n mental primiti\ a y al delirio
alucinatorio.

Por otra parte, los traumatismos tan frecuentes en la cabeza y las conmociones
cere! rales pro enientes del ofdo por los estampidos de los grandes ca&ones producen
un estado emocional, que se agra a extraordinariamente con el espect&culo iolento
y desolador que los rodea, a punto de pro^ ocar a erdaderos delirios incoherentee, p^-
dida de la memoria, conhi8i6n y desequiliVrio mental, demenda y estados de neuras-
tenia, de histeria, de locura, y adn ataques de epilepsia y de pardlisis general trau-
matica.

Basta esta bre e sfntesis para demostrar la imp(»rtancia m^co-sodal del tema que
tratamos. La guerra tiene un fondo de neurosis colectiva y su consecuenda ine . i-
taV le son las distintas formas de las neurosis indi iduales.

Desde un > apole6n que experimenta en cada batalla la ^ iaidn de una eetrella]»e-
cursora de la ^ ictoria, que se ocultara en Waterloo, hastael modesto oficial que contagia
0U entusiasmo b^lico al grupo de soldados que manda, enloquecidos por el ruido de la
fusilerfa, el tronar de los cafiones, el espectdculo de la camiceria trdgica, el olor a
p61 ora y el vertigo de la pelea; desde aquel conquistador de la antigtiedad que suefia
con un estandarte ostentando en letras de sangre la insciipci6n "in hoc signo * inces,"
hasta el poderoso sefior de nuestros dfas que sufre en pleno siglo XX el delirio impe-
rialista de dominar al mundo por las annas, todos y cada uno padecen en sus plaamaa
ner iosos un trastomo mds o menos intenso de su acti idad ordinaria.

Solamente que el genio y la locura, que se tocan por sus extremes, en el arco doblado
de las des iaciones frenop&ticas, atraen para el primero una admiraci6n romintica de
las gentes, que en toda ^poca les fu^ propicia para dispenaar sus locuras y desasties
mlentras que a los otros, a los pobres locos sin genio, pero causadoe por los genios de la
guerra, no les acompafia la mds minima consideraci6n de los ajenoe.

III. El dolor fisico no es superior al dolor moral y asi tampoco las enfennedades del
alma imp<«tan menos que las del cuerpo. La unidad natural del cuerpo y del ea-
piritu, cuyo dualismo combatimos desde hace mucho, nos impone esta concluai6n
cllnica, que es asimismo una verdad filosdfica y real. £1 sentimiento de gratitud y de
protecci6n social que las \ictimas de la guerra suscitan en todos los pueblos, debe

560 PBOCEEDIKGB SEOOND PAN AMBBIOAK 80IENTIFI0 00KGBE88.

haceiBe exteneivo a lo6 que sufren con leA6n palpable o sin ella. Si en tiempo de pas,
la lucha por la vida rinde tantoe oiganismoe fuertes en las sombias temiblee de psicaa-
tenias, ner . osismoe y neurastenias dolientea, simplemente gra\e0 o mcuiablee, calcdleea
lo que no har& la g:uerra, en el infierno de bub horroreB y penuriaB, entre las viciflitudea
de tantoB sacrificioB y peligroB.

El princlpio de Bolidaridad y de fraternidad humana, que Be ha quebrado quien
Babe hasta cuindo, en la bora m^ triste de la historia de nueBtra ci ilisacidn, parec^
reflejarse de esta manera entre noBotroB, pan Ber devuelta en el dfa de la paz, como el
mejor homenaje a bub h^roeB, a bub institacioneB y a bub hombreB, en eeta contribuci6n
a BUB m&s altos propdaitos de pre . isi6n y de juBticia social.

CAPItULO Vn. — DOS PBOBLBMAS ARGBNTINOS DB MBDiaNA SOCIAL.

I. Projilaxia 90cuil del alcoholismo. — La educaci6n antialcohdlica en la eBcuela
constituye la forma m^ eficaz de previsidn y profilaxla modema contra la mds temible
de las plagas hl8t6rica8.

En etecto el g^nero bumano Be intoxlca desde largos siglos con alcohol, el pecado
original de la leyenda bfblica parece sustituirse en la hiBtoria de loe pueblos, por el
vicio fisiol^co que se extiende sobre todos como una condici6n.

Cuenta un redin de los irabes, que derto magnate pidi<S a uno de sus B^bditos que
escogiera entre las tres siguientes penas; matar a la madre, envenenar a los hijos o
beber una copa de alcohol. Opt6 por la dltima; pero se embriag6, mat6 a la nuuire
y env6non6 a los hijos.

La afici6n a la bebida es tan antigua como el mundo. Al prindpio fueron las
bebidas fermentadas provenientes de productos naturales como son la uva, las man-
sanas, las peras; m^ adelante, se prefirieron las bebidas destiladas, obtenidas arti-
ficialmente del mafz, de la remolacha y de las papas, l^timamente, las esendas son
el grado mayor de complicaci6n industrial, entre las preparaciones alcoh61icas.

Antiguamente, era frecuente la embriaguez por el vino o por la sidra, deepu^s de
copiosas libacioneB. Los sfntomas del '* alcoholismo" eran jubilosos, expansivos y
alegres; sus fen6menos se dislpaban mediante un Buefio reparador, durante el cual
los tejidos eliminaban por los rifioneB, por los pulmones y por la piel, la substancia
ingerida. I^ts formas del alcoholiBmo agudo son impresionantes, pero menos graveB,
en sus primeros pasos, porque cuenta con las defensas naturales del oi^ganismo. Ac-
tualmente, por desgracia, el alcoholismo se produce a tragos cortos. No es el cuadro
callejero del borracho que se derrumba en mitad de bu camino, entre la tabema y la
casa, ni del gnipo de orgiacos que ruedan bajo la mesa de un fsBtin, sine del miaerable
bebedor que toma a pequeflos sorbos bus copitas.

El alcoholiBmo cr6nico viene asf matando la reeistencia de los 6iganos al veneno que
los invade pooo a poco.

Los excesos de intoxicaci6n aguda que se repiten con mds o menos irecuenda, pueden
ii^ar a un estado general y permanente de alcoholismo cr6nico; pero la in versa no
es indispensable. Puede producirse en etecto, sin que el Bujeto haya pasado jam^
por una borrachera franca; es lo que se observa entre nosotros, y muchos otroe paises,
donde se n^aba, por esa raz6n, el problema del alcoholismo.

Persiste por lo tanto un error popular que conviene desarraigar a tiempo. El
alcoholista cree que no lo es, porque no se ha embriagado nunca, siendo en realidad
lo que le ha faltado, el "accidente alcoh6lico." Nunca m^ necesario tambi^n que
en estos casos, el *'con6cete a tf mismo '^ del gran fil<3Boto, paia contener a tiempo el mal
que ni<^n.

Porque en Us clases populares la gente bebe con cualquier pretexto. En inviemo
para c^entarse, en verano para enfriarse; en todas las estaciones para levantar d
espfritu, el coraz6n y el est^mago.

Respecto al primero la ilusidn ee falsa. Deed e Olaudio Bernard , Be viene demostran-
do que el alcohol ee el tipo perfecto de los venenos del Bistema nervioBo. Las estadfii-

PUBLIC HEALTH AND MBDIOINE. 561

tlcas de nueetro hospital de alienadoe revelan, eeg6n el doctor Cabred, que eziste el
66 por ciento de intemados por locura alcoh61ica. En un intereaante cuadro sobre
"Alcohol y locura" aparecido en "La Vanguardia" el 16 de abril del afio pr6ximo
paaado, el autor clasifica loe locos por su origen alcohdlico y obtiene que el 29 por
ciento bebieron ajenjo, el 56.30 por ciento bebieron aguardiente, ginebra, whiskey y
ihum, el 5.50 por ciento licores dulcee y finoe, y sefiala que loe consumidores de ajenjo
dan 246 probabilidades de producir un loco, loe de aperitives y biteres, 170, los de
licores dulces y fines 143, los de alcohol (aguardiente, rhum) 77, los que acuaan un
(ndice mia discrete son el vino, la sidra y la cerveza.

Sobre los sentimlentos, la influencia del alcohol no es m^ feliz. Los arrebatoe
amorosos del excitado alcoh6lico son fugaces e inestables. Ixm "hijos del domingo,"
que dicen los franceses, son los pobres descendientes endebles y raqufticos engendrados
en esos dlas de tabema. Sobre esos hijos pesa la herencia alcoh6lica que puede ser
la simple predisposici6n a la tuberculosis, las taras nerviosas y pslquicas, el idiodsmo,
la epUepsia y las degeneraciones mentales, o el alcoholismo propiamente dicho.

En el orden moral, las manifestaciones son igualmente graves. Las lesiones cere-
brales que produce el veneno, como son la meningitis el reblandecimiento, la congestidn,
la hemorragia, loe aneurismas miliares y la arterioesclorosis repercuten sobre la vida del
espfritu y la concienda de sus vlctimas.

Segdn la intensidad y el grade de lesion serdn los trastomos en una y otra esfera de
la actividad humana. El manicomio por un lado, el asilo para los hijos degeneiados
por otra, la prisi6n y la cdrcel luego. Desde el simple atentado penonal a las mis
temibles manifestaciones del delito y de la'criminalidad.

En tercer t^rmino, el est6mago, segdn dijimos. Ya el gran clfnico iranc^ Trousseaa
ensefiaba "que los aperitives son la llave falsa para abrlr el apetito. " Las digestioneB
se retardan con el alcohol. Las gUndulas g^Btricas disminuyen las secreciones de mm
jugoe, luego se inflaman y se producen dispepsias de alcoholistas.

A medida que los excesos avanzan se determina una verdadera gastritis, con vdmitoe
matutinos llamados "pituitas" acompafiados de inapentencia y enflaquecimiento.
£1 bebedor pierde las ganas de comer y para tener apetito bebe. He ahf un drculo
vidoso que se estrecha indefinidamente.

Por dltimo el sujeto mal nutndo pierde fuerzas, abandona el trabajo, se debilita y
queda predispuesto a todos los contagios y miserias fiaiol<5gicas.

El alcoholismo, dice Landouzy, tiende la cama al tuberculoso. He ahf el cuarto
destine del alcoholista: el hospital. Se puede asegurar que el 90 por ciento de los
alcoholistas mueren antes que por eee estado de enfermedad por la infecci6n tub^cu-
losa, aparte de las foimas graves que por sf misma reviste.

Como se ve, el porvenir de un alcoholista, el horizonte de una tabema, se abre a
cuatro grandes caminos: por ellos se pueblan las durceles, los manicomios, los hospitales
y los asilos. Entre los pafses de Europa, Francia posee 483,000 despachos de bebidaa
dedarados, es decir, un despacho p<Hr cada 80 habitantes. Es un triste record, ya que,
por ejemplo, s6lo hay un despacho por 246 alemanes, uno por 380 norteamericanos,
uno por 430 ingleses y uno por 3,000 suecos.

Paris posee 33,300 despachos de bebidas para 2,601,000 habitantes, Londres no tiene
m^ que 5,860 "bars'* para una poblaci6n de 4,536,000 y Nueva York solo cuenta con
10,821 despachos p<nr 3,437,000 moradores.

La sodedad prefiere mantener todos esos establedmientos que contienen y no curan,
en vez de opener al triste mal sus medios de previsidn y de defensa.

Hace algdn tiempo varies diputados franceses encabezados por Siegfried, BuissoQ
y Reinach, presentaron al parlamento una solidtud formada por 220,000 mujeres
casadas, pidiendo la reducci6n del ndmeio de "cabarets" existentes en Franda*

Es un grito mia de alarma, que ha de conmover un tanto la atend^ de loe poderes
ptiblicos del pals.

La eqxMa obrera aiente m^ de cerca la ruina moial y material del peligro aloohdUoo*
Por su sangre cruza, "sin culpa, " el veneno que de^nda los hijos y la espede; ante

562 PBOGEEDINQS SECOND PAN AMEBICAN SCIENTIFIC C0NGBE8S.

SOB ojo6 06 deeenvuelveii loe cuadroe m^ trtBtes del hombre en la plena derrota de
todoe BUB sentidoB.

La veigilenza de nneetra especLe 86 refleja en la lacra social que combatimos. Ltcuigo
embriagaba a loe ilotae paia que el eepecticnlo degradante fueia un ejemplo de absti-
nenda y de mod«uci6n entre loe condudadanoe. Nuestroe legialadores tienen recunos
mifl eficaces de {wevisi^n y profilaxia. Los paises como Noruega, B61gica y Nueva
Zelandia, ban inrosperado en fuerza y riqueza, gradas a sus leyee de ludia antialcdidlica.
Actualmente con modvo de la guerra continental, Franda, Inglatena y Rusia ban
dictado leyes especiales prohibiendo la venta de alcohol.

Esta medida en Rusia ha provocado la crisis de sus destiler^ dando lugar a que
^stas tengan acumuladas en sus dep^tos grandes cantidades de alcohol a las que no
saben que destino dar.

Con tal motivo el Gobiemo del Imperio ha (»ganizado doe concursos internadonales
cuyo objeto es estimular a loe qufmicos y ttoiicos en la materia para efectuar investi-
gaciones encaminadas a encontrar substandas aptas para la desnaturalizaddn del
alcohol y dar nuevas aplicadones industiiales a dicho producto.

£1 primero de estos concursos tiene por fin fomentar una amplia aplicaddn del
alcohol (eeptritu de vino) a las necesidades t^cnicas, y para ello se crean tares premios
de indemnizad6n uno de 30,000 rubles, otro de 15,000 y un tercero de 5,000.

Los concurrentes a este certamen deberin inventar nuevos desnaturalixantes o
perfecdonamiento de los procedimientos de desnaturalizad6n ya existentes, de mode
tal que asegurando la libre circulaci6n del alcohol desnaturaUzado, hagan imposible
el empleo de ^te como bebida.

El segundo concuiso tiene por objeto fomentar el desarrollo intenstvo de la apUca-
ci5n del alcohol o sus derivadoe a la calefacci6n, al alumbrado y a la producddn de
fuerza motriz, asl como para favorecer la aplicaci6n de alcohol en las diversas lamas
industrialeB de la tecnologia qufmica.

A este efecto se ofrecen numeroeos premios en metdlico que varian entre 75,000 y
5,000 rublos.

La l^|islaci6n argentina tunbien inspirada en el espiritu y la pr&ctica de la m4i
alta dvilizad6n, debe adherirse cuanto antes nuestro ambiente por sus leyes, por sus
escuelas y por la educaddn popular a este movimiento de defensa univ^nal, que tiende
a alejar el peligro alcohdlioo que amenaia a la humanidad y a la raza con el pear de los
venenos.

II. Profilaxii iocial de la ttd>erculo9%$, — ^Entre las enfermedades sociales, ninguna
plaga afecta m^ hondamente la sanidad del pais como la tub^tnilosis. La ''peste
blanca" constituye todavia, y desde hace mucho, un peligro uni venal; pero su gra-
vedad ha cobrado de un tlempo a esta parte tal difu8i6n e intensidad entre nosotros^
que asome la proporddn particular de un problema nadonal.

Es, desde este punto de vista, que parece resolverse por fin, su defensa higi^nica.
La creciente morbilidad y mortandad que eefialan sin ceear las eetadfsticas, muestran
hasta que punto son infructuosos los esfuerzos aislados contra el mal y como la campafia
racional requiere recursos mis vastos y heroicos. La beneficencia ptibHca, la asistenda
hospitalaria, la caridad privada, no ban hecho, como se eabe, mis que aliviar la situa-
ci6n, pues no eeti en bus medios remediarla positivamente.

Desde hace alglin tiempo el Poder Ejecutivo ha comprendido, la necesidad de
intereearse por este asunto, apr^niado por su misma magnitud, y ha designado, por
intermedio del Ministro del Interior, una comisidn permanente encargada de eatudiar
el mejor aistema que ha de adoptarse para la lucha antituberculosa. Esta inieiativa de
gobiemo, cualquiera que sea el resultado prdctico que consiga mis adelante, m^-ece
tenerse en cuenta por el alto propMto que la inspira y por la significaddn especial
<|ue le corresponde en los procedimientos modemos de profilaxis.

En efecto, las enfermedades colectivas, como la tuberculosis, el alcoholismo, la
avariosis y otras, tienen caosas sodales determinantes, y es con remedios sodales,

FUBUO HEALTH AKD MiaXOIKB. 568

que redden en la eociedad o en el Estado, que pueden contenerse y dominane. As!
per ejemplo, loe origenee de la tuberculosis, son, aparte de su microblo especifico, el
bacilo de Koch, que es el principio eficiente, otras m^, como son lamala alimentaci6n,
la mlseria fisiold^ca, las viviendas malsanas, la ignorancia popular, loe malos h&bitos
y el vicio alcoh61ico. Fonnan el grupo de las causae coadyuvantes, que preparan el
"terreno" org&nico a favor del ''germen;" sin el suelo viviente predispuesto para
recibir la semilla pat^gena, ^sta se agosta y no prospera sobre ^1. Por eeo siendo
tan frecuente el bacilo de Koch, que pulula por todas partes, sobre todo en el aire,
en el cual se aventa con el polvo atmosfMco caigado de loe esputos deeecados que
arrojan los enfermos, no todos nos contagiamos, porque no oirecemoe al microbio
que pasa un lugar propicio a su penetraci6n y virulencia. Es gracias a esas con-
diciones fisicas y biol6gicas de menor resistencia vital y orgdnica, que el germen
m6rbido prospera en los tejidos que invade; luego, depende de esas mismas circuns-
tancias que la lucha que se establece entre las c^lulas propias y las extrafias, cuyo
fen^meno aparente constituye la enfermedad, se incline hacia uno u otro sentido en
la suerte del sujeto humano. Por lo tanto, la previsi6n y el tratamiento dependen
de un r^imen anilogo con respecto a la tuberculosis; consiste fundamentalmente
en mejorar el individuo y el ambiente, saneando con el aire oxigenado, con la buena
alimentacidn y con el descanso fisioldgico, los oiganismos expuestos a la enfermedad o
en camino a agravarse con ella cuando la ban contrafdo.

La slntesis expuesta disimula apenas la amplitud real del problema. La profilaxis
social de la tuberculosis requiere, ademils de la acci6n inmediata del estado y de las
instituciones oficiales, para contrarrestar por via l^al los factores econ6micos y sani-
tarios de la enfermedad, la cooperaci6n de las colectividades, dispuestas inteligente-
mente hacia el mismo fin. De ahi la necesidad de formar mediante la cultura popular la
conciencia higi^nica de las multitudes, ya sea para la lucha antituberculosa, como para
la antialcoh61ica y antiavari61ica, que es la triada m6rbida contempor^ea, que debiera
llamamos uno por uno a la defensa comdn. En ese esfuerzo soUdario es que reside
el 6xito definitivo de la empresa.

Felizmente, acabamos de distinguir el primer sfntoma muy interesante en tal
sentido. Es una tentativa de mutualidad, con fines de aaistencia m^dica para tubercu-
losis que se ha organizado hace poco entre el personal de correos y tel^grafos de la
Reptiblica, que empezard a funcionar el afio entrante y que abarca iina poblaci6n
pr6ximamente de 13,000 empleados. Por todos conceptos, constituye el ensayo m&a
completo y mis acertado de previsi6n que se ha Uevado a cabo entre nosotros, no sola-
mente por la importancia que reviste para sus propios afiliados, sine tainbi^n por la
trascendencia moral que tendri sobre el clrculo de las demis reparticionee que no
tardardn en imitarlee. Por ahora la asociaci6n titulada *^Sanatorio mutualista de
empleados de correos y tel^grafos,'' fundada a iniciativa del actual Jefe de la Direcci6n
de Correos, D. J. B. Jimenez, el 13 de abril de 1915, ir4 capitalizando 0.25 centa-
vos mensuales por cada empleado, que constituiri en 1916, para el primer ejercicio
active, un fondo de 40,000 pesos, con el cual se comenzari la obra destinada a
atender en establecimientos adecuados y durante todo el tiempo que lo requiera
la asistencia m^dica e higi^nica de los socios afectados de tuberculosis. Creemos,
por encima de toda ponderaci6n, este movimiento de mutualidad con fines de prevision
sanitaria.

El modelo de Inglaterra, en que se ha inspirado, asi como los resultados obtenidos
en Alemania, en Francia, en Italia y otroe paises del viejo continente, donde la
campafia contra la tuberculosis alcanzara su mayor intensidad, muestra hasta donde
la cooperaci6n individual es dtil para el ^xito colectivo. La pequefia suma se acumula
y da derechos morales y materiales, que ningdn otro aistema puede consentir. Para
el tuberculoeo, ambos aspectos tienen importancia, porque la indole de su mal le
permite sufrir por cada uno. Peter, el ilustre cUnico fnuices, deda que la tristeza
6843e— IT—VOL IX 87

664 PBOGEEDIKOS SECOND PAN AMEBIOAN 80IBKTIFI0 COKGBESS.

podfa ser causa de tiaiB; bi^ podemoe agr^gar que las situaciones tristes retardan y
agravan su evolucidu. £1 enfermo que disfruta tranquilamente loe beneficios de la
ayuda mutua, como el producto inteligente de un sistema de previsidn social, se halla
por todoB conceptos en mejores condiciones que cuantoe se disputan per el mismo
motivo un lugar en los asiloe pdblicos. A medida que las gentes comprendan m^or
las ventajas de la protecci6n, por sf mismoe, obligaiin mi» l&cilmente la accidn del
Estado, para los que quedan accidentalmente fuera de ella, realiisando sin violenda
y casi sin sentirlo, la obra social mis duradera y m^ ben^ca en la hlst(»ia hlgi^nica
y sanitaria de los pueblos.

CAFITXTLO Tm. DBFBNSA SOCIAL DE LA MATBRNIDAI>— LBaiSLACl6N ARGENTINA.

La medicina modema peraigue el estudio de importantes problemas sodales, al
tiempo que la sociologfa clenU fica orienta hacia la biologfa, la clfnica y la fisiologfa
experimental, loe orfgenes reales de sus doctrinas positivas.

Estas tiltimas son las que inspiran el cuerpo de la legislacidn obrera, que en todos
loe pafses y parlamentos del mundo, caracterizan el mayor grado de evolucidn alcanzado
en el piano principal del progreso y del bienestar nacional.

Por una doble causa hi8t6rica, las clases proletarias ban atraido la atencidn de los
hombres de ciencia y de gobiemo; en primer lugar, porque se ban organizado en
fuerzas gremiales y poll ticas, de influencla mis o menoe considerable en el mecanismo
que mueve el funcionamiento del Estado, y luego, porque se ba aprendido, mediante
las ensefianzas de la higiene a apreciar mejor el valor del capital bumano para la
rlqueza comdn y la raz6n que asiste a todos los bombres para pretender, sin privilegios,
su parte de buena salud.

Como no se niega a nadie los derecboe a la existencia, tampoco puede complicarse
a la sociedad en los motives que afectan oetensiblemente su legitime desarrollo. De
abf que las primeras conquistas de la bigiene social se apliquen a la defensa de esos
organismos en peligro y que loe pueblos de mis avanzada civilizaci6n bayan compren-
dido antes las ventajas de incoiporar a sus medios de conservaci6n las leyes protectoras
que se siguen sancionando.

En realidad, pues, no son reivindicaciones airadas de los obreroe, las que impulsan
el advenimiento de sabias legislaciones del trabajo, sino el determinismo superior
de fendmenoe mejor estudlados, el que va sefialando la manera de acertar con las
aspiraciones comunes. Las colectividades ganan con el miximum de rendimiento
de cada individuo y conspiran contra los propios intereses cuando abrevian su
existencia o permiten que se invalide prematuramente en su capacidad productiva.
Tales conaideradones generales son de nuestro tema, en cuanto ^ste abarca la zona
doblemente interesante del trabajo f emenino y de la matemidad obrera. A la primera
parte le corresponde cuanto se refiere al estado de la mujer asalariada, en relaci6n
con su especffica inferioridad de resistencia orginica, y la otra, a la atenci^n que la
misma merece cuando se transforma en la madre y formadora de las generaciones
futuras.

La simple ecuaci^n individual que el obrero representa sociol6gicamente y que en
los cases mis complicados es siempre im producto de adici6n, se convierte, por
analogfa, en la f6nnula femenina, en una especie de progresi6n geom^trica, o cuando
menoe, en un problema de multiplicaci6n. La legislacidn social sobre el proletariado
lemenino, abaica, por lo tan to, la triple faz de la mujer, de la madre y de los bijos
en la organizaci6n del trabajo; resuclve la manera de defender las tree fuentes prin-
cipales de conservacidn y de crecimiento social.

En este sentido la Repdblica Aigentina ba iniciado hace poco sus primeros ensayos.
La ley respectiva, promulgada el 14 de octubre de 1907, parecerfa destinada a prot^er
esa actividad titil y fecimda, de la explotaci6n inmoderada y peligrosa. Fero su
trascendencia aparente, se resiente por varies defectos esenciales, y, en primer

PUBUO HEALTH AKD MEDIOIKB. 665

tdrmino, par la fonna elemental en que ha side sancionada. Seguramente la intensidn
originaria ha sido m^ elevada y m^ justa, peio el temor de la primera prueba ha
malogrado bu verdadero alcance.

En un pais como el nueetzo, en pleno deearroUo de todaa sue eneigfas, pero con
una superfide veinte vecee mayor al ntimero actual de bus habitantee, el problema
de la matemidad y de la poblaci6n infantil adquiere una singular importancia desde
el doble punto de vista politico y econ6mico. Las mejores tentativas de nado-
nali£ad6n intensiva de eztranjerosy que se pretende, serin, en efecto, inferiores a la
que resulta natuialmente del aumento de ciudadania por el credmiento vegetative de
la propia poblaci^n. En cuanto a la riquesa colectiva, de la cual cada individuo
es un valor dtil y apreciable — ''life capital/' que dicen loe inglooeo oo aumenta
asimismo, en reladdn a cada uno, y a la suma de sus capacidades productivas.

El "industrlalismo" modemo mantiene en peligro ambas determinantes hi8t6rica8.
£1 trabajo de la mujer, que es el sintoma m^ grave, expone, como veremoe, la
primera fuente de existenda humana, la matemidad.

En Europa todos los gobiemos comprendieron oportunamente la importanda de la
cuesti6n, y ninguno ha deecuidado hasta ahora la defensa m^ o menos eficaz de sus
consecuendas. En adelante, es probable que esas medidas se acentden, con motivo
de la devastacidn de vidas que produce la guerra continental, segCai se puede ob-
servar una en Alemania, donde empieaan a organizarse comit^ ofiriales para dictar
dispoflidones que tevorescan la contracd6n de matrimonioe, de combatir mediante el
celibate impueeto a IO0 solteros, premios a las familias fecundas, y otro mis del mismo
orden y con iguales propMtos.

Mientras tanto, la legislad6n universal tiende en todos sentidns, a proteger a la
mujer que trabaja durante el embaraao. En Austria, Holanda, Hungria, Inglaterra,
y Portugal, dicha legislacidn dispone .que no deben concurrir mujeres a los talleres
durante las cuatro semanas deepu^ del parto. En Suecia se prescribe el deecanao
anterior y posterior durante el mismo tiempo, es decir, de echo semanas.

En Noruega, el repoeo prescrito es de seis semanas y en Dinamarca, una semana
antes y cuatro despu^ del parto.

El prindpio general e incontrovertible es la necesidad fisiol^Sgica y material del
descanso, en el periodo de tiempo que corresponde al Ultimo mes de la gestad6n y a
los primeroe veinte dfBM del puerperio.

La legislad6n de 1907 reconoce la necesidad de proteger el trabajo de la mujer,
sin cuidar como conviene de la fund6n de matemidad a que se halla vinculada. El
proyecto de ley primitive resolvla en todas sus partes la dificil cuesti6n.

Poeteriormente, su artfculo correspoudiente, se ha incluido en el proyecto sobre acci-
dentes del trabajo, puesto a estudio de la C6mara de Diputados, d 24 de julio de 1912.
Ezpresa en su articulo cuarto, que gosari de una indemnizacidn igual a la mitad de su
salarb, "la mujer durante los 61timos 40 dias del embarazo y el mes subsiguiente al
parto."

No debiera repetune el regateo de los dias que se exigen, ni hacerse la discusidn
sobre d caricter impositivo que debe daise a la dispodci6n. La experienda ha
demostrado plenamente que las leyes se determinan por los hechoe, y que Mas no
crean sine que rigen los acontedmientoe.

En este caso, no depende del kgislador que la gestaci6n reclame sus mayores pre-
caudones en los cuarenta dltimos dias de su proceso, y que los drganos interoos de la
mujer requieren para recobrar su podddn y vdver a su estado normal, despu^ de los
trastomoB fntimos suiridos, d minimum de 30 dias.

El mMico higienlsta que los sabe y los ensefia, no hace por su parte mis que repetir
una lecd6n de la natundeza, a la cual es indtil contiariar si se pretende recoger 8U»
buenos drutoe.

Disintiendo, tambito, en los dias que marran al reposo, que son de 00, 30 ante»
y 30 despute dd parto, la diputaddn sodalista ha presentado redentemente, en la.

566 PBOOEEDIKOS BEOOND PAN AMEBICAN SGEBNTIFIO CONQBESS.

se6i6n del 25 de septiembre del corriente afio un proyecto sobre "protecci6ii a la mat^-
nidad obrera," que pretende, prindpalmente, resolyw la con8ecuci6ii del wegaro
especial que permita una 8ubvencl6n pecuniaria a las embarazadas; durante fA
perfodo de inanstencia obligatoria al trabajo. Propone en tal sentido, segdn el Mticulo
2, que el subsidio sea equivalente al sueldo (ntegro, que no podr& ser menor de 45
pesos, y en el siguiente, que eA fondo del seg^uro estar& constituido por la contribucidn
semestral obligatoria, por parte cada mujer asalariada entre 15 a 45 afios de edad, C(m
una cuota correspondiente a una jomada de su sueldo, luego de una participacidii
igual por parte de sus respectivos patronee y de otra del Estado. Oomo se ve, es el
sistema alem^ dei seguro en que intervienen por partes igui^ el estado, los patrones
y los obreros, lo cual es perfectamente razonable, sobre todo en este case, que a todos
interesa la suate de la cosa asegurada.

La tercera !az de nuestro estudio, dos de las cuales dejamos atrte, la defensa del
proletarlado femenino y el amparo a la madre obrera, es la protecci6n a la prim^m
infancia entre las clases trabajadoras. La matemidad tiene deberes con la naturalesa
y los humanoe, red^n nacidos., tienen bus derechos con la vida. El m^ importante
en el que se refiere a la leche de la madre, que constituye la savia insustituible que
nutre al hijo. For lo tanto, si imaginamos resuelto el problema bigi^co del deecanso
durante los dfas que precede al parto y que le sigue, y al mismo tiempo, regidanzado
por el seguro obligatorio, que le da su base econ6mica estable permanente, nos queda
a(in el conflicto de la matemidad obrera, cuando en la 6poca conveniente vuelve al
taller, y no puede seguir amamantando a su criatura durante los echo meses que le
restan de lactanda maternal.

En el inciso 8 del artfculo 9 de la ley vigente, se prescribe a este respecto, "que en
los establecimientos donde trabajan mujeres, se permitihi que las madres puedan
amamantar a sus hijos, durante quince ndnutos cada dos boras, sin computar ese
tiempo en el destinado al descanso,'' pero no impone la obligaci6n al industrial de
disponer de im sitio adecuado donde las madres puedan guardar a sus hijos. Por lo
tanto, la ley resulta inaplicable pues ninguna obrera puede costeane la comodidad de
trasladar desde su casa, por cercana que sea, y menos atin cuando se haUa lejos, como
es lo m^ irecuente, a su criatura cada dos boras. De ahf que d Dr. Alfredo L.
Palacioe, haya comprendido la urgenda de presentar durante su tUtima actuad6n
parlamentaria im proyecto de ley, disponiendo la instaladdn de "salas cimas" en los
establecimientos industriales del pais. La intensi6n del legislador coindde con
nuestro empefio en favor de la puericultura argentina. El fendmeno desolador de
la nifiez enferma y decr^pita, tiene sus origenes en los defectos de la estimuladdn
radonal en las primeras necesidades no comprendidas de que es vlctima. Con los
adelantos de la higiene inlantil se ha detenido en todas partes la suerte fatal de los
red^n nacidos, y los "candidatos a la muerte** que decfa Michelet, adquieren cada
vez m^, mayores probabilidades a incorporarse al mundo de los vivos.

Precisamente, es esta la oportunidad cuando estamos en plena propaganda de la
defensa nadonal de la infancia y cuando hemos crddo mis necesaiio la atenci^
de la mujer en favcnr de los pequefios. Oon ese propdsito, es que inidamos la ense-
fiansa de la puericultura en las escuelas normales de la capitel en 1912, y despu^
de adoptada en sus planes de estudios, la perseguimos todavfa en las Escuelas Pro-
fesionales de Mujeres donde se haUa pr6xima a ser implantada oficialmente. Deede
la Escuela y desde la cdtedia popular, desde el aula universitaria y el Pariamento,
deben partir los esfuerzos intelectuales y morales por esta obra fecunda y patri6tica.
El pueblo siente la desgracia y soporta su mayor peso pero no sabe defenderse. D6-
mosle la instrucd6n de sus individuos y en la oiganizaddn de sus eneigfos los medioa
inteligentes de hacerlo. El grado de dvilizaddn que se mide y se define por la
capacidad de satisfacer un mayor ndmero de necesidades creadas, debe completaise
en el orden social por la aptitud de distribuir el t^rmino medio dd bienestar indi-
vidual a la mayorfa de la colectividad. Nuestra aspiraddn en ese sentido no puede

PUBUG HEALTH AND MEDICINE, 567

deteneise en la l^g;idaci6ii incipiente que acabamos de estudiar, ni en el estado
actual de nuestra ozganizaci6n proletaria. £1 progreso del pais exige recursoe mi»
acertadoB de gobiemo social, que ban de realizaise a medida que aumente el nivel
de nuestra cultura y se fonne para estos idealee la conciencia popular. £n ^Bta
reside el secreto de todas las revoluciones bist^rlcas y conviene entregarle tambi^n
la responsabiUdad de las conquistas pacfficas que ha de levantar su propio nivel en
la humanidad futura.

CAPItULO IX. DBPBNSA SOCIAL DE LA INFANCIA ABANDON ADA EN LA BBPI^BLICA

ABOENTINA.

La higiene moral de nuestra especie define en* pnncipio la f6nnula modema de
previsi6n y profilaxis, para la lucha social contra la delincuencia humana.

£1 crtte? io legal de la pena, no satisface mSm que en parte, los recuisos naturales de
defensa. La represidn del delito, ejercida sistemdticamente por todoe los pafses, no
ha contenido la crixninalidad ni ha conregido los desvlos de la conciencia colectiva.

La escuela cUsica consideraba el crimen tinicamente, como una entidad juHdica,
y negaba, por ignorancia, seglin Ferri, toda influencia antropol6gica o sodoldgica
Bobre la criminalidad. £1 cardcter filosdfico de las enfermedades en general, ha
cambiado tambi^n en este sentido y, tanto el vitalismo de los antiguoe como el libre
albedrfo, no idcanzan ya a explicar, respectivamente, los fen6menos anormales de
la materia y del esplritu.

La escuela positlva contempordnea, para negar a nuestra actividad la espontaneidad
propia y permanente de todos sus actos, hubo de buscar fuera de la intenci6n y de
la voluntad individual, las causas determinantes de la salud, de la enfermedad y
del delito. Los fiactores antropol^cos aportim a ese respecto las primeras bases
cientlficas para la etiologia clinica y criminal, demoetrando la influencia de las causas
bioldgicas y oigdnicas en las genesis de todos los procesos patol6gicos.

Luego, la escuela francesa hizo predominar la importancia del medio ambiente
aobre la existencia Ksica y moral de los hombres, la concepci6n materialista de la
historia, introdujo por su parte en el campo de la «iencia de la criminologfa, el factor
econ6mico, hasta pretender que fuera la causa tisica, o por lo menos la mds efidente,
para el desarrollo moral de los pueblos.

Los demds sistemas, **ecl6ctico," de "explicaci6n patol<Sgica,*' la "espiritualista'*
y ^'estadistica,'' y la llamada ^'Tercera escuela" de Italia, reconocen en distintas
maneras la condici6n subaltema del delito como forma original y libre de nuestra
existencia ordinaria. Representan, en vez, el sfntoma mayor de un proceso fntimo
y anterior, cuya e^ oluci6n concluye con esta manifestacidn pctrticular de la con-
ciencia enferma. Los estudios sobre la herencta flsioldgica y m6rbida, del ambiente
fisico, econ6mico y mcHral sobre nuestro organismo, de la educaci6n sobre la inteli-
gencia y los sentimientos sociales, ha permitido establecer una relaci6n natural entre
el sfntoma temible y el estado m<^bido que lo autocode y determina.

La historia natural del delito, cambia asl por completo el criterio racional de
defensa, y los procedimientos puestos en pr&ctica, hasta ahora, para combatir sue
principales consecuencias.

£n \ ez de atender en su dltimo pedodo los peligros del mal, crimen y castigo,
serfa posihle adelantarse a sus efectos, atacando las primeras causas y las des\ iacionea
preliminares de las conciencias criminosas. Como las demds enfermedades oa itables,
la delincuencia y la criminalidad, tendrlan sus medios propios de presenci6n,
tanto mds eiicaces cuanto mejor se conocen los principioe naturales a que obedecen.

La modema profilaxis tiene en este sentido un amplio capf tulo en la higiene moral a
que nos referfamoe. £1 tema de este estudio se justifica, asimismo, ante el problema
de triste actualidad, como es el de infantilidad delincuente. £ntre nosotros, en
efecto, es un fen6meno local y permanente cuya etiologia debe preocuparnoe, m&a
que nunca, ante el peligro incesante de sus e.identes progresos. Se ratifica esta

668 PROCEEDINGS SECOND PAN AMEBICAN SOIENTIFIO CONGBESS.

afinnaci6n, con 1m conclufiiones muy precisas de Boberto Le^^illier, en su interennte
sintesiB sobre la "Criminalidad enBuenoe Airee, " publicadacon motivodel centenario
argentino en el Genso general de la capital.

La poblacl6n callejera de nifLoe es realmente extraordinaria; hay ana multitud de
pequefioB de 6 a 7 afioe, traficando en las callee con los oficios m^ diveraos. Vende-
dores de diarioe, mensajeros, lustradoree de betas, vendedores de billetes de loteria.
Un mundo de gente menuda expuesta a todoe los contactoe y a todos loscontagioe de
la \ida miserable e inmoral.

El cficulo doloroeo que describe el pobre nifio, hasta caer en la falta, en el delito,
o en la c&rcel, es de una cruda realidad.

Desde luego, pesan sobre ellos tree factores que raras vecee lee faltan o actdan aisla-
damente. En primer t^rmino, la negligencia de los padres, sub malas herendas, y
muchas veces, las instigadones perversas que ejercen sobre la conducta de los hijoe;
mds adelante, el medio ambiente, propio a todas las desviaciones de la conciencia
apenas en formaci6n, la mala \ida en el hogar y en la calle, el ejemplo de todoe los
vicios y de los peores consejoe; por dltimo, en el orden de enumencidn, pero no es de
importancia intrlnseca, la falta de educaci6n, de disciplina mental y la influencia
delet^rea del analfabetismo sobre el desairollo del espfritu y de la inteligenda de los
nifioe.

Afio por afio, la inmigracidn trae de tierras extrafias un nthnero considerable de
nifios, que engrosan el contingente nacional. Asi, por ejemplo, en 1912 ban entiado
al pa^ 15,847 nifios de 8 a 12 afios, es decir, dentro del ciclo escolar; 24,309 de 1 a 7
afioe y 81,411 de 13 a 20 afios. No nos es posible precisar exactamente la cifra de loa
que no saben leer ni escribir; faltan los datos. Pero se puede calcular que sea el 90
por ciento, teniendo en cuenta la procedencia geogr&fica y el origen humilde que lea
corresponde. Se agrega, como se ve, el problema inmediato y urgente, de la edifi*
cacliSn escolar, para atender a ese aumento singular, y a los peligros del anaUabetumo
de importaci6n.

En esas condiciones, se imagina la trayectoria de casi todos los delincuentes juve-
niles. Solicitado por cualquiera de las causas sefiadadas, o por todas a la ves, no le
&Jta oportunidad de cometer un mlnimo atentado o alguna contravenci6n vulgar.
Una tentati\ a de robo, una pelea con lesiones, una complicidad servil con adultoe;
cualquier inddente que le pone en los umbrales de la comisarla mia cocana; es el
primer paso. Luego es expuesto al contacto de los delincuentes adultos, durante el
arresto, en la prisidn, en todas partes. El contagio se produce, y el nifio absuelto o al
cumplir una pena leve, sale en libertad, reindde y vuelve, cada ves que su deflgrada
le hace rodar mds bajo en el camino del delito ya traaado.

En una estadistaca redente de Laurent, sobre la criminalidad inftmtil en Paria, se
comprueba que m^ de la mitad de los detenidos son menores, y que se cometm doe
veces m^ de la mitad de erf menes y delitos, desde los 15 a 20 afios, que desde los 20 a 40
Segtin Paul Drillon, en su ^'Jeunessecriminelle," la cifra de delincuoites de 16 a 21
afios, que era de 6,979 en el quinquenio de 1901, alcanza en un solo afio, en 1902, a
30,344.

Para noeotros, la cuest]6n reviste, segtin se ve, an&loga importancia. Los podena
ptiblicos y distinguidos hombres de gobiemo, ban demostiado en diversas oportn*
nidades su preocupacidn por el peligro alarmante, y la concietaron en Inldativas muy
plausibles, que no ban side apoyadas suficientemente. Nuestzas estadisticaB de
delincuencia inftmtil, adelantan mientias tanto, sin esperansas dertas de reducddn
ni de mejora.

En este sentido, la piimera medida de prc^laxis social consistirfa en prot^ger la
nifiez extraviada, para evitar bus tendencias fatales a la vida delictuosa. Randall
escribe, "salvad a los nifios y habr& menos hombres que corr^gir y caBtigar."

PUBLIC HEALTH AKD MBDICDTE. 569

Desde hace veinte afioe, nuestna infltitucioneB de beneficenda y de Estado, al
<Mmaia de Senadores y de Diputadot, la Munidpalidad, la Policfa y el Ministeiio de
Justida, vienen proyectando la manera de atender a eeta funcidn de gobieroo y de
■alud sodal. Con todo, la l^gialaddD aigentina no eziste y el pals la redama ince-
santemente.

El 6 de eeptiembre de 1892, d Fatronato de la Intoda, en 1100 del derecho de
petid6n, ee preeentd al Senado de la naci6n, solidtando la aanddn de un proyecto
de protecddn a la infancia y a la adoleecenda deevalida. A manera de referenda
hlstdrica, agreg^emoe que en agosto dd afio anterior, ee habla promulgado ya la ley
de protecd6n a loe animaleB, y que uno de bus mejores fundamentos fu^, "que los
actos de crueldad no podlan toleraree y debian deeaparecer para honor dd paie y de
la dvilizad6n." Se juatificaba cad con anilogas condderadones, el amparo legal de
loe nifioe, y la neceddad urgente por parte de la eociedad, de socorrerloe contra d
abandono, el exceeo de trabajo y los malos tratamientos. Hasta d 25 de jullo de 1902,
eea corporad6n filantr6pica repiti6 en loe 10 afioe, por cinco vecee coneecutivae, sua
proyectoe al respecto, uno de loe cualee iu6 favorablemente deepachado por lot miem-
broe de las comieionea parlamentarias.

£1 17 de agoeto de 1896, la municipalidad de Buenot Aires, propuso en d artfculo
6* de sus ordenansas, la focultad de contener la vaganda en la comuna, castigando
con 3 a 6 meees de arresto a las personas que indujeran a sub hijoe menores, o menores
que tuvieran a su cuidado o servido, a ejercer la mendicidad, y poner a dispodddn
dd liinisterio Publico loe menores que recogieran en esas condidones.

El primer proyecto de protecci6n a la infanda, presentado a la Cdmara de Diputados,
corresponde al doctor Antonio V. Obligado, d 21 de septiembre de 1896; luego, en
materia de defensa de la menor edad en el trabajo, se ban ocupado desde 1892 a la techa,
d doctor Emilio R. Goni, en un proyecto de la ordenanza municipal; en el mismo
afio otro de los doctores Migud Gan6 y Lfdoro Avellaneda, en d Senado de la naddn,
que fu^ aprobado y dd cual no se ha ocupado nunca la otra O^unara.

En 1904, el doctor J. V. Gonz^es, BCinistro del Interior, elev6 en representaddn dd
Poder Ejecutivo d Honorable Gongreso, un proyecto reg^amentando d trabajo de loe
nifios, y d 22 de junio de 1906, la Oimara de Diputados aprob6 d Dr. Alfredo L.
Palados, con fnerza de ley, su proyecto sobre d trabajo de las mujeres y de los nlfioa,
que ha renovado en las sedones dd afio prdximo pasado, insistiendo en sua dispod*
clones oiiginarias, aendblemente diaminuidaa por laa modlficadonea con que fu4
eandonada.

For fin en junio dd afio proximo paaado, el Dr. Luia Agote, ha propueato la legiala-
ci6n eapedd d reapecto, en doa proyectoe que comentaremoa m^ adelante.

En Europa, Francia, cuenta deade 1811, con au ley de protecd^ a la infanria,
ampliada aucedvamente en 1874, en 1888, y completada en 1889. Alemania tiene la
auya de marzo de 1878 y junio de 1887; Auatiia, de junio de 1811; Suiza, deade 1831,
habi^dola modificado cuatro vecea haata 1887, que ea la que lige; Eapafia tiene aa
ley de 1889; por tiltimo, Inglaterra, la m^ adelajitada en au legidaddn al reapecto,
perfecdond en 1886 au aiatema actud de loa Induatrid Schoola.

En AmMca, Nueva York, tiene au ley de 1863, y, entre laa rep^licaa meridiandea,
d Braail y la Repdblica dd Uruguay ae han adelantado aendblemente a eataa inidatlvaB
de gobiemo.

Por ley dd 21 de febrero de 1911, en Congreao dd Uruguay, cre6 un Oonaejo de
Educaddn de Menorea, en cuyo artfculo piimero eatablece, que loa padrea perderia
la patiia poteatad aobre aua hijoa, de pleno derecho y ain que aea neceaaria dedaraddn
expreaa d reapecto en los siguientea caaoa: d fueron condenadoa a pena de peniten*
darte como autorea o cdmpUcea contra la peraona de uno o varioa de aua hijos; d fueren
condenados dos voces por priaidn por laa miamaa razonea; d por doa vecea fueren
condenadoa por dtuaddn, ocultaddn, atiibuddn de falsa fitiaddn o patenddad,
ezpoaicidn o abaadono dd nifio; por vaganda o mendiddad ordenada, eatimulada

570 PBOGEEDINOS SBOOKD PAN AMEBICAN SCIEKTIFIO COKQBESS.

o permitdda; si excitaren o favorecieren, en cualquier forma, la comipcidn de menoras'
BX por BUS contumbres dei^avadas o escandalosaa, ebiiedad habitual, maloe trata-
mientOB o abandono de sub deberes, pudieeen comprometer la salud, la seguridad o
la moral de sua hijos.

Una de las atiibuciones mis interesantes de ese consejo, consiste en establecer la
distinci6n legal entre menores delincuentes, viciosos y simplemente abandonados,
con el fin muy importante de distribuirlos en secciones distintas, rigurosamente
separadas, salvando de la contaminaci6n consecutdva, tan frecuente en nuestro T^gimem
pc^cial actual, de un grupo con los demds. Bealiza todavfa, como se comprende, la
educaci6n elemental, el aprendizaje de algun oficio y la correccidn met6dica de
varones y nifias, atendi^ndoee a un plan pedag6gico, perfectamente preparado.

A Norte Am^ica corresponde el m6rito del primer tribunal para menores, creado en
Chicago, en 1899; luego el 2 de septiembre de 1902, en Nueva York, y en Boston, el
16 de junio de 1906. Actualmente, sobre los 45 Estados de la Uni6n, 30 cuentan con
ese sistema de justicia para delincuentes menores de edad.

La especializaci6n del juez en la materia juridica que atiende, se acompafia con
todas las ventajas inherentes al concepto de la individualizaci6n de la pena, de tal
mode, que resuelve como dnico drbitro y sin c6digo, todos los procesos criminales que
ocurren en su jiuisdicci^Sn. Se comprende que, para depositar tanta confianaa en el
Magistrado, debe exigfrsele una competencia y ima dedicaci6n especial, en todo lo
que se refiere al conocimiento de la vida y del alma infantil.

Para ejemplo del criterio con que abordan el estudio psicol^co y el tratamiento
penal de la inlanda delincuente, apuntamos la clasificaci6n que establece sobre
eUos el Juez Mayer, de Nueva York.

PriTmra categoria, — ^Nifios batalladoree, que arrojan piedras y hacen peligroso el
trinsito pdblico, aunque no tienen nada de malvados. Repre8i6n y libertad con-
dicional.

Segunda categoria, — ^NifLos que se dejan tentar y cometen pequefias infracdones.
La libertad condicional se halla muy bien indicada.

Tercera categoria, — Nifios vagabundos, de padres negligentes en los deberes de la
patiia potestad; es precise recunir a menudo a la casa de correcci6n.

Cucaia categoria. — ^Nifios que tienen por padres a i)er8onas malvadas; la libertad
condicional es ineficaz, siendo necesaiio recluirlos en casas de correcci6n o de patronato.

Quinta categoria, — NifLos desprovistos de sentido moral; la casa correccional es
impreedndible.

Sexta categoria, — Nifios aventureros, fugitives, etc., la libertad ccmdicicmal es a
menudo excelente.

SSptima categoria. — Nifios clasificados per sus padres de incorregibles, su ntimero ha
disminufdo mucho desde que la ley obliga, a los padres a pagar su mantenimiento en
las Casas de reforma.

Segdn Leonce Andr6, que sigue muy atentamente este nuevo regimen de justida
infantil, de los 5,000 a 6,000 nifios puestos en libertad condicional en Chicago, en el
primer quinquenio de su funcionamiento, la reincidencia de menores ha disminuido
en proporciones considerables. En un informe del director de nuestra Cdrcel de
encausadoB, don Joe^ Luis Duffy, presentado al Ministerio de Justicia, sobre cuestiones
andlogas, observa que la legislaci6n nacional ''no tiene ninguna eficacia para contener
el mal de la reinddenda." Sostiene luego — coincidiendo con un informe elevado a
esa misma repartici6n, el 15 de abril del corriente afio, por el doctor Ricardo Seeber,
Presidente de la C4mara de Apelaciones en lo criminal y correcdonal de la capital-*
la necesidad de individualizar la pena, ooncediendo al magistrado plenas atribuciones
para condenar segtin el examen m^co psicol<5gico de cada delincuente, antes que
por el valor intrfnseco del delito cometido; y, como m^todo de re&>nna motdl de loe
detenidos, propone tambi^n sustituir el indulto, que socorre pero no enmienda, por el
■stema de libertad condidonal, que sostiene desde tiempo atf4s> el doctor Rodolfo

PUBUO HEALTH AKD ICSmOIKB. 571

Bivarola) en su crftica del C6digo Penal aigentino. For nuestra parte, no contamos
para hacer frente a este movimiento de modema profilaxis, mis que con dos esta-
blecimientos carcebrios, que difidlmente se adaptan a semejante destine. El primero,
denominado 'Taaa de Correcci6n," fu6 creado per decreto del 13 de diciembre de
1897 y se halla habilitado para nifioe procesados de 8 a 18 afios; el otro, deede el 28 de
junio de 1905, constituye la colonia de menores varones establecida en Marcos Paz,
con el fin de intemar a ks j6yenes de 8 a 17 afios, encausados o simplemente confiadoe
a Bolicitud patema, con el propdsito de ^'educarlos moral y teamen te, y darles capa-
cidad necesaria para dedicaise principalmente a las labores rurales, agrf cdas y gana*
deras."

En principio, ambas instituciones serfan aceptables si no adolecieran de defectos
capitales que las incapacita para bus fines.

Sua respectivas construcciones son reducidas e inadecuadas; en una y otra, la pro-
miscuidad en que viven loe jdvenes detenidos, bastarla por sf sola para malograr cual-
quier tentativa de verdadera correcci6n. El contagio moral pervierte a los menos
malos y estimula los instintos de los peores.

De ahi la ineficacia deplorable de sus resultados, como ambientes de reforma moral.
La reincidencia en el delito de casi todos loe ingresados confirma este juicio. Para
ponerle algtin remedio, el Poder Ejecutivo cre<5, el 7 de febrero de 1906, una infitituci6n
denominada del PatTonato, destinada a proteger a los llbertados y a bus iamilias, facili-
tdndoles los medios de rehabilitaci6n. Pero tampoco realiza, por deficiencias intemas
y por BU eecasez de recursos legates, la misi6n importante que tiene en los distintos
palses donde rige desde hace mucho.

Por tiltimo, nos falta todavla, como observa muy bien el doctor A. Meyer Arana, en
su magistral alegato ^'Por el nifio pobre,'' las escuelas de pre8ervaci6n y de oficio que
realizan, en otras partes, la ensefianza regenerante de los menoree indigentes, per
medio del trabajo manual, del aprendizaje profesional y de las artes aplicadas; como,
asimismo, la ayuda al nifio y su estudio cientifico, segdn la modema Podologfa, que
este afio, precisamente, parece pr6xima a implantarse por el Consejo Nacional de
Educaci6n y el Patronato de la Inlancia, en loe respectivos eetablecimientos pedagd-
gicos.

En Europa existen algunos modelos de establecimientos que nos conviene conocer.
En Francia, hay doe tipos principales; los unos bajo el nombre de "colonias" o de
"escuelas de reforma,'* reciben los nifios absueltos, pero sometidoe a la correcci6n; loe
otroB, denominados "cuarteles correccionales," tienen el doble encaigo de iJojar y
educar a los menores condenados a mia de doe afios de correcci6n, y de acoger los
discipuloB diflciles y sin enmienda de las colonias.

En un eetudio muy prolijo de M. Roux, sobre el cuartel correccional de Lyon,
fundado en 1873, recogemos algunas observaciones muy interesantes sobre sus 386
pupilos. Esa poblaci(3n "mds de^;raciada que culpable,'* seglln el autor, se recluta
entre familias, en que la mayorla llevan en sf mismas, por razones de su vicio de
constitucl(5n, el principio de disgregacidn de sus elementos; la moralidad detestable
0 muy dudosa, y los medios de subsistencia muy escasos, cuando no faltan en absoluto.
£}s a esas causas diversas, afirma, que los j6venes delincuentes deben en un principio
sus antecedentes deplorables; luego su abandono, su comipci6n y su ignorancia, y,
como t^rmino final, el delito y el arreeto. Los defectos de oi^ganizacidn de la familia,
la miseria, los hdbitos de pereza, la embriaguez y los males ejemplos, son para la nifiez
los agentes m^ activos de de8moralizaci6n. En la sociedad como en la naturaleza,
loB g^rmenes peores son los que mils f acilmente se reproducen y dif unden . El microbio
del mal, al decir de Sighele, tiene una potenda de expansi6n infinitamente mayor que
el del bi^n, en el eupuesto que este tiltimo exista; pues, mientras se sabe que muchas
enfermedades son contagiosas, no est& demostrado que tambi6n la salud se contagia.
Es el fen6meno vulgar de las manzanas podridas que pierden a las dem&s, sin que las
sanas mejoren a las podridas.

572 PBOOEEDIKGB SECOND PAK AMEBIOAK SOIBNTIFIO 00NGBB88.

El c6digo penal aigentino preecribe para la edad mfnima de loe delincaentefl, los
diez aflos complidos, antes de los cualee los niilos criminalee son entregadoe a la co-
rrecci6n dom^stica de sub prog^nitores, sin x>eTJmcio de la cooperaci6n y vigilancia de la
autoridad, Lu^o, enlsre esa edad y los 15 afios, b61o se castiga el crimen voluntario o
sea el que se ha comeddo " con discernimiento " ; por dltimo, hasta los 18 no cumplidos,
las penas se van rebajando de tal manera, que la de muerte se sustituye por penin-
tenciarla de 10 a 15 afios, la de presidio por prisi^n y asi de seguida, teniendo en cuenta
el grado de desarrollo mental, de cultora y de moralidad del sujeto culpable.

£1 mismo c6digo italiano, en su artfculo 54, es menos severe para ese perfodo de
culpabilidad, y, trat&ndose de restringir la libertad, prefiere siempre la casa de co-
rrecci^n a cualquier otro sistema, y entrega de todas maneras al criterio del juez el
optar por un establecimiento carcelario.

£1 principio psicoliSgico, ratificado por la experiencia, segdn el cual debe concederoe
la preferencia a la retenci6n en medios correccionales y no penitenciarios, ee que el
espiritu de los procesos encarcelados se corrompe en ellos, o acaba de corromperse
hasta el (iltimo. Como observa muy bien en su *^Jragazzi ddincuentiy " Vitorio Stagi,
la compafiia de los depravados, estimula en los demis un mal entendido amor propio,
por el cual, habiendo perdido para siempre la estima de las personas houradas tratan de
atraer a la de los malvados, demostrando no temer la policfa, los tribunales y la ctoel;
aprendiendo a delinquir burlando la policia, la sociedad y la justicia.

£1 tratamiento social del delito. es cada vez menos, una cuesti^n de simple penalidad
o de rigor judiciario. El criminal no premedita su pena, ni desiste ante eUa para pro-
ceder con sus impulsos; ni el castigo puede aparecer como un desquite o un desagravio
de una sociedad m^ o menos cruel que se venga. El espiritu de la ley es en todo caao
mds elevado y trascendente; tiende a contener y corregir, por los medios a su alcance,
la reincidencia y la repetici6n de los actos que afectan el derecho comdn, ejerdendo
la defensa natural contra los elementos de peligro que atentan a su desenvolvimiento
l^timo. La funci6n social del delito, si es hist6ricamente exacta, para hacer honor a
Lombroso, que lo estudia bajo ese titulo sugeetivo en un trabajo muy original, que
recomendamos, no modifica la esencia del mismo, ni disminuye la importancia biol6-
gica de la justicia para mantener y mejorar la sanidad moral de los pueblos.

Trat^ndose de la delincuencia juvenil, estas consideracioneshacen mds reealtante el
error, si en vez de evitar y prevenir, se espera el mal declarado para acudir a 61 o para
curarlo.

"Prima del codice penale che condanna," escribe Lino Ferriani, en bu "Fanciulli
abbandonatti," "deveimparare 11 codice dell'amore que previeneil male''. Unpoeta
espafiol, Crist6bal de Castro, propone todavfa el CkSdigo de Nifioe, que renueve y deeeche
la vieja doctrina de Justiniano, demasiado favorable a la poteetad patema, x>or otra
mis adecuada a la idea que actualmente tenemos de su destine y del cuidado que el
Estado debe a su desarrollo. Una de las aberraciones himmnas que menos alcan-
zar&n a comprender las sociedadas futuras, declara entre nosotros el doctor R. Seeber,
es que se haya podido considerar, durante siglos, como delincuentes a loe menores, y
sujetoe a la jurisdicci6n y a las leyes que procesan y castigan a los adultos. £1 emi-
nente crimin61ogo, Scipio Sighele, sintetiza muy bi6n en su "Monde criminale,"
andlogos juicioB. £1 juez de nuestra sociedad, dice, se asemeja al cirujano que amputa
o extrae un 6rgano ya declarado incurable. Para sanear el ambiente, concluye, debe
acudirse a loe m^icos higienistas expertos, que saben impedir el desarrollo del mal.

La legislaci6n universal, ya estudiada, es favorable, segtin se ha visto, a esta nueva
orientaci6n de la sociologia criminal modema. La ReptibUca Argentina no se ha
adherido a ella en ninguna forma, aunque puede esperarse que la inicie con la reforma
del C6digo Penal y de Procedimientos Criminales, anunciada por el sefior Presidente
de la Naci6n, en su mensaje del presente aflo, y con la sanci6n del proyecto de protec-
ci6n a loe nifioe vagabundos, que ee halla a estudlo de la Cdmara de Diputadoe de la
Naci6n.

FUBUO HEALTH AND MEDICINE. 673

Creemos iatereeante asmxismo, anticipar una referencia breve sobre un proyecto
de G6digo de Procedimientos en lo criminal, que se halla en preparaci6n, a cargo de
una comisi6n demgnada por el Poder Ejecutivo, compuesta por loe doctores M. A.
Montes de Oca, P. F. Agote y R. Mendez. En eee estudio, que aparecerd pnSzima-
mente, figura bajo el Titulo XX, que trata de la "Detenci6n y prisi6n preven-
tiva," un artfculo 289, que segtin los codificadores esti deetinado a salvar para la
in&ncia delincuente, los principales defectoe de nuestra actual jurisprudencia.

Desde luego, defiende al nifio de la reclusi6n carcelaria, disponiendo ''que IO0
menores de 18 afioe, cum](flan la detenci6n o priaidn preventiva en loe domicilioa
de BUS padres o tutoree, o en institutos de reforma, oficiales o particulares." No
estatuye todavla los tribunales especiales para la justicia infantil, aunque reconoce
con una reciente publicaci6n en loe ''Anales del Patronato de la Infancia" sobre el
perfeccionamiento judicial que ellas significan; por dltimo, advierte el peligro de las
prisiones, para los menores, como ambientes fatales de depravaci6n, de corrupci6n y
de delito. La sociedad, concluye el proyecto, interesada en enmendar tendencias
criminosas y en estimular la actividad titil de todoe bus miembros, debe cuidar que las
inflexibilidades de la ley no impongan al Magistrado ''a pretexto del orden y de la
seguridad del memento, a conspirar contra el orden y la seguridad ptiblica del future,"
exacerbando posibles inclinaciones morbosas que, contenidas a tiempo, habrian
quiz^ deeaparecido totalmente.

Mientras tanto, la instituci6n policial a cuyo cargo se halla la vigilancia y el cuidado
inmediato de la poblaci6n callejera de la ciudad, no deja de preocuparae cuanto
puede, del grave problema que noe ocupa. La funci6n del jefe de policla, eecribla en
1906, el inolvidable Miguel Can^, desde Paris, al doctor Francisco Beazley, reciente-
mente impuesto en ese cargo, es de un intendente urbano ''de la gran metr6poli, y
parece confirmarlo, desde entonces, el inters con que atiende 6sta y otras cuestiones
que en tal sentido le afectan. Desde 1906 a 1912, todos los jefes de esa repartici6n,
Beazley, Fraga, Falc6n, Dellepiane, reiteraron insistentemente ante el Ministro del
Interior, el peligro sin Ifmites que comporta para la comuna y para el pais, esa publica-
ci6n incontenible de menores vagabundoe.

£n las calles de esta metrdpoli, infomuiba en una de sus notas el Coronel Falc6n,
trafican una cantidad numeroea de nilioe entre 7 y 15 afios de edad, lanzados en una
pendiente peligrosa, sin direcci6n y sin tutela, entregados a la vagancia y a la odosidad
mis pemiciosa, ctumdo no son obligados por sus mismo padres a que contribuyan por
cualquier mode y manera, al sost6n del hogar, orillando a esos monores a convertir la
via ptiblica en su residencia habitual. Otra comunicaci6n al Ministro Gdlvez, el 13
de junio de 1910 agrega refiri^ndoee a loe miamos, "son elementos que con el andar del
tiempo pesar&n sobre la sociedad y dar6n trabajo a las autoridades; son los que Mn a
engrosar las filas de los delincuentes profesionales o a reemplazar bus bajas. Esta
tiltima teoria, del general Dellepiane, acopia nuevos argumentos para pedir la
creaci6n de asilos polidales y de los asilos econ6micos propidados anterionnente por
el general Fraga, a la vez que solicita del Consejo nadonal de educaci6n, por nota del
24 de octubre de 1912, la educaci6n moral de la intimcia, en el sentido de cultivar en
el ambiente popular el respeto a la autoridad y a las buenas costumbres.

A este reepecto, los dos proyectos de ley del Diputado Agote, son terminantes y
oportunos. El primero prohibe la venta de diaries, de publicadonee y de cualquier
otro trabajo en la via ptiblica a menores de 15 afios; el segundo propone la tutela del
Estado para los menores abandonados« La critica, Mcil de salvar por otra parte, que
ambos ofrecen, son de car&cter policial y de orden priUitico. En primer t^rmino, la
dificultad de comprobar la edad en sujetos fuera del dominio policial que pueden negarla
o ocultarla; luego, y, m^ importante, seguramente, la necesidad de arbitrar recursos
para fundar establecimientos, eecueks de reforma y colonias, con capacidad para
alojar todos los nifios que de hecho sefin contraventores de la ley, al dia siguiente de
promulgarse.

574 PBOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONQBESS.

Waldeck-Koiuseaa divide en dos clasee Ut poblaci6n de nifios abandonados: los que
se hallan mateiialmente sin ^unilia, y los que se ha substraldo pw la ley al contacto
de lo6 suyoe. Lu^o, la claBificaci6n particular para cada uno, en nifioe abandonados,
recogidoe, hu6rfonoB, pobres, nifioe maltiatadoe y nifioe 'M^laiss^'' o descuidados.

Este mundo de pequefios miembrofl sodalee, ee el que debe amparar la legidaci6n
nacional que propiciamoe. La primera funci6n de Estedo a este respecto, es la accidn
educacional intensiva, extendida a todoe loe limites del oiganismo social. £n lo que
a loe nifios se refiere, expuestos por su herencia, por su constitucidn o por su amblente,
a seguir la pendiente del deli to, la pedagogfa cientifica, ^uenta con establecindentoB
escolares y m^todoe especiales de ensefianza. Los ''paidocomios/' son un tipo de loe
primeros, destinados a reprimir mediante la educaci6n fisica, moral e intelectual, la
conducta y los sentimientoe de los nifios predispuestos al delito. La educaci6n pre-
ventiva, es a su vez el sistema pedag6gico general, que tiende a edificar, a restituir y a
reformar fisiol6gicamente, la ccmciencia moral de los nifios delincuentes.

Ambos aprovechan con ventaja un ambiente comtin, que es la vida al aire libre y la
labor rural. Entre noeotros, las colonias agricolas que propcmdriamos para aislar a IO0
menores recogidos y loe delincuentes, tendrlan a su favor el aprovechamiento de
muchas zonas de cultivo y la simpatia ind igena por las faenas del campo. Franda posee
muchas colonias, sobresaliendo la de Mettray, hmdada en 1839, por M. de Metz con
el siguiente lema: "Am^liorer la terre par Thomme, et I'homme par la terre/' En
Inglaterra, donde la criminalidad infantil ha sido combatida con mejor ^xito, existen
deede 1788 ima serie de institucionee que se perfeccionan constantemente, destinadaa
a educar, mejorar y moralizar el alma de los nifios delincuentes. A sus 50 escuelas de
reforma, ''Reformatory Schools," y a las 142 escuelas industriales, ''Industrial
Schools," han pasado directamente, sin sufrir la hospitalidad bochomosa de las pri-
Biones, los 22.190 nifioe que en ellas asilan.

Atendiendo esta situacidn apremiante de nuestro medio social el actual gobiemo ha
piocurado ad elantarse por sus medios, a las iniciativas propias de una futura legislaci6n
nacioniJ. Por un decreto del 19 de octubre de 1911, el Poder Ejecutivo dispuso la
adqul8ici6n de 425 hectdreas de un terreno ubicado en las imnediaciones de la estacidn
Olivera (P. 0. O.) que destin6 para construir un asilo de "nifios abandonados y vaga-
bimdoe," confiando la obra a la Comisi6n asesora de asilos y hospitales regionales. Es
un establecimiento pr6ximo ya a temunarse, con capacidad para 1,200 nifios, 900
varones y 300 mujeres, de ocho a quince afios de edad, que nunca tengan ninguna
relaci6n con los tribunales de justicia. Segdn el presidente de esa comisi6n, doctcff
Gabred, en su tiltima comunicacidn al Ministerio de Relaciones Exteriores, la en-
sefianza ser& para ambos sexos "a la vez pedag6gica, industrial y agrlcola," agregando
861amente para las nifias la que le corresponds por ese car&cter. Como podrla apreciarae
serd una verdadera educaci6n preventiva de la iniancia y de la adolescencia, cuyos
resultados estimular&n la atenci6n en ese sentido de nuestra Iegi8laci6n social.

En un informs presentado en estos dlas al Ministerio de Justicia de la naci6n, por
una comisiiSn especial nombrada al efecto, se proponen tambi^n algunas medidas que
significan por ahora algdn progreso en nueetros medios de acci6n penitenciaria. Las
propoeiciones mis importantes son, la creaci6n de im intemado nacional para menores
varones, acusadoe o sospechados de delitos, con capacidad para 300 detenidos; lu^o,
la de aumentar a ocho pabellones, con capacidad para 50 cada uno, dividido en doe
salas de 25, el actual reformatorio modelo de Marcos Paz, Aconseja aaimismo, trasladar
la Penitenciaria Nacional a un reformatorio para penados, con capacidad para 1,000
hombres, en im punto de la Provincia de Buenos Aires, distante 125 a 150 kil6metros
de la capital; transformar aquella en cdrcel de encausados y ampliar la actual Prisi6n
nacional para destinarle a c^rcel de mujeres penadas y encausadas, aialando en pabe-
llones independientes a las menores de edad.

Estas mejoras allviadm hasta donde sea posible, la diffcil situaci6n que noe ha
creado el exceso de poblaci6n de penados. Mientras tanto, quedaiin en pie laa

PUBUO WSJkLTK AND MEDiCINE. 575

grandes causas que la determinan, y por cada nifio sin escuela o sin hogar habii que
habUltar un sitio m^ en la piiBidn o en la durcel futura. Luego como hoy, una y otm
volveiin a aer eetrechaa.

Lob puebloe modemos ee resioten cada vez m^ a eetoe extremoe de su viejo empiriamo
judiclario. La Ieg:i8lacl6n contempoiinea ee tambi^ menoe dlsciplinada, in^ res-
petuo6a y m^ consciente del valor humane, cuyas en^fglas aplica y aprovecha en
beneficio de la colectividad, del individuo y del estado. La defenaa social del nifio,
que nos ha ocupado hasta aquf, constituye su capltulo de mayor actualidad e impor-
tancia. Tdcanos adhedmos a ^1, para resolver a nuestra vez eee problema de civiliza-
ci6n que el pals tiene por delante.

OAPfrULO Z. LEGI8LACI5n SOBBB IN8PSC0i5n mai^KICA DEL TRABAJO EN LA RBP^BUGA

ABOBNTINA.

La organizaci6n social de la industria y del trabajo trae a nuestro estudio el problema
m^ interesante de la legislaci6n modema.

Desde la eegunda mitad del siglo pasado, en efecto, los pafses mia adelantados
vienen reconociendo como funci6n del Eetado la protecci6n legal de las clases obreras.
El ejemplo de Biamark, en 1883, imponiendo al Imperio Alemdn el segiiro obligatorio
de BUS masas asalariadas, adem^ de un Ministerio especial, ''Retdisamt des Innem,''
ccm encargo de elaborar bus proyectos de legislaci6n, es como se ve de una trascen*
dencia histdrica innegable.

El sentdmiento de la reSponsabilidad social, parece haber determinado ese movi*
miento progresivo de previ8i6n humana, que distingue nuestra civilizaci6n. La
higiene ptiblica, decla ya a ese respecto Padl Bert, es la moralidad de las sociedades.

