63 ??? o Km. Sur. Manoel Duarte. Dr. Andrade, Dr. Linta, Dr. Tomaz and I discuss proposed contract frankly. No difinite conclusion reached. Dr. Barros Barrett0 says Fraga is agreeable in principle to mission for investigation of \ 1 Ieptos irosis in north and asks for conference \ with p rag& Friday. @ragao notified. 5 5 ; &Y 31p. Office in AM. Holiday of Brasil. Swim at Post 6 waves strong. Mey 4. Conference with Dr. Decio Pefieiras on malaria. Probable easy solution of malaria situation. Pernambuco notified that he can sail in June. Visit from Dr. Guilherme Silve of malaria service of Minas Gerees. Dr. Henrique and talk over t BB says the DNSP is says material should be sent here for study and that he needs time to brush up on leptospire technique. He offers to buy two monkeys. and St&, work ,and I authori'&?'purchebe 'with R.F. i ??*??o .<- Dr. HH promises to work out detailed p%%s for work of commission to be presented next Thursday when we are to have further conference. by 5. Connor telegraphs of suspect case of y.f. in Timbe'& (Pernembuco). Telephone to 1 Borges asking for "pn&6" f@--weti May 6. To top of Tijuce with Capt Babcock end family. by 7. Return cflost engineer "Costa" Leite. Accountant comes to check 1927 accts. Advise Dr. LaFeyelte agd Dr. B. Barrett0 of the suspect case in Timba$ba. Dr. Kerr arrived / Asuncion. May 8. Dr. Muench sails on Oranie for Bahia i receive wire from Connor saying nothing posi i appears in investigation of Timbabe case. May 9. Leave card on Dr. J Iemagine et Hotel. Visit auto show. May 10. Connor sails from Recife for Bahia. Dr. H. Arageo and I visit Dr. Harros Barrett0 end talk over plans for commission on study of r icterus in Brazil. Dr. HA submits typewritten ,&&. outline of proble .t be studied by joined forces +-!zz -4 Lk.kc,.Ls~ \ of C.R., DNSP, 5. Aof Bahia and Ins. OS. Cr. Pr-d?ac.. 63 $ See Ion Cheney in Monster of the Circus. May 11. Wire from NY "Connor - do not understand your letter April 24th, No doubt about diagnosis yellow fever - Case is not Weils disease Russell." Send report on commission mentioned for study to Russell and Connor. May 12. Gerald Golden, British, from &%$&&. Goyes, comes to office for information regarding Hookworm and malaria. Wire from NY announces :! that Davis will sail June 2 to join Connor. i -- May 13. Sunday. Lunch with Consul G. Dawson. May 14. Interview Ietocoere to see.3.f passage for Muench can be arranged. Dr. Fraga has just returned from Cexambu. I discuss the yellow fever situation with him ; 1 end tell him of steps already taken by Dr. Aregao. Also tell him of $FFR's attitude toward Course of Hygiene in Rio and give him invitation to go to the USA. He states that action in Congress on Course can be delayed until after his trip to US even if he does not go before Sept. I also inform him that Dr. Davis will arrive in June. May 15. Wire from N.Y. asking for "current" to be used by Davis in laboratory list of "currents' in north secured from General Elect&. Conference with Drs. Fre m Aregao. The situation of%north is discussed. Why did yellow fever disappear once end for all time in Rio, Sao Paul0 and Amazon River when control : measures were adopte t but fails to do so in the Northeast of Braril;. All are agreed that studies must be made. D. Aragao is to work up details for conference with Davis on arrival. \ Also proposed to send one M. rhesus north now. Dr. Aregao is proposing many details including i the examination of each town in danger zone every three months.for at least a year after last suspect case. From letter of FFR to MEC Apr. 24. .f. lesions _u'"- first described byrRocha Lima wh c are necrosis of the midoone cells of i the liver lobtiles are accepted by Klots, McCallum~~ Darling, Callender end others as characteristic of y.f....... 1 might say that at the present time i this lesion is the most definite a-- istic thin which we know in the diagnosis of $-3x6x&." From letter of FFR to MEC Apr. 23. i 11 . . ..No Leptospire have been found in Africa!" 65 Ftter FFR to D.W.B. Apr 28. . ..one of the most difficult problems in yellow fever control, t e is, the recognition of cases so mild and aty & end so limited in number, that the diagnosis on clinical grounds alone presents great difficulties...... In Iegos, e virus has been obtained from cases so mild that a diagnosis on clinical grounds cuuld not have been made.... mild cases may occur in adults as well es in children andgDung persons... As you know, the American pathologists who have studied the question are quite convinced that the lesions first described by Roch,& Lima are pathognomonic of y.f. Darling while still et Panama discovered the same thing end taught it to his assistants but, so far es I know, never published anything on the subject." ' Dr. Fraga's attention has been called to work in Cempin$ Grende end Alagae &ende. Municipal control checked by state control should ble %e &b-J- .._ . ------A< May 16. Conference with Dr. Frega. DF asks for use of Costa Leite in Jacerepegua for one or two.months granted. I suggest that CR needs new office end that Nurses