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Page 1: Sanitation in Panama - Welcome to WatCutwatcut.uwaterloo.ca/gorgas/gorgas-final.pdf · they landed at Siboney as could probably be got-ten together, but after two months’ campaigning
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Concreted Ditch. Ancon.

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SANITATIONIN PANAMA

BYWILLIAM CRAWFORD GORGAS

CHIEF SANITARY OFFICER, PANAMA CANAL, SURGEON GENERAL, U. S. A.,MAJOR GENERAL, U. S. A.

I L L U S T R A T E D

NEW YORK AND LONDOND . A P P L E T O N A N D C O M P A N Y

1915

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Preface to the electronic edition 2017

WilliamGorgaswas amedical officerwith theU.S. Armyin the early 20th century. He was in charge of sanita-tion in the city of Havana when Walter Reed conductedthere his pioneering work on the transmission of yel-low fever. Reed proved that a mosquito—known thenas Stegomyia, but today as Aedes aegypti—is the solecarrier of this disease. While not immediately involvedin Reed’s experimental work, Gorgas followed it closely,and after the conclusion of Reed’s trials, he immedi-ately launched a campaign to drive the mosquito, andwith it the disease, from the city.

In the first seven chapters of this book, Gorgas givesa vivid account of these events. For his mosquito erad-ication campaign, Gorgas waged a veritable battle ofmaterial. One of his routine measures was to fumigatethe homes of yellow-fever patients with pyrethrum, ofwhich he used one pound for every 1,000 cubic feet ofenclosed space (see page 55). In commenting on thismeasure, an astonished Reed suggests that one ouncemay be sufficient for such a task (see page 83). However,Gorgas ultimately carried his point by surprising Reedand everyone else by driving the disease from Havanawithin a year.

Gorgas was subsequently put in charge of sanitationin Panama during the construction of the canal. There,he took a similarly determined approach to drive outyellow fever. He subjected every house in the city ofPanama to three successive rounds of sulphur fumiga-tion, stating that “we used up . . . some hundred andtwenty tons of insect powder, and some three hundredtons of sulphur” (page 151).

After successfully smoking out yellow fever, Gorgasfocused mostly on the suppression of malaria. While

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eradication could not be achieved, morbidity and mor-tality due to this disease were very significantly re-duced. Gorgas here gives an overview of this work, butdoes not go into very much technical detail; he clearlywrote for a general audience, for whose benefit he lib-erally sprinkled this book with anecdotes and generalhistory.

A much more thorough account of the sanitary workat Panama has been given byMalcolmWatson, anotherpioneer of malaria control, who visited the Canal Zonein 1913. His book “Rural Sanitation in the Tropics”also describes Watson’s own, no less impressive workin South East Asia, and it gives a good idea of the stateof the art at the beginning of the 20th century. Anelectronic version of Watson’s book is available frommy website.

About this edition

This electronic version was produced from page scans ofthe printed book that I obtained from archive.org. Thepage scans were subjected to OCR using tesseract,and the output was post-processed to generate LATEXmarkup based on the TikZ package that produces aclose semblance of the original layout. The font usedhere—TEX Gyre Schola, which is derived from CenturySchoolbook—also resembles that used in the originalquite well.

While I did proofread the OCR-generated text, someerrors likely still remain. If you want to help with proof-reading, you can find a copy that shows the originalpage scans next to the recreated pages on my website.

Michael Palmer, April 2017

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CONTENTS

CHAPTER PAGE

I. Yellow Fever and the Discovery of ItsTransmission . . . . . . . . . . . . . . . . 1

II. The Experiments of the Reed Board . . 18III. The Discoveries of the Reed Board . . . 32IV. The Sanitary Board of Havana . . . . . . 40V. Sanitary Work at Havana . . . . . . . . . 50

VI. The Results Accomplished in Havana . . 63VII. Correspondence with Dr. Reed . . . . . 77VIII. History of Yellow Fever . . . . . . . . . 110IX. Geographical Limits of Yellow Fever . 124X. Appointed Chief Sanitary Officer for

the Isthmus . . . . . . . . . . . . . . . . . 138XI. Preliminary Organization and Work

at Panama . . . . . . . . . . . . . . . . . . 148XII. Yellow-fever Work at the Isthmus . . . 159XIII. Nombre de Dios . . . . . . . . . . . . . . . . 175XIV. The Work of the Sanitary Inspectors . 182XV. The Work at the Hospitals . . . . . . . . 206

XVI. Malaria Work and the Hospital System 219

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CONTENTS

CHAPTER PAGE

XVII. Medical and Surgical Service of AnconHospital . . . . . . . . . . . . . . . . . . . 241

XVIII. The Sanitarium at Taboga . . . . . . . . . 248XIX. The Leper Colony . . . . . . . . . . . . . . 256XX. Quarantine System . . . . . . . . . . . . . 260XXI. Measures Against Bubonic Plague . . . 275XXII. The Work of the Sanitary Department

of Panama . . . . . . . . . . . . . . . . . . 279Index . . . . . . . . . . . . . . . . . . . . . . 293