La briUante definici6n del eminente fisidlogo franc^, se ofrece oportunamente a
manera de intreducci6n, para el estudio de la higiene industrial que constituye uno
de SUB capftulos mia importantes. Consiste, como se sabe, en la ciencia que ensefia a
preservar la salud del personal en los establecimientos de la industria y del comercio,
correspondiendo segdn Leclerc de PuUigny y Boulin, en las siete ramas siguientes:
el estudio de las enfermedades profesionales, sobre todo, las que atacan a los obreros
en las industrias insalubres e infectantes; las estadfsticas de la higiene profesional;
la interpretaci6n de las estadfsticas de la morbilidad y mortalidad, segdn los oficios;
el saneamiento del trabajo individual, colectivo y de los talleres; la suBtituci6n de
los procedimientos industriales peligrosos por otros m&B convenientes, por tiltimo, la
legis]aci6n de la higiene del trabajo, y la repaTaci6n legal de las enfermedades
profesionales.

La simple Qnumeraci6n de estos tftulos, da una idea del alto propMto de interns
social que revisten sus aplicadones. De ahf que la legislacidn del trabajo se inspire
en sus propias bases, y que sus principios sean el cuerpo de leyes mia acertadas y
ben^ficas.

Desde el 15 de octubre de 1810, que recuerda el primer decreto napolednico, relativo
a las manufacturas y talleres insalubres, inc6modos o peligrosos, hasta el 30 de marzo
de 1881, que corresponde a la ley sanitaria de 8ervia, los dem&s pafses de Europa,
Inglaterra y Rusia en 1878, Austria-Hungrfa, dos afios antes, Italia en 1880, Espafia
en 1873, Dinamarca en 1852, B61gica y Portugal en 1863, han legislado con m&s o
menos amplitud sobre la higiene en sus respectivas industrias.

La funci6n de salubridad profesional, instituida legalmente, ha creado en cada
parte el 6igano de vigilanda y de fiscalizaci6n correspondiente. Noe referimos a la
inspecci6n del trabajo, que en algunos pafses se ejerce de una manera aut^ncnna,
dependiendo directamente de algtin Ministerio, como en Inglaterra, Austria, Ale-
mania y Rusia, a saber, el "Labour Departament" y la Inspecci6n Central de la
Industria, correi^ndientes a los dos primeros, y dependientee de sus respectivos
Ministerios de Gomerdo; la comisi^n y la oficina de la estadfstica dd trabajo y la
inspecci6n del trabajo, dependiente en el liltimo del Ministmo de Hacienda; y en

576 PROCEEDINGS SECOND PAN AMEBICAN 80IENTIPI0 C0N6BB88.

otros pafsee, ae halla anexa a reparticionee m&B completas como son, el Departamento
de Trabajo en B61gica, dependiente del Ministerio de InduBtrias, y en Francia, Nueva
Zelandia y Australia, a la ofidna central del mismo nombre, correspondiente al
Mlnisterio del Trabajo, y en Estados Unidos, desde 1884, a la Oficina Central ;del
Trabajo, que nos ha servido de modelo.

Pero entre nosotroe, el fen^meno inidal ha ocurrido inversamente, y luegoTcomo
instituci6n prosigue todavia, aunque por otras razones, en una de6articulaci6n tdcnica
y administrativa de las m^ lamentables.

Desde lu^o, su origen antecede como oiganismo a las funciones legales quejle toca
ejercitar. El alto prop68ito de gobiemo y de acci6n pariamentaria que inspirara
el proyecto del 9 de enero de 1907 del Diputado Julio A. Roca (hijo), eficazmente
apoyado en ambas C&maras por el doctor M. A. Montes de Oca, a la saz6n Ministro del
Interior,]creando nuestro Departamento de Trabajo, no se ha mantenido ulteriormente
en el campo de la legislaci6n social a que aspiraba adelantarse. Por otro lado, la
reglamentaci6n actual de tan importante oficina reparte con cuatro administraciones
adyacentes, la Munidpalidad, el Departamento Nacional de Higiene, el Consejo Na-
cional de Educaci6n y la Policia, las atribuciones propias de fiscalizacidn, de vigi-
lancia y de inspecci6n industrial que le corresponden en principio.

Es lo que ha venido sosteniendo con toda elocuenda en la C^unara de Diputados
el Doctor Alfredo L. Palacios, desde 1907, habiendo propuesto en la sesidn del 13 de
mayo del a£Lo pasado, respecto al segundo, ''que en cumpllmiento del art. 3^ de la
ley 8,999 se traslade con todo el personal al Departmento Nacional de Trabajo la
Becci6n segunda de la tercera divisi6n del Departamento de Higiene, denominada
Secci6n de Higiene Industrial y Social."

La legislaci6n del trabajo que, como hemos dicho, nace de la higiene industrial,
dene como instrumento de aplicaci6n la inspecci6n higi^nica del trabajo. E^s sobre
esa cadena natural, sin 8oluci6n de continuidad, que se extiende la obra moral y
material del progreso obrero, a tal punto, que el primer Ministro del Trabajo db
Francia, Luis Viviani, puede decir a este respecto en plena C&mara ''que una ley de
trabajo, es lo que son los inspectores encargados de aplicarla." Esta alta responsa-
bilidad se halla sintetizada en la acertada definici6n del Dr. Augusto Bunge, en su
conocida obra "Las conquistas de la Higiene Social.'' Son los agentee, dice, de
propaganda de las ventajas de todo orden para el mejoramiento higi^nico de las indus-
trias y del perfeccionamiento de los m^todos de trabajo, que ejercen sus funciones de
vigilancia y de sanci6n penal, como otros tantos medios de educaci6n de patrones y
obreros.

Es por otra parte, el espiritu de la ley originaria el atribuir especialmente al Departa-
mento del Trabajo facultades de agente en este movimiento cientifico que se favorece^
Han en nuestro^ambiente con la prdctica met6dica y permanente que seflalamos.

La fisiologia y patologfa del trabajo, el conocimiento de la capacidad normal y
exagerada del esfuerzo himmno, el estudio de las condiciones de la mujer y de los
ni£ios en los talleres, el diagn6stico de las intoxicaciones profesionales, de los accidentes
ye de las enf ermedades contraf das por razones del oficio son otros tantos problemas de
profilaxia individual y colectiva, que solamente el espiritu medico ha podido llevar
a la luz y podrd mantener en ella.

Un Departamento de Trabajo no puede existir sin una inspecci6n cientifica de los
trabajadores; he ahf el dilema. Para resolverlo, es que proponemos la integraci6n
de la nuestra con el personal medico que se indica en la secci6n correspondiente del
Departamento de Higiene, salvando, de paso hasta las razones econ6micas que pudieran
oponerse porque el presupuesto de la naci6n, no se alterari en nada con esa nueva
ubicaci6n de partidas.

En cambio, habremos devuelto al medio obrero el resorte m&s eficaz'de sus programas,
que son tambi^ los de los pueblos cuya evolucidn histdrica acompaila. Nuestra
legislaci6n social que ha de Uegar tan pronto y tan completa como debe esperarse^

FUBUO HBALTH AHD WSmOtSm. 677

Ber& la coiisagraci6n definitiva de ese nuevo oiganiamo, que se levanta en nombre de
la sociedad y del Estado para velar por todos los hombree que trabajan en el pals.

OAPfruLO xn. frotbcto db crbaci6n db una nubva SBoadN bibuoorAjica db

MBDIGINA SOCIAL BN LA BIBLIOTBCA DB LA FACULTAD DB CIBNCIAS M^DICAB DB BUBN08
AIRB8.

La evolucidn de las cienclas y de las artes literarias, impulsa, en todos los 6rdenes
del penaamiento y de las actividades humanas, el desarroUo del libro y de la version
escrita, como medio superior de difu8i6n de ideas, para los fines de la ensefianza, del
estudio o del simple intercambio intelectual.

Son asf , cada vez m^ raros los temas sin amplias literaturas al maigen, cuya fillaci6n
hlst6rica suele remontar a todas las ^pocas conocidas. En este Ultimo medio siglo,
sobre todo, la producci6n bibliogr&fica ha tornado un desenvolvimiento may<nr, esti-
mulada por la multiplicaci6n incesante de todos los ramos del saber humane. Desde
luego, de las ciencias sociales y filosdficas; m4s adelante de la ffsica, la quimica y sus
eepeculaciones consecutivas; (iltimamente, de las ciencias biol<3glcas, de la micro-
biologfa, de la medicina y de la higiene.

Se h&a determinado asf, sucesivas transformaciones y divisiones, que han enri-
quecido el campo propio a cada una de ellas, sin disminuir, por cierto, el caudal
comdn. Muchas se independizaron totalmente, deq>rendidndose libremente del
tronco originario; otras, slguen siendo ramas m&s o menos dependientes, aimque
espedalizadas en sus funciones; las dem^ esperan todavfa alguna oportunidad para
librarse por entero a sus destines.

Este fen6meno de incesante multiplicaci6n y renovaci6n cientffica, mantiene en el
mundo de los libros una preocupaci6n constante de ordenaci6n y de m^todo, que
permite contener, sin desviarse, la direcci6n de todas las corrientes que en 61 circulan.
El arte de guardar y conservar los libros, de los antiguos, se ha convertido en la ciencia
de coordinar su existencia, de conocer su destine, de disciplinar su permanencia en el
recinto de las grandes bibliotecas.

La funci6n del bibliotecario modemo es, cada ves menos, la del simple catalogador
sumiso y mecdnico, que ordena los voldmenes por fndice o por tamafio en los estantes,
que la de un eq>fritu ilustrado, capaz de seguir el movimiento cientffico de cada
6poca, para mantener a su nivel, el estado interne del organismo que dirige.

Mi inidativa consiste en crear, en la nomenclatura existente, una nueva repartici6n
denominada de "Medicina Social." No se trata, como se sabe, de una rama pertene-
dente a otra dencia affn, como las que hemoe sefialado anteriormente, dando origen a
ramas libres; es, en ves de eso, una dencia nueva que levanta sobre la base de sus
propios conodmientos y proyecdones fisioldgicas. Los materiales de estudio se hallan,
sin embargo, im tanto disperses todavfa, y urge reunirloe para facilitar la unidad a que
corresponden. En otros pafses, sobre todo en Alemania y en Italia, la medicina social
se halla en pleno desenvolvimiento, consagrada en la dltedra imiversitaria y sostenida
por una actividad literaria muy interesante.

The Chaibman. The chair has the pleasure to invite Dr. Ross, the
president of the American Sociological Society, to share with him the
honor of presiding at this session.

(Dr. Guiteras and Dr. Ross presiding.)

Dr. GuiTBBAS. With respect to this paper that has just been read
by Dr. Sarmiento Laspiur in the name of Dr. Feinman, of the Argen-
tine Republic, I shall read the index of the extensive document,
which is divided into 12 chapters: (1) The medical clinic and legis-
lation of labor; (2) sanitary hygiene of labor; (3) social defense of

578 PBOGEEDINGS SEOOVB PAK AACEBICAN 80IBNTIFI0 CONGBESS.

health; (4) social defense of women; (5) social defense of the work-
man's health; (6) social defense of infantile health; (7) social medi-
cine and war; (8) two Argentine problems of social medicine, in-
cluding social prophylaxis of alcohohsm; (9) social defense of ma-
ternity, Argentine legislation; (10) social defense of abandoned in-
fants in the Argentine RepubUc; (11) legislation upon hygienic in-
spection of labor in the Ai^entine RepubUc; (12) project of the
creation of a new bibliographical section of social medicine in the
library of the faculty of medical sciences in Buenos Aires.

From this program representing the whole document, Dr. Laspiur
has picked out and has read to you *'The social defense of maternity
in the Argentine RepubUc." He finds that the work has been
initiated in the Argentine RepubUc, but is still quite behind. The
law for protection to maternity dates from October, 1907, and thereby
the woman is aUowed to remain from her work 30 days after confine-
ment; but there are many measures abeady presented before the
Argentine Congress to increase these measures of defense to mater-
nity. There is a project now, with prospects of being passed by the
Argentine Congress to the effect that the woman may be allowed
for 40 days before and 30 days after confinement to remain away
from her work, but there is no insurance provided at the same time-
Also, with respect to nursing during labor, the law allows now that
a woman may have 15 minutes every two hours to nurse the child,
but the law does not oblige the owners of the factories to provide
nursing rooms for such function. It is projected that this shall be
attended to.

The program for the morning being completed, discussion is now
in order upon the several subjects that have been treated during the
session.

Mr. G. O. HiGLBT. I should Uke to say a word, Mr. Chairman and
gentlemen, about some sanitary work that has been done at Delaware,
Ohio, by the department of chemistry, of which I am the represen-
tative here. Delaware, Ohio, is a city of 9,000 poptdation, with a
good pubUc water supply and sewerage. Notwithstanding that the
water supply is good, typhoid fever has been endemic, there having
been up to 1910 about 15 or 20 cases annually in a city of 9,000. In
1910 there was an epidemic in which there were 34 cases, with 26
cases at one time about the 1st of August. As the city water supply
was good and had always been such, suspicion, of course, fell upon
the weU water as a possible cause. The department of chemistry of
the Ohio Wesleyan University took up the problem of the study of
the supply of this well water, analyzing, bacteriologically and chem-
ically, the water of about 100 wells and foimd the water of 26 per
cent of them badly contaminated. In fact at the time of the epidemic
in 1910, the first analysis made showed that the water of a weU on

PUBLIO HSALTH AND MEDIOINB. 679

premises where there was typhoid fever (four children sick of the
disease in one house) was very badly polluted indeed. In another
place where there were two cases of typhoid in the house, the water
of the well was also found to be highly polluted. These people were
not using city water, but were using well water because it was cold
and sweet and as they supposed pure.

Further work in the study of well water was done to determine to
what extent filth passed through the soil of the city from cesspools
and vaults to wells. The vaults selected were in different parts of
the city, and in widely different kinds of soil. There were 13 vaults
from 58 to 113 feet distant from weUs. The water of the weUs was
sampled and analyzed for chlorides, and then a barrel of salt was
thrown into each vault. Tests were then made of the water for
chlorides at intervals of a week for about a month thereafter. The
results showed that the water of the wells was in most cases receiving
sewage from the vaults, the chlorides in one well increasing to four-
teen times the previous amount.

The following year we repeated the experiments. We met some
objection at this time to the putting of the salt into the vaults,
one man claiming that I had by this means spoiled the water of his
well and that it had been one of the best wells in the city.

These results, both on the analysis of the water in general and
on the passage of filth through the soil from vaults to wells, were
reported to the health officer of the city, imd he took action in
regard to the cleaning out of cesspools and in some instances to the
filling up of wells. An abstract of the results was also published in
the city papers. The procedure of going into the homes of the city
diuing several years to get water from the wells for purposes of
analysis called the attention of the people of the city to the fact
that there is such a thing as impure weU water; that water may be
clear, cold, tasteless, and odorless and yet be very impure. The facts
are that whereas there were 15 to 18 cases of typhoid per year down
to 1910 and 34 cases in that year in the city, the cases of this disease
since 1910, when the epidemic occurred, have greatly diminished, not
more than two or three cases per year.

If I may be permitted to take a few minutes more, I should like
to say a few words about an antifly campaign which was conducted
also by the scientific departments of the university. There were,
perhaps, two or three novel features in this campaign. First, sticky
fly paper was purchased and put into the hands of the children of
the public schools. They took it home and used it out of doors
properly baited in the catching of flies. Prizes of considerable value
were awarded to the schools whose pupils brought in the largest
nmnber of flies. This method of fighting the fly obviated the objec-
tion which is sometimes made to the children catching flies in their
68486— 17— TOL]

680 PBOOEEDDffGS SEOOND PAIT AMBBICAN SdENIIFIO C0NQBB8&

fibigers. Here they caught them on paper and did not need to
touch them. Thousands of sheets of sticky fly paper were tacked
upon the rear of buildings and fences along the alleys. The paper
was streaked over — ^the sticky side, that is to say — with a mixture
of very ripe banana and sugar, well ground up together. This
method was used to clean up the last of the flies after the city itself
had been put in pretty fair sanitary condition and flies were not
numerous.

There was still a third way in which we worked. Thirty flytraps
were built, baited with banana, and put upon the streets placarded
in the following way: On one end of the trap were the words, in very
large, plain letters, '^ Starve that fly," and on the other end of the
trap the words, **The typhoid fly." We believe that the people of
the city, on account of this piece of work alone, have been brought
to realize more clearly the danger that lurks in the fly.

Dr. Cabter. Dr. Dearholt laid great stress upon the advantage of
newspaper publicity, publishing articles in the newspapers and
magazines on health subjects. I agree with him ; but the newspapers
need a good deal of supervision and great care must be taken as to
who writes these articles. A large number of our daily papers, as far
as I see, have health articles every Sunday. Most of these papers
seem to treat their readers mainly to shocks and thrills, as the French
say, and these articles abound rather in startling paradoxes and in
overtruths, than in real, scientific knowledge. Certainly that is so
with those I am in the habit of seeing. I want to make exception of
the articles written by Dr. Evans, at one time health officer of Chicago.
His articles are real sanitary truths; the others are frequently over-
truths, telling what is so, but a great deal more than is so. I can illus-
trate it better by recalling to you the drama of ^'Damaged Goods,"
or what the boy said about the adventures of Tom Sawyer, "that all
those things could happen to boys, but that all those things did not
happen to one boy one after the other." That is what I meant by
overtruths, and many of these articles are full of them.

I think that newspaper articles can do a great deal of good; I am
not certain whether at present they do not do a modicum of harm,
excepting, as I say, those by the one syndicate.

I have been engaged in the last two years on some educational
work, I suppose you might call it publicity work, on malarial fever,
which is a great problem in the South and Southwest. It struck me
that the two most efficient agents to employ were, first, the teaching
of facts concerning malaria in the public schools; to teach them,
gentlemen, to little children in the very beginning, that they may
learn the basic facts of the disease there so that they would come to
it, you might say, naturally, just as children know that the roimd
letter is O and that d-o-g spells dog, and they will not argue about

PUBLIO HSALTH AND MEDIOINB. 581

it or dispute it. That is a very bad habit for the adult, but it is a
very good thing for the child. In many of the Southern States — in
Vkginia, in portions of North and South Carolina, and Arkansas — at
present there is quite a fair little course in malaria made a part of
the school teaching, and I think it is a thing all the normal schools
should teach in order that the teachers may know something about it.

First, as I said, the teaching in the schools and then demonstrations.
In my observation, lectures and lantern slides, etc., are all very well;
but to take a community and do antimalarial work there, to free it
from malaria, is worth more in teaching the advantage of antimala-
rial work than any nimiber of lectures or thousands of lantern slides.
A very great nimiber of the citizens of other States are really "from
Missouri,'' and ''have to be shown." The work has not been very
well advertised, but at Roanoke Rapids, a little place in North Caro-
lina, the work in its results — not in any sense in its difficulty — is
comparable to that in Panama. I was informed that the year before
the work was started the inefficiency due to sickness was from 45
to 60 per cent through the months of July, August, and September.
Last year, from all sickness, it was put down as from 2 to 4. The
miU physician, who attended the people free at that time — the firm
consisted of three men — ^had a record of an average of 50 visits per
day on the books for the first year. Last year they had about one
case every three days. I say the result, not the difficulty, is compa-
rable to Panama.

The work of the lecture bureau has been equally successful, but
has been going on only two years instead of three. A number of
places in the South — ^Lanett, in Alabama; Crystal City, in Missouri;
and Emporia, in Virginia — ^have also had demonstrations of anti-
malarial work done there. There is a place in Arkansas — Stuttgart —
where the work is planned and laid out in detail; also in Virginia;
but the result is still on the lap of the gods. I do not know what
it will be. But these demonstrations of the malaria work — ^mainly
but not exclusively on mosquito work — are being done in selected
commimities in a large number of the Southern States. The results,
so far as we have been able to try them out, have been extremely
valuable, not only to the conmiunity, but to the people who hear
of it.

I say, "in selected communities." Two things are necessary in a
conmiunity. First, it must be a fairly malarial conunimity. It
must not be very bad this year and not bad last year. I had to
reject Walker Coimty, Ala., on that account. We foimd it a very
great advantage also to take communities where there are large —
or large for the city — ^manufactories, rather than those mainly en-
gaged in commerce or trade. Malaria is naturally a small-town dis-
ease, and we chose towns where the mills worked, say, 15 to 20 per

582 PBOOEEDDffGS SEOOND PAN AMBBIOAN 8CIBNTIFI0 OONQBESfik

cent of the population, which you would not get in the large cities.
Take, for example, Roanoke Bapids. We did not go to the people.
We went to the mill owners and explained to them how we could do
it — ^they to put up the money; we to put up the sanitary engineer with
the brains, a man who did the detail work for Gorgas in the zone, plan-
ning the drainage, the ditches, the fiUs, and estimating the cost. These
mill men were men who were willing to spend a dollar to get a dollar
and a half. Tlie ordinary common council and mayor of the modem
small-sized town in the South are not willing to spend a dollar, no
matter what they will get in return.

In Electric Mills I called on the manager of seven or eight large
sawmills there, and he said, ''Well, if what you have said will happen,
it will pay me; it will pay me a hundred per cent, and if it does not
pay me, bless me" — ^he did not say "bless" — "but I will do it any-
how." Later on, I am very sure, after seeing the results in these
towns, he was glad he did it. We wish to try about seven or eight
more this next summer, and others will follow their example.

To my mind — ^I do not know anything about newspapers or maga-
zines— a great deal can be done by education of children, and in the
matter I am working on — malaria — ^I am sorry to say that there will
be plenty of time for this generation to grow up before work is value-
less in that direction.

Dr. HuBTT. I think that Dr. Carter is right in paying attention to
children. Youth is the time to serve the Lord. If you do not serve
Him in youth, you will not serve Him at all. Foimdations must
then be laid for education, foundations must then be laid for morals
in after life. Teach the children hygiene in the schools, and when
they grow up it will be practically applied to everyday life. In our
work in Indiana, where I have been engaged in pubUc health work
for 20 years, I have given up trying to teach adults for the piupose
of securing action from them, but solely for the purpose of securing
permission from them to teach the young, or silencing them in their
objections. An adult has his habits formed physically and mentally.
His habits of thought are fixed, he is fixed in his beliefs. If he
behoves that the mosquito does not carry malaria, it is almost futile
to try to teach it to him.

I have a brief story that illustrates this point. In one of my
northern counties a great deal of malaria prevailed, according to the
reports of the doctors, and we found, again and again, the malarial
Plasmodium in patients. The county had many little lakes in it.
We surveyed these, and found the Anophiles mosquito very abun-
dant. So I made an engagement and appeared before the county
commissioners, who at that time had control over drainage. Sani-
tary improvements, I am thankful to say, have now been taken from
them, for under the old conditions no progress could possibly have

PUBUO HSALTH AND MEDIOUTB. 588

been made. I went before this board and presented to them statis-
tics in regard to malaria. I told them how much money it probably
would cost to remedy conditions, and then told them how the mosquito
carried malaria, llie three commissioners sat behind a long table
and listened intently with eyes wide open. I thought I had made a
great impression upon them, and sat down congratulating myself,
metaphorically rubbing my hands at my success. One commis-
sioner, sitting in the center — he was the chairman — ^talked to the
one on the right and the one on the left, combed his beard with his
fingers, and picked a few pieces of manure out of it, and then turned
to me and said, ''Young fellow, you don't believe all that mosquito
stuflf, do you?" Now, those three men there were so practical they
could amass a fortune farming, and each one of them did have a re-
spectable fortune; yet the presentation of all the facts that have been
discovered in regard to the transmission of malaria, when presented
to them as clearly as I could possibly do it, made no impression;
they simply did not believe.

Having some similar experiences of that kind, we went to the
legislature and got sanitary powers taken away from them. It was
given to another body of men who were just as bad. The method
was changed again, and now we can clean up a county from the cen-
tral power alone, for there is, fortunately, a clause in the law that in
the event the local authorities do not do what is necessary for the
prevention of disease the State board of health shall have authority
to do it. I do not believe much in local government in the Central
Western States. I do not know how it is in the Ekistem States or
the extreme Southern States. We must govern from the center,
or we get nothing done.

In regard to publicity. Newspapers are a great force. If used
rightly you can secure great results. I have foimd it desirable in
instances to arouse their opposition and bring about a good, strong
fi^t in a commimity, so tiiat every side of the subject will be dis-
cussed. We think ourselves fortunate in some instances to have the
downright enmity of a newspaper man. He will fight us and fight
us, and we will bring the matter before the people in a way that
otherwise could not be done. But, on the whole, we want their
support. In the time that I have been State health commissioner
I will say that practically all the papers in the beginning were op-
posed to the work. Now practically all of them are in favor of it.

The distributing of health circulars is attended, of course, with
good results. It is a rational and reasonable thing to do, but you
scarcely get yoiu: seed back, I beheve, further than to simply silence
people, and influence them so they will not object.

I want to tell of one other thing we have done in Indiana that was
very successful. Four years ago we went to the legislatim) and

584 PBOOEEDINGS SECOND PAN AMEBIOAN 80IENIIFI0 00NQBB8S.

asked for $5,000 with which to publish what we would call the "In-
diana Mother's and Baby's Book." We desired to bind it in cloth,
and make it a really nice book, and in it to tell the story of the care
of the baby and of prenatal care. They thought it over, and con-
cluded to let us have $2,500 to save babies with, and the next item
on the bill was $25,000 for saving pigs. The pig item went through
beautifully, but only $2,500 was given for saving babies. That is
1 to 10; I wondered why they did not make it 1 to 16, but they
did not.

Since publishing the baby book and sending it out to all first
mothers and asking them to speak in its favor if it pleased them, our
officials have been flooded with letters from mothers praising the
book, and it has made a great impression; so great, indeed, that when
we went to the last legislature and asked them for $5,000 to extend
this book, they gave us $10,000, and we coimted that a success.

We have numerous other methods in use, but I want to say again
that I agree on the whole pretty well with Dr. Carter.

Dr. GurrsRAs. The chair would like at least to call attention to one
point in this paper read by Dr. Laspiur. I would like to know why Dr.
Laspiur, out of a catalogue of 12 distinct chapters, picked out the one
on maternity, which, in the paper he presented here, occupied the
ninth place. I do not know why maternity appealed to him at that
moment as the most important subject. It evidently was not so for
the author of the paper, because it is placed in the ninth place. And it
is so with legislatures on this matter of social insurance. The insurance
of maternity, the protection of maternity, the protection of the nurs-
ing woman, the chair finds, is always relegated to the last place. In
the German law on social insurance, maternity is not a major topic,
simply one or two articles in that enormous, complicated program in
the German law of labor insurance. Lately more attention has been
given to the subject, but it still is a side show in that general law of
labor insurance. I simply say this to point out briefly that it seems
to me that it ought to occupy always the first place. The protection
of the pregnant woman, the protection of the nursing woman, it
seems to me, will do more than all other social legislation to elevate
the race.

Dr. KoBEB. May I be permitted to reaffirm what Dr. Guiteras
has so forcibly said. I had an occasion to present an address at our
last tuberculosis meeting in Seattle on the subject of the child and
the home, and I emphasized what Dr. Guiteras has so very tersely
stated, the importance of the fact that we are laying the foundation
of the futiue race with the pregnant woman, and practically recom-
mended what has been recommended in Germany — special schools
for the education of mothers, a school for young women at about the
age of 18 to 20 so that they may be taught in all the duties, domestic

PUBUO HSALTH AND MBDIOIKB. 585

and sooiologicaly pertaining to motherhood and to the baby, and how
to be really a competent head of a family. It has been shown very
clearly in Germany that mothers who had enjoyed the benefits of the
social insurance and could afford, therefore, to give themselves a rest
of three to four weeks before and after pregnancy bore offspring
which on the average were very materially greater than the offspring
of mothers who were deprived of that rest and care.

And naturally, after all, our struggle in the prevention imd the
eradication of preventable diseases depends to a great extent, I think,
upon the physical vigor of the child, and naturally the vigorous child
may be blessed in the way of enjoying general vigor, especially when
they are brought up under intelligent, careful mothers who know
something about personal hygiene. Take our struggle in the pre-
vention of tuberculosis. Why, to my mind, it depends so much upon
the power of resistance of our individuals, and the more we can do
to promote a strong, vigorous, healthy race, the greater our victory
will be in the prevention of disease. The whole struggle resolves
itself into a contest between the microbe and the individual power
of resistance. So I feel that there is very much to be said for having
presented to us strong pleas for proper legislation and r^ulation of
the broad subject of maternity, particularly among the least resource-
ful people.

Dr. GuTTERAS. The chair understands that Dr. Devine is here and
invites him to speak.

Dr. Edwabd T. Devinb. Mr. Chairman, I am very much disap-
pointed at not having heard the paper, and will therefore have to
speak without a knowledge of its contents. If I may make a remark
upon the discussion of the paper, instead of on the paper itself, I will
say that for the past three years a conmuttee of the association of
labor legislation, of which I have the honor to be chairman, has been
working upon a draft of a sickness insurance bill such as would be
suitable for introduction in the various States of the American Union.
Among other things, provision is made in this bill for maternity
insurance. There is a provision not only for insurance to the wife of
a working man who is insured which would cover the medical care
and if necessary hospital care, but there is in addition to that a cash
benefit for the insured working woman, giving her not only medical
and hospital care, if necessary, but also a cash benefit for a period of
eig^t weeks.

It will interest the secticm to know, after what the chair has said a
moment ago, that this is the only feature of the draft which we have
prepared to which there has been vehement objection, and the
objection has been made by those who are str^iuously opposed to the
employment in industry, in factories especially, of married women.
It is said that this cash benefit in addition to tbe medical benefits will

686 PBOGEEDDffGS SECOND PAN AMERICAN 8CIBNTIFI0 C0NQBE88.

invariably have the resiilt of encouraging men to send their wives to
work and that it will therefore run cc»itrary to what is as jet a well-
estabhshed tradition in our country that married women, mothers ol
young children, shall not be employed when th^^ is a competent male
head of the family. There is some evidence to show that there is
soundness in the objection. It is testified, for example, by Mr.
Howard Cheney, that in his extensive mills in New England, where a
social insurance scheme on a voluntary basis had been introduced,
that there was a liberal cash benefit to mothers, amounting to $70*
There had not been a large number of married women employed in
the mills, but as a direct result of this benefit a very large increase
took effect inmiediately among the married women who were em-
ployed in these mills, notwithstanding the fact that their husbands
were also employed. Mr. Cheney and his associates have not aban-
doned the maternity instirance plan (m this account, but they have
reduced the amount of the cash benefit and lengthened the time that
the woman must be employed before the benefit can be received.

Mrs. Kelley, who heads the opposition to this maternity insurance
feature of our bill, on behalf of the Consumers' League, points out that
in the United States, although we have no distinctive statistics on
the feature, the married women who are working and who would
come under these schemes appear to be chiefly of three classes: First,
negro women, who are very largely employed, their husbands not
earning enough to support the family, as they say because occupa-
tions are not open to them, as their critics say because they prefer to
have their wives support the family. For whatever reason it is, most
negro married women do work at some kind of labor. Secondly, the
wives of incompetents and drunkards and inefficient and feeble^
minded men and those who can not support their families, throwing
the burden upon their wives, lliird, the wives of newly arrived and
as yet unassimilated immigrants, Italians and others, who go to work
on a very large scale, largely because the men very soon af t^ arrival
begin to buy a house and save, having their wives and children work
as well as themselves and at a very low standard of living, in this way
trying to improve their economic position. That this is not a neces-
sity, however, seems to be shown by the fact that the very poorest of
our inamigrants, viz, the Russian Jew, does not send his wife to work,
though it is customary among other immigrants,

I speak of these things, Mr. Chairman, just to show that the subject
is a complicated one and that there are sound economic objections, at
any rate to cash benefit. As you say, in the German insurance plants
it was one of the last things to be taken up. Provision was made in
an earher law, but the amount of the cash benefit was very slight
imtil the b^inning of the present war. A great extension of cash

PUBLIC HSALTH AHD MXDIOINB. 687

benefit b^an in Noyember, 1914. This wa& very distinctij a war
measure, perhaps partly for the purpose of increasing the population.
Dr. QurrBBAS. If there are no other remarks on the subject, the
discussion is closed. The following paper, owing to the absence of
the writers at this session, will have to be presented as read by title:

LA INFLUENCU DE LA ANKTLOSTOMUSIS SOBRE LA PROSPERIDAD
DE LA AGRICULTURA T SOBRE LA MORTALIDAD INFANTIL.

Por LOUIS SCHAPIRO,
Director en Costa Riea de la Junta Internacumal de Sanidad de la Fundaei&n

Rockefeller.

MAURO FERNANDEZ,
Director Asistente de la Fundacidn Rockefeller de Costa Riea.

Uno de loe problemas mis importantes para el perfecto deearroUo de la agricultiira
en GoBta Rica, es el de propordonar hombree fuertes para el trabajo (y por eeo deben
lo0 Grobiernoe prestar gran atoicidn al mejoramiento de eee servicio).

La eecasez de brazos que se nota en Costa Rica se debe en gran parte a la falta de
salad de la mayorfa de los peones, sobre todo en las regbnee infestadas de ankyloe-
tomiasis y malaria.

En aflo de 1914 a 1915 se ban practicada 50,000 exdmenes de heces y el resultado ha
side, que el 80 por ciento de la poblaci6n rural, que es la que se dedica a la agricultura,
eetd infectada de ankylostomiasis, y el promedio obtenido de los exdmenes de sangre
hecbos entre los ankylostomiiticos, durante este tiempo ta6 el 62.2 por ciento de
hemoglobina.

A los finqueros les interesa mis que a nadie este problema y es en provecho propio
que debieran procurar instruir a sus peones, en la manera de preservarse de esaa
enfermedades; porque la fuerza para el trabajo eetd en relaci6n directa con el tanto por
ciento de hemoglobina, asl, un pe6n, enfermo de ankylostomiasis, que s61o tiene un
62.2 por ciento de hemoglobina podri producir, tan 861o eee porcentaje del trabajo de
otro sano que debe tener 100 por ciento de hemoglobina.

Para la agricultura se necesitan hombres fuertes, que den un buen rendimiento por
su trabajo y la dnica manera de obtenerlos es curindoles sus enfermedades y previ-
niendo su contagio. Uno de los sfntomas de la ankylostomiasis es la apatfa con que
miran los enfermos el eetado de su salud, pues no se preocupan por hacerse examinar
de un medico ni por curarse, sine que toman bebidas estimulantee y alcoh61icas, para
sentirse bien, de sus fatigas corporales y muchos acaban por ser vfctimas del alco-
holismo.

De una eetadfstica hecha en el Hospital de San Juan de Dios durante los afios de
1899 a 1905, acerca de ankylostomiasis, se deduce: que la proporci6n de enfermos de
6 a 18 afios que iba en busca de tratamiento, era muy baja, tinicamente el 12 por ciento,
lo que demuestra que el campesino no se preocupaba por enviar a bus hijos a consultar
el medico o por ser tratados en los hospitalee, sino hasta que la enfermedad estaba en
un perfodo avanzado, lo que va en perjuicio de ellos, pues los nifios deben ser curados
antes del perfodo del desarrollo para que cuando ^te Hague, el future pe6n pueda ser
un individuo que d^ buenos rendimientos con su trabajo. Buscaban tratamiento los

588 PBOCEBDDffGS 8B00ND PAN AMBBIOAN SClEJNllFiO C0NQBE88.

viejoB, gastados ya por IO0 aflos, por el esfueno que baclan para el trabajo y por el
envenenamiento producido por la gran cantidad de ankylostomas que vivlaii en soi
intestinos.

Es alarmante el eetado de degeneraci6n fisioldgica a que Uegan los individuoe
atacados de ankyloBtomiaais, sobre todo en el campo, donde las condidones son muy
f avorablee al deearrollo del par^to y la gente contrae f&dlmente la inf ecci6n y adn
cuando se curen, vuelven a infectarse, mientras no observen las medidas que aconseja
la higiene.

De la estadfstica de Coeta Rica se deduce que el 18 por ciento de las defunciones son
debidas a anemia, no dudamos que ella sea produdda por la ankylostomiasis.

Este grave problema tiene una soluci6n relativamente sencilla, si para ello se usa
la eneigfa y la padencia neceearias. Ya lo hemos visto en Puerto Rico. £1 gobiemo
americano dict6 medidas muy severas para contrarreetar la plaga de ankylostomiasis
que diezmaba Ibo peonee, tan necesarios a la agricultura, y el resultado ha sido de lo
m^B satisfactorio.

Hace 17 meses que la Junta Intemacional de Sanidad comenz6 la campafia contra
la ankylostomiasis en Costa Rica, con resultados muy halagQefios y mejores esperanzas;
pues si antes, hasta 1905, apenas el 12 por dento de IO0 adolecentes fueron tratadoe,
hoy lo ban sido el 50 por dento; es decir que los futures peones, ser&n m^ fuertes y
productivos.

No hay que desmayar en esta campafia, pues el resultado que darfa la extirpaci6n
de una enfeimedad que agota a los hombres de trabajo, que lleva la pobreza y el
infortimio a los hogares y empobrece los oiganismos, hasta influir poderosamente en
la degeneraci^n de la raza, serla altamente provechosa para la salud y la prosperidad
individual, que es la base de la riqueza de una Naci6n, que como Coeta Rica cifra su
porvenir en la agricultura.

MOBTALIDAP ZNFAN1XU

En el afio de 1914 murieron en Costa Rica 5,787 nifios no mayores de 5 afios de edad,
es dedr, 279 por cada mil nadmientos.

IJl qu6 se debe esta tremenda mortaltdad in&ntil?

En t^rminos generales, la ignorancia, la pobreza, los venenos oigdnioos, etc., son
las causae que la produoen; pero en Costa Rica: en las dudades se debe, en gran parte^
a las toxinas (sifiUs, tuberculosiB), a los vidos, a la mala alimentaddn debida a IO0
' pansitoB intestinales y a la pobreza. En los campos, donde la natalidad es mayor, ea
produdda por la ankylostomiasis; pues el 80 por dento de la pobladdn rural esti
inlectada. En todo el pais la inf ecd6n de ankylostomiasis alcanza al 60 por ciento y
el 95 la de los dem&s par^toe intestinales.

^Qu6 probabilidades de vivir, podri tener un nifio d^il, naddo de padres an^micos,
■i la leche de la madre no alcanza para alimentailo bien y su padre, vfctima tambidn
delaankylostomiasbysusomsecuenciasnoganasufidente para oomprar to necoaario
parasupliria artificialmente? Porque un hombre enfermo, con un tanto por ciento de
hemoglobina, que oedla entre el 10 y el 65; no tiene sino de un 10 a un 65 par ciento
de fueisas para el trabajo, y el dinero que gana est& en la misma pioporci6n. No ea
que sea pecezoso, no es que no quiera trabajar; sino que no puede, es que est& enfermo,
es que necesita el tratamiento del medico y el consejo del hlgienista.

Por eeo dedmos que la ankylostomiasis es la causa de la mortalidad infentil en Costa
Rica.

Vamos a anaJizar lo que pudidramos Uamar las ''consecuendas de la ankylos-
tomiasu" y para explicario mejor to desanoUaremos en forma objetiva.

Una de las prindpales oonsecuendas de la ankylostomiasis es las anemia; y 6b^ a
su vez, produce debilidad fistol^ca y mal desarroUo, to que influye mudio en la
mfflrtftlldad ttffan|:ii.

PUBLIO HBALTH AND MEDIOINB« 689

La ankylostomiaflb produce p^resa y por oonsecaenda la pobiesa que es una de
las causM de mortalidad ipfantlK

La odosidad es causa de muchos vicioe, entre ellos el alcohoUamo cuyas couaecuen-
das, bien conocidafl, aobre todo la degeneraddn fiaioldgica influyen en la mortalidad
Infuitil.

Otro de lo8 leBultados de la ankylostomiaaia es la debilidad mental^ que da una
proporcidn grande de individuoe piediapueetos a los vidoa, Bobre todo al alooholiBmo.
£1 campesino, enlenno de ankylostomiaaia, tiene la costumbre de tomar un tngo de
lioor (cad aiempre aguardiente) y lo hace para obtener miB fuersaa. Poco a poco va
anmentando la cantidad haata que ae convierte en alcoh61ico.

Cualquier eafuerao que ae haga para extirpar laa cauaas de mortalidad infantil en
Goata Rica, ea de aplaudirae; la fundad^n de '*La Gota de Leche/' ''£1 Abrigo de los
NifioB,'' "El Aailo de la Infanda," etc., influiri a reducir la mortalidad inlantil, pero
eeo no ea aufidente, hay que combatir d mal de ralz, aiguiendo la lucha contra la
ankyloatomiaaia, con toda la fuersa y apoyo del Gobiemo. Hay que curar a todo
individuo atacado de eae mal y haceclo que aiga loa conaejoa higi^nicoa para evitar
futuraa inf ecdonea.

La ignorandaae ir4 combatiendo poco a poco, por medio de conlerendaa apropiadas
y porque en realidad la ignoranda de laa madrea ea una de laa cauaaa de eaa mortalidad
infantil, pero vdvemoa a repetirlo, la ankyloatomiaaia en Goata Rica ea la prindpal
cauaa de eate estado de cosas y combatirla es d deber dd Gobiemo, para Doder adquiiir
una generaddn mis fuerte, mis rica, mia sana, y mia felis.

Adjournment.

GENERAL SESSION OP SECTION Vm.

New Ebbut Hotel,
Friday (iftemoon, December SI, 1916.

Chairman, William C. Braistosd.

The session was called to order at 2 o'clock by the chaiiman.

The Chairmax. I have watched the growth of this subsection on
sanitation with a great deal of interest, and I think we have in our
papers material which will be historical. One scarcely realizes mitii
after the transactions are published how valuable the papers are.
I know I did not in the previous Pan American Congress until after
I had gotten the transactions and gone over them. As a part of a
library or an office they are invaluable, and in our office we still turn,
in many questions that interest us, to the proceedings of that past
congress, always finding a great deal of help. In order that we may
take advantage of the time and get through with the afternoon's
work, we must begin at once. I will therefore call on Lieut. Col. Mun-
son, whose great work in sanitation in connection with the Army is
known all over the world.

MEDICAL PREPAREDNESS FOR CAMPAIGN.

By EDWARD L. MUNSON,
Lieutenant Colonel^ Medical Corps, United States Army,

In view of the acute interest now manifested throughout the civilized world in all
that is implied by preparedness in relation to military efficiency, a brief outline of the
part which the medical department of an army should play in connection therewith
may be worthy of attention.

We, on our side of the Atlantic, are essentially individualistic and prone to dis-
regard national obligations which are not immediately pressing; yet if there is any
one lesson preeminently to be drawn from the great struggle abroad it is the efficiency
reetilting from collectivism and forethought. Too many are willing to admit Um
virtues of preparedness, but are without the willingness to make such effort as would
convert theory into accomplished fact. Possibly this outline may help to show that
for a medical service in war, preparedness is both logical and worth while.

It is well recognized by military men that success or failure in a modem campaign
or war is laigely determined by the degree of preparedness thereto which has been
reached in advance. The work leading to preparedness must be done before war
breaks out, and it involves years of labor, study, trial, and rectification. In this great
general scheme of military purpose, an army medical department has a very definite
and important part of its own to play. This medical department plan, in the nature

590

PX7BU0 HEALTH AND MEDIOINB. 691

of thingB, can not be an independent scheme conceived primarily for hnmanitariaa
reasons— fluch as could » for example, be the medical relief work to meet the needs oi
great national disaster from earthquake, storm, or flood. On the contrary, it must
always be dependent upon, and coordinate with, the general combatant plan of
campaign. It must be wholly subservient to the paramount military idea that war
is waged for the purpose of imposing the will of the nation upon the enemy; and that
all else, humanitarian considerations included, is wholly secondary. Before the
medical department can plan as to what it itself could best do, it must therefore know
the limits for its activities created by the general purpose and methods upon which
the General Staff has decided.

The representatives of the medical department who work out the proper part for it
to play in the great military scheme of things have none of the functions of iiractidng
physicians in civil life, and have nothing to do with the treatment of illness and injury.
Instead, they are searchers of history, interpreters of conditions, casters of sanitary
horoscopes, planners, and organizers. With them drugs and instruments give place
to maps and books— the ward and amphitheater to the quiet desk of the student.
Yet, from a humanitarian standpoint, these medical oflScers will do far greater good
than if engaged in the busy practice of their profession. Though not engaged in curing
existing sickness, yet their work is such that they will prevent diseases which, under
the anticipated military c<mditions would otherwise arise; though not now operating,
they take the steps by which infinitely more than their own numbers may later do
effective surgery. They make the advance i^ans without which sanitary disaster is
inevitable, and solve, in so far as this be humanly possible, that most dificult of all
problems — how to bring the disabled, the medical oflScer, the relief establishment, and
the supplies together, to the greatest sanitary advantage and with least interference
with military purposes.

As the line officers of the General Staff plan to make the combatant forces of an
army more effective as destructive agents, so the medical officers plan to render the
medical service more efficient as a constructive force. Put into medical terms, it
will be accepted that before a suitable prescription can be written the symptoms of
the patient must be recognized and set forth in their proper sequence and relative
importance and a diagnosis reached. So, too, in a wider application, in preparing
effectively to meet the exigendee of any situation, it is necessary to make a careful
estimate of the nature and scope of the various factors by which this situation is am-
trolled. Such need of prevision applies particularly to the sanitary and medical
factors of any military plan or movement, and especially those of the latter in which
the taking of the offensive in a foreign territory is contemplated, where unfamiliar
conditions and untried difficulties must be met. It is a fact to our peculiar advantage
that medical needs and plans can be worked out in advance with much greater cer^
tainty and exactitude than can the purely tactical considerations on which they are
necessarily based, for while the latter depend largely upon the unknown, variable^
and presumed future plans and activities of a human enemy, the accompanying
sanitary arrangements necessary and proper can largely be estimated and worked
out by a study and proper interpretation of actual sanitary conditions and occur-
rences in the anticipated theater of action which may be existent in the present or
have existed in the past.

In the medical study of the tactical plans for any proposed campaign, many basic
factors, as here roughly outlined, need to receive attention, and each of these main
component factors has its subdivisions and ramifications, the study of which should
be pursued to every profitable extent. It ia an axiom that nothing should be left to
hypothesis, chance, or gueeswwk which can be reduced to a basis of fact and exact-

Besetting dangers and difficulties which are appreciated in their proper significance
before they occur may very often be avoided or minimised by appropriate precau-

692 PBOOEEDINQS SECOND PAN AHBBIOAN 80IBNIIPI0 OONOBBSS.

tioDS in advance, and by so much the military efficiency of the force will be incroaaod,
suffering and death be reduced, and the labors of the medical service in cuing for
the disables will be diminished.

Medical fcnrethought for preparedness thus implies the application of measures of
business efficiency in the prevention of avoidable wastage in numbers and strength
of the human factor in war.

It has aheady been mentioned that war is waged for the enforcement of the national
will and the accomplishment of military purpose, and that tactical and not sanitary
considerations are paramount. Yet it must not be overlooked that the very tactical
advantage sought in a plan of campaign may be wholly dependent for its results
upon the preservation of efficiency of troops, and that in every case, just as probable
resistance by the enemy is duly considered in advance by the combatant officers and
plans are made to avoid or neutralize its effects, so the sanitary handling and envi-
ronment of troops will have their powerful influence upon the problem of minimiz-
ing human wastage and loss of military efficiency. For such reasons, then, every
possible source of inefficiency and wastage will be searched out and investigated in
advance by the medical department, to the end that plans may be made in advance
by which any power for harm may be avoided or reduced to the minimum.

In the general scheme of preparedness every tactical contingency liable to occur
in any anticipated campaign will have been studied by the General Staff, the nature
and extent of its problems will be determined, and the best method of meeting its
opportunities and difficulties will be formulated and set forth. As soon as a tentative
plan governing the tactics and strategy of the campaign in question has been worked
out in this manner, and provisional estimate made as to the number and kind of troops
required to accomplish the desired result, the whole scheme, with all necessary infor-
mative data as to time, place, purpose, methods, difficulties, etc., should be turned
over confidentiaUy to the medical officers selected to handle the medical end of the plan
for further careful consideration and sanitary study. For the proper and intelligent
prosecution of the work, it will be clear that not all medical officers are fully qualified
to conduct it, and that no inconsiderable knowledge of general military <»ganiza-
tion, methods, and tactics is necessary for the medical officers who are to have this
study in charge.

The medical department representatives, in carrying out the latter, must deter-
mine and bear constantiy in mind the various medical contingencies which migjit
arise and their relation to the tentative tactical plan as formulated, and in returning
this plan to the General Staff with comments, would submit a memorandum enumer-
ating in detail the advantages, drawbacks, and disabilities of this plan frcHn the med-
ical standpoint. These would be given in the order of their impc^tance, and, if pos-
sible, estimates by number and percentage would be made as to the probable losses
from disease which any features of the plan unfovcarable from the medical stand-
point might be expected to cause. This memorandum should also include an out-
line of the measures by which such disease casualty arising under the plan proposed
could be minimized or avoided, and to what probable extent, In commenting upon
the proposed General Staff plan, its medical-officer students should criticize freely
where such seems indicated and set forth all i>ertinent facts in such way that their
nature and importance may be fully realized by the laymen officers whose dedsicm
must be final. Having done this, the responsibility of the medical department
toward the plan temporarily ends.

On receipt of the above medical information the General Staff would now be pre-
pared to continue and complete its plans with definiteness. Being informed as to
the probable total discount from disease which under the proposed or other plans
of procedure would have to be made from the effective strength, and to some extent
even the places and periods for which fractional discounts would very likely have to be
made, it is in a position to readjust its ideas as to the total effective force required.

FUBUO HEALTH AND ICEDICINB. 698

and to add such allowance as might be neceeaary to meet loases from diaeaee, either
by incorporating in the initial force the additional troops needed or by preparing
to forward them as reinforcements at the proper time. It will also be prepared to
decide whether the sanitary advantage to be gained through suggestions by the
medical officers of possible modification of the original plan— as, for example, by
changing a military movement to a more favorable season, or by avoidance of un-
healthful areas or limitation of the stay of troops therein— will not present advantages
from the standpoint of military econcmdcs which will more than compensate for
changes in certain of the tactical arrangements originally contemplated. Having
given all due weight to medical considerations and recommendations, the General
Staff now completes its general tactical plan. The requirements of this plan are
thereon fixed, and impose definite obligations and limitations of function upon the
medical department. This determined plan is now again referred to the medical
officers concerned, with instructions to outline all necessary medical requirements
as to policy, resources, and methods as a coordinate part of the general plan as a whole.
The medical department is now faced by a definite medico-military problon, and it
sets about its solution. In accomplishing this result, much of the study already
done in the tentative plan is of great value. It carries out this work systematically,
thoroughly, and with appropriate detail, but in the present article only the more
important factors can be considered.

It is essential to the purposes of the General Staff that it be informed as to the nature^
place, and probable time of the more important diseases which will.be encountered,
their prevalence, their probable effect upon the efficiency oi the conmiand, and
any means of avoidance of these diseases or mitigation of the severity of their incidence
on troops. It is quite as necessary, in the accomplishment of military purpose, to
know the causes and extent through which fighting ^dency will be reduced by
disease as it is to estimate the nature and extent of probable opposition by the enemy
and the depletion of the fighting force consequent thereon. Of course, neither the
military nor the sanitary factor can be forecasted with mathematical certainty; but
in regard to the effects of disease, at least, shrewd estimates can be made which, sup-
pcMTted by adequate administrative provisions for carrying out the necessary pre-
cautions, should leave but a small margin for error and little in the way of unexpected
emeigency to hamper and interfere with military action.

In procuring information on sanitary conditions as above, and in arriving at con-
clusions thereon, the medical department will consult all available sources of perti«
nent fact. Much sanitary information of an authoritative nature will naturally be
given in the statistical and other published health reports of communitiee and regions
in the proposed area of military activity. The value of these reports of course depends
proportionately upon their completeness and accuracy. They give health data
relating to civil populations in time of peace, and these furnish a starting point on
which to base comparative estimates for both civilians and soldiers undtf the conditions
of war. The higher the sanitary standards reached in the areas under consideratiaQ
the more complete will be the sanitary information furnished by the health reports.
In these health reports the factors relating to the transmissible diseases are of par«
ticular interest, so far as the health of troops themselves is concerned. Upon such
diseases, and especially those of an acute nature with liability to become epid^nic,
the efficiency of an army will largely depend, and all items relating thereto will
receive especially thorough study and consideration.

It is clear that the nature of diseases occurring among civilians and the frequency
with which they may normally be expected to be met are of much importance in
estimates as to sick rates among the troops passing through or occupying the area in
question and who are naturally brought into close contact with the inhabitants thereof.
Military garrisons of the enemy may have been maintained in the areas under con-
sideration, and study of the medical r^xNrts rdating thereto may be able to throw

594 PBOOEEDINQS 8B00KD PAN AMBBIOAN 80IBHIIPI0 00HGBB88.

much light directly upon the nature and amount ci aickneM liable to affect troope
In banmcks and cantonments. Besides such general reports, individual medical
essays or articles bearing on the subject of the healthfulness and sanitary develop-
ment of the region in question will be sought out and studied. Nanatives by travelers
will ottea be utilized. Further, if practicable, a special sanitary reccmnoisBance will
be made by competent medical observers of the area to be operated over, new infor-
mation acquired, and the accuracy of that previously obtained checked up. If the
sending of medical observers over the ground proves for any reason impracticable,
then the observers sent in pursuance of the General Staff plan should have very
definite instructionB as to the nature and scope of the observations they are to make
for the medical service.

If the country in question has previously been the theatw of military opaationSy
the medical history ol these will be carefully studied with a view to determining
the past effect of war conditions and local environment upon the health of the waning
troops and what present value these past occurrences should be given in view of
modem scientific sanitary progress and improved methods of disease control. This
study of medical history is of the greatest importance, for nothing is more cwtain
than that such hiatary will repeat itself unless the contingencies upon which its un-
toward happenings were based are appreciated, forestalled, and avoided, or at least
minimized as fiur as possible with the resources available. If properly intopreted
and applied, the occurrences of the past are one of the best guides for appropriate
sanitary omduct in the future. But in sparsely settled districts, or those in which
civilization and medical sci^ice are less advanced— and this includes a voy large
area of the gbbe— the direct information which is available from sanitary reports
or records is incomplete or even lacking. It needs to be supplemented by further
studies of other conditions from which much valuable sanitary information can be
inferred.

The general question of disease, in both its nature and prevalence, is very closdy
related to climate. To this must be added the factor of customs and modes of life, m
to food, clothing, housing, personal cleanliness, degree of education, religious belief
and other matters. Finally race has to be considered, for one may be especially
susceptible to certain diseases and relatively immune to others.

The microscopic flora and fauna of divers communicable diseases have a climatic
distribution more or less analogous to the distribution of vegetation and animal life
of a larger growth and more complex organization. While some infectLons, like
tuberculosis and plague, either are or may be almost ubiquitous, the restricted di*
matic limitations of such diseases as the moequito-bome fevers and amoebic dysentery
are apparent to all. Climatic conditions, from the sanitary standpoint, relate chiefly
to the factors of temperature, humidity and rainfall. On these the occuxrenoe of
certain zymotic diseases directly depends, snd they determine whether a dieoaao may
continuously exist, can not maintain itself at all, or can occur from time to time in
periodic outbreaks. With than is associated character and porosity of soil and height
ofground water as further contributing factors. A sanitary study of the meteorology,
geology and terrain of the country over which the campaign is planned, based on the
above factors, will therelore be carried out.

Temperature is usually regarded as depending primarily on distance from the
equator. The latitude of the area of combat in question must of course be coosideted
as one of the fixed and unalterable pr^nises of the sanitary problem under cansidera<
tion. Temperature is also dependent upon altitude, and ^us variations of the latter
may result in wide differences of temperature in places only short distances apart.
Altitude therefore may or may not be an essential factor in the sanitary fvoblems ol
campaign— for it may be possible, in working out their solution, to avoid in whole
or part the areas in which the factor of altitude would work to the disadvantage of
troops. Temperature is also depend^it upon season. This latter is not neceasarily

PUBLIC HEALTH AND MEDICINE. 595

always a fixed factor in military plan. It may be that military purpoeee will not
imperatively require a campaign to be conducted at a time of the year when seasonal
conditions would impose undue hardships, unhealthful environment and unnecessary
losses on troops. On the other hand, such a period may be exactly the time that mili-
tary necessity may demand that active Operations be instituted. Both contingenciee
should be provided for in arriving at the medical plans.

Humidity and rainfall may depend upon local conditions, as proximity of laige
bodies of water, or the influence of mountains. The firBt factor is constant and una-
voidable; in r^ard to the second, in the mountains the distance of even a few milee
may mean an entire change in the precipitation, climate, environment, and health-
fulness. Winds of course are a potent factor in precipitation. Their general direction
usually depends on season. It may be possible to choose for the military movement
a season when the sanitary and other difficulties dependent on rainfall may be
reduced to the minimum. Such change might materially contribute to military
efficiency and success.

The geological nature of the soil and its porosity, and the formation of the terrain
as a whole, will be given careful consideration. Upon this feature depend surface
and subsoil drainage, dryness and decreased liability to congestions of the respiratory
and alimentary tracts due to chilling. Upon it depends also the existence or not cKf
fever breeding maishes, swamps and potholes. Certain soils favor the development,
more than do otherp, of various animal and vegetable pathogenes outside the body.
Frequently in these matters, and especially in respect to terrain, a choice is avail*
able which presents many advantages in respect to diminution of wastage from disease.
It may be possible to move troops through fever areas by day, or to locate camping
places away from unhealthful surroundings. To work out and recommend appropriate
action under all probable conditions is one of the proper features of the medical study.

The habits of the people, and their modes of life, will be carefully studied. In
these will be found factors having a strong influence not only on the health of the
civil population but on the military forces necessarily quart^^ among them . Stand-
ards of morals and temperance have a close relation to the social diseases and alco-
holism. Poor cleanliness of person favors such diseases as typhus, or the dermatoses.
Lack of community organization means absence of concerted effort at disease control,
and the existence of such infections as smallpox and typhoid fever. Poverty, igno-
rance, aud superstition exact their toll through incomplete means of prevention of
disease resulting in an unduly high death rate. All these, and other factors, will be
fully weighed in the medical study in respect to their probable deteriorating effect
upon the troops.

It is thus quite possible to work out a sanitary study of the original tactical cam-
paign, showing the weaknesses and advantages of the latter from the medical stand-
point, and forecasting with much certainty when, where, how, by what diseases, and
to what extent sickness would be a disturbing factor. It would also show how various
of these sanitary difficulties could be overcome, avoided, or minimized. It would
often be practicable and desirable to work out a sanitary map for campaign areas,
especially for those in which there is considerable climatic variation, so as to show at
a glance the areas in which the diseases more important from the standpoint of mili-
tary efficiency might be prevalent.

It may be mentioned here that after the final tactical plan of campaign is decided
upon, a brochure embodying in simple terms all necessary sanitary information on
how to keep well under the controlling conditions should be prepared for printiog,
so that on mobilization copies could be freely distributed throughout the troops
concerned. Drafts of appropriate sanitary orders should also be prepared in advance,
so as to be furnished immediately to higher commanders on their assumption of
command, as a basis or guide for the sanitary orders which they would issue.
68436— 17— VOL ix 39

596 PBOOEEDINGS SECOND PAK AMEBIOAK SCIEKTIFIO CONQRESS.

Besides the niunber of sick to be expected, campaign plans naturally include the
battlefield casualties to be provided for. With respect to the number of wounded
which may be expected, that can only be forecasted in general terms. But within
certain limits a rough intelligent guess can be made. The General Staff should be
able to foretell the places at which, for strategic or tactical reasons, the enemy may
be expected to make a stand, the probable strength and composition of his forces,
the efficiency of his resistance, depending on his niunbers, equipment and morale,
the strength which we propose to bring against him, and — shaving the advantage
of the initiative — even the approximate time of conflict. From this data may be
deduced, in general terms, the probable casualties on our own side to be cared for,
with their various timee and places, and even a rough guess as to those of the enemy
which may fall into our hands. Analyzing these general figures in the light of the
study of casualty statistics of past battles and campaigns, we now come into position
to classify the wounded as to severity of injury, and thereby to estimate not only
the nature and amount of transport and hospital facilities necessary to their care,
but even the periods from and through which these would be required and the gen-
eral locations available at which they would be most useful. The latter can be deter-
mined from the plan of the General Staff up to the time of contact, as it would show
the length and nature of the line of communications, the location and character oi
the base, the relations with the home country, and other essential factors.

By adding to these figures of battle casualty the amount and classification as to
severity of unavoidable disability from sickness, as already forecasted, and taking
into consideration the extent to which the medical service will find it necessary to
participate in the medical relief of civilians, a final estimate will be arrived at as to
the nature and amount of the transportation required and the kind, place, and
extent of the hospital facilities necessary.

A study will then be made of the local resources in these respects in the area included
in the General Staff plan, so as to determine what items can probably be obtained
from civilian sources in the vicinity, what may be brought from some other part ol
the occupied area, and what must be provided for in the equipment of the military
tcftce itself. The amount and nature of rail, automobile, and wagon transport which
will be required, and also that probably locally available, will be worked out. Full
information as to all existing hospitals should be set down, the locatbn, capacity
and description of all buildings suited to use as hospitals should be noted, and the
deficiencies for their care of any places where sick and wounded would probably
largely resort should be specified. Field Service Regulations show the nature,
organization, and capacity of the various official mobile sanitary establishments and
further specify the number of each to accompany fighting troops. But it says noth-
ing of the number of these required along the line of conununications, at the base
and in the home country. This«matter must be worked out for the present problem,
based on probable sick rates, estimated casualties, plan of campaign, length and
nature of conununications, etc., so that it may be known in advance about what
and where hospital facilities should be provided. Based upon all this information
appropriate measures to remove the recognized faults and deficiencies will now be
worked out and put into concrete shape ready for application, so that when the
proper time comes directions may be ready as to wlutt to do and when and how
to do it.

The matter of medical equipment and supply also needs careful study. The
official medical supply tables eniunerate practically all the articles ordinarily re-
quired. The amounts, however, as set forth therein, are not necessarily appropriate
to the particular conditions and purpose under consideration. They must be care-
fully studied from the standpoints of the probable niunber of sick and injured to
be treated, the nature of their diseases, the probable places for and duration of treat-
ments, the hospital formations concerned, periods of and facilities for resupply, and
other factofB.

PUBUO HEALTH AND MEDICINE. 597

Study will need to be made as to the probable nature, amount, and location of
drugs, medicines, dressings, and supplies useful in the care of the sick and wounded
which are ordinarily maintained in stock in the civilian drug stores, supply houses,
hospitals, dispensaries, etc., of the expected zone of action, which might be available
after occupation; and the extent to which these would have to be discounted as a result
of the hostilities preceding or the needs of the civil community.

Finally the study must show not only the varieties and amounts of supplies which
will be needed after all deductions have been made, but when and where and the best
methods of supply and distribution.

The nature and amount of sanitary personnel necessary need very careful study. It
is based of course upon the probable amount of medical, siurgical, and sanitary work
which will have to be done, as indicated in the subjects of inquiry already out-
lined. This personnel with troops is already oiganized into standard groups, some of
which, as regimental detachments, ambulance companies and field hospitals, are
intended to operate in the zone of active hostilities and bear a definite and fixed
numerical ratio to the niunber of combatant organizations whose needs they serve.
X)ther standard sanitary groups, as the personnel of evacuation hospitals, base hospitals,
ambulance columns, hospital trains, and boats, etc., are intended to serve in the
zone of communications. Their number is not fixed, but is left to be determined
according to the needs of the situation. This determination can be made only after
careful study of the general military plan as a whole, and of its component sanitary
elements, as already brought out. Such study in advance transforms the necessary
sanitary personnel from an uncertain quantity to a fixed factor. It will go a long way
toward insuring that in time of need sufficient trained personnel will be at the proper
place.

Besides the sanitary personnel to be officially provided to meet the needs of troops^
a study should be made of the area to be occupied with reference to the local personnel
available for medical purposes. The operations of civil hospitals and other charitable
institutions will have to be continued and may very likely need to be expanded.
Wounded prisoners of war may very properly be cared for by physicians and nurses of
their own nationality. In the disruption of the civil administrative machinery which
accompanies war, sanitary difficulties among the civil population may become very
great. All this means an inquiry into the number of civilian physicians, pharmacists,
and nurses normally in the area in question, and the number which might be expected
to remain after military occupancy. The location and strength of local branches of
the Red Gross Society or other humanitarian organizations, of religious orders who
would assist with the sick, or of civic societies who could give assistance along certain
lines, are all proper subjects of study, and their capacities for usefulness should be
estimated and recorded.

The necessary health work among the civilians remaining in occupied territory is
conducted by the medical department through sanitary personnel drawn from the
military force, by continuing the organization and personnel of any previously exist-
ing civil health service, or by a combination of the two. General plans for this work,
including health organization, personnel, supply and administration will be prepared
in advance, subject to such later modifications as emergency may require. As troops
occupy a district, the sanitary organization previously drifted on paper is promptly
created in fact and put into operation. Through such preparedness no valuable time
is lost, disease has no opportunity to become epidemic, and friction and lost motion are
reduced to the minimum.

For the sanitary govoimient of the civilians in the area to be occupied and under
military control appropriate sanitary orders will be drafted in advance to meet the
needs of the situation. These will doubtless confirm and apply the provisions of any
previously existing civil law where such seems suitable and adequate, and to this end
all existing local sanitary laws will be gone over and carefully studied. They will
then be supplemented by such other general requirements as military and sanitary

598 PROOEEDINOS SECOND PAN AMEBICAN SCIENTIFIG CONGBESft.

necessity may demand. These orders when issued have the great advantage over
ordinary civil sanitary requirements in that they are based on the latest sanitary
knowledge and are unaffected by local considerations or those of business or political
expediency. Within the limits of the military situation anticipated they will prob-
ably be more scientifically correct than the sanitary laws of any civilian conmiunity
outside the war area. When issued by the provost marshal general they have the
force of law and will be thoroughly enforced in both letter and spirit by an inflexible
military government.

All the forgoing information bearing upon the medical service, and the plans
which have been based thereon, will now be gone over. All useful items relating to
each community or district will be brought together under its individual heading and
entered as a general medical memorandum governing information and action in such
community. Each such memorandum is put on file available for use when necessity
demands. A copy will be furnished in advance to the headquarters of the force pro-
posing to operate in the zone which includes such community; and similar memoranda
for each other community in such zone will also be forwarded. Information not only
as to the local conditions which will probably be encountered in each place enta*ed,
but also as to the best way to modify, avoid or utilize them in the interests of the
invading force, will thus be at the disposal of the medical authorities of the expedition
before or at the time it occupies a community or district. No time need thus be lost
in investigation of local conditions relating to health of troops and administration of
the medical service and initiating appropriate action in each case; there is no un-
certainty, no lost motion, and no avoidable sickness or unnecessary suffering. Only
the minor contingencies and battle dispositions which can not be foreseen remain to
be met, and these need in no wise affect the main plan and purpose. The chief
surgeon need spend no energy in study and plan — that has been done for him at the
proper time and under the best conditions before the war. He is •thus practically
free in time of stress to carry out the primary functions of his position as an executive
officer in getting results.

All the foregoing information, formulated as a coordinate factor in the general plan
of campaign, is now sent to the General Staff. The latter checks up its provisions
with much care, to make sure that they do not impede but assist in the execution of
the general plan. After any minor difficulties or points of friction are removed the
plan is officially approved and thereby becomes the controlling factor in the conduct
of medical department affairs under the conditions specified. However, the plan
will not be regarded as fixed and unalterable, but, on the contrary, as conditions change
suitable modifications in detail of the plan as a whole or in its medical features will
be made. It will at all times represent a temporarily perfected coordinating structure.
Under it order, abundance, and efficiency replace friction, improvisation, and want.
A medical department smooth in every working presents itself in place of scenes of
unnecessary sickness, suffering, and horror. A plan which welds all the previous
inchoate resoiux:es of the medical services into a great medico-military machine has
been evolved. When the moment for its application comes the medical service will
be found efficient and complete so far as human foresight and industry can accomplish
subject to the requirements of the military situation and within such limitations of
personnel and material as may have been imposed by Congress.

The Chairman. (Gentlemen, you have heard the paper of Col.
Munson. It will be of great mterest to all medical military officers.
Are there any remarks or discussion on this paper ?

Col. HoFF. The subject is vitally important in its application
to the efficiency of the military body and demands a very careful
study. To those of the Army and Navy Medical Corps what Col.
Munson has said appeals with the greatest force and is accepted as

PUBUO HEALTH AKD MEDIOIKE. 599

authoritative, but unfortunately the very large proportion of the
people of our country, to whom in the last analysis we must look for
decision as to what shall be the procedure of the Medical Corps, are
practically wholly ignorant of the duty of the medical officer. Not
long since I heard it said, when the question of the reorganization of
the Army under tliis great generic term * ^preparedness'* came up,
'*We need not trouble ourselves about that; the country is full of
medical men; we need but get them and then we will have a medical
department.'' I need hardly say that if the individual who made that
remark had heard Col. Munson's paper to-day, if he could have
appreciated in any sense what Col. Munson has so well said, he would
have realized the utter impossibility of improvising a Medical Corps
for the Army or the Navy any more than we can improvise an efficient
fightmg force. The medical officer is a very special individual.
He must know a great many things that the physician, no matter
how skillful he may be, can not know until he has had the opportunity
of learning them.

The point that I wish to emphasize is that we must appeal to the
public in such meetings as this and in every other of like kind, that
we may be able to bring to the attention of our people the fact that,
if we are going to avoid all the trials and tribulations of suffering,
sickness, and death that have attended each and every one of our
campaigns in the past, we must have a Medical Corps organized
adequate to the situation before the situation presents itself, and we
must have aU our plans and provisions in personnel and material
clearly defined and provided. Then the responsibility rests with us;
but if the people do not give us the personnel and the material, then
the armies will suffer, and the responsibility must rest upon the people.

The Chairman. If there are no more remarks, we will proceed to
the reading of the next paper. I take pleasure in introducing
Medical Director J. D. Gatewood, of the Navy. Dr. Gatewood is
well known as perhaps the greatest expert in naval sanitation in the
world and by us is considered as the dean of our Medical Corps. I
will ask him to present his paper on '^Artificial illumination.''

A CONTRIBUTION TO THE STUDY OP ARTlFiaAL ILLUMINATION.

By JAMES D. GATEWOOD,
Medical Director, United States Navy.

There is no more sublime passage in literature than that found in the Biblical account
of Creation: "And God said, Let there be light; and there was light.''

In that statement of the birth of light one finds material for the construction of a
picture of wonder as a radiant flood of energy sweeps away the barriers of absolute
darkness, of continuous night, and brings into existence the very first day of a world
in chaos.

600 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

And in that record of the birth of light as on the very first day man finds something
closely in accord with such dim appreciation as he may have of the eternal fitness of
things. To him who is so helpless, whether in the darkness of ignorance or in thjtt
darkness which is the absence of light as a physical agent, there is appeal in the thought
that even in the work of creating a world the first requirement was light. He knows
the primary requirement in all his own work to be that same essential. From his own
banning he has been stumbling in the darkness of ignorance, struggling to make
some agreement between ideals and realities, and in that struggle he has gathered,
often in a haphazard way, a little luminous material with which he has now begun to
build a shining temple of science; and in his daily mechanical work he has awaited
the dawn, the coming of the light, for permission to till the soil and to gather the
fruits of his labor. Through the time of his existence he has been in darkness as a
child afraid to take a step, and night, without his own contrivances, would neces-
sarily be a period of resting helplessness. It would seem as though nature had imposed
upon man the obligation of general inactivity during half the hours of his life — the
primitive obligation to lay himself down as the curtain of night descended and to
await the dawn, the coming of that light which in the beginning was divided from the
darkness and called day.