Residence would be ideal. C. F. agrees in principle but suggests / q-$@f--@--y that we take nursing service quarters end that Mrs. Parsons move to Residence. To this I reply that I prefer Residence office. Cell on Capt. R.A. Warner. -- See What Price Glory? May 17. Ascencion Day. No Holiday. May 18. Dr. C.F. agrees to our occupation of Nurses Residence. Visit from James H. Roth. Rotary 221 East Cullerton St. Chicago. Advise Mrs. Parsons that our contract with Federal Government expired April 1, 1928. Dr. Salles Comes, Dr. Geo. Hesselmann Parsons visit office almost simultene- ously. S-afternoon Dr, Aregeo informs that tissues 1 of Almeide, Tii&a#ba. are nositive. Later I learn of suspect case in Rio end advise 2onnor and NY. late Set. night Rocha Lima confirms both diagno&s. I Sunday 20. Wire NY end Connor of R.L. diagno&;/ afternoon in hills with Mrs. Parsons Mdm LeDog and Miss Dennherdt. Monday 21. Wire Connor that Frega wishes him to come to Rio for conference. Another ' I soldier is deed but Frege doubts if it is yellow 1 66 fever. w*,- Tuesday 22. Connor received wire in Bahia but 1 ", went to Recife as planned - From Muench's station 1 ~ journal) Received this wire at noon and sailed 1 that night for Recife. Authorized to move to ' Nurses Home from N.Y. arrangements made with S-dard Oil for recei$T-o? @*`FGd$;-- . .* -' -._- _.... I _- ,-._, -., ,-, -(.I_^. In the afternoon Dr. Tomaz and I went to Manguinhos where we received something over five cantos which leaves Osweldo Cruz owing but 3 cantos and this an old account which Hydrick refused to collect by going to the treasury. We meet Dr. Magarinhos Torres who has been con- tracted for the medical school in Asuncion. He \ shows liver of Timbaule case and we get specimens 07 liver ver end of liver and 1 1 kidney from the second soldier. IaOer in the afternoon Dr. Torres calls to say that liver of i second case is yellow fever. N.Y. notified by ceblejalso Connor. Newspapers carry news of death of Noguchi et Accra, -*--^__ i . ..^W.^ .-,__* " -.61*., Gold Coast of yellow fever. 1 Dr. Aragao reports no new cesesaspected. Drs. I L Fraga and I&Fayette not seen because at Santa Crus. ' i Wednesday 5-23. Connor wires he is enroute for &-r4A i?.u-c Recife. $m~ect case in Parehyh. Dr. Guedes ..,..-*-.I.-,. ._ *-. Pereira also has wire about case. Together we .&L.hA.+ $A- l52-.2& go to Dr. Lafayette and discuss situation. Dr. i ; w 'Ls LucLU l&Fayette is willing for same cooperation in Fortedese as in Natal. +&23 -- Dr. Albert0 da Cunha is 4_,Y"_.~ ~^-. .a.-.-.. . heading up stegomyie contx=e. Dr. Frega sick in bed. .a.--LI.. _- _. Drs. Decio Perreiras end A. Andrade come to office to I-Mk over Rio malaria situation and we agree on contract basis for 1928. Quarterly report for 1st quarter mailed. Government &.e. lower house of Congress passes motion lamenting loss of w&i. i Dr. Sousa Pinto reports trypanosoma in blood of child at Sante Cruz. Thursday May 24. I Take citrate tubes to Dr. Aragao at Manguinhos. Consult Dr. Fra and tellhim :het Ruswrieed&n Rio if I i Fraga is doubtful i III e &Xii on-these two cases is now as fallows:Possideon Nino, Pernambuco in Rio five mohths reported to hospital ill on March 14th - died March 15th. History of previous illness since January with bloody stools continuing in spite 0 9. emetine end bismuth. He became ill at the quartep at Campinho. History not very definite. At autopsy 500 cc of urine was found in the bladder. Only liver sections 67 were taken for diagnosis - these were diagnosed positive by Drs. i Torres and Roche Lfma on 19th. : Pedro Lopes, Alagoas, in Rio one year, entered hospital militar for Rx for scabies on May 4th or 5th, leaving on the 16th for Sante Crua, 40 or 50 M. but in Be&era1 District. Reentered hospital with high fever on May 18th. Died on May 20th. Symptoms suspicious of yellow fever. Anurie reported2 ?J- Bladder empty at autopsy. Dr. Fraga sew a opsy and did not believe case to be y.f. Liver red end solid. Peryassu cut liver et autopsy and was not convinced of y.f. Liver diagnosed poisitive by Drs. Torres, Osweldo Crus end Bomfim (militer) but kidney is not typical of yellow fever. Discussion. 1. These two soldiers are both from northern states where yellow fever has in the past been endemic. 2. They are from different branches of the service and no possible point of contact such as sleeping in the same barracks has been es- tablished. 3. P.N. did not suffer from anuria and 500 cc of urine were reported at autopsy. 4. P.L. had anuria but the kidney is not that of p.f. (Rocha Lima stresses kidney lesions and BW Crowell considered them more important than those of the liver. 5. Both cases must have been infected in the federal'district. This means that one or. more previous cases must have occurred. P.L. could only have been infected in the military hospital. No other cases have occurred in the hospital nor do the records reveal suspect cases. 