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LIST OF ILLUSTRATIONS

FacingPage

Concreted Ditch. Ancon . . . . . . . . . . . Frontispiece

Map of the Panama Canal Zone, Showing Hospi-tals of the Sanitary Department . . . . . . . . 1

Stegomyia Squad. Havana . . . . . . . . . . . . . . 52Screened Water Barrel. Havana . . . . . . . . . . . 52Concreted Ditch. Gatun . . . . . . . . . . . . . . . . 112Screened Yellow-fever Ward. Ancon Hospital,

Panama . . . . . . . . . . . . . . . . . . . . . . . 150St. Charles Ward, Ancon Hospital. Building in

Which Twelve Hundred Frenchmen Died ofYellow Fever . . . . . . . . . . . . . . . . . . . . 150

Oilers at Work in Marsh . . . . . . . . . . . . . . . 184Burning Out Ditch with Oil Spray . . . . . . . . . 184Old French Engine Tender Used as Storage Tank

for Oil . . . . . . . . . . . . . . . . . . . . . . . . 194Mule for Packing Oil to Oilers . . . . . . . . . . . . 194Distilled Water Cart. Culebra . . . . . . . . . . . . 220Ward at Ancon Hospital . . . . . . . . . . . . . . . 220Stoned Ditch near Tivoli Hotel. Ancon, Panama . 234Bad Anopheles Breeding-ground on Artificial Fill.

La Boca . . . . . . . . . . . . . . . . . . . . . . . 234

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Map of the PanamaCanal Zone,ShowingHospitals of theSanitaryDepartment.

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SAN I TAT IONIN PA N AM A

CHAPTER I

YELLOW FEVER AND THE DISCOVERIES OF ITS TRANS-MISSION

YELLOW FEVER for two hundred years be-fore the Spanish-American War caused great

loss of life and much destruction of wealth. Everyfew years portions of the United States would be-come infected with this disease. In the earlierpart of this period the disease was more or lesslocal. As the Mississippi valley became morethickly populated, the extent of the disease and theinjury caused became very much augmented. Theepidemic of 1878 was probably the deadliest andmost extensive epidemic of yellow fever which everaffected the United States. In this epidemic overthirteen thousand people in the Mississippi valleyalone lost their lives, and the loss of wealth isestimated at considerably more than one hundredmillions of dollars.

It is very difficult to convey to a reader any ideaof the conditions which exist during an epidemicof yellow fever. All business is entirely para-

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SANITATION IN PANAMA

lyzed, the quarantines not allowing any communi-cation between the affected districts and thosenot affected. In an epidemic of any extent thismeans hundreds of local quarantines. Some ideaof the condition of affairs can be obtained by pic-turing what would occur in any community if allthe income of that community should entirelycease for six months. And this was the conditionof business all over the Mississippi valley everytime yellow fever gained entrance.

The population originally feared yellow feveron account of the poverty, suffering and businessdepression always caused by the quarantineswhich had to be enforced to prevent its spread,and in time people came to associate this idea ofdread with yellow fever itself. When this diseasewas announced in a town, everybody left whocould. The sick were frequently left without care,and often a great deal of cruelty and cowardicewas shown. If a person escaped from an infectedregion and became sick with the disease, or sickfrom any other cause, he was generally treatedas if he were a leper, and would often be left tostarve or die on the roadside.

It requires continuously warm weather for theyellow-fever mosquito to breed in sufficient num-bers to propagate yellow fever; therefore, thisdisease never became endemic in the UnitedStates. I mean by endemic, existing all the year

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YELLOW FEVER AND ITS TRANSMISSION

round and over a number of years. The frostsof winter, wherever they occur, either destroy allthe yellow-fever mosquitoes, or reduce their num-ber below the point at which yellow fever could bepropagated.

It was known in the United States that yellowfever was always brought somewhere from thelittoral of either the Gulf of Mexico, or the Carib-bean Sea, and the city of Havana, located on thenorthern coast of the island of Cuba, was known tobe the center of this endemic area.

Yellow fever in 1898 was looked upon as theexample of a filth disease, par excellence, and itwas thought that if Havana were put in a properstate of cleanliness, it might cease to be the greatpoint of infection for the United States. It wasknown that yellow fever had existed in the cityof Havana continuously for one hundred and fiftyyears. It is interesting to note that the endemicinfection of Havana occurred in 1762, when Ha-vana was besieged and captured by Americantroops. I say American troops, because the expe-dition was largely composed of men from the pres-ent United States, then colonies of Great Britain.It is also interesting to note that this infection wassupposed to have been brought by a vessel fromVera Cruz.