But man in his restless ability to alter his surroundings has never been satisfied
with the restrictions imposed by such a division. Light gives liberty of action, pre-
cision of movement, and increased social opportunity; and the ability to provide light
leads to a greater sense of security and a higher appreciation by man of his own int^li*
gence and his own power to contend against natxuid limitations. He is the reasoning
animal and much of his reasoning is devoted to the furtherance of his own inclina-
tions. He struggles for freedom but always finds he has to live under natural laws.
He fights for liberty and he pays for everything he gains. Yet, in it all he lives by
his visions, by the things that he sees.

In his struggle his career has been marked by the burning candle, burning at one
or at both ^nds, and by the biuming midnight oil. While to-day, having observed
the shattering of darkness by the lightning's stroke, he has harnessed the lightning
itself, and has driven it with all its splendor into his home, his school, his counting-
house, and his laboratory.

Man reaches into the darkness with shining fingers constructed by himself and
finds the distant ship making its way over the dark waters, or with shortened and
slender fingers of light he touches the printed page and reflects into the mind of the
scholar the thoughts of the world.

Yes, man has become the intellectual animal and has even learned to love mental
activity for its own sake. He makes theories to account for the phenomena around him
and becomes so intense in his affection for those same theories, or beliefo, that they
are his intellectual children for whose welfare he would suffer martyrdom itself.

And man has learned so to admire what he calls knowledge that he insists upon its
general diffusion. He invented written language and he invented the art of printing
and has so improved its methods that the leaves of books threaten to become as common
as the leaves of the trees of which so many are sacrificed each year to make those very
pages that, under a compulsory system of education, the young are required in day
and night schools to laboriously scan for hours at a time — ^pagee often printed in small
type and viewed with straining eyes under poor illumination and through concave
or compound glasses, for newspapers and books have caused an enormous increase
in the number of oculists and have caused the saddle to be placed upon many a nose.
While man seeks freedom he places his own eyes in harness and at the same time
often gives rein to minds made wild by the whip of that little knowledge which is a
dangerous thing. Indeed, it sometimes seems that whenever masses of mankind ace
lifted, or lift themselves, above the primitive plane there is damage which is generally
excessive along some line.

PX7BU0 HEALTH AND UEDdOIKR. 601

Certainly the very inteiifle and general effort of mankind to live in the light of Buch
knowledge as comee from the prolonged drilling of each generation in the near w(»rk
required for the study of many thousands of printed pages has involved a damage to
eyes that is very much in evidence . Some of this damage is undoubtedly inseparable
from the near work itself, especially when it is forced on children under 7 years of age.
But, on the other hand, not a little of it accrues from the use of small type and from
faulty methods of study, including improper illumination of schools and homes, both
natural illumination and artificial illumination. Certainly there is a lamentable
lack of legislation on the part of the State in regard to proper paper and type in the
making and printing of the books its citizens are required to read. Then, too, many a
youth spends delightful hours trying his eyes with the very small type generally
found associated with the cheap paper of the dime novel or even of many low-priced
editions of standard or classic works. And this reading is often done in the home at
night with the aid of a flickering light or an improperly placed light that may even be
of such little j^wesr that the small type has to be brought closer than should be neces-
sary for recognition — ^an approximation that facilitates in increased degree that defa-
mation of the eyes which is the condition of myopia.

The most interesting part of this entire situation is the fact that few seem to give
attention to the abuse of the most valuable special sense man possesses. Fathers and
mothers, who are the guardians of the home, and even the administration of a number
of places of learning, often, or generally, seem quite unaware of their responsibilities
in this connection. They seem to be unaware of the tremendous strain to which eyes
are subjected by the requirements of our boasted civilization. They do know the
humiliation illiteracy entails, and, theref(»re, the more studious their children are
under any condition, the greater is the parental pride.

Is it not strange that, while one hears of niunerous societies and associations formed
for the purpose of disseminating information of such subjects as fresh air, exerdse,
diet, pure food, pure water, the white plague, the red plague, and a host of others,
one fails to find public interest so expressed in illumination, in those measures so
clearly necessary in the homes and schoolrooms of the people for the preservation of
the sight of a nation? Th^e is ^ degree of examination and consideration in some
public schools, and, of course, there is the important medical effort in prophylaxis in
relation to that blinding ophthalmia of the new bom, but those minds that are working
in the direction of meeting the physiological requirements of the eyes of the people
in relation to near work find a lack of interest on the part of the people themselves —
the need of a certain degree of education it has been difiicult to secure. However^
there are signs of an awakening, and one might now predict that the time is coming
when at least the sleeping porch will not be more common than properly lighted
rooms devoted to near wOTk. One might even predict that the time will come when
the illuminating engineer with the illumination photometer will be as freely avail*
able for the homes of the people, and will be reg^urded as quite as necessary f<»r the
prevention of damage, as the health officer is to-day.

The idea the average individual has of the eye is quite interesting. At various
times he has had some foreign body in the eye or under the lid, and the result has
led him to the conclusion that the eye is a very delicate organ. The thought gen-
erally stops there, confined in its relation to foreign bodies or injuries. If he thinks
of the eye in any other way, it is usually as some kind of a wonderful optical instru-
ment that in his own case is constructed to meet all possible requirements except
looking at the sun or seeing in the dark. It is, he thinks, such an obedient, wiUing,
and capable servant that ''seeing is believing, " and yet, at the same time, it is such
a delicate organ that it gives immediate warning of any injury it sustains or is sus-
taining. And ordinarily such ideas seem to control the individual until some deterio-
ration in function is observed by himself or his guardian. It seems that the millions
of glasses straddling the millions of young noses are regarded as an expression of either

602 PROCEEDINGS 8E00KD PAN AMEBIOAK 8CIENTIFI0 00NGBES6.

80 much unavoidable misfortune or as merely an indication of price paid for knowledge
acquired. And unfortunately to a certain extent that is true, but only to a certain
extent.

It is not necessary, or even advisable, so far as the purposes of this article are con-
cerned, to indulge in any attempt to describe the ey0 and its connections. It does
seem proper to recall certain things in relation to the eye that have important relation
to artificial illumination and near work. In such connection is the fact that the
human being is bom hypermetropic, or with the eyeball so short that parallel rays
come to a focus not on but behind the retina. It is only as the eyes develop and ma
they are used that they generally come to their own, and perhaps the majority do not
acquire full elongation until 14 or 15 years of age. But some eyes eventually go
beyond, or develop myopia, the antero-posterior diameter becoming too great, as they
are converged on too much near work and pressed by the very muscles that give
them movement. It is noticeable, however, that the effects of such pressure are
only apparent on some eyes, that they appear in youth, or at a time when consid-
erable demands are made upon the eye in the way of near work, and that in such
acquired myopia there is often a degree of predisposition depending upon anatomical
peculiarities apt to be inherited, as the children of nearsighted parents show a greater
tendency to become myopic. Thus, at the United States Naval Academy it appears
that the eye troubles associated with eye strain are in general the cases of hyperme-
tropia, which are those eyes that have never developed and which, requiring muscular
effort of accommodation even for distant objects, appear most frequently at sick calls
complaining of the pain incident to the additional accommodation required for near
work; and the cases of myopia which get along often without coming to sick cidlsy
but which are disclosed at the examinations to which the personnel is regularly
subjected.

In considering these cases in relation to illumination it is quite evident that hyper-
opia, such as is found at the Naval Academy, is not produced by near work, but is
traceable tolurrested development of the eye. However, good illumination is required
by such cases because, for instance, if the illumination is insufficient the work has to
be brought nearer to the eye, and the accommodative strain, already greatly taxed,
becomes to that extent so much the greater. But in myopia there is a direct causative
relation between the condition and the near wcurk itself. Gases of myopia would
appear in nimiber even if the student's life were passed under no other light than
that of day. Yet it is certain that nearer work, such as is reqtdred by insufficient
illumination, accentuates results in those predisposed to myopia and in a certain
number of cases produces it in those who would otherwise have remained free. Never-
theless, the myope finds in the near work itself the chief exciting cause which is oper-
ating in cases of progressive myopia upon eyeballs predisposed to elongation. There-
fore, it seems quite clear that, so long as hyperopia is congenital and the myopic
eyeball is very generally produced by the intense near work itself, no system of
artificial illumination can keep a school free from such defects. If the hyperope is
not to be found at a naval school, he will have to be excluded at the physical exam-
ination for admission; and for the myope to be much more rarely found there not only
is proper illumination required, but also a very careful exclusion by examination for
admission of all eyes that do not very readily see true Snellen type at the prescribed
distance of 20 feet. Certainly a school for naval work is entitled to start its students
free from any discoverable defects in either eyes or ears.

Yet, in any school, or anywhere, proper illumination decreases the strain of the
hyperope, diminishes the progression of myopia, lessens ciliary spasms, and makes
near work easier for all eyes by limiting or abolishing iris and retinal shocks, and»
when a reasonable amount of area is illuminated, by permitting changes of poaitioa
while studying, thtis relieving the body as well as the eyes from fatigue. In general,
it is essential for school efficiency.

PUBLIC HEALTH AKD MEDICINE. 603

It ifl very important to recognize that there is a fixed relation in normal eyes
between degree of convergence and degree of acconmiodation, and t'at relation is
disturbed both in hyperopia and myopia. In both there are tendeuciee to unbal-
anced action between the ocular muscles and the muscle of accommodation. Thus
spasms of the ciliary muscle develop as a consequence of continuous near work.
However, though much more common in the hyperope and myope, they may even
appear in eyes having no refractive error. All these cases are in the class that is so
often greatly improved by atropine and rest, and in relation to the exciting cause
of such spasms the increased strain incident to insufficient illumination is apparent,
inasmuch as it necessitates closer approximation of work to eyes, and consequently
greater convergence and more acconmiodation.

In artificial illumination there are also important considerations that depend upon
the behavior of the pupil under different degrees and varieties of illumination. In
this connection it is not sufficient to realize that the pupil contracts in the light and
dilates in the dark. For instance, it is stated that if, beginning in a dark room, a
light is placed to one side of the eyes and the person looks straight ahead into dark-
ness the pupil remains dilated, or even dilates, but if the person, while appreciating
the light, looks in its direction but maintains the focus for distant vision the pupil
contracts. The conclusion is that light stimulating the peripheral parts of the retina
does not cause contraction of the pupil. It is when the light falls on the central
region of the retina that contraction occurs. Yet it is away from the fovea that the
retina has the greatest light sense or power of distinguishing different degrees of
brightness. It is also there that perception of movement is greatest, in spite of the
fact that the fovea is the location of greatest visual acuity.

It is quite evident from these facts that it is from the peripheral parts of the retina
the individual must receive many very necessary warnings. And, perhaps, not the
least of these warnings is found in the sensation of glare. In a room vision is bounded
by walls, in the direction of which one often looks, frequently with eyes as for dis-
tant vision. But under any circumstances of vision white walls highly illuminated^
or any walls that seem brilliant in comparison with one's desk or work, are reflecting
too much light that reaches the peripheral parts of the retina. It is enabled to do
that the more readily because, as has been shown, such brightness is not associated
with corresponding degree of contraction of the pupil, and also because in whatever
direction one may look some one wall is acting as a side light. This is true even
when one is engaged in near work.

It is along such lineti that a part of the indictment is found against the use of side
lights in the artificial illumination of any study room, and also against the utilization
of walls, but not ceilings, as reflecting surfaces for even the larger proportion of light
required in near work. Yet there is recognition that good general illumination is an
essential in all good lighting schemes.

Even daylight itself can not be allowed to illuminate A\dthout restriction the white
walls of a room. WTien reading, one tends to get somewhere near a window in order
that the best daylight may be on the page rather than on the walls, and the reader
does not face the window which is acting as the source of the diffused liglit. And
for even a better reason he is unwilling to be under the influence of the glare derived
from white walls. In no sc boolroom, study room, or office building should white
walls be permitted. Then why under artificial illumination should one obtain eye
comfort when the walls themselves are acting as though they were the very source
of light?

On the other hand, it ia just as important to observe that dark surroundings cause
quite as much discomfort as excessively brilliant ones. The contrast in looking up
from well-illuminated work into comparative darkness causes the same variety of
shock the eye receives in going from a light into a dark room, and, having looked
into the dark, the return to the illuminated work is made with dilated pupils, which

604 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

for a period permite the retina to be dazzled by light. It is in this direction of iiib
shocks that indictment is found against a complete direct system of lighting — ^the
system which, with opaque shades, floods the work with light while leaving the sur-
roundings in comparative darkness. A good lighting system must provide well-
illuminated surroundings, sufficient to prevent marked contrasts either in the form
of darkness or brilliancy when comparison is made with the degree of illumination
required on the work itself.

It is interesting to note that the whole question of glare is intimately associated
with the peripheral parts of the retina, because there is found in greatest degree the
visual purple or visual rose. Under the action of light this pigmentary albuminoid
photochemical substance is bleached, and in corresponding degree the light sense is
diminished. In the dark this substance accumulates, and it is then that the eye is
in condition to be painfully dazzled when exposed to relatively bright light. On
the other hand, it is in light that this substance changes until there is adjustment,
the eye becoming accustomed because it has lost some of its appreciation of light.

Recent observations seem to show that, while the visual purple appears to be almost
entirely among the rods, its particles are in reality not fixed, there being movement
or flow toward, between, and then away from the cones of the macula, where it must
rapidly undergo modification or bleaching. Nevertheless, it appears almost entirely
as visual purple in the peripheral parts of the retina, where its presence accounts for
the greater light sense of that area, and consequently for the greater sensation of glare
when the eyes are under the influence of brilliant side walls or direct sources of light
on such walls.

The primary functions of the visual purple declare the meaning of such terms as
''light adapted " and "dark adapted '' when applied to the eye. When a i>er8on re-
mains for a time in a dimly lighted room, or a comparatively dark room, an increased
sensitiveness to light results, due to increase in the visual ptirple. Such an eye is
''dark adapted.*' When, under such circumstances, one comes again into the light,
the eye is very sensitive and there is sensation of glare which decreases as the visual
purple decreases under the bleaching action of the light. Ultimately under H^t
of reasonable brilliancy tolerance is established and then the eye is said to be "light
adapted," so far as the particular brilliancy to which it is then subjected is concerned*
But if the brilliancy exceeds the power of adaptation, the visual purple is bleached
more rapidly than it can be formed and a certain insensitiveness to light results which
causes a variety of dimness of vision, as the surroundings though brilliantly lighted
seem indistinct. Too often this situation has been in evidence when uncovered
electric filaments have been used as side lights. It constitutes not only a veary im»
economical use of light, but also a direct attack upon the integrity of the eyes. But
even within limits of ultimate adaptation it is quite evident that glare will result
whenever a lighting installation requires rapid eye adjiistments such as are demanded
in any complete direct S3rstem of lighting or in any indirect system that causes side
walls to seem brilliant in comparison with the apparent luminosity of the work. Near
work itself causes a degree of contraction of pupil which is lost on looking up from the
work. Therefore, if side walls are even as brilliant as the work itself a greater volume
of light is admitted than when the eyes are on the work. Students find more comfort
when the work is rather better illuminated than the surroundings. Such a situation
tends to avoid objectionable contrasts.

In seeking standards of illumination for near work such as is found in schools and
homes, it is quite evident from the above that a fairly well "light adapted" eye is
desirable. There must be good illumination from that point of view, but well within
the limit of possible discomfort even imder prolonged use. The object is a fairly
stable state of eyes, and that object would be defeated by excessive brightness of
objects liable to come within the field of vision., such for instance, as the light source
itself.

PUBLIC HEALTH AND MEDICINE. 605

Concentration of light shown by the light source is generally spoken of as '* intrinsic
brilliancy," and expressed as candlepower per square inch of surface. The intrinsic
brilliancy of an ordinary candle is only 2.5, which is the same as the average bright-
ness of the sky to which the eye may be considered to be more or less adapted. But
the carbon filament has an intrinsic brilliancy of 400 and the tungsten filament of
1,000. Such high intrinsic brilliancies constitute a veritable danger to eyes unlen
the light source is screened, which is also economical because it is not light on the eyes
that is desirable but light on the surroundings, on all the things that are to be seen.
Thus suitable screens or reflectors are a means of managing the light supply, giving it
the desired direction and at the same time protecting the eyes from the light source
itself. A Holophane globe, although completely surrounding an electric bulb, directs
more of the light downward and at the same time, by substituting a large area for the
small area of the filament, lowers the intrinsic brilliancy even of a tungsten lamp to
about that of the candle or daylight sky, which many regard as the maximum that
should be allowed in any study room.

However, as the absence of side lights is a prerequisite for proper artificial illumina-
tion of a study room, it is evident that fixtures must be on or suspended from the ceil-
ing. Among the objects in so locating sources of light is their removal not only from
the line of vision, but also from the ordinary field of vision, and, of course, if that is
accomplished the requirement for very low intrinsic brilliancy becomes less important.

In placing lamps overhead in any ordinary' study room at home, it is believed that
the minimum and ordinary distance from the floor should be 8 feet 6 inches in whas
might be called the semidirect system. That is the system in which diffusive shadet *
are used but a larger proportion of direct light furnished than in the semi-indirect
system which utilizes a dense opal glass bo^ 1 hung about 3 feet below a white ceiling
upon which much the larger proportion of light is thrown for reflection.

In a large room, such as a public school, there would be more light units and, in the
semidirect system, necessity for greater elevation of fixtures in order to secure a fair
degree of removal from the many lines of vision at varying angles. In that relation
it has been stated that the angle made by the line from lamp to eye with the line from
eye to work on a desk should not be less than 30^.

In a Boston public schoolroom (28 by 28 by 14 feet) th^e are nine light units, each
consisting of a tip-frosted 60-watt tungsten lamp placed in a diffusing prismatic
reflector coated on the outer or inner surface with white enamel to the degree of appear-
ing frosted. This is evidentiy for the piurpoee of increasing the proportion of direct
light. Yet, it U stated that "the diffusing quality of these shades is so great that the
foot-candle illumination on the desk directiy below one of the lamps was appreciably
no greater than the illumination on the desk in any one comer." These lamps are
placed 10 feet 6 inches above the floor, each swung from the ceiling by a chain which
suspends the shade holder, shade, and socket.

The nine fixtures are arranged in rows of three and in such manner that the center
of light distribution is slightly to the left of the middle of room. That is done in
order to throw the dominant shadow to the right of scholar.

The arrangement is shown in the following plan which has been in use since 1907,
when the fixture was selected and the adjustments made by a committee of oculists
and electricians appointed by the Boston school committee.

Another illustration of a rather typical installation is foimd at the United States
Naval Academy, where the usual study room is 16 by 16 feet, with ceiling height of
about 11 feet 6 inches. This room is occupied by two students, who work at a center
table with top 3 feet 6 inches square and 2 feet 6 inches from floor. In this case
the artificial illumination, which some think is deficient in relation to surroundings,
is derived from two 60-watt clear tungsten lamps each inclosed in a clear Holophane
stalactite hanging 6 feet above the table or 8 feet 6 inches above the floor. These
fixtures are 2 feet 8 inches apart and are arranged symmetrically and diagonally with

606 PBOOEEDINGS SEOOND PAN AMEBIOAK SCIEKTIFIO C0KGBE8S.

reference to the table, so that the midpoint of line joining them is over the midpoint
of the table. They are suspended by cords from the ceiling and an asbestos mat is
utilized to close the top of each in order to keep out dirt.

These installations (Naval Academy and Boston public school) are typee of what
may be called the semidirect system of lighting or the system depending partially
on direct and partially on diffused light, but with the former in greater prop<Htioii.
There is, however, a semi-indirect system, or a system in which, while depending par-
tially on direct light and partially on light reflected from the ceiling, the proportion of
direct light is relatively small. From an engineering point of view the efficiency of
this system is low when comparison is confined to expenditure of current in relation

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Fio. III.— Plan of standard schoolroom, chowlng location of lights (Boston public schools).

to illumination of the work or desk. From a mechanical point of view it is also sub-
ject to criticism, because it requires more care not only in regard to cleanliness of
interior reflecting surface of fixture, but also to maintenance of color and deanlinen
of ceiling used as an intense reflecting surface. In other words, after installation more
care is required to prevent a marked drop in efficiency. In extensive installations,
such as at the Naval Academy or in a city's public schools, additional care of fixtures
presents quite a problem, and in not a few public schools lack of care has caused within
a year a drop of 40 per cent in efficiency, even in the case of semidirect installati(»u9.
However, semi-indirect installations are rapidly gaining in public popularity, not only
on account of the softness of the light secured, but also from the aesthetic point of view,

PUBLIO HEALTH AKD-MEDIOINE. 607

and quite a number of medical men, as well as illuminating engineers, believe that
greater eye comfort is secured from well-adjusted installations of this character.
Probably on account of increased expense in current and upkeep, there are very few
extensive installations in this system of lighting for the purpose of school work. Where
installations have been made for that purpose they are more or less recent and seem to
be regarded as in a more or less experimental stage.

The complete indirect system, owing to absence of shadow, difficulty in main-
taining efficiency of reflecting surfaces, and lack of rather more light on work than on
surroundings, has not been generally regarded as suitable for school work. In the
semi-indirect system shadows are not abolished in the strictest sense, but they are
not ordinarily perceptible to the eye, yet in having the fixture within view the result
ceases to impress one as specially unnatural. In fact, so far as limited experience
goes, there Is testimony of the practicability of the beet efficiency in these installations
from the physiological point of view; that is, from the eye-comfort point of view.
However, the subject is left open here, although improvement in the efficiency of
lamps has made the additional current expenditure less objectionable, even if rela-
tively the same as formerly, being about 50 per cent greater than is required in the
semidirect system. Nevertheless, in the large majority of semi-indirect installations
one happens to see, the illumination is insufficient for near work, the additional
expenditure of current required for that purpose not having been provided, i)os8ibly
on account of increased expense. Yet, as very many illuminating engineers con-
sider that up-to-date illumination means semi-indirect illumination, this subject can
be left to a little more time and experience in use for adjustment. Certainly the
reflectors or bowls employed in this system have been rapidly improved, and the
tungsten lamp in its present form is making the high candlepower required seem
nothing unusual.

In the semi-indirect system the minimum number of outlets or light units is four
in the ordinary public schoolroom, and, as the question of shadow is not involved, the
fixtures are so placed that the center of the lighting system is over the midpoint of
the room. The lines joining the fixtures make a rectangle with two sides each one-
half the length of the room and the other sides each one-half the width of the room.

Each of light units is made up of a dense opal glass bowl, or inverted reflector, con-
taining in this case a 200-watt clear tungsten lamp. The material used in these
bowls should permit the paasage of sufficient light to give the bowls, which are sus-
pended 3 feet from the ceiling, the same luminosity as the white ceiling directly
above them.

In artificial illumination secured by eith^ the semidirect or the semi-indirect
system there are important considerations relating to color of surroundings as well aa
to their finish or character of surface in effect on manner of reflecting light.

Color of walls and of furniture has relation not only to percentage of light reflected,
but also to confusion of eyes due to disturbances of focus. Such disturbances are very
different from the question of focus in relation to distance. They depend upon
changes of focus necessitated by the colors themselves. For instance, a red room
seems smaller than if it were colored blue. Artists take advantage of this difference
in focus required by different colors. They utilize red to make certain portions of a
picture appear to stand off from the canvas and they use blues and violets to push
back other portions of the canvas. This situation is considered to depend upon asso-
ciation of judgment of distance with degree of effort to secure a focus, the red end d
the spectrum, containing rays of slower vibration, requiring more effort than the
more quickly vibrating violet and blue rays at the other end of the spectrum. Aside
from any question of effects upon the visual purple, no red or blue should be used in
tinting the walls of any study room. They tend to disturb orientation and are very
trying to the eyes themselves. They represent a variety of marked contrast that
seems to follow departure in color of surroundings from the midsections of the spec-

608 PBOOEEDINGS SECOND PAN AMEBICAN SCIENTIFIC C0NQBS88.

trum. And in artificial illumination yellow seems to please the eye more than green;
but in rooms under natural illumination, with opportunity for sunlight effects, green
may be more desirable. A light buff has been found the most satisfactory of all
colors for study rooms under artificial light. By its reflecting power it lends itself to
the requirement for well-illuminated surroundings and by its color it tends to give
eye comfort. But all walls should be without gloss. It is the matt surface that pre-
vents sheen or the regular reflection that is trying to the eyes, whether it comes from
walls or the glazed paper of books. Such a light-buff wall reflects about 50 per cent of
the light it receives. It is the white ceiling and light-buff walls that give bright
surroundings and abolish violent contrasts in any acceptable system of artificial
illumination.

In the effort to avoid undesirable contrasts it is also very undesirable to have any-
dark woodwork in a study room. The ordinary deal woods are the best fcv tables
and desks. Such wood reflects about 50 per cent of the light it receives, and thus is
in harmony with the walls. The wood should be finished in its natural color and
without gloss.

It is in this relation that the blackboard of the night school is so objectionable.
Black reflects only about I per cent of the light it receives. Such a violent contoist
is, of course, reduced when the boards are a dead black and additional illuminaticm
is provided for them by special lights. The amount of such illumination may be as
much as 60 per cent in excess of that provided for the room as a whole. Roller shades
of the same color as walls should be provided to cover blackboards when they are not
in use.

In a number of schoolrooms window shades are conveniently arranged by having
two rollers at each window. They are placed on a board which is at the level of the
meeting line of sash. The upper shade is controlled by cord and pulley. This
arrangement facilitates the management of sunlight in day schools and of ventilation
or air in day or night schools. In rooms used for both purposes the color is often a
sage green, as is the case in the New York schools. It would be better in a ni^t
school to have the shades about the same color as the walls. In the New York achoola
hollands have been discarded as material for these shades, on account of annoying
reflections. Oiled shade cloth of roughened sur&tce has been found much more
satisfactory.

The amount of light on any surface is generally expressed in foot-candles, a foot-
candle being the illumination derived from one standard candle at the distance of I
foot. One quite generally finds it stated that an illumination of from 2 to 3 foot--
candles is usually enough to read by.

However, there is no hesitancy in stating that in making plans for the piopet illn-
mination of the table in a study or of desks in a schoolroom provision for from 2 to
3 foot-candles will be found insiifi^cient in practice. This is due to several caoses,
among which are the hyperopic condition of young eyes, the drop in power of filament,
and chiefly the accumulation of fine dust on fixtures even under ordinary care. This
drop in efficiency may be considered to average about 20 per cent in the semidirect
system. A much wider variation may be expected in a semi-indirect system. This
situation emphasizes the great advantage to be obtained from reasonable supervision —
from periodical cleaning.

Experience seems to show that in a school room average type eeemB well illuminated
when the foot-candles are not below 2.5, and that, for (ordinary prolonged study, com-
fort is found at from 2.5 to 3.5 foot-candles. Therefore, in view of the 20 per cent drop
in efficiency common in all installations, it is considered advisable for provision to be
made for 3.5 foot-candles at the start. In semidirect lighting about 66 per cent off this
would be calculated from distribution curves to be derived directly and the rest as
incident to the required illumination of surroundings.

PUBUO HEALTH AND MEDICINE. 609

The standard of 3.5 foot-candles from new installations accords with experience at
the United States Naval Academy and fairly well with results at the New York and
Boston public schools. At the Naval Academy an initial illumination of about 2.3
foot-candles was tried and in the Boston schools about 2.5 foot-candles. Such installa-
tions did not provide for drop in efficiency, and acuteness of vision falls rather rapidly
as the illumination goes below 2 foot-candles. At the Naval Academy it became neces-
sary to increase the illumination one-half and it is understood that about the same
change has been more or less in progress in the Boston schools, 60-watt lamps taking
the place of 40-watt lamps. In the New York public schools it seems that 3.2 foot-
candles were obtained when all equipment was new and clean. In study rooms at the
Naval Academy the illumination of the walls at the level of study table is only about
1.5 foot-candles, and the reading area is a circle 8 feet in diameter.

Methods employed in the calculation of foot-candles to be expected from any given
illumination are very interesting and very valuable. They can be found in any work
on illuminating engineering or in the data on illtimination put out by the engineering
departments of electric companies. It is sufficient to state that each shade or reflector
has with its lamp a certain distribution curve by the use of which it can be located
with reference to desk or table to give the required number of direct foot-candles,
and that studies of photometric curves can be made to give a very good idea of the
prop^ selection for the illumination desired. However, in investigationB with view
to extensive installations, such as for public schools of a city, wires are stretched hori-
zontally at different levels from wall to wall and different fixtures are tried at varying
levels until desired results, as shown by photometer, are obtained.

Of course, there are very many varieties of shades or reflectors on the market,
designed for different requirements. Howev^, in meeting the requirements of a
study room it is the all-inclosing shade or the deep bowl of prismatic glass that ib
most eatiafactory in semidirect lighting. The bowl should have its interior surface
without polish, as otherwise the work is liable to be illtiminated in streaks of varying
foot-candles, a situation very detrimental to eyes and often produced by the polished
shades of desk lamps. A desk lamp should never be allowed in a study room. It
can be too readily utilized to overilluminate the work and is too frequently employed
at the expense of general illumination, excessive shading being required, as the light
source is close and very liable to be directly in the line of vision. The desk lamp has
been a fruitful source of eye troubles and is at all times at least equivalent to a side
light. It is an expression in a study room of improper overhead lighting.

In this article effort has been made to emphasize the important place in sanitation
occupied by artificial illumination. Food, air, water, and drainage occupy prominent
places in any work on hygiene, and not a little appears in such works on the relation of
sunlight to body metabolism; but one looks in vain in that direction for a compre-
hensive exposition of the sanitary relations of artificial illumination to the preserva-
tion of that wonderful and most valuable special sense known as sight. Proper
illumination is a fundamental sanitary requirement and education in matters of health
should be made to include care of the eyes— the windows through which we see what
the mind, the heart, and the imagination are gifted to see.

The Chairman. Gentlemen^ you have heard the paper of Medical
Director Gatewood. If there are no remarks or discussion, we will
pass to the consideration of the next paper. I have great pleasure
in introducing Dr. D. F. Reeder, of Ancon, Isthmian Canal Zone.
Dr. Reeder, I imderstand, has been in the Canal Zone for about
10 years and is to give us the benefit of his experience and work
there.

610 PROCEEDINGS SEOOIH) PAN AMERICAN SCIBNUPIO CONGRESS.

THE SANITATION OF THE PANAMA CANAL

By D. F. REEDER,
Ancon» Isthmian Canal Z<me,

The sanitation of the Panama Canal haa involved the employment of many things
that would not necessarily be employed in the sanitation of any other place. Unlike
Habana and other cities in the United States, the population of the Panama C^uial has
shifted continually, being composed of recruits from the northern sections of the
United States who were not immune to malaria, as well as laborers recruited from
Jamaica, Barbados, and the other islands of the West Indies.

I must confess that I am not in any sense a sanitarian, but my residence in Panama
for the last 10 years has enabled me to observe the methods of sanitation employed by
Gen. Gorgas in his masterful work in Panama. I have observed this work as an on-
looker and have endeavored to record some of his most notable achievements with the
camera. The essential ones in this collection wlH be presented on the screen this
afternoon. Personally, I have put the best efforts that I had into the specialty which
I have chosen, of the ear, nose, and throat, and how well I have been able to observe
the sanitation of the Panama Canal as an onlooker you wili be able to judge from the
selections presented.

You will understand that in the sanitation of a strip of country 10 miles vdde and 47
miles long, in which the most stupendous undertaking of engineering ever undertaken
by man has been carried out, it has necessitated nonimmunes from malaria going into
the zone, opening up new settlements which had not previously been made sanitary,
together with a constant influx of noninununes both from North America and the West
Indies as well, as stated above. This has made the problem of the sanitation of the
Panama Canal a most difficult one.

Then, again, a force of 50,000 laborers, which is constantly changing, having to be
renewed by more nonimmunes who, going out into the jungle and contracting malaria,
would come back to the towns to reinfect others located in places that were sanitated,
made the problem still more difficult.

The work of Gen. Goigas in Panama was a coordinated work between sanitation,
medicine, and executive work. It was necessary to maintain an efficient medical
corps and an efficient sanitary corps, as well as an efficient executive department, the
three working in coordination continually in order to secure the results obtsdned.

How the mosquito problem was solved and kept below the level at which yellow
fever would develop, even if it were introduced into the country, is told by the pic-
tures which will be presented. In 1913 a test was made of this mosquito level. A
man, bound for Panama on a steamer, falsely reported that he had not landed in a yel-
low fever infested port of Colombia. After landing in Panama, passing the required
quarantine from the original port of departure without developing any fevw, he was
passed through quarantine and was engaged in the cigar factory in Panama City,
where he developed yellow fever and subsequently died. The mosquito index was at
Buch a low point that no case of yellow fever developed from this case, proving Gen.
Gorgas's contention that if the st^omyia mosquito is kept at a certain level, even if
yellow fever is introduced into the country, it will not spread.

Malaria under the present conditions in Panama \^ith efficient sanitary measores
should be entirely eradicated, because now instead of the population being increased
all the time it is diminishing; instead of new inmiigrants coming to the country who are
nonimmune, they are sending away those who have recurrent illnesses and the popu-
lation is decreasing. Furthermore, the outlying districts in the Canal Zone are b^ng
depopulated and the people are being concentrated in the cities of Colon, Panama,
Cristobal, and Ancon, where sanitary measures can be carried out with a certainty that
if efficiently prosecuted, they will bring the malarial rate to practically zeto.

The bad effect of the Tropics on the white man, in my judgment, is not so mudi the
effect of the Tropics per se as it is the effect of malaria, uncinariasis, and other tzoittcal

PUBLIC HEALTH AND MEDICINE. 611

diseases which are the real hanaful agents that cause the enervation of man in tropical
countries.

In order to properly appreciate the difficulties of sanitation in Panama, I shall
present several slides showing the Panama Canal, the locks, and other features incident
to the construction of the Panama Canal. You will understand that the largest arti-
ficial fresh-water lake in the world is located in the Canal Zone, which will constantly
breed mosquitoes and will be a continual menace to the complete destruction of the
mosquito.

Dr. KoBEB. If it is in order at this time to present a resolution,
I would take the Uberty to do so, as I have another meeting at 4
o'clock. Before introducing the resolution, I would like to state
that I am a member of the medical brotherhood who are opposed
to war and who naturally consider it as criminal to settle our inter-
national disputes by wholesale slaughter, quite as criminal as it is
for individuals to settle their differences by force individually. We
beUeve in the absolutely life-saving profession, the only profession
that we know to be strictly engaged in such service, outside of the
coast life-saving service, and we beheve it to be the duty of the Gov-
ernment to give encouragement in the highest possible degree to the
Medical Corps for its various services, so that their efficiency and
life-saving work may not be impaired either in time of peace or in
time of war. I therefore submit a resolution to this effect relative
to the Medical Corps.

Dr. Agkamonte. I second that motion, Mr. President.

The Chairman. Are there any remarks before the adoption of this
resolution?

Col. HoFF. It seems to me that this resolution has direct appli-
cation to every one of the nations interested in this Pan American
Congress. It is not presented as a war proposition, but as a himian-
itarian proposition. War is cruel, and it is the duty of the medical
departments of armies to so far as possible mitigate that cruelty.
It is, therefore, the duty of all hiunanitarians, and I take it we are all
humanitarians, to so promote the efficiency of the medical depart-
ments of the various public services in all our countries that at least
some of the horrors of war may be mitigated.

Dr. KoBER. I move the reference of the resolution to the committee
on resolutions of the section.

Seconded and approved.

The Chairman. We have listened to the very interesting paper
of Dr. Reeder, showing the conditions at the Panama Canal and the
sanitary features of the work of Dr. Gorgaa. If there are no remarks,
we come next to the presentation of two papers by foreign delegates,
to which I know we have been looking forward with much interest
and shall be very glad to hear them. If Dr. Varela is here, we shall
be very glad to have him present his paper.
68486— 17— VOL ix ^

612 PBOOEEDIKGS SEOOND PAN AMEBICAK 80IBKTIFIG COHOBE88.

EL PABELLON MODELO DE CLlNIOA MfiDIOA DEL HOSPITAL RAWSON.

For TOMAS S. VARELA.
Profuor de la Univenidad Nacional de Buenoi AvreM^ Argentina.^

Como repreeentante de la Facultad de Giendas M^dicas de Buenoe Aires ante esle
Ck>ngTe8o, he meditado la forma en que podrfa dirigir la palabra a mis col^ias venidos de
todas partes de AmMca, y he decidido presentarles conjuntamente con mi saludo
m&s cordial, ima serie de proyecciones luminosas del ''Pabellon Modelo de Clinica
M6dica del Hospital Rawson " (Director: Profesor Luis Agote) por ser un sitio espedal-
mente destinado a la ensefianza.

Deploro no poder mostrar a mi auditorio la Facultad de Medidna fntegramente coo
sus secciones, laboratorios, hospitales, etc., asl como referirme a los planes de estodio
y a los progresos de la ensefianza mMica en mi pais, porque debo ajustanae estncta-
mente a los pocos minutos de que disponemos los oradores por el reglamento de esta
asamblea, y apenas me alcanzan ellos para ima ligera converaaci6n.

La Clinica MMica, sefiores, uno de los ramos que figura en todos los progiamas de
medicina, es ensefiada en Buenos Aires por varies profesores simult&neamente y en
distintos hospitales dado el gran ntimero de alumnos y la importanda que ahi se le
da a cada materia de la ciencia m6dica.

Voy a referirme en este momento 86I0 a las comodidades de que dispone uno de los
profesores, el Dr. Luis Agote, director, al mismo tiempo, del Instituto Modelo, anezo
a la Facultad de Medicina.^

Debo declarar a mis col^;a8 que no he elegido para mi conferencia de hoy lo dnico
bueno de la medicina argentina; pues podrfa igualmente hablar de los demis ramos
y verfais las comodidades de que disfrutan los profesores de anatomfa, bacteridog^
histologfa y todo lo dem&s que ponen en evidenda el esfuerzo constante del cuerpa
directivo de la facultad a que pertenezco y del concuiso decidido y eficaz de pro-
fesores y alumnos pudiendo asegurar en este instante a mi auditorio, que cualquier
materia de la medicina que hubiera escogido para mi conferencia serfa igualmente
interesante y demostrarfa que en mi pals la medicina, los m^icos y los hoepi tales,
siguen de cerca la evoluci6n progresista del mundo entero. Y si me refiriese ahotm
por ejemplo a otra materia del programa como es la psiquiatria, de la que es profeaor
el Dr. Domingo Cabred, tendrla, si quisiera narrarles de la manera como enseoa 7
los elementos de que dispone, para una larguisima conferencia, para moetrarlee los
hospitales que dirige, los salones inmensos donde da sus dases, los aparatos cine-
matogrdficos y todo lo que dispone para ensefiar el ramo del que es profesor.

En Buenos Aires, sefiores, la Facultad de Medicina toma un gran inters para me-
jorar dia a dia sus laboratorios y hospitales a fin de presentar a la poblaci6n univ^^-
taria los tilttmos adelantos, y cuenta siempre con el concurso personal y active de
todos los profesores que ayudan con eficacia a la obra de conjunto y asl, en la realisa-
ci6n del Pabell6n Modelo, que tengo el gusto de presentar, la participaci6n del pro-
fesor Dr. Agote hasta en los menores detalles es muy digna de aplausos, dd mismo
modo que los hospitales y asilos para alienados y las nuevas y modemlsinias instala-
ciones de ensefianza del Hospicio de las Mercedes se debe a la intervenci6n constante
del Profesor Dr. Domingo Cabred; y para citar solo otro caso de la armonla con que
trabajan el cuerpo directivo de la facultad y sus profesores podrfa mencionar d Museo
de Obstetricia de la Maternidad del San Roque, cdebre por sus colecciones y formado
durante el profesorado del Dr. Eliseo Cant<5n y con su inmediato concurso.

Este Instituto Modelo del que me vengo ocupando y del que muestro vistas y foto-
graffas hace ver que en ^1 todo ha side previsto, y que la cooperaci6n del anilisis de
laboratorio puede a>nidar al diagn66tico cHnico en cada instante pues todo se tiene
a la mano.'

1 Conferencia dada por el autor con proyecciones luminosas.

s £1 orador moestra en la lintema mnltltnd de vistas del exterior del ediflcio, interlor,8a]a de cliwa, labo-
ratorios, etc., y explica detalladamente todas las comodidades de que disponen los ahunnoB para apnodar
el profesor para ensefiar y los enfermoe para procurar su salud.

• El orador muestra y explica detalladamente varlas secciones del Pabelldn.

PUBLIC HEALTH AND MEDIOINE. 613

Y cada laboratorio esU dirigido por un especialusta competente que ayuda con su
preparaci6n especial a la obra del profesor y por las fotografi^ mostradas es f^il
enterarse del ndmero del personal t^nico.

En este Instituto, hay cllnica de mujeres, hombres y nifios y cada sala posee sus
medicos, practicantes y personas dedicadas a todas las atenciones necc^arias.'

Sin menoscabo de todo lo cientifico y toda la higiene modema, tambi^n se ha tenido
en cuenta el alma de cada enfermo y se ha tratado con razones de arte y buen gusto
qui tar la frialdad que por lo general transpiran las paredes de los hospitales y en esas *
se han cubierto de cuadros murales, figuras en mosaico que representan escenas
infantiles con el prop6sito de hacer viajar el espiritu de cada ni£Lo cerca de su8 padres
y de sus juguetes, mientras la ciencia mantiene sus cuerpecitos enfermos como cosas
es^rilizadas.

Finalmente, presento a todos en mi nombre propio y en el de los medicos argentinos
un saludo franco; una felicitaci6n por todo lo que hagamos de bueno; un deseo que
consagremos lo mejor al que siifre; una esperanza para nosotros, y muchas para los
enfermos.

The following papers will be presented as read by title:
Climate and hygiene of Rio de Janeiro, by Dr. J. de OUveira Botelho.
Buildings for human occupancy, by Robert W. de Forest.
The means by which infectious diseases are transmitted and their
extermination, by Alvah H. Doty.

CLIMATE AND HYGIENE OF RIO DE JANEIRO.

By JOAQUIM DE OLIVEIRA BOTELHO.

A country so vast as Brazil, extending over eight and a half millions square kilo-
meters and with a shore line of about 3,600 kilometers spanning an arc of meridian
of nearly 37°, must possess a great diversity of climates. It is therefore only too
natural that the ardent climate of the tropics and the mild and temperate climate of
certain countries of Southern Europe are found in Brazil, which is almost as large as
that continent.

The capital of the United States of Brazil, Rio de Janeiro, plainly tyi)ifies the
climate of almost the whole Brazilian territory.

The large metropolis which is one of the most remarkable beauties of nature that
I know, possesses a mild climate, the thermic amplitudes of that beautiful capital
being of no consequence. The city of Rio de Janeiro lies between the latitude of
22** 54^ 32^^ south, and 43* 10^ 34'^ west of Greenwich. The highest temperature
reached during a 40-year observation was 37.6° C, the lowest 10.2°; the average 23.5°,
with the amplitude of 27 .3° G . The meteorological observations of the last years show
a certain decrease in high temperatures. The high mountains obstructing the free cir-
culation of the mild breezes from the sea, seem to have been what has softened the
climate of the beautiful capital of Brazil. In January and February, the hottest
months in Rio, the mean temperature is 26.6° C, in June and July, the coolest ones,
the mean temperature is of 20.8° C. The annual rainfall amounts to about 1.123 m.

An interesting phenomenon is easily observed in Rio: The breeze from the sea
constantly blows between the hours of noon and 5, thus rendering agreeable the tem-
peratiu'e which ought to be rather high during that period. The higher the ambient
temperature is, the stronger blows the breeze from the sea, or vira^do, while the
thermometer falls one, two and sometimes more degrees.

1 £1 ondor describe en detalle las dtvenas salas y en especial se reflere a la de los nifios.
* El orador muestra una vista de la sala de los nlAos enfermos.

614 PROCEEDINGS SECOND PAN AMEBIOAN SCIENTIFIC CONGRESS

The breeze from the sea, called in Brazil, '' vira^io* ' of the southeastern quadrant,
frequently blows from 8 in the morning until 6 in the afternoon, being then followed
by the so-called foolish breezes, which are themselves later followed by the Terral
or land breeze, of the northeastern quadrant. The breeze from the sea is favorable
to the vessels that seek the wonderful bay of Guanabara, and the land wind to those
that put out to sea.

Now and then, when the vira^iio is lacking, there is in the dty a sensible rise of
temperature, but soon the releasing ozonizing storm winds blow, generally from the
southwest, Pampeiroe, and occasionally from the southeast. In summertime, there
come often violent northern storms.

The absolute minimum for the humidity, during a 40-year observation, was 77.33
millimeters, and the maximum 79.70 millimeters with a variation of 2.40 millimet^s.

According to the above data, one easily comes to the'conclusion that Rio de Janeiro
is a city whose climate is uniform and mild, and one which agrees with the nature
of the life of Europeans, who really find in it a quite propitious spot for their activity.

The topography of Kio, which lies by the wonderful bay of Guanabara amidst the
highly impressive scenery of the surroimding mountains, obviously must have an
influence upon the climate of that city. On the prominent mountains of the interior
as the Tijuca, Corcovado, Santa Thereza, and the sentinel of the harbor — the ** Sugar
Loaf, " the temperatiu*e is several d^jees lower than on the plain.

The nice and well-cared for surroundings, the chain of mountains which overlook
the city resembling a large Koman amphitheater; the great number of picturesque
islands, covered with palms of different varieties which decorate its bay; the live
Nictheroy capital of the State of Rio de Janeiro, which lies opposite, give Rio its
notable conditions of habitability, thus allowing its population to make their domi-
cile, far from the zones where commerce, industry and the upper administration
have their headquarters. Moreover, the public welfare is greatly enlarged by the
numerous public parks, the easiness of means of transportation, the abundance of
diversions, and the careful solicitude of the department of hygiene whose services
are as good as those of the most advanced countries.

Rio is inclosed within a circle of carefully preserved thick woods which are, so to
speak, the lungs of the dty, and are supplied with plenty of perfectly potable water
and with an extensive drainage.

There are hundreds of dairies as well as abattoirs, bakeries, and markets, regularly-
visited and controlled by the department of hygiene, which also makes house-to-houae
inspections, and exacts the notification of infectious-contagious diseases.

The capital of Brazil is nowadays a healthy and hygienic town where the mortality,
reduced to the very minimimi, never exceeds, during the worst years, the rate of 18
and 19 per thousand inhabitants.

Owing to the complete extinction of yellow fever which formerly swelled the rate
of mortality, and to the disappearance of malaria and other epidemical diseases, the
sanitary demography of Rio is that of a town which offers the most perfect conditions
of habitability. As a matter of fact, the city of Rio de Janeiro has undergone quite
"a notoble transformation, and in a rather short period a series of well-planned and
strictly enforced measmres has caused a great improvement in its sanitary condition.

The streets of the great capital have been enlarged and improved by an asphalt
pavement, the ground under the habitations made impermeable, and the intericH* of
the houses provided with large openings and windows in all of the apartments, in
order to allow free circulation of air and light.

The service of disinfection is now carried on with extreme care and its underlying
aim is the destruction of the larvae of the '^stegomyia, " ^' anopheles, '' and other mos-
quitoes, all the probable focuses of infection being destroyed, being disinfected by
means of the Glyton gas. In the stables, the cows affected with tuberculosis are
subjected to the tuberculin test and isolated if there is any evidence. Furthfflmore,
the anti variolous vaccine became very popular and the sanitary polides are accu-
rately carried on.

PUBUO HEALTH AND MEDICINE. 615

The landmaking of the shores traDsfonned the still waters and the large and long
grounds formerly uncovered by the ebb tide into gorgeous, gardenlike, and radiantly
lighted avenues, running by the modem and solid pier, three and a half thousand
meters long, easily accessible to large steamships.

A remarkable bacteriological institute, deservedly named ''Oswaldo Cruz," pre-
pares the serums for the treatment of several infectious-contagious diseases, and the
different vaccines for the immunization or the detection of pathological conditions.
The institute is also provided with a special department where the pathogeny of cer-
tain infirmities, namely, the tropical ones, are successfully studied . There is a service
charged with the prophilaxis of the infectious-contagious diseases, which depends
upon a special department, and several laboratories under the direction of the most
comi>etent bacteriologists.

The service of sanitary engineering, the police of insulating hospitals, and finally a
Pasteur institute which undertakes the care of the preparation and application of the
antihydrophobic serum, fill up the list of the hygienic measures which protect the
public health in Rio de Janeiro.

The above considerations lead to the conclusion that the inhabitants of beautiful
Rio possess satisfactory securities for their own health, principally in so far as are con-
cerned the hygienic measures with which civilization assists man in matters of his
welfare and the duration of his life.

BUILDINGS FOR HUMAN OCCUPANCY.

By ROBERT W. DE FOREST,

President National Houdng Association.

The purpose of a paper on this general subject which is allotted to me in the Pan
American Congress can, I think, be best served by first pointing out the chief lines
of recent progress in improving the conditions of buildings for human occupancy in
many of our North American cities. It 1b probably along these lines that there is
more of example and inspiration for other cities and even for country districts.

These lines of progress are:

1. The introduction of running water, and consequent facilities for (a) washing and
bathing (making possible the general introduction of the bath) and (6) toilets within
the house (making possible the abolition of the open privy vault).

2. Better light and ventilation, by legislation compelling air spaces and abolishing
dark rooms without windows to the open air.

3. Fire protection.

The result of these and other like changes is reflected not only in the greater com-
fort of living but in a marked decrease in death rate. The cities in which these
changes have been made are more healthy than the surrounding country districts
with all their advantage of better air and sunlight.

This progress has been so gradual that it is difiicult to realize its extent. The older
generation can do so by contrasting present conditions with those of their childhood.
That the younger generation may do so I illustrate some contrasts from my own expe-
rience.

I was graduated from Yale University in 1870. At the time of my graduation no
students in the college dormitories had running water in their rooms. None, even
those who lived in private houses, had access to baths within the house. The bathing
^ilities for the entire university consisted of four bathtubs located in the basement
of the gynmasium. To-day there are few students in the university who have not
access to both running water and to baths under their own roofs. I had occasion to
contrast the lack of bathing facilities of students of my time (1870) with those now
afforded by the city of New York to its tenement population in the presence of Dr.
Timothy Dwight, then President of Yale University. He smilingly remarked that

616 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIO C0NGBES8.

that contrast was insignificant compared with the contrast between conditions in
Yale University when I was there in 1870 and those which existed at the time of his
graduation, 21 years before. Then, he said, not only did no student have access
either to running water or to a bath anywhere, but every student who lived in the
college dormitories was compelled to go to the college pump for his own water supply
and empty his slops with his own hands. "And when," added President Dwight,
*'as a younger member of the faculty, I proposed in 1851 that some person should be
employed to carry water to the students' rooms and to dispose of their slops, I waa
met with violent opposition from the older members of the faculty, on the ground
that relief from these elementary household duties would inculcate luxury in the
student body, and the younger members of the faculty only succeeded in carrying
my proposition over the heads of their elders by a majority of one."

In 1902, when the new tenement-house law went into operation in New York City,
there were practically no baths in the New York tenements. At the present time,
1915, over 1,500,000 are living in new-law tenements, about 86 per cent of which have
baths. In 1902 there were in the city of New York over 9,000 open privy vaults.
At the present time there are practically none.

Having now emphasized certain encouraging recent advances in housing condi-
tions, I recur to such consideration of the general subject given to me as is possible
within the allotted time.

There should be certain requirements for all buildings which are occupied by
human beings. Such buildings shotdd be weatherproof, damp proof, vermin proof,
well lighted, well ventilated, and they should afford protection against extremes of
temperature and against imdue fire hazard.

To these requirements should be added certain requisites for wholesome, decent
living; and adequate and convenient supply of water and proper toilet facilities.

But when it comes to applying these generalities there is evident at once a clear
distinction between two classes of buildings, those occupied as dwellings and those
occupied as work places. What may be a satisfactory standard for the second claas
would in many instances be far from satisfactory for the first. This fact has not been
sufficiently recognized in much of our legislation dealing with buildings, as is shown
in such recently enacted building codes as those of Sjracuse, N. Y., and Enoxville,
Tenn. The custom in drafting building codes has been to group dwellings and work
buildings, and inevitably there has followed a tendency to consider what may be
adequate for one will be adequate for the other, or if it is recognized that one rule
should not apply to both, the lower standard for the work place has oftentimes influ-
enced the legislators in fixing a standard for the dwelling when both standards are
fixed in the same paragraph.

WHY DIFFERENT STANDARDS FOR DWELLINGS?

The most important reason why dwellings shoidd be treated differently from work
places is that ^ey are occupied more nearly continuously by the same persons and
so affect them for good or ill more than do the work places in which an individual
spends a considerably smaller portion of the 24 hours.

It is, of course, assumed that dwelling and work place are not to be combined in
one; a rule which admittedly has exceptions, but exceptions that become fewer as
we advance in our desire for efficiency in work and in our appreciation of the need
for better standards in the home. Aside from housework, which is only technically
an exception, perhaps the most important work carried on in the home is that con-
nected with the farm. But in progressive fanning communities we are beginning to
separate those tasks which have to do with the producing or manufacturing end from
those which are part of home keeping, and to provide, if not entirely separate build-
ings for them, at least distinct parts of the building which may be set off from that
part occupied by the faunily. This has gone so far that we find in the western United
States farm houses with a separate dining room and wash room for the laborers and

PUBUO HEALTH AKD MEDIOIKB. 617

bedrooms reached by a separate flight of stairs.' The only room which continues to
#drve a double function is the kitchen.

Practically we must still except such work as that of the individual seamstress
who works either in her own dwelling or in the dwellings of her patrons. But this
and similar exceptions are of comparatively small moment. What we can not except
is the presence in the dwelling of any manufacturing enterprise which employs
steadily or for long periods several members of the family or adds to the family group
outsiders, so in effect transforming the dwelling during work hours into a worksh op
or factory.

CLASSES OF DWBLUNQS.

Having made this distinction between dwelling and work place we must nez
divide each of these two classes. Dwellings, for example, must be divided into those
occupied by families and those occupied by individuals not associated in family
groups. The reason for this distinction is the needs of children. I realize that there
are children in asylums and in other buildings which according to this classification
would fall in the second division. But this condition is exceptional and temporary,
for experience teaches us that even in the best constructed and the best managed
institutions children do not thrive as they do when given the normal family relation-
ships. Consequently we look forward to a day when all children will be given family
life or a close approximation to it in buildings designed to meet fetmily needs.

NONTAMILT DWBLUNQS.

For the nonfamily dwelling the only requirements of first importance are those
designed to safeguard the health and safety of the individual. If the building is
weatherproof, damp proof, well lighted, well ventilated, etc., if it provides protec-
tion against extremes of temperature and against the fire hazard, if it supplies its
tenants with pure water and sanitary toilets adequate in number and conveniently
situated, it does all that we can draiand. But even between such a dwelling as this
and an office building there should be a difference in minimum standards permitted.
In both every room occupied by human beings should have windows opening to the
outer air. But in the case of a dwelling the imoccupied space outside the window
should be more ample, greater effort should be made to secure sun and a free circula-
tion of air. Moreover, the provision of water supply and of toilets should be much
more ample in a dwelling, for the use made of them is greater even when the dwelling
is used only temporarily by any given individual, as in the case of a hotel patronized
exclusively by transients. Facilities that will amply meet the needs of a day popu^
lation which presumably has made its toilet will not meet the needs of a day and
night population.

The dwelling must moreover provide in its floor plan for greater privacy within the
rooms or apartment than is necessary in the office building, and it must do so while at
the same time providing better light and ventilation. This necessitates greater restric-
tion on the proportion of lot that may be occupied, wider open spaces outside every
window.

Again the dwelling must provide greater safeguards against fire, as a fire which
breaks out when the inhabitants of the building are asleep is hur more dangerous to
life than one which starts when everyone is awake and so can respond immediately
to an alarm. This statement, of course, is based upon the supposition that the
dwelling and the work place are comparable in number of stories and that they
shelter equal populations. A tall loft building containing many hundreds or even
thousands of workers should be fire-proof, while a two or three story dwelling properly
isolated from its neighbors and containing only one or two families may be built of
nonfireproof materials.

> See plftDs for ICninesota term booses prepared under aofploes o f ICinneeota Art Society.

618 PBOGEEDINGS SECOND PAN AMEBIGAN SCIEKTIFIO COKGBESS.

FAMILY DWELLINGS.

When we come to family dwellings — family in this connection is taken to mean
several people living as a family group and representing two or more generations-
still other requirements should be insisted upon. There should be a common living
room and there should also be enough bedrooms at least to permit of a separation of
the sexes. Moreover the family dwelling should be so designed as to provide prop-
erly for children. And as we assume that the greater part of the adult population of
any community will have children, the dwelling which provides for them should be
the predominant and the most important type. This involves the deliberate adop-
tion of a policy which will favor the erection and maintenance of such dwellings.
The ideal family dwelling is the detached, single-family house surrounded by private
yard , garden or lawn. It is not enough here to secure light and air inside the dwelling,
there must be usable space outside. The adult may find all the wholesome, out-of-
door recreation and exercise he needs in the streets and other public or semipublic
places. Children can not. During their earlier years especially it is important that
they be kept close to the home and yet have opportunity to spend the greater part of
the day in the open air, free from constraint, free to exercise not only their growing
bodies but also their developing mental faculties. For this, open space is essential.
And the closer this open space is to the home, the further it is removed from the tur-
moil and crowds of closely built areas the better.

CONSIDER BOTH PRESENT AND FUTURE.

We must consider our cities and towns both as they are and as we would have them.
In the future we shall build them better and so achieve our ideal for a constantly
increasing proportion of dwellings. In the present we must decide what is the least
that we shall tolerate in dwellings far from ideal but stlready erected or sure to be
erected before our methods of city building have been materially improved. In most
of our smaller cities and towns the great majority of families occupy dwellings which
in this particular of ample private grounds approximate the ideal. With wise regula-
tion and guidance the fortunate conditions of these cities may be continued even
though their population does multiply. But in the largest cities, except for their
outlying areas, and in already densely crowded sections of some of the smaller ones
lives a large family population for which, in the near future at any rate, we must
accept lower standards. The question is, what are the lowest standards we can accept?

We shall start with the statement that where the present standards in any coni-
munity are now of a high order, either as to land occupancy or in other particulan
mentioned later we must use our utmost endeavors to prevent their falling lower
than we believe is consonant with the highest development of family life, while at
the same time we strive to raise standards in any particular which we believe of per-
manent importance to the well-being of the commimity. Our study of city planning
during recent years, added to our success in imposing and maintaining housing
regulations, makes us confident that we shall ultimately be successful in both these
endeavors.

THE PRESENT PROBLEM.

At present, however, we must deal with situations that are far from ideal. Starting
with the single family detached house, surrounded by ample grounds, which is the
typical, traditional family dwelling in the United States of North America, we regress
through a series of types which ends with the tall row tenement or apartment house
characteristic of New York City. To this series belong the semidetached single-
family house, the group or terrace of single-family houses, the long row of single-
family houses, the two-family house — one family above the other — the three-decker-
characteristic of New England's urban housing.

Once these lower types of family dwelling have become well established in any
locality it is practically impossible ever to supplant them with a higher type. The

PUBUC HEALTH AND MEDICINE. 619

only hope for their disappearance lies in the expansion of business which will demand
their sites for its even more remunerative purposes. Then, if no more of their type
have been erected, the housing standard will be raised.

But we have these dwellings, and more like them will be erected during the years
just ahead while we are studying the problem and beginning to apply the new methods
of city building. Our first step, then, should be to devise and enforce such building
and especially such housing regulations as will tend to encourage the erection of better
types of dwellings and to discourage the erection of others.^ Both the building regu-
lations and the housing r^ulations should be based upon a clear conception of the
social value of the single family house. In New York City this conception has not
guided the framers of our present building code. The requirements for thickness of
foundation, for instance, are based upon the requirements for a tenement house of sev-
eral stories. As a result, small single family houses must have foundations consider-
ably heavier than their purpose necessitates, and in this way the small house is penal-
ized, the multiple dwelling encouraged; quite the reverse of what we desire.

EMPHASIS HAS BEEN ON SANITATION.

Moreover, the purely sanitary or health side of housing has been emphasized more
than the social side. The history of the housing movement shows that this was a
logical development for housing reform in America as in the Old World, began in the
largest cities where conditions were worst, where the connection between public
health and housing was most obvious, and where land overcrowding had already gone
80 far that any attempt in the early years of the movement to secure ideal conditions
would have been quixotic. The first step — and proverbially the first step is the most
difficult — ^was to clear out plague spots, to set and maintain standards which would
not be a constant menace to health.

This first step we have taken in our largest city. In other cities all over the land it
is being taken. There is still much to do, but the final result is no longer in doubt.
Our cities are, or soon will be, sanitary. The proof is in such reports as that issued by
the New York State Board of Health in October, 1915, which showed that the death
rate in the cities as a whole is lower than that in the country and the death rate in the
largest cities — those which have done most to improve sanitary conditions — lower than
that in the smaller cities." The long fight for more healthful living conditions has
been, won. What remains is — to use a term made familiar by war dispatches— to con-
solidate the victory.

Prr DWELLINGS TO SOCIAL NEEDS.

But no victory is an end in itself. It simply releases our energies for other tasks.
And in housing the next task is to fit our dwellings to our social needs. Even from the
beginning this task has occupied no inconsiderable part of our attention. Occupied as
we were in getting the only practical results then attainable, sound, as we are con-
vinced, was the reasoning which led us to lay emphasis first on sanitation; we could not
pay much attention to changing the types of dwellings or to controlling the develop-
ment of new areas. Our task was too great and too immediate for that. W e left it as we
must leave many desirable things, for the future. Yet within the dwelling we brought
about changes of the greatest social importance. And it is upon the basis of this work
done that, I believe, we must set our standards for family dwellings in the already
closely built sections of our cities. I would even go farther and say that this work
already done has established one principle at least which in the future must be applied
to all family dwellings, one which now frequently is not applied even where there
is no question whatever of land overcrowding.

1 The distinction I would make between building regulations and housing regulations is that the former
deal- with such questions as strength of materials, the latter with the health and well being of a dwelling's
inhabitants. One deals primarily with property, the other with liie.

> Death rate per 1,000 hi New York State: Rural, 13.6; cities, 13.3; dUes over 176,000 popatotioii, 13;
cities of 50,000 to 176,000, 14.6; dues of 20,000 to 60,000, 14.7; dties of 10,000 to 30,000, 14.6; dties under
10,000, 16.1.

620 PROCEEDINGS SECOND PAN AMEBIOAN SOIENHFIO C0NGBES8.

THE NECESSITY FOR PRIYAOT.

This principle is the necessity for privacy within the dwelling. When the housing
movement began it was a commonplace to find not only all the members of one family
but all the members of two or even more feonilies occupying one room. Such a situa>
tion was admittedly a menace to all decency; to morality. Yet, it was a diflScult one
to deal with, for it was held to be a result of economic necessity. Years of effort have,
however, resulted in remarkable improvement. We still have our problem of room
overcrowding and shall continue to have it for years to come. We still have the
problem of the lodger — and shall continue to have it. But we are getting rid of the
one-room family dwelling. With the addition of more rooms comes the possibility
of greater privacy, of the separation of the sexes, of more decency in living.

At first the additional rooms were planned merely to suit the convenience and the
sense of economy of the builder. One opened directly into another, so that middle
rooms were in reality passageways. This was true not only in the great tenement
houses of New York, but even in the little shacks which have replaced the one-room
log cabins in the Middle West and the South. Such an arrangement made privacy a
little more possible than in the one-room dwelling. Advantage was often taken of
this possibility by hanging a rug or carpet across the middle of the room, so shutting
off the bed from the passageway. The next step was taken when the laws required
that rooms be so arranged that access to every living room and to every bedroom,
and to at least one water-closet compartment shall be had without passing throu^^
a bedroom. This standard has been adopted in all of our cities which have modem
housing codes.

MINIMUM SIZE OF ROOMS.

But with this reqidrement must go another. However great the number of rooms
within a dwelling, none which is occupied for living or sleeping should ^11 below a
definite minimum size. Admittedly, the cubic air space within a room is not a satis-
fsLCtoTy means of measuring the quality of the air. Moisture, temperature, movement
are of greater importance than quantity. A small room, with windows in two wallSy
and the windows open so there is a constant circulation of out-door air, is a more
healthful sleeping place than a laige room with only one window. But the difficulty
is to keep the windows open, especially during the cold months. So we are forced
to the expedient of measuring the cubic air space and limiting the number of occu-
pants.

Experience seems to show that the minimum size permissible for any living or
sleeping room is 70 square feet of floor space, with ceiling eight to nine feet above the
floor. Moreover, there should be at least one room in the dwelling with lio less than
120 square feet of floor space. These minima could, with advantage, be increased
to 100 and 150. But there is, as you doubtless recognize, a limit to the floor area per
room which may wisely be required. For if the room becomes too large we are in
danger of having it occupied by too many persons, and so bringing back in effect the
old one-room family dwelling. On the other hand, we can not content ourselveo
with merely requiring a certain floor area, but must also prescribe a minimum width.
For we have foimd that without this second provision builders were constructing
rooms only five feet wide. Though such rooms might contain the required cubic
air si)ace, they were not livable. Not only is such a room difficult to furnish so that
it may be comfortable, but almost inevitably the bed must be put directly before the
window, so that every draft strikes the sleeper. And this almost inevitably means
that the window will not be opened. So we have found it necessary to require that
rooms must be at least seven feet wide.

PROPER PROVISION OF TOILETS.

In the question of privacy is involved a proper provision of toilets. This, again,
is more tban a matter of sanitation. We accept it now as an axiom that in doeely
settled communities the yard closet or privy vault is no more than a relic of the dark

PUBLIC HEALTH AND MEDICINE. 621

ages. Until sewer syetems or other methods of safely carrying away hiunan excreta
can be installed, we must put up with these relics. But we are making rapid progress
and every year sees many thousands of vaults abolished in our cities and towns.
Even in some of the more progressive farming communities they are being superceded
by indoor water-closets of latest design.

It is not enough, however, to abolish the vault. The toilet must be brought within
the dwelling, made convenient and accessible, so that it may be used by the youngest
and oldest members of the &mily at any hour of the day or night, and in any kind of
weather. This means that it must be thoroughly clean and sanitary, that the room
in which it is located must be well ventilated and lighted, so that it may be in no way
a menace to health, while at the same time, by its accessibility, it ministers to the
preservation of. health.

This removal of the toilet from the yard to the dwelling makes possible anothe
advantage of great social importance which we must not permit ourselves to lose.
The outdoor closet is at best semipublic. What this has meant to health, physicians
can tell you. What it has meant to morals we need not be told. So when it is re-
moved to a place within the house care must be taken to insure privacy, access to it
should be possible without passing through a living room or sleeping room likely to
be occupied by others.

WATER SUPPLY.

Scarcely less important is an adequate and convenient supply of water for house-
hold purposes and a proper means of disposing of slops and other liquid waste. Of
all the drudgery connected with the old time dwelling none was more burdensome
and is now more needless than the carrying of water from some out-door source of sup-
ply and the carrying back again of the waste after the water has been used. Its
effect upon women is not to be measured in terms of tons, nor even in years cut from
life. It has lowered standards of living and through these has had its effect upon
children generation after generation. So we must require that there be a conven-
iently located supply of water within the dwelling and in connection therewith a
proper sink and means of disposing of the waste.

PIRB PROTECTION.

Though as a general proposition we may state that protection against the fire-hazard
should be greater in dwellings than in work-places, still the degree of protection
afforded by individual dwellings should vary with their character. The ideal would
be to make every dwelling incombustible, for accidents are always possible. But it
is essential that we keep dwellings as inexpensive as is possible while having a due
r^ard for the well-being of their inhabitants and of the community. So it is not
practicable to require that the detached single family house, well separated from its
neighbors, shall be fireproof. Nor is it practicable to insist that even its outer walls
shall be constructed of incombustible materials unless these materials are as satis-
factory in other respects and approximately as cheap as those against which we would
legislate.

But when dwellings are crowded closely together, especially when they contain
story above story filled with many families, or even with individuals not associated
in family groups, the situation is altered. The danger of a fire starting is increased by
common use of parts of the building, by the decreased sense of responsibility; the
danger of fire spreading is increased by the proximity of one building to another —
which also increases the difficulty of controlling or extinguishing a Gie once started;
the hazard to individuals is increased in proportion to the number endangered and by
the difficulty in reaching the ground from upper stories. So with increase in land oc-
cupancy, with the erection of multiple dwellings should go a more vigorous regulation
as to building materials that may be used and as to interior arrangement. It is per-
iectly justifiable to require that multiple dwellings more than two stories in height

622 PBOCEEDINGS SECOND PAN AMERICAN SCIENTEPIC 00N0BES8.

shall be fire-proof throughout and that they shall be so designed that stairways, ele-
vator shafts, etc. , may not serve as flues for flames and smoke. This has been required
in one of our recent housing codes, that of Grand Rapids, Mich. , while the great dty of
Chicago has long set a similar standard for multiple dwellings more than three stories
in height.

WORK PLACES.

I have used so much of my alloted 30 minutes in dealing with what I feel to be,
from the social point of view, the more important of the two great classes of buildings
for human occupancy that no time is left for an analysis of the different groups of work
buildings and a discussion of the principles which should guide us in their erection
and maintenance. I shall therefore close with a brief paragraph dealing with few
specific points raised in the preliminary program of the Congress.

POINTS RAISED IN THE PROGRAM — SELECTION AND PREPARATION OF SITE.

If we were considering only the building of future cities and towns, or only the
location of farmhouses, we would begin by selecting, so far as economic needs per-
mitted, a site which provides natural drainage, which presents no great irregularities
of surface that must either be smoothed off at great expense or remain a constant
handicap to intercourse, and which has available an ample supply of good water.
Doubtless in the future as in the past cities and towns as well as individual birildingB
in the open country will be placed in swamps, on rocky hills and far from an adequate
supply of xmter; for commercial and industrial needs must usually be first considered.
But in the future more than in the past we shall lay greater stress upon the adapta-
bility of a site, for modem inventions free us in large measure from the necessity f<ff
locating upon the very edge of deep water or at the exact confluence of two rivers.
Bailroads, canals, and artificial harbors supplement and extend the traffic routes
provided by nature and so give us a wider choice of sites.

Even where there is considerable latitude of choice, however, it is probable that
in new communities as in the old we shall find that seldom is a site ideal, that
it is necessary to weigh advantages against disadvantages and finally that certain
parts of the site are better adapted to one group of activities, others to a different
group. A level area, even if it is a swamp which must be drained, will better meet
the needs of industry than a very hilly area; while the latter, despite the difficulty
of constructing roads, sewers, and water mains, will offer compensating advantages
as a residence district. So within the city we must have some liberty of choice which
should be availed of. Yet there will be occasions when even this liberty is denied
us, when we must make the best of a bad situation.

So varied are the possibilities that it seems to me impossible to suggest in more
than the most general way what should be our policy, leaving to the engineer the
task of solving individual problems.

The solid mass of buildings on Manhattan Island cover a site which origioally
offered our city builders nearly every problem. It had level, easily drained areas
with a good subsoil which affords excellent support for foimdations; it had swamps
through which the tide rises and which in the oldest parts of the city — as in the district
where the proposed court house is to be erected — still offer problems that have not
been permanently solved: it had rocky hills that we have blasted away at a cost that
has added greatly to the selling price of lots on which residence buildings are erected.