6. Analysis of recent mortality records shows no increase which might be attributed to an undiagnosed epidemic. The epidemiology of these cases does not clearly fit the picture of yellow fever. May 25. No'new cases have developed. One suspect case proved to be lobar pneumonia confirmed by autopsy. Dr. Connor notifies that Smith goes to Fortaeesa. Muench to Parehybe. Reports that Seth believes that case in Parehyba was positive. Bases belief on microscopic appearances et time of autopsy. '-%sit'by Dr. Guedes Pereira. Saturday 26, Visit nurses ho#e with Dr. Agg$ who is to make estimate of cost of changes wan&bed. Dr. Mattos shows room available for deposit of ! 68 heavy objects. Dr. Aggeo states that military hospital will again be fumigated. "A Manha" carries scare story of 60? cases of yellow fever is Rio. Dr. Fraga reports nothing new. In considering the Sergipe and other northern I / cases, it would appear that the difficulty of I recognition came from the small percent of foreigners ; in the region and an underestimation of the previous endemicity of the disease. It is quite possible that these two factors have been respon- sible for giving an epidemiology different from that of other fields with which Dr. Connor was familiar. May 27. Home all day except to Post office in PM with Mrs. Muench. Monday May 28. No new developments Rio. Wire COMOr to come to Rio at request of Dr. Fraga. I Tuesday May 29. Dr. Guedes Pereira lunches with me at 125 Bolivar. Dr. Guedes is director of P.R. in state of Parahyba. Still no new develop;; ments in Rio. Nurses Residence. See "Aurora" with Dr. Jansen de Mel10 and Susa. Play poor. Wednesdey May 30. Meet Miss Bertha Lutz, Feminista. Connor to leave Recife for Rio tomorrow. Wire to R.J.S. - Gov. bmartine and C. Dantas to lunch. Thur. May 31. Authoril;e work at Nurses Home done by Arge Dr. Lessa Y tells me of suspect yf case in Portuguese who became ill Monday, May 28. Dr. ', Albert0 Cunha confirms and says case is now \ at Sao Sebastiao Hospital. Dr. Cunhe says case 5 is from Praca Republica but that patient slept in Rua Sao Pedro. Dr. Cunha considers clinically 1 Yf. Later: Visited SRO Sebastiao with Dr. A de Cunha. Surely a beautiful location for an isola- t%jn hospital. Patient, .Jose Te@eira, by name, 19 years of age, Portuguese workedCin candy ' factory in Praca de Republica. After he became 1 ill he went to sleep (one night- at 257 Sao Pedro St. Had not newspaper articles appeared recently calling attention to possibility of yf in Rio the doctor who notified this case would not have considered it yf.but an acute severe case of grippe according to his .own statement; ! When he saw the patient he was semi delirious. #hhc'&@d~~~&;,,ar&continuously mumbling * . 69 T1\:'1 ii Dr. da Cunha says td facial expression iS CharSC- teristic. Examination wes by electric light and icterus could not be well observed. Fever reported as 385 axillary. Respiration very rapid and not too deep. Pillow end sheet soiled 1 with some black clotted material and with steins of red blood. Eyes did not appear greatly congested. Teeth in poor condition and gums very congested but no hemorrhage on pressure. Dr. da Cunha examined lungs very superficially and insisted they are clear. Dr. da Cunha demonstrates-the marked sensitiveness of the stomach region. Examination of urine (catheterized) was recorded as "alb. trecos accentusdos." In conclusion Dr. da Cunha insists this case presents the typical signs of yf. The similarity however of this patient to certain patients seen during the flu epidemic of 1918 is marked. Dr. Henrique Aragao had seen this case and drawn blood before we arrfved. I noted, in addition to the site of venepuncture, certain d&k black deep subcutaneous spots over the region of both biceps. Could these be deep hemorrhages as found in yf? June 1, 1928. Yesterday Dr. Washington Iuio went \ home after only a week in the Case da Saude, !, Pedro Ernesto. Again we can use the Avenida : Mem de Sa. A few days ago I spoke to one of the : policemen who prevented traffic from approaching ' thekDspita1. "Boa tarde" "Boa tarden "How much longer must we go the back streets which are poorly paved?" @They say the Presidente will go home Saturday." "Very well. But you know when I had my appendix taken out, no streets were blocked off nor soldiers stationed to maintain silence in the neighborhoodf How do you explain the difference?! "Mas o dontor operou - se aqui em Rio de Janeiro?" "No in Baltimore." "Ah, that explains it." And he gave me to understand that were I to be operated here the whole city would be closed! Such delightful technique! Today Dr. Seidejof Sao Sebastiao told Dr. Tomaz that case of yesterday (Jose Teixeira) had died with diagnosis of "hepato nephritis." This made us feel good for a while as Dr. SeideL also suggested "grippe." However I went out to Manguinhos and saw the: -v& and talked with t Dr. Aragao. There is no doubt but that this case is yf. Blood was taken and has been injected into one Macacus rhesus and one Brazilian monkey. The microscopic examination made hurriedly showed cylindrical casts (calcareous) in the kidney. The liver could not be satisfactorily diagnosed 70 because of previous lesions. Together with Dr. Aragao I went to see another suspect case at Sao Sebastiao, vi%. Alfred0 P. Reis who is a Portuguese and who became ill Monday May 28 the same day a Jose Teifeira. This case is from the Rua B &%"de Sao Felix 76 P $,q$& and was picked up by Dr. Le.