Yellow fever peculiarly affects shipping, andtime and again ships in the harbor of Havana

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SANITATION IN PANAMA

have had every living soul of their crew die fromthis disease, and these vessels would have to liethere for months until another crew could be ob-tained.

When we went to Havana in 1898 we knew nomore of the sanitation of yellow fever than wehad known a century before. The army whichwent to Santiago suffered as severely from yellowfever and other tropical diseases as any militaryexpedition into the tropics had suffered beforethat time, and its death rate, had it remained,would have been just as high as was that of theFrench army of similar size, which was exter-minated in the island of Haiti just one hundredyears before.

A very deep impression was made upon meby the condition of our army at the end of twomonths’ campaigning in this tropical region. Itwas utterly used up and of no value whatever asa fighting machine. Fully four-fifths of the menwere having fever. This small army of sixteenthousand men was as fine a body of soldiers whenthey landed at Siboney as could probably be got-ten together, but after two months’ campaigningin this tropical jungle, and after several weeksof fever from which no one was free, their staminaand morale were completely gone. After the sur-render of the Spanish garrison there was a com-plete let-down on our side. Everybody wanted to

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YELLOW FEVER AND ITS TRANSMISSION

go home. No-one could see any need of stayingin Cuba, and every individual was perfectly cer-tain that he would die if he remained there amonth longer. Officers and men became nervousand hysterical. I commanded the base hospitalat Siboney, and it was my disagreeable duty toselect from day to day those who would have toremain. Many times every day the poor fellows,officers and men, would break down and cry whentold that they could not leave on the next ship. Icould form some idea of what it must have beenamong the French at Haiti when they knew thatthey could not get away, but had to stay and die.

Being immune to yellow fever, I made applica-tion to go with the troops that took possession ofHavana. We arrived there in December, 1898.The military authorities concluded that this wasthe opportunity which the United States had beenawaiting for the past two hundred years. Think-ing that yellow fever was a filth disease, theybelieved that if we could get Havana clean enough,we could free it from yellow fever. It was feltthat if we could eliminate Havana as a focus ofinfection, the United States would cease to besubject to epidemics. This meant so much to theUnited States, financially and otherwise, that theauthorities determined to make all other effortssecondary to this sanitary effort.

The city was cleaned as well as it was possible5

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SANITATION IN PANAMA

to cleanse it. This remark applies as well to theprivate premises as to the public highways. Ener-getic and capable Army officers were placed atthe head of various municipal departments, andthese departments were thoroughly organized andmade as efficient as possible. By the middle ofthe year 1900 all the city governments were per-fectly organized, and were accomplishing all thatit was possible for them to accomplish. I believethat Havana was cleaner than any other city hadever been up to that time.

The health regulations of the Sanitary Depart-ment, such as the isolation and care of yellow-fever patients, were thoroughly and carefully car-ried out. But in spite of all this work and care,yellow fever had been steadily growing worse eversince we had taken possession of the city, and in1900 there were a greater number of cases thanthere had been for several years. The Cubanstwitted us with the fact that all our cleaning upand expenditure not only had not bettered things,but had even made them worse. They called at-tention to the fact that the very cleanest and bestkept portions of the city were by far the worstsufferers from yellow fever, and the evidence wasso staringly before our eyes that we had to ac-knowledge the truth of what they said.

The health authorities were at their wits’ end.We evidently could not get rid of Havana as a

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YELLOW FEVER AND ITS TRANSMISSION

focus of infection by any method we then knew.A few years before this period, an Italian

savant had announced in Brazil that he had dis-covered the organism which caused yellow fever.This organism was known as the bacillus icter-oides of Sanarelli, and it was quite generally ac-cepted that Sanarelli had proved this to be thecausative agent in yellow fever.

Drs. Reed and Carroll had proved that thebacillus icteroides of Sanarelli was identical withthe hog-cholera bacillus. They made this demon-stration while comparing the bacillus X of Stern-berg with the bacillus icteroides of Sanarelli.The work was carried on by them during the years1897 and 1898, at the laboratory of the ArmyMedical Museum in Washington. The investiga-tion was undertaken at the request of GeneralSternberg.

In 1899 our Public Health Service published thereport of a board of medical officers who had beensent to Havana to investigate Sanarelli’s organ-ism. This report made a great impression.Surgeon-General Wyman, in his letter transmit-ting the report says:

The findings of this Commission, verifying thediscovery made by Sanarelli, and making still fur-ther advances than did Sanarelli himself by de-termining the specificity of the bacillus icteroides,and that the primary infection of yellow fever is

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received through the respiratory tract, in otherwords, verifying one discovery and making othersof almost equal importance, at the same timeeliminating incorrect theories, must be considereda notable achievement in medical science and oneof the greatest practical value to the people of theUnited States and other countries infected, orliable to be infected by yellow fever.