The site of New Orleans has offered a different problem. Low lying, with the river
surface often far above the level of the land, it has prevented the use of cellars and
compelled the adoption of a kind of foimdation different from that characteristic of
the metropolis. And now that New Orleans is being properly sewered, its water
level lowered, it faces a new problem due to the decay of the wooden foundations
upon which its older buildings stand.

PUBLIC HEALTH AND MEDICINE. 623

Seattle, built on a narrow strip between the hills and the harbor, has found it
necessary to wash away whole mountains of earth.

So can we do more than say that where the character of the soil permits and the
cost of the building warrants, there shall be a cellar, the floor and walls of which shall
be water proof? Of the value of a good cellar in keeping a building warm and dry, and
properly ventilated, I assume there is no question. But what is necessary to secure
a good cellar will vary with the site. In the tide swamps of Manhattan the utmost
\re can do in waterproofing will not keep the tide out. On the sandy hills of Grand
Rapids the so-called Michigan cellar, which is merely an excavation without any
flooring, seems to be quite satisfactory. A\Tien a good cellar is impossible, or will
add unwarraiitly to the cost of the building, an acceptable substitute is an airspace
beneath the house, which is raised some 2 feet above the groimd. But with cellar
or without, there should be a damp-proof course or other means of preventing damp-
ness rising from the soil through the walls of the building. In the case of cellarlesB
buildings the lowest floor should be more substantial in construction, as beneath it
is not the comparatively equable air of the cellar but the cold or hot air of the open.

CONCLUSION.

The subject, ** Buildings for Human Occupancy," opens so wide a field that it is
impossible to cover it even in the most superficial manner in one paper. Even that
phase of it to which I have confined myself, can be no more than outlined in 30
nodnutes. I hope, however, that I have succeeded in putting before you a point of
view which merits your attention and that I have made clear a line of endeavor
which some of us at least believe to be of vital importance.

THE MEANS BY WHICH INFECTIOUS DISEASES ARE TRANSMITTED
AND THEIR EXTERMINATION.

By ALVAH H. DOTY.

I am aware that the subject of infectious diseasee and the means by which they are
transmitted has been exhaustively discussed, yet I believe we have only begun to
appreciate the great practical value of the knowledge which has come to mb within
recent years regarding the true media of infection; furthermore, we have not given
full consideration to the use which may be made of this information, for it not only
enables us to deal successfully with outbreaks of these diseases, but, what is still more
to be desired, it will go far to aid in their extermination. I do not feel that my views
are too optimistic for we have good reason to believe that the latter can be successfully
accomplished. It is this to which I wish to call particular attention.

In the past there have been reasons why infectious diseases could not be eliminated,
chiefly because erroneous theories were generally accepted concerning the media of
infection; for prior to the researches of Pasteur and Koch, which made known the
germ origin of disease, it was universally believed, both by the medical fraternity and
the public, that while diseases are conveyed by personal contact, they are also com-
monly disseminated by clothing, baggage, money, books, rags, and innumerable other
articles; vehicles by which the infectious matter is transmitted from one person to
another.

Such articles are known as fomites. This theory is of very ancient origin, and for
centuries past has dominated all health regulations, the object of which is to prevent
the transmission of infectious diseases. We have ample proof of this in the description
of very early sanitary regulations, for instance, about the period that maritime quar-
antine was established at Venice during the fourteenth century, for it very clearly

624 PBOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIO C0NGBES8.

stated that clothing, as well as various articles of the ship's cargo, were placed on the
deck of incoming vessels, and kept there for days and often weeks for so-called purifi-
cation.

The fomitee theory once having beea established, grew until it was familiar to every
household, yet it is important to bear in mind that this theory was bom in ignorance,
and its chief support has not been scientific evidence, but rather its plausibility; for
it offers satisfactory explanation for outbreaks of disease when the true source of in-
fection is unknown. It is possible that in rare instances, infectious organisms may be
transmitted in this way; however, this need cause no concern; it is the common
media of infection which should engross our attention.

At first the publication of the work of Pasteur and Koch, so far as the fomites theoiy
is concerned, only added fuel to the fire; for it seemed to offer full justification iar the
belief that infectious organisms are conveyed upon almost every article and in every
direction. It is not an exaggeration to state that this belief reached a hystoical stage,
and disinfection was everywhere rampant; even iron rails were treated with various
agents to prevent the transmission of yellow fever. Unfortunately, this notion was
encouraged by the medical fraternity, and public-health officials offered bu^ little
objection to it.

A fitting companion for the fomites theory is the belief that infectious diseases are
transmitted over long distances through the air. This is not sustained by scientific or
even reasonable evidence, and is not entitled to serious consideration.

The fomites theory has become so firmly fixed in the public mind that, if for instance,
a bank clerk, a cashier of a restaurant, or some one else who is constantly handling
money, contracts an infectious disease, it is promptly stated that money was the
medium of infection, and futher investigation is usually deemed unnecessary. Or if
a ragman is found to be infected, it is heralded as proof that rags convey infectious
organisms from one person to another. Apparently it does not occur to those who
accept these theories of infection, that such persons are subjected to the same outside
exposure that others are, and that there is no reason why they should not contract
infectious diseases in the ordinary way. The only scientific and logical proof that
these articles are media of infection would be evidence that those who are constantly
dealing with them are more frequently infected than others. Such proof has never
been presented and never will be, for diseases are not transmitted through these sources.
Physicians have been reluctant to abandon the fomites theory of infection even in
the face of the most conclusive evidence that it is erroneous. This is largely because it
is plausible and it is convenient to explain the origin of outbreaks of infectious diseases
wherever or whenever they may occur; besides there is a natural imwillingness to
abandon a theory which has long held sway, for fear that some trouble may ensue.

If all cases of infectious disease appeared in a well-marked and tjrpical form the
fallacy of the fomites theory would have been recognized long ago. It is only in late
years that we have fully appreciated the frequency with which they occur as a mild,
ambulant and unrecognized type; conclusive proof of this has been presented in many
ways; for instance, the modem method of school inspection has revealed some rather
startling facts in this direction. Many children apparently well but with symptoms
of an ordinary cold, have been found upon careful investigation to have measles, and
what are often regarded as simple sore throats — ^not deemed severe enough to keep
children at home — ^have proved to be diphtheria or scarlet fever. All are media of
infection and go far to explain why these diseases are increased in nimiber at the
beginning of the school year, and furthermore, that this increase is not due as it was
formerly supposed, to the transmission of pathogenic organisms on the clothing of
children.

Within recent years we have learned of even a more dangerous and insiduous source
of infection. I refer to ''carriers " or persons who while they may present no evidence
of disease, contain actively infectious organisms within their body, and transmit in-

PUBUO HEALTH AND MEDICINE. 625

fection to others. The extent to which this occurs is, I am certain, far greater than we
are aware of; abundant proof of this will be forthcoming.

I believe that no factor has contributed more to the dissemination of infectious
diseases than the fomites theory, for it has led to carelessness and in various ways has
discouraged investigation to discover the true media of infection. Yet even with this
serious drawback we have gradually arrived at a truthful solution of this important
matter, and the facts are so simple and easily imderstood that we do not need the aid of
the fomites or aerial theories to explain the presence of infectious diseases.

We know that infectious diseases are transmitted by persons rather than things, by
actively infectious organisms, either by direct contact or in the form of sprays or drop-
lets emanating from those affected: by coughing, sneezing, etc., or by comtaminated
hands or through the medium of food and drink containing these germs, and by the
bite of certain insects which act as their hosts.

Sometime ago when the fomites theory was universally accepted, it was a common
practice among health officials, in instances where an outbreak of infectious disease
occurred, and no previous case had been reported, to assume that the infectious organ-
isms were brought into the community by clothing, baggage, or some article of mer-
chandise; therefore but little was done in the way of prevention, except to deal with
subsequent events. To-day health officials, who accept modem views regarding the
transmission of infectious organisms, carry out an exhaustive investigation to discover
the origin of the outbreak, which is usually foimd to be a previous case, often in a mild
and unrecognized form. By this means outbreaks of infectious diseases are becoming
more and more easily controlled, and by these means also, provided they are univer
sally employed throughout the world, we may confidently expect that at least some of
the infectious diseases will be exterminated.

If oiur hopes in this direction are to be realized, the diseases first to disappear will
probably be the group commonly referred to as "quarantinable;" that is, cholera,
typhus fever, plague, yellow fever, and smallpox. This will be largely because phy-
sicians as well as the public throughout the civilized world have been more thoroughly
warned and educated regarding the danger of these diseases and the rapidity with
which they are disseminated, and as a result more effective cooperation can be depended
upon — a most important consideration. As a rule these types of infectious disease
make only occasional visits, and are of comparatively short duration when properly
dealt with.

Until recent years typhus fever was a menace to the world, yet modem sanitation
has rendered it almost a negligible factor, so far as public danger is concemed. It is
true that the present conflict in Europe has for the time being given this disease a new
lease of life, but the outbreak has iJready been brought under control even in the
presence of insanitary and revolting conditions such as the world will probably never
know again.

Furthermore, there is documentary evidence that for the past 125 years various
sections of the United States have from time to time been devastated by yellow fever.
It would be difficult to overestimate the loss of life which has occurred under these
conditions. To this may be added the injury to commerce and the many unpleasant
interstate disputes resulting from this cause, which have seriously retarded the growth
and prosperity of the Southern States. Yet when a determined effort was made the
medium of infection in yellow fever was discovered; as a result this disease has dis-
appeared from this country as well as from Cuba, and largely from South America.

Cholera has a permanent home in the far East, not because its origin is there, as a
large part of the public believe, but because every condition is favorable to its propo-
gation and perpetuation, and also because proper means are not taken to ext^minate
it; for this reason it is a menace to the world. On the other hand, we have ample
proof that outbreaks of cholera are of short duration when modem methods of preven-
tion are employed.

626 PROCEEDINGS SECOND PAN AMEBIOAN SCIENTIFIC CONGRESS.

Measles and scarlet fever are more or less constantly with us, because there is little
or no determined effort made to get rid of them. We rather feel that our duty has
been performed if the number of cases are kept within reasonable bounds. The
public subscribes to this belief, for they extend practically no cooperation in eliminat-
ing them. Besides there is a popular notion that it is necessary that children should
have scarlet fever and measles, and some other infectious diseases incident to this
period of life, and the earlier they have them the better.

It may be asked to what extent have we tried to show the fallacy of this belief.
The truth is that measles and scarlet fever prove fatal far of tener than the smallpox of
the present day. From 600 to 1,000 children die annually in New York City from
each of these diseases; besides the sequelae are often dangerous or disabling. For
proof of this it is only necessary for physicians to recall the many persons who are physi-
cally or mentally defective from this cause who have come imder their observation*
Yet this condition is constantly occurring without the least evidence of alarm on the
part of the public.

It seems entirely at variance with modem sanitation that no well defined and sub-
stantial international effort has been made to eliminate infectious diseases. This
would not only be of incalculable value, so far as the preservation of life and health is
concerned, but would also be of great commercial and financial interest, for each
country is now quarantined against the other to prevent the entrance of infectious
diseases; yet each country does but comparatively little in eradicating this serious
menace to the public health.

Maritime quarantine inflicts upon commerce and shipping, as well as the travelling
public, an enormous penalty, so far as time and money are concerned, in the enforce-
ment of protective regulations; whereas if modem preventive measures were uniformly
carried out. these expenses and annoyances would be reduced to the minimum, and
the extension of infectious diseases would be of comparatively little concern.

Success in this direction is impossible without the cooperation of the public. This
will not be secured until the latter is carefully educated regarding the true means by
which infectious diseases are transmitted and the probability of their exterminatioQ
if proper measures are employed. This cooperation must begin at home, for we know
only too well that when sickness occurs it is the common practice not to send for the
family physician until all sorts of domestic remedies and patent medicines have been
tried, and during this period infection is often widely disseminated. The public
should be taught the importance of prompt medical advice when sickness or symptoms
suspicious of infectious disease occiur in the household . In addition , instruction should
be given that when medical aid is not available that the most important factor, so far
as the public health is concerned, is the prompt and careful isolation of the patient.

Careful observation to detect symptoms which are suspicious of infectious diE^ease
should be faithfully carried out, not only in the family but on the part of employers,
school-teachers, and others who have many persons under their observation and care.
It is such cooperation combined with other means of prevention, and under the guid-
ance of health officials, which justifies the belief that at least some of the infectious
diseases may be exterminated.

No greater opportunity has been offered for the careful and extended consideration
of this subject than the present Pan American Congress. 1 1 would be difficult to over-
estimate the far-reaching importance of such action.

Dr. Frederick L. Hoffman. Mr. Chairman, I would like to
present a brief resolution, which is based upon a very extensive
discussion, held in the last few days with Gen. Gorgas, Dr. Blue,
and a number of others, concerning the advisability of an organized
Pan American movement against malaria. We are convinced that
the principles which imderlie the modem tuberculosis movement, the

FUBLIO HEALTH AKD MEDIOIKB. 627

modem accident and insurance movement; the infant mortality
movement; are all so thoroughly established that for the attainment
of the highest degree of disease eradication; the governmental
authorities require the cooperation as well as the development of a
thoroughly well-educated public interest. I would, therefore, like
to present to you a resolution which is based on the work that has
been done in India in regard to malaria eradication, and which we
believe is applicable to the Pan American coimtries in a peculiar
way. There has been probably no disease quite so thoroughly
disseminated throughout all these coimtries as malaria; which, how-
ever; has not received, broadly speaking, even in this country, the
required degree of public interest or of aroused public conscience,
which lies back of a successful public effort to reduce every prevent-
able disease to its minimum. I would like, therefore, to present to
you the following resolution:

Whereas, the supreme importance of malaria as a public health problem throu^^out
the semitropical and tropical regions of the Western Hemisphere is recognized by all
governmental, medical, and sanitary authorities, and,

Whereas, the economic loss and diminished physical efficiency as well as the heavy
morbidity and mortality from this disease are among the most serious hindrances to
the highest attainable degree of health and happiness, and,

Whereas, the malaria problem in all its aspects is as yet far from having received the
required amoimt of public interest and scientific consideration commensurate with its
world-wide importance.

Resolved by Section VIII of the Second Pan American Scientific Congress, That we most
respectfully recommend to all the countries of the Pan American Union that each and
all inaugurate without unnecessary delay a well-considered plan of malaria eradication
and control, based upon the recognition of the principle that the disease ia preventable
to a much larger degree than has thus fax been achieved, and that the education of the
public in the elementary facts of malaria is of the first order of importance to the
countries concerned, and that further scientific and general research is necessary to
establish the true nature, geographical distribution and local incidence of the disease
as a prerequisite to its ultimate more or less complete elimination from the Western
Hemisphere.'

The Chairman. Gentlemen, you have heard the resolution pre-
sented by Dr. Hoffman. Is there any comment or discussion ?

Leeut. Col. Munson. I move that the resolution be referred to
the Committee on Resolutions.

Seconded and approved.

The Chaibman. Is there any further business before this session f
If there is not, the meeting will stand adjourned and as you go I
wish you all a very happy New Year.

1 Bee Article 39, p. 6.
68436— 17— VOL ix tt

JOINT SESSION OF SUBSECTION C OF SECTION Vm AND
THE AMERICAN PSYCHOLOGICAL ASSOOATION.

Raleigh Hotel,
Monday morning, Jarmary S, 1916.

Chaiimaii; Geoboe M. Kobeb.

The session was called to order at 9 o'clock by the chairman.
The Chaibman. We will hear first from Dr. Henry H. Goddard.

THE DEFECnVE CHILD AND THE PREVENTION OF FEEBLE-MINDEDNESS.

By HENRY H. GODDARD,
Director of Piychological Research, Training Sdiool, Vineland, N, J.

Thanks to the genius of the famous French psychologist, Alfred Binet, it is noiw
recognized that it is possible to measure the intelligence of children, and it has been
clearly demonstrated that normally the intelligence develops as the body develops.
That, for example, a normal child of 10 years has \^'hat may be called the intelligence
of a 10-year child, "vrhile a 3-year child has the iDtelligence of 3 years. Any child
who does Dot have the intelligence normal to his age is said to be defective, and if his
intelligence is as much as three years behind the chronological age he is considered
mentally defective or feeble-minded. The change \^'hich this discovery has brought
about in oiur thinking and in our attitude toward various social groups is remarkable.
We are realizing that many persons whom we thought bad, vicious, perverse, careless,
indolent, lazy, the result of bad environment in one form or another, are in reality
feeble-minded. Because of their lack of intelligence they have fallen victims to
the bad influences of their environment, which had they been normal, they would
easily have overcome.

We recognize three principal grades or degrees of mental defect. We have the idiot,
with the intelligence comparable to that of a child of 2 years and under, the imbecile,
whose intelligence ranges from that of a normal child of 3 to 7, and, highest of all, the
moron, whose intelligence is that of a child from 8 to 12 or possibly 14.

As a part of the census of 1890 the United States Government secured information
as to the number of defectives. The question was asked ** whether defective in mind,
sight, hearing, or speech, or whether crippled, maimed, or deformed, with name of
defect.'' A special supplemental schedule was sent to every person who in answer
to the above question was reported as an imbecile or idiot, and the data thereby
obtained were tabulated and published in a special report on the insane, feeble-
minded, deaf and dumb, and blind in the United States at the Eleventh Census.

This report ehows that 2 in every 1,000 of the population were idiots or imbeciles.
That such an inquiry would not result in the discovery of all the idiots and imbedlee
is evident as soon as we realize that both of the conditions may escape detection at
birth; that imbeciles at least can not be discovered until the age of 3 or 4 and many
of them not until a considerably later |>eriod; and that the high-grade imbecile with
the intelll^nce of 6 or 7 years is generally considered by his parents only "peculiar."
Add to this the fact that morons were not taken into account and that recent invest!*

028

PUBLIC HEALTH AND MEDICINE. 629

K&tions have led unmistakably to the conviction that there are at least three times as
many morons as idiots and imbeciles, and we are forced to the conclusion that the esti-
mate of 2 defectives in 1,000 is certainly not more than half large enough— probably
only one-fourth or one-fiftJi laige enough. If, however, we take the more conservative
figure, we discover that we have in the United States alone at least 250.000 feeble-
minded persons. A very large proportion of these are morons. Morons, called feeble
minded in England, have been defined by the Royal Coll^:e of Surgeons of London as
''persons who on account of brain defect existing from birth or early age are unable to
compete with their fellows in the struggle for existence or to manage their own affairs
with ordinary prudence." They are capable of earning a meager sort of living, but
only under the most favorable conditions. The most marked mental characteristics
of such persons is a lack of judgment or good sense or reasoning power, of ability to
generalize and hold abstract ideas and conceptions, such as moral principles and
general rules of conduct. They have approximately the same instincts and impulses
as other people but without that power of control which enables most of us to keep
our lower impulses in abeyance and to conform to the canons of society and live a
decent, respectable, and moral life. This being the case, it is immediately evident
that we have here a group of people who may easily become paupers, criminals, pros-
titutes, drunkards, ne'er-do-wells, tramps, or other incompetents. This shows us at
once that we have a social problem of no small importance. Many persons whom we
have thought of as lazy, ignorant, or unwilling to learn are actually incapable of
learning or acquiring skill or ability to take care of themselves. This situation once
realized leads directly to the question, "What can be done?'' Experience has
abundantly proved. that these persons can not be cured. There is no known method
by which a feeble-minded person may be made ncnmal. There are left to us therefore
only two lines of action. One is to take care of the mental defectives that now exist,
to keep them from doing harm, make them as happy as possible, and direct what little
intelligence they have to the end that they may become as nearly self-supporting
as possible. The other is to turn our attention to the prevention of feeble-mindedneas
in the future. This part of the problem compels us immediately to turn our attention
to the question of cause.

What is the cause of feeble-mindedness? Here we find two groups. Some are
bom, some are made. It is a question of heredity or environment. Students differ
somewhat in the relative importance of these two factors. It is, however, pretty
generally accepted by the closest students of the matter that feeble-mindedness is
hereditary in at least two-thirds of the instances. The other third is the result of
accident or di^ase, using these terms in the broadest sense, including the influences
upon the unborn child as well as those acting at birth or later. Here then we have the
indications for a program of action in the direction of preventing feeble-mindedness.

So far as accident and disease are concerned, we can at present only say that extra
care and attention will undoubtedly result in reducing somewhat these causes. For
example cerebrospinal meningitis is a conmion cause of feeble-mindedness. If this
disease can be controlled as it now seems possible through the serum treatment, it is
possible that the percentage of feeble-mindedness due to this condition may be largely
eliminated. Greater care of the mother during pregnancy, greater care to prevent
accidents at time of birth, may also result in some reduction of the condition. Our
greatest hope of reducing feeble-mindedness, however, seems at present to lie in the
direction of the hereditary cases, preventing the birth of feeble-minded children.

It is accepted that at least two-thirds of the feeble-minded have inherited the con-
dition. If we can prevent procreation in such families we will reduce feeble-
mindedness at a rapid rate. This, however, is far from being as simple as it might
at first seem. Not only do we know that mental defect is hereditary, but we now
know that it probably is transmitted in accordance with the Mendelian law of inher-
itance. According to this law there are five kinds of matings that may either produce

630 PBOGEEDINOS SECOND PAN AMEBICAN 8CIENTIFIG CONGBESS.

feeble-minded children or produce persons who, if they marry, may in turn produce
defectives. The first of these is where two feeble-minded people marry; all of the
children are feeble-minded. This leads at once to the obvious conclusion that we
should prevent the marriage of feeble-minded people. If a feeble-minded person
marries a normal person of duplex normal ancestry, the children will all be nomiml
but capable of transmitting their defect if they mate with persons like themselves;
that is, descendants from families where feeble-mindedneas exists. Again, if a feeble-
minded person marries a person who is normal but who has defect in his family, thmt
is, he is what is called technically a simplex, half of the children will be feeble-minded
and half will be normal but simplex ; that is, capable of transmitting the defect. Again,
if two persons of bad heredity— that is, simplexes — ^marry, one-fourth of the children
will be feeble-minded and one-half of them will be capable of transmitting the defect.
Finally, if one of these simplex persons marries a thoroughly normal or duplex person,
half of the children will be simplex, capable of transmitting the defect if they mate
with simplexes. Thus, we see that while the prevention of procreation by feeble-
minded persons will eliminate a large part of the inheritance, iJiere is always a poan-
bility of the mating of two simplexes giving rise to more feeble-minded persons.
Since science at present is unable to tell us which children in a family are the sim-
plexes and which duplexes, we see it is impossible to control this element of the
problem and that there must always arise feeble-minded children from families where
we were unable to predict it.

Turning our attention to the feeble-minded themselves, it is evident as already
indicated that we must prevent marriage or parenthood by such persons. This,
however, is more easily said than done. The carrying out of this rule becomes an
exceedingly big problem. Two methods have been proposed and are to-day popu-
larly supposed to be the simple solution of the problem. One is segregation in coloniee
or institutions, and the other is sexual sterilization, through perhaps surgical inter-
ference. We have only to turn our attention again to the question of numbers aa
already indicated to discover how exceedingly difficult is segr^fation of so large an
army of persons — 250,000 in the United States alone. As to sterilisation, there are
now 13 states that have laws authorizing this under certain conditions. None of
these laws, however, are applicable to any feeble-minded persons except those in
institutions for the feeble-minded. So that at the present time this method la
dependent upon that of colonization or segregation. Moreover, such are the diffi-
cidties or such is public sentiment that of the 13 states only one is malting any use of
the law. Apparently we may not hope for any help in this direction until society is
willing to authorize the sterilization of any feeble-minded person wherever he may be
found. Whether any coimtry will ever take such a drastic step, it is at least certain
that it is a long way in the future. Meanwhile the propagation of the feeble-minded
is rapidly going on. Careful studies indicate that tlris class of people are reproducing
at from two to six times the rate of the normal population. There is, however, a ray
of hope in another direction.

There are indications that if the moron is recognized when he is a child and his
training conducted in accordance with his mental needs and capacities, he may be
brought to a condition where it is comparatively easy to keep him from entering into
matrimony or becoming a parent outside of matrimony. There are certain psychic
characteristics of the feeble-minded that favor this. First, the feeble-minded lack
energy and initiative. On this account they are, more than the normal child, creaturee
of habit, and it is fairly easy to impress upon them fixed habits from which it is very
difficult for them to depart. We, as yet, lack the evidence and the statistics to show-
to what extent this can l.e accomplished, but careful studies of the latw career of
persons who have been trained in institutions for the feeble-minded or in special
classes in the public schools will show us what may be expected in this direction.
There are indications, however, that persons who have been thus carefully trained

PUBLIC HEALTH AND MEDICINE. 631

from childhood to perhaps 16 or 20 years of age if kept away from vicious companions
may live their lives in comparative harmlessness, and pass out without leaving anv
progeny behind them.

Here we come, however, to a rather marked difference in the sexes. The males
are much safer than the females. Their very lack of energy keeps them from being
the aggressors, and a normal woman will have relations with a feeble-minded man
much less often than vice versa. Therefore, the women constitute the serious prob-
lem. Because of their weakness, their lack of control, judgment, and understanding
they are easily victimise by evil men. A man of normal intelligence but of low
moralB will seek a feeble-minded woman and easily lead her astray, with the result
that she becomes a mother either of defective children or of those who can transmit de-
fect. Even here, however, a knowledge and recognition of the condition by the
intelligent people of the community would go a long way toward preventing disaster.
In other words, it would seem that here, as in other lines of social endeavor, publicity
goes far toward a solution. How to obtain this publicity is then the next problem.

The idiot and the low-grade imbecile are recognized by their outward appearance,
their physical defects, and stigmata of degeneration. The high-grade imbecile and
moron are much lees easily detected. They can, however, be detected with great
accuracy by means of tests of intelligence . These tests can be applied to school children,
and the mental condition thus be determined. The school authorities should determine
every case of mental defect among their pupils, ^lien such cases are discovered
they should be given the special training which is adapted to them. Careful records
should be kept, and when such children are of an age or condition to leave school
they should not be allowed to go out as free and independent citizens, but be placed
in the care of some group of citizens who would be in a measure responsible or would
at least have an oversight of them. Such committee, knowing the condition and
the liability to evil, would keep a watchful eye, exercising such help as they might,
in the way of securing suitable employment. Whenever a tendency to go astray is
discovered they should be reported to those who are in a position to secure admission
to a colony or institution. If present indications when carefully studied prove true,
we shall find that a goodly proportion of these persona will live out their lives in harm-
lessness and even with some usefulness. That is, under direction, they may become
self-supporting or partially so, and thua the burden of their maintenance be reduced.

I trust that in the foregoing discussion I have indicated something of the enormous
size and seriousness of this problem;* the necessity of immediately attacking it; and,
more than all, the need of investigation and study, the accumulation of facts on all
phases of the aituation, in order that we may proceed wisely in dealing with a problem
that so clearly underlies our largest and most important social difficulties.

The Chaibman. Before proceeding with the discussion of this
paper I shall call for the paper of Prof. Johnstone. I take great pleasure
in introducing Prof. Johnstone, superintendent of the Training School,
Vineland, N. J.

THE TRAINING OF DEFECTIVES.

By E. R. JOHNSTONE,
Superintendent Training Sehooly Vineland^ N. J.

The formal training of normal children generally begins when the child enters
school, usually at the age of 6 to 8, with a mental age the same as the chronological
age. The formal training of a defective child usually begins when it enters an insti-
tution or a special class, with a mental age of from 6 months to 12 years and a chrono-
logical age anywhere up to 20 or 30 or more.

632 PBOCEEDIKQS SECOND PAN AMEBIGAN SCIENTIFIG C0NQBB8S.

The defective children in institutions are broadly divided into idiots, imbecilee,
and morons. The idiots have a mental age up to 2 years. They are usuaUy undean
in their personal habits, unsteady of gait, often very excitable or very apathetic; their
vocabulary is limited to monosyllables. Some can learn to feed themselves and
discriminate between food and other substances. Their condition is usually easily
recognized by their flabby muscles, drooling mouth, lusterless eye, and inert hand.
They are generally considered hopeless and helpless.

The imbeciles have an intelligence comparable to that of a normal child of from
3 to 7 . Their personal habits are usually clean, although accidents frequently happen.
Their gait is unsteady and slovenly, their vocabulary much limited. They may
learn to dress and undress, but need assistance at the **hard parts. " They learn to
do many useful things under direction, if they thoroughly understand and if the task
is simple. They lack reason, judgment, and will; their attention is easily distracted;
they do not concentrate; they are easily led; they have little comprehension of prop-
erty rights, and are generally amoral — not inunoral. Their training is mostly of ^le
larger muscles — ^picking up trash, wheeling and shoveling, scrubbing floors, dressing
and undressing. They learn simple table manners and simple occupations about the
house, which they will do over and over again with much pleasure, providing, how-
ever, there is someone having oversight to step in whenever an emergency arises and
to give them plenty of praise and commendation. They may usually be recognized
by their physical and mental instability, their childlike actions, or scnne asymmetry,
although a few have well-formed bodies and make a good first impression.

No hard-and-fast line can be drawn between the high-grade idiot and the low-grade
imbecile, and the gradings are almost imperceptible up to the high-grade imbecile
and into the moron class.

The inteUigence of the moron ranges from 8 to 12. His personal habits are dean;
he usually walks and talks well, while he may be slovenly he often takes some pride in
his personal appearance. He can learn to do simple tasks without oversight and
fairly complex ones if some one is near to give direction. He can do errands, scrub,
mend, make and lay concrete blocks, use simple machinery, care for and handle
animals. He makes a good institution helper in every way, in the house, the tikop
and on the farm. He has but little concentration. A plausible tale will lead him
astray and he is particularly subject to suggestion. Mostly innocent or ignorant of
consequences, yet with the appearance of ha\ing good sense, he frequently falls into
the hands of the law, where he is all too often not recognissed, and pimifdmient or an
attempt at reformation follows. There are no permanent results.

It i.s difficult to recognize the moron. When he grows to manhood his childish re-
actions, his ideas of grandeur and power, his queemees and the desire for attention
(which often leads him to do wrong rather than to remain unnoticed) frequently
attract attention to him. The best idea of his needs may be obtained if you will think
of a child of 8 to 12. However, the moron's growth and development give him certain
characteristics not found in the normal of the same mental age. Changes have come
about through his en^'ironment and experience.

Those who are over 20 years of age chronologically should not be grouped with the
yoimger ones of the same mental age. As Dr. Goddard says:

Some study of the situation showed that these older persons were doinff tasks that
seemingly required a higher mentality, but they were doing them not intelligentlv
but automatically — i. e.. after long training and drilling thev had learned to go tlm>ug^
the motions in a more or less efficient manner. This well illustrates the way in which
feeble-minded persons sometimes seem to have an intelll^noe beyond their mental
age. The man who is 40-years of age but of 10-year mentality had SO years in which to
learn not only more 10-year accomplishments tJian any one normal boy could acquire,
but also he has had time to do by habit and drill many things that he can not possibly
understand.

The moron can learn to read and write, to do simple number work and to under-
stand the elementary facts of nature, but it must all be very concrete. If great care is

PUBUG HEALTH AND MEDIOINB. 633

not exerdsed we may often tliink we are speaking concretely when the thing is really
abstract to the child, because it is outside of his experience. For example, the fol-
lowing conversation between one of my boys and the examiner occurred while we
were trying to learn how much he understood of numbers:

Question. How much are 2 and 17 — ^Answer. Three.

Question. How much are 4 and 3?— Answer. I don't know.

Question. If you had 4 apples and Mr. H gave you 3 how many would that be?—
Answer. Seven.

Question. If you had six apples and gave me two how many would you have left?—
Answer (after much hesitation). Four.

Question. If you gave eight ears of com to your horse — (interrupting and laughing—
"We don't give my horse eight ears of com.") But suppose you did give him eight
ears of com — (Intermpting again— "But we don't give him ei^t ears of com."— You
will observe that he could not suppose a thing that was not done.) How many ears do
you give him? — Answer. Ten or twelve.

Question. Well, suppose you gave him 12 ears of com and Mr. H said you were
only to give him 10, how many would you put back in the bin? — ^Answer (promptly).
Two.

Question (after a number of other questions. .) How much are 12 less 107"— Answer.
"I don't know that many."

Question. Suppose you took 12 loaves of bread to the matron and she only wanted
10, how many would you take back?- Answer. I don't haul the bread from the
storeroom.

Question. Well, but suppose you did take the store boy's job for a day and gave
the matron 12 loaves and she only wanted 10, how many would you take back?-
Answer (after a great deal of hesitation— 105 seconds). Three.

You see, therefore, that com that he fed to his horses was concrete, but bread which
he did not handle is abstract to this boy.

Whoever undertakes the training of defectives must not only subscribe to the princi-
ples which say "from the concrete to the abstract," "from the simple to the com-
plex," and "from the known to the unknown," but he miist also be sure that he is
really putting them into practice.

To exercise the right arm forward and back, up and down; then to do the same with
the left, then both together; then to step forward and back with the right foot, then to
do the same with the left, then to go through the movements with hand and foot at
the same time seems like proceeding from the simple to the complex. But the de-
fective finds it much simpler to start at the end — ^but with his exercise made concrete
by having a medicine ball in his hands. He exercises arm, leg and back in the sim-
plest manner, by catching and throwing a medicine ball. He is happy doing it, and
the formal exercises must come later — ^much later; if indeed they are needed at all.
The same application may be made to writing or drawing, to music or to sewing or any
other thing to be taught.

He who would train the defectives must encourage at every turn and never dis-
courage, he must develop the child's desire to express and never repress, and he must
radiate happiness. And in the early period of training there is not much happiness
foimd in a formal musical scale, or the threading of a needle, or the drawing of a
triangle or the writing of the letter A when the child wants to sing "I have rings on my
fingers" or wants to "make a dress for dolly" or "draw a picture of a man" or "write
a letter to dada." The childish nund does not draw plans, gather materials, lay
foundations, and erect a superstmcture to build his house. He finds a brick and sets it
down and says "This is a house." The successful teacher of defectives must be will-
ing to start right there with the child.

Upon his admission to a good institution the defective child receives a complete
examination in the medical, psydiological, and educational departments. He is

634 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIPIC CONQEESS.

placed for his home life with the group with which he lives most coDgenially. His
general routine of life is based upon the above examinations.

For his training he is sent to the educational department and for a week or two he
goes rather freely from class to class — in the English room, the weaving class, the wood-
working class, the domestic-science room, the brush shop, the repair shop, the poultry
class, the sewing class or the gardening class. For, as all of these and similar occupa-
tions go to make up the daily life of the instituticHi, so must the school department fur-
nish training in all of them in order to properly fit the child for the life it will actuilly
lead when it grows up.

At the end of a couple of weeks the child will have begun to show preference for
certain classes, and it is in these that his firet real training begins. If we feel that he
needs some branch that he has not chosen, we talk about that and its advantages, we
speak of it as a privilege for him and tell him that if he does real well in the other dinee
some day he may go to that one, and soon he asks for it. In that class he is shown how
it helps in the other things he likes so much.

In every class there is some formal work to be done, and here the personality of the
teacher miist play a large part. She must constantly encourage, see the good work,
and literally pat him on the back. I should like to emphasize the fact that patting on
the back is most effective, however, only when it is applied above the waistline.

The learning of the three R's is very difficult for defective children. PuentB who
say that their one great desire is to have the child learn to write a letter home or to
read for his own pleasure seldom realize what a task they set. There is grave dangw
of developing a nervous irritability or creating a dislike for all school work by trying
to force the child to do this sort of work when it is neither ready nor able to do it
Often after much patient effort the child proceeds in a parrotlike fashion withont rail
understanding of what it is doing. The results are of course unsatis&u^tory to child,
teacher, and parent. It is significant in this connection that out of 400 children we
have been able to find only 6 who are really able to set type ton the writer press, and
yet for several years we have been selecting only trainable children, and visiton from
other institutions say we have a larger percentage of upper-giade children than most
institutions.

I have in mind a child of II with a mental age of 7. His reports say: ''Plays all
games well, canes a chair hidy well, makes a hammock, completes small woodworking
pieces, is making good progress in the band, a good worker in the gardening class, can
do simple knitting." Yet although he wants to write a letter he only succeeds when
he tells someone else what he wants to say and then copies the letter that is written for
him. He wanted to learn a Christmas recitation, and after weeks of effort succeeds
with it until he comes to the part where he spells s-l-e-d and k-n-i-f-e, and here he
always stumbles, often reversing the letters.

TIm real training of defectives must come through the hand . So there must be tnin-
ing in personal habits and caie, in household duties, in ftum and garden w(«k, in tiie
shops, and along musical lines. The school department should furnish the beginmngp
of all of this with kindeigarten and classroom, looking forward to the life the child is
inevitably to lead.

Sometimes after much training along vocational lines a child shows its readinesi
for the three R's, and then of course it must be given its opportunity.

When you hear a teacher of defectives say she is sorry that Saturday and Sunday, or
vacation time, break into her teaching, because the children foiget what they have
learned, you may be sure she is attempting to teach things Ua which the child is not
ready, and she is depending upon memory to take the place of understanding. It is
the same sort of thing that leads the fourth-grade teacher to say: ''I am wasting my
time teaching over again things that should have been taught in the second or third
grade." Many defectives are passed from grade to grade because they are able to
memorize well.

FUBLIO HEALTH AND MBDIOIKB. 635

The teacher of defectives must xue few and simple words, so that she may he under-
stood, and when she gets an unexpected answer she should see if she is not to blame.
She must define things in terms which are familiar to her children. She must have a
voice which is pleasing to the ear. She must never scold . And she must have a great
heart full of sympathy.

The Chaibman. These very interestmg papers are now open for
discussion.

Mr. Amos Butler. It seems to me that we are to be congratulated
that a brighter day is breaking, particularly with respect to the feeble-
minded, to be congratulated that so much interest is being awakened
and that so many people are being grouped into organizations for
advancing our knowledge. Those of us who have been associated
with the problems of the feeble-minded for many years realize the
ramifications of this subject, how it reaches out into pauperism, how
in our reformatories and prisons we have to deal with the defective
delinquent, and how many of them there are who really ought to be in
some other class of an institution than a reformatory or a prison. I
recall one school for delinquent girls where the institution was con-
tinually in turmoil, where one superintendent after another came
and went, largely due to the turmoil created by these mentally
defective girls, when finally a superintendent was selected who had
had experience as assistant vice president in a hospital for the insane,
and since then there has been no trouble with those inmates. She
knew how to deal with them. The first thing she did was to size them
up, sort them out, had three or four of the most pronounced cases
transferred to a school for feeble-minded youth, where they properly
belonged. Now things go smoothly there.

I note with interest the care that is being taken to ascertain the
individual conditions of the inmates of these penal and reformatory
institutions, to ascertain something of their condition before they
come to trial, before judgment is passed upon them, and before they
are sentenced. I refer to the work of Dr. William Healy, of Chicago,
and to the work that Judge Collins is having done in the Indianapolis
court. I had the pleasure of visiting Dr. Southard last August and
of seeing something of the work that is being done in cases that are
referred to him by the courts of Boston. The thing is to socialize
the legal profession, so that they are going to deal individually with
these mental defectives.

In the office of the board of State charities, of which I have the
honor to be secretary, we have 140,000 cards representing inmates of
institutions, collected during the past 26 years, and it is surprising,
as we check up one family after another, to see how two, three, four,
five, and six, and sometimes seven generations are represented in that
series of cards. Some run off in the direction of feeble-mindedness,
others are in the hospitals for the insane, others are paupers, and others

636 PBOGEEDIKGS SECOND PAN AMEBIOAN 8CIEKTIFIG C0KQBE88.

we find as truants, others in the penal and reformatory institutioiis,
and many of them come into the children's homes and there they
have to be sorted out, and they are passed on from one institution
to another.

And so I wish to express my appreciation, not only of the papers
that have been read by these two gentlemen who are promin^it in
this work, but also of the interest that is being taken in this country
in one State after another. We are coming to recognize the problem
of the feeble-minded, and we are coming to recognize it in a way that
shows we must deal with it intelligently and simmiarily.

The Chaibman. Is there any further discussion ? If not, we wiD
proceed to the next paper, by Dr. Healy, of Chicago.

YOUTHFUL OFFENDERS— A COMPARATIVE STUDY OF TWO GROUPS,
EACH OF 1,000 YOUNG RECmiYISTS.

By WILLIAM HEALY and AUGUSTA F. BRONNER,
Director and A$mtant Direetar, respectively , of Pgychopatkic InsOt^iUe, Juvenile Court

of Chicago.

The after careen o{ young offenders of our first series, studied some years ago, show
very clearly the immense importance of studying the causation of delinquency at the
only time tibat it really can be studied satisfactorily, namely, during the years when
delinquency begins. All of our experience goes to show that the many writers who
insist that practically all criminal careers begin during youth are entirely conect.
Not only is the high point for crime according to ages well within the later years of
adolescence, but also very many delinquents begin their careers even younger.

That thorough case studies can only be made during these earlier years is amply
witnessed to by many facts we have observed. Later the individual has broken away
from his family, frequently has taken on a new attitude which makes the ascertain-
ment of fundamentals difficult, is more likely to have drifted from his home town,
perhaps shows deterioration from dissipation that is altogether hard to distinguish
from innate mental defect. Besides this, the many interesting and more subtle pey-
chological considerations concerning the earliest growth of criminalism steadily
becomes more difficult to discern.

Treatment of delinquent tendencies, to say nothing of prophylaxis, rapidly becomes
more difficult with the increment of years; while etiology and diagnosis may not be
fairly developed without a wide range of facts.

There should be every rational demand for this more thorough study, both as a large
social issue and because, if anything is going to be offered to courts and institutional
people that is safe as a guide, it must be from the standpoint of safe diagnosis and
prognosis. In this country we have swerved already, with the advancing sodaHxft-
tion of our courts, from the tradition of set punishment for a given offense, but to help
the adjudicating authorities in their decisions they must not be given a mere bald
statement of what the individual b on the physical side and on the mental side from
the psychiatric standpoint; there is much more at the foundations of delinquency
than that. What are all the main elements which have caused this offender's con-
duct? What efficient remedies can be offered? To meet these fundamental issues a
broader study is necessary.

PUBLIC HEALTH AND MEDICINE. 637

We have watched many caaee from our first aeriee steadily develop antisocial trends,
and we have observed many others achieve great moral successes. To discuss reasons
lor the variance would necessitate the introduction of a large number of long case
histories. To get some general li^t on our subject we have undertaken now a differ-
ent studyf namely, that of a comimrison of a number of important facts pertaining to
two groups, each of 1 ,000 young recidivists. A study of the first series was elaborated
in " The Individual Delinquent." The later series is of a similar group not in any
way overlapping. From this laige number, so carefully studied during several years,
it is hoped that there may be found many points of practical significance in this field.

By way of warning against superficial inferences from our fijidings, it is well to
insist that conclusions must be drawn with circumspection. We present a picture of
facts without any direct interpretation of causes of delinquency that reqtiires careful
evaluation of factors in each case. Concerning differences between the two series
particularly relating to environment we feel that these may express little else than
chance selection of cases and different standards of judgment about conditions.

AOE8.

There is no essential variation in the ages of the two groups; the average is about
16 years, as mig^t be expected in juvenile-court material where the upper limit for
boys is 17 and girls 18 years. That we had to include children as young as 8 or 9 years
will not surprise anyone of laige experience, since, as the result of effective teaching,
perhaps by a criminal parent, already at this age there may have been a couple of
years of successful thieving. But these cases are rare, and much the largest proportion
is formed of adolescents.

0BZ.

The sexes are involved in about the same ratio as in ordinary court work, the males
being from two and one-half to three and one-half times as many as the females.

OFFEN8B8.

Our figures on offenses should be of much interest to the student of criminalistics.
They are worked up with a great deal of care and include much information other than
the ordinary court charge— in other words, they represent with considerable accuracy
the actual antisocial trends of these young offenders. The interest of these statistics
lies (a) in comparison of the sexes, (6) in comparison of the offenses of young indi-
viduals with what is generally known about offenses at larger ages, (e) in showing some
changes that are taking place in types of offenses under the rapidly altering conditions
of our material civilization, and finally (d) in the remarkable differences which exist
between the usual run of offenses committed in the older cities of Europe, and even
of the United States, as compared to Chicago. Our city, with its problems of immigra-
tion, new growth, etc., without the more manifest problems of excessive poverty and
social degeneracy of many European cities, is thoroughly typical 3t certain phases of
life in the United States.

Stealing.— In our old series (hereafter to be designated as O. S.) G6 per cent of the
males and 33 per cent of the females; in the new series (hereafter to be designated as
N. S.) 70 per cent of the males and 30 per cent of the females had engaged in stealing.
Under the head of stealinp we include all ordinary kinds of thieving where violence
is not used.

Burglary.— 0. S. maleB 8 per cent; N. S. 17 per cent. Burglary consists in actually
** breaking and entering" for the purpose of stealing. This indulgence on the part
of our American youth in desperate and adventuresome undertakings is a very sig-
nificant fact, and that in two successive series there should have been a doubling of
the number of those engaged in burglary is itself of importance.

638 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

Street robbery with violence— '* Holdup$.**—0. S. males 1 per cent; N. S. 4 per cent.
Very striking is this increase in the desperate delinquency of street robbery. Every-
one knows that this type of crime is committed for the most part by young msm over
the juvenile court age, but there has been a steady tendency with us in the last few
years to an increase of this delinquency among younger males. (Of course it ia very
rare that females engage in either burglary or street robbery, although sometimes we
find that they are accomplices. Occasionally out of pure spirit of adventure a g;irl
may indulge in housebreaking.)

Stealing automobiles. — ^A new type of offense which offers peculiar inducements
to the adventuresome youth is the stealing and driving away of automobiles. Be-
cause of the increase of the number of automobiles in the last few years, no i
factory comparison is possible, but within the time that our N. 8. was studied i
of cases have been brought to the juvenile court.

Picking pockets. — O. S. and N. S. 1.5 per cent each. It would be interesting to
compare these figures, were it possible, with the same offenses in cities, such as those
of Europe, where poverty is much more prevalent.

Forgery. — O. S. males 1.7 per cent, females 2 per cent; N. S. males 2 per cent,
females 1.5 per cent.

Carrying concealed weapons. — 0. S. males 1.5 per cent; N. S. 2.5 per cent.

Of other types of ** crime against property** we need say little, because the pro-
portions are small and show no essential variation.

Sexual offenses. — In any practical situation it is impossible to follow the classicml
lines of differentiating delinquences according to ** crimes against property," '* crimes
against the person," etc. But considering offenses of the latter order, we first enu-
merate sexual offenses.

Female offenders. — O. S. 60 per cent; N. S. 73 per cent. In studying the females
of our old series we did not discriminate between a slight amount ot sexual offense
with the opposite sex and the promiscuity which characterizes all grades of prostita-
tion. But of the females in our N. S. 57 per cent were guilty of promiscuous ofifonses,
thus being young prostitutes or on the border of becoming so.

Other sex offenses of which females are found to be guilty are homosexoal per>
versions, exhibitionism, extr^ne obscenity, and, particularly significant, the grave
misdemeanor of deliberately^ teaching bad sex knowledge.

Male offenders. — 0. S. and N. S. 4.5 per cent. This represents those who were
charged or were otherwise known to us as being sexual offenders with the opposite sex.
These figiu^, with their great contrast to females, undoubtedly represent the truth
of the situation, particularly being based on information ovw and beyond that which
has been revealed in court. The fact ia that males up to 17 are very infrequently
guilty of such offenses. Another proof of this is the infrequency of venereal diseaee
among males coming before the juvenile court. On the contrary, a large number
of the females are thus diseased. This last fact should be especially noted, in reply
to those who assert that young males are not brought before the court for sexual de-
linquencies and thus females are unfairly treated.

Sex perversions. — O. 8. males 4 per cent, females 3 per cent; N. 8. males 4 per cent,
females 1.5 per cent. Exhibitionism and extreme obscenity appear about equally
frequent in each sex. The more violent sex offenses belong, of course, almost en-
tirely on the male side. We find 1 per cent of our boys guilty of tampering with
little girls and 0.5 per cent were guilty of a serious sex assault. Also, 0.5 p^ cent of
our males engaged in the strange offense of touching women on the street— an indirect
sex demonstration with no attempt at assault.

Tnumcy. — 0. S. males 32 per cent, females 7.5 per cent; N. 8. males 43 per cent,
females 4 per cent. Under the head of truancy are counted only those cases where
nonattendance at school has been excessive for reasons other than illness. Many of
the boys had alrea<ly been to the parental school, a detention institution for truants.

PUBLIC HEALTH AND MEDICINE. 639

From these facts it may be sunnised that, since the earliest o£feDse is so frequently
truancy, a $rood vantage groimd for the early understanding of delinquent tendencies
and treatment of the same is to be foimd in thorough studies ot truants at the earliest
possible moment.

Runnino away from home. — 0. S. males 39 per cent, females 25 per cent; N. S. males
48 per cent, females 37 per cent. By running away from home we mean more than
merely staying away overnight. (Of course we know of many others who have run
away from home when the action was justified on account of deplorable family con-
ditions. ) The unexpected large percentage of young females who run away from home
is due to the general nature of their delinquencies, namely, sexual offenses, which
lead them to leave home in order to seek illicit partnership.

Vagrancy.— O, 8. males 2 per cent; N. S. 5 per cent. Vagrancy in the female is
very uncommon.

Not working, etc. — N. S. males about 10 per cent. Except family circumstances
justify it, not working is to be considered as a delinquency. It is an irregular charge
and frequently brought by families themselves and is not to be fairly enumerated for
comparison.

^*Out nights. ^^ — N. S. females 10 per cent. In city life this constitutes a very real
offense, particularly for young females, but the chajge is only irregularly made and
figures, as for *'Not working," are quite incomplete.

Delinquencies of violence. — N. S. males 15 per cent, females 15 per cent. Under the
head of violence it is necessary to include malicious mischief, bad temper, and vio-
lent general behavior. These delinquencies are only of interest in comparing males
and females. The physical characteristics of the average female who comes before
the juvenile coiurt explain the unexpected large number of offenses of violence. The
fact of physical over development is shown below.

Attempted suicide. — O. S. males 0.5 per cent, females 3 per cent; N. S. the same.

Other delinquencies, such as cruelty to children, threats to kill, attempts to poison,
manslaughter, arson, and rarely, murder, occur, but only infrequently, generally in
less than 1 per cent of our cases.

False accusations. — O. S. males 1 per cent, females 5 per cent; N. S. males 0.2 per
cent, females 9 per cent. This category includes only cases of very serious and per-
sistent false accusation.

Excessive lying.— O. 8. males 14 per cent, females 27 per cent; N. 8. males 7 per
cent, females 14 per cent. This charge was made only when lying was a notorious
characteristic of the individual. The overwhelming preponderance of this charge
against females is, of course, quite characteristic and often conmiented on.

Alcoholic intoxication. — Each series about 3 per cent for each sex. Drinking as a
contributory cause of sex delinquency in young women is of course more common
than is shown in the above figures. But, on the whole, there is very little use of
alcoholic stimulants among oiur juvenile population.

Drugs. — ^The use of drugs is quite imcommon with offenders until the period beyond
the juvenile coiurt age; it is very seldom that we encounter a case of it.

Gambling. — O. 8. and N. 8. males 2 per cent. Sometimes the passion for gambling
even at an early age leads to serious thieving.

PHYSICAL CHARACTERISTICS.

From the time of our earliest work we have noted that physical conditions of offend-
ers found to prevail in Europe do not appear nearly so frequently with us. What is
true for Italy or England in these respects is not at all true for Boston or Chicago.
Nothing so well illustrates this as our small proportions of those who are suffering from
malnutrition and who are victims of the developmental conditions resulting in so-
called "degeneracy.''

640 PBOCEEDINGS SECOND PAN AMEBIOAN SGIENTIFIG C0NGBE88.

** Age-weight correlations,^^ — ^Perhaps the beet indication of nutritional and general
developmental conditions is to be found in correlating wei^t and age, and oomparing
with the established norm. For comparison we have always used Burk's curve, built
up from data concerning 69»000 American young people. Males 0. S. 50 pw cent,
N. S. 64 per cent we find falling above the normal curve, and females 0. S. 73 per
cent, N. 8. 72 per cent were more than average weight for age. The status of the
males is only of interest inasmuch as it shows that crime in our commimity is not mt
all the matter of malnutrition following upon poverty to which it is largely ascribed
by writers in the older countries. Of very great interest is the frequent physical
overdevelopment of the young females. There can be no doubt that the conunon-
sense observation of many judges is true, namely, that a girPs sex delinquency fre-
quently begins upon the basis of physical overdevelopment, perhaps directly causing
her attention to be drawn to sex life, as well as leading her to be attractive to the
opposite sex.

GBNBBAL DBVBLOPMENTAL CONDmONS.

Under the following headings we enumerate only cases where the respective con>
ditions are well marked:

Poor general development. — O. 8. 5 per cent; N. 8. 17 per cent (males 21 per cent,
females 8 per cent).

General poor phyeicaX conditions, — O. 8. 3.5 per cent; N. S. 7 per cent (males 7.5 per
cent, females 6.5 per cent).

Delayed puberty. — 0. 8. 1 per cent; N. 8. 5 per cent (practically none of these caaea
were among females). In estimating this point we have used the ordinary physio-
logical standards.

Excessive over development for age, — O. 8. 4.5 per cent; N. 8. 9 per cent (males 5 per
cent, females 20 per cent). In both sexes we find this factor to be one prime cause
of delinquency.

Premature puberty. — 0. 8. 7.5 per cent; N. 8. 14 per cent (nudes 16 per cent, females
9 per cent). The early onset of adolescence peculiarly gives rise to the well-known
instabilities of this period and so readily leads to delinquency.

Good general physical conditions. — N. 8. males 25 per cent, females 32 per cent. In
our N. 8. we enumerated this positive finding to show how many could be considered
physically well equipped.

Sensory defects.— Detective vision: 0. 8. 10 per cent; N. 8. 15 per cent. We have
only counted this where the vision was less than half normal, or where there was some
disabling from other ocular troubles.

Defective hecuring,—0, 8. 1.5 per cent; N. 8. 1.6 per cent (of course, only marked
defects included).

Other ailments.— DiaeBseB and defects of nose and throat (serious cases): O. S. 6lper
cent; N. 8. 18 per cent.

Otorrhea, — Only enumerated separately in N. 8. 3 per cent.

Defective teeth. — (Cases of excessively carious teeth) 0. 8. 3 per cent; N. 8. 5 per cent.

Signs of nervous disease. — 0. 8. 2 per cent; N. 8. 4 per cent (in general this repre-
sents the distinctly neiux)tic types).

Somatic signs generally regarded diagnostic of congenital syphilis.— l!^. 8. 5.2 per cent
(0. 8. not enumerated in this way). On many of these a negative Wasserman test
was reported, but as everyone knows, this blood test sometimes shows negative when
damage has been done previously to bodily structiure.

SigTis of head injury,— O. 8. 2 per cent; N. 8. 2.7 per cent. (This does not include
ordinary scalp wounds or slight involvement of the skull.) It is interesting to note
the frequency of this injury preceding delinquency as compared to the infrequency
in the general population. Other minor ailments are found, of course, in various
degrees. For a closer analysis of physical conditions which are probably^ to be

PXJBLIO HEALTH AND MEDICINE. 641

regarded as causative factors of delinquency in om O. S., we may refer to the chapter
on statistics in '*The individual delinquent."

'* Stigmata of degeneracy.*^ — 0. S. 13 per cent; N. S. 3.8 per cent. In this category
we have placed only those who showed marked signs suggesting the ''degenerate"
type of individual . (Stigmata are found with us in greater proportion among the lower
mental grades who are not recidivists. They are being sent to institutions with in-
creasing frequency before environment has led them farther astray.)

MENTAL CLASSIFICATIONS.

The subject of mental classification of delinquents being so much before the public
nowadays, we have made our diagnoses with much care. Many cases which have
been difficult of diagnosis at first, have been seen by us over and over at intervals,
and considerable follow-up work has been undertaken.

A quite unselected group of 500 delinquents brought into the Juvenile Detention
Home, Chicago, some of them being only first offenders, showed 89 per cent to be
clearly normal mentally, according to tests given; of the remainder, 9 per cent were
probably feeble-minded, and 2 per cent were imdedded. These are important
figures as bearing upon the general problem of how many delinquents are mental
defectives — the group studied being the most unselected large series that has yet
been studied.

Certainly normal mentally. — O. S. 67.5 per cent; N. S. 75 per cent (males 76 per
cent, females 70 per cent). The remainder fall in various groups as follows:

Clearly feeble-minded. — O. S. 9.7 per cent; N. S. 11.5 per cent (males 10 per cent,
females 15 per cent). (It should be remembered that oiur figures here do not neces-
sarily represent fair proportions of all juvenile coxirt delinquents, since our services
are sometimes invoked first because the individual is suspected by some one as being
mentally subnormal.) Our grading has been made upon the basis of standard defi«
nitions and by the use of the Binet scale, supplemented, as it should be, by a con-
siderable range of other tests.

Subnormal mentally, — O. S. 8.1 per cent; N. S. 6.4 per cent (males 7.5 per cent,
females 3.3 per cent). This is a class of those not ranging low enough on Binet and
other tests to be graded as feeble-minded, but who are certainly not normal, not even
belonging to the group designated as poor in ability, but normal.

Dull mentally from physical causes. — O. S. 7.9 per cent; N. S. 3 per cent (males 3.1
per cent, females 2.6 per cent). This group is composed of those who are not to be
considered innately defective, because they have physical diseases or defects, which
may rationally be expected to interfere with normal mental functioning. A few
cases of epilepsy are included which were not otherwise classifiable.

Psychoses.— O. S. 6.9 per cent; N. S. 4.3 per cent (males 3.8 per cent, females
5.5 per cent). Attempts to classify these psychoses meet with much difficulty.
Undoubtedly, the dementia precox group preponderates, but even so it is not nearly
so frequent at this age as one would expect from the general literature of criminology.
Certainly not more than 2.5 per cent of our O. S. showed this disease, and, indeed,
we are inclined to discount even that figure, because oiur follow-up records show some
of these suspected cases unexpectedly recovering. In our N. 8. dementia precox
does not show as a probability in more than 1 or 2 per cent of the cases.

Other insanities and psychotic ailments, such as traumatic constitution, hysteria,
choreic, and epileptic psychoses, etc., appear in very small numbers.

CanstUutioTial inferiority. — 0. S. 2 per cent; N. S. the same. There are 5 times as
many cases among our males as among the females. This psycho-physical condition
forms a definite clinical entity, the individual being neither insane nor feeble-minded.

A contribution to the problem of the relationship of mental defect in females to
prostitution is found in the following table, based upon combined data from oue
O. S. and N. S. It is to be remembered that our cases were studied at the averagr

642 PBOOEEDINGS SECOND PAN AMEBICAN SGIENTIFIO CONGRESS.

age of about IS, at an age when the standard tests are known to be safe and before
bad habits can have caused mental deterioration, that from our good histories is not
recognizable as such. Our studies of these groups have been made with great care.

Mentality of 614 female offenders.

aalltyof-

Normal.

Feeble-
minded.

dtLO&CS,

Sub-
nonnal.

Pun from
phyafcml
causes.

Extreme and promiscuous sexual offsnses (182 cases).
Less extreme sexual offenses (808 cases)

Percent.
flO
66
74

Percent.
17
16
10.5

Percent.
11
10
5.6

Percent.

4
7

PereemL
8
7

Nonsexual offenses (124 cases)

EPILEPSY.

EpiUptie. — O. S. 7 per cent. Accurate comparison between the two series is im-
possible because of incompleteness of developmental histories in N. S., but even so
we learned of 4 per cent. Many of the epileptics were to be classified as mentally
nonnal, some were feeble-minded or insane, others merely showed the vascillatiDg
mental states peculiar to so many cases of this disease, and were either called sub-
normal or dull from physical causes.

MENTAL FECULL^RITIBS.

Adolescent instabilities and impulses. — O. S. 11 per cent; N. S. 21 per cent (males
18 per cent, females 27 per cent). No one can properly reckon up the genetics of
criminalism without laying great stress on the peculiarities ci the adolescent period.
We have constantly been brought up squarely against these phenomena, and have
enumerated merely the extreme cases.

Extreme social suggestibility. — O. S. 2 per cent; N. S. 3 per cent. Of course we
enumerate here this special mental trait as it was shown tQ bear upon the production
of delinquency.

Other mental peculiariHes, — Certain other characteristics come out, such as the
racial qualities of the negro, obsessive mental imagery, the love of gambling, racial
characteristics, and, finally, abnormal loVe of excitement and adventure, which
leads some of our young people to seek unusual experiences, appear in lesser per-
centages. Inordinate love of adventiure, N. S. 2 per cent.

MENTAL CONFLICTS.

The fact of there being mental mechanisms which, unsatisfactorily functioniiig,
produce delinquency, form one of the most considerations for the student of crimi-
nalistic beginnings. Nothing stands out any more clearly in our experience. We
ofifer no estimation of the extent of these phenomena: in both series we have met
with scores of cases, among both males and females. It is a confession of a weakness
in any study of a series of cases that mental conflicts are not carefully looked for in
every instance.

BAD HABITS AND EXPERIENCES AS CAUSES.

In both series we have known with considerable fullness the facts concerning habits.

Masturbation in excess.— O. S. 10 per cent, N. S. 11 per cent (males 13 per cent,
females 7 per cent). We would not allege that these figures are complete, bat our
findings are of highest significance even in the proportions given. Ordinary amount
of indulgence of this habit has not been counted in the above.

Use of alcohol.'—DnBkmg alcoholic stimulants to the extent that could be alleged
important is as follows: O. 8. 3 per cent; N. S. 1.7 per cent. Of course even a nnall
amount of drinking during adolescence is of great importance, and we have counted
it as such.

PUBLIO HEALTH AKD ICBDIOnaL 648

T6baeco,^The use of tobacco to a serious extent was found as follows: 0. 8. 7.5 per
cent; N. S. 10 per cent. Of course this was always entirely among males. Naturally,
we have not counted a slight amount of indulgence.

Drugs. — ^Very few cases of drug habits, even of the use of cocaine, notwithstanding
the popular ideas on this subject, are found during the juvenile court age.

Extremely early improper sex experienees, — O. 8. IS per cent; N. 8. 15 per cent (males
13 per cent, females 23 per cent). Probably this does not include by any means all
of the cases, but the figures are highly significant. In the analysis of the mental histwy
of delinquents these early harmful experiences show themselves ascf vast importance.

Early experience with sex perversions, — 0. 8. 1.5 per cent; N. 8. 2.5 per cent. The
males suffer far more frequently in this respect. We have found that these experi-
ences are particularly provocative of prolonged tendencies to misconduct.

ENVIRONMENTAL BACKO ROUND.

Through information obtained from various sources our knowledge of the general
environmental background in all cases is accurate enough in both series to be used
for comparison.

Good home conditions. — ^N. S. 5 per cent. In our O. S. this positive point of there
being a really good home was not enumerated.

Extreme lack of parental control.-^, S. 23 jter cent; N. 8. 46 per cent. Percentages
for both sexes is about the same. In enumerating this factor we have had to include
many types of causes, such as lack of control through negligence, through both parents
being away working, through an excessively large family, etc.

Extreme parental neglect, — 0. S. 4.5 per cent; N. 8. 16 per cent. This does not over-
lap with the former group.

Alcoholism, immorality f or criminalism in the home. — O. 8. 20 per cent; N. 8. 28 per
cent. The proportions are practically the same for both sexes.

Poverty.-^. 8. 8 per cent; N. S. 24 per cent. We have only enumerated poverty
where it is a factor sufiScient to apparently account in some way for the delinquent
tendency. We are not sure that the difference between the two series represents
anything significant.

Home broken up. — O. 8. 10 per cent; N. 8. 7.5 per cent.

Excessive quarreling in the home. — O. 8. 12 per cent; N. 8. 8 per cent.

Mentally abnormal parent in the home. — ^N. 8. 7 per cent. This fact was not enu-
merated in this form for our 0. 8. This cat^ory includes cases where at least one
parent at home was insane, feeble-minded or epileptic.

PAMILT RELATIONSHIPS.

In estimating the statistical value of the facts given below, it must be remembered
that the average age studied in both series is about 16 years.

Both parents dead. — O. S. 6 per cent; N. 8. 2.8 per cent.

One parent dead.—O, 8. 26 per cent; N. 8. 28 per cent.

Parents separated. — O. S. 20 per cent; N. 8. 14 per cent. Actual desertion by a
parent (included in the above): O. 8. 8.6 per cent; N. 8. 7.7 per cent.

Both parents living at home.—O. 8. 48 per cent; N. 8. 55 i)er cent.

niegitimacy.—O. 8. 2.6 per cent; N. 8. 2.8 per cent. These figures are probably
accurate, and as compared with European statistics of delinquents, are remarkably
small.

Alcoholism of parents. — ^Aside from alcoholism of a parent in the hoibe at the time
when the child showed delinquent tendencies, we must also, for fairness, enumerate
alcoholism of parents dead or deserted. By alcoholism we mean drinking to the
extent of at least occasional intoxication; in most instances it is more than this.
0. 8. 31 per cent: N. 8. 26.5 per cent.
68486— 17— VOL ix 42

644 PBOCEEDINGS SECOND PAN AMERICAN 80IENTTPIC CONGRESS.

BAD COMPANIONSHIP.

This was found in the following proportions: 0. S. 84 per cent; N. S. 55 per cent.
There is practically no difference in the findings for the sexes separately.

Conclusions to be drawn from the above analysis of findings are too varied to be
discussed here; many of them are too obvious to need comment. It is clear that much
is involved which should be of particular interest, not only for the present awakening
of psychologists in this field, but also for physicians who are constantly being drawn
more and more into cooperative work with courts. That all officials dealing with
offenders need to know basic facts goes without saying. Our whole work shows
nothing more certainly than that no satisfactory study of delinquents, even for prac-
tical purposes, can be made without building sanely upon the foundations of all that
goes to make character and conduct.

Dr. VON KleinSmid. Mr. Cliairman, ladies and gontlemon, there
are many excellent and suggestive features in the paper of Dr.
Healy. There are some things that are surprising to some of us
who have been thinking along the same lines and giving a great deal
of careful consideration to this problem. The writer defines very
clearly the field of this investigation of these recidivists and those
who have passed through the juvenile court.

The term '* feeble-minded/' for mstance, is one of those more or
less blanket terms. "Subnormar' is not coincident with feeble-
minded. The institutions that have more or less carefully organized
and well-manned departments for psychological research, institu-
tions of reform and correction, are doubtless not using the
term "feeble-mhided*' or the term "subnormar' with exactly the
same meaning. They are sending in figures, for instance, ranging all
the way from 33 per cent to 50 per cent feeble-minded. Some of
these institutions adopt the terra "feeble-minded" and use the term
"subnormal. '' In the matter of stigmata, in one histitution I have in
mind, 50 per cent of the cases show very clearly the generally accepted
stigmata of degeneracy. In the 50 per cent not so classed there
were a great many stigmata that would, without great generosity on
the part of the examiner, have been so classed. We are very careful
to use the words "sex perversion" for one type of offenders and
"sex perversity" for another class. Under the head of "sex perver-
sion" of girls, I was very much surprised at the figures given here,
as I thought them entirely too low, not for Dr. Healy 's investigation,
but altogether too low for other investigations which are being
carried on at this time.

Sex perversity would nm very much higher. In fact, I think,
without any question at all, 80 per cent would be a low figure for
a certain type of sex perversity found in the institution with which
I am most famihar. I think ttiis thing, as Dr. Healy has stated, is
of the greatest importance, but I carry around with me rather a
feeling of surprise that with recidivists passing through the juvenile
courts, feeble-mindedness will seem to play so small a part. My own

PUBLIC HEALTH AND MEDICINE. 645

impresRion from this type of work, and the impression which I think
is gaining ground with others who are in the same field, is that
feeble-mindedness plays a very much larger part in crime than we
have ever given it credit for.

I wish to express my appreciation of this careful study and most
excellent report.

Prof. E, E. Southard took the chair.

The Chairman. The next paper on the program is by Dr. William
A. White.

MENTAL HYGIENE— THE ETIOLOGY AND PREVENTION OP INSANITY
PROM THE SOCIOLOGICAL POINT OP VIEW.

By WILLIAM A. WHITE,
Superintendent Government Hospital for the Inecnxe^ Washington^ D. C.

In preeenting the subject of mental hygiene to this audience I desire to preface my
remarks by the statement that I am preeenting my own views of the situation as it
exists in this country, and although the general principles involved must necessarily
be the same elsewhere, still naturally the avenues and agencies through which
approach to the various problems must be had, will di£fer somewhat in different
countries.

Until the present generation, the study of mental diseases has been to medicine a
thing apart, and despite the emphatic statements from the medical men who followed
this specialty to the contrary, it has been so considered. The very fact that mental
disease was largely coextensive with insanity in the ]>opular estimation and that
insanity involved segregation in a public institution, necessarily separated the practice
of psychiatry in a very material and effective way from the other medical specialties.

While I believe that this separateness of psychiatry has been based to some extent
upon the philosophical doctrine of psychophysical parallelism, which raises what I
have called a pseudo-problem in philosophy, and as Prof. Meyer has aptly said >
raises a "medically useless ** distinction, it is my contention that this separateness
has been largely furthered by the concept of insanity itself. I do not want to enter
into a lengthy discussion of ^lis point at this time further than to say that it seems to
me that the concept of insanity has no longer, if it ever had, any medical usefulness,
in other words the concept ''insanity '' is not, in my opinion, a medical concept at all,
but solely a legal and sociological concept. The designation * * insane '' is only properly
applied to patients who have been declared insane by ''due process of law. " They,
therefore, come to make up a certain social class, burdened by a specific legal dis-
ability. Insanity is, therefore, to all intents and purposes synonymous with certi-
fiable, and the word tells us no more about the individual than this.

As a social class we know nothing more about the insane, from the standpoint of the
concept of "insanity," than we know of any other social class, aE, for example, book-
keepers. On the other hand, if we use "insanity'' as a medical term at all we cer-
tainly can use it only as the name of a symptom, a certain type of conduct which is
certifiable, and as such it gives us no more specific information about the individual
than the term fever or cough. The social significance of the term "insanity" is
directed entirely to defining a certain type of conduct, in general, conduct that is

» Meyer, Adolf: Objectivo Psychology or Psychobiology with Subordinatloii of the ICedicsUy C^wIcbs
Contrast of Mental and Physical. Jour. A. M. A., Sept. 4, 1915.

646 PBOGEEDINGS SECOND ^AK AMERICAN SdENTTFIC COKGKKB.

socially destructive in its tendencies. It makes no difference to the commimity whMt
a man thinks, or for that matter what he suffers mentally. He may think all he ploaoes
of acts of violence, for example, but let him so much as threaten to put them in action
and at once the community is interested. It is not what goes on in a man's mind, it is
what ia expressed in his conduct that is of social significance, and so the term " insane'*
only applies to certain types of conduct and it is readily seen that it is by no means
coextensive with the term " mental disorder." Many types of mental di8(mier do not
lead to that type of conduct disorder to which the tenn *' insanity" is api^ed, while
there are also many types of conduct disorder that do not raise the issue of insanity.

Then if we come to think about it and realize that the term ''insanity " is used as if
insanity were a disease, thereby implying that the whole group of people that we find in
institutions for the insane are all suff^ing from the same disease, the concept confronted
by our present day knowledge of psychology becomes little else than ridiculous. To
have the idea that the human mind is only susceptible to one disease, or else, to put it
more exactly, that all of the individuals in our institutions for the insane have one
disease, is to fail utterly to grasp the meaning of mind at all.