&e. He is subicteric, he8 vomited all night, black vomit, has only 37 temperature and is able to carry on a conver- sation but does not talk freely. Detailed history not obtainable. Blood taken by Dr. Are, 60 for me. t Bloods from both ceses put in ice ' t 6:30 PM in thermos bottle. Dr. Lessa makes positive diagnosis on this case. J Impossible to see Fraga but call him late at night. He reports conference with President and Minister and says he has been given carte blanche as far as yf is c;ncerned. I suggest possibility of Connor subordinatie personnel to which he agrees and insists that as many good subordinate employees as possible should come. The following wires aqe sent: "Rockfound NY. Two casesyAracaj,Z Stop. Two civilian cases Rfo One a#topsy positive. Monkey injected. Government undertaking control. Soper." "Rockfound Bahia If possible Connor should bring trained guards chefes with him." Dr. Lessa Reports other suspicious h'&/tories V" such as Portuguese husband and wife who died last Sunday May 27 after 7 days illness. Alfred0 Reis (entered 8:30 PM May 31 - died 4:30 AM June 2) w&ked into hospital because motor did not come rapidly. Anuria practically complete. 20 cc in 24 hrs and 20 cc in bladder. Albumina +++++. This case never appeared ill but a few hours before death began to show signs of lowered arterial pression. Autopsy showed typical yf and stomach and intestines full of blood. June 1. Conference with Mrs. Parsons on yf situation. Mrs. Dawson and Mrs. Muench to dinner. Fraga has conference with President and is given "carte branca" in control. Credit of 2000 cantos opened in Tribunal das Contos. June 2. AM in office. PM visit Se0 Sebastiao and take two tubes of blood from Candid0 Fernandes who became ill on May 30. Dr. Fraga says all guerdes and servants are taken from other Services and control is starting rapidly. British consul has been d b vised not to permit personnel of H.M.S."Co allis" now in port to sleep ashore. Dr. Werner comes to office and I explain situation 71 as is to him. He says that the child of Commander Wilson had something which mayhve been yf. Dr. Fraga asks me to investigate and report. Set. PM. Two tubes blood from Candid0 Fernandes, Rua Berao Sao Felix 198 Portuguese, 27 took sick on May 30 with headache and fever. Has vomited and has heavy album&n in urine. Marked icterus. Taken by me. Dr. Aragao took blood of Ant. Barb. da Silva case for me. This case probably grippe is cal$,ed Antonio Barbosa da Silve (my tube marked Guiparaes) Portuguese 22, Rua Bareo de S. Felix 218. June 3 Sunday. Go to Manguinhos with Dr. H. Aragao. Special screened sections are being completed for expsriments'with double screens. Only one monkey has been inoculated so far viz from Jose Teixeira. Inoculation made June 1 from blood drawn May 31, patient b came ill on May 28. Temp. at midday June 3 3 9% C which is about 5 or 6 above normal. Visit Sao Sebastiao and find Antonio Berbose apparently with a simple grippe. C&did0 Fern- andes appears sicker than he did yesterday. Albumin very heavy but Candid0 urinated 700 cc which is hopeful. Had black vomit during the night end today is yellower then he was yesterday. The upper floor has been screened and is being fitted up with 25 beds. Petients were transferred to this section. Dr. Linta and two or three other MD's were present. Cadaver of suspect case arrives and proves to have been pneumonia, Dr. Fialho says. Willson Russell 9 years old. Beck from Petrop. Apr. 30. Child became ill abou$ May 20. OK at 8 PM and 1 AM high fever 104 C delirium. Enema and cold bath. Fever down to 103 but back to 104 during morning. In the evening back to normal. Vomited during day illness and also at end of 36 hours after temp had been normal for 12 hours. Mrs. Willson described as "coffee grounds." Has not been to school nor to other side of tunnel since April 30. Candid0 d Almeida, 16, Brasiliera, died on May 14 after takin sick on May 9 (Palmyrao friend on hillside f Not yf symptoms. Diagnosis Typhoid with sudden cardiac collapse. Monday June 4. Make arrangements to supply DNSP 100 lamps and probably will give 100 more if Connor does not need. Dr. Fraga insists that Alfandega ten be arranged. and authorized order of large amount of supplies. I offer services of Dr. Tomaz Alves if necessary but Dr. Fraga 72 says he does not need. Visit Manguinhos and learn monkey's temp. is back to normal. TO Sao Sebastieo and get blood (3 tubes) from Antonio de Oliveire Portuguese, 47 years of age, Travessa das Partilhas 68 who became ill yesterday June 3. Symptoms very light and may well indicete something other than yf. However, he comes from the same street where the couple died May 27. Headache, slight vomiting and fever. Manoel Pereira de Amarel, 28, Port. entered Sunday June 3. Became ill on May 29. Blood not taken. This is tppical case. (Rua Barao de S. Felix 48) Candid0 Fernandes continues to urinate well Prognosis good. Antonio Barbosa (Guimaraes) appears to have First female case arrived today. Blood not taken as patient is on 6th day of illness. Nina Marie de Conceicao from Visconde de Nichteroy #37. Negress. Abluminurie +. Diagnosis not made. History indefinite. D. H&age0 ret urns to Manguinhos. Cell on Ambassador Morgan and give him details of situation. Europe. Dr. Samuel phoa calls enroute to Is June 5. Dr. Connor arrives on '$taimbe" at aboht 8:30 AM. Newspapers in North have reported 70 cases in Rio. Connor isnowready to consider A/.. Me. - the entire yf .zone of..Brasil.as infected or i%&&ibXe, from Santa-s..to.