With the passing of insanity as a medical concept the way is at once opened up for a
consideration of the whole question of mental inefficiency no longer hampered by
arbitrary lines of division which b^:in or end at the door of the as3rlum and as a result
we are enabled to see the problem in an immensely broader way which illuminates the
whole subject of the meanings of reactions at the psychological level.

In order that I may make this statement somewhat clears, and in order that we may
be scientifically oriented toward the problem of mental hygiene, let me pause at this
point to briefly indicate what I mean when I speak of reactions at the psycholpgicml
level.

If we will consider for a moment the pathway along which biological phenomena
have finally found a culmination in man I think we may admit, for purposes of descrip-
tion, that the earliest types of reactions which living beings show were laigely phjrmcal,
that is, such reactions for example as depend upon the amount of moisture in the envi-
ronment, upon the temperature, upon expansion and contraction, and the like, that,
however, very early, and perhaps from the first, they assume in additon a chemical or a
physlcocheraical character; the problems of nutrition, of meatabolism, are found in
the unicellular organisms and are confessedly of a chemical and a physicochemlcal
character. The nervous system comes into existence relatively low down in the animal
scale, and when we find it we find a very simple series of ganglia and nervous cotrda,
which, in their earlier beginnings have largely to do with problems of nutrition directly
or indirectly. Probably these earliest forms of nervous systems are more nearly com-
parable with what we call in the human being the sym]:)athetic or the vegetative ner-
vous system . It is only relatively late m animal development that we find the central
nervous system, and last of all that we find evidences of anything to which we can
properly give the name of psyche.

¥^m this evolutional point of view we may consider, for descriptive purposes only,
the various functions as we see them exhibited in man. The physical reactiona are
such as are involved in the maintenance of the erect posture, the relation of the variooa
curves in the spinal column, the adaptation of the joint surfaces to one another, and
numerous other things; the chemical and plysicochemical reactions are still laigely
taken up with questions of growth, of nutrition, and of metabolism ; the central nervooa
system functions occupy a still higher place and serve for bringing about larger coor-
dinations between the various parts of the body; while the psyche manifests Its^ in
all mental functions at a level hardly approached even by any of the lower animala.

If we will take the broadest concept of the relations of the individual to his enviroBh
ment and of the functions of these various levels, if I may so call them, we will see at
once that the individual is always endeavoring—to use a teleological term — to bring
about an adjustment between himself and his surroundings, and that in order to do

FUBLIO HEALTH AND MBUEODniL 647

this it always in a position where it is advantageous to be able to concentrate all efforts
in a given direction and make everything subservient to that particular end. The first
function is the function of adjustment. The second function is the function of inte-
grati<m, and at each level we find the functions of the organism subserving both of
these ends. As we proceed from the physical through the various nervous levels to
the psychological level we find that each series of functions, as they increase in com«
plexlty, also serve to more thoroughly and more efficiently integrate the individual
and therefore make it possible for him to bring all of his energies together and concen*
trate them upon a specific goal. At the same time this function of integration is the
very necessary precondition to efficiency of adjustment to the environment. Let me
illustrate.

If I were to specify the type of instrument which man uses at the various levels to
bring about these two ends— namely, adjustment and integration — I should specify
first, at the physical level , the lever. This is exemplified by the type of action between
muscles and bones which serves the purpose of integrating man's frame-work so that
he may direct his exertions toward any particular end he wishes and thereby effect
to that extent an adjustment with his surroundings.

At the next level, the physicochemical, the hormone is the type of instrument
which is used to effect these two purposes. The chemical regulation of metabolism
is a means whereby the body is related to itself in its different parts so that it grows
and develops as a whole, each portion receiving and utilizing only its proper amount
and character of nutriment to serve the specific purpose of the development of that
part in so far as it may be useful to the whole <Mganism. Integration is thus served,
the organism as a whole is raised by this integration to a higher level of efficiency
and thereby adjustment with the environment to a greater nicety is rendered possible.
This hormone regulation which is effected through the medium of the endocrinous
glands is already with higher animals under the control, very largely at least, of the
vegetative nervous system, and so even at this level we are dealing with nervous
control. At the next level, the level of the central nervous system, the reflex is the
type of instrument which is used. The reflex is brought into action by contact
between the individual and the environment. It may be simple, it may be compound ,
it may be conditioned or unconditioned, but it is by building up series of intricately
int^related reflexes that the oiganism comes to respond accurately to certain aspects
of its environment. It is needless to illustrate further how this process of compound-
ing of reflexes serves both the purposes of integration and of adjustment. Still higher
and further advanced in the course of evolution the type of instrument which is
brought into play to effect these two purposes is the idea. The idea not only inte-
grates by keeping before the individual the goal which he is endeavoring to reach
and thereby serving to bring all his forces to bear to that specific end, but it also
reflects the environment much more accurately than can the stimulus which brings
about the reflex and thereby leads to a much finer adjustment. And last of all we
have arrived at that region which Mr. Spencer called the region of superorganic
evolution, the region of social psychology in which conduct gets its values from the
approval or the disapproval of the community of which the individual forms a part.
The type of instrument which is used at this level to effect the double purpose of
integration and adjustment is the social custom. Customs serve to integrate society
rather than the individual perhaps by binding all its units together to a common
end and in so doing they serve also to effect a more efficient adjustment of the indi-
vidual to the requirements of the community.

It will thus be seen that in the process of evolution there is an orderly progression
from the lowest to the highest types of reaction until they culminate in the reactions,
as I have put it, at the psychological level, and these latter take on social values.

While the individual may properly be considered as a biological unit, still the
brief summary which we have given of the evolution of his various types of reaction

648 PBOCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGBBSS.

shows a constant interplay between the individual and his environment which pre-
cludes the possibility of considering the individual as apart from the environment,
and this impossibility is especially to be borne in mind when the individual is con-
sidered as a social imit and his reactions are considered from the standpoint of the
social level.

All this is preliminary but necessary to the understanding of the place that the
psychological type of reaction occupies in the general scheme of the individual V
development and it is also necessary to the understanding of how, by a proceaB of
evolution, the type of reaction which the individual manifests gets its values reflected
from the social community. Conduct is the basis upon which the community judges
the individual. The individual may think as he pleases and the community his
no interest in his thoughts, but he must act along fairly well-defined Unes if he expects
to be left imdisturbed. Conduct, therefore, has a social value and its social value
is based upon its worth to the conmiunity. Every individual owes certain duties
to the community in which he lives in return for the immense benefits that that
community bestows upon him. Practically all of the things for which we coDsider
life worth living are made possible by the social organization, and in retom for all
these gifts from society the individual has a duty toward that society and it is iip4»
the basis of the eflSciency with which he discharges this duty that society passes
judgment upon his conduct as good or bad.

I>om this standpoint we see the individual evaluated on the basis of his usefulnen
to thS community as expressed in his conduct. Now conduct is essentially psycho-
logical, at least in its final manifestations, and so it is proper to inquire whether all
forms of social inefficiency may not be viewed, and properly viewed, from the stand-
point of mental deficiency. The so-called insane, and the various grades of feeble>
minded are already viewed in this way, while there is pretty general agreement
that approximately 50 per cent of the criminals and an equal p^ cent of the prosti-
tutes can easily be gathered under such a classification. To my mind it will be valu-
able to look at all the socially inefficient classes in this way and we will have no trouble
in doing it if our judgment is not hampered by the preconceptions of the old-time
* 'insanity" concept, in other words, if we can look upon mental inefficiency in the
broad way in which I have indicated, rather than from the narrow point of view d
certifiabiUty.

If we take this viewpoint for the moment and look at the 50 per cent of asocial
individuals who are not regarded as certifiable, and realize that they can not live
in the conmiunity as useful citizens, that they have to be shut up in some form of
institution or other, and then try to measure this fact alongside of our sch^ne ol
evolution of reactions, we see instantly that these individuals fail at the social level.
It is not necessary to find in such persons evidences of mental defects which show
themselves at what I have called the purely psychological level. Many such indi-
viduals are well behaved, well conducted, and relatively at least, efficient persons
within the milieu of an institution, but subjected to the increased complexities with
the resulting stresses of social Ufe they show immediately their inability to make
adequate adjustment. They fail at the social level of adjustment, and to eay that
this failure is not psychological is to lack in appreciation of what psychological meanp.
Of course I am intentionally refraining here from discussing the moral issue.

Now let us go to the extreme. Let us take the case of a pauper; not the ordinary
average pauper, because I think such an individual, we might all agree, fails in thk
same way. The criminal, too, may fail perhaps more than the average pauper, but
failiu'e to be able to care for one's self, earn one's own living, etc., is a failure very
much of the same general defective character. The only difference between the two
types of failure is a difference in the particular way in which the failure has come
about. In one instance there has been a positive offense against the standards of the
community, and in the other not. The level, or the depth of defect from viiich the

PUBLIC HEALTH AKD MEDIOINB. 649

individual su£fan may be the same in both instances. Let us, however, take as an
example the individual who has gone to the poorhouse because he can no longer
earn his living, and the reason he can no longer earn his living is because he has
received certain physical injuries, perhaps he has lost an arm or a leg, or his eyesight,
or some other of the organs upon which he has been accustomed very largely to
depend. One would naturally say at first blush that such a case catainly showed no
psychological evidences of deficiency, that the whole difficulty was entirely physical.
I do not think that is a fair way to. judge the situation. I have in mind Miss Helen
Kellw, who in her earliest infancy was stricken absolutely blind and absolutely deaf.
This young woman to-day is not only a highly respected and much loved member of
the community, but she is highly efficient. She writes beautifully, she takes the
lecture platform effectively, and ehe has trained her other senses in a way to take the
place of those which were lost, to a degree that is nothing ehott of marvelous. She
gets from life all of the wonder that a highly cultured and highly educated individual
can with his senses intact, and vastly more than the average normal individual.
Now when we see a person who, because he has lost an arm — ^perhaps he was a black-
smith, but it matters not—when we see such a person go to the poorhouse the only
possible explanation that we can come to for such conduct is that his inefficiency is
psychological. It may be expressed in such common terms as '*he has lost his
nerve," or ''he is unequal to making a readjustment, '' or ''he is too old to begin over
again," or a thousand other formulas, but reduced to their least common divisor, to
resort to a mathematical figure, all of these formulas contain by implication the
single element of mental inefficiency.

I will not burden you furthw with what I am afraid you will consider to be a rather
tedious and stnnewhat philosophical discussion of what ou^t to remain upon prac-
tical grounds, but it seems to me a very valuable thing to get a viewpoint of the
individual along the lines that I have suggested. It is only when we begin to see
the true meanings of the failures in life as they surround us that we are able to
approach the problem of mental deficiency in a practical way througji the natural
avenues. The main emphasis of the argument should be upon the fact that socially
efficient conduct is an end result depending, not alone upon psychological integrity,
but back of that upon integrity at all the various reaction levels as I have described
them. Each level is dependent upon the one beneath — ^its historical antecedent.
Conduct is the end result of the whole complex of mechanisms and resulting compro-
mises and its efficiency is a function of their integrity.

In the preface to our recent wwk on the Diseases of the Nervous System,^ Dr.
Jelliffe and I have said:

Man is not only a metabolic apparatus, acciu^tely adjusted to a marvelous efficiency
through the intricacies of the v^tative neurological mechanisms, nor do his sensori-
motor functions make him solely a feelii^, moving animal, seeking pleasure and
avoiding pain, conquering time and space by the emiancement of his sensory possi-
bilities and the magnification of his motor powers: nor vet is he exclusivelv a psychical
machine, which by means of a masterly symbolic handling of the vast horde of realities
about him has ^ven him almost unlimited po* ers. He Is all three, and a neuroloey
of to-day that ftiils to interpret nervous disturoances In terms of all three of these levels,
takes too nairow a view of the function of that master spirit in evolution, the nervous
system.

Mental hygiene is therefore the last word in preventive medicine. The asylum,
the prison, the poorhouse are where we find the results of failure. Such types of
failure as are represented in these institutions will, of course, alvays be vith us, but
the work of mental hygiene is not primarily Tnth these except in so far as they are
salvable. Mental hygiene is primarily addressed to preventing such failures who-
ever possible.

> JellifTe and White: Diseases of the Nervous System. A Text Book of Neurology and Psycliiatry.
Pub. by Lea & Febiger, Philadelphia and Now York, 1915.

650 PBOGESDING» SBOOITD WAN AllBBIGAN 80IBNIIFI0 COKGBB88.

For a great many mental diflordecB, eq>eciaUy the imrioos typee of '
and tlie so-called ''functional' ' conditionfl— the benign at oppoeed to the more i
tjrpes founded upon marked defect— for euch conditione, especially among tduhi,
the public hospital for mental diseases, the psychopathic clinic, and the public ^
pensary are the natural avenues throu^ whidi to extend help. It will take some
little time, however, and some effort before the mass of people know that much ageociai
exist or are available and also some little time and effort before there are enoui^ of
such agencies or those that do exist are prepared to meet the demands.

For the more serious conditions, particularly for the frankly defective states, the
schools are the places to work in. Here the individual is found at an eariy age, when
remedial agencies will be effective, if ever, and if not, then steps can be taken to ipeit
society an enormous amount of wasted eneigy in trying to make a useful cttiaea out
of material that can never arrive.

In this connecti<m comes the whole problem of education. The study of the atypical
and subnormal child has thought into relief certain vital problems in our educatlosal
scheme. Many modifications are already working throughout this scheme and it ii
ever coming nearer and nearer the ideal of fitting the educational treatment to the
individual rather than expecting all individuals to fit the same edocaiioiial mold.
We would not think of prescribing mountain climbing to a person with a broken ta^
diac compensation. We should be as careful in our educational prescripticns. H«e
comes also the problem of vocational training, for example, a still more qpecifie att«npt
to make educational means serve living endb.

Qoing deeper still, all problems of factory sanitation, of the employment of wooMa
and children, of employer's liability acts, workingmen's insurance OKganisatsons, dan-
gerous occupatioBs, compulsory education, and innumerable others, all take on a new
aspect when viewed in the li^t of the ultimate goal, the end product of individual
development, especially efficient c<mduct. Viewed in this li^t they are all prob-
lems of mental efficiency, and so, from this angle, belong to the field of mental hygiene.
This is true too of eugenics which, it seems to me, is a worse than useless type of effort
unless it rests upon the broadest foundatioub.

And so the mental-hygiaie movement is a movement calculated to pu^ the whole
problem of the consideration of the sick individual to a little higher (>lane. It has
been the custom to treat the child with PotVs disease so as to bring about an arrest of
the tubercular process and subsequent cure of the disease. The problem now becomes
one of helping the individual to get the maximum of good from life in individoal
expression and by social usefulness. This aspect is beiiig met now by the nurse who
goes to the house of the patient and helps regulate his way of living after he leaves
the hospital. We will probably see further developmtnta along these lines.

From this higher plane of observation the criminal law that punishes is unintelligent
Disorders of conduct need constructive handling. To destroy the individual dther
by capital punishment or by the slower process of constant repression i« a low-level
means of meeting the situation.

The mental-hygiene movement has as one of its functions the encouragement of aU
those lines of inquiry and research that lead to a better knowledge of the human
animal, particularly of his conduct reactions, and aims to secure less wasteful, more
efficieat means for dealiog with the problems that arise at this level.

The Chaibman. The next paper is by Dr. Bernardo Etchepare, of
Uruguay.

PUBLIC HEALTH AND MBDICU^B. 651

EDUCAaON DE LOS NiNOS NfiRVIOSOS.

Por BERNARDO ETCHEPARE,
Prc^eKT de CHnica Pnquidtrica de la FacuUad de Medicina de Montevideo, Urugtu^.

A lo6 efectOB de U educaddn merece investdgarae prolijamento el eetado pefqiiico a
iMTvioeo de todos los nifios. Deber&n set objeto de educad6n especial los niiios nervio-
800. A eie fin conviene establecer como son los niiios novioaoe.

Sin tener en cuenta los verdaderos d^biles mentales, d^biles simples pvopiamente
dichos, imbeciles e idiotas de que nos ocuparemos, diiemos que, en general, los nifios
nerviosos se ban caracterizado desde su entrada a la existenda por circunstandas que
no son ncnrmales; ban tenido perfodos de ezdtabilidad iicH en fonna de llantos con»-
tantes, rabietas, a voces episodios convukivos, con retardo o anomallas en el estable-
dmiento de la dentiddn, de la marcba y del lenguaje.

M^ adelante duennen mal, algunos de ellos son presa del sonambulismo; son de
car&cter iiasdble, col6rico; suelen ser capricbosos, testarudoa, todo lo que manifee-
lado por su modus vivendi en la &milia y en la escuela, traduce el efecto de taraa
infKngidas por la berencia o adquiridas en la primera infanda.

Desde temprano revelan a menudo repugnancia por caai toda actividad, ezperi-
mentado sensadones dolorosas varias, biperestesias, neuralgias; ofrecen iicH rojez y
palidez emotivas, tendenda al sfncope por inddencias f (itiles; sufren de dertas formas
de entero-cditis, dianeas nerviosas, anorexia, incontinencia noctuma de orina; suelen
tener tics espasmddicoa, asma nerviosa, etc.

Del punto de vista psfquico y emotive puro, adolecen de fiitiga m^ o menos r&pida
de la atenci6n, depresi6n intelectual intermitente, con claudicad6n de la memoria,
miedo general excedvo, accesos de cdlera inmotivada, terrores nocturnes, temores
mdrbidos o fobias, impulses mia o menos irresistibles, etc. En su parte afectiva,
espedalmente, pueden BuMr de falta o exceso de sensibilidad, de debilitamiento o
ausencia de sentido moral; pueden ofrecer carifios y aversiones, repulsiones y mal-
querendas curiosaa; suelen ser mentiroeos tanto como sugestionables en grade sumo.
Siendo a voces fotuos y vanidoeos son frecuentemente tfmidos al extreme de aparecer
torpes 0 tontoe, no obstante su inteligencia y basta brillantez intelectual.

Ya dibujan su nerviosidad con caprichos y fantasfas originales y bizarras que suelen
provocar gracia, pero que a una madre perspicaz, no pueden menos que alarmar;
IHresentan seriedadee precoces o alegrias extravagantes; son retrafdos en demasla o
juguetones en exceso, traviesos con maldad, etc. Como otros son perezooos, de una
pereza aparentemente invendble, malos discfpulos, con pobres notas de clase, a pesar
de su innegable inteligencia en m^ de un case, pero con una pereza que puede ser a
menudo astenia, tendenda a la incertidumbre, a la vacilad6n, en una palabra,
delatando una insufidencia psicol6gica que es en realidad una manifeetacidn de
berencia patoldgica o bien JB^un un des&dledmiento del oigamsmo fidco de m^ o
menos laboriosa investigacidn.

Pero tambito a los efectos de una mejor educaddn y con el fin de prevenir o modificar
cuanto antes y en lo posible, la apariddn de los sintomas ya descritos, conviene englobar
en esta cat^goria de nifios, los bijos de gotosoe, diab^ticos, artrfticos en general, que
presentan signos de una constitud6n patol6gica manifestada ya por una sensibilidad
desarreglada, una emotividad exceaiva, un burner pasando, casi sin motivo, por todas
las foaes de la alegrfa y del descorazonamiento, no siendo eeta situacidn otra coea m4s
que una manifestacidn previa de un estado constitucional de excitacidn y depreed6n
que amenaza la vida entera y que convendrfa combatir con tiempo.

Pero vamos m^ lejos. Dado el becbo que en el origen de estas constituciones
neurop&ticas hay, ya una berencia que hace sentir su efecto de generacidn en genera-
ci6n, ya episodios patol6gicos durante la ^poca gravida, en el nacimiento o en los

652 PROCEEDINGS SECOND PAN AMERICAN SCIENHFIO CONGRESS.

piimeroB afios de la vida, creemos que deben ser objeto especial de buena investiga-
ci6n m6dica y de cuidadosa educaci6n, a manera de buena profilaxis de la neuiopatia,
loe nifios que, por nonnalee que parezcan, cuenten en bus antecedentes familiareB
con enfermos nervioeos o mentales, sobre todo, y tambi^n los que en la ^poca de ^efr-
taci6n, pueden haber sufrido por el hecho de molestias del embarazo, loe que ban
nacido en malas posiciones, en estado asffxico o de muerte aparente, los p^minoe,
los convulsos de la primera bora, los que ban side vfctimas de una afecddn cere-
bral o meningftica, o que ban sufrido traumatismos craneanos en la edad temprana.

En todos estos casos, cualquiera sea la situacidn aparente'del nifio, no puede olvi-
darse que el sistema nervioso es, en el caso particular, un centre de menor reeistenda.
No se trata y^ de retardados en el sentido corriente de la palabra, como que puede
tratarse de sujetos muy inteligentes, pero se trata de nifios en potencia de ancmnali-
dad futura, tal vez derrotados de la vida, no obstante su apaiente normalidad y
basta casi perfecci6n.

Con este objeto, todo nifio deberfa no 86I0 ser examinado, sobre todo en el principio
de la segunda infanda, edad escolar, sine tambidn investigado en su anamnesia beiedi-
taria y personal, al fin de despistar una predispo8ici6n hereditaria o adquirida de
cahU;ter patol6gico que permitiera deecubrir la causa 0 la na6n de ser de alguna
pequefia anormalidad existente ya, y aconsejar la orientaci6n educativa apiopiada
para poner a cubierto la pequefia persona contra las contingendasdel futuro.

II.

Dentro de la mayor o menor fatalidad de la ley de berencia, es indiscutible que es
sobre todo en la infancia que contra ella se puede lucbar y preparar una vida ulterior
en que queden neutralizados, en lo posible, los efectos bereditarios. No cabe duda
que la fuerza de la berencia puede ir agravdndose por acumulaci6n de circunstancias
favorables a su desarroUo, pero tampoco cabe duda que con el mismo criterio puede
aceptarse que con procedimiento desfavorable no es temerario pretender aminorar la
acci6n de aquella obstaculizdndola, por lo menos.

En efecto, siendo la personalidad un complejo en proporci6n diversa, de varios
elementos que, los unos, provienen de las generaciones pasadas por via de berencia
y constituyen el ndcleo fundamental de aquella, y los otros, son fruto de la ambien-
cia, del ejemplo, de la ensefianza, en fin, adquiridos, los unos y los otros son neceaa-
rios en la dinimica moral. De otro modo habria que aceptar que nadie puede
modificarse, lo que no es admisible. '

Pues bien, en ese orden de cosas la educaci6n debe ensayar combatir las tendenciaa
anormales, modificarlas para oi^nizar titilmente el car&cter. Asf, buyendo de loe
extremes, siempre viciosoa, bemos de aceptar que si la educaci6n no tiene dempre
la intensidad de eficacia que por algunos se le ha atribufdo, al punto de baberse
pensado que basta el talento puede ensefiarse — ^no obstante, debe ser y es on agente
morigerador importante, suavizando o evitando un derrumbe o un episodio pato-
16gico. Es evidente que una berencia cargadisima no podrd ser resistida con fadli-
dad, pero nadie podrd afirmar que no lo serla en cierto grade y entfetanto, son
numerosos los casos en que una berencia menos preponderante puede llegar a aer
combatida dtilmente. En esta idea se basa el tratamiento preventive de la neuro y
psicopatfas.

Y para nuestro caso, tratdndose de nifios nervioeos, no es iina vista del espMtu ni
la persecucidn de una quimera, modificar en buen sentido las tendencias patoliSgicas
hereditarias basta su neutralizaci6n completa, pudiendo esperarse que una educaddn
bien hecha sin desmayos, con tacto y perseverancia, ha de poder basta sustituir la
tendencia congenita perversa pot otra bienhechora y adquirida.

Para noeotros pues, educar inteligentemente un nifio predispuesto ee evitar o
aminorar en el futuro la histeria, la psicastenia, la neurastenia y enrarecer por lo
menos, la alienaci6n mental. Esa misma educaci6n contribuird a suavizar caracteree,

PUBLIC HEALTH AND MEDICINE, 653

a pulir impulsoB, a regenerar insuficiendas que por lo menos, harin m^ f ^rtil y podble
la adaptaci6n a la familia y a la sociedad.

Por dltimo, nadie diBCutir& que una mala o deecuidada educaci6n contribuird al
fluigimiento de la neuroBis o a la conBtxucci6n de anomallaB mentales.

Vale indudablemente la pena constxuir asilos y priBionee, pero vale m^ saber ensefiar
con tiempo como debe marcharBe en la vida, para evitar aqu^lloe. No noe resignemoe
puee, a comprobar con Spencer, que se ensefia a cuidar caballoe y no a educar hom-
bres, sobre todo, agregaremoe, cuando estos niiioe pueden llegar a ser hombree en! ermoe,
aean ellos inferioree, locos o criminales.

III.

La educaci6n de los nifios nerviosos debe comprender la primera y segunda intancia,
hasta la pubertad inclusive. Sobre todo la segunda infancia, pubertad cerebral,
como se la ha llamado, 6poca en que se imprimen definitivamente o por lo menos, se
van a pronunciar en bus grandes lineas, los caracteree de la personalidad futura.

Pero tampoco debe descuidarse la primera infancia donde pueden manifeetarse
algunas peculiaridades denotando la susceptibilidad nervioea de los niAos. Aquf
los verdaderos educadoree deben ser los padres, ayudados eficazmente por la acci6n
del medico.

En el caeo de que el ni&o deba ser alimentado por una nodriza, convendrd que esta
sea sana, sin hdbitos alcoh61icos y lo que quizd parezca anticipado, de buen car^Urter,
no Bolamente porque la salud del nifio sufrird por malestar o infecci6n de la nodriza,
sine tambi^n porque es importante que desde temprano el infante est^ rodeado de
personas de buen cardcter, uniforme, que se observen y se contengan ante el nifio
puee no es discutible que en un medio de personas irritables, emotivas en demasia,
su idiosincracia nerviosa no harla sine expandirse mds y mds. No olvidemoe que el
gran Montaigne ha dicho que nuestro principal gobiemo eet& en manos de las nodrisas.

Hay, en efecto, ya boequejada en estos pequeilos seres una emotividad indudable.
£s asf que hasta se ha descrito, en el memento del sewage, una especie de nostalgia
desde que la relaci6n entre la madre o la Jiodriza y el nifio queda interrumpida, tras-
tomando la efectividad naciente del infante. No es diffcil darse cuenta de la sus-
ceptibilidad nerviosa de estos nifios que ofrecen sobresaltos a los ruidos fuertee,
Ihmtos fdciles por cualquier causa, hasta miedo de toda percepci6n nueva, con facili-
dad de temblor y aun mds raramente de convulsi6n originada por la fiebre, el dolor
o una indigesti6n.

Dos sentimientoB suelen aparecer en esta ^poca denotando la nervioeidad y son la
c61era y el miedo. £1 primero es una manifeetaci6n bien precoz de mal cardcter,
no hay duda como tampoco es dudoso que el tratamiento es un poco diffcil, pero bien
eetablecido el hecho de que el nifio grita, llora, se agita no por sufrimiento ffsico, lo
que hay que averiguar bien, sine por c61era, conviene dejar pasar la tempestad sin
gritos ni voces en^igicas y sobre todo sin las severidades a que recurren algunos. En
todo case un bafio tibio calmard mejor esta excitaci6n puramente preventiva y esta
hidroterapia tibia continuada mejorard esta tendencia.

El segundo sentimiento es el miedo. Ya cuando el nifio tiene varios afios hay
que mantener mds que nimca una actitud tranquila, calmindolo con la voz y el
gesto, sin aspavientos ni gritos. Es precise tranquilizar de tal mode que el nifio
aprenda poco a poco a no dar valor a lo que lo alarma. En particular la viuta de los
animales suele asustarlos; hay aquf un gesto atdvico que cuesta veneer. A ello
puede Hoarse familiarizdndolos poco a poco con la vista de lejos, luego de cerca, etc.
Para eso es precise que si los padres si alguna repugnancia m6rbida tienen por ellos
como para los truenos, etc., se dominen si es posible, para no exaltar la tendencia
heditaria hacla la zoofobia u otra.

Por dltimo es oportuno recordar aquf, que es ya de acuerdo general reprobar la tan
extendida coetumbre de distraer o adormecer al nifio con cuentoe fantdsticos en que

654 PBOOEBDINQS SBOOHD PAN AMBBIOAN 80IBVTIFI0 00HGBE8&

86 introducen noticiae a veces tiigicafl, a menudo penosaa. No hay coBtambie i
triste porque es exaltar la emodvidad en sentido d(doro80 o depresiTO y provocar
con el insomnk) o la pesadilla, verdaderoa ea tadoa de miedo, creandoespfritua tinuxatoB
que 80 asustan de la soledad, de la obscundad, do la nocho, etc., fabzicando futmoo
doprimidos, pidximoa obaesionadoa, ^bicos o mdanc61iooB . Ea jnociao puoi giitaidane
do cuentOB absiurdoa y tristes.

£a adomis oportono el conaojo do Oullorro. ^' Ea preciao puea, eafofsane on ovitar
a Ids nifioa norvioaoa todaa laa ocaaianoa auaceptibloa do deapertar prenatniamflnte
su sensibilidad eapecial y por eso ahorrarlea laa picmiacaidadea aoepochoBae, no
confiarles m^ que a airvienteB de moialidad experimentada, alojarloa do loa maJoo
ojemplos, de loa espocUculos dbsconos, de las convorsacionoa atrovidaa."

Por m^ quo opinamoe quo la doctrina del panaoxuallamo do Freud ea un tanta
oxagerada, no obstante y contando con la emotividad procoa de algunoa do estoa
niiioe, conviene ovitar todas las ocasiones poaibles de traumatiaino monl o aoxuai
dentro de lo descrito por el clfnico de Yiena. Uno do loa caaoa que m^ ha Uamado
nuestra atenci6n compronde la historia do una softora pslcast^ca quo asiatimoa
durante unoa afios y que tenia una preocupaci6n genital, un eacr^pulo sexual quo la
hizo desgraciada durante toda su adoloaconcia y ligada ciratamonto a la impfoaidD
que hacia loe 4 6 5 afLoe de odad 8ufri6 por arte de un sirvionte negro Mbrico. Otia
conocimos que en alguna mayor odad fij6 una proocupaci6n sexual por la vista de un
acoplamiento de p^rros, detonnmando una vordadera mania que la torturd durante
mucho tiempo.

IV.

Pero como lo hemes ya dicho la vordadera oducaci6n se efectuari en la segundA
infancia, a partir de los 6 6 7 afios. Es en este momento que la sensibilidad ae
perfecciona, que la personalidad consciente se organiza y que en consonanda la
actividad so desenvuelve. Es esto tan cierto que, como lo hemos ya dicho, este
perlodo por ello ha merecido por algunos el nombre de pubertad cerebral.

Si es en cierto modo discutible que el nifio tiene mejor memoria que el adulto,
desde que ^te ejercita mejor esta funci6n por otras circunstandas, no es discutible
que lo que podrfa llamaise la memoria esendal, la memoria simple, es superior en el
nifio, siendo ella la destinada a acaparar los primeros conocimientos que encontrando
terrene nuevo, virgen— impresionan, de manera indeleble a voces, el cerebro infantil.
Hay que aprovechar esta plasticidad para introducir en una psiquis nadente &vida
y creyente, las nociones mds fundamentales y propicias para establecer una convicci6n
propla 0 criterio personal adecuado para la lucha por la vida.

Pues bien, hay hoy una tendencia muy natural a preocuparse ante todo de la salud
flsica del nifio. Es innegable que si no hay salud mental completa cuando no U
hay f(sica en cualquier momento de la vida, en esta ^poca especialmente es precise
que las percepciones extemas como las verdaderamente cenest^cas se desenvuelvan
todo lo normalmente posibje. Sobre esta base se edificard una afectividad, una
emotividad dtil y eficaz y sobro todo ello desarrollard una inteligenda mejor
equilibrada. El adagio mens sana in corpore sano es siempre oportuno y mucho
mds cuando so trata de la mentalidad en lormaci6n.

No ignoramos que hay excepciones a la regla y que algunos genios ban side en su
infancia desgradadfsimos sujetos. Pero estas excepdones no pueden tenerse en
cuenta por su mismo car&cter y adem&s porque tratdndose del comdn de loa mortales,
nuestro dehor es producirhombres Utiles para la actividad personal, familiar y aodal,
y aptos para la mejor preparad6n de la especie.

Descartando aquellos cases, aun debemos considerar los cases denominados inteli-
gencias precoces, nifios prodigios. Si algunos de ellos realizan las esperanzaa que
inspira su precocidad, hay que tener presente que una buena parte son neurdpatas
y que alguien ha pensado ya que son candidates a la locura o a menudo condenados
a la esterilidad intelectual a breve plazo. Entre los cases que he observado de de-

PUBLIO HBALTH AHD MSDIOIirB. 655

k preeoi he vialo algvno de estos prodigioe inteatilet. No perdiendo de viata
eata penpeciiTa, convieBe mim que a otroe, lodeerleB de una verdadera anitencia
moral.

Pnee bien pent todoe IO0 casoe, debe pensane ante todo en la educacidn finca, en
la moralidad flaica como la llama el Profeeor Ballet.

El nifio en general necesita deeplegar su actividad (isica, mayor en la intencia,
pueito que repreeenta lu casi tbiico modo de actividad. Etta actividad exuberante,
un tanto desordenada por exigencia de su miama univerBalidad, por su joie de vivre,
debe ejercerse por rasdn del deaanollo en vista, en las mejores condiciones de oxi-
genaddn.

Bete concepto nos lleva inmediatamente a la conclusidn que debe favorecerse
la actividad en pleno aire libre, siempre que sea podble.

En la campafSa la educaci6n de la actividad se hace casi espont^eamente. No
Bucede lo mismo en las ciudades en que el nifio carece de eepacio y aobre todo de aire.
De eate punto de viata nueetra ciudad de Montevideo eet& (avoredda, puee se extiende
en una sona enorme, con calles amplias y casas de un solo piso en general sin olvidar
la vedndad del mar.

Pero en todos loe caaoa no debe olvidaiae el aforiamo de Moebiua: ''el campo ea el
paralso de los nifioa.*' En efecto, su actividad ae ejerce en atm^fera bien oxigenada»
en ambiente halagador a au aimpatla por laa coaaa de la naturaleaa.

Sin entrar al eatudio crftico del regimen eacolar, creemoa que debe daiae mucha
importancia al tiempo de la alimentaci6n y a la abundancia de recreoa, ain reatzingir
laa boraa de auefio. Una buena higiene para loa nervioa lo requiere asf .

En cuanto a la actividad miama, creemoa que loa nifioa nervioaoa, m^ que loa otroay
requieren la pr&ctica de juegoa comunea a la infancia, en general, carreraa, aaltoa,
carreraa de peraecucidn, etc. En eatoa nifioa eapecialmente ee aumamente titil aliar
un inter^ agradable a la neceddad del ejerddo y de la disdplina ya para combatir
una instabilidad de caricter que debe atenuarae o corregirae, ya para habituar a la
obediencia. Ea en tal creenda que, ya que la gimnaaia demaaiado cientlfica deapierta
menoe un inters agradable inmediato, que preconizamoa laa marchaa, laa evoludonea
de conjunto, laa marchaa militarea y loa juegoa que tienen reglaa eapedalea como el
"foot-ball." En eate Ultimo caao, como en el "lawn-tennia," el ejerddo se hace en
ambiente magnifico. Cuando el nifio tiene algunoa afioa, creemoa que el ejerddo
ideal es el remo.

Deade que la mayor parte de eatoa nifioe aon auto-intoxicadoa por una raE6n o
por otra, hay importancia en emplear en elloe sobre todo una buena gimnaaia reapira-
toria, no debiendo preocupar demasiado o sistemdticamente, la educaci6n muscular
general, salvo indicaci6n especial. Al contrario conviene, en personitas demasiado
susceptibles al impulse y a las tendendas m6rbidas, no cultivar el acrobatismo o la
(abricaci6n de h^rcules.

Uno de los mejores medios, sin duda, de combatir la auto-intoxicad6n, es facili-
tar la circulad6n de la sangre por medio de ima actividad general. De ahf la con-
veniencia de loe ejerdcioa ^cos que llevan con el esfueno r^pido la sangre a la oxi-
genad6n y a la eliminaci6n de toxinos por todas partes y provocando espedalmente
lo que se ha llamado la sed del aire que contribuiri muy seguramente a una completa
oxigenaci6n de esa sangre m^ o menos viciada, aegtin laa aptitudea viscerales de
cada uno.

4D6nde debe hacerse la educaci6n del nifio nervioso? Por lo que diremos despu^,
debe preferirse las inatitudones que est^ a loa ahededorea de la dudad, ee dedr, caai
aiempre fuera de la ftunilia. Laa pr&cticaa de hidroterapia forman tambidn parte de
una buena educad6n fisica; ea preciso no solamente ensefiar a practicar la higiene
de la piel que exdtarA un buen emonctorio en peraonitas que tendr&n neceddad de
eUo, flino tambi^n que fortificari la senaibilidad perif^ca, ya con bafioe o duchaa

656 PROCEEDINGS SECOND PAN AMERICAN SCIENTIFIC CONGRESS.

m^ o menos frfoe o templadoe que ejercen acci6ii i6m<% y sedante sobre el i
nervioeo, suavizando la emotividad y estimulando la buena actividad con un suefio
reparador.
No eetk demis que el m^co instituya el regimen diet^tico apropiado a cada caeo-

VI.

La educacidn moral propiamente dicha requiere doe coeas esendalee: el conod-
miento perfecto del educando y una preparaci6n o disposicidn especial del educador.

Si en la primera infancia, como fdcilmente se comprenderd el educador ha podido
0er la madre o el padre o la nodriza; en la segunda la cuesti6n se vuelve muy ardua.
Siendo ^ste el verdadero periodo de educaci6n, es aquf que las condiciones del educa-
dor requieren una delicadeza de eetnictura y calidad de procedimiento que no todos
los padres de nifios nervioeos pueden ejercer.

Ante todo es necesario adquirir un ascendiente especial sobre el nifio; la autoridad
moral debe ser indiscutible y esta autoridad ha de basarse a la vez sobre el lespeto y el
carifio. De otro modo no hay autoridad eficaz.

Dice Binet: "Si quer^is tenor ascendiente empezad por hacer vuestra pcopia
educaddn, tratad de adquirir un car&cter y el resto marchari 86I0." Nada mis cierto
y nosotros afiadirfamos voluntariamente: '^Con los nifios y especialmente con loi
nerviosos nada vale la pr^ica del ejemplo. Hay que ofrecerse como modelo y ofrecer
todos los modelos posibles/'

Pero ante todo, es precise que el nifio se habitde a ver en su educador una persona
tranquila, siempre duefia de s( nusma, sin un gesto airado, sin un movimiento de
c61era: el enojo no convence, la eneigfa tranquila, la fuerza impasible es mejor. Asf
como en drcunstancias graves, nada inspira m&B respeto y confianza que un valor
tranquilo, asf tambidn nada tranquiHza o calma mejor a un nifio nervioso, timorato o
col^co, que una actitud tranquila, una frase sin exaltaci6n, exteriorizando una
convicci6n absoluta y segura. Hay que saber qu6 creer para saber qu^ hacer.

Esto convence, domina y modifica. Dentro de un gesto de en^gia colocar en la
palabra un acento y un aliento de esperanza y seguridad. Un optimismo aJstemitiro
es de rigor en el case, dice CuUerre, y asf lo creemoe.

Por eso muchos padres, nerviosos jra, diffcilmente pueden ser educadores en el
presente case y hasta no deben serlo. El hogar de una familia desequilibrada, que
ofrece sus penosos espect&culos de reyertas, de exaltaciones 0 discusionee, etc., no es
el m^ propicio para organizar debidamente el car^ter de un nifio nervioeo. Al
contrario, es la prosecuci6n acumulada de la tara nerviosa hereditaria.

VII.

Bien estableddo esto, es precise conocer el nifio, hacer su observaddn como si ee
tratara de un enfermo y antes de abordar de frente su educaci6n, no ignorar ningnna
de sus caracterfsticas, buenas o malas. El m^co alienista espedalizado ayudari
con eficada.

Ya lo hemos dicho: la educaci6n debe tender a eetimular las buenas tendencias y
a substituir las malas, at&vicas por otras costumbres adquiridas.

Esta educacidn moral debe comprender dos capftulos importantes: (a) Emotividad
y (b) Actividad.

Respecto de la afectividad, lo que m&a llama la atenci6n por la Irecuencia es el miedo
en sus diversas formas, sentimiento tanto m^ adherente cuanto que es ancestral.

Combatir el miedo y no asustar jamds: creemos que ese es el medio de evitar lot)
tfmidos, los vacilantes y atin loe esorupulosos. No hay duda que el sacudimiento
producido en la infancia per un susto, no afirma la confianza en ei mismo, al
contrario, pues deja vibrar una emoci6n depreeiva que puede llegar a eer continua.
segdn la intensidad de la impref»i6n y el temperamento f«ii?reptible del nifio. Inais-

PUBLIC HEALTH AND MEDICINE. 657

tiremoB de nuevo sobre el hecho que m^ de una fobia tenaz, mds de un escrdpulo
invencible despu^s, m^ de una mania dolorosa, m^ de una excitaci6n desagradable
dificil de coiregir, ban tenido su origen en un miedo infantil. Mucbas manifesta-
ciones pflicast^nicas (lobiae, obsesionee, impuboe, agitacionee) ban nacido en la
infancia.

Debe cuidarse mucbo del procedimiento que bay que emplear para combatir un
miedo. Y sobre todo bay que guardarse bien, con el objeto de combatir un temor,
de inaistdr en afrontarlo. Cuando ^te es grande, combatir la emoci6n por la emoci6n
es un error, pues se puede despertar asl no 86I0 una fobia diuradera sine tambi^n una
ansiedad patol6gica peligrosa. Conviene no afrontar el temor sine prudentemente,
despu^ de un periodo mis o menos grande, de descanso, para disminuir ante todo la
vibratilidad nerviosa enfermiza. Cuando no bay mis remedio, predicar la resigna-
ci6n por necesidad, con palabras bdbiles de aliento, pero niinca exaltar la sensibilidad
so pretexto de experimentaci6n. £1 enfermo comprende mejor lo inevitable, pero
se rebela contra la experlmentaci6n obligada o de sorpresa. Es en algunos cases un
verdadero traumatismo sobre agregado.

El nilio que no ha sido asustado o que no ha side cultivado en su temor, no seHL
f^ilmente miedoso a menos de una poderosa herencia. Aqu^l que aprendi6 a tran-
quilizarse, viendo la tranquUidad de su educador y oyendo su palabra persuasiva, a
qui^n se razon6 amablemente en sus primeroe miedos, necesariamente suavizar4 o
neutralizard inmediatamente la emocidn producida y ella se desvaneceri. Se evitari
asf la creaci6n de lo que con raz6n llama Cullerre una impresionabilidad sistematizada.

Casi todo el mundo estk de acuerdo en el rol de la emoci6n en la genesis o en el
exacerbamiento de las psiconeurosis, histeria, psicateria, etc. Muy precox el miedo
en los predispuestos conviene no alimentarlo con cuentos absurdos, como ya bemos
dicbo, con bistorias de fantasmas, ladronee, fantasias mds o menos tristes, etc. Hay
allf rafces para miedos futures, d if iciles de combatir. Por lo mismo, conviene en derta
medida, evitarle los espectdculoe de enfermedad, agonia y ceremonias ftinebres.

Existe hoy una prdctica tan generalizada como lamentable de llevar a los nifios a
los cinemat6grafos sin estudio previo, sin distinci6n de edad ni caracteres, sin conoci-
miento de la calidad del espect&culo. Desgraciadamente la baratura de ese especti-
culo, lo pone al alcance de todo el mundo, y s^^uramente las empresas pulsando U
avidez del ptiblico por las impresiones fuertes, no ponen reparo a esas exhibiciones,
que en tales circunstancias, vulneran poderosamente la tranquilidad de los nifios
nerviosos, exponi^ndolos a miedos, honrores, que les quitarin el suefio o se lo poblar&n
de pesadiUas, preparando para m^ adelante una afectividad patol6gica. Es nece-
sario, en alto grado, modificar las condiciones de esa clase de espectiUnilos, para bacerlo
accesible en forma agradable, instructiva y amena 0 crear cinemat^grafos especiales
para nifios.

Del mismo mode conviene separar de la vista de los nifios nerviosoe las obras o
producciones polidales que tan en boga est^ y que ban creado en cierto modo un
detectivismo original^ i>ero que ciertamente turban no 86I0 el suefio sine la serenidad
de eepfritu de los nifios, poblando su vida de inquietudes y malestar. El nifio ner-
vioeo, exageradamente imaginative, a voces, sugestionable en grado miximo en otros
ca8O0, confunde sin protesta lo real con lo imaginario, y hace un criterio falso, abeurdo,
de la maldad y de loe sufrimientos humanos. iComo si no bubiera ya bastante con la
que en realidad tendri que aprender a ver y soportarl

Indudablemente es impodble evitar totalmente la vista del dolor, ni ccmviene
hacerlo en absolute, a los nifios nerviosos; i>ero es prudente amortiguar impresionee,
prepardndoloe para ellas con razonamientos tranquilos, atribuyendo a los hechos una
importancia moderada, sin explosiones de sentimentalismo inoportunas y hasta
pemiciosas. Se trata ante todo de evitar, en suma, las impresiones doloroeas bruscas
que son traumatiBmos morales intenaos a vecee, pero nada hay al fin, que no pueda

658 PROCEBDINGB SBOOKD PAK ABCBBtCAK 80IEKTIFI0 00KGBEB8.

fler estudiado siempre, que con tacto y pnidenda se fadlite ese estadio, evitaado las
flacudidfts mondee.

Ee neceBario acostumbrarloe a la vista de las gentes, alentarlos en su pfesentadite
de modo indirecto, UevAndolos poco a poco de lo conoddo a lo desconoddo, Migifliido
medios, ambientee y personas para no alannar. Asf se evitar6n mnchas timideGes,
fruto de una mala iniciaci6n en las reladones con los dem^.

Existe una timides curiosa que paralisa, que c<^be, sobre todo en eodedad, entre
extrafioe. Es lo que podrfa llamaiae la timides de las ideas que anula y esterilisa
mis de una inteligenda. Asf se tiene una idea que a voces puede ser el efe de una
re6oluci6n importante y no hay el valor de expreearla. Mia tarde se reconoce y ss
recrimina esta falta de energia cuando esa idea es luego emitida por otro o se reconoce
que si se hubiera procedido como se pensaba se estaba en el 6xito. Es preciso fomentv
la confiansa en si mismo, en la idea propia, desacostumbrando asf al nifio de la tntela
ajena. Con esto se evitari quisi o se diBm]nuir& esa necesidad tan imperioea que
estos sujetos, paicast^nicoe ya adultos, tienen mis tarde en la vida, que eer dirigidos o
que obtener la aprobaci6n extrafia anulando asf en gran parte el resultado que podrk
esperarse de su intdectualidad.

Pero ademib es preciso aguerririos contra su minno dolor, conm bus propios sufri^
mientos. Ha dicho R«iAn que el gran agente de la marcha dd mundo es el daht.
Por eso e§ precise habituarlos prudentemente a 61, No en balde Huysmanns ha
eecrito que el dolor ee el verdadero desinfectante del alma.

Siempre que un nifio enferme o se lastime, en ves de alarmarse y donoetrar est
alarma como hacen muchas madres, es preciso aparecer como no dando importanda
mayor al hecho produddo y llevar los cuidados con tranquilidad. Siempre que sea
posible convendrfa tambi^ que el nifio mismo se man^ara b61o para reparar el mal.
Por ejempio, cuando un nifio se cae al suelo o de alguna altura pequefia, no hay que
predpitaree a recogerlo y acariciarlo. Es mejor dominarse y observarlo y en todo
case sin apresuramiento, suministrarle auxilio si lo aecesita. Ee bueno que el niio
aprenda a contar consigo mismo ante todo.

Para combadr la pusilanimidad y la preocupaci6n de salud tan frecuente en estM
criaturas hay que proceder con cautela en presencia de sus ansiedades. Asf como el
m6dico en un neurast^nico o un preocupado debe guardaise mucho de los eximenes
fisicos frecuentee; asf tambi^ deben evitarse en el nifio nervioso las exploradonei
prolongadas y frecuentes o manifestar dudas. Al contnuio se debe ser alentador.
Pero para eetimular su prudencia deberi dedrse que algunas precandonee deben
tomarse para no ir mis lejos. La imaginaci6n del nifio, alerta, ir6 asf hasta un punto
razonable sin sobrepasar el Ifmite justo.

Sobre esta base de cultura de la confianza en sf mismo que es fundamental para la
continuad6n de un csnictstf conviene tambi^n combatir algunas otras tendendas y
sentimientos anormales o excedvos. Uno de estos, y muy frecuente, ee la c6\en,
Siempre que se pueda al igual de lo que efectuamos en presencia de una excitaci6ii
mental, es {M'eciso mostrame tranquilo y en el caso, ejerdtar un rasonamiento moderedo
demostrando no solamente la sinnz6n de la c61era sino espedalmente los resultados de
esa c61era, resultados que conviene sean soportados raaonablemente por el nifio. 6i
esto no fuera sufidente, como no lo es a menudo, empleamos un bafio tibio, como ya lo
hemes dicho o un repose en cama. En algtin case hemos empleado un poco de
clinoterapia con un relative aislamiento. Nada mejor si se tiene cuidado de mani-
festar al nifio que se hace todo eso para calmar su exdtaci6n nerviosa y que la cama
modificar& su nerviosidad para lo sucedvo. Asf se suele obtener la conclusidn caii
inmediata de la excitad6n que suele ser grande hasta la convulddn, y lo que es nh
importante afin, la sug6sti6n de que tal procedimiento lo curari, neiido asf que se
esforzar& tambi^n para dominar su c61era.

En esta misma v^ podr& ensefiarse poco a poco el dominio de los impulses y de otrti
manifestaciones como las averdones y antipatfas que se observan tan a menudo. 8e

PUBUO HEALTH AKD MEDICINB. 659

podiia Uegar en eeta forma, con la demoetraci6n de la inconveniencia de este senti-
miento por raz6n del propio interne de la persona, razonando aiempre con el ejemplo
a la vista o dtando ejemploe de grandee hombres o con Idb de pequefios camaradas que
pnedan servir de norma para constitnir lo que podrlamos llamar el cardcter intrfneeco,
a cultivar la forma superior de la voluntad, el poder de inhibici6n, en otras palabras,
el dominio sobre sf mismo que consideramos lo fundamental de una personalidad.

En estos nifios existen todavfa doe manifestadones muy frecuentee y que deben
corregirse desde temprano: la tendencia a la mentira y los celos.

Indudablemente la mitomania acentuada acusa un dispoeitivo psfquico especial
que puede ir hasta el delirio de imaginaci6n, ya bien conoddo en cllnica mental*
Pero aun en forma pequefia la tendencia a la mentira resulta a menudo, cuando no ea
un impulse o carencia de memoria y aun a vecee, en estoe cases, el resultado de unn
ausencia total de un buen ddculo de consecuenda y puede ser combatida por un
tratandento moral. Esta psicoterapia debe tender a la demo6trad6n del inters que
hay en no mentir, haciendo comprender que el primer dafiado es el mentiroso y
hadendo luego estimar que el sufrimiento de loe dem^ Ber& obra suya. Algunos
ejemploe, siempre tan eficaces en la nifiez, ser&n utilfsimos.

En cuanto a la otra manifestacidn, nada hay m^ triste que un temperamento celoso.
Nada hay m^ doloroeo que los celos verdadera tortura que m^ que todo otro senti-
miento patol6gico, conduce al pesimismo, a la tristeza, al deeencanto cuando no, dee-
graciadamente, a reacciones de cardcter punible y hasta criminal. Aun en cases leves
los celos son uno de los sufrimientos morales m^ agudos que se conocen y es menester
combatir desde temprano la suspicada o una derta envidia que en el fondo del cardcter
■e manifiesta asf precozmente. Esos mismos celos inlantiles son reveladoree de una
idiosincrasia desconfiada que es bueno amortiguar en su prindpio, para evitar o dis-
minuir la multitud de interpretadores mis o menos patol6gicos que en la vida, m6a
tarde, se creen agraviados, escarneddos o perseguidos, cultivadores incondidonalee
del conocido aforismo: **Pien8a mal y acertards.^*

La substitucidn de la emulad6n a los celos y a la envidia serd la obra que debe
realizarse utHizando la f uente de amor propio en ocasiones exagerado, de estos pequefios
anormales.

No insistiremos sobre las buenas costumbres y el culto del honor que se ensefiaidn
pr&cticamente.

VIII.

Entre tanto es preciso observar, eetudiar la forma, direcd6n y capaddad de la
actividad del nifio nervioso.

Ya en sus ju^os, en sus relaciones con la familia, puede observarse alguna mani-
festaci6n desagradable en la producd6n de la actividad volimtaria o razonada. Doe
de ellas deben tratarse temprano. Son la deeobediencia y la pereza.

La primera requiere grades condidones de tacto, de parte del educador y un
conodmiento perfecto de la sensibilidad del educando. Util seri la observad6n
razonada y siempre tranquila, amistosa, demoetrando el mal efectuado pero al mismo
tiempo insistiendo sobre la posibilidad en que se encuentra el nifio de hacer las cosas
de otro mode; m^ atin, enaltedendo su dignidad y amor propio had^ndole comprender
que se tiene la seguiidad de que no procederi m^ asf. De esta manera se alienta
sin provocar rebeliones ni deemayos. Dedr a un nifio que es male, que es incapas
de nada bueno, que es un incorregible, es sugestionarle su incapacidad de proceder
bien.

Pero si a pesar de todo es necesario reprimirle es menester hacerlo con paraimonia
y usando de medios no brutalee: la cama, la privad6n de un paseo, de un plato pre-
ferido, de postre, etc. Los castigos corporalee son contraproducentes y en m^ de un
caso originan una situad6n indtil de odio.

La verdad es que en materia de correcd6n, loe castigos corporalee ni deberlan
mendonarse; en todo caso, la violenda de los i^ocederes de educaci6n arrastra la
violenda de reacddn emodonal, jra en sentido de exaltaci6n, ya en sentido depresivo*
68486— 17— VOL ix 48

660 PBOCEEDINGS SECOND PAN AMEBICAN SOIENTIFIO CONGRESS.

Adem^ hay que tener presente que en algunos nifios n^vioeos loe castigos y las
amonestaciones muy severas hechas sm diapasdn, han conduddo a mis de uno a la
desesperacidn y al suiddio.^.Hay que saber tambi^n contemporizar alguna ves
para que el nifio vea que no se aistematiza la repre8i6n.

La sensibilidad que puede en ocadones ser grande o que puede ser excedva llega alguna
vez a extremos lamentables. Uno de mis j6vene6 conoddos se Buicid6 por no atreverse
a comunicar a su padre, que lo trataba con severidad, que habla sido rechazado en
un examen. Tengo en asistencia dos j^venes psicat^cos, muy inteligentes, que aon
hoy, cad adultos, tiemblan, se sienten mal cuando oyen hablar fuerte a su padre
y son sujetos de un achicamiento lamentable de esplritu, a pesar de su inteligencia,
con una deeesperanza inmensa de la vida. He conoddo la existencia de algtin hombre
de cuarenta y tantos afios que ha sido, y lo es algo todavla, por causa an^oga de una
timidez ridfcula y dolorosa.

No hay que castigar. La amonestaci6n debe ser un razonamiento cordial; debe
ser una demostracidn del mal hecho y la persua6i6n de hacer mejor; hay que alentar
en la censura, hay que redimir en la observacidn dolorosa y siempre inroceder con
eetzicta justicia; esto es capitalfaimo.

Ha de Uegarse asf a que el padre o el educador sea el mejor amigo del nifio y no su
juez o su justiciero.

En cambio toda vez que el nifio cumple debidamente su deber, depaiarle discreta-
mente un elogio. Pero todavla es mejor, lo m^ a menudo posible, demoetrarle en ese
elogio cu^es son las ventajas positivas de su acci6n o la belleza moral que ello indica.

La actividad del nifio nervioso debe ser encarrilada en forma provechosa. Es
precise primeramente infundirle, ya que puede ser f&cilmente susceptible de cansan-
cio, la convicci6n de que es capaz del esf uerzo y para eso nada mejor que darie tarea
que pueda llevar a cabo f4cilmente. Esto le demostrari que su actividad es Uevadera
y poco a poco se ir&n aumentando las dificultades para habituarlo a la laboriosidad.
Es ventajoeo que proceda solo, para cultivar su espiritu d^ iniciativa, y b61o en casos
realmente dificiles para ^1, ayudarlo, pero siempre exigiendo su cooperaddn.

No debe olvidarse, como lo hemos indicado ya que estos nifios son ttcilmente ast^-
nicos, desalentadoe, vacilantee y es menester desarrollar la confianza en si mismo,
evitando las tareas prolongadas y dolorosas.

Mucho se ha hablado de la pereza de los nifios. Pero pocos saben que esta pereza
obedece a menudo a causas que contempladas pueden modificar la 8ituaci6n favora-
blemente.

Asf deben estudiarse las tendencias agradables, y favorecerlas si son convenientes.
No es posible perder de vista que en estos nifios la tarea dolorosa puede conducir sea
a lo que se toma por pereza, sea a estadoe depresivos.

Pero en otras direcciones es precise escudrifiar primero si no existe un defecto de
atenci6n o de memoria. Luego ver si esa pereza es ocasional; ocurre a<in en los adultos,
que de tiempo en tiempo se experimentan cansancios, en apariencia inexpUcables,
con mayor raz6n en estos nifios de agotamiento Mcil. Estos cansancios y no perezas,
deben contemplarse mWcamente.

En algunos casos estas peeudo perezas adoptan la forma intermitente traduciendo
ya una constituci6n psicost^nica que merece tratamiento especial.

En todos estos casos la funci6n tiroidea, ov&rica y supra-renal debe ser investigada.
Hemos obtenido buen ^xito en algtin caso procediendo asf. Espedalmente en la pu-
bertad de la mujer el tratamiento opoter&pico ha sido benefice.

Indudablemente en alguna ocasidn la f alta absoluta de interns o cierta repugnanda
demostrada en alguna actividad, o una mala direcd6n interesando de modo desgra-
ciado otro g^nero de actividad, puede sefialar una pereza en el sentido vulgar de la
palabra. Pero adn asf, un tratamiento moral bien dirigido puede triunfar de tal
emeigencia. En otras circunstancias un estado m^ o menos visible del organismo
ffdco puede explicar dertas asterias. El pulm6n y el rifi6n especialmente deben ser

PUBLIC HEALTH AND MBDICINE. 661

interrogados. En la 6poca vecina de la pubertad este episodio y el crecimiento
originan fdciles cansancioe.

Y no podemos olvidar particularmente la preparaci6n lenta, infiidioea, que prefiere
casi siempre esta edad, de la afecci6n mental denominada demencia precoz que se
caracteriza en sua primeros slntomas por una p^rdida absoluta de la actividad con
detalles bizarroe, caprichosoe, hasta extravagantee. Hemos visto ya porci6n de estos
perezosos, realmente bien enlermos.

En todo case, fuera de la enfermedad manifiesta, seri necesario reglamentar la acti-
vidad, no haci6ndola pesada ni prolongada. La colocaci6n de horae frecuentes de
recreo, la suavidad de loe programas de instruccidn, tan personalee como poedble,
haci^ndoloe menoe recargadoe especialmente en mateiias que no sean de neceeidad
abeoluta en la vida, contribuiri al bieneetar y al interns real de estoe sujetoe,

A guisa de trabajo tambi^n, un entretenimiento artistico, consultando el gusto del
nifio, serd de valor inapreciable: la mtisica, el dibujo, la pintura, etc.

Pero al lado del evangelio del trabajo, bueno es prodamar tambi^n el evangelic
del deecanso, como dice el Profeeor Ballet. Hay que organizar paeeos al campo o a
las playas un par de dlas por semana, por lo menoe. £1 contacto con la naturaleza
durante unas horas es bienhechor.

Y al lado de esas condicionee, tampoco debe olvidarse el suefio que nutre el c^bro
y que prepara las fuerzas del dfa siguiente. Muchos de estoe nifioe duermen mal con
I>eeadillas, terroree, etc. Alguno duermen poco o casi nada. Ha dicho Monier con
raz6n que: '*no hay como las noches blancas para engendrar las ideas n^ras.''

Si se hace una vida bien trsnquila, sin fiitigas ni emociones, estos nifios nervioeoa
dormir&n mejor y se prepanuri -una pubertad, que pueda ser, bien vigilada, la aurora
de una reconstituci6n de la personalidad humana.

IX.

En loe alrededores de la pubertad debe ser mucho m^ prolija adn. Para todo el
mundo es el memento crftico. Para Freud ee el memento en que el pan-sexualismo
en actividad va a dirigirse hacia la via normal o a la patol6gica. En este tiltimo case
se produce una efloresencia lamentable con tristes ramiUetes de neurosis.

Pues bien, la educaci6n sexual que debe haber sido inidada algtin tiempo antes no
debe temerse. Es hoy muy raro que los nifios de 10 y 12 afios ignoren en absoluto loe
misterios de la sexualidad. Los conocen por mtiltiples conductos, es inevitable.
Desgiadadamente esos conodmientos vienen a menudo envueltos en una atmMeia
de curiosidad malwana con f6rmula de apetitoe sensuales. Ese es el peligro.

ES| pues, precise combatir esa tendencia por medio de explicadonee hechas con
tacto y prudenda. El m6dico puede hacer oir su voz persuasiva tanto como den-
tlfica y por lo nusmo sana y respetable.

Esto ee cuestidn de tacto, segi&n el car6cter, la emotividad, las tendendas del nifio.
Pero en ningdn case ai la ensefianza se hace bien, habri inconveniente. Al contrario
se ensefiar& de un mode la verdadera apredaddn de la sexualidad con el significado
natural que debe tener. Es esto tanto m^ necesario cuanto que, en estos nifios, el
instinto sexual suele carecer de freno y hay que crearlo.

Se evitar& entonces el exceso solitario, el exceso compartido, el insomnio Itibrico,
las perversionee, todo lo que las conversadonee y lecturas pemiciosas puedan despertar
en este sentido.

Se eyitar& tambi^ lo que hemes visto muchos mWcos: el horror de la c6pula, la
aversidn por la matemidad y se conseguir6 el respeto y la consagraci6n de las leyes
natundes, la normalidad y la moral de la fund6n gen^tica.

Se evitar&, por tiltimo, por un conodmiento apropiado las enfermedades consi-
guientes y en todo caso las fuentes de pesimismos y desencantos sexualee que suelen
arrastrar ya a una neurastenia y hasta al suicidio que liquida tantos sifilffobos o tantos
escrupulosos de la fimd6n genital.

No es esta tarea imposible ni diffcil. Es solamente delicada.

662 PBOCEEDINQS SEOOND PAN AMEBIOAK SOIEKTIFIO C0NGEB88.

Eayt que demostrar que d amor n auprema ley de vida y aceptando iin hennoso almil
de Gullerre, establecer que el amor tiene Hempre la misma idtntidad de funddn y de
9ign\fioado tanto en el animal como en laflor.

The Chaibman. Dr. Ricardo Sanniento Laspiur will now pres^it
a series of moving pictures, showing the treatment of the insane at
large in Argentina.

Dr. Laspiub (at the close of the exposition): One of the greatest
advantagte claimed for this method of treatment is that the men are
in a better state, as they do not consider themselves prisoners. They
are not locked in. They see no walls aroimd them. Another great
advantage is that the State is at no expense in conducting the insti-
tution, as it not only pays for itself but brings in a large income to
the State every year, on account of the fact that it is able to support
all the other hospitals at Buenos Aires. I also wish to state that
the insane treated by our method are improved very much on accoimt
of the hygienic conditions under which they live and work.

The following pages are taken from a previously printed article
without date, submitted by Dr. Sanniento Laspiur in connection
with his presentation:

£b un hecho de observacidn, comprobado, diarlamente, en la vida de los aailoe de
alienadoB, que una gran parte de eetoe conservan el sentimiento de libertad, y que no
ae reeignan a perderla, protestando contra el enderro a que se creen injustamente
condenados. Muchoe ae entristecen, y entrando en la via, ya prepaiada, de laa inter-
pretaciones falaas, atribuyen a bub deudoB, a bub amigoB, a las autoridades y a loa
m^dicoB de los asiloB, el deeeo de perjudicarloB. OtroB, Bin abrigar esaa convincciones,
caen, aimplemente, en una triateza, ocafiionada per la Beparaci6n de la familia y por d
nuevo medio en que entran a vivir. ObB^rvaBO, igualmente, que la inmensa mayoria
de loB alienadoB, Bobre todo una vez desaparecido el perlodo agudo de la afecci6n. Be
caracterizan por la tranquilidad y por la inofeuBividad, y que estoB enfermoe son sus-
ceptiblee de eer ocupadoe en laa in^ variadas tareas, con positivaa ventajaa para su
Balud y para el r^imen intemo de loe eetablecimientoB. Puede calcidarBe que el 80
por ciento de la poblaci6n de Iob aailos urbanos, Be encuentra en eeta situacidn.

£1 tratamiento inatituido en elloB no es, por lo tanto, el indicado para la mayor parte
de loe insanoB, puee talee eetablecimientoB, boIo diaponen de reducido eepacio, est^
rodeadoB de idtaa murallaa, que lea dan un aapecto triate, carcelario, y no ea poaible
ocupar gran ndmero de enfermoa en laa saludablea tareaa al aire libre. Por todo eeo,
Manmdon de Montyel loa llama f&bricaa de cr6nicos, y Maudaley cementerioa de la
raE6n alterada.

£1 tratamiento en libertad eetk deatinado a obviar eaoa inconvenientea, y ae efecttia
en eBtablecimientoa aituadoa en la campifia, o colocando a determinada claae de enfermoa
como pupiloa, en el aeno de familiaa trabajadoraa, que viven tambi^ en el campo.

Loa aailoa de eeta claae cuentan con una gran 6xtenai6n de terrene, y loa edificioa de
que ae componen tienen, en au aapecto exterior, y aun en au diBpoaici6n interior, los
caracterea de caaaa de familia. Son chaleta o villaa aencillaa, el^gantea y c6modaa, ain
rejaa ni muroa que laa aialen, rodeadaa de jardinea que lea dan un aapecto adn m^A
pintoreaco. Tambi^ loa pabellonea al tratamiento de las formaa agudaa de la locura
tienen la arquitectura de chalet, porque la clinoterapia, o aea la cura por el repoao en el
lecho, empleada en eaoa caaoa, evita la conatrucci6n de laa aombrlaa aecclonea celulares,
y permite conaervar el miamo agradable aapecto a todoa loa edificioa. Eatoa chalets,
diaeminadoB en una vaata ext€ii8i6n, dan en au conjunto, la inpreaidn de un pequefio

PUBLIO HEALTH AND MEDIOINE. 663

pueblo, y no la de un hospital de alienadoe. Lob pabellones denen las puertas abiertas,
duiante el dia, de suerte que loe enfermoe pueden entrar y salir sm dificultad alguna.
Tampoco hay muros que circundeu loe establecimientoe y que oculten el horizonte.
For eeo los escoceeee ban deeignado, muy acertadamente, eete aistema con el nombre
de "Open-door.*'

El g^nero de vida que Uevan la mayor parte de los moradoree de estos asilos, se parece
mucho, tambi^n, al de los habitantes de una aldea de campesinos trabajadores. En
efecto, el trabajo, en bus mtiltiples formas, constituye la principal ocupaci6n de los
enfermoe, y la base del tratamiento moral a que est^ sometidos. Las ^nas al aire
libre ocupan al mayor ntimero de ellos, porque son las mia tavorables para la salud del
cuerpo y del eeplritu. La agricultura, la horticultura, la iruticultura, la jardinerfa,
los trabajos de lecheria, de la crla de aves y de cerdos, la albafiilerfa, etc., son los
preferidos. Tampoco se descuida el trabajo de los talleree, porque asf se utiliza la
habilidad de muchos artesanos en los m^ variados oficios. Es muy merecido, pues,
el nombre de asilos colonias que se da a estos establecimientos.

Persiguiendo siempre el prop69ito de influir, lo m^ favorablemente posible, en el
espiritu de eetos enfermos, se les proporciona todo g^nero de entretenimientoe. La
mtisica, el teatro, el cinemat6grafo, los juegos de 6al6n y al aire libre, los paseos, loB
picnics, etc., oonstituyen otros tantos elementos de la medicaci6n moral. Disfrutan,
tambi^n los alienados, de un gran bienestar material, en lo que se refiere a la alimen-
taci6n, vestidos, y comodidad de bus viviendas, contribuyendo, todo ello, a hacer-
les agradable su permanencia, que, en muchos casos, se prolonga largo tiempo.

Fuera de la gran libertad que gozan los enfermos en el interior de los mismos asilos,
se les conceden, adn, otras franqidcias, como, por ejemplo, la llamada libertad bajo
palabra, "liberty on parole,** que consiste en permitir, a los alienados, que salgan, solos,
de los establecimientoe, a visitar a bub parientes o amigos, con el compromise de
regresar, dentro del plazo que se les ha otorgado. Esta prdctica no ofrece inconveidentes,
pues los enfermos cumplen con la palabra enpefiada, haciendo honor a la confiansa
depositada en ellos.

Escocia, Alemania, Inglaterra, Holanda, Rusia, Franda y Estados Unidos de Norte
America, poseen establecimientos de eete g^nero, siendo la segunda de estas naciones
la que ha fundado loe mejoree modelos.

En la America del Sud, tambi^ existen en el BrasU y en la Argentina. La Colonia
de Yuquery, en San Paulo, y las dos de Luj^ y la de Oliva, en la Kepdblica Argentina,
demuestran el camino hecho por el nuevo sistema de asistencia. Los pianos generales
de esos tree establecindentos, que tengo el honor de presentaroe, dan una idea del
siBtema y de la magnitud de tales institutes.

La otra torma de tratamiento en libertad, o Bea la que se lleva a cabo en el seno de
familias agricultoras, se establedd hace muchos siglos en B61gica, en la c^lebre Colonia
de Gheel, y parecfa constituir un monopolio de los habitantes de la aldea de ese nombre;
pero no ha sido asf, pues se ha instituido, tambi6n, dltimamente, con excelente resulta*
do, en Escocia, Alemania y Franda. En el Brasil, en la provincia de San Paulo, ha
comenzado. igualmente, a practicarse, merced a la iniciativadel sabioalienista Franco
da Kocha. Pero, el tratamiento familiar, es solamente aplicable en cases cr6nico9, en
tanto que, en los asilos de puertas abiertas, se asisten todas las formas mentales, cuales-
quiera que sean bus perfodos.

Del punto de vista terap^utico. los reeultados obtenidos en estos asilos de puertas
abiertas, son muy satisfactorios: la propord6n de curadones y de mejorfas es mucho
mayor que la que se observa en los asiloB cerrados de las ciudades. Ia salud general es,
igoalmente, mejor, porque las condidones higi^nicas son m4i favorablee. El bienestar
moral de los enfermos es asimismo infinitamente m^ grande, pues, fuera de las comodi-
dades, que disfrutan, no se sienten propiamente encerrados, desdequedisponende
grandes espacios abiertos y pueden circular con libertad. Y no hay que temer que,
hadendo use de olla, sobrevengan accidentee graves que comprometan el orden y la

664 PBOCEEDINGS SECOND PAK AME&ICAN SCIENTIFIC CONGRESS.

disciplina de los eetablecimientOB, pues, los enf ermos que, por su estado mental, pudie.
ran dar lugar a eeoe accidentes, se hallan cuidadoeamente obeervadoe en las secdones
que lee eetdn destinadas.