+anaos. and from coast to--Andes. -^.-" Brings tissues of Parahyba case, 53 years of age, who worked two days ill and died on fourth day. Uver reported by Dr. Aggefl" Magalhoes of Recife as not Rocha Lima picture but only excessive hemorrhage. Admits that Murchison wes probably yf and that Bahia will probably have cases in next tao months. Does not believe that yf in Rio is limited to present discovered focus. Suggests possibility of other then A& carrying or o_ther species of M, p+ssibi+ty of animal reservoir, esibility of repeated infections in the same individual and a-lso thepssibility of virus becoming attequated to ,.I - ,. ._ indigenous population but not to foreign stocks t~@ssibi~it,y~.of Rio beliiiga permanent endemic center and the impossibility of R&Fever having c8Gjs"~i.n pas? 29 years. We ca 11 on Fraga a'ird partially discuss the situation and agree to present ideas in writing. Connor would like to hzae Rio and make yf in Braal-'one unified project. Request Dr. Warner to keep tab on the Wilson menage and to let me know about Elisebeth Babcock. 73 Connor and I visit Manguinhos and find monkey with normal temperature. Dr. Aragao has ordered one dosen monkeys from Hamburg on my authorization. We go to Sao Sebastiao and find that Nina Maria de Conceiceo had pneumonia and not yf. Two other womnm are in hospital as suspects. Hospital notes June 5. Manuel Concalves Braoiliero 28 Rue dos Cajuerios 12 took sick June 4th 2 AM. Awakened by headache, fever, has not vomited. Connor considers very suspicious becauuf hour Two tubes of blood taken. Candid0 Fernandes better also Manoel Pe&ira. Francdsco Curte Itslieno Albumin++++. Became ill June 7 AM June 1. (June 7th this cese considered 'cc serum seal in ampules. For Africa on Curt&Candido Fernandes and Manoel Pereira. Probably also worth while to get sm~um for treetmnnt purposes from these men.) June 6. Blood from Candid0 Fernandes Manoel Goncelves, and Antonio Oliveira sent to NY. to- gether with tissues Jose Teixura and Alfred0 Reis. on W. World. Anna Jose da Silva, Portuguesa 27 Trav das PaPrtilhas #80 c/l. Took sick et 5 AM June 5th. Fever Back ache. Blood taken at 5 PM June 6. June 7. Joao Bittar, Syrian, 15 years works for tailor. Entered hospital 10 AM June 7. Blood taken 5 PM. Rua Itapiru 49, casa 6. 9 years ihn Biasil. Took sick June 4 at 10 PM. Had contack Thursday May 31 with tailor shop in Rua Baron SPO Felix. Mesa today June 7 subicteric sclerae. Declared positive by Dr. MEC. Two tubes blood taken--* June 8. Maria Jose da Conceiceo Rua Itapirn 49 Tpro days sick. Breathes like pneumonia? Blood taken. Lives next door to Jo30 Bittar. June 9 looks like pneumonia. June 10 Gives history of vomiting "red" end complains of gastric pain. June 11 is pregnant, etc. June 10. Six new cases have come to hospital from the following addresses yesterday end today. 9th. Joao Ventura,, Rua Dua Maria (Esticao Coqueioe) 9th. gq;$ de Silva, 23 yrs., Rue da Costa, Port. 10th. J~enkl;~ Sergio Ferreira, #30, Villa Deque de Caixiae, zJ= _ & /J. C.GCk..?,~ 74 June 6. Dr. Connor and I visit Dr. Fraga but find him giving attention to many other metters especially newspaper men and so we leave to go to Manguinhos. ic (J(@n;r\CL. June 6. GE@IiZe Visi Dr. Fraga and have long and L on y.f. situation. Dr. Dr. Guedes Pereira comes to office with the idea that Rio-d north. There can be no doubt ofpresence oTyf"% Rio for some time. . .._- -ayu a-.. is. ..". - _ rrrulfmc x_-w-:'wMw-` -.I,H..*-Tc _ I June 7. Conference with IsFayette de Fnaitss. He says yf must have been here some time aa ~~~~~~~~~~~~~0 11 _I_....-.-a I anuc-~ Bras& Memorandum prepared for Dr. Fraga not visited. Syrian, Joao Bittar, from Rua Itepicu isolated today. First civilian cese recorded outside of known infected aone and his contact has been estiblished through visit to tailor shop in Rus Bareo de Seo Felix dtn May 31 and June 2 during daytime. Became ill 10 PM June 4. Mrs. Sheppard end Allen to dinner. BowUemily go to Sao Faulo tomorrow. June 8. Conference with Dr. Fraga and present- &-Lb-=- ap7W'kc _.-. i.etion of Dr. Connor's memorandum to Dr. Fraga i rc asks for TomaaL&-W. 4-u TC z= June 9. Call on Mr. Dewson with Connor and see Rocha Lima. Dr. Tomas goes to work in danger sane because survey by Fraga showed larvae after area had been covered. Tomas says Frega e2so asked us to supply him with cer. sonnor end Rocha Lima end I go to so Sebastiti Find new ceses et hospital but not new enough blood. Talk with Dr. Lessa who asks cer information in regard to past ceses. asks if R.F. would teke,over Brt of D-rT"le7oiiiiok ._,- de .,. encj T"'Eibfh` t&I-him we'*thi -.--m:." .^b. II-A ._c/I.".l...s.l .,__ ,-_ .,"~_e- . . .,... ._.. . _ --, edvis.able to begin any part..uFy measures. Oeble arrive;i~~~~~~ina;"sailing of Bauer a&Da,v,is and gp$yy; fi;y;;sw;s; t;Frx Copaca~- I "\ Dr. Somas's first day at work results in request for auto for him. Mrs. Parsons promises Ford for Dr. Alves. \ June 10. Sunday AM conference with Dr.\ Connor. let DNSP continue until the arrival of Connor which will require ten days. Connor will continue district8 and mrdeg end oilers a8 et @e&&t ..d..*._ - . _ . .__."a_*.. .I CiiiiL%@,mn. No isolation& patients and no fumigation to b%TZ%%?$nus.~ '. Get map8 of city with Peryassu's districts Include anticulex measures in discussion with Fraga. / Connor*s it&a of ore*> Seocao de Febre Amarella reporting directly to him with representative of Board in immediate charge with right to employ discharge and regulate the number end salaries of all employees. Funds may be advanced by the board and the Departments pro-rata share later collected. Trucking trans- portation and custom8 privilegea/0rmpaign to be developed on a three ear basis %ominal salaries for our medical .~,.%x.+--*'-;' rectors permits of reduced passenger rate8 on foreign boats. Connor estimates that 250 contos per month should carry the whole progremme which would mean 125 for the govt on a 50-50 basis. situation and talk to Aragao. Get Davis end Bauer ~~!g!!!Y? in u$iing. Davis end Bauer probably- go to Recif$ after one or two week8 in Rio going direct with monkeys and nmterial. Best on Costeire boat which stops in Bahia end Recife gives one day in with Aragao and epd copy o ragao programme if possible. Get his ideas of programme for Davis and Bauer and atk permission to Davis end Bauer to come and see him frequently during stay in Rio. Present Davis end&&suer to Rocha Lima end maint8id contact. \ err,$#8~J~~s& Bahia immediately on Soper Connor be=& our entry here will be 76 about Se d t of latter part of August&y trip should be over by middle of August.) k&r& should arrive Parahyba June 15 and Rio July 15. Cannor plans to r-n t early in Nov. but will come to Rio when I return from the Argentine. Information for weekend cable to NY will be wired in each Friday. Biao will deal directly with this office. Connor believes organisation can be made largely self supporting except for administrative charges through fines and collecting done. Idea to be presented to- considered a)- ! 4 visable. Requires official support. Estimate of rotating funds Bahia 30000,000 Sergipe 7000,000 Alagoas material at 4000 to dollar Pernambuco increased as per wire. Perahyba 5000,000 Natal as is Fortalesa wait for telegram. Requisitions every three months trying to eliminate emergency requisitions. Requisitions can come direct with right to cut if demands . are excessive referring to Connor for decision. Same in regard to exceptional material. Burke due for vacation in 1929. End of Conno& notes. Connor sails on Andes Mrs. Allen and Mrs.' Shepperd sail on Voltaire. Three bloods including Joao Bittar on Voltaire with Purser. Advise mission personnel in Saude (L-q1 district to leave if possible. If not me to take all precautions. 5 cases entered today as suspects including one from Sao Christobal and one from Villa Militar (Rua Duque de Caixias.)' Meet Dr. Amaury de Medeiros who is going to talk to Congress about yf. Arrange to talk to him tomorrow. June 11. Conference with Dr. Amaury to Medeiros explaining importance of African work and- 6~ of problem in Brazil. Service as unit. Dr. Warner calls. Dr. Peryassu calls and I Cede 18 lamps leaving 40 in stock. Find Dr. Fraga rather impressed w-s of Sunday after two days of comparative freedom. He says that he himself believes only-at& larval measures but that because of question of nmorale~~~ go on with frimigation and 77 and isolation. Fraga says he has refused to take more men off the other services to increase the Wexpurgo" group; that the newspeipers are making a big fuss but that the government is behind him absolutely. Peryassu says that many physicians are being used in the service of wvigilancia,fl that he is a voice crying in the wilderness and that Fraga even suggested that he should strain water having larvae. Peryassu insists that only results obtained will be these obtained by his section. Fraga agrees to get Davis monkey and cases right through the customs. %-call Dr. Fragats attention to our joy over t& Parahyba case being diagnosed liver abscess as this clears our service fi the present. Visit Manguinhos and Sao Sebastiao as I have everyday since June lstja& 3 suspects have entered of which two are positive. June 12. Dr. Burke wires of German nun at Sgo Christovao, Alagoas, sick five days with black vomit, icterus and albumimina. Dr. Fra received wire of suspect case in Bahia Rasselmann?) T has who had not been out of city. Two medicos have been suspended for 30 days because of appearance of old cases i.e. more than 3 days in zone under observation. Dr. Tomaa is hard at work with car 689. Purchase a /&a~ - &.c?J To Manguinhos - not Aragao has gotten ^ri @,J& /e.xDJ,, from Sao Paulo. Three suspect cases in Sao Sebastiao. June 13. Five tubes placed in cold storage at -2oc. Examination of one tube left June 9 at -12OC. showed no breakage. Three tubes Olivio Ant. da Silva, Novello Miguel and Jacob Kaufmsnn and convalescent serum from Francisco Curte sent to NY care of Purselfon Monargo. Called on Dr. Fraga. Nothing new. Mrs. Parsons says that the report is going round that Fra said he would either control this or-commit suicide. outbreak"< f 'ye'llow* fe;i"e"r' -_.. _ ,.._._ i,,. .