Las evaaionee no son frecuentes, como pudiera creerse, porque, independiente-
mente de que se ejercita tanta vigilanda, los enfermos se hallan tan Men tratados,
que no sienten deeeos de f ugarse, al rev^ de lo que sucede en los asilos cenados d<mde
se encuentran, realmente, como en una pri8i6n y hacen todo lo posible por libertazBe
de ella, consigui^ndolo a menudo.

£con6micamente considerados, los asilos colonias son mis baratos que los urbanos,
tanto en sus constnicciones como en su funcionamiento. La edificaci6n es mia
sencilla, y menor es el costo del terrene. Ademis, el producto del trabajo de los
enfermos contribuye, grandemente, al sostenimiento de los asilos.

Para dar una idea mis completa de la constituci6n material y del r^jmen intemo
de estos establecimientos, par^ceme oportuno describir, aunque sea r&pidamente, la
Colonia Nadonal de Alienados de Lujdn, y proyectar algunas fotografias de ella.

Se levanta ese asilo en un terrene de seiscientas hect&reas, alto, f^rtil y ondulado,
pr6ximo a dos lineas de ferrocanil y a 67 kil6metros al oeste de la ciudad de Buenos
Aires. Un lerrocarril de trocha angosta, sistema Koppel, liga el establedmiento a la
estaci6n ^'Open-door" de la llnea del Pacifico. Esti dividido el asilo en dos sec-
ciones principales, separadas por una avenida de treinta metros de anchor el asilo
central y la colonia propiamente dicha. El primero se halla destinado al tratamiento
de las formas agudas de locura, o de los episodios de este caricter que aparecen en el
curso de las psicopatias cr6nicas, al de los padecimientos intercurrentes, al de los
debilitados, y al de cualquier case que exija una vigilanda constante.

Los pabellones que constituyen el asilo central tienen, exteriormente, la misma
forma sencilla y elegante de los de la colonia; pero poseen la diferenciaci6n intedor
apropiada al tratamiento de los enfermos que deben alojar.

La parte de la colonia, est& destinada a los enfermos tranquilos, inofensivos, trabtt-
jadores, y a los convalecientes. Los chalets estin sepaiados, por lo menos, cincuente
metros unos de otros, y se hallan ubicados en orden disperse y rodeados de jardines.
Se componen de dos pisos, encontr&ndose en la planta baja, los comedoree, las salae
de reuni6n y los servicios sanitarios, y en la planta alta, los dormitories, la ropeila, y
tambi^n los servicios sanitarios. Todos los chalets poseen amplias galerias exteriores
a la vez que corredores interiores. Tienen capaddad para sesenta enfermos, siendo
hoy la poblaci6n de mil alienados y una vez terminadas las constnicciones habii
capacidad para mil cuatrocientos.

En el centre de la colonia se encuentran: el pabell6n de la administraci6n, la cocina,
la casa de miquinas, la torre de agua, los talleres y el lavadero. Un poco separados de
este grupo de edificios, estin : la capilla, el teatro y el pabell6n de hidroterapia. Mucho
mis distante, en las afueras de este pequefio pueblo, se hallan: la lecheria, el criadeio
de aves, el de cerdos, las caballerizas, etc. Ademis, en distintos puntos de la cokmia,
hay varios chalets destinados al director del asilo, a los mMicos internes y a otros
empleados. Rodeando todos los edificios, se encuentran los campos de cultivo, con
una superficie de 500 hectireas.

El establecimiento no tiene muros que lo circunden, de suerte que realixa perfecta-
mente el tipo de asilo de puertas abiertas. Ha recibido, durante los echo alios que
Ueva de funcionamiento, 1,625 alienados, procedentes, en su casi totabilidad, d^
Hospicio de las Mercedes. De estos, han salido: curados, 20 por ciento; mejorados, 18
por ciento; falleddos, 4 por ciento; y fugados i por ciento. Durante los pnmeros
afiOB, los insanos asistidos eran, en gran parte, alienados tranquilos, y cr6nicos; y sola-
mente, despu^ que se construyeron las villas de clinoterapia se recibieron gran
cantidad de cases agudos. Asf se explica que el porcentaje de curaciones y de mejorfas
no haya side mis elevado. Esto no obstante, las cifras citadas son muy halagfiefias, y
demuestran la bondad del sistema empleado.

PUBUO HEALTH AND MEDIOUrB. 666

Los reeultadoB ec6nomico8 han eido muy satisbM^torios. £1 trabajo se halla oigani-
sado en grande eecala, pues el 90 por dento de la poblad^n se ocupa en las mia variadas
tareas.

Deede agoeto de 1901 hasta diciembre de 1908, es decir, durante siete afios y medio
el rendimiento obtenido es el siguiente: producto nominal, $971,096.60, moneda
nadonal, y en efectivo, 195,133.44 moneda nadonal. Por mia que aparezca como
nominal, la elevada dfra citada repreeenta, sin embaigo, un rendimiento efectivo,
pues es lo economizado por el Estado, mediante el trabajo de los insanos. Paar
valorar la que ^te importa, se tiene en cuenta lo que cuesta en el comerdo d producto
obtenido, o lo que se paga por la mano de obra de un operario cuerdo, y lo que vale en el
establecimiento eeo mismo, realizado por los alienados. La diferenda que resulta
representa un benefido muy grande para d erario nadonal.

Como una justa compenBad6n y como un estimulo, se halla estableddo d ''peculio
de salida," que asegura ima pequefia recompensa, en dineio, a todos los alienados
trabajadores, con lo cual est&n en condiciones de subvenir a bus primeras neceddades,
una vez que han salido dd establecimiento.

Resumiendo, pues, nueetra opini6n, sobre la importanda dd tratamiento libre de
los alienados, llevado a cabo en los asilos-colonia, diremos que d estd completamente
de acuerdo con la naturaleza de las enfermedades mentales, cualesquiera que sean bus
formas y perfodoe, y permite asf aplicar una terap^utica radonal, a la vea que propor-
dona a los alienados un bienestar mond y material m^ grande que d que pueden
gozar en los aailoe urbanos. Estos, por consiguiente, ya no deben servir, en addante,
IMura la aaistenda dd mayor ntimero de los alienados; y sf, solamente para d trata-
miento de uigencia y como centroe de ensefianaa cllnica de la pisquiatria.

Dr. Shepherd Ivory Franz took the chair.

The Chaibman. Dr. Hickling has promised to open the discussion
of the papers of Dr. White, Dr. Laspiur, and others.

Dr. Hickling. Mr. Chairman, owing to the latenQss of the hour, I
will confine what I say to Dr. White's paper which sets forth very
clearly the modem concept of mental conditions, which is very far
away from the popular or legal concept of insanity. To-day just as
soon as we are bro\ight in contact with the courts in many legal
questions, and many of these cases do come in contact with the
courts, the question becomes "sane or insane.'' If a man is insane,
he is absolutely beyond the pale; he is legally and socially dead.
He is immime from punishment or anything else, and usually by
legal force he is locked up in an insane asylum, and that ends it.

Now, there is nothing that is more unjust; nothing that is more
untrue. The next question is, that if he is not insane he is of sound
mind and responsible for his actions. Such a division, of course,
does not exist in reality.

. I do not want to go into the question of the mistakes, the abuses
and conditions which a failure to reaUze the truth of Dr. White's
paper brings upon us every day, but I do wish to caU attention, with
respect to the modem medical conception of mental conditions, to
the fact that they are best called to our attention in the homes where
the children or the adults do not get along with their environments,
i. e., at school or in the State and city where they present difficulties
to the government. All of these cases, no 'matter what variety they

666. PBOOEEDIKGS SEOOKD PAK AMEBIOAIT SOISNTIFIO C0KGRB88.

may take, whether it may be through dehnquency, through truancy,
through inabiUty to make the mental requirements of the curricu-
Imn, or whether it be in antisocial or domestic acts, through alco-
holism or other criminal acts, it does not make any diflFerence, they
all belong under the same head and all receive the same mental
consideration, because that is the cause, and the remedy Ues along
those lines.

Another point which seems to me to be given consideration by
the lawmakers and by the workers in this field, is that these mental
cases require to be taken care of by the public and at the public
expense. And the pubhc is taking care of them in the most deleteri-
ous manner, as far as the individual is concerned, that it is possible for
it to take.

There is, of course, one good side, and that is imder our present
system of management they do protect society from them as mudi
as possible. And it is a question just how good that is. But it is
certainly deleterious to the individual.

Dr. Tom Williams. These papers attempt to destroy superstition
in regard to mental disorders. To say that an insane man should be
considered sui generis, and that he who is not insane is perfectly nor-
mal, places us in the danger, namely, of labeling individuals such and
such — epileptics, dipsomaniacs, feebleminded, etc. Dr. Healy has
protested against that point of view by showing that the estimate of
each patient shotdd be individual. Dr. Southard has emphasized
that also. The 'state of these individuals is very complex. It is
easy to detect and confine a person who is completely demented or
completely insane, and it is very easy to deal with a person who is
quite normal, if there is sudi a thing, but a case which has peculiari-
ties and occasional manifestations, slight defects in intelligence or
aberrations in the direction of even an excess of some of our poten-
tialities, is a difficult problem and requires exceptional treatm^it,
and that, it seems to me, is a most important fact to bear in mind in
connection with these cases. We must take these people when young,
and study them in the public schools, if we can get at them; and we
should provide for their future in the proper way by fitting them to
the proper kind of environment for their particular individuality.
That is far less expensive in the long run than the present haphazard
way of dealing with people. The problem for a body like this, it
seems to me, is to impress this fact upon the public and do it in a uni-
form way. I think that the principles which we all know and accept
should be adopted in order that there may be coordination on the part
of legislative bodies and philanthropic workers.

The Chaibman. The following papers will be read by title:

Regimen de convalecencia en los alienados, by Santin Carlos Rossi.

La equivalencia mental entre el hombre y la mujer, mirada del
pxmto de vista psicol6gico, by A. Moraga Porras.

PX7BLIC HEALTH AND MEDIOINE. 667

(El ejercicio muscular de la respiracidn, sistema sueco, es fisio-
16gico ? by A. Moraga Porras.

Autofrasias mentales, by Fernando Gorriti.

Higiene mental en sus relaciones con el desarroUo y conservaci6n
de la energia psfquica y de la fatiga producida por la ensefianza
escolar, by A. Moraga Porras.

RfiGIMEN DE CONYALECENCU EN LOS AUENADOS.

Por SANTIN CARLOS ROSSI,
Director de la Colonia de Alienados del Uruguay.

CONSroERACIONES GENBRALB8.

La asistencia de Iob alienadoe comprende algunos problemas de orden secundario,
cuyo deaden puede comprometer las conquiBtas m&B brillantee de la psiquiatria
moderna.

Advertida en sus prodromos una psicosis, descubierta la etiologia, dominado el
efntoma y en vfas de reint^rarae una personalidad, a menudo noe encontramoe con
BUJetoB que vegetan en la (iltima etapa de su enfennedad que tiende a curar, o que,
curadoB m^icamente, no nos atrevemos a devolver a sus actividadee anteriores, teme-
roBos de que el primer contacto con la sociedad sea el **latigazo" causal de nuevo
acceso.

Es que a medida que los psiquiatras ampllan el horizonte de la cllnica, nuevos con-
ceptos etiol6gicos o viejas verdades reeucitadas presentan indicaciones menos sonoras
que los abcesos de fijaci6n, los bafios permanentes, las inyecciones de oxigeno o las
jomadas de suefio, pero no menos nobles ni eficaces, y que concurren a completar el
dclo terap^utico de la locura con m^todos educativos y medidas profil&cticas.

La convalecencia de los alienados es uno de aquellos problemas. Ese estado, acaso
el m&B delicado de una psicoeis, no es 86I0 la transiddn de la enfennedad a la salud,
como en patologfa comdn, sin6 tambfen, como lo advierte el Dr. Legrain, "el perfodo
de reeducaci6n del alienado y de su readaptaci6n al medio social, al mismo taempo
que la acomodaci6n de este medio para el alienado con un fin de protecci6n durable."
La actuaci6n combinada del medico y la administraci6n — agrega el referido autor —
ax)arece aquf en toda su importancia, suponiendo para ambas entidades una serie de
obligaciones imperiosas y exigiendo el empleo de medidas oportunas.

Obra de profilaxia social como orientaci6n dominante, aunque doblada de un aspecto
dlnico que exige su terap^utica, interesa especialmente a la asistencia oficial, por eso
consagramos este estudio exclusivamente a las instituciones de asistencia ptiblica y
proponemos medidas exclusivamente administrativas.

CONSIDERAC10NE8 DE Indole m^dica.

Indicaciones de la etiologia, — Al mismo tiempo que enriquecen las tablas nosol^cas,
las nuevas invesdgaciones sobre la etiologia de la locura tienden a corregir el simplismo
de la asistencia hospitalaria. La doble f6rmula del alienado de 1860 — la degeneraci6n
hereditaria como antecedente y el manicomio como conclusi6n — va cediendo el trono
a las leyes de la patologia general, y los psiquiatras hallan que tambi^n en la esfera del
enc^falo se cumple la ley general de la claudicaci6n del resto del oi^ganismo, seglin la
cual ante una causa ocasional s\ificiente, cada sujeto claudica en la regi6n anatdmica
de la menor resistenda.

Ofrezcamos una colad6n excesiva a tree sujetos respect! vamente taradoe: uno, como
cardfaco, tendrd una asistolfa; otro, hep&tico, presentari un calico; otro, cerebral,

668 PROCEEDrNGS SECOND PAN AMERICAN SOIENTIPIO CONGRESS,

hard un sindroma delirante o un estado confusional. Imaginemos ahwa un trauma-
tismo moral euficiente, una emoci6n intensa: el cardiaco tendri un sfncope, el hepitico
una icterida, el cerebral bu acceeo mental de predispuesto.

La tesifl no es menoe fatal que la antigua, puesto que la prediBpo8ici6n edgue reinando
Boberana en la orientaci6n de la enfennedad; pero es mis consolador porque, poniendo
de relieve loe factored secundarioe, permite pensar en la profilaxia de las causae ocasiona-
les, y no eetd lejano el dfa en que el alienado tendri, como el cardfaco, como el hepi-
tico, como el renal, su cartilla de higiene.

Por eeo, dominado un cuadro clinico en toda su complexidad y hecho el lote de
responsabilidad de cada factor, \ma terap^utica completa debe atender a todos, y si
esa predestinaci6n, dejada como un estigma de vida artificial en el soma misteriosD
del embri6n, nos reduce a un nivel mental que no puede sobrepasarse, nos queda la
eficaz neutralizaci6n de los fetctores secundarioe, a fin de que por lo menoe falte d
''latigazo" sin el cual no se hubiera produddo, se hubiera retazdado o hubiera sido
menos rebelde el cuadro que combatimos.

Al lado de la predisposici6n y de la herenda — ^ftu^tores piimordiales, pero no sufi-
cientes ni necesarioe, volvemoe a repetirlo, de una psicoeis— la etiologfa de la locura
comprende todas las causas directas de la patologia comtin:— bid^gicas, fiBiol^gicas,
ifsicas, patol6gica6 — ^y ademis, en mayor escala que la de las otras vlsceras, sin excep-
tuar siquiera el fatf dico pulm6n, sufre la influencia depresiva de laB causae morales y
aociales. £1 ^^surmenage/' la miseria, el desaliento, el dolor, las emodones violentas,
las pequefias y grandee causas morales y sociales que engendran "la tristesa de vivir,"
todos esos factores sin microbio son proveedores tan frecuentes del manicomio, que
Guislain los encontraba en el 66 por ciento de sus vesinicos.^

De esa comprobaci6n se deriva la imcorporaci6n a la terap^utica de nuevos m^todos
o etapas complementarias de asistencia. Las alteraciones endocrfnicas susdtan li
opoterapia; las causas t67icas, la deeintoxicad6n; las causas intelectuales, la psico*
terapia; las causas morales y sodales que ban deprimido una personalidad, la recooBr
tituci6n del tono ceocstMco mediante la satisfacci6n arm6nica y normal de todas lit
exigencias vitales.

Ahora bien, salido el enfermo de la sala de clinoterapia e iniciada la conyalecencia
del sintoma que determin6 la intemad6n, el medico que ha dominado inteligeut»-
mente el cuadro patol6gico y averiguado, por sus reladones con la fetmOia del enfenno,
el medio social de ^te anterior a la afecci6n, encuentra en muchos cases que la vida
libre es una amenaza o por lo menos una sombrfa interrogaci6n, pues la sodedad bi
sido la antesala de la clfnica: los foctoree ocasionales no se ban rendido a la desin-
toxicad6n.

En el ambiente bien provisto de K asistencia privadai las indicacionee torap^uticas
de la convalecenda son ficUee de llenar: preparaci6n intelectual del medio paia
redbir al ex-enfermo, o aislamiento mitigado en una casa de campafia; prepaiaddn
gradual del sujeto, bajo direcci6n m^dica siempre, para reasumir sus actividades
anteriores.

Las causas directas del acceso curado pueden tener asi eficaz neutralizad6n. P^io
en la asistenda a los indigentes, en la asistencia oficial, ese sistema ^la por la base:
el m^ico no domina a su cliente sino dentro de los muros del asilo, y aunque pudieia
acompafiarlo al hogar, a menudo retrocederfa al ver erguiree en el imibral de la pobra
vivienda loe factores morales y sociales, abiertas las fauces como monstruos insadadoB.

Estudiemos la situaci6n del medico, en cuyas manos la sociedad ha puesto la salud
mental de uno de sus miembros, ante el dilema que se plan tea: el hogar o el asQo.

(a) El convaleciente es enviado al hogar, — El regimen que se indica al convaledento
es, dentro de las variantes particulares a cada ca^o: ambiente taranquilo y cordttl;
vida sencilla y gradualmente activa, sin preocupacionee econdmicas; alimentaddn
Sana y reparadora; confianza en Hi mismo y en el porvenir.

iCitado por Toulouse: "Causes de la folie."

PUBLIO HEALTH AND B£EDIOIK£. 669

Tales condicionee son indispensables para la curaci6n completa, sin ellas, o se alarga
la convalecencia y el eujeto queda en deficit mental o por lo menoe intelectual, o el
<:onyaleciente sufre una recalda que obliga a una nueva reclufii6n, antes de la cual
pudo haber cometido un acto antisocial o autoperjudicial.

La pr&ctica que tenemos todos los m^icos de manicomio nos indica que, en U
inmensa mayorfa de los cases, pretender que los indigentes hallen aquellas condicionee
en BUS mfseros hogares es una quimera, y no tenemos que apelar a la literatura de
melodrama para pintar los cuadros que observamos.

£1 ambiente tranquilo y cordial, a pesar de que es diffcil conciliarlo con el estado
-de pobreza, puede en rigor hallarlo el convaleciente, previa la disposici6n de la fetmilia
favorable al retomo del ausente: no queremos ser eec^pticos y evocar, ya que son loe
menos, los enfermos borrados del afecto, borrados del recuerdo, bonrados de la vida
<x>n mis fuerza que a los muertos, y cuya vuelta inesperada, tras empefiosas reitera-
ciones del medico, eb la del intruso o la del estorbo.

La vida sencilla y gradualmente activa exige que el sujeto encuentre pronto — y si
es mujer lo posea la familia — el trabajo remunerador y met6dico, lo bastante remune-
rftdo para alejar el factor miseria, lo bastante f&cil y liviano para alejar el foctor sui -
menage, lo bastante seguro para alejar el factor ansiedad. I^ alimentaci6n sana y
fluficientemente reparadora es un corolario de lo anterior.

Pero la buena voluntad de la familia y la disposicidn del sujeto no bastan, deegra-
ciadamente, para abrir un taller, conseguir cr6dito si no hay trabajo, ablandar un pro>
pietario. Los peregrinajes inti tiles en busca de recursos; las vueltas al hogar con las
manos vacfas, fpdgados y excitados; los reproches mudos que contra la suerte se pin-
tan er los rostros queridos, esas mismas dificultades que un dfa provocaron el primer
acceso en terreno desconocido, hieren ahora en campo m^ indefenso, y el convale
clente vuelve a ocupar la cama hospitalaria.

Reconocemos que este cuadro no se produce a menudo, pero no por ser diffcil, sino
simplemente porque el m^ico, consciente de la gravedad de una recaida y de su pro-
pia responsabilidad, se abijtiene de extemar a su enfermo mientras no domine su por-
venir, y de ahl provienen los observaciones cllnicas de alta alocuencia: la superpo-
blaci6n de los asilos, y la diferencia del porcentaje de curados entre los sanatorios y
los manicomios, diferencia que suele alcazar el 20 o el 30 por dento.

En nuestro servicio de la Colonia de Alienados, de reciente creaci6n, sobre un primer
contingente de cien alienados cr6nicos hay doce asilados con probabilidades cHnicas
de vida social activa. Son convalecientes detenidos en la dltima etapa, d^biles men-
tales y alcoholistas la mayorfa, y dos vesdnicos.' (Uno de los dltimos est& haciendo
oficio de pe6n en el eetablecimiento, pero es padre de &milia y su lugar no seria ^te
si su mujer no le hubiera sido infiel probablemente decepcionada por una espera
de dnco afios en plena miseria.)

He ahf, pues, la conducta por que opta el m^co: dejarlos donde estdn.

Estudlemos, en este segundo estado, el por\'enir del enfermo.

(b) El convaleciente permanece en el atUo. — Las indicaciones terap^uticas siguen
aiendo las mismas: ejercicio gradual y arm6nico de todas las funciones humanas,
tanto de la vida v^etativa como de la vida de reladdn.

£1 ambiente de un asilo depende en gran parte de la dispo6ici6n arquitect^nica
del mismo. £n el manicomio tipo antiguo es imposible pretender la eficacia de una
buena oiganizad6n te6rica. En el manicomio modemo, dispuesto en pabellones
aislados, separados sufidentemente, con predios agrfcolas y talleres completes, que
den una ficci6n de colonia d\ il, pueden encontrarse todos los elementos terap^uticos
de la con^ alecenda que no sean la libertad social del sujeto.

La condlci6n primera sigue siendo el ambiente, que desgraciadamente se descuida
en los manicomios comunes por falta de una organizaci6n cientffica adecuada. Es
curioso obser^'ar que mientras el cllnico que hay en todo medico de manicomio tiende

1 Es predaamante ma ciroaiistaiida Is que motiva esU trabajo.

670 PBOCEEDINGS SECOND PAN AMERICAN SCIENTIPIO C0NGBB8S.

a IndiA idiializar las psicosis, el terapeuta que lo acompafia tiende a umfonnarlas. Ni
hay asiloB especiales para convaleclenteB en todoe los palses, y en eeta afirmacidn.
podemos salir del Continente, ni hay seccionee eepeciales en todoe loe asiloe, ni hay
patios particularee en todas las seccionee. Una promiscuidad peligroea se encaiga de
inutilizar la fina labor de la eala de observacidn, promiscuidad que ee la nanna de
ambiente para el alienado que no tiene una familia aneioea de recogerlo tan pronto ae
inicia la convalecencia.

Queremoe insistir sobre este ambiente, porque si bien estamos lejos de loe tiempos
en que Las^gue pretendia que el funcionario m^ importante de un manicomio era el
portero, todavfa sigue en pie la bien fundada acusaci6n de Batti Tiike, para quien
'^si cierto ndmero de alienadoe curan a cauea de la aglomeraci6n y cierto ntkiero a
peear de ella, a ella hay que atribuir la demencia de otra porci6n de enfermoe."

La aglomeraci6n puede, en contadoe cases, ser un medio coadyuvante, por lo que
tiene de aociedad, en la reconstrucci6n de una personalidad, pero jamis la premie-
cuidad, sea con agudos, sea con cr6nicos. En esta pemiciosa comunidad el enfeimo
se eterniza en una etapa vecina de la curaci6n, apenas apagada la idea delirante,
eobre todo en loe estadoe melanc61ico6 y ceneetopdticoe, o apenas salido de su estup^
confusional y readquirida la conciencia. Muchas \eces hemes pensado, ante eeta
clase de sujetos que no progresan, en esas osteopatlaB tuberculosas o eeoe eczemas que
mantienen una supuraci6n insidiosa en el lecho de hospital, y que curan sin mis
remedio que el aire y el sol cuando las exigencias del sen icio les reclaman el sitio.

Los dos sfntomas dominantes que nosotros registramos en nuestras obsenadoDee
sobre esta dase de cr6nicos son la abulia y la sugestibilidad mim^tica.

Los d^biles y los alcoholistas pronto se acostumbran a la vida de holganza, sin el
quid divino de la energia impulsiva que bulle en las c^ulas de los seres completoa,
y concurren a engrosar la legi6n de loe **tuboe digeetivoe" que cubre loe patioe
policlfnicoe.

La abulia ee a menudo consciente y voluntaria, si este adjetivo no es una paradoja.
"iPor qu6 he de trabajar," nos dice un ex-alcoholista de la colonia que diiigimoa^
"si los otros mMicos me han asistido cuatro afios sin hacerme trabajar?" Ysin em*
bargo ee perfectamente apto y todavla joven, al extreme de que quizd la mejor pro-
tecci6n fuera para ^1 arrojarlo del asilo, corriendo loe alburee de su temida miseria y
vagancia delictuosa. Este cinismo es adquirido, porque lo tienen otros asiladoo que
no se atre\ en a manifestarlo verbalmente, sine en su resistencia al trabajo.

La sugestibilidad para la imitaci6n es m^ temible y sobre todo m^ rebelde, cona-
tituyendo a voces una verdadera forma mental. Se sabe que la sugestibilidad que
nosotros Uamamoe mim^tica, ee decir, por simple imitaci6n de actitud, no ee mis que
una de las variantes del contagio mental, la sugesti6n colectiva por imitaci6n involun-
taria, cuyo mecanismo hasidoadmirablemente dilucidados por Vigouroux y Juquelier.
El contagio mental es otra de las causae directas de la locura, un factor secundario;
pero ^1 no se limita a deformar una inteligencia con el fanatismo de una propaganda
religiosa o el vigor de una idea delirante, y la simple imitaci6n involuntaria o la
sugesti6n colectiva por el mo%imiento, formas menoe sonoras, hacen como las otraa
sus vfctimas y requieren terap^utica como las otras. Uno de nuestros enfermoe, que
tiene la mania de hacer cuernos con la mano, acompafiando el geeto de una mimica
expresiva, ha hecho varioe proe^litoe, encantadoe de la facilidad y el efecto teatral
del gesto. Igual acontece con diversas estereotipias demenciales. De paeo, mani-
festemos que, como tantos \icios ffsicos o mentales, esta forma de contagio tiene
aspecto consolador, porque a esa sugestI6n mim^tica del medio debemos la conquista
para el trabajo de mds de un '*tubo digestive."

En cuanto a la confianza en si mismo y a la del porsenir, la hemoe sefialado porque
creemos que se le da poca importancia en los textos did^ticos a la idea del tiempo
en el genesis de loe estados depresivos. Noeotroe hemoe notado que la evocaci6n del
pasado y el temor del pon enir tienen enorme importancia en el pesimismo y en la

PUBUO HEALTH AND MEDIC3IKB. 671

anaiedad, y algunos estadoe que no eran melaiic61icoe y asimismo algunas ideas
de grandeza ban cedido en nuestro consultorio a una peicoterapia persuasiva.

He ahf , en resumen, las indicaciones terap^uticas que se derivan de loe factoree
etiol6g:icoB que estudlamos, y cuyo descuido tiene por consecuencia aumentar el
pcfcentaje de cr6mco6 e incurables, i Se dir& que el problema es insoluble, el reeul-
tado fatal y que nadie tiene responsabilidad de que eso ocurra ni inters en que eeo
cese?

A esa pregunta responderemoe en el p&rrafo siguiente.

C0N8IDXBAGI0NBS DB InDOLB SOCIAL.

Si noeotros crey^ramos que el numen de la organizaci6n humana es la justicia, nos
bastarfa tiaducir en una p^ina sincera los dates de nuestra joven experiencia para
hacer el proceso de la sociedad en sua relaciones con la locura — es necesario ser m^
dice, y m^co alienista; partir de la causa de la enfermedad a la causa de la causa;
ll^ar a *Ma fuente,'' tantas veces enturbiada por la tiranla del prejuicio, la imposici6n
de la moral dogmitlca, la explotaci6n o el vicio de todos — ^para comprender la tre-
menda injusticia que cometerla la sociedad si se limitara a ofrecer los cuatro muros
del asilo al p6ic6pata que la molesta.

Afortunadamente, sin n^ar que la inteligencia humana no desoye las incitaciones
a la justicia cuando el Uamado estd revestido de piedad, sin negar la tendencia a la
protecci6n del que se declara venddo, nos bastard dejar sentado que este problema
clentffico tiene un fundamento econ6mico de capital importancia.

La desproporci6n alarmante entre las entradas y las salidas de los alienados en los asiloe
ptiblicos amenaza con una carga pesada a las administracci6nes en todos los palses.
Oomo el Estado no es, en suma, m^ que el administrador de los dineros del pueblo,
el lazo de uni6n entre la sociedad que da y la misma sociedad que recibe, resulta que
no es precisamente el Estado, sino la sociedad quien mantiene los invdlidos del meta-
bolismo social. Por eso le conviene, primeramente para honrar la seriedad cientifica
de las instituciones que crea, y en segundo t^rmino para disminiiir esa carga en per-
petuo crecimiento, que la asistencia de sus alienados sea la mds eficaz de las que la
terap^utica indica. Si los convalecientes demoran mia tiempo del necesario en salir
del asilo o si quedan como hu^edes permanentes en los patios de los cr6nicos, caldo
de cultura propicio a todas las deformaciones de la inteligencia, no es sin perjuicio de
loe recursos que ella dedica a ese rubro, y hasta de los mismos agudos que se ven
fatalmente descuidados en la proporci6n que les quitan los cr6nicos. Es, en resumen,
un doble capital social improductivo.

Si la ciencia aconseja determinado medio para atender m^ eficazmente a los aliena-
dos, si el humanista prueba que es una obra de reparaci6n social, si el financista agrega
que eso es econ6micamente ventajoso, ^no es un deber cat^rico de la sociedad
reeolver a un tiempo cientlficamente, humanitariamente y econ6micamente un pro-
blema vital para el mejoramiento de la raza?

iSerfamos menos Idgicos que los espartanos, cuyo ideal dionisiaco los llevaba a pre-
cipitar sus incompletes desde la roca Taigetes.

SOLUGIONES Y 8ISTBMA8.

SoluciSn cutminiatrativa. — Cualquiera que sea el aistema que se adopte, debe respon-
der a las indicaciones terap^uticas que hemes enumerado: ambiente tranquilo y cor-
dial; alimentacidn sana y reconfortante; trabajo met6dico y gradual, sea resumiendo
las actividades anteriores, sea siguiendo una nueva orientaciiSn si el m^co asf lo in-
dica; seguridad en el presents y confianza en el porvenir, vida de familia y sociedad —
todo ello forma un sistema de psicoterapia cuyo director debe ser el m^ico alienista.

Los sistemas propuestos son varies, cada uno con sus excelencias nadonales o regio-
nales, dependiendo la elecci6n mis de la posibilidad de aplicarlos que de la virtud de
Bu excelencia. Los expondremos sucintamente, no recomendando ninguno por la
raz6n apuntada.

672 PBOCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONQBE88.

1. El ambienU. — £1 ambiente hospitalario no es mds que un remedio de neceadad
para el convaleciente; a ^1 se recurrird en dltimo extremo. £1 medio natural es la
propia fainilia del enfermo, cuando el medico no tema la comunidad familiar. Siem-
pre que sea poaible, debe ensayarse la reacci6n afectiva por breves paseoe al hogar,
estancias de boras o dias, antes de la salida definitiva del asilo.

Para los que no tengan hogar, o para aquellos que no lo resistan en los primerot
tiempos o, en fin, para cuantos residen lejos de los asilos, la administraccidn cueata
con los varies medios siguientes.

(a) Distribticidn o colonizacidn familiar, — E^te excelente m^todo ha hecho bus pniebas
y es universalmente aceptado en principio. Aunque se emplea mis para los cr6nicos
tranquilos que para los convalecientes, estos se benefidarfan extraordinariamente del
ambiente afectuoso y protector de una familia extrafia, bajo la direcci6n mMica del
asilo o enfermerfa cercanos.

(6) El atilo especial. — £s un buen m6todo del punto de vista administrativo. Son
generalmente colonlas rurales, de recreo y trabajo al mismo tiempo, donde el convale-
ciente debe hallar el ambiente tranquilo y cordial junto a los medios de enaaymr sus
actividades en los diversos rubros de trabajo. Desgraciadamente no existen mim que
en teoria, pues en la pr^tica son colonlas de alienados tranquilos, pero donde est^
mezclados los convalecientes — que a menudo llegan demasiado tarde — con dementes
en remisi6n, cr6nico6 inofensivos, idiotas, etc. ; lo cual no le quita por completo al
medio agrfcola la cualidad y los inconvenientes de la aglomeraci<Sn hospitalaria.

(c) La secciSn especial. — £s el m^ modesto y practicable de los m^todos buenos^
siempre dentro de la esfera administrativa.

Pabell6n abierto en la ciudad o granja de colonia, tambito abierta al exterior, coq
BUS m^todos de ensayo gradual de vida activa y social, verdadera escuela de trabajo
y de sociabilidad, la seccidn especial es lo menos que puede pedirse para asistir a los
convalecientes sin recursos. Situado en el mismo asilo donde empes6 la awstimcia,
presenta la no despreciable ventaja de que el enfermo puede seguir dirigido por el
mismo medico asistente.

En la colonia que dirigimos, todavfa lejos de estar completa, hemes puesto oa
pr&ctica un procedimiento personal que hasta ahora no ha presentado incGnvenientes.
Inidadala convalecencia y examinada la posibilidad del alta, el asilado pasa a tnbajar
y vivir en comunidad con los empleados obreros del asilo, en el local que a Mob se
destina, conservando su calidad de intemado para el efecto de la libertad, que y^
reconquistando gradualmente. Los enfennos adquieren asf un dominio de sus actos-
que les satisface, conservando la disdplina sin BumiBi6n humillante, y siguiendo una
reglamentaci6n casi tan severa como la de un asilo sin dejar de estar considerados
como los obreros, que no son enfennos. Despu^ de un prudencial perfodo de prueba
se les permite salir del establedmiento con sus compafleros de labor o solos, hasta que^
se les otoiga el alta definitiva.

Se comprende que este procedimiento no puede extenderse a los grandes asilos,
pues s61o permite la inclu8i6n de pocos enfennos en el local de los obreros y nosotros
mismos no tenemos mayor experienda al respecto; pero lo seflalamos como una pmeba
de que siempre es prudente y conveniente aislar a los convaledentes del medio
heterog^neo.

(d) La libertad protegida. — ^Llamamos asf el sistema que permite la salida del enfermo
para procurarse trabajo en el exterior, conservando en el asilo su cama y su mesa, o
teniendo derecho a estos recursos en un refugio espedal, asf como redbiendo en su
domicilio socorro por un tiempo.

Para que sea eficaz, este m^todo exige una protecd6n constante del sujeto, y dirfamos
vigilanda, lo cual no es ficil de conseguir por simples medios administrativos. Aban-
donado a sf mismo, el enfermo no lograr& combatir el factor desaliento u holgazaner&t,
y en reaUdad los tales refugios suelen no ser m^ que ^' hotel de holgazanes." Esta
libertad debe forzosamente ser protegida por alguna institud6n — administrativa o

PX7BU0 HEALTH AND MEDIOINE. 673

social — que airva de b&culo al convaleciente en 8II8 primeros pasoe por una aociedad
donde casi fatalmente reinan prejuidoe reacioe al *4oco." Sin eeta protecci6n,
dejar libra al convaleciente equivale a entregarlo a su buena ventura.

2. Lo9 recunos. — ^Hallado el ambiente, daro eetk que la admini8traci6n tendria que
comceder m^ o menoe pr6digamente Iob recunoe, salvo en Iob casos en que la coloca-
ci6n del ex-enfenno fuera rentada, y vlgilando en todos los casoe la calidad del trato
que redbe el sujeto.

3. El trabajo.—Eete noble auxiliar de la terap^utica estd consagrado en la hifltoria
de la peiquiatria desde hace muchos afioe, ''Haced de manera, '' decfa Leuret en 1840,
^ 'que un alienado eet^ tan ocupado que no pueda pensar en lo que constituye el objeto
de 8u delirio, que el resto de bu tiempo est^ dado al suefio, y la curad6n no se haii
eeperar. '' £1 optimismo de Leuret ha eido autorizado por obeervadores eminentee,
entre loe cuales recordaremos al Dr. A. Marie por su estudio especial y por la experien.
cia diaria de cuantoe nos dedicamos a la asistencia en colonias agrfcolas.

£1 £stado puede proveer este inapreciable reciurso terap^utico y social de varias
maneras: establedendo talleres y granjas por el estilo de las 'Workhouses" inglesas
o empleando a los alienados convaledentes en industrias y empresas oficiales, estable-
dendo oficinas de colocadones anexas a los asilos, etc.

Loe medios dependen de las fadlidades de cada pals o regi6n.

Soluci6n social. — ^Hasta aqul hemos estudiado 86I0 la acd6n administrativa, dejando
de lado la acd6n social, que es sin embargo la m^ eficaz. Susdtar ^ta, fomentando
sodedades de protecd6n para los alienados y familias, es una verdadera obra de salud
pdblica. Pero entre la tutela administrativa pura y la sodedad de patronato privada
habrfa lugar para un sistema intermedio, que consistirla en subvendonar sodedades
filantr6picas de acd6n puramente social, o en establecer (vganismos extemos del
asilo, a base de fundonarios judidalee, escolares, medicos, por ejemplo, que no tar-
darfan en interesar al pueblo.

Lo esencial es que el £stado no descuide esta eficaz tutela del alienado y conozca
la via de acceso.

CONCLUSIONES.

Todas esas medidas, de que hemos dado una simple enumeraci6n porque no pro-
pondremoB ninguna concretamente, deber&n venlr acompafiadas de una reg^amenta-
d6n especial de la asistencia de los alienados convaledentes, reglamentad6n que
instituya las salidas en prueba, la cread6n de pdiclinicas y dispensaries psiqui&tricos,
la adaptad6n de las medidas judidales de protecd6n a las libertades graduates de
Indole m^ca, etc.

£1 objeto de este anilisis queda cumplido con sefialar la importanda de los factores
etiol6gico8 secundarios, los inconvenientes de la promiscuidad, las exigendas de la
tentp^utica de los aUenados convaledentes, en una palabra, y las cGnsecuendas de
8U desd^n para el individuo, la sodedad y la administraci6n.

Si tenemoB el honor de ver compartidas las condderadones que anteceden por los
eefiores miembros de la Secci6n Vlll del Segundo Gongreso Gientffico Panamericano,
pedimos su adhed6n y su veto para las siguientes conclusiones:

Primera. Loe alienados convaledentes no deben estar en promiscuidad ni con los
alienados agudos ni con los cr6nicos.

Segunda. La protecci6n del £stado sobre los alienados indigentes no debe terminar
en el asilo.

Tercera. Conviene que el £stado reglamente la asistencia de los alienados convale-
dentes sin recuisos, y los prepare para reanudar sus actividades sodales, por el sistema
que m^ se adapte a cada pals de entre los varios que la denda y la experienda pd-
quiitricas indican.

Cuarta. Conviene que el £stado fomente la cread6n y el fundonamiento de institu-
dones sodales para la protecci6n dd alienado.

674 PBOOBEDINGS SECOND PAN AMERICAN SOIENTIFIO C0N6&ESS.

LA EQUIYALENaA MENTAL ENTRE EL HOMBRE T LA MUJER, MIRADA
DEL PUNTO DE VISTA PSIC0L6GIC0.

Por A. MORAGA PORRAS,
MSdico Cirujano de la Universidad de ChUe.

Primera Pabtb.

Voy a ocupanne, debo confesarlo, en desarrollar una teeis diffdl por lo compleja y
quizd superior, por raia de un motivo, a mis eecaflas fuerEas; tesis que, a peear de
haber sido dilucidada por eminencias en la materia, o sea, por soci61ogoe y p8ic61ogo8
notables, no ha podido ser resuelta, todavla, en forma eficiente y definitiva: me refiero
a la equivalencia mental entre el hombre y la mujer, que algunoe aceptan con ento*
siasmo y otros combaten con vehemencia e igualmente, a las cuestiones Bociol6gicas,
pedag6gicas e higi^nicas derivadas de ella.

Esta tan escabrosa al par que interesante cuesti6n ha side tratada, muy principal*
mente, del punto de vista fisiol<5gico, y, como constituye, alin en la actualidad, un
problema todavfa no resuelto, me abstendr^ de estudiarla en esta forma y b61o me
ocupar6 de ella, mirada del punto peicol6gico.

El lado psicol6gico de la cuesti6n enunciada ee, sin duda, mis claro y mejor eetudiado
y de ahf que me atreva a abordarlo, dentro de mis facultades, animado solamente del
inters que despierta en mi este interesante asunto, digno de ser diluddado por una
pluma m^ autorizada que la mia; y que, una vez resuelto, ha de reportar no pocos
bienes a la colectividad social en genend.

Pero, antes de entrar en materia, s6ame permitido decir dos palabras acerca de la
facultad de pensar o inteligencia, base fimdamental, que nos ha de servir durante
el desarrollo de este tema, como punto de mint u objetivo.

La inteligencia comprende, un conjunto de facultades que se relacionan, coordinan
y complementan entre si, siendo las principales: las de intuici6n o adquiBici6n espon-
t^ea, mediante las cuales, el sujeto, poniendo en juego la raz6n natural y la percepci6n
externa e interna (conciencia), se pone en relaci6n con el mundo exterior, redbiendo
las excitaciones c^smicas; las de elaboraci6n, mediante las cuales conocemos o enten-
demos, discurrimos y juzgamos, en forma de pensamientoe, raciodnioe y juicios,
poniendo en juego la atenci6n y voluntad, asf como las facultades de companddn,'
abstracci6n, generalizaci6n, inducci6n y deduccidn, loe conodmientoe intaitavos o
los sugeridos de una manera did^tica; y, en fin, las de conBervad6n y combinaci6a,
que nos sirven para recordar los conodmientoe adquiridos intuitivamente o por
medio de la ensefianza, tales como entraron en la condenda o en forma font^btica,
poniendo en juego la memoria, asociacidn de ideas e imaginad6n.

En suma, la inteligencia, comprende: un conjunto de facultades, de intuiddn,
elaboraci6n, conservaci6n y combinacidn, las cuales, obrando solas o de consuno coo
la atenci6n y voluntad nos sirven para conocer, radocinar, juzgar y recordar los cono-
cimientos adquiridos eepontineamente o elaborados consdentemente.

VA0X7LTADES INTUITIVAS.

Oonocida la inteligencia y las facultades que la forman, podemoe entrar en materia,
con conocimiento de causa y en forma 16gica y cientffica; ya que, de otra manoa
podrla no ser comprendido, por todos, sobre lo que vamos a decir en seguida.

Desde luego, para apreciar las facultades del hombre y la mujer, condenzudamente,
en lo que valen en sf mismas, del punto de vista psicoldgico o mental, ee necesario:
analizar la mujer y el hombre del punto de vista de su complexi6n fisica, primero, a
fin de poder aducir consecuencias de otro orden, despu^.

Que la mujer posee una constituci6n fisica mds d^bil y delicada que el hombre,
en la generalidad de los cases, es un hecho que nadie niega, ni podrfa negar, porque

PUBUO HEALTH AND MEDIOIKE. 676

6st4 a la vista; que la debilidad de complexidn femenina supone, como ee 16gico, una
reebtencia menor a la acci6n excitante de los agentes exterioree, y por ende, un
esfuerzo fisico menor y una impresionabilidad o excitabilidad refleja mayor, es igual-
mente innegable; y, en fin, que, a consecuenda de sub relaciones mis inmediatas
con el mundo exterior, dada su mayor impresionabilidad refleja que el hombre, hace
que BUS impresiones extemas y las percepciones intemas que se generan, en su con*
ciencia, sean igualmente m&B numerosas: lo que equivale a decir, que, a influjo de
los excitantes c6Bmico8, se sugieren espont&neamente, en la concienda femenina,
un mayor ndmero de percepciones o im^enes, recuerdos de las impresiones extemas
o asociaciones que en el hombre, o sea, de ideales intuitivos que se guardan en la
concienda y son susceptibles de reprodudrse o rememorarse despu^, cada vez que
ae despierten las impresiones primitivas que les dieron origen.

Pero, puede suceder que la mujer posea una constituddn ffsica igual o nUis vigoroea
que el hombre y una resistencia similar o superior; en tal case, de acuerdo con laa
leyes fisioldgicas, la excitabilidad refleja femenina tendrd que ser igual o menos
marcada que la del hombre: lo que equivale a decir que las impredones y per-
cepciones cdsmicas y los conocimientos intuitivos que impHcan, se hallahoi, en este
caso, de acuerdo con la complexi6n, en amboe.

En suma, a causa de la complexi6n y resistencia m^ d^biles de la mujer que del
hombre, y a consecuenda de la exdtabilidad refleja mayiur de aqu^Ua que de dste,
en la generalidad de los casos, las impresiones y percepciones mentales (asociadones)
que representan conocimientos intuitivos o espont&neos, son m&B numerosas en la
mujer que en el hombre, salvo excepd<mes y por consiguiente mds desarrolladas las
facultades de intuici6n en ella que en ^1.

taoui;tade8 db blaboraci6n.

En cuanto a la equivalenda mental del hombre y la mujer, para la elabcraddn
consdente y voluntaria de los conodmimitos intuitivos o sugeridos didiUsticamanta,
hay mucho que decir; ya que 6ste es un problema muy complejo y de diflcil sduddn.
Sabemos ya que la mujer, en la generalidad de los casos, posee un desarrollo de laa
focultades intuitivas m^ condderable y las rasones que abonan esta verdad; veamos,
ahora, d las facultades de elaborad6n se hallan en las mismas o distintas condiciones.

Las focultades de elaboraci6n, suponen: sea que propendan a crear asodadonea
que encamen percepdones o ideales nuevos; sea que tiendan a coordinar los peosa-
mientos en forma racional; sea, en fin, que se expresen por juidos formados medianta
la cooperaci6n de las facultades de comparad6n, abstncci6n, generalizaddn o deduc-
d6n, la acd6n de la atend6n y voluntad o de la atenddn voluntaria, en lugar de la
atend6n espont&nea que regla la intuici6n; en ima palabra, un mayor esfuerzo inta-
lectivo que se obtiene a expenses del excitante voluntad y que contribuye, obrando
de consuno con la atend6n, a deepertar la sensibilidad y las impresiones y percep-
ciones correspondientes, o sea, a crear asociaciones intelectivas y a determinamos a
obrar en forma consdente.

Trdtase, pues, ahora, de conocimientos adquiridos voluntaria y consdentemente o
de ideales que demanden un esfuerso mental mucho m&B consid^able; de pcmer an
actividad diversas facultades que exigen un consume de eneigia m&B grande; y, an
fin, de crear, en la mente, un mayor ndmero de impredones perdbidas o asodaciones
objetivas que sintetizan los conocimientos adquiridos y que se guardan en la memoria
de una manera m&B durable como im^enes, recuerdos o representadones concretas
del mundo exterior y que son susceptibles de rememoraise despu^.

F^ua resolver d problema de la equivalenda mental, relative a las facultades de
elaboraddn, hay neceddad de inquirir, primero, lo siguiente: si lo ffsico supone lo
psfquico o vice-versa, como crefan los antigoos, si es verdad que una constituddn
ffmca vigorosa o d^il implica una complex!^ mental de la misma eq^ecie; y, en fin,
d es derto que, a una atend6n voluntaria m4s o menos desarrollada corresponde una
mentalidad equivalente.
6848^-17— VOL 1

676 PBOOBEDIKGS SECOND PAK AMEBIOAK 8CIEKTIFI0 C0KGBB88.

Que lo ffsico importe lo pefquico, en coanto al timnpo, no cabe la menor duda,
puesto que ambos se verifican a la ves, simult^ea y paialelamente; pero qae lo fiaco
8ai>onga lo pef quico, en coanto al grado, o aea ,que a una complexidn yigaroBtk equi^alga
Biempre una inteligencia de la miama clase, ello no ee verdad sine mi la generalidad
de lo6 casos, siendo muchas las excepciones.

En ef ecto, hay mujeres de una complexi6n ffeica vigoro6a y de inteligencia mediocre
e igualmente, de una capacidad intelectiva muy deeanollada y de constitaci^ fiflica
d^bil; pero repito, en la generalidad de loe casoe, lo hmco conesponde a lo pdqoioor
en el tiempo y aun en el grado, siendo las excepciones apuntadas debidas: a la herenda
o a la cultura adquirida diddcticamente o por intuici6n, del medio ambioite.

La berencia tiene, sin duda, una influencia bien marcada en el deeanoUo intelec-
tivo; pues, frecuentemente se observa que mujeres inteligentes engendran hijoe dotados
de la misma cualidad y que las d^biles mentales o idiotas, tienen hijos de la mkma
clase. De suerte que la berencia tiene eco en la descendencia, en la generaHdad de
las drcunstancias, salvo excepciones, naturalmente.

En cuanto a la educaci6n influye, tambi^n, poderosamente, aun en m^ alto giado;
pues, si un sujeto cultiva lo psiquico con preecmdencia de lo ffsico, o vice-verea, puede
observarse, si no en todoe los casos, en la mayor parte de ellos: que la cultura tie&e una
influencia bien marcada en que lo ffsico y lo psiquico no se correspondan, mncliaB
voces en el grade, aimque sf en el tiempo.

En suma, en la comunidad de circunstandas, lo ffsico supone lo psiquico en el
tiempo y en el grade "mens sana in corpore sano;'' pero, hay caaos, en que didK>
prindpio no se cumple, siendo las causae prindpales la herenda y la claee de cultura
del sujeto.

Nob queda que analizar el rol de la atend6n voluntaria en la equivalenda mental
del hombre y la mujer, en cuanto a su grade.

La atenddn, estado mental que importa un esdarecimiento de loe ccmodnuentos
adquiridos intuitiva o didicticamente, esclaredmiento que se exjH^sa por una mayor
exactitud y pureza de las percepdones o un^lgenee-^ecuerdos objetivas (aaociaciones)
influye poderosamente, como se comprende, en el desarroUo de la inteligencia o de
las facultades mentales.

La voluntad, despertando directamente la sensibilidad y por ende, las impreaiones
y percepdones sensoriales y determin^donoB a obrar consdentemente en uno a otro
sentido, constituye una fuerza flsica o exdtante de eeta misma espede e igualmente,
una fuerza moral o estimulante de igual clase ; un factor psico-fisico de gran importanda
en el desarrollo de las facultades intelectivas de elaboraddn, en una palabra.

Siendo esto asf , se comprende perfectamente cdmo, la atend6n voluntaria sintetiaa,
el esfuerzo psiquico (volitivo y mental) puesto en juego, en el ejerddo de nuestros
actoe. Y, como eete esfuerzo eetd reladonado con la inteligencia, puede dedrse : que,
en la generalidad de los casos, a mayor esfuerzo de atend6n voluntaria corresponde
mayor energia mental. Mas, mi este case como en el anterior, puede suceder, excep-
donalmente, que una atenddn voluntaria d^bil se halle en Bujetos muy inteligentes
y que, por el contrario, individuoe dotados de una fuerza moral o volitivo muy
grande, sean poco inteligentes. Esto depende, de las dos cauaas anterionnente
enunciadas: la berencia y la educacidn.

En suma, en la generalidad de los casos, una atenci6n voluntaria bien desanollada
8Ux>one una complexi6n psico-fisica de la misma espede, salvo excepdones debidaa
a la berencia o cultura.

Despu^ de lo dicho que precede, cabe preguntar: ^la mujer ee capaz de un esfuerzo
de atend6n voluntaria e intelectivo tan intense como el hombre?

Desde luego, la mayor impresionabilidad refleja femenina, hace, que por lo comdn,
la mujer sea m^ distrafda que el hombre, y por cwisiguiente, menos capaz de un
esfuerzo volitivo; hecho muy ficil de comprobar en la prictica, obaervando la

PUBUO HEALTH AND MEDfOnTB. 677

vida femenina en sua mtUtiplee relacionee con el mundo exterior, tanto en su
calidad de sujeto que comprende, raciocina, juzga y recuerda, como de individuo
que obra.

De otro lado, la complexi6n d^bil femenina suponei naturalmente, un eefuerzo de
la misma especie; ya que la energfa flsica y moral se hallan subordinadas, en gran
parte, a la constituci6n del sujeto, salvo excepciones. Y, en efecto, en la pr^tica
vemos, a diario, que el eefuerzo psico-flsico de la mujer se halla de acuerdo, en la
generalidad de los casoe, con el grade de atenci6n voluntaria y la complexi6n
femeninas.

El aniUisis del caricter de la mujer, constituye, una prueba de lo que venimoe
diciendo. En efecto, ella no posee, comtinmente, la misma fuerza de voluntad y
acci6n que el hombre; carece, salvo excepciones, de la energfa moral correspondiente
a ^te, y no tiene, en consecuencia, el valor, dedsidn, audacia, iniciativa, dominie
de sf misma, perseverancia, del tiltimo, sino en proporciones m^ moderadas. En
otras palabras, el h&bito de querer, hacer u obrar femeninos, no es equivalente al
maeculino; puee, mientras que aqu^l importa menoe atenci6n voluntaria y menoB
energfa, 6ste encama un eefuerzo flsico y moral mia pronunciado.

En suma, la mujer, dada su complexi(5n psico-ffsica menor y su excitabilidad refleja
mayor que el hombre, se puede estimar como dotada, en la comunidad de lascircuns-
tancias, de una fuerza de atenci6n voluntaria menos deearroUada que ^te.

Lo que precede, noe ensefia: que, si miramoe el problema de la intelectualidad como
intin^amente relacionado con la atenci6n voluntaria, hay que convenir en que, comtin-
mente, el hombre se halla dotado de una inteligencia m^ desarrollada que la mujer,
tratdndoeedelasfacultades de elaboraci6n consciente.

Mas, si analizamos la dicha cuesti6n en las mlsmas condiciones fisioMgicas, es decir,
en individuos de ambos sexos dotados de una misma complexi6n psico-ffsica y de
m^ o menoe atenci6n voluntaria semejante, tendremoe: que tanto el hombre
como la mujer son capacee, en este case, de un eefuerzo peico-ffsico similar, y por ende,
de m&B o menoe la misma actividad mental.

Mas, como en la pr&ctica, la mujer se halla, comdnmente, en inferiores condiciones
al hombre respecto de la elaboraci6n consciente y voluntaria de los conocimientoe
adquiridoe intuitiva o did^ticamente, segtin queda demoetrado, a causa de su tem-
peramento y car^ter m^ d^bilee, salvo excepciones, hay que convenir: en que, en
tales circunstancias, la intelectualidad femenina es inferior a la masculina, vuelvo
a repetirlo.

De lo dicho anteriormente, se deduce: que si consideramos, comtinmente, a la mujer
de una capacidad mental inferior al hombre, para la elaboraci6n consciente del ideal,
no es porque creamos que esta inferioridad sea algo anexo al sexo, o a la personalidad
femenina, sino porque la mujer ha side dotada, a natura, de una constituci6n y aten-
ci6n voluntaria menos marcadas; no por raz6n del sexo, repito, sino por las causas
tantaa voces enunciadas.

Pero, si equiparamos, por excepci6n, la dicha desigualdad de temperamento y
atenci6n voluntaria, tendremos que la inferioridad mental de la mujer respecto del
hombre desaparece, por la circunstancia enunciada, y, por lo tanto, puede decirse,
que la dicha inferioridad no es mia que relativa y no absoluta.

En reeumen, en la generalidad de loe cases, las facultades intelectivas de elaboraci6n
son mAa desarrolladas en el hombre que en la mujer, a causa de la complexi6n psico-
ffsica y atenci6n voluntaria mds d^biles en 4sta que en aqu61; pero, si por excepci6n,
las dichas causales deeaparecen y se equiparan, en ambos, puede verse: que la inferio-
ridad mental femenina se equipara igualmente, en este caso, con la masculina.

FACm/TADBS DB CONSERVAadN T COMBINACI6n.

En cuanto a las facultades de conservaci6n y combinaci6n, el hombre y la mujer
las poseen en grade diferente, segtin se trate de guardar loe idealee, tales como fueron

678 PROCEEDINGS SECOND PAN AMEBICAN SCIENTIFIC CONOBESS.

8ugerido6 0 en forma did^tica, esto es, adquiridos por mtmci6n mediante la ateiici6n
espontdnea o elaborados conscientemente a expensas de la atenci6n volantaria.

La recordaci6n de loe conodmientos adquiridos espontdneamente y sin eafuerzoe
de parte del sujeto, supone: creaci6n de asociacionee o repreeentadones objetivafl
provenientes del mundo exterior y susceptibles de rememoraiBe cada vez que se des-
piertan las impresiones primitivas que les dieron origen.

La recordacidn de ideales adquiridoe intuitivamente en forma fantdstica, ea dedr,
adomados con un ropaje que en realidad no les pertenece, pero que los vuelve miB
atrayentes, sin hacerles perder, por eeo, sus cualidades objetivas, encama la creaci6n
de asodaciones, que, sin perder sus propiedades naturales, end^ran, al mismo tiempo,
cualidades fantdsticas y se guardan en la memoria combindndoee lo objetivo con lo
imaginativo, en forma de imdgenes-recuerdoe que tienen loe caracteree de amboe»
susceptibles de reproducirse cada vez que se despiertan las impresiones primiti'vas
que implican.

Ahora, si se recuerda lo dicho anteriormente, ''que la mujer tiene mia desairoUadaa
las facultadesdeintuici6n que el hombre/' resulta que forzosamente ha de tener igual-
mente mds desarrolladas las de conservaci6n y combinaci6n reladonadas con aqudllas.

Pero, las dichas facultades de conservad6n y combinad6n. no 86I0 son de natoralesa
intuitiva, sine correspondientes a las de elaboraci6n consciente, a expensas de la
at6nd6n voluntaria; de conodmientos cuya adquiBici6n importa un eefuerzo volittvo
y mental mds 0 menos considerable y cuya rememoracidn puede verificarae, como en
el case anterior: objetiva o imaginariamente.

La recordad6n objetiva de conocimientos adquiridos consdente y voluntariamente
supone: la creaci6n de asociadones concretas capaces de grabarse en la condencm
tales como fueron sugeridas y de recordarse por la memoria f&dlmente, como imdgenee-
recuerdos dificiles de olvidar, y mds 0 menos perdurables y por lo tanto, fiU^es de
recordar, despu^.

Y, en cuanto a la rememoraci6n de ideales conscientes, en forma imaginaria, es muy
diflcil, por cuanto exige que los conocimientos objetivos elaborados efidentemente
se hallen revestidos de un ropaje fantdstico, que, al par que loe vuelva mia intere-
santes, corresponda racionalmente al ideal que encama, 0 sea, que se expree^i por
la creaci6n de asociadones objetivas al par que fantdsticas combinadas radonalmente:
imdgenee-recuerdos 0 repreeentaciones mixtas que se conservan en la memoria y aon
susceptibles de rememorarse m&s tarde, siempre que se despierten las impresiiniea
primitivas que lee dieron origen.

Recordando, ahora, lo dicho acerca de la equivalencia mental del hombre y la
mujer, relativa a las facultades de elaborad6n, que, segdn queda expresado y demoe-
trado, significa, en la generalidad de los casos, una inferioridad mental femenina,
resulta: que las facultades de conservaci6n y combinaci6n de loe conodmientos adqui-
ridos voluntaria y conscientemente son, comtinmente, mds desarrolladas en el hombre
que en la mujer, salvo excepciones, naturalmente.

CONCLUSldN.

De lo dicho anteriormente, se deduce: que las facultades de percepci6n espon tinea,
o intuitivas, asf como las correspondientes a ^stas de conBervaci6n y combinad6ny se
hallan mds desarrolladas en la mujer que en el hombre, el la generalidad de los casoe;
que las de percepci6n consdente y voluntaria 0 de elaboraci6n, que suponen la adqui-
sici6n de ideales mediante un esfuerzo psfquico (de atend6n voluntaria y mental)
mds o menos considerable y las correspondientes a ^tas de conservaci^n y combina-
ci6n, son mis desarrolladas en el hombre que en la mujer; y, finalmente, que, como
^tas importan una elaboraci6n efidente del pensamiento y sintetizan una actividad
intelectiva mds apreciable que aqu^llas, por cuanto se expreean por la concepci6n de
ideas, coordinaci6n de 6stas o ideaci6n (raciocinio) y por la comparad6n de las i

PUBUO HBALTH AND MBDIOIKB. 679

pmt% deducir el juicio, se dgue que la intelectualidad, peicoldgicamente hablando,
correeponde a la facultad de elaborar el pensamiento en fonna consciente y voluntaria,
por cuanto significa la inteligencia en acci6n, y, como eeta facultad se halla menoe
deeairollada, salvo excepdones, en la mujer que en el hombre, es forzoeo concluir
que, en la generalidad de Ice cases, ^ste es xnAa inteligente que aqu^lla.

Sbounda Pabtb.

DBDUCaONES 80aOL60ICAB.

Las deduccionee de orden social derivadas de lo dicho en la primera parte, se refieren
muy principalmente al feminismo; doctrina modema que concepttia al hombre y a
la mujer dotadoe de las mismas aptitudes ffsicas y psfquicas, en la lucha por la vida.

El feminismo, mirado del punto de vista de la igualdad de actividad psico-flsica
del hombre y de la mujer no es aceptable, sine en ciertos cases, psicoldgicamente ha-
blando; pues concepttia, repito, la capacidad de amboe en igualdad de condidones,
Bin tomar en cuenta loe fines femeninos.

La doctrina en cuesti6n, atin estimada en general, o grosso mode, no puede aceptarse
l^camente, en la comunidad de circunstancias; pues, peca por su base, aunque
aX>tf entemente, no por su forma, como vamos a ver en seguida.

Digo ^'que peca por su base," por cuanto, teniendo el hombre y la mujer una com-
plexi6n distinta, como queda demoetrado, no es posible someterlos a un mismo esfuerzo
flsico o mental; ya que la constitud6n femenina es mds d^bil que la masculina, en
la generalidad de los casos.

Pero, si la mujer, por excepd6n, poeee una complexi6n igual o superior al hombre,
es m^ que claro, evidente que serfi capaz del mismo o superior eefuerEO, y, en tal
caso, el feminismo reeulta 16gico y atin aceptable, case que respete por lo demas
las finalidades naturales correspondientes a uno y otro.

Pero lo enunciado, relative al temperamento m^ d^il femenino, en la comuni-
dad de circunstancias, no quiere decir que la mujer no pueda desarrollar m&s o menos
la misma actividad que el hombre, sine que, cuando ese esfuerzo se hace intensivo o
muy prolongado, ^lla, a causa de su menor resistenda, se fatiga mis pronto que ^1.
De ahf porqu^, aparentemente, el hombre y la mujer pueden deeempefiar una misma
labor, por cierto tiempo; pero, en el fondo, no, sobre todo cuando el trabajo exige
mncho consume de eneigfa, o, es muy prolongado.

De manera que, sostener, como lo hacen los feministas, que el hombre y la mujer
son capaces de la misma actividad, es un error, en la generalidad de los casos y una
verdad en algunos.

Lo dicho anteriormente se refiere, mis bien, a la actividad ffsica y no de un modo
especial a la pefquica, que depende del grade de atencidn, voluntad e inteligencia
y encama la energfa moral puesta en acd6n, en el hombre y la mujer.

Y bien, la atenddn voluntaria que deepierta y determina el ideal no es, en general,
igual en ambos sexes, salvo excepcionee; pues esti intimamente subordinada a la
complexi6n psico-flsica de uno y otro. De ahf que el esfuerzo que entrafia la energte
moral, hijo de la con8titud6n, sea, por lo comtin, mis d^bil en la mujer que en el
hombre, dado el temperamento y resistenda especiales de aqu^lla.

Si el esfuerzo de atenddn voluntaria es mis d^il en la mujer (salvo en las que
poseen una constitud6n como el hombre) y, esta clase de energfa influye poderosa-
mente en la mise en funci6n de las facultades de elaborad6n, por cuanto deepierta
y determina el ideal, es mis que claro, que no puede decirse, en buena 16gica, sobre
todo tratindose de una labor intelectiva intensa, sin incurrir en error, que implica
un mismo esfuerzo, en la generalidad de los cases, sine dnicamente en algunos.

Lo dicho que precede, explica por qu^, la labor femenina que demanda una energfa
moral muy grande o muy prolongada no sea mis que durante derto tiempo equiva-

680 PBOOEEDIKOS SECOND PAN AMEBIOAN SOIENHFIO 00NGBE88.

lente a la masculina; ya que la resistencia pefquica Yolitiva y mental, son, comdn-
mente, m&s limitadas en la mujer que en el hombre.

Pero, si la mujer no puede gastar la misma eneigia fisica y pefquica que el hombie,
sino por excepci6n, por las causae tantas vecee enunciadas, ^c6mo explicarae la doc
trina de loe feministas que sostdene, h otUranoej predsamente lo contrario? ^OSmo
sostener un ideal semejante, siendo que eetk abiertamente en pugna con lo que nos
ensefia la Fisiologia y Psicologfa? ^Por qu^, en fin, atribuir a la mujer una actividad
psico-flsica de que en realidad carece y ni podrfa tenerla, dada su natural complexidn?

No es fdcil expUcarse eeta tendencia, que importa una anomalia o propensi6n
nacida, m^ bien, a impulses de una natural simpatia que por otra causa; no es ttdl
darse cuenta, por qu^, a pesar de ver que la mujer obra guiada por sus sentimientos
mejor que por la raz6n — en forma distinta que el hombre — se la considera sin embaigp
capaz de una igual actividad, que en realidad no tiene, comdnmente, salvo en ciertoe
cases.

Hay, en el fondo de la doctrina en cuesti6n, un no b6 qu6 misterioso e inexplicable,
que, por m^ que se le estudie y analice desapasionadamente, no se llega a com-
prender el significado sociol6gico que se le da en la actualidad; pues, nadie podri
expUcarse la causa que ha inducido a los feministas a ver la igualdad donde briUa
la desigualdad; a fomentar y sostener ideales que estdn en pugna con lo que nos estd
diciendo, a voces, la experiencia; a hacer de la mujer un hombre * * » dendo
que es una mujer.

La doctrina del feminismo no puede, pues, aceptarse, 16gicamente, en la generalidad
de los cases, sino en algunos; ya que, en el fopdo, es contraria a lo que nos ensefia la
experiencia y por consiguiente, la ciencia.

Por fin, mirada la doctrina en cuesti^n del pirnto de vista de la finalidad social j
moral del hombre y la mujer, posee igualmente mds de un inconveniente, Uegando
a ser, a veces, hasta peligrosa.

£n efecto, el rol social de la mujer, es, por m^ de un motivo, distinto del hombre,
en la generalidad de los cases; puesto que ^te se halla destinado para el esfuerzo que
supone la labor de la cabeza a el trabajo m^ o menos intensivo y aqu^Ua se halla dis-
puesta para el esfuerzo moderado que sintetiza la labor del coraz6n. Y, si el primero
se gobiema por la raz6n y la segunda por los sentimientos, y, si el impulso que guia
a ambos en el camino de la vida es diferente, por lo menos en el grade, ^c6mo no sig-
nificar objetivos diversos? Efectivamente, si el hombre y la mujer se hidlan, natural-
mente, determinados a obrar por diversas causas, es, porque, en la lucha por la vida,
desempefian roles distintos.

El feminismo no se preocupa ni mucho ni poco de los fines natunJee de la mujer,
y, al llevarla al campo de la actividad masculina, no procura sefialarle, como serfa
lo 16gico, la ruta que El Creador le ha indicado, sino que la deja abandonada a sn
propia voluntad; s61o dispueeta a obtener su independenda individual y econ6mica,
sin preocuparle sus objetivos ^tnicos y ^ticos, que son fundamentalee.

Esta circunstancia hace, que, la mujer feminista se aleje voluntariamente, las mis
de las veces, del matrunonio, como ha podido comprobarse, prdcticamente, en todos
los paises feministas: lo que importa decir, en buena 16gica, que, tarde o temprano, la
mujer llega a ser, en vez de un factor ^tnico, uno de despoblaci6n.

Fuera de lo dicho que precede, el feminismo, obligando a la mujer a vivir en un
ambiente masculine, tarde o temprano, llega a inculcarle los hdbitos o costumbre;
masculinas, en gran ndmero de casoe; lo que la obUga a olvidar sus donee naturales,
SUB encantos y hechizos, asf como sus atractivos, masculinizdndola.

En Buma, el feminismo, aleja a la mujer del cumplimiento de sus fines natuiales,
pues, ademis de separarla del matiimonio, la hace cambiar de car&cter, masculini-
z^dola.

Pero, el hecho de no ser aceptable el feminismo, en la forma dicha, no aignifica,
en manera alguna, que no lo sea de otro mode.

PUBLIC HEALTH AND MBDIOINB. 681

£n efecto, la actividad femenina de acuerdo con el temperamento, caricter y fines
de la mujer— el feminiamo 16gico y natural — es perfectamente aceptable y compatible
con ella.

Somes, pues, partidarios convencidos de que la mujer ejerdte su actividad, para
bafltarse por el 861a, dentro de bus facultades, salvo excepdones; de que gaste bus
fuerzas en una labor determinada que le reporte utilidad, sin desgastar indtilmente
8U constituci6n o en conformidad con sua eneigfas; en fin, de que elija una carrera,
a que, en ningtin case, puedo desviarla de cumplir bus deberes sociales y morales,
eeto es, de ser buena esposa, buena madre y buena duefla de casa.

Dentro de este ideal, el tinico que se armoniza con las facultades de la mujer, caben
mdltiples maneras de desarrollar la actividad femenina, con el objecto de conseguir
eu. independencia econ6Auca.

En suma, el feminismo que supone la mise en action de las focultades de la mujer,
de acuerdo con sus aptitudes, su manera de aer y fines natunJes, es, el dnico aceptable,
l<5gicamente hablando.

CONCLU816N.

El feminismo, como doctrina que conceptda al hombre y a la mujer dotados de la
nusma actividad y aptitudes, en la lucha por la vida, sin tomar en cuenta la comple-
xi6n, car&cter y fines sociales y morales distintos de ambos, no es aceptable, en la
generalidad de los casos, salvo cuando la mujer posee facultades similares al hombre;
I)ero sf, el que concepttia a uno y otro dotados de temperamento, manera de ser y
finalidades diferentes, y, que, en la lucha por la vida, estima a ambos, capaces de
bastarse por si solos, dentro de sus respectivas facultades, tinicamente, salvo excep-
ciones.

DEDUCaONES PBDA06GICAS.

Las deducciones pedag6gicas se refieren: a la cultura psfquica o intelectual de la
mujer, que tanta importancia tiene, en la prdctica.

La cultura psfquica femenina debe propender, tomando en cuenta lo dicho en la
primera parte, grosso modo: a doctrinar eficientemente las facultades de la mujer
de acuerdo con sus aptitudes, su cardcter y sus fines naturales, en la generalidad de
los casos, salvo en los que posee un temperamento similar al del hombre, 0, se cultiva
ex-profeso, a fin de tenerlo, mediante una preparaci6n suficiente.