^ : Tell Argeu notto"'do*anything to nurses home. New focus today in Rua dos Invalidas, also report that case was at Guanabara Casa da Saude. Two soldiers reported from Nichteroy. A~EXvir WFraga not greatly pleased with Chagas' interviews in papers. To Manguinhos and Sao Sebastiao in afternoon. June 14. Wild rumors are heard that Bahia is full of YF and Santos has ever so many cases 78 In contrast to this Dr. Connor wires that the single suspect in Bahia is probably positive. \ The case at Sao Christovao died. Dr. Fraga says that Dr. Chagas is to see him today about programme of studies for Oswalaio Crus, Dr. Chagas insisting that Manguinhos must get in on the situation. Fraga is I believe disgusted with ,, Chagas and his attitude. Confer with Dr. Amadeg Fialho on the question of pathology He is anxiuus that the DNSP shuuld have a*hand in on that I did not . had an&&need r,m,&.c-^ -... ._I .,_ ,_ pr_agS- insists he CR had not found any cases for so long in the north that no one living could have suspected the possibility of Rio becoming infected at the time it was. He says that Rio must have been infected abcut 3 1 A-1 /___ _ ____ ___,,_ I _, i .*<-, --..i_-..--- thetime the first susp+Y case in Estancia. 2;L.P e.p"."."-I - -"sl..-.__*_-".. -... ~~,. _.~ ._l-l- ---... th~?i&essary information on which to base an- --.I--xv-x." - "<*,. _-,. -,.-x___.-!*.._ "^_ He seemed quite _I.-*..,.- _ _ _,, _,__ --I-. -7 -. surprised to learn -*--Y--^..^II ..I."*,; _,__l..-, _" ,._. - .I. - - Braail!) Ister in the evening Dr. RA says Macacus cynomalogus probably from Japan is expected die during the night. June 20. Called O.C.1 at 8:30 AM and find A-asleep. He lay down at 5 AM. At 11 AM start to SS. Find one new suspect case. CPositive diagnos@are being made with great circ&mspection Man of family of 3 noted under 6-18 came to 2 - - autopsy todamy the case was yf with icterms, black vomit and anuria. I saw the body just before autopsy. It was very icteric and there were signs of hemorrhages into dependent portions of subcutaneous tissues, scrotum, etc. Dr. Fialho said this was the first body showing these characteristic hemorrhages he had selJn. 81 I However, when the first incision was made through the subcutaneous fat, he said the case was not yellow fever but malaria. And it proved to be. Blood slides from the wife and child were both positive for malignant tertian. Discussing this i question of diagnosis today with various phy- ; sici~ns~ the idea seems to be gaining ground that the clinical diagnosis of even typical cases is at times impossible.) (Mrs. Parsons reports th& a couple of her nurses say that many i DSNP doctors are beginning to think that yf may f have been in Rio for a long time.) PJCSWS: (A From S.S. to Manguinhos. M. cynomalogus ragaos #7) died at 9 PM yesterday; injected with be&U from Novello Miguel and Jacob Kauffmann on June 12 this big savage monkey showed no gigns of infection until June 18 when loss of appetite and high temperature were noted. This temperature dropped by crisis on 19th and monkey collapsed and died. Autopsy revealed a more typical gross pathology with intestinal hemorrhages than did Mr. N8. The liver ections are full offat and the mideone net h 61s is very typical. Liver for freezing and liver tissue in Z@ 10 90 formal were secured for sending to NY. Citrated blood from the following cases was forwarded to NY en iae by the American Iegion today: (left Out by Jane) Also two ampules with convalescent sery from Candid0 Fernandes and Ant. Pereira de Amarpl, two sealed tubes with frozen liver from monkeys 7 and 8 and bottles with tissues in 10% Formal from monkeys 7 and 8. Miss McK. also goes. June 21. Dr. Fraga says that 6 cases occurred during the irst week, & durrg the 2nd week %--- -- and l&during he third week. However the failure to have more cases during the 3rd week than during the second week may not be significant of a real let up. It may be that only the 4th or even 5th weeks will show. Capt. Warner went to Manguinhos and to S.S. with me. Discuss vaccine for yf with Aragao. Luta also goes to S.S. June 22. Return to*~~~~a_~rt. and find that he ha~oit`tl%Ged the auestion ofw%ether the CR had claimed yellow fev& extin ished or not. This re-prt' ap~~~~~d---+.g-~~4`.~ ";;'.in/jr~~..G-/& !r I sent translations of parts-of it-to M.Y. March 22nd. (Actually published in Journal do Commercio Feb 18, 1928). This report to et " ._I ., ,.