Lo que precede significa: que es necesario imponer a la mujer un esfuerzo mental
que se halle en relaci6n con su complexi6n y sus fines; 0 sea, en conformidad con la
energfa de que es capaz, salvo excepciones.

Los fines u objetivos de una cultura intelectiva femenina son m(iltiples: psfquicos,
est^ticos, econ6mico6, sociales y morales.

Los de orden pslquico, propiamente dichos, encaman, en cierto modo, los de otro
orden, ya enunciados; pues, de una manera general, s61o tienen por objeto, crear
asociaciones objetivas mis o menos numerosas y cultivarlas eficientemente hasta
formar hdbitos, o nutrir el intelecto con un caudal de conocimientos determinados,
adquiridos intuitiva o did^ticamente, con el objeto de habilitar a la mujer en la
lucha por la vida, asl como para Uenar sus deberes sociales y morales.

Para llenar dicho desideratimi se hace necesario formar un programa ad hoc, dis-
tinto del que sirve para la cultura del hombre, que abrace: generalidades sobre
ciencias cosmol^gicas y noBol6gica8, es decir, de las que estudian el mundo y el
espfritu humane— ciencias matem&ticas, ciencias naturales, ciencias ffsicas y qufmicas,
ciencias morales, ciencias filosdficas, etc. — ^y de una manera especial, aqu^Uas que
miran a los fines sociales y morales femeninos.

Dlgo, ''generalidades sobre ciencias," por cuanto el estudio especial de ellas exige,
por lo comdn, un gasto considerable de energfa intelectiva que no se aviene bien
con las aptitudes femeninas; mas, esto no reza, naturalmente, para la mujer que posee
dotes excepcionales, o, que los adquiere a fuerza He constante labor: ^sta podri

682 PBO0EEDINQ8 SEOOHD PAN AMBBIOAN 80IENTIFI0 00NQBE8S.

dedicarse al eetudio eepedal de laa dendas, sm inconveniente, con tal que no deje
de lado lo concerniente a Iob fines sodales y morales de la enaefiansa en cueatidn.

Lob fines econ6niico6 de la cultura intelectiva de la mujer, siendo hindamentaks,
puesto que tienden a darle la independenda y bienestar de la misma espede, se refie-
ren, en slntesis: a cultdvar, efidentemente, en ella dertas fooultadee que se hallan
m&B desanblladas y que pueden servirle, preferentemente, para bastazse por sf sola»
sin alejarla, repito, de bus objetivos naturales.

Esto se consigue: creando en su mente asodad<mes concretas que encamen cono-
cimientos dtiles y que no demanden un esfuerzo intelectivo conaidaable, conod-
mientos que import^i un arte, profesi6n, industria u ofido que se hallen de acuerdo
con las aptitudes de la mujer y con su rol en la sodedad. Para que los ideales asf
adquiridos resulten realmente titiles, es necesazio: cultivarlos frecuentemente, de
una manera prdctica, hasta convertirlos en hdbitos o costumbres, o sea, la ensefiansa
convertida en acd6n que ezprese la profesidn u ofido elegidos.

Los fines econdmicos de la cultura en cuesti6n, encamando un caudal de conod-
mientos pr&cticos espedales, pueden considerarse como derivados de los objetivos
psfquicos enundados.

£n cuanto a los fines est^ticos de la ensefianza en cuesti6n se refieren: al cultivo
de la est^tica sintetizada en el estudio i»r&ctico de las bellas artes— mdsica, canto,
pintura, escultura, composid6n, po^tica, etc. — con el objeto de formar el gusto artiis-
tico de la mujer y educar sua facultades de observad6n, concepd6n e imaginaddn;
o sea, la atend6n, la voluntad y la memoria, de acuerdo con la experienda.

Los objetivos est^ticos miran, pues, a la ensefianza especial de ciertas asignaturas
que sintetizan el gusto por lo bello y que tanto armonizan con las dotes naturales
de la mujer.

En fin, los objetivos sodales y morales, en cuanto importan el doctrLnamiraito
de la voluntad muy principalmente y la cread6n de asodadones que encamen la
adquisid6n de ideales para formar a la mujer como buena esposa, buena madre j
buena duefia de casa, o sea, sufidentemente versada en la denda de los deberesy
son de indiscutible valor; ya que ensefian la economla dom^stica, la 6tica, la religidn^
la 16gica, la historia, etc., y en general todas las obligadones sodales y morales que
competen a la mujer como miembro de la colectividad social. Esta misma dase de
educad6n, llevada a la pr&ctica, mediante el buen ejemplo o aun de una manera
did&ctica, sobre todo en la forma primera, contribuye por sf sola, a doctrinar mis o
menos efidentemente la voluntad y a formar h6bitos de reflexi6n, abnegad6n, con-
fianza en sf misma, perseverancia, espfritu de justida y de benevolenda, etc.; es
dedr, de buenas costumbres que importan el buen caricter femenino.

La finalidad en cuestion es, pues, de las mis importantes, trat&ndoee de la educa-
ci6n de la mujer; ya que constituye una ensefianza sodal y moral de acuerdo con
los objetivos naturales de ella.

La cultura ffsica de la mujer constituye el complemento de la intelectiva; puesto
que, mientras ^ta propende a perfecdonar las f acultades psfquicas, aqueUa doctrina,
desarrolla mds o menos efidentemente las potencias mecinicas, mediante una
gimnawia especial o de ejerddos deportivos adaptables al temperamento y fines
femeninos.

La educad6n ffdca encama, como la intelectiva, objetivos diversos: higidnicos,
est6ticos, econ6micos y morales.

Los fines fisiol6gicos de orden higi^nico propenden: al restablecimiento del equi-
libiio de las fundones orgdnicas, o sea, de la salud; los de orden est^tico, al desarrdio
arm6nico de las formas y de las facultades de expresidn, y por ende, a la fonnaci6n
de h6bitoB que implican vigor, vida, grada, convenienda, etc.; y los econ6mioos, a
la adquisid6n de cualidades que sintetizan la agilidad, destreza, fttdlidad en los
movimientos.

PUBLIC HEALTH AND MEDIOINB. 683

Los fines morales de la cultura en cuestidn se refieren: al doctrinamiento de la
voluntad, mediante ejercicios especiales, que, eficientemente cultivados, puedan
crear hdbitoe de abnegaci6n, confianza en si misma, reflexi6n, dedsidn, dominio de
bI misma, perseverancia, etc., cualidades todas de un buen caricter.

La educaci6n ffsica de la mnjer supone, todavla — y esto es fundamental — ^la for-
inaci6n de un programa especial, distinto del que sirve al hombre; pero, en todo
caso, adaptable a las facultades lemeninas y a bus fines: un programa tinicamente
femenino, para decirlo todo de una vez.

La cultura en cuesti6n, convenientemente hecha y cientfficamente dirigida, con-
tribuye, no b6\o al perfeccionamiento 4e las potencias mecinicas sine de la voluntad,
o sea, de la fuerza moral; lo que vale decir, que, forma a la mujer, dot&ndola de
buenos hdbitos fisiol6gico6 muy principalmente y de orden moral.

En suma, la cultura flsica femenina debe ser distinta de la masculina, para per-
feccionar preferentemente las potencias mecinicas de la mujer y cultivar, al mismo
tiempo, la voluntad o el caricter de ella, de acuei^lo con su constitucidn, manera de
ser y fines naturales.

DEDUCCIONB8 HIQIAnICAS.

Las deducdones higi^nicas, se refieren: de un lado, a disminuir laexdtabilidad
refleja femenina, vigorizando su constituddn y aumentando las fuerzas y resisten-
das oiginicas, para evitar la fatiga, y de otro, a reglar elconsumo de eneigfa ffsica y
psfquica de la mujer, de acuerdo con su temperamento, car&cter y fines naturales.

La excitabdidad refieja puede corregirse, mis o menos completamente: alejando a
la mujer, en cuanto sea posible, de la acd6n de exdtantes diversos (especticulos u
ocasiones emodonantes), como sesiones de hipnotismo, de espiritismo, de adivina-
d6n, representadones esc^nicas fuertes, lecturas pasionales, cuentos fantisticos, en
fin, de todo lo que exdte moralmente la sensibilidad e imaginad6n.

Los estimulantes que despiertan en alto grado la sensibilidad e imaginaci6n, suelen
provocar, ademis, muy frecuentemente, crisis nerviosas y aun verdaderoe estados
patoldgicoe, en no pocas ocasiones.

For razones semejantes debe precaverse a la mujer de situadones sociales criticas,
que, i>or si solas, pueden acarrearle trastomoe sensorlales y emotivoe variables y el
enervamiento correspondiente: emuladones basadas en el amor propio exagendo y
Bintetizadas en el lujo, la vanidad, envidia, necesidad de parecer y valer, ambid6n,
etc.

Estas situadones sociales u otras similares, si se repiten, degeneran, las mis de las
voces, en neuropatfas que se conocen con los nombres de nervosismo, neurastenia,
etc. De ahi por qu^ la sociedad suele ser, en no pocas ocasiones, campo fecundo de
p^turbadones nerviosas desarrolladas a expensas de las paaiones egoistas, difidles de
evitar y aun de preveer; perturbadones que fiotan, por decirlo asi, en el medio am
biente y que se adquieren por imitad6n o intuitivamente, segdn loe casos.

Suprimir loe estimulos enunciados y las situadones anormales seria, en nuestro
sentb, el mejor y mis eficaz remedio profilictico; pero, precise es confesar que llega a
ser difidl, en la prictica, realizar dicbo ideal: ya que la supresi6n de loe exdtantes
mendonadoe importa, la de dertos gustos y placeres sociales femeninos, impuestos
por la moda, en la mayor parte de loe casos y la omisi6n de aqu^llos que encaman el
amor propio exagerado y que suponen, igualmente, costumbres sociales adquiridas
e impuestas por las mismas causales, difidles, si no imposibles de corregir, prictica-
mente.

Toca al bigienista recomendar, por todos los medios que eette a su alcance, estas
ensefianzas y procurar llevarlas a la prictica; sin olvidar, prescribir, al mismo tiempo,
con el mismo objeto, la dnesiterapia, electroterapia, hidroterapla, climatoterapia, etc«

El incremento de las fuerzas y resiBtendas que significa el de la mejor complexidn,
e igualmente, de la adquisid6n de la buena salud, se obtiene de muchoe modes: regu-

684 PBOOEEDIKGS SECOND PAN AMEBICAK 8CIEKTIFI0 C0NGBE88.

larisando la alimentacidn en fonna m6t6dica y adaptable al sujeto; deepertando laa
funciones fisiol^gicas por medio de ejercicios ad hoc, gimn&sticos o deportivos, Begtkn
drcunstancias; metodizando de mil maneras el g^ero de vida de la muj^; verifi-
cando el aseo peraonal, en forma conveniente y cotidiana; prociuando que los gastos
org&nicos sean equilibradoe de manera que haya una relacidn entre Ice ingresoB y
egreaos del oiganismo; evitando el trabajo exagerado, que tan frecuentemente trae
consigo la fatiga; prescribiendo una indumentaria apropiada o acdecuada, que permita
loe movimient06 naturales y que no acarree, ni pueda acarrear, defonnaciones ffaicaa
de ninguna especie; sefialando las horas de labor, de comida, de suefio, y de paaeo;
en fin, reglamentando de mil maneras la vida femenina, en bus mtiltipleB manifesta-
ciones, domdstlcas y sociales, etc.

No es, pues, f^U tarea, dar a la mujer Mbitos higi6nico6, a fin de desarrollar su
cuerpo y sus funciones, en forma fisioldgica. Es preciso sugerirle siempre estas
enaefianzas, did&cticamente y con el ejemplo, si fuera posible, desde la infancia,
hasta crearle las costumbres corre8t>ondientes a los ideales sugeridos.

En suma, darle hdbitos higi^nicos a la mujer, es, en mi sentir, uno de los fines
m^ importantes que es necesario imprimir a la educaci6n femenina, en nuestroe
dfas; ya que de esta manera se le procura una buena salud y se la defiende de las
enfermedades.

Nos queda, todavla, que reglar la energfa psfquica de la mujer sin exigirle un
esfuerzo considerable, sino el correspondiente a sus facultades natiu^les, evitdndole
asf la fatiga intelectiva o mental.

He aqul los consejos que pueden ddrsele al respecto:

1. Ejercicio de la actividad intelectiva practicado preferentemente en la mafiana,
y, en la tarde, 86I0 dos horas despu^ de haber comido;

2. No efectuar un trabajo mental continuado, cualquiera que sea, por mis de
50 minutos, despu^ de los cuales se hace necesario un descanso de 10 a 15 minutes;

3. Preferir y elegir siempre una labor variada, mds bien que de la misma especie,
ya que la homogeneidad del trabajo acarrea m^ pronto la fatiga;

4. Tener siempre presente que, la energfa psfquica decrece en raz6n inversa de
la actividad intelectiva gastada, 0 sea, que' a mayor trabajo mental corresponde
menor energfa de la misma especie, y vice versa;

5. No olvidar, igualmente, que la actividad dicha y la fatiga siguen distinto
nimbo, es decir, que a mayor esfuerzo mental mayor fatiga y vice versa; y,

6. Tener muy presente que es f&cil y hacedero disminuir la fatiga intelectiva,
reglamentando el trabajo mental de acuerdo con la capacidad femenina.

En suma, observando ciertas prescripciones higi^nicas tendentes a exigir a la
mujer un trabajo mental adaptable a bus facultades, se Uega a conservar la eneigla
psfquica al estado normal y a evitar, en consecuencia, la fatiga, que, una labor
intelectiva no reglada, ni elegida convenientemente, puede acarrear.

RSCAFrrULACldN.

Las deducciones sociol6gicas que se derivan de lo dicho, en la primera parte, se
refieren: a la no aceptaci6n de la docUina que establece la igualdad de aptitudes y
de actividades del hombre y la mujer, en la lucha por la vida, en la generalidad de
los casos, 0 sea, al feminismo; las de orden pedag6gico se relacionan, con la nece-
sidad de cultivar al hombre y a la mujer de una manera distinta y de verificar la
cultura de acuerdo con la complexi6n, cardcter y finalidades sociales y morales de
cada cuil, salvo excepciones; en fin, las de orden higi^nico, importan, la cQrrecci6n
de ciertos hdbitos femeninos, flsicos o morales que se expresan, ya por un incremento
de la excitabilidad refleja hasta llegar al estado patol6gico, ya por des6rdene8 psfquicoe
generadoB por la irregularidad en el consume de eneigfa intelectiva, durante la labor
mental.

PXJBLIO HEALTH AND MEmOINB. 685

RBSUMBN GBNBRAL.

La equivalenda mental entre el hombre y la mujer, puede estudiaree del pimto de
vista fisiol6gico y psicol6gico; el primero estk lejos de ser dilucidado, en la actnalidad,
y el segundo, sf, aunque no todavia de una manera completa. Voy a estudiar la
cue8ti6n desde este tiltimo punto de vista, exclusivamente, y, antes de entrar en
materia, estimo conveniente decir dos palabras sobre la inteligenda en sus diferentes
modalidades o aceixdones.

La inteligenda, psicoldgicamente hablando, comprende: un conjunto de faculta-
des — de intuid6n, elaboraci6n y combinad6n que, obrando solas o de consuno con la
fttenddn y voluntad, nos sirven para conocer, radodnar, juzgar y recordar los conod-
mientos espontdneamente adquiridos o elaborados consdentemente.

Las facultades de intuid6n o adquiaiddn espontdnea, a causa de la complexi6n y
resistencia mils d^biles, en la generalidad de los cases, y, a consecuenda de la exdta-
bilidad o impresionabilidad mds grande, de la mujer que del hombre, salvo excep*
ciones, se hallan mds desarrolladas en ella que en 61.

La equivalenda mental relacionada con la elaboraci6n consdente y voluntaria,
exige el conodmiento previo de si lo fisico supone lo psfquico, y, si a una atenci6n
voluntaria mds o menos desarrollada corresponde una mentalidad equivalente.

En cuanto a si lo fisico implica lo psfquico, ello es derto en cuanto al tiempo, pero
no en cuanto al grade: asf, es un hecho que, cuando ejecutamos una acci6n, al mismo
tiempo pensamos, nos damos cuenta de ella, pero no siempre una constitud6n vigoroea,
por ejemplo, supone una mentalidad de la misma espede; hay excepdones que se
refieren a la herencia y a la cultura del sujeto.

Respecto a si una atend6n voluntaria bien desarrollada implica una intelectualidad
de la misma espede, ello es verdad en la generalidad de los cases. En efecto, la
atend6n, esclareciendo los ideales adquiridos intuit! va o diddcticamente y la voluntad,
despertando las impresiones y percepdones sensoriales que sintetizan la cread6n de
asodaciones intelectivas y determindndonos a obrar, constituyen una fuerza fisica y
moral, que, obrando de consuno expresa, en sfntesis la mayor o menor intelectualidad
del sujeto y por ende, una mayor o menor eneigfa mental directamente propordonal
al mayor esfuerzo de atenci6n voluntaria (en la generalidad de los cases), salvo
excepciones debidas a herencia y cultura, como en el case anterior.

^Es capaz la mujer de un esfuerzo de atend6n voluntaria equivalente al del hombre?
Evidentemente, no; por cuanto la mayor impresionabilidad refleja femenina hace
que ella sea mds distrafda y menos capaz de un esfuerzo de atend6n voluntaria que
61, y de otro lado, su complexi6n mds d^bil, en la generalidad de los cases, hace que
la eneigfa ffsica y psfquica sean mds moderadas, y, como el esfuerzo peico-ffsico de
que el hombre y la mujer son capaces, se halla de acuerdo, comdnmente, con el grado
de atenci6n voluntaria y complexi6n de ambos, salvo excepdones, se sigue que si la
intelectualidad estd fntimamente reladonada con la atenddn voluntaria, hay que
convenir en que, por lo comtin, para la elaborad6n consdente del ideal, el hombre
se halla dotado de una inteligencia mds desarrollada que la mujer, salvo excepdones,
naturalmente.

En suma, en la comunidad de circunstandas, las facultades intelectivas de elabora-
d6n, son mds desarrolladas en el hombre que en la mujer a causa, repito, de la
complexi6n psico-ffsica y atenci6n voluntaria mds d^biles, en 6sta que en aqu^; pero,
si por excepd6n, las dichas causas desaparecen o se equiparan, en ambos, puede
verse que la inferioridad mental femenina desaparece igualmente.

En cuanto a las facultades de conservaci6n y combinaci6n difieren en la mujer y
el hombre, segdn se trate de rememorar conocimientos intuitivos puree o elaborados
consdentemente. La recordaci6n de ideales adquiridos eepontdneamente y que
importan representaciones objetivas del mundo exterior, tales como fueron sugeridas

686 PBOCEEDINGS SECOND PAN AMEMOAN 80IBNTIFI0 OONORB8S.

y p^xdbidas, mediante la atenci6n espontdnea, o, adornadas con un ropaje que las
vuelve m&8 atrayentes, o sea, las que suponen la combinaci6n de lo objetivo con lo
imaginativo en forma de im^enes— ^ecuerdos o asociacionee que poeeen loe carac-
teres de ambos, en la comunidad de drcunatandaa, Be hallan mis desarroUadas en la
mujer que en el hombre. Pero, la remem(Hraci6n de ideales— «entimient06 adquiridos
consciente y voluntariamente, o, que encarnan un esfuerzo de atenci6n voluntaria
que se sintetiza en la fonnaci6n de asociacionee concretas susceptibles de grabarae
licilmente en la conciencia y de recordaree, como imigenes— ^ecuerdos diffdlee de
olvidar, seliallan m&s desarroUadas en el hombre que en la mujer, Y, esta focultad,
tratdndose de idealee ccmscientee e imaginarios, que suponen asociacionee objetivas al
par que fantdsticas (representaciones mixtas), es igualmente m^ desarroUada, en la
generalidad de los casos, en el hombre que en la mujer.

Segtin lo dicho que precede, y, en sintesis, puede decirse: que las tacultades de
percepci6n eepont&nea o intuici6n, asi como las correspondientes a estas de conser-
vaddn y combinaci6n, o sea, la percepci6n externa e interna (la memoria e imagina-
cidn de los conodmientos adquiridos espont&neamente), se hallan m^ desanolladaa
en la mujer que en el hombre, salvo excepciones debidas, principalmente, a la herencia
y cultura; y que las facultades de elaboraci6n consciente y las de conservaci6n y
combinaci6n correspondientes a 6sta8, que importan im esfuerzo de atenci6n volun-
taria y sintetizan una actividad intelectiva m^ apredable que aqu^llas, por cuanto
expresan la concepci6n de ideas y la coordinaci6n o ideaci6n — el raciodnio— que es
base del juicio, es decir, la inteligenda propiamente dicha, se hallan mis desairolla-
das en el hombre que en la mujer, en la generalidad de los casos, salvo excepcionea
debidas, particularmente a la cultura y herencia, como en el case anterior.

De suerte que, la mujer, se puede dedr que es mis inteligente que el hombre, para
conocer ideales que no demandan esfuersos mental o de atenci6n e igualmente para
rememorar dichos conodmientos; mientras que el hombre es mis inteligente que la
mujer, para conocer idealee que exigen un esfuerzo de atend6n voluntaria mis o
menos considerable que importan la intelectualidad en acd6n asl como para la recor-
dad6n de loe mismoe. Pero, en ambos casos, hay excepdones que pueden provenir
muy especialmente del grade de cultura del sujeto y de la herencia, como queda didio.

II.

Las deducciones sociales se refieren muy prindpalmente al feminismo, doctrina que
conceptda la capaddad del hombre y la mujer o la actividad peico-fiisica de amboe
igual, sin tomar en cuenta los fines morales femeninos.

La doctrina en cuesti6n peca por su base, por cuanto teniendo el hombre y la mujer
una complexion psico-ffsica diferente y por ende, distintas resistencias, no pneden
someterse, salvo excepciones, a un mismo esfuerzo ffsico o mental; p^o esto no
quiere dedr que ambos no sean capacee de desarrollar la misma actividad, por algdn
tiempo, ya que si el esfuerzo es muy prolongado o intensivo, ella, a causa de su menor
resistenda, se fatiga antes que 61 en la gen^^idad de los casos.

De otro lado, la atenci6n voluntaria que importa el esfuerzo volitivo por cuanto
despierta y determina el ideal e igualmente, la fuerza moral que lo sostiene, estando
subordinada a la constituciOn psico-ffsica del sujeto y ^ta siendo mis d6bil en la mujer
que en el hombre, salvo excepciones, no puede servir en ambos del mismo mode, sine
por algtin tiempo; ya que, case que la labor mental B6a prolongada o intensiva, se
vuelve mis diflcil de verificar por la mujer que por el hombre, dadas las resistendaa
desiguales que hay entre ellos.

La mujer no puede gastar, pues, sino por excepd6n, la misma eneigfa flsica y
psfquica que el hombre y por eso, en el fondo, la doctrina en cuestidn es contraria a
a ciencia y a lo que nos ensefla la experiencia.

Fuera de lo dicho que precede, el rol social y moral de la mujer, es muy distinio del
que corresponde al hombre; pues, mientras dste esti deetinado a soportar la labor de

PUBLIO HEALTH AND MEDIOINE. 687

la cabeza, aqu^lla se halla 861amente dispuesta para el esfuerzo moderado que importa
la labor del coraz6n: el primero sintetiza el razonamiento, y la segimda, el sentimiento.

El feminismo de que hablo, h outrance, no se preocupa ni mudio ni poco de los fines
sociales y morales de la mujer — ^tnicos y ^ticos-Hsino que la deja abandonada a au
propia voluntad, llev^dola al campo de la actividad, con el objeto de que obtenga su
independencia individual y econ6mica. E^sta circiuistancia la hace alejarse del
matrimonio, por lo comtin, y Uegar a ser, con el tiempo, un factor de despoblaci6n.

Y, por dltimo, obligindola a vivir en un ambiente masculine, tarde o temprano
-dende, dadas las cualidadee educadoras del medio, a masculinizarse.

El feminismo h outrance, no se halla de acuerdo, pues, con las focultades psico-
ffsicas de la mujer, ni con sus fines sodales y morales, y por tanto, no puede aceptarse,
«n la generalidad de loe casos, salvo cuando por excepci6n, 1& mujer posee ftu^ultades
fdmilares al hombre.

Pero, la actividad femenina puesta en juego de acuerdo con la complexi6n, car&cter
y fines de la mujer, es decir dentro de sus facultades, con el objeto de bastarse por si
eola y sin excluir, en ningtin case, el cumplimiento de sus deberes sodales y morales —
^tnicos y 6ticos— me parece perfectamente aceptable. En otroe tdrminos, el feminis-
mo que encama la labor femenina de conformidad con sus aptitudes y finalidades
naturales, a objeto de obtener su independencia econ6mica, me parece completamente
l<3gico y aceptable, repito.

La cultura intelectiva de la mujer debe hacerse en conformidad a sus aptitudes,
cardcter y fines naturales en la generalidad de los casos, salvo excepdones, o sea,
cultivarse sin imponerle un esfuerzo de atenci6n voluntaria e intelectiva superior a
sus facultades.

Los objetivos de la cultura femenina, son: de orden psfquico, a objeto de crear
asociaciones objetivas m^ o menos numerosas y cultivarlas eficientemente hasta
formar Mbitos, o, de nutrir el intelecto de la mujer con un caudal de conocimientos
intuitivos o diddcticos, a fin de habilitarla para la lucha por la vida y para el cumpli-
miento de sus deberes sodales y morales, mediante la formad6n de un programa
especial o ad hoc; naturaleza econ6mica, o, que propendan, a sugerirle ideales titiles
que sinteticen una profesi6n compatible y encuadrada dentro de sus focultades; de
orden est^tico, o, que se refieran al cultivo de las bellas artes, a fin de formarle el gusto
por lo bello y lo artistico, que tanto se armonizan con las dotes naturales femeninas;
en fin, de orden social y moral, o, que tiendan a doctrinar la voluntad creando hdbitos
de abnegad6n, confianza en sf misma, perseveranda, benevolencia, etc., y, los que
sintetizan la dencia de los deberes: buena esposa, buena madre y buena duefia de

La educad6n fisica de la mujer, propende a perfeccionar las focultades o potencias
mecinicas y a cultivar, al mismo tiempo, la voluntad o el cardcter, de acuerdo con su
constitud6n, su manera de ser y fines naturales.

La cultura ffsica encama diversos objetivos, como la intelectiva: higi^nicos,
est^ticos, econ6mico6 y morales.

Los fines fisioi6gicoB e higi^nicos, tienden al establecimiento de las funciones
oigdnicas o de la salud; los eet6ticos, al deearrollo arm6nico de las formas y de las
facultades de expresidn, y por ende, a la creaci6n de hdbitos que importen vigor, vida,
gracia, conveniencia, etc.; los econ6micos, a la adquisici6n de cualidadee medinicas
muy necesarias en la vida, como facilidad, deetreza, agilidad, etc.; y, loe de orden
moral, al doctrinamiento del car&cter. La educaci6n ffsica de la mujer supone,
todavfa, la formaci6n de un programa especial, adaptable a las facultades femeninas;
un programa exclusivamente femenino.

Las deducciones higi^nicas, significan disminuci6n de la excitabilidad refieja
femenina, a fin de vigorizar la constitud6n, aumentar la resistencia de la mujer y
evitar la fatiga y reglamentaci6n del consume de energla pefquica, de acuerdo con
su temperamento, car&cter y fines naturales.

688 PROO££DIKQS SECOND PAN AMERICAN 80IBNTIFI0 00NQBB88.

La di8miiiuci6n de la impreeionabilidad refleja de la mujer, ee obtiene alej^uiidola
de lo6 excitantes c6Bmico6 o de otra especie (espectdculos u ocadonee ^nocionanteB,
sesiones de hipnotiBmo, de espiiitiBmo, o de adivinacidn, lecturas paaionales, cuentoa
£antd8tico6, etc.)} y^ precavi6ndola de las situaciones eocialee criticaB (emuladoneB
basadas en el amor propio exagerado, en el lujo, vanidad, envidia, necesidad de
aparecer y val^, ambici6n deemedida, etc.). La vigorizaci6n de la constitacidn
femenina, se alcanza: regularizando la alimentaci6n; deepertando las hinciones
fi8iol6gicas, por medio de ejerdcioe gimn^ticoe o deportivos; metodizando el g^noo
de vida y procurando que los gastos org&nicos se equilibren con loe ingresos; pre»-
cribiendo una indumentaria adecuada a la mujer que le permita los movimientos
naturales y que no acarree deformaciones flsicas; sefialando las boras de comida, de
labor, de suefio y de paseo; en fin, reglamentando de mil maneras la vida femenina
y credndole hibitoe higi^nicos.

La reglamentaci6n de la energia psfquica, importa la recomendaci6n del tiabajo
mental matinal m^ bien que el de la tarde; la reducci6n de la lab<^ intelectiva a 45
o 50 minutos y su variaci6n despu^ de cierto Uempo, para evitar la monotonia y la
fatiga; la perBuasi6n de que la energia pslquica decrece en raz6n inversa de la actividad
mental gastada y que a mayor esfuerzo corresponde mayor fatiga, y la posibilidad de
disminuir la fatiga psfquica, reglamentando cientificamente el trabajo intelectivo;
en fin, la observancia de ciertos preceptos higi^nicos tendentes a exigir a la mujer
una labor intelectiva adaptable a bus facultades, a fin de conservar la energia peiquica
y evitar la fatiga de la misma especie que un trabajo mental no reglado puede acairear.

;EL EJERaCIO MUSCULAR DE LA RESPIRAaON, SISTEMA SUECO,

ES FISIOLOGICO?

Por A. MORAGA PORRAS,
Santiago, Chile.

Se trata de investigar, cientificamente: (1) Si el ejercicio muscular de la respira-
ci6n es fisioldgico; (2) si es educador eficiente de la respiraci6n normal o natural; y
(3) si es indispensable en la ensefianza de la gimnasia, como se ba creido deede an-
tafio; o, de analizar, en su defecto, si dicho sistema ba experimentado, con el correr
del tiempo, una evoluci6n substancial, que nos baya demostrado lo contrario de lo
que hasta abora creiamos, como una verdad irrefutable.

Para apreciar debidamente el primer punto, se hace precisq conocer, antes, lo que
es una respiracidn fisiol6gica, a fin de entrar en materia, con conocimiento de causa.
La respiraci6n normal, debe ser: nasal, suficiente, completa y ritmada; estar for-
mada por movimientos voluntarios, espontdneos, directos o conscientes; no importar
su ''mise*' en actividad, esfuerzo ni gasto de energia apreciables; y, en fin, ser orde-
nada, controlada y dirigida a expensas de los centres respiratorios correspondientes,
exclusivamente.

El ejercicio muscular de la respiraci6n, del m^todo sueco, sintetizando una res-
piraci6n maxima o forzada, es decir, casi exclusivamente cuantitativa y no cualita-
tiva, no puede decirse que supone una respiraci6n suficiente, puesto que ^sta se
caracteriza por la entrada y salida del aire en cada movimiento respiratorio, de 500
a 1,000 c. c, aproximadamente, segtin se halle el sujeto en estado de reposo o activi-
dad, de los cuales los dos tercios son utilizables, segtin los fisi61ogos; ni que significa,
tampoco, una respiraci6n ritmada, ya que dicho ejercicio, tan pronto alarga la ins-
piraci6n como acorta la expiraci6n, interrumpiendo o perturbando la armonia fisio-
16gica que debe existir entre los dos tiempos de la misma, entre si y en relaci6n con
el tiempo; en fin, que no demanda esfuerzo y gasto de energia apreciables, por cuanto
exige uno tres o mds veces superior al de la respiraci6n normal: todo lo cual demuestra^
con la evidencia de los bechos que el sistema sueco estd muy lejos de poseer una
base fisiol6gica.

PTJBLIO HEALTH AND MEDIOINB. 689

Peio la respiracidn mdxixna que el m^todo de ejercicio muscular de la respira.
ci6n exige ^puede implicar el aprovechamiento de los do8 tercioe del aire respirado,
durante un acto respiratorio fisiol6gico7

Diffcilmente, en mi opini6n.

La re8piraci6n mdxima importa: de un lado, una mayor actividad muscular y
respiratoria, de natiu*aleza mecdnica producida por el mayor volumen del aire respi-
rado, actividad que acarrea, forzoeamente, un desgaste proporcional al esfuerzo que
la genera, lo que vale decir, un consume de aire aprovechable variable Beg6n las
condiciones fisicas del sujeto y la intensidad del trabajo muscular y respiratorio, y,
de otro, un aumento de la capacidad pulmonar y tordcica, de orden mecdnico igual*
mente, que se traduce por un desarrollo anat6mico mis pronunciado del pecho; pero,
de ningun modo quiere decir, que se incremente, al mismo tiempo, la capacidad
pulmonar fisiol6gica de la reepiraci6n suficiente, completa y ritmada (que el ejercicio
de la respiraci6n forzada mds bien pertiirba) y que sintetiza un coeficiente de aire res-
pirado equivalente a los dos tercios, como queda dicho.

La respiraci6n mijcima no importa, pues, un coeficiente fijo de aire utilizable,
eino uno variable, segdn las condiciones del sujeto y del ejercicio, que se halla rela-
cionados con la naturaleza mecdnica del movimiento respiratorio y no con el orden
fisiol6gico.

Pero, hay todavfa una pnieba poderosa que demuestra, de un modo evidente,
que el ejercicio muscular de la respiraci^n, no es fisiol6gico: la que se refiere a la es-
tructura biol6gica de los movimientos musculares y respiratorios. En efecto, el
m^todo de Ling, sdlamente produce movimientos respiratorios provocados, indirec-
tos, involuntarios y automAticoe; mientras que el ejercicio fisioldgico de la respira-
ci6n, s61o genera movimientos espontdneos, direct os, voluntaries y conscientes:
diferencia suficiente para no atribuir al primero base fisiol6gica y al segundo, si.

^El ejercicio muscular de la respiracidn, es educador eficiente de ^sta?

El m^todo sueco cultiva s61o al mtisculo por cuanto ^ste se halla ordenado, controlado
y dirigido por un centro 6xito, motor cerebral o mds exactamente cortical, sin el cual
no serla posible la educaci6n muscular. El ejercicio fisiol6gico de la respiraci6n cul-
tiva exclusivamente 6sta y tiene su centro cultural en el bulbo raqufdeo y de ahf
8US cualidades educativas especiales sobre la respiracidn suficiente, completa y
ritmada, que se halla controlada por este centro dnicamente.

El m6todo de ejercicio muscular de la respiraci6n, teniendo un centro educador
distinto del fisioldgico, como queda enunciado, si puede cultivar el mdsculo, no tiene
influencia educadora alguna aobre la re8piraci6n normal; del mismo modo, el ejercicio
fifiiol^co de la respiraci6n, si puede cultivar eficientemente ^ta, no tiene valor
alguno como educador del mdsculo.

En cuanto a los efectos mecdnicos que el sistema Ling produce sobre la capacidad
tordcica y desarrollo del pecho, ya hemes dicho, que, un ejercicio de la respiraci6n
forzada puede, naturalmente, provocar el ensanchamiento tordcico y aun el pulmonar;
pero, esto no quiere decir en manera alguna que cultive igualmente la capacidad res-
piratoria fisioldglca, que implica un coeficiente determinado de aire utilizable, en
cada respiracidn. El ensanchamiento del pecho, es un en f6meno ifsico-mecdnico,
exclusivamente, y el aumenjx) de la capacidad fisiol6gica supone, la adquisici6n del
hdbito de bien respirar, o sea de acuerdo con el coeficiente fisiol^gico de una respira-
ci6n normal, de que ya hemes hablado.

En efecto, es frecuente ver, en la prdctica, individuos de t6rax estrecho y de capaci-
dad pulmonar fisiol6gica muy grande y por el contrario, sujetos de un pecho muy
desarrollado y capacidad vital muy reducida: lo que prueba, que, el ensanchamiento
del tdrax se refiere tinicamente, al aumento o desarrollo anat6mico del mismo, mien-
tras que el incremento de la capacidad pulmonar fisiol^ica supone, la cultura efi-
ciente de la reBpiraci6n normal.

Los efectos mecdnicos del ejercicio muscular de la re8piraci6n no importan, pues,
ni pueden importar, los fisiol^cos; ya que aqu^llos son anat6mico8 y ^stos culturales.

^Es necesario, en gimnasia, el ejercicio muscular de la respiraci6n?

690 PROCEEDINGS SECOND FAN AMERICAN SCIENTIFIC CONGRESS.

Si 86 tiene presente, lo dicho acerca del ejercido fisioldgiGO de la respiracidn que
flintetiza una funci6n respiratoria nasal, suficiente, completa y ritmada y movimientoB
espont&neos, voluntaiios, directos y conscientee, que no exigen eefuerzo muscular y
86 hallan controlados, coordinados y dirigidos a expenaas del centra respiratorio, y, al
mismo tiempo, que el ejercicio muscular de la reepiracidn posee cualidades en sa
mayor parte opueetas, casi exclusivamente cuantitativas y se halla bajo el control del
centre cortical, completamente distinto del reepiratorio, se puede concluir: que, si el
primero es dnicamente educador de la respiracidn, s61o puede aplicarse en gimnasia
m6dica, como medio terap6utico, y, que, ai el segundo ee cultivador exclusivo d^
mtisculo, 861o puede indicarse en ginmaaia pedag<5gica, como aistema de desarrollo
ffaico; todo lo cual quiere decir, que, eete tiltimo, en ningdn caso, puede considerarse
como ejercicio reepiratoiio, aino como muscular.

£1 hecho apuntado de que el ejercicio muscular de la reapiracidn sea indispensable
en gimnaaia, no quiere decir, que se pueda descuidar la reapiracidn durante un ejerci-
cio gimndstico; por el contrario, aignifica, que, es indiapensable cuidar y vigilar
atentamente dicha funci6n, a fin de que no se perturbe de ningun mode, poniendo
en pr^tica, durante loa ejercicios, ciertaa prescripciones higi^nicaa: pureza del aire,
aseo y ventilaci6n bien hecha del medio, adaptaci6n de los movimientoa a las condi-
cionea psLcofisicaa de los educandos, etc.

De esta manera, reemplazando los ejercicios musculares especialee de la reapiracidn
por las buenas condiciones higi^nicas del medio y de los alumnos, se conaigue cultivar
mejor el mtisculo y adn la respiracidn.

La cueeti6n relativa al slatema aueco de gimnaaia, aobie ai el ejeddo muacular
de la reapiiacidn ea o no fi8iol6gico, apenaa ai ba aide eabozada por otroa, deade hace
mia de un aiglo, o sea, deade que el aueco Ling echara las basea de au m6todo de gim-
naaia. De abf que hayamoa aprendido a mirar como reapiratorioa verdaderoa ciertoa
ejercicioa muacularea, ain analizarloa conscientemente y cientificamente y de ahf
que bayamoa conaiderado, tambi^n, como educador de la reapiraci6n, al aiateina
Ling. M^ que eato, bemoa ido adn m^ alU, eatimando que loa movimientoe mua-
cularea de la reapiraci6n eran indiapenaablea en la ensefianza de la gimnaaia.

Dicba manera de apreciar la cueatidn de que me ocupo, ba ido modificindoee, ooa
el tiempo, y la evoluci6n ba becbo au obra« en eatoa (iltimoa afLoa, y, boy, noa hallamoi
en aituaci6n de dar una opini6n diatinta, aobre el m^todo de ejercicio muacular de la
reapiracidn; ya que podemoa cconprobar loa becboa que \ an a aer\ ir de base a nueatro
eetudio, de una manera pr&ctica o experimental, en contrapoaici6n a la emplrica en
que eatuvieron baaadoa, deade antafio, loa preceptoa fundamentalea del aiatema Ling,
o, mia exactamente, loa correapondientea al m6todo de ejercicio muacular de la
reapiraci6n.

No me voy a ocupar, en el curao de eate eatudio, en demoatrar, ai loa movimientoe
gimn&Bticoa muacularea del m^todo aueco, miradoa de un punto de vista genenl,
son o no fiaioldgicoa, que, ^ta, por abora, ea una cueati6n aparte; pero, af, da
analizar, en forma cientffica, el \alor del ejercicio muacular, como respiratorio*

El examen pr^tico del movimiento muacular de la reapiracidnr^n^todo de Ling—
tiende a demoatrar, ain lugar a duda, que loa ejercicioa en cuestidn no poeeen lot
caracterea correapondientea a una reapiracidn natural o eapont&nea, aino provocada
a expenaaa del ejercicio muacular. Hemes estado, pues, en un error al conaidetar
el aiatema aueco como fiaiol6gico, en cuanto la reapiraci6n, y ba side neceaario que la
evoluci6n se baya encargado de probarnoa lo contrario para reconocer nueatro engallo.

Para la cabal inteligencia de lo que voy a manif eatar en aeguida, aobre el punto en
referencia y otroa relacionadoa con ^te, eatimo conveniente decir doa palabraa aobre
lo que debemoa entender por reapiraci6n fiaiol^ca, antea de entrar en materia.

La reapiraci6n fiaioldgica, aegdn la concepcidn m^ moderna, debe poaeer laa aiguien-
tee propiedadea: aer naaal o importer la permeabilidad de laa foaaa naaales; aer
auficiente o implicar la entrada y aalida, en el pulm6n, durante una inapliaci6n y
expiraci6n naturalee, de 500 a 1,000 c. c. o m^ de aire utilisable; aer completa o
aignificar el juego de toda la region del pulm6n y de loa didmetroe tatidcoB; aer

FTJBLIO HEALTH AND MEDICINE. 691

ritmada u ordenada de manera que un cierto ndmero de reepiraclones ooireeponda
a un tiempo determinado, un minuto por ejemplo; ser confitituida, exclufdvamente,
])or movimientos propios del aparato respiratcnio, espont&neos, voluntarios, directos
y conscientes; ser despertada, coordinada y dirigida por los centres reepiratorios
y no implicar un esfuerzo y p^rdida de energfa considerables etc.

Todas estas condicionee o una buena parte de ellas constituyen la respiracidn
fisiol^ca, normal o natural. De modo que, el ejercido respiratorlo propiamente
dicho, no puede llamarse tal, sin dichos requisitos.

El primer punto que es preciso dilucidar, es el siguiente: iEl ejercicio muscular
de la respiracidn— sist^na sueco— importa una respiracidn fisiol(5gica?

Desde luego, es necesario tener en ^ista, primero, que el m6todo de Ling es casi
exclusivamente cuantitativo y no cualitativo; puesto que mira, preferentemente,
a la entrada y salLda del pulm6n de una gran cantidad de aire oxigenado y muy poco
a la manera de efectuarse la respiracidn.

H^ aquf, lo que el ejercicio muscular de la respiraci6n (de Ling) prescribe, entre
otras cosas: que la cadencia lenta de los mo^.imientos de los miembros corresponda
a una inspiraci6n y expiraci6n profundas, o, a una in8piraci6n profunda y expiraci6n
corta y en^rgica.

^Estas dos acepdones de la manera de consid^nr el movimiento muscular de la
respiraci6n, corresponden al m^todo fisiol<3gico de dicha funcion? Evidentemente no.

En efecto, la primera, puede decirse que peca de tres maneras: por suficiencia,
puesto que una respiraci6n normal supone el juego de aire corriente, en el pulm6n,
durante una respiracion, o sea, una cierta cantidad de aire aprovechable que fluctda,
(Rosenthal) entre 500 y 1,000 c. c. o m&, segtin el estado de reposo o acti\idad mus-
cular del Bujeto; pero en manera alguna el de un volumen de aire respirado (en el
curso de una inspiraci6n y expiraci6n).tres o m^ voces mayor, puesto que una respi-
raci6n maxima (como el sistema Ling, exige) implica, la adicl6n al aire corriente de
la respiracidn, del complementario y de resen a, es decir, 500+1,670+1,600 c. c;
o sea, 3,270 c. c. aproximadamente, cantidad m^ de tres veces superior a la normal,
repito, que, no pudiendo ser utilizada en totalidad en el pulm6n, por cuanto la
utilizable en cada respiracidn o suficiente es de 1,000 c. c. m^ o menos, como tendr^
oportunidad de probarlo despuds, queda retenida ahf para ser quemada o para agre-
garse al aire de reserva o al residual: lo que equivale a decir, que, el sistema sueco,
exige una respiracidn exagerada o llevada a sus dltimos llmitee, muy distinta de la
fisiol6gica.

En segundo lugar, el slBtrana Ling, peca, por prolongaci6n del primer tiempo de la
re6piraci6n y pertiu:baci6n del ritmo respiratorio. En efecto, en el estado normal,
la inspiraci6n es casi la mitad m^ corta que la expiraci6n, y el m6todo sueco la
vuelve m^ o menos igual, puesto que prescribe una inspiracidn profunda, que,
naturalmente, resulta m^ laiga que la natural. Esta circunstancia, hace, que el
primer tiempo se modifique, y, esta modificaci6n implica, una desarmonfa con el
s^^ndo que trae consigo, inevitablemente, la perturbaci6n consiguiente del ritmo,
o, del tiempo preciso en que deben verificarse la inspiraci6n y expiraci6n.

La perturbad6n del ritmo, mediante el ejerdcio muscular de una respiraci6n
m&xima, es, pues, evidente y constituye un grave defecto fisiol^gico, en nuestro sentlr,
del sistema en cue8ti6n.

Por (iltimo, el m6todo muscular de la respiracidn mixima acarrea, fatalmente,
un mayor esfuerzo y gasto de energia, que el de la respiraci6n fisiol6gica; por cuanto,
en este caso, no s61o entran en acti\idad los mt!ificulo6 inspiradores y expiradoree de la
respiraci^n natural, sino los del abdomen, miembros superiores e inferiores, etCy en
fin, los que deben encontrar un s61ido punto de apoyo en el t6rax, durante el esfuerzo
respiratorio que la respiraci6n maxima implica. Hay, pues, en esta clase de movi-
mientos respiratorios provocados por el esfuerzo muscular, una p^ida considerable de
fuerzas que no se observa en el de re6pirad6n fisioldgica.
68436— 17— VOL ix 46

692 PB00EEDINQ8 8B00ND PAN AMEBIOAN 80IBKTIFI0 00KQBE88.

La segunda acepci6n del m^todo sueco supone perturbadones respiratorias i
jantee a la primera, en la sufidencia, en el ritmo y en el eshieno respiratorioe.

En efecto, en eete case como en el precedente, ee verifica un cambio cuantitativo y
cualitativo de la reapiracidn; ya que la reepiraci6n miixiina supone una entrada eza-
gerada de aire oxigenado en el pulm6n, muy superior al suficiente o utilizable; una
perturbaci6n en el ritmo volviendo la expiraci6n xnia corta que la normal, siendo que
^ta es casi dos voces m^ laiga que la inspirad6n; y, por dltdmo, una exageraci6n dd
esf uerzo (aunque no tan grande quizd como la precedente) que se traduce por una
p^rdida de fuerzas superior a la que se gasta, normalmente.

Gomparando esta acepci6n con la primera, del pun to de vista fi8iol<5gico, Mcilmente
se comprende que tiene menos inconvenientes, sin duda; ya que, si es verdad que
importa, tambi^n, la respiracidn m^bdma, no lo es menos, que, volviendo la ezpira-
ci6n m^ corta se atentia un tanto, la p^rdida de energla.

''Las inspiraciones profundas seguidas de expiradones, fuertas y cortas," no son,
tampoco, admisibles, como ejopcidos musculares de la respirad6n de orden fisiol6-
gico; ya que encaman modificadones en el ritmo, en la sufidenda y en el gasto de
energfa respiratorios, vueh o a repetlrlo.

Queda por resolver, todavia, una cuesti6n fisioldgica nacida a raiz de los inconve-
nientes apuntados que se relacionan con la cantidad de aire utilizable durante una
respirad6n mdxima, ya que nos es conocida la de la fisioldgica.

Los partidarios del ejercido muscular de la respirad6n conceptdan, que, mientras
mayor es el voliunen de aire respirado m^ cantidad se-utiliza y por ende, mejores
efectos fisioi6gicos se obtienen. Esto, mirado en general y como un efecto mecinico,
es verdad ; pero como una acd6n sobre la respiraddn fisioldgica, no lo es, por las razones
que aducir6 en seguida.

Durante una respiraddn fisioldgica nasal, sufidente, completa y ritmada, la cantidad
de aire utilizable fluctda entre 500 y 1,000 c. c. o m^ y como de dsta se apro\ echan,
s^dn los fisidlogos, los dos terdos, o sea, 330 y 660 c. c. respectivamente, en cada
respirad6n, y el otro terdo se expele al exterior, resulta, que, tratdndose de un acto
respiratorio normal, exlste un coeficlente de aire utilizable variable, tinicamente,
segtin el sujeto se halle en reposo o en mayor acti\ idad fisioldgica.

Durante una respiraci6n mdxima, que importa la entrada al pulm6n de un vdumen
de aire respirado tres o m^ a eces superior al normal y un mayor esfuerzo proporcional
muscular y respiratorio que sintetiza igualmente un mayor desgaste, puede acontecer:
que la cantidad exceaiva de aire respirado, obrando como eetimulante mecAnico,
active las funciones respiratorias provocadas por el esfuerzo muscular, y, que, a causa
de esta mayor actividad oig&nica, se incremente en forma paralela el gasto de eneig^
saldindose los ingreeos y egresos fisiol6gicos, segdn la cantidad de exdtante que acdona
y las condidones del sujeto; lo que equivale a decir, que la respiracl6n forzada acarrea,
un estfmulo mayor o menor de las funciones musculares y respiratorias y un deegaste
equr alente a consecuenda de las mismas, o, tambi^n, que dicho excitante cuan-
titativo 7 mec&nico, obra sobre el pulm6n y el t6rax y diUta el pecho en propord6n al
esfuerzo que encama, trayendo como consecuenda un incremento de la capaddad
mec&nica respiratoria, que, varla, naturalmente, segtin las condidones apuntadas y
que se traduce, por un desarroUo igualmente variable del pecho. En otras palabras, d
ejercido de la respiraddn mixlma, si puede importar un incremento cuantitati^ o del
trabajo muscular y respiratorio y un aumento mec^ico de la capaddad pulmonar y
torAdca, no significa en manera alguna, una pauta en orden a inveetigar la cantidad
de aire que se aprovecha en cada respiraci6n, ya que varla ^sta segtin divenas di^
cunstancias, como queda dicho.

No es posible, pues, durante una respirad6n forzada, apreciar de una maneia pre-
cisa, la cantidad de aire utilizada, en cada acto respiratorio, sino como un factor me-
cinico y cuantitativo variable de expansidn y desarrollo toHUdcoe y de actividad
respiratorio y muscular; pero, en manera alguna como factor fisioldgico de una respira-

PUBLIC HEALTH AND MEDICINE. 693

cidneuficiente y ritmada, que, como queda enunciado y probado, m^ blen perturba
que culti\a, la reepiraci6n m&xima.

En 8uma, durante el ejercido de una respiraci^n m^bdma, Be cultiva, tanto la activi-
dad muscular y respiratoria de orden mec&nico, como la capaddad pulmonar de la
misma espede; pero, de ningun modo la actividad y capaddad fisiol6gica coirespon-
diente, a una respiraddn natural: ''mientras dura aqu^lla el mayor trabajo muscular
y respiratorio implica im deegaste equivalente, pudlendo variar cuantitativamente
ambos, durante ^sta, la actividad respiratoria no importa deegaste apredable y
dempre se halla sintetizada en un coeficiente de respiraddn casi invariable. "

En concluBi6n, la respirad6n mixima, no supone ni puede suponer, d aprove-
chamiento de una cantidad fija de aire equivalente a los dos terdos, como la fisioldgica,
por las razones aduddas anteriormente.

Queda demostrado, en forma efidente, que la respirad6n maxima del aistema
sueco, no es, ni puede ser fisiol^ca, dada su naturaleza cuantitativa y las perturba-
dones cualitativas que acarrea.

Examinemos, ahora, a la luz de la denda, el ejercido muscular de la respiraci6n y
el fisiol(5gico, en cuanto a su estructura bioldgica.

El primero, ya lo hemes dicho, encama: una actividad muscular y respiratoria
equivalente, ya que la respirad6n, es, en este case, el eco del trabajo muscular; una
labor que supone im gasto considerable de fuerzas ffsicas musculares y respiratorias,
al mismo tiempo; en una palabra, ima respirad6n provocada por d movimiento
muscular y por ende, involimtaria, autom&tica e indirecta.

En cuanto al ejercicio fisiol<5gico de la respiraci6n, s61o significa: un trabajo dd
aparato respiratorio, exclusivo, que no supone gasto de esfuerzo y de eneigfa; una
labor natural verificada a impulsos de la voluntad e inteligenda y por conaiguiente,
hija de movimientos espontdneos, voluntaries directos y consdentes.

En suma, el ejerddo muscular de la respiraddn no puede equiparaise, en ningdn
case, con el fidol<5gico, ya que el primero es fruto de la labor muscular, como queda
dicho, y el s^uudo de la respiracidn exduaivamente.

Pero, si el m^todo del ejercicio muscular de la respiraci6n no tiene base fisioldgica,
tampoco puede estimarse como educador de la respiraci6n normal, como reza el sistema
cuando se llama, ''cultivador dd ritmo y amplitud reepiratorioe; " ya que carece de
los requidtos culturales relatives a la formad6n de buenos hdbitos respiratorioe, como
vamos a ver en seguida. Y, desde luego, el sistema sueco importa, dnicamente, la
cultura del aparato locomotor, o, mds exactamente, de los centroe ^tcH-motores
corticales; mientras que la del m^todo fidol<3gico de la respirad6n implica, la educa-
ci6n de los centres de la resplraci6n normal, excludvamente. De suerte que, tanto
el mtisculo como la respiraci6n se hallan controlados y dirigidos por centros culturales
diferentee, y por esto, el uno no puede servir de sistema educative del otro.

Para apredar, ahora, si el m^todo de ling es educador de la amplitud respiratoria^
como dicen los partidarios del sistema, bastard analizar, primero, en que consiste esta
propiedad de la respirad6n normal.

La ampliaci6n torddca fisioldgica, importa, la entrada y salida de derta cantidad
de aire respirada y la expand6n pulmonar y del pecho condguientee a una inspiraci^n
y expiraddn hecha en dertas condiciones. De manera que, la ampliaddn normal
del t6rax, viene a ser equivalente en consecuenda, a una respiraddn suficiente, en
que el aire utilizable constituye loe doe terdos del reepirado (estimados en 500 a
1,000 c. c.) como queda dicho.

^06mo puede el m6todo sueco cultivar la ampliad6n toridca normal, dendo que
es casi excludvamente cuantitativo? iC6mo puede controlar dicha cualidad de la
respirad6n fidol^gica, d 6sta se encuentra dirigida por el centro respiratorio tiiti-
camente?

694 PROCEEDINGS SECOND PAN AMEBIOAN SCIENTIFIC C0NGBB8S.

No puede, puee, en consecuencia el ejercicio muscular de la leBpiracidn Borvir pant
cultivar la amplitud reepiratoria normal, por cuanto ^eta supcme la suficiencia reepi-
ratoria,que el m^todo de ling, m^ bien perturba, como queda probado.

En cuanto al ritmo, ya estd igualmente comprobado, que, el siBtema en cue0tidn«
alaigando la inspiraddn o acortando la expiraddn, en ambos casoe, en ves de rega-
larizar el movimiento respiratorio de acueido con un tiempo determinado (1 minuto
por ejemplo) hace predsamente lo contrario, rompiendo aaf la armonfa que debe
existir entre las doe fases de la reepiraci6n y el tiempo. De otro lado, la sinagia y
ritmo respiratorioe se hallan igualmente controlados por el c^itro lespiratorfo y en
manera alguna por el muscular; por lo cual, el sistema sueco no puede estimarse,
tampoco, como educador del ritmo respiratorio, que mds bien altera.

En suma, el m6todo de ejercicio muscular de la respiracii^ no puede, en ningun
caso, considerarse como cultivador de la amplitud y ritmo de la respiraci^n fieioldgica,
ni de ^sta, hablando en general.

Por (Utimo, el sistema Ling, propende, como objetivo primordial: a ensanchar el
pecho, volvi^ndolo mds potente y flexible.

Que los ejercicioe muscularee respiratorios, casi exclusivamente cuantitativoe
tiendan, a ensanchar el t6rax, no me toca a ml afirmarlo, ni negarlo, en esta ocasi6n y
quiero creer, m^ bien, que eUo sea verdad; pero, que dicha acci^ importe, como
creen los partidarios del sistema sueco, un aumento de la capacidad vital, al mismo
tiempo, no me atreveria a sostenerlo. El hecho conocido de que durante ima req[>ira-
ci6n mdxima hay expansi6n toridca y pulmonar, a la vez, ^es suflciente para hacemos
creer que esta expansi6n ffsico-mecinica importa un mayor desairoUo de la capacidad
pulmonar fisioldgLca, como creen algunoe? Yo, creo que no.

En efecto, el aumento del volumen de aire respirado, ''durante una inspiraci<^ y
expiraci6n profundas/' s61o esta relacionado con el esfuerzo muscular y en manera
alguna con el respiratorio; ya que el primero es mec4nico puro y el segundo fisiol^co
de verdad. No hay, pues, en este caso, un movimiento natural del pulmdn que impli-
que el espontdneo de la respiracidn normal, sino imo muscular, repito, que supone un
esfuerzo muscular y el gasto de energia que se traduce por una respiraci6n provocada,
como queda dlcho. Para que ima respiracidn forzada o maxima, pueda consideraise
cultivadora de la capacidad pulmonar, serla necesario que estuviese formada por
movimientos voluntaries y conscientes, y, que, durante la re6piraci6n, no se utilizaia
m&s que la cantidad de aire suficiente, estimada en 500 a 1,000 c. c. como queda dicho:
doe condiciones que no se verifican en manera alguna, en el sistema sueco, que s61o
produce movimientos reepirat(»ios provocados y utiliza cantidades de aire respirado
tres 0 cuatro veces mayores que las sefialadas.

Lo dicho que precede, nos ensefia, con la elocuencia de los hechos comprobados,
que, no hay relaci6n entre el aumento anat6mico del t6rax, y el fisiol<5gico de la res-
piraci6n; ya que se encuentran sujetos de un pecho bien desarrollado y de capacidad
reepiratoria minima y por el contrario, de t6rax estrecho y capacidad vital maxima.

En suma, los ejercicios musculares de la respiraci6n, si contribuyen a deearroliar el
t6rax, no tienen influencia sobre la capacidad vital pulmonar; ya que 4sta importa la
cultimt de la respiracidn fisioldgica tinicamente.

Respecto a la necesidad de crear ejercicios musculares de la respiraci^, en ginmasia,
no me hallo, tampoco, de acuerdo con los partidarios del sistema sueco, que los con-
sideran y reconocen como fundamentalee e indispensables, en la ensefianza.

En efecto, siendo el ejercicio muscular de la respiraci^n casi exclusivamente cuanti-
tativo y no cualitativo, puesto que perturba la suficiencia y ritmo fisioldgicos e impor-
tando, adem^B, movimientos respiratorios provocados por el trabajo muscular y un
esfuerzo y p^dida de energia m^ o menos considerable; no puede llamarse necesario
e indispensable, en ginmasia, como ejercicio respiratorio, pero sf como muscular.
De otro lado, estando dirigido y controlado por el centre cortical cerebral, tinicamente,

PUBLIC HEALTH AND MEDIOIl<nB. 695

no puede servir como educador de la respiraci6n fisiol6gica que se halla reglada y
coordinada por el centre reepiratorio, completamente distinto de aqu61.

Per las consideraciones apuntadas m^ airiba, podemos concluir: que la necesidad
de un ejercicio muscular de la re6piraci6n, en gimnasia, no se halla en manera alguna
justificada, hoy, puesto que en realidad, dicho ejercicio (en cuanto a la re8piraci6n
se refiere), no es fisioldgico, ni educador de 611a, sine exclusivamente del mtisculo.

El concepto false que se ha tenido, desde hace m^ de un siglo, del ejercicio mus-
cular de la respiracidn (que ha side considerado como fisiol6gico y educador de la
reepiraci6n normal), ha provenido de haber considerado la respiracidn provocada
por el ejercicio muscular como igual a la verdadera o normal, suficiente, completa y
ritmada, siendo que aqu^lla no posee las cualidades de ^sta. Fuera de lo dicho que
precede, tampoco se tuvo en vista, que los movimientos respiratorios provocados no
tienen ni pueden tener el mismo valor fisiol6gico que los espont^eoe; ya que los
primeros suponen un gasto de energfa considerable y los segundos, no. De ahl
porqu6, el ejercicio muscular de la respiracidn, si puede indicarse como sistema de
gimnasia pedag6gica, no es posible aplicarlo como despertador y cultivador de la
reBpiraci6n fisiol6gica. Por el contrario, el m6todo fisiol6gico de la re6piraci6n que
sintetiza la gimnistica respiratoria, si estd indicado y debe aplicarse como desper-
tador y reeducador de la respiraci6n normal, no puede aprovecharse como ginmasia
de desarrollo; pues, s61o estd destinado a servir como medio terap6utico, en indivi-
dUos enfermos que han suMdo cambios respiratorios y que no pueden someterse a im
esfuerzo mis o menos considerable, a diferencia del muscular de la respiracidn que se
halla precisamente indicado en individuoe sanos, resistentee o eficientemente expe-
dites.

En una palabra, el m^todo sueco, no es respiratorio de verdad, sine muscular y
conviene a los individuos que se hallan en buena salud, mientras que el fisiol6gico, es
realmente respiratorio y no muscular y conviene a los sujetos enfermos: el primero
implica la gimnasia de desarrollo y el segundo, la ginmasia m^dica.

Mas el hecho de que no sea indispensable el ejercicio muscular de la respiracion,
en ginmasia pedag6gica, por no ser respiratorio de verdad, no quiere decir, que, su
adopci6n, deje de ser necesaria como cultivador del sistema locomotor, y, que, por
dicho motive, no sea precise vigilar la respiraci6n durante los ejercicios musculares
de la gimnasia pedag6gica. Por el contrario, en todo case, se hace indispensable
ouidar y vigilar atentamente la re6piraci6n, a fin de que se verifique lo m^ fisiol6gi-
camente posible. Y, desde este punto de vista, todas las ginmasias deben propender,
a im mismo objetivo: ejecutar los ejercicios en forma que de ninguna manera perturben
la respiracion fisiol6gica.

Para llenar dicho fin que constituye, hoy, im desideratum, se han propuesto diversoc
medios y entre otros, los siguientes: procurar que los ejercicios se verifiquen al aire
libre o en un medio ambiente donde las condiclones higi^nicas relativas a pureza del
aire, perfecta ventilaci6n y cuidadoso aseo, no dejen nada que desear; habituar a loe
educandos a respirar exclusivamente por la nariz y jam^s por la boca, durante loe
ejercicios y fuera de 611os; reglar la intensidad, calidad y celeridad de los movimien-
tos de acuerdo, con el sexo, edad, constituci6n y grade de preparaci6n de los alumnos;
adaptar los ejercicios a las condiclones psico-fisicas de los educandos que se refieren a
la raza, clima, costumbres, g^nero de vida y necesidades de los mismos, etc.

En suma, mia bien que ejercicios musculares respiratorios se necesita, en gimnasia
pedag^ica, verificar los movimientos de acuerdo con las condicionee higi^nicas apimta-
das. que son, indudablemente, m^ convenientes y mds pr&cticas; ya que de esta ma-
nera, en cada ejercicio, se vigila y cuida la resplracidn, del punto de vista higi^nico,
asf como de su conservacidn y eficacia.

Concltuum. — El ejercicio muscular de la respiracion, m6todo sueco, no es fisio-
16gico; no es educador de la respiraciOn normal; ni es indispensable, en gimnasia.

696 PBOOEEDINGS SECOND PAN AMEBIOAN SCIENTIFIO C0NGBES8.

AUTOFRilSIAS MENTALES.

Por FERNANDO GORRITI,
Midico de la Colonia Nadonal de Alienados de Argentina.

Damoe la denominacidn de autofrasias, a ciertas fonnas de expresidn en el lenguaje
de lo6 enfermoB mentalee.

Muchas son las modalidadee, en las perturbaciones de locuci6n, descritas hasta el
presente, pero sin semejanza, creemos, con nuestra nueva deeignacidn.

Consiste la autofrasia, en \ina repetici6n segulda, llmitada en bu ndmero, intami-
tente, voluntaria, intencional, de ciertas frases eomunee usadas por el enfermo en el
cuiso de su conversacidn, para expresar sus ideas dellrantes o no, sin altemr por ello
la ilaci6n general; acompafiada generalmente de un lenguaje expreaivo, adecuado a
las ideas manifeetadas, y con el prop6sito deliberado de llamar la atenci6n sobre
ciertos puntos de su relaci6n, y persuadir a su oyente u oyentes de la varacidad de
sus afirmaciones.

Esta autofrasia, que la hemes llamado as! , por opoeicidn a la ecofrasia o repetici6n
de las frases ofdas por el enfermo a su interlocutor, y muy distinta a su vez de la ecola-
lia, puede ser verbal y eecrita en el mismo sujeto; estd en re]aci6n, a nuestro modo
de ver, con una perturbaci6n de la ideaci6n, y comprendida por lo tanto en las dislo-
gias o disfrasias de Kussmaul, pero sin considerarla no obstante, como una especie
de estereotipia verbal, en la cual, la repetici6n autom&tica e indefinida, constituye
el cardcter dominante; mas en relaci6n en este case, con un estado de automatismo
psfquico, como se observa en ciertas formas de demencia precoz (neolpgismoe, jargo-
nofrasia, etc.).

La verbigeraci6n, descrita por primera vez por Eahlbaum en el afio 1874, consiste
en la repetici6n indefinida de las mismas palabras o frases sin significaci6n alguna, y
acompafladas de un tone declamatorio, como si estuviese el enfermo diciendo un dis-
ciirso.

Tenemos en nuestro servicio de la Colonia Nacional de Alienados, un demente pre-
coz, que por temporadas, se pasa todo el dfa repitiendo sin cesar: "puerta ventana,
ventana puerta, puerta ventana, ventana puerta,*' etc., o ''mesa silla, siUa mesa,
mesa silla, silla mesa,'' etc., en una forma mondtona e interminable. Tampoco ^ste,
es nuestro case.

Para explicamos, expondremos un ejemplo tfpico:

Se trata de Yitaliano Ga., italiano, soltero, actualmente de 55 afLos de edad, joma-
lero; ingres6 al Hospicio de las Mercedes el 8 de agoeto de 1911, y fu6 remitido, con el
diagn6stico de delirio sistematizado progresivo, a la Colonia Nacional de Alienados,
el 29 de octubre de 1913.

Efectivamente, Yitaliano Ca., es un perseguido sistematizado, con ideas delirantes
Claras y bien coordinadas de persecuciones para con determinadas personas; Idcido,
con verbosidad y cierta elegancia exterioriza su estado mental, cuya clasificacidn no
da lugar a dudas. Y bien, en medio de su conver8aci6n se nota una repeticiiSn, de
cuando en cuando de sus propias frases, cierto ndmero de voces, con un tone de voa
hasta cierto punto agradable al of do, y acompafiado de una expresi6n mimica adecuada
a las ideas manifestadas; aire de distinci6n, en contraste muy grande con su po8]ci6D
social, instrucci6n, hdbitos de vida anteriores.

En el curso del interrogatorio dice, entre otras cosas, al preguntdrsele su estado civil:

Yo no me quiero casar, yo no me quiero casar, yo no me quiero casar, jro no me
quiero casar con ninguna mujer; ni en este mundo ni en el otro mundo, ni en este
mundo ni en el otro mundo, ni en este mundo ni en el otro mundo^ ni en este mundo
ni en el otro mundo; yo tengo que morir soltero, yo tengo que monr soltero, yo tenflo
que morir soltero, yo tengo que morir soltero, porque ese es mi deseo y voluntad de
morir soltero. Yo no sirvo para el casamiento, yo no sirvo para el casamiento, yo no
sirvo para el casamiento, yo no sirvo para el casamiento, porque soy impotente. Yo
no soy responsable de lo que dicen otros, yo no soy responsabfe de lo que dicen otros,
yo no soy responsable de lo que dicen otros.

PUBIJO HEALTH AND MEDIOIKB. 697

Cuando ee le pregunta porqu6 repite tantas vecee las palabrae, contesta: ''para
perauadir que yo digo la pura verdad, para persuadir que yo dlgo la pura verdad, para
persuadir que yo digo la pura verdad, para persuadir que yo digo la pura verdad."

£n otro momento dice: ''no es posible una sociedad sin leyes, no es poeible una
sociedad sin leyes, no es poeible una sociedad sin leyes, no es posible una sociedad
sin leyes, yo no soy fil^fo; soy un diletante de filosofia, soy un diletante de filosoffa,
Boy un diletante de filosofia " ; y asf , en el ciurso de su expo6ici6n, se nota eeta repetici6n
eepontdnea y por momentos, de sus propias frases, con cierta tonalidad de voz euf6nica,
y deede luego, sumamente llamativa.

Esto hace recordar, en cierto modo, algunas formas permitidas en la sintaxis figu-
rada, o en el lenguaje literario, aunque en este terrene, no es posible deslindar Hmites
preclsos entre la gnunitica y la literatura; pero claro es que nunca tendremos la ocu-
rrencia, por estas rememoraciones, de querer asignar a la autofrasia, un si tie legal
en el buen decir.

Las figuras de construcci6n m^ comunes, son: el hip^baton. la elipsis, el pleonasmo,
la silepsis y la tra8laci6n.

Parecerfa que en nuestro case, hubiese pleonasmo, es decir sobra, redundancia, pero
anormal, de palabras.

El c^lebre poeta y escritor Rub^n Darfo, en ''La Naci6n" del 22 de agosto del
corriente afLo (1915), para citar un ejemplo a mano, publica una correspondencia
enviada de Nueva York, con el tftulo " Apuntaciones de Hospital," y en uno de sus
pirrafos dice: "Nieva, nieva, nieva, con una monotonia melanc61ica que yo siento
aqul mis que en otras partes/' etc. (tres nieva).

Tambi^ se acostumbra decir enfdticamente, por ejemplo; no quiero que vengas, no
quiero que vengas, y no quiero que vengas. Pero en este case, la conjunci6n copu-
lativa y, viene a terminar oportunamente, la negaci6n rotunda, marcadamente acen-
tuada en ]^ frase expresada. y que no se repetird, en adelante, al interlocutor.

Dos ejemplos de repetici6n, distintos por cierto de los carac teres que presenta
nuestra autofrasia mental, la cual puede ser verbal o escrita, como lo hemes dicho
anteriormente.

Podrfa suponerse, que estas breves consideraciones de orden literario-gramatical,
se apartan del verdadero objeto de una comunicaci6n de cardcter psiqui&trico; pero
precisamente el lenguaje, en ciertas formas de psicosis, tiene a veces estos puntos de
eontacto, como se describen en algunos textos corrientee sobre medicina mental,
las modificacionee de la sintaxis, del estilo, etc., tan to mis notable, cuanto mis re-
saltan a la vista, por el contraste que ofrece una dicci6n verbosa, el^ante, galana, en
boca de un enfermo mental sin instrucci6n alguna, como en nuestro case, que se
trata de un picapedrero, que apenas sabe leer y escribir, y de un origen de lo miia
humilde.

Cuando nos hablaba Yitaliano Ca., de su impotencia, que por dicho motive odiaba
a las mujeres, porque para ^1 ya no le sirven, agr^gaba: "y con estos cabellos de plata.
tampoco seria permitido pensar todavia en las mujeres." Expresi6n que encuadra
en una de las formas literarias, conocida con el nombre de tropo, lenguaje traslaticio
0 figurado, que comprende la metifora, sin^doque y metonimia.

"Y con estos cabellos de plata," por decir: Y con estos cabellos blancos (como
8in6nimo de vejez), tenemos un buen ejemplo de metonimia; efectivamente, Yitaliano
Ca., es un enfermo bastante canoso, por su edad avanzada (55 afios).

Terminaba dicl^ndonos: "creo que por lo quc^he habiado, habrd visto el ilustrfsimo
sefior doctor, que no estoy loco, sine al contrario, soy un iluminado de la raz6n, soy un
iluminado de la raz6n, soy un iluminado de la raz^n."

Y, en cualquier momento del dfa o de la noche, quien quiera que fuese el que le
hiciere preguntas, personal de vigilancia u otros enfermos, siempre se expresa Yita-
liano Ca., con sus autofrasias, "sin haber conseguido con veneer toda^'fa. a peear de
que repite lo mismo hace muchos afios," segiln sus propias palabras.

698 PBOCEEDINGS 3B0OND PAN AMEBIOAN 80IENTIFI0 COKGBESS.

mCIENE MENTAL EN SUS RELACIONES CON EL DESARROLLO Y CON-
SERVACION DE LA ENERGU PSIQUICA Y DE LA FATIGA PRODUCDOA

POR LA ENSERANZA ESCOLAR.

PoR A. MORAGA PORRAS,
Santiago, Chile.

OONSIDBRAOIONES GENBBALES 80BRE LA LABOR INTELEOUVA T LA FATIQA MENTAL.

En el ejercicio del trabajo intelectivo, como todo el mimdo lo sabe, entran en activi-
dad divereas fetcultades del espfritu, adem&B de la atenci6n: la inteligencia, como
potencia que adquiere, elabora y recuerda Ice conocimientoe ensefiados y sugeridos; la
afectividad o eensibilidad, como facultad que siente y se emodona; y la voluntad^
como potencia que quiere o no quiere, Y bien, todas eetas facultadee, denominadas
tambi^n ^^potencias pefquicas/' mientras entran en actividad, son eeclarecidas e ilua-
tradas por la atenci6n, estado del espiritu encargado de volver m^ netaa y mis com-
prensivas las ideas o im^nee percibidas, que representan laa ensefianzas sugeiidas.

Una vez que las facultadee psiquicas o intelectivas entran en acci6n, cada una,
repito, deeempefia el papel que le corresponde: la inteligencia percibiendo, cono-
ciendo y entendiendo loe conocimientos sugehdos y record^doloe por medio de la
memoria; la afectividad, sinti^ndolos como afectos o deeafectoe; la voluntad, queri^-
doles o no queri^ndolos y en consecuencia, aceptdndoloe como buenos o males; y la
atenci6n, esclareci^ndoloe y volvi^dolos m^ puros y diifanos, por decirlo asi. Cuando
todas estas facultadee trabajan por algun tiempo, es claro, que cada una o todas en con-
junto, pueden experimentar la fatiga, segdn la cantidad y calidad del trabajo ejecutado;
en otras palabras, la fatiga mental se produce al mismo tiempo que la flsica, ya que
como esti probado y admitldo por psic61og08 y pedagogos, las funcionee del eepfrita
son simult&neas y paralelas con laa del cuerpo.

Siendo esto asf , natural es creer, que, tratdndose del tiabajo mental eecolar, la fatiga
pueda sobrevenir cuando ^te es recai^ado o mal distribufdo. De ahl la necesidad de
dar reglas higi^nicas tendentes, no s61o a repartir las tareas escolares convenientemente,
sine a procurar que la fatiga no sobrevenga, seleccionando la tarea y el tiempo de
trabajo, a fin de no de^gastar intitilmente la eneigla psiquica o la capacidad mental con
una labor excesiva y mal distribuida. Y, como en el desempefio de una tarea eecolar,
cualquiera que sea, entran en juego, como queda dicho, la atenci6n y las facultadea
del espfritu, estimo conveniente, para ser Idgico, hablar primeramente de la higjene de
eee estado de la mente que ilumina las potencias intelectivas, mientras funcionan, y,
en seguida, de la correspondiente a la labor pefquica propiamente dicha.

En suma, el trabajo mental se verifica a expensas de laa facultadee intelectivaa
guiadas y dirigidas por la atenci6n y esta labor, como la flsica, puede, en ciertos casoa,
produoir la fatiga.

FUNCI6N DE LA ATENCI6N EN EL TRABAJO MENTAL.

El papel de la atenciiSn en el trabajo intelectivo, ee inmenso. Se puede decir con
toda propiedad, que no hay fetcultad psiquica de las que entran en actividad, en un
memento' dado, que no est^ influenciada directamente por la atenci6n. Asf, la memo-
rializaci6n o el recuerdo del pasado, eetk intimamente subordinada a la atenci6n; ya
que no nos serfa dado en manera alguna reproducir en el espiritu impreeiones de otros
tiempos o mantenerlas volimtariamente reproducidas, sin la participaci6n activa de
una cierta conciencia, de ese estado de la mente que nos hace apreciar y recofdar lo
que pasa y ha pasado en nosotroe. De ahi que se pueda decir con toda propiedad y
verdad, que la facultad de la memoria se halla casi por complete implicada en el
estado del espiritu que hemes llamado atenci6n. En conaecuencia, debemoe conduin
que no nos es posible recordar sin estar al mismo tiempo dirigidos por la atenci6n.

La asociaci6n de ideas, o sea, las im^nes-recuerdos, los idealee sugeridos mediante
las impreeiones percibidas provenientee del mundo exterior y que encaman relacionea

PUBLIC HEALTH AND MBDIOINB. 699

de contraste, de semejanza y de contigtddad, no podrlan tener lugar o crearae en U
mente, sin que la atenci6n entre en acci6n. La atencidn establece, mediante el juego
de las ideas, pensamientos ricoe y vaiiados que implican, en slntesis, im^igenes l^cas,
ordenadas y metddicas. La a80ciaci6n de ideas no podrla, puee, crearse, ni desper-
tarse una vez formada, sin el concurso de la atenci6n.

Los sentimientos afectivos y emotivoe, sean agradablee o desagradables, cuando se
prolongan por algtin tiempo sobre todo, es porque hacen un Uamado a la at;enci6n; de
otra manera se sentirian muy r^pidamente o pasarfan inadvertidos.

La voluntad, la atenci6n y el eefuerzo mental, tienen un gran poder sobre la actividad
intelectiva puesta en ejercicio, tanto, que el buen funcionamiento de la misma
depende, de la vigilancia y adaptaci6n de dichos tres elementos, obrando de consuno.
La actividad sin la atenci6n, tenderia, naturalmente, a di^;regaiBe; ya que el trabajo
mental dingido por la atencidn, asocia y coordina los sentiniientoe y emocionee de
acuerdo con la voluntad.

En resumen, siendo la atenci6n pariente muy proximo de la memoria, de la asocia-
ci6n de ideas y hermana de la voluntad e influyenlo al mismo tiempo en las manifee-
taciones de la afectividad, puede considerarse como colocada en el punto m^ alto de la
jerarquia de los fen6menoe intelectivos.

LA ATBNCI5n Y lab POTBNCIA8 FISIOL6qICA8.

Mientras se desarrollan, en el espMtu, los fen6menoe psfquicos, intelectivos o men-
tales, que mediante la atenci6n tienden a hacerse m^ vivos, mds netoe, m^ claroe y
mds ordenados; mientras esta serie de modificaciones tiene lugar en la esfera de la
intelectualidad, al mismo tiempo, simult^nea y paralelamente se verifica, en todo el
cuerpo, otro oiden de fen6menos, puramente fisioldgicos, musculares, reepiratorios,
circulatorios, sensitives, t^rmicos, etc.

En efecto, diirante el ejercicio de la atenci6n, los movimientos musculares son modi-
ficados en precisi6n, vigor y rapidez y su mecanismo queda subordinado exclusiva-
mente a la voluntad; la circulaci6n general, es comprimida, dificultada y por lo tanto
acelerada, en un principio, aumentando al mismo tiempo o disminuyendo la frecuenda
del pulso, segiin la maneia de reaccionar del sujeto; la circulacidn cerebial aumenta y
la peril^rica, que es independiente de la cerebral, disminuye, produd^ndose la vaso-
dilataci6n central o tendencia a la congeetidn y la va80-constricci6n perif^ca o ten-
dencia a la anemia; los cambios qufmicos que tienen lugar en el interior de nuestros
tejidoe (durante la nutrici6n Intima), se revelan por el aumento de la cantidad de
orina, del &cido fosfdrico y de las sales de cal y magnesia eliminadas; los gl6bulos rojos
disminuyen marcadamente durante el trabajo de la tarde y no tanto por la labor matinal;
en una palabra, al ejerddo de la atencidn trae consigo, como se ve, modificadonee
fisioldgicas bien claras, que influyen jd&b o menos marcadamente en el organismo.

Fuera de eeto, se ha recomendado como estimulantes de la atencidn y de la eneigia
pefquica, a los exdtantee del sistema nervioso, el t^ y el caf4. M^, se ha comprobado
que dichos estimulantes, solo tienen un papel supei^cial; no constituyen, pues, una
ayuda segura, un estfmulo eficaz y durable de la actividad psiquica, sine mis bien
conducen a la fatigabilidad, drcunstancia que es precise tener muy preeente en el
r^;imen de la vida escolar.

En conclu8i6n, la atend6n, tiene, pues, una acd6n indudable en la vida fisioldgica.
De ahf que se haya pretendido definirla: **un sentimiento de tension psfquica que
nace, por una parte, de la acci6n de los fen6menos cerebralee y por otra, de la con-
taracci6n t6nica genmul voluntaria o eepont^ea de los mdsculos.''

LA ATBNCI6N T LA FATIQA.

La atenci6n, como queda dicho, puede producir y produce en efecto, como el
trabajo ffsico, cuando se ejercita por algtin tiempo, la fatiga general; ya que, labor
pslquica y flsica son solidarias.

700 PBOGEEDINQS SECOND PAK AMEBICAK BOIBHTDnO OOKaBESS.

Las tranflformacionee psico-flaicas que se experimentan en el ofganismo, deepu^ de
un trabajo mental en que acciona la atenci6n o de una labor puramente material, son
miB o menofl equivalentee: la eneigia intelectiva y flflicm tienden a gafltaree, dis-
minuyendo en consecuencla la acti\ idad psfquica y fiaioldgic* correepondientes. La
de0aparici6n de la energia estd, naturalmente, en relaci6n diiecta con la cantklad y
calidad del trabajo efectuado; pero la tatlga no Bobre\iene sino cuando los recunoe
Bon m^ o menofl \ ivamente gastados.

El trabajo intelectivo que se localiza en una regl6n dad* del cuerpo, es el a^nte
ocasional de una hitiga flaica que puede ser general, pero que permanece limitada
principalmente al drgano que trabaja.

La inmo . ilidad de Iob mtbculoe que se produce mientras la atenci6n entra en fun-
ci6n, ee, como se comprende, una de las causaa mis maicadas de la fatiga.

Es un hecho aceptado y demoetrado, que la tatiga mental estd en relaci6n estrecha
con el eefuerzo de la atenci6n, asf como con el estado del sensorio; ya que, lo psfquico
y lo fisico Be corresponden, como queda dicho.

For t&ltimo, nos resta saber cuidee son los aignoe de la hitiga mental. H^ aqui loe
principalee y los m^ importantee: tendencias a destniir, romper objetoe y a la cdlera;
deseos irresistibles de hacer locuras; irritabilidad ner\iosa que se traduce por una
excitaci6n o depre8i6n, exceso de sensibilidad (hiperesteeia) o abolici6n de la misma
(anestesia); en fin, dolores de cabesa, menos tonicidad de los mtksculoe, diaminuci6n
de las fuersas, etc.

Loe individuos mal constitufdos y nerviosoe, son incapaces de laigos eefuerzos de
energfa ptlquica; por el contrario, loe bien constitufdos y vigorosos, poseen mia
resistencia y no sufren tan f^ilmente la fatiga despu^ de un trabajo mental.

En resumen, los esfuenos de atenci6n y de trabajo intelectivo, deqgastan las energias
psfquicas y ffsicas, y con el tiempo se revelan por la tatiga que es firil de reconocer
por los efectos que produce.

maiBNE DE LA atengi6n.

La higiene de la atenci6n puede comprender y comprende en verdad, doe puntos
fundamentales: ^Cu&l es el momento m&s favorable al esfu^xo mental? ^Cuiilet
son las condiciones oi|;&nicas— de abetinencia o sobre alimentaci6n— nUuB fovorables
para el funcionamiento psfquico?

Estas dos cuestiones abrazan, no solamente la higiene que es precise obeervar
cuando hacemos un esfuerzo de atenci6n, sino cuando verificamos un trabajo mental;
ya que no puede desplegarse la energfa intelectiva sin que est^ ordenada, esclarecida
y metodizada por la atenci6n.

En cuanto al primer punto, puedo decir, teniendo preeente los reeultados a que
pedagogos y psic61ogos ban arribado: que el trabajo intelectual hecho por la »«^f<(tT>a
es preferible al ejecutado en la tarde. La raz6n, no es diffcil de apredar, si se toma
en cuenta: que en la mafiana, despu^ del reposo de la noche, procurado por un
suefio tranquilo, el organismo en general estd m^ descansado y mis apto en conse*
cuencia para emprender una labor y de otro lado, que las &M:ultadee psfquicas se
hallan tambi^n en mejoree condiciones; ya que no habiendo sido hitigadas por un
trabajo inmediato anterior, se encuentran mis hdbiles para ejercitar su actividad.
En tales circunstancias, es incueetionable — ^repito — ^la ventaja que el trabajo mental
de la mafiana tiene sobre el de la tarde. Es probable igualmente (?) que el estado
atmosfMco, la temperatura y el ambiente matinales, tengan tambien su influencia
favorable; pues dl aire de la mafiana es comunmente m^ oxigenado y mis puro, asf
como la temperatmra mis baja que en la tarde y en consecuencia, mis a propiisito
para la vida: lo que podrfa traducirse por una mayor resistencia oiginica para el
trabajo mental.

En cuanto al segundo punto, mucho se ha discutido y se discute al respecto, sobre
si el estado de abstinencia, es o no, mis convenlente para el trabajo mental que el
de sobrealimentaci6n.

PXJBIJO HBALTH AND MBDIOnTE. 701

Sin mencionar todas las expeiiencias hechas, lo que me obligarfa a ir mucho m&B
all4 de lo que pretendo, me voy a pennitir eetampar aqui las conclusionee a que se
ha llegado, por creerlas mis l^caa y tambi^ m^ fidol^cas:

1®. Ud trabajo mental prolongado, ejecutado durante la abstinencia o sobreali-
mentaci6n, consumiendo anonnalmente las fuerzas oigdnicas y produclendo como
coneecuencia la hitiga, forzoeamente tiene qu3 ser perjudicial;

2^. Una labor mediana, verificada en las mismas condicionee fisiol^cas (de absti-
nenda o 8obrealimentaci6n), ee m^ favorable durante la abstinencia, puesto que en
este tiempo, el desgaste siendo mis o menos el mismo, no se perturban con el trabajo
otras funciones orginicas, que (como sucede durante la 8obrealimentaci6ny deepu^s),
se encuentran en plena acti\ idad; y,

3^. Porque el esfuerzo psfquico veiificado inmediatamente deepu^s de la allmen*
tacI6n, cuando se estd en plena digeeti6n, no s61o demanda una acti\idad cerebral
mayor, sino que perturba, muchas vecee perjudicialmente, repito, las funciones
orginicas que habiar entrado precedentemente en acci6n, ee decir, la digeeti6n,
absorci6n y nutiici6n, por cuyo motivo se hace necesario — ^Indispensable — no trabajar
mentalmente sino despu^ de doe horas, a lo menos, despu^ de haber comido.

En conclusidn, el trabajo de la mafiana, principalmente el ejecutado de 6 a 8 A. M.
y el que se hace durante la abstinencia, en ayunas, con tal que no sea muy prolongado,
es el que puede verificarse en condiciones de tensidn psfquica m^ felices, puesto que,
como queda probado, es el que se hace en mejoree condiciones fisioldgicas.

XL TRABAJO PSfQUICO CONTINUADO B INTERRUMPIDO T LA PATIGA.

Cuando se ejecuta un trabajo mental continuado — simias y multiplicaciones, por
ejemplo— despu^ de numerosas experiencias hechas en estos dltimos tiempos, se ha
comprobado, sin lugar a duda, lo siguiente: que a los tree cuartos de hora de labor
(45 m.) t^rmino medio, la energla comienza a decrecer progresivamente de una
manera cuantitati\ a y ciialitati\ a, mia o menos en la misma proporci6n y que la fatlga
comienza un poco antes, algunas veces deepu6s de media hora.

Estoe hechoe, nos estdn probando fehacientemente, que es necesario procurar que
las clases no duren m^ de 50 minutos.

Mas suele suceder frecuentemente — y esto es de siuna importancia prictica — que,
a medida que se repite el trabajo intelectivowy que decrece la energla, la labor se hace
mis facilmente y el desgaste orgdnico va siendo menor, asf como el mental: esto es
debido, a la ben^fica influencia del ejercicio, que, cuando vuelve la labor instintiva,
llega a ser un corrective de las p^rdidas y de la fatiga.

Pero, un inconveniente suele presentarse, que perturba la ben^fica acci6n del
ejercicio: es la homogeneidad del trabajo intelectivo, que, indefectiblemente,
acarrea la fatiga. En efecto, una labor psfquica igual, produce el disgusto, puesto
que carece de atractivo, y, esfuerza, de otro lado, la accidn de la voluntad, ya que
obliga al sujeto a ejecutar una tarea que lo tiene molesto y aburrido; lo que le impulsa
a trabajar contra su voluntad y a imponerse otra nue\'a fatiga. Por eso, la homoge-
neidad de la labor, puede decirse, que genera una doble fotiga: la que produce la
monotonia y la que implica la acci6n ejecutada en contra de la voluntad. De ahf el
precepto de cambiar de trabajo durante cierto tiempo, a intervalos determinados.
como un consejo pedagdgico mds que conveniente, sabio en alto grade.

Sin embargo, adn en este case, se tropieza todavla con un pequefio inconveniente,
subsanable por lo demis, pero muy digno de ser tomado en cuenta: me refiero a la
acomodaci6n. Siempre que se pasa de un trabajo a otro, quedan en la mente pensa-
mientos retenidoe correspondientes a la labor precedente, que es necesario eliminar»
del todo, si ee posible. Para subsanar este obst4culo que tiende a perturbar, en un
principle, el trabajo que se empieza, no hay otra coea que hacer, en todos los casos,
que interrumpirlo por algdn tiempo conveniente hasta que los ideales que consti-
tuyeron la tarea anterior, no perturben la iniciaci6n de la siguiente. Esto se consigue,
mediante las pausas, como lu^;o veremos.

702 PB00EEDING6 SEOOin) PAK AMEBIOAK SCIENTEPIO C0KGBB8S.

El trabajo intemimpido cada tres cuartos de hora, por ejemplo, durante el cuno de
la mafiana compuesto de cinco horas, puede producir un decrecimiento de la eneigfa
mental que, segdn las experiencias hedias, podrfa eetimane asf : la cantidad del tra-
bajo, que era pequefia durante la primera bora, sube m&a y mis en la segunda y
tercera, comenzando a decrecer en la cuarta; la calidad del mismo aumenta y disminuye
m^ 0 menoB en la misma proporci6n.

Estas experiencias nos est&n enseflando, que no es conveniente hacer ejecutar on
trabajo mental interrumpido (clases y eetudio) durante un curso matinal de mis de
cuatro boras, y en la tarde, de m^ de doe o tres boras, como m4ximum, dadas 1m
diferencias apuntadas relativas a las ventajas de la labor intelectiva matinal.

Tanto el trabajo continuo, como el interrumpido convenientemente, determinan,
despu^s de derto tiempo, la fatiga. De abl la necesidad de reglamentarlos bigi^nica-
mente, tomando en cuenta lo aconsejado en el curso de este capitulo y la duracidn
de las pausas, de que me voy a ocupar en seguida; es dedr que, no s61o se procuraii
reglar la duraci6n de las clases, tomando en cuenta la influencia del ejercicio y de la
acomodaci6n sobre el trabajo, asf como lo que debe diirar el curso matinal y vespertino,
sino precisar la duraci6n de los descansos o pausas.

DE LAS PAUSAS O INTEBBUFCIONES PERi6dICAB DEL TRABAJO PSiQUICO, COMO MEDIO
DE EVITAR LA FATIOA T P^RDIDA DE LA ENEBQIa INTELECTIYA.

La pausa o descanso peri6dico, intercalado en el curso del trabajo mental, de una
manera general, tiene por objeto, evitar en cuanto sea posible el desgaste de la eneigfa
y en consecuencia la fatiga.

De la misma manera que despu^ de una marcha mis o menos prolongada o a con-
tinuaci6n de un ejercicio flsico, sentimos p^rdida de las fuerzas y sensaci6n de can-
sancio que nos obliga a tomar reposo; no de otro modo, despu^ de un trabajo intelectivo
experimentamoe un decrecimiento de la energla mental y un sentimiento de fotiga.
Y asl como, en el primer case, el reposo m6s o menos prolongado, nos hace recuperar
el vigor y la agilidad perdidos, pudiendo emprender una nueva jomada; del mismo
modo, ima pausa conveniente, en el segundo, nos hace adquirir de nuevo la eneigia
gastada, dejindonos bien dispuestos para continuar im trabajo intelectivo interrumpido
a causa de la fotiga.

Mas, la pausa, mirada desde el pun to de vista de su extensi6n, tiene un inconve-
niente: la eliminaci6n del ejercicio como auxiliar del trabajo mental.

En efecto, si durante un trabajo en que se ha dejado ya sentir la mayor facilidad ea
su ejecuci6n que da el ejercicio, se interrumpe la labor, por algdn tiempo, es natural
creer, que, se pierda un tanto (segtin el tiempo que dure la pausa), la acci6n ben^ca
de la costumbre adquirida a expensas de la repetici6n. Sin embargo, en los casos
comunes, tratdndose de tareas escolaree, en que la inteRxipci6n (durante un curso
matinal o vespertine) no es nunca muy laiga, la p^rdida de la eneigfa psfquica adqui-
rida por eliininaci6n del efecto del ejercicio es tan poco notable, que, no hay para que
tomarla en cuenta; salvo el caso que fuera muy prolongada, de dfas y semanas, en ves
de boras y minutes.

Las pausas encolares, pudiendo eliminar la acci6n ben6fica del ejercicio, deben ser,
pues, cortas; de algunos minutos de preferenda, pudiendo extenderse hasta una o
dos boras, algunas veces, cuando el trabajo no se olvida fddlmente, atendida su natura-
leza y los atractivos que puede poseer.

Pero, la pausa, tiene un efecto beneficioeo sobre la acomodaci6n: tiende a hacer
perder la acci6n perturbadora de ^ta, cada vez que se cambia de materia. En efecto,
siempre que se reemplaza un tema por otro, quedan en la mente, al comenzar el nuevo
trabajo, ideales correspondientes al precedente, que impiden o mis bien perturfoan la
adaptaci6n mental. Se comprende, que, si una pausa se intercala entre ambas labores
(la anterior y siguiente) puedan subsanaree en parte o completamente los efectoe de
la acomodaci6n, segun la extensi6n del descanso y la oportunidad con que se piocuia.

PXJBIJO HEALTH AND MEDIOIHB. 703

De otro lado, como los trabajos experimentalee fatigan el espiritu y hacen decrecer
la eneigla psiquica, mucho menos que los de memoria, se hace neceeario tomar en
cuenta estas circunstancias para la intercalaci6n de las pausas. De ahi que acon-
sejemos una pausa de cinco minutoe, despu^ de un trabajo continuado de 50 minutoe,
si la labor intelectiva es experimental, y de 10 minutoe, si el trabajo es mnem6nico.
Del mismo modo, despu^ de un curso de labor interrumpida, en la forma aconsejada
m^ arriba, que comprenda tres o cuatro horas, es neceeario una pausa larga, diurante
la cual le sea dado al sujeto recuperar la energfa perdida y restablecerse de la fatiga:
de dos a dos boras y media, ya que tiene que incluirse el tiempo de la comida y dejarse
el correspondiente al periodo digestivo, libre.

En suma, la interrupci6n peri6dica del trabajo mental, higi6nicamente eetablecida,
si puede eliminar un tanto el efecto del ejercido, tiende a evitar la perdida de la
energia intelectiva, la producci6n de la fatiga y la perturbaci6n de la acomodaci6n,
cuando se varla de labor. Es, pues, ima medida bigi^nica de alta importancia prdctica,
principalmente dentro de las aulas.

LA ENSEJi^ANZA ORAL O DE VIVA VOZ, MBDIANTE LA LECTURA DE UN TEXTO Y POE MEDIO
DE APUNTES, CON8IDERADA8 DE8DE EL PUNTO DE VISTA HIQI^NICO.

Es una cuesti6n muy debatida* entre los pedagogoe, la relativa a la importancia que
se debe dar a la ensefianza oral sobre la obtenida por la lectura del texto y la que con-
siste en tomar apuntee en las clases orales. Unoe dan la preferencia a un sistema,
y otros, a otro. No hay, pues, uniformidad de pareceres a este respecto.

Y, cientlficamente hablando, no es posible definir, en todoe los casos, si es preferible
un sistema de ensefianza a otro de los mencionados. En efecto, bay sujetoe que asimi-
Ian con mayor facilidad los conocimientos adquiridos oralmente, a causa de que las
impresiones y percepciones auditivas se graban en el espiritu mds fdcilmente que las
de otra especie; conservan preferentemente las im^enes — recuerdos de naturaleza
auditiva: son auditivos, en una palabra.

Del mismo modo, es frecuente encontrar entre los educandos, sujetos, que aprenden
mejor leyendo el texto, en voz alta o en silencio, que de otra manera. Estos asimilan
mejor las ensefianzas que producen impresiones y percepciones visuales, imdgenes —
recuerdos de esta naturaleza: son, pues, visuales.

Por tiltimo, hay todavfa alumnos que aprenden mejor, escribiendo con el dedo lo
que oyen o haciendo representaciones o movimientos involuntarios que traducen las
explicaciones del profesor de tal manera, que se puede formar una idea clara de ellas,
observando atentamente los sujetoe; estos aprenden mas bien las ensefianzas que
recuerdan imdgenes motrices: son mot6ricos.

Ademds de estos tres tipos intuitivos, hay otros intermedios, que recuerdan las
im^nes grabadas en la conciencia, vali6ndose a la vez de impresiones visuales y
motoras, auditivas y motoras, visuales y auditivas, etc.; y esto, enti^ndase bien,
cuajquiera que sea la naturaleza de la ensefianza sugerida, objetiva o mnemSnica.

Hay, pues, tres maneras principales de adquinr conocimientos o ensefianzas (la
auditiva, visual y motora), que los pedagogos clasifican como tipos de intuici6n
mtema o maneras de recordaci6n de las im^nes de objetos determinados, perceptibles
en forma sensible, o por sus cualidades parciales.

Y bien, para resolver la cuesti6n relativa al valor higi6nico de las lecciones de viva
voz, por medio del texto o aprendidas grdficamente, serd, pues, neceeario resolver pre-
viamente el problema siguiente: ^A qu6 tipo de intuici6n interna perteneceu los
alumnos? Una vez resuelta esta cueeti6n, se preferird la ensefianza oral, si la generali-
dad de los sujetos son auditivos; la del texto, si son visuales; y la por medio de apuntes
si son mot6ricos.

Mas resuelto asl el problema, queda todavfa un punto que definir: ^cu41 de las tres
f orraas de ensefianza debe pref erirse en la prdctica, en general, dada la misma especie
de conocimientos sugerldos, objetivos o mnem6nicos? Por lo comtin, la que deje

704 PBOOEEDINQS SECOND PAN AMEBIOAK SCIENTIFIO 00KGBE8S.

las im^genes — ^recuerdos m^s acentiiados y m^ f^iles de rememorar; ee decir, &i este
caso, la forma oral y grifica.

En efecto, el alumno que aprende por la lectura, muy f^ilmente se difltrae— bu
atenci6ii no es contfnua — ^y, en el mejor de los caaos, consigue, grabar en su conci^icia
imigenee vimialee dnicamente. £1 que oye una lecci6n, por el contrario, mantiene sa
atenci6n, por lo comtin, m^s fija, segtin el atractivo que a sus lecciones d6 el profeaor
y las imigenes— recuerdos, no son tinicas; pues, al mismo tiempo que el alumno oye
las expUcaciones, observa, de visu, la expresidn o mlroica del que las da y si toma
apuntes o el institutor las ensefia de una manera gr&fica, no 86I0 las graba en su espiritu
mediante im^enes auditivas, sino tambi^n motoras y atin visuales. De otro lado, la
p^rdida de la capacidad mental, en este caso, asi como la fatiga producida, es menor.
Hay, pues, en este tiltimo caso, tres clases de percepciones que tienden a reproducir o
rememorar, mis bien dicho, una misma clase de ensefianzas y adem^, menor desgaste
intelectivo. De ahf que, por lo general, sea pref erible la enseiLanza oral y sobre todo al
que se hace procurando que los alumnos tomen nota de ella, por escrito.

En resumen, la sugestidn de ideales de viva voz puede, por lo general, conaiderarse
como la m&B conveniente, ya que es m6s fdcil y de^;asta menos la energla psfquica, pro-
duciendo en consecuencia menos fatiga; pero, en los casos en que el tipo de intuicidn
interna de los alumnos no sea auditivo, sino visual p. ej., el sistema de ensefianza pre-
f erente serd el de lectura del texto, y asf en otras circunstancias, el m^todo adoptado
deberd estar en relaci6n inmediata con el tipo de intuici6n predominante de los alumnos

O8CILAGIONB8 DB LA ENBRgIa. PSIqUICA T DE LA ATENCI6n, 8U IMPORTANCLA. DBSDE.
EL PUNTO DB VISTA DEL TRABAJO MENTAL HIGliNICAlfENTB DISTRIBuIdO.

La labor intelectiva, no es siempre imiforme e igual ; experimenta, a cada momento
variaciones que dependen de la naturaleza del trabajo (prdctico 0 mnem6nico), del
tiempo que dura el mismo, de la homogeneidad o variedad de la labor, de la forma en
que ^ta se hace (de un modo continuado o interrumpido), de las inflencias de la
acomodaci6n y del ejercicio, etc. ; lo que quiere decir claramente, que, experimenta una
serie de oscilaciones, mis 0 menos marcadas, segtin influencias distintas. Una prueba
de ello es que la atenci6n mis sostenida (o sea, el estado de la mente que esclarece,
coordina, metodiza y dirige el trabajo intelectivo) experimenta igualmente oscilaciones
que se traducen visiblemente por modificaciones fisioldgicas, circulatorias, muscularee
y otras. Las influencias extemas e intemas, los ensayos preliminares de adaptacidn,
la concentraci6n de la energla para alcanzar el objeto que se propone el sujeto, son
otras tantas causas de oscilaciones de la atenci6n. Para que se verifique un acto de
atenci6n, es necesario — ^indispensable — que tenga lugar un esfuerzo mental, un senti-
miento de tensi6n psiquica y de voluntad que nos obligue a tener plena conciencia de
nuestra personalidad. La oscilaci6n, llev^donos aqul y alii, nos hace experimentar
impresiones diversas correspondientes al conocimiento del objeto, y, sin fatigamos,
DOS obliga a ejecutar una labor consciente y provechosa. De abi que no seria posible,
en buena ]6gica, ejercltar la atenci6n sin la acci6n ben^fica de las oscilaciones: nos
dejarla de otro modo, en la contemplaci6n de un solo ideal (monodeismo mental) que,
despu^s de algtin tiempo, produciria en noeotros perturbaciones de la sensibilidad,
haciendo nacer alucinaclones de la vista que nos obligarian a ver lo que no existe «i
realidad o permanecerlamos en un ^xtasis inconscientc, donde el esfuerzo y la voluntad
quedarian excluidos.

Lo que pasa con la atenci6n, sucederia, igualmente, si fijiramos nuestra actividad
mental en un solo orden de Impresiones y percepciones, sin que se verificase un cambio
cualquiera que viniera a hacer entrar otros factores que hicieran ver ese ideal de otra
manera: sobrevendria la monotonia, la fatiga, la eliminaci6n de la personalidad cons-
ciente en una palabra. ''Cuando yo miro constantemente un cuadro n^ro, lo puedo
ver siempre igual; pero, con el tiempo, llegar6 a comprender que deberia tenw varia-
ciones sensibles en la representaci6n que yo me haya formado de la intenaidad del

PUBUO HEALTH AKD MEDICINE. 705

color. Estas v^rlaciones constituyen la condici6n misma de la percepci6n del cuadro.
Bate color negro oscilard sin cesar en mi eepfritu. El mismo dia y en los aiguientes,
ver6 edempre el negro m^B o menoe pronunclado. Cesar de ver lo negro, seria engaiiarme;
pero verlo en el espacio de algunos minutos, un poco m^B claro, un poco mia negro, es
obedecer a la ley de las oscilaciones y al mismo tiempo asegurarme de que estoy atento.
Sin duda, manteniendo el cuadro como en un principio, si yo me hubiese fijado exclu-
dvamente en 61, habria experimentado cambios de la vista, que me lo habrian hecho
ver gris pdlido o gris pronunciado*' (Nayrac). Es necesario, pues, que la atenci6n, asf
como la energia mental, sulran continuamente pequefias fluctuaciones que, m^ bien
que a debilitarlas, tienden a fortificarlas, porque mantienen siempre presente en
nuestro espiritu la sensacidn del esfuerzo psiquico, que, naturalmente, tiene que
despertar la voluntad. De ahi que todas las fluctuaciones, exteriores e interioree, que
a cada instante experimentamos constituyan, otros tantos ensayos de adaptaci6n de
nuestras facultades psfquicas y de la atenci6n, al trabajo que ejeojitamos. Es de
esta manera c6mo aprendemoe adominamosya damos cuenta de lo que pasa en y al
rededor de nosotros, que nos haya impresionado de algtin modo ; es igualmente asf como
podemos conservar un espiritu sano, consciente de su energia y adaptable al mundo
real.

En resumen, el trabajo intelectivo, no debe quedar sintetizado en una idea tinica,
que, con el tiempo, tienda a disgregar la personaUdad consciente, sino estar sujeto a las
fluctuaciones que causas diferentes, obrando sobre el espiritu, tienden a hacerlo variar
u oscilar; 86I0 de esta manera se verificard con plena conciencia del sujeto, esto es,
generado por el esfuerzo psiquico y dirigido por la voluntad. Hay, pues, que variar
el objeto de la labor intelectiva, si se quiere que esta se haga de una manera consciente
y voluntaria: las oscilaciones son siempre necesarias para fortificar la atenci6n y la
energia mental misma.

LA RAPIDEZ DB LA LABOR INTBLBCTIVA INDIVIDUAL NO TIENE INPLUBNCIA ALGUNA EN
LA PRODUCC16N DB LA FATIOA NI EN LA ENEROfA PSIqUICA.

Es un hecho comprobado por numerosas experiencias, verificadas en estos tiltimos
tiempos, que, la mayor 0 menor celeridad en la actividad pslquica que corresponde a
un mismo individuo, no infiuye en el aumento o decrecimiento de la energia mental,
oi tampoco en la producci6n de la fatiga, puesto que existe para cada persona una
rapidez dada correspond ten te a su actividad mental.

Mas esta ley individual no es aplicable, por cierto, a distintas personas, no; por
cuanto cada cuil posee, como queda dicho, una intelectualidad determinada y una
capacidad mental distinta, como vamos a ver.

Asf, si se hace ejecutar a un sujeto dlstintos trabajos intelectivos, aunque sean de
diversa naturaleza, siempre puede observarse el mismo fen6meno psiquico: que la
rapidez del trabajo mental, cualquiera que sea, se verifica en las mismas condiciones.
De manera que, la acci6n de aprender una lecci6n de historiao de otraasignatura cual-
quiera, de ejecutar distintas operaciones aritm^ticas, de escribir un dictado, aunque
demanden esfuerzos intelectivos diferentes, tratdndose de un mismo individuo, se
ejecutardn, en todos los cases, con la misma rapidez pslquica. Durante este tiempo,
es decir, roientras se desarrolla m^ o menos rdpidamente la acci6n mental, en un in-
dividuo, la energia intelectiva queda siempre la misma, asl como el estado de las
fuerzas, no hay pues desgaste mental, debido a dicho estado, repito. De manera que,
la p^rdida de la energia pslquica sobreviene en dicho caso. por las mismas causas
enunciadas anteriormente y no— vuelvo a repetirlo — ^porque el trabajo intelectivo se
haga mds o menos rdpidamente: circunstanda digna de ser tomada en cuenta, desde
el punto de vista de la higiene intelectiva.

Pero, esto que sucede en una persona determinada, cualquiera que sea la naturaleza
de la labor mental, no se verifica, cuando dos o m&B personas distintas ejecutan una

706 PBOGEEDINGS SECOND PAN AMEBICAN SOIEKTIFIO C0KGBE8S.

misma labor: unas terminan ems tareas antes que otras, aunque hayan trabajado en
las mismas condiciones, relativamente al tiempo, edad y cultura. Lo que quiere
decir bien clarameate, que, todos loe sujetos no tienen una misma capacidad inte-
lectiva.

En conclusi6n, cadasujeto tiene una actividad mental que le es propia, que caracte-
riza su capacidad, de manera que, esta caracterlstica, no influye en manera alguna
en la energia psfquica, ni en la producci6n de la fatiga; puee estas se incrementan o
decrecen como en loe casos comunes. Pero, esto no quiere decir que todos loe indi-
viduos desarroUen su actividad de la misma manera, dadas las mismas condiciones
del trabajo, no; por el contrario, cada uno desarrolla su eneigfa de conformidad con
la caracteristica de su capacidad, es decir, de un modo diverse. En consecuencia,
debe darse a cada sujeto un trabajo mental que sea compatible con su capacidad
intelectiva o con su rapidez de funcionamiento pslquico.

MEDIDA DB LA FATIGA MENTAL.

La fatiga psfquica, trayendo consigo la fisioldgica o material y vice versa, claio
estd, que, midiendo esta dltima, se tendr& al mismo tiempo una medida de aqu^lla:
ya que lo psiquico y lo ffsico entran en actividad a la vez, paralela y simult&nea-
mente, como queda dicho.

Mas una dificultad se presenta, desde luego: es la de saber, si un trabajo local o
parcial, puede acarrear la fatiga general.

Siempre que se verifica un trabajo intelectivo, sumar o eecribir, por ejemplo, en
ambos casos, entran en funci6n facultades de orden diferente, procesos motoree,
asociaci6n de ideas y potencias ffsicas igualmente distintas; sin embargo, a pesar de
que una parte del sensorio trabaja (lo que se revela por los movimientos del miembro),
cuando la labor se prolonga, la fatiga, que estuvo localizada en laregi6n que entrd en
actividad, se irradia en seguida a todo el cuerpo. Sucede en este case, lo siguiente:
que la labor mental a medida que va de^astando la energfa psfquica, deegasta igual-
mente la ffsica. En ambos casos, las funciones fisiol^gicas se modi£can, los procesos
ffsico-qufmicos se activan y la actividad nerviosa y muscular decae, a consecuencia
de las p^rdidas orgdnicas que se hacen mayoree. De este modo, un proceso psfquico
o ffsico local, determinando gastos de la provision general de energfa, tiene fatal-
mente eco en el sistema nervioso y muscular, no solo en el punto que trabaja, sine
en el organismo entero; ya que las p^rdidas oi^gdnicas de la r^6n que entra en acti-
vidad, forzosamente tienen que afectar otros puntos del cuerpo fntimamente rela-
cionados con aqu^Ua. De este modo se comprende como alteraciones mentales,
tengan eco en el sistema muscular reduciendo su actividad y que leeiones ffsicas,
traigan consigo un decrecimiento bien marcado de la capacidad psfquica.

En resumen, el foco central, l^ae una modificacidn en la regi6n correspondiente,
y, ^sta, por intermedlo del sistema nervioso, en los 6rganos que tienen relaci6n con
aqu61; todo lo cual se revela por una alteraci6n an^oga del sistema muscular. En
consecuencia, midiendo el trabajo muscular, se mide la actividad nerviosa y como
^ta estd estrechamente relacionada con la energfa psfquica, se deduce: que, mi-
diendo la fatiga de los mtisculos, se puede deducir la mental.

IMPORTANCLA. DEL E8TESI6mBTRO COMO INSTRUMENTO DB MEDIDA DE LA CAPACIDAD
MENTAL, DB LA FATIGA PRODUCIDA POR LA EN8E19ANZA BSCOLAR Y DE LAS OSa-
LACIONBS DB LA ENERGIa PSfQUICA.

La estesiometrfa consiste, en la medici6n de la sensibilidad, en sus div«:sas
modalidades, a fin de apreciar la naturaleza y la graduaci6n de la sensaciones, dedu-
ciendo en consecuencia, las modificaciones correspondientes que experimenta el
sujeto, en la esfera mental. Las alteraciones de la sensibilidad est&n, pues, en raz6n
directa de las del sensorio comdn y ^stas son paralelas, como queda dicho, con la

PXJBIJO HBALTH AND MEDIOINB. 707

que, a la vez, se notan en la esfera intelectiva. De ahf que, la medida de la sensi-
bilidad nos ensefie o nos ilustre, repito, eobre el eetado de nuestra intelectualidad.

El e8tesi6metro mds usado ee el de Weber y cooBiste, en un instrumento destinado
a detenninar la distancia minima que hay entre dos puntoe tocadoa y que eon sentidoe
como doe excitaciones diversas. Eetk formado por un compis provisto de un circulo
graduado y de puntas muy finas. La separaci^n de las puntas vaHa segtin el estado
de la sensibilidad del sujeto y la correspondiente de los centres nerviosos. En gene-
ral, puede decirse, que toda alteraci6n cerebral se traduce por una modificaci6n de
la sensibilidad y por una separaci6n mayor o menor de las ramas del comp&s. Gracias
a la estesiometrfa se puede Igualmente, por deducci6n, medir la intensidad mayor o
menor de la f atiga generada por la enseflanza eecolar, asf como las fluctuaciones de la
eneigia.

Las conclusionee a que ban Uegado los sabios, en esta materia, son: que la f atiga
mental depende, de la naturaleza del trabajo, de su duraci6n y de la bora en que se
ejecuta. En las clasee de la noche, la intensidad de la fatiga llega al maximum, a
causa del empobrecimiento relative de la sangre cerebral despu^s de la comida. 8e
ha reconocido igualmente, que el trabajo deepu^ de clase, realizado por el alumno
en su casa, produce mayor fatiga e igualmente, que es m^ fuerte la tenai6n mental
en la 6poca de los exiUnenes.

Los trabajos verificados en Alemania, se refieren al examen estesiom^trico hecho
en escolaree de 14 afios. ''La 8eparaci6n de las puntas del compis era normalmente,
tannine medio, 3.5 millmetros, en la frente. Antes de la clases de la mafiana, media
5 milfmetros y despu^s de 4 boras de lecciones, 13; bajaba a 10, desde el principio
de las clases de la tarde y se elevaba basta 22, cuando dichos trabajos se hacian en
casa."

El esteaidmetro es, pues, un instrumento precioso que nos hace conocer gr&fica-
mente las oeciladones de la eneigfa psiquica y de la fatiga, sirvi^ndonos en conse*
cuencia, para medir la capacidad desarrollada durante el trabajo intelectivo en las
diversas horas y para distribuirlo de una manera cientifica. Basta tomar en cuenta
la curva estesiom^trica obtenida de las fluctuaciones que experimenta la energla
pdquica y la fatiga, asi como de la correspondiente a las distintas horas de labor
para concluir: que el trabajo mental debe ejecutarse preferentemente en la mafiana
(3 a 4 boras), en seguida en la tarde (2 a 3 horas) y de ningtin modo en la noche, despu^
del trabajo matinal y vespertine.

Las oscilaciones de la eneigfa psiquica, pueden medirse igualmente por el eetefli6
metro o el eigdgrafo; pero, debe preferirse el primero, por cuanto no demanda el
ejercicio muscular del sujeto, durante la experiencia, como el segundo.

En resumen, el estesidmetro, puede informamos, no solamente acerca del estado
de la sensibilidad, sine del grade de la eneigfa mental y de sus fluctuaciones, asi
como de la intensidad mayor o menor de la fatiga. Es, pues, un intrumento precioso
e Indispensable en todo institute.

INFLUENaxa QEOORinCAS O REOIONALBS XN EL DE8ARROLLO T PRODUCCI6n DB LA
XNBRGtA PSiQUICA T DX BUS OBCILAaONES.

Si las acdones producidas por las impresiones cdsmicas (venidas del mundo exte-
rior) tienden, per se, a hacer variar la capacidad mental, asf como las influencias
debidas al g^nero de vida, necesidades fisiol6gicas, hdbitos, etc.; y si, dichos factores
qambian naturalmente en las diferentes localidades y atin en una minna regi6n (si
^sta presenta condiciones especiales), se puede 16gicamente concltiir: que la energfa
psiquica varfa en las distintas zonas geogrifiicas y que las variaciones de ^sta est^n
en raz6n directa de las fluctuaciones a que obligadamente se hallan sujetas aquellas
causas eficientes de dichas oscilaciones.

El hecho de que un pais obtenga una curva anual de la capacidad mental, aunque
esta investigaci6n se verifique en una misma naci6n todos los afios, y, m^ que eeo
68486— 17— VOL ix 46

708 PBOOEEDINOS SEOOKD PAK AMEBIOAK gOIEKTIFIO OONQBE88.

todavla, auiKiue se trate de una regi6n geogrifica de condicionee cteoicaa semejamtes,
no autorixa en manera alguna a creer, que, en todas partes las cosas sucedeiiii de la
mtsma manera. Y esto se explica ficilmente, recordando que las influencias enun-
ciadas que hacen variar la energfa, pocas veces se presentan en distintas regionet
geogrificas de la misma manera; son siempre diferentee.

De ahi que, el hecho bien conocldo, de que en Alemania, por ejemplo, y en otro0
pafNs, se haya formado la curva anual de la capaddad psfquica, no noa autoriza, aino
muy remotamente, a concluir, que, en Chile, la gr4fica obtenida, ha de ser semejante
a la tormada en esas o en otras regiones geogrilficas; cuando mia, dichoa dates ezperi-
mentales nos servuin, para deducir consecuendaa generales, aproximativaa, pero
jamits exactas.

En Chile, estando dividida la superficie territorial en tres regiones propiamente
dichas— mnte, centro y sur— donde las influencias mencionadas son diferentes, pode-
moa, desde luego. Idgicamente concluir: que, es necesario formar tres curvaa anuales,
•n Iquique, Santiago y Puerto Montt por ejemplo.

En conc]u8i6n, las influencias c(3smicas y regionales, influyen podoosamente en el
desarroUo y variaciones de la capacidad mental.

MBDIDA DE LA CURVA DIURNA DB LA CAPACIDAD MENTAL.

El coDodmiento pr&ctico de las oscilaciones de la actividad pefquica, sea que el
oiganismo est^ o no en trabajo, ha inducido a los psic6logos y pedagogos, a medir
gr&ficamente eses fluctuacionee, todos los dias, a fin de obtener una curva cuotidiana
de ellas.

Las experiencias hechas hasta hoy, nos prueban: que durante el trabajo matinal«
de 7 a. m.-12 m., la energla psfquica decrece, constituyendo dichas horas, el maximum
y minimum de ella e igualmente, que, de2a7p. m., un fen6meno semejante tiene
lugar: la capacidad mental m&xima y mfnima corresponde tambi^n a las horas indicadas.

En las oscilaciones cuotidianas de la energia psfquica, ademis de las causas c^smicas
e individuales relatlvas al g^nero de vida y h&bitos, pueden influir tres factores: el
suefio, el estado de abstinencia o sobre alJmentaci6n y la fotiga.

El suefio, si es reparador y se hace en buenas condiciones fisiol6gicas, de modo que
el sujeto despierte s61o antes de levantarse, tiende, naturalmente a aumentar la energla
psfquica. De ahf el valor del trabajo matinal. Pero, si el sujeto duerme mal en la
noche y solamente bien en la mafiana y no despierta sino en el memento de levantarse,
se halla fatigado y en consecuencia su capacidad disminufda; no se encuentra, en tal
case, dispuesto para el trabajo y su energfa intelectiva estd, al princlpio, mis bien
decrecida. De ahf la conveniencia de despertar la energy, mediante un ejercicio
gimndstico moderado, antes de la tarea escolar.

La abstinencia y la alimentaci6n, influyen asimismo, en las fluctuacionee de la
labor intelectiva. Por lo general, como queda dicho, la primera, cuando no es muy
prolongada y el trabajo no pasa de tres cuartos de bora es fttvorable, mientras que la
segunda, solo lo es, cuando la tarea se lleva a cabo algtln tiempo despu^ de la alimen-
taci6n (2 boras a lo menos), siendo desfavorable si el trabajo se hace durante el perfodo
digestive. De ahi la prescripcl6n higi^nica de no ejercitar la actividad mental sino
dos horas o mis despu^s de haber comido.

La fatiga, rara vez se observa en la mafiana, salvo en los sujetoe que no han dormido
bien; mas una vez que comienza el trabajo mental, el aumento de la misma se verifica
en progresi6n ascendente, hasta las 12 m. De la misma manera, en la tarde, sucede
exactamente otro tanto, de 2 a 7 p. m., es decir, desde que comienza la tarea escolar
vespertina hasta que concluye. En consecuencia, la fatiga, sigue una curva ascen-
dente 0 descend ente en relaci6n con el gasto de eneif^.

Mas, de otro lado, mientras mds energfa pueda desarroUar el sujeto, en la mafiana,
por ejemplo, menor tatiga experimentari; otro tanto pasa en la tarde, a las 2 p. m..

FUBUO HBALTH AHD KEDIOIHl. 709

cuando se verifica el m4ximuii de capacidad, se nota el mlnimun de httiga. De ahi
que la energfa propia del sujeto est^ en raz6n iDvena de la latiga que se produce en el
nusmo*

En conduflidn, la curva diuma de la energ(a intelectiva y la de la tatiga, estarian
0ujeta0 a las siguientas oedlacionee:

Mafiana: eneigia peiquica maxima, 7 a. m. y minima, a las 12 m.

Tkrde: energfa peiquica m&xima, 2 p. m. y minima, a las 7 p. m.

Mafiana: tetiga intelectiva minima, 7 v n^* y mdxima, a las 12 m.

Tarde: fatiga intelectiva minima, 2 p. m. y maxima, a las 7 p. m.

En ccmsecuencia, la mafiana, es mii aparente para el trabajo mental, ya que la
energla pslquica estd mAs desarrollada en relaci6n con la de la taide y la latiga menoe
pronunciada, en consecuencia. Hay, pues, en cada curva diuma, dos miJTimaB (a las
7 a. m. y 2 p. m.) de la actlvidad, mental y dos mlnimas (12 m. y 7 p. m.)> siendo las
de la latiga de aentido opueeto; lo que es preciso tomar muy en cuenta en la distribu-
ci6n higi^ca de las horas escolares.

MBDIDA DB htL CURVA ANUAL DE LA CAPAaDAD INTBLBCTTVA.

Procediendo como lo hemes hecho antes para obtener la curva diuma, durante un
afio eecolar, se conseguird formar ima gr&fica correspondiente a dicho tiempo; es decir,
una curva anual, de las oscilaciones de la energla pslquica. La formaci6n de una grd-
fica semejante serla, indudablemente, mds que iltil en Chile; pero, para esto, como se
comprende, habrla necesidad de hacer una seiie de experiencias durante un afio
eecolar, experiencias que, por ahora, segdn creo, no nos serla dado verificar. ya que no
estd instalado el gabinete de peicologla.

La curva anual nos ensefiarla, como la diuma, a conocer las ^pocas de alzas y bajas de la
energla intelectiva, durante el afio escolar ; en otroe t^rminos, nos darla a conocer experi-
mentalmente, loe perlodoe m^ aprop<5sito para llevar a cabo los estudios que demandan
mayor capaddad mental, para fijar las ^pocas de exdmenes y para sefialar en cons^
cuencia, de un mode cientlfico, las vacaciones.

Como careceipos, por ahora, de los datos enunciados, no nos serla dado, por m^ que
pretendi^ramos, establecer r^las precisas al respecto, derivadas de nuestras propias
experiencias; e6\o podrlamos, tunddndonos en experimentos hechos en otros palses,
deducir aproximadamente las oscilaciones probables que, en Chile, puede experi-
mentar la capacidad mental.

Las experiencias, hechas en el extranjero, hasta ahora, pmeban: *'que la capacidad
mental decrece desde la apertura del afio escolar m&B o menos hasta la mitad de ^ste —
de marzo a julio — ^llegando a un nivel m&a bajo en este tiltimo mes. Despu6s, sube de
nuevo por corto tiempo y vuelve a decrecer hasta octubre, ascend iendo nuevamente
de un modo duradero.'' Estas observaciones dan a entender, que, en la 6poca frla y
templada del afio (inviemo y primavera) se ha observado un aumento de la capacidad
Intelectiva; circunstancia muy digna de ser tomada en cuenta, entre nosotros, que,
mis 0 menos, pueden verificarse los hechos de una manera semejante o aproximativa.

Mas estos hechos, estin de acuerdo con la fisiologla. En etecto, durante el inviemo
y primavera, mientras diua el tiempo frlo y templado, por lo general, la circulaci6n
cerebral y visceral (interna) predominan sobre la perif6rica (externa); las oxidaciones
org&nicas y la nutrici6n se hacen, en dicho tiempo y por esa causa, en mejores condi-
clones, siendo las p^rdidas orgdnicas menoree: lo que se traduce, naturalmente, por
un aumento en la energla nerviosa y muscular, que corresponde, en la esfera peiquica,
a un incremento paialelo de la capacidad intelectiva.

Durante el verano, pasa lo contrario: la circulaci6n perit^oa predoijiina sobre la
interna; la irrigacido del cerebro no se hace tambi^n como en inviemo; las oxidaciones
y nutrici6n son m4s lentas y las p^rdidas oigdnicas mayores: hay, pues, di8minuci6n
de la energla fisica y pslquica, en consecuencia.

710 PB00EEDIKQ8 BEOOHD PAK AMSBICAIT 80IBKIIFI0 COKaBBSS.

Tomando en cuenta las experiencias hechas en otroe paises y los datos fimd^cos
apuntadoe, podiiamoe eefialar, aproximadamente, las oscilaciones, que, &i CSiile
deberla experimentar, en un afio escolar, la capacidad mental y dirfamoe, hipot^-
camente, sin detenninar de una raanera precisa loe asc^isos y descensos de la curva
anual, que: durante los meses de marzo a septiembre, puede ccmsideiarae como la
^poca en que la capacidad mental estd m&a desanollada, entre nosotios. Dlscummos,
repito, en la hipdtesis que aquf sucedan los hechos de una manera parecida a loe obaer-
vadoB en Europa. Y, aceptando (?) una curva anual cuyo miudmun se relacionaa
con el tiempo fresco y su minimun con la ^poca del calor, podrkmos conduir:

1*. Que los ex&menes que demandan mayor actividad intelectlva y mejores con-
dicionee fi8iol6gicas de parte del sujeto, debieran verificarse, mtre nosotros, durante
los meses de junio y julio;

2*. Que la 6poca de inviemo y primavera, podrfa destinarae igualmente a loe eetudios
m^ dificiles; y

3<>. Que, en consecuencia, s61o convendrfa dedicar al trabajo mental el menor tiempo
posible en verano, 6poca m^ aparente para vacaciones.

BELACI6n HIOIAnICA QUB DEBB BZI8TIB BNTBB EL TRABAJO MKNTAL T KL BJBBClCaO

Fisico.

Si el ejercicio gimnistico o de otra eepecie, actdva la circulaci6n general y contri-
buye a la irrigaci6n mds amplia de los centres nerviosos y a la reconstdtucidn de las
fuerzas flsicas; si dicha actividad se re vela por un incremento de las oxidaciones y de
la nutrici6n, de la asimilaci6n y desasimilaci6n org&nicas: si, en fin, ayuda poderosa-
mente a levantar las energias fisiol^gicas y a vigorizar el cuerpo en consecuencia,
forzoso es concluir: que el ejercicio fisico contribuye tambi^n a aumentar la capacidad
intelectiva, siempre que se practique higi^camente, sin fatigar el cuerx>o.

Fluye de aqui la necesidad de reglamentar el ejercicio fisico de manera que sea
provechoso para incrementar la energla fisiol6gica y psicoldgica.

B.6 aqul las reglas higi^nicas que, a mi juicio, deben observarse:

1**. Un ejercicio gimn^stico (de movimientos libres, eepecialmente respiratorios)
debe preceder siempre al trabajo mental de la mafiana, con tal que sea moderado y
no pase de 30 minutoe de duraci6n;

2^. Entre las clases, durante los recreos, pueden hacerse ejercicioe gimndstict*? o de
otra especie, con tal que no provoquen la fatiga;

3^. En cuanto se pueda, todo ejercicio fisico debe ser hecho al aire libre;

A^. Por r^la general, los ejercicios flsicos, de cualquier naturaleza que sean, deben
intemunpirse apenas se sienta fatiga;

5*. Lob ejercicios hechos despu^s de las comidas, no deben ser nunca muy agitadoe,
pues perturban la digesti6n;

6<*. En la tarde (de 3 a 5 o de 4 a 5) se verificard, todos los diss, la clase de gimnasia,
durante la cual se podr^ llevar a cabo toda clase de ejercicios flsicos, sin excepcidn;

7^. Los ejercicios flsicos activos, no deben hacerse tampoco inmediatamente antes
de las comidas, pues no es higi^nico ir a la mesa muy agitado, es neceeario deecansar
siquiera una media bora;

8*. En el curso matinal y vespertine, se establecer^ las tareas escolares, de 7 a 12
y de 2 a 7, alternando con los ejercicios, en la forma dicha; y,

9"*. Durante la noche, no debe hacerse trabajar mentalmente a los alumnoe, mis
bien se distribuir& este tiempo en conferencias que presenten algun atractivo o en.
recreaciones.

PUBLIO HEALTH AND MBDIOINE. 711

O80ILACIONB8 DB LA FATIGA A CAUSA DEL TRABAJO MBNTAL T MANERA DE BVITARLA.

Ya hemos visto, al hablar de las oscilaciones de la capacidad mental, que, no es
indiferente trabajar en la mafiana o en la tarde, en ayunas o despuds de haber comido,
en una labor continua o intemimpida, en un trabajo homog^neo o divereo, en una
labor pr&ctica o mnem6nica etc.; puesto que, en todos estos cases, si es verdad que
las fluctuaciones de la energla psiquica gastada estdn en relaci6n directa de la fatiga
producida, no lo es menos, que, trat&ndose de la capacidad mental desarrollada por
un mismo sujeto, la energfa psiquica estari siempre en raz6n inversa de la fatiga. £n
efecto, asf como una labor intelectiva desgasta la enei^ y genera la fatiga en raz6n
directa de la actividad desplegada, del mismo modo, un sujeto que trabaja deepu^
de haber desarrollado y acumulado un m&ximum de energla, sea por las condicionee
especiales en que ejercita su actividad o por las correspondientes a su constituci6n
ffsica, necesita gastar menoe energla mientras m^ posea y en consecuencia, la &itiga,
llega a ser tanto menor cuando m^ actividad sea capaz de gastar el sujeto.

Mas en la ensefianza, el institutor deberd tomar en cuenta, adem^, un gran nthnero
de otras circuntancias relacionadas o no con las precedentes, a fin de ajustar su con-
ducta a las necesidadee cientlficas que la cultura modema encama, sin fatigar las
facultadee de los alunmos.

H^ aqul la manera de evitar la &itiga, en ciertos cases especiales, que son los miis
frecuentes e importantes.

1*. Siendo la fatiga tanto mayor cuando m^ dura la labor y m^ energla se gaste,
asl como mientras m^ dlficil sea el trabajo y menos energla posean los alunmos, se
hace necesario: (a) Procurar que el trabajo continuado dure tres cuartos de bora o
menos, segdn la edad de los nifios, y que, en un curso matinal o vespertino, se vaya
disminuyendo la duraci6n de las clases a medida que la fatiga se vaya acentuando
mds y mis; (b) comenzar siempre el trabajo por la labor m^s fdcil y saber aprovecbar
oportunamente el alza de la energla psiquica (que, como queda dicho se verifies
deepu^ de algtin tiempo de haber empezado), para pasar a la mds dificil; y (c) acortar
las clases (a menos de tres cuartos de bora) en los nifios menores de once afios, por
ejemplo, a fin de no demandar de los pequefios ima eneigla superior a la que realmente
son capaces de desarrollar y gastar.

2*. Tendiendo las interrupciones del trabajo a disminuir la fatiga y a subsanar los
efectos de acomodaci6n, cuando se pasa de una labor a otra distinta, se hace nece-
sario evitar que vuelvan ineficaz el ejercicio que tanto facilita la tarea. Esto se con-
seguird, en general:

1*. Haciendo que la duraci6n de la labor intelectiva y las interrupciones a que debe
estar sujeta, sean siempre adaptables a la capacidad mental de los alumnos, en el
sentido que puedan recordar las ensefiaazas despues de las pausas, sin perder los efectos
del ejercicio, lo que se obtendrd: (a) Procurando que los recreos despu^ del trabajo
intelectivo objetivo, sean la mi tad m^ cortos que a continuaci6n de una labor mne-
m6nica, que demanda el doble gasto de energla; (b) determinado la curva diuma pro-
ducida por una misma labor y por dif erentee— dada una pausa igual — en sus relaciones
con la adaptaci6n e igualmente, la gr^ca correepondiente a un trabajo dificil, despu^
de un descanso igual; las curvas asl obtenidas nos ensefiaran gr^camente la extensi6n
de las pausas en sus relaciones con los efectos de la adaptaci6n y como consecuencia
con los del ejercicio y la manera de r^larlas cientlficamente; y, (c) haciendo que los
m^todos de ensefianza, en cuanto fuese posible, sean pr^ticos u objetivos, que deman-
dan menos gasto de actividad, antes que mnem6nicos.

2*. Ensefiando las experiencias hechas en estos tiltimos afios que, por lo general, la
fatiga producida por el trabajo intelectivo de la mafiana, es menor que la generada
por el de la tarde, se hace precise: (a) Medir la curva grdfica de las oscilaciones de la
fatiga experimentada durante el curso de la labor matinal y vespertina; (b) una ves

712 PBOGEEDINOS SECOND PAN AMBBIOAN 80IBNTIFI0 00NQBBS8.

comprobada experimentalmente dicha verdad, distribuir el trabajo de manera que el
que demanda mayor actividad se haga a la hora en que la enei^ eetk m&B desanollada;
y» (c) po^ tiltimo, hay que tomar en cuenta tambi^, la influencia que tiene el pro-
fesor, segdn el m^todo de ensefianza que emplee, la mayor facilidad del aprendizaje
y el menor gasto de energia.

3*. Mas, esti igualmente comprobado, que, la fatiga diaria, puede acumularae y
traer consigo el agotamiento, despu^ de un tiempo m&B o menoe largo. De ahf la
necesidad de evitar dicha acumulaci6n, que implica un desgaste equivalente de
energfa. Esto se conseguird: (a) Dando im dla de descanao (el domingo) para mibaa-
nar la fatiga provocada por la labor de la semana, cuyo m&ximum se hace sentir el
B&bado; (b) interrumpiendo las tareas un medio dia, en el curso de la semana, a fin de
evitar la fatiga que la labor de los tres primeroe dfas de la misma ha producido, eligidn-
dose en consecuencia, la tarde del juevee; y, (c) procurando obtener ciu^as diumas
irecuentee, a fin de medir la fatiga producida y acumulada e interrumpir el trabajo,
si se colige que pueda sobrevenir el agotamiento intelectual del sujeto.

H6 aquf, en pocas palabras, las reglas relativas para evitar, en las aulas, la fatiga
producida por las tareas escolares. Puede que haya olvidado involuntaiiamente algo,
que espero ha de recordar el profeeor; ya que la materia es tan vasta y tan difidl de
condensar en unas cuantas Ifneas.

OONCLUSIONXS OXNBBALB8.

Piimera. El tiempo mis a prop68ito para el ejerddo de la actividad psfquica,
hablando en general es el de la mailana.

Segimda. La labor intelectiva, sine es muy larga, debe hacerse mds bien en ayuDM
que despu^ de haber comido.

Tercera. La extensidn de un trabajo mental continuado, sobre todo mnem6nico, no
debe pasar de 50 minutos.

Guarta. La repetici6n de una labor psfquica, o sea, el ejerdcio de ella, influye
mucho en la mayor facilidad de ejecuci6n.

Quinta. La homogeneidad del trabajo cansa y fatiga la atencidn y el espiritu.

Sexta. La acomodacidn, si se hace sobre materias diferentes y a cortos intervaloe,
tiende a disgregar la actividad mental.

S^ptima. El curso matinal de trabajo interrumpido, no debe pasar de tres a cuairo
horas y con mayor raz<5n el vespertine.

Octava. Si el trabajo es continuado, deepu^ de 50 minutos m^ o menos, se inter-
calard una pausa de 5 a 10 minutos, segdn sea de naturaleza objetiva o de memoiia
la labor emprendida.

Novena. Si la labor es interrumpida despu^s de un curso de 3 o 4 horas, la pausa
(sobre todo si tiene liigar despu6s de las comidas) se hard durar doe o mds horas.

D^cima. La uniformidad del trabajo intelectivo tiende a disgregar la personalidad,
m, se prolonga, mientras que la diversidad del mismo, contribuye a dar m^ atractivo
a la labor, pudiendo entonces Uevarse a cabo de una manera consciente y voluntana.

Und^cima. La energfa intelectiva decrece en raz6n inversa de la actividad de»-
plegada; mientras mds labor mental gastada menos eneigfa resta y viceversa.

Duod^ima. La rapidez de la enei^a psfquica no se modifica por la naturaleza del
trabajo, trat^dose de un mismo individuo; queda siempre igual, constituyendo IfL
caracterfstica de la capacidad mental.

D6cima tercera. La rapidez de la energfa intelectiva, tratdndose de distintos sujetos,
se modified segdn la naturaleza de la labor.

D^ima cuarta. La fatiga y la actividad mental, sea el trabajo matinal o vespertino,
siguen siempre una marcha opuesta: a las 7 a. m., maximum de eneigfa psfquica y
mfnimun de fatiga; a las 12 m. maximum de fatiga y mfnimum de capacidad maital;
a las 2 p. m. y a las 7 p. m. pasa lo mismo que en las horas de la mafiana.

PUBLIC HEALTH AND MEDICINE.

718

D^dma quinta. Tanto las ofldlaciones de la capacidad mental, como las de la f atiga,
son ■nsceptiblea de eer medidaa por el eeted^metro, el erg<5grafo o de otra manera.

D^dma sexta. Se puede eetablecer una curva diuma y anual de dichas oeciladones,
a fin de saber las alzas y las bajas de la energia y la 6poca m^ a propdsito para la mayor
o menor actividad psfquica.

D6cima s^ptima. Se puede igualmente reglamentar las horas de trabajo intelectivo
en relaci6n con las que es neceeario dedicar a loe ejercicios flsicos, que deben altemane.

D^dma octava. £s posible igualmente disminuir la f atiga reglamentando higi^ca-
mente el trabajo mental.

HORARIO.

Tarde,

Labor veepertina de 3 a 4 horas; varia-
da y poco intensiva.

12.20-2 p. m. Recreo.

2-2.45 p. m. Trabajo mental fdcil o
diffcil — 15 minutes, descanso.

3-3.45 p. m. Labor recreativa; mtisica,
canto, dibujo, etc. — 15 minutos, repoeo.

4-4.45 p. m. Trabajo intelectivo muy
fdcil — 15 minutos, pausa.

5-6 p. m. Gimnasia — 30 minutos, des-
canso y toilette.

6.30-7.15 p. m. Comida.

7.15-8.45 p. m. Recreo.

8.45-9.30 p. m. Conferencias instruc-
tivas y recreativas (urbanidad).

Maflana,

Tarea matinal de 3 a 4 horas, variada y
m&s o menos intensiva:

6-6.30 a. m. Toilette.

6.30-7 a. m. Ejercicios libres, hasta 30
minutos.

7-7.50 a. m. Trabajo mental f^il o
dificil — 10 minutos, descanso.

8-8.15 a. m. Desayuno — 30 minutos,
reposo.

8.4&-9.30. Trabajo intelectivo fdcil o
diffcil — 10 minutos, pausa.

9.40-10.25 a. m. Labor mental fdcil—
10 minutos, descanso.

10.35-11.20 a. m. Trabajo mental mds
f^cil — 16 minutos, toilette.

11.35-12.20 m. Almuerzo.

NoTA. — ^Este horario ha side formado muy principalmente para los intemados
y puede sendr Igualmente, para loe extemadoe. En este tiltimo case, bastar& tomar
en cuenta las tareas matinalee y verpertinas: 7 a 11.20 a. m. y 2 a 6 p. m.

En los alumnos menores de 11 afios, las tareas eecolaree matinales y vespertinas
deberin ser de 2 a 3 horas solamente; las clases de menos de 45 minutos; los descansos
de m4s de 10 y 15, respectivamente, segdn la labor, y, siempre, la intensidad del
trabajo, menor.

Las pausas enunciadas servir&n de preferencia para la labor nmem6nica, debiendo
ser m4s cortas, si el trabajo ee objetivo.

The Chairman. The chau* begs to report the presentation to the
Congress, through Section VIII, of the following printed books* or
pamphlets by Dr. Jos6 Moreno, profesor suplente de materia m^dica
y terapia en la facultad de medicina de Buenos Aires y medico del
Hospital Francisco Javier Mufliz.

Antisepsia digestiva y bacterioterapia. Argentina M6dica, afio XI,

Pseudo-tuberculosis pulmonar Coco-bacilar. Las Ciencias, Buenos
Aires, 1905.

Estaciones invemales Argentinas. Anales de la administraci6n
sanitaria y asistencia ptlblica; pag. 213, 1909.

1 For further refertnoe, lee pp. 336, 336, 337, 338 of vol. X of the Proceedings of the Second Ptn Ameri-
can Sdentifie Congren.

714 PROCEEDINGS SECOND PAN AMEBICAN SCIENIIFIC COKOBS88.

Sobre un caso de tachipnea hist^rica simulando ''coup de chalear "
Anales de la adininistraci6n sanitaria j asistencia ptiblica; pag. 389,
1909.

Batallones escolares. Las CienciaSy Buenos Aires, 1913.

Lecciones de terapia higi6nica. Aguas minerales. TalleresGrftr
ficos, Buenos Aires, 1914.

Hemofilia familiar de tipo? Hemoptoico sistem&tico. Imprenta
Flaiban y Camilloni, Buenos Aires, 1916.

Las nuevas orientaciones en terap6utica. Talleres Gr&ficos, Buenoe
Aires, 1915.

Sobre las transformaciones que sufre en el organismo el 606. Las
Ciencias, Buenos Aires, 1914.

Lecciones de terapia higi^nica (aeroterapia, fototerapia, helio-
terapia y aereaci6n). Talleres Gr&ficos, Buenos Aires, 1914.

Thereupon the session adjourned at 1.10 o'clock.

a.,0«^'»3075l'^

fl10'm307S11

B89094307B19A

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Full text of "Proceedings of the second Pan American scientific congress, Washington, U. S. A., Monday, December 27, 1915 to Saturday, January 8, 1916"

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