`.l_ ,..x -..-I bx wiw a-0 Ca art which% as now been published in -the-,a.rchivas-da Hygiene #3'show"clearly that we were in the wai.tIhg,stage when-the Rio situation _II__-*- _ . . . &?2SRz has To Man inhos one monkey with African virus high gmperature. 82 TO S.S. and all quiet and peaceful. (One man comes in walking as we were leaving. He insists that he is not sick but was wanting two days leave from work and asked for it on the basis of being sick. The company called a doctor & d he was sent right out to S.S.) Dinner atCapt. Warner's, Commanders Atkins and Wilson present. C&g. ~~dk_n_,a~~,-~~h._~~;1~er .Fa.ed,..W been. ordered to Minnesota but ___- __ ._I_Mw--Y-)-'--. ^. 2 that he fo,und the expense of winter-undse. ,!And .wmxxta ta -. fw his. fapLil.y too gr@~mziLb..ce asked for and secured % transfer to Cuba where the yf investigations Icyycar^.~.,e=--~ L-s...---,i-.d=-~ -. . ri..--l -. ,-,r91 .*.. _ I _ were carried o~t.~. ,_, . _ ~%"$%%'*I&? says that both Dr. '&D and Dr. A#+&ju wish the laboratory for Bahi-a and that he !\ has agreed to ins~'"~Gth6?%~*'~I advise Dr. I! 'i Fraga that Dr. Tomaz has a swollen ankle and probebly connot long continue and also of plans to install lab. in Bahia. In conversation with Am. Morgan I let it be known that probably the R.F. will either increase the scope of its yf control or retire entire&X Wilson's arrive f in Parahyba. June 23. Dr. Tomaz believes that article of D@.F. should be called to the attention of the We start to Journal but find Chateau-6UIedP nd I resolve to give copies of both reports (Connor and Fraga) to Ambassador Morgan instead which I do in the afternoon. Jule and 1 I go to SS in the afternoon. Bleed two patients. Do Jo?& not see Dr. Fra - be#loons etc. $ today. (Vespera de o F June 24. Sunday. To S.S. with Aragso who feels that epidemic is on the wane. No cases bled. \ June 25. Dr. Warner predicts cessation of present epidemic with fire up Xn%%Gi%er. Drs. %uer and Davis arrive onBan Dyck with 48 M I rhesus. Dr. H Aragao meets boat. Monkeys taken to Oswaldo Crus. Bauer says Stokes probably infected from autopsy on monkey still in infective stage which had died accidentally as it was being bled from heart. Stokes had been bitten on hand by monkey earlier in the day but perfommed autopsy without gloves. Virus of yf remains infective in mosquitoes during so called period of extrinsic incubation. Dr. Aragao suthorized to begin using tinkeys right away. Call- Chagas and then to autopsy at Manguinhos Hospital. Gse proves typical. 83 on the subject of his interview said that this interview was given at the request of and based on information given by Dr. Fraga. I tell Chagas that we do not care for any.newspapems@' -*-_cI%-.,#-.w- .".s,l_.-m.l ,_-, ., - * m'that he canget the actual data f$fi-&ir jT&giigtc-FG-~~~~e,~~~~i~~~~i %J& &&L&a 1. ,Reporte and from the ,Jour$l,,of Commerce of ~~~,~-i8,:"~~~~~~~"*'~agas says that Vasccncello; and othe;Te attack-he C R only to,&-%s.ck -4-e ,.,* 5. him since it was he who permitted the CRto begin work in Brazil. He says that all the north rX.w-~--Pili*...~' _ of- havingyellow,~fever when-.the CRY. a,,.-- .:. came in and that it so%*-iractically d+appeared. -Llir;;i~i~~~4~~~- ^ '~"'Y...#+-r,.~-r*e~c -aI _\ _FI 11 on Fraga whom I-invite to dine but who nei er accepts nor refuses definitely. June 26. To S.S. in AM with Dr. D%d B.?%r ,~!?a Lins shows us over the available cases. B. says symptoms of yf here are same as those of yf in Africa. Wire from MEG says that BB in Bahia has offered new building for laboratory and that he has accepted; screening to begin at once. Davis and Bauer suggest that screening be delayed untiliheir screen can be used. Wire sent to that effect. MEC reports.--,case in interior of Pernambuco"between Belle Jardim and Pesqueira. D.CZnzxEed of this case and also of absence of cases all last week. C.F. says that Cardoso in Recife whom Connor wants i$ going to Espirito Santo - that all he wants is double salary and that he cannot be spared at the present time. Dr. Bauer suggests to Dr. Aragao the need for trying as many sera as possible on different monkeys. be Aragao. Five,were already fnje2ted last night The final outline @ye to Aragao is that he shall do this work using our monkeys and shall give us the results. Results to be published by Aragao. We are to furnish monkeys now but must have viruses and convalescent serum em grande cantidadel June 27.- Drs. &- 4 D and B go to Manguinhos in PM. Take serum oP'Ninchelli for injection in monkey #3O. Dr. B. after seeing cases and slides considers yf of Africa and Brasil the sam. Three cases arriving from Bahia on the "Para." have been sent to S.S. as suspects. They all arrived in SaU Salvador from Ilheos June 21 remaining at the Pensao Velloso (Calcada) until Sunday (6-q) when they embarked for Rio. The first took sick on Saturday (6-23) with symptoms of grippe. Dr. Bauer injects monkey #30 himself for "sorte." Dr. Rocha Lima and Dr. Aragao and families dine at 125 B f; lfvar with Dr. Davis and Bauer. I