. . . . . .In view of the widespread interest which the

report will excite and the practical deductions tobe drawn therefrom, I have respectfully to re-quest authority to have the same printed.

The findings of this Commission were:First. That the microörganism discovered by

Professor Giuseppi Sanarelli, of the Universityof Bologna, Italy, and by him named “bacillusicteroides” is the cause of yellow fever.

Second. That yellow fever is naturally infec-tious to certain animals, the degree varying withthe species; that in some of the rodents localinfection is very quickly followed by blood infec-tion, and that, while in dogs and rabbits there isno evidence of this subsequent invasion of theblood, monkeys react to the infection the sameasman.Third. That infection takes place by way of the

respiratory tract, the primary colonization in thistract giving rise to the earlier manifestations ofthe disease.

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YELLOW FEVER AND ITS TRANSMISSION

Fourth. That in many cases, probably a major-ity, the primary infection, or colonization, in thelungs is followed by a “secondary infection,” or asecondary colonization in the blood of the patient.This secondary infection may be complicated bythe coinstantaneous passage of other organismsinto the blood, or this complication may ariseduring the last hours of life.

Fifth. There is no evidence to support thetheory advanced by Professor Sanarelli that thisdisease is primarily a septicemia, inasmuch ascases do occur in which the bacillus icteroides can-not be found in the blood, or organs in which itmight be deposited therefrom.

Sixth. That there exists no causal relationshipbetween the bacillus X of Sternberg and thishighly infectious disease; and that this bacillusX is frequently found in the intestinal contents ofnormal animals and of man, as well as in the urineand the bronchial secretion.

Seventh. That, so far as your Commission isaware, the bacillus icteroides has never been foundin any body other than of one infected with yellowfever; and that whatever may be the culturalsimilarities between this and other microorgan-isms, it is characterized by a specificity which isdistinctive.Eighth. That the bacillus icteroides is very sus-

ceptible to the influences injurious to bacterial life,9

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and that its ready control by the processes of dis-infection, chemical and mechanical, is assured.

Ninth. That the bacillus icteroides produces invitro as well as in vita a train of the most markedpotency; and that, from our present knowledge,there exists a reasonable possibility of the ulti-mate production of an antiserum more potent thanthat of Professor Sanarelli.

About the same time an officer of the PublicHealth Service, Dr. H. R. Carter, was making inMississippi his epoch-marking observations uponthe extrinsic incubation of yellow fever. Meas-ured by the results produced, this was one of themost important papers ever written. Yet as highan authority as the Surgeon-General of the Pub-lic Health Service expected the greatest results toflow from the conclusions reached by this Board,and did not notice the report from his subordinateconcerning the extrinsic incubation of yellowfever. The conclusions of his Board turned out tobe all wrong and useless as to results. The reportof Carter turned out to be pure gold, and was oneof the great steps in establishing the true methodof the transmission of yellow fever. I do not saythis in criticism. It is almost impossible for con-temporaries to judge the true value of discoveries,or to give the proper position to the men of theirown time who make these discoveries.General George M. Sternberg, the then Surgeon-

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YELLOW FEVER AND ITS TRANSMISSION

General of the Army, was one of the leading bac-teriologists of the profession, and was also oneof the best known authorities on yellow fever. Hedoubted the findings of this Board, and obtainedauthority from the Secretary of War to appointa board of Army medical officers to investigatethis same subject. He appointed on this nowfamous and immortal board Reed, Lazear, Car-roll and Agramonte. They came to Havana, andspent several months in investigating Sanarelli’sorganism. They proved beyond peradventure thatit had no causative relation to yellow fever, andidentified it as a well-recognized organism.

It is an interesting historical fact that one ofthe yellow-fever patients in whom the Board ofPublic Health Service found Sanarelli’s organismwas a patient of mine. He was a soldier, PrivatePatrick Smith, Eighth Infantry, a non-immuneliving in an infected part of Havana, so that Ithought that he ought to be reported as a suspect.The case continued nine days, long enough to con-vince me clinically that the disease was not yellowfever. The symptoms in a case of yellow feverdying on the ninth day are always so well markedthat the diagnosis should not be in doubt. Butthe Board found Sanarelli’s organism, and beingthemselves convinced that this was the organismof yellow fever, they believed the case to be thatdisease. It shows the necessity in scientific mat-

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tors of being on one’s guard, and of approachinginvestigation with an open mind.

The Army Board having satisfied themselvesthat Sanarelli’s organism bore no relation to yel-low fever, but was simply the ordinary hog-cholerabacillus, turned their attention to other matters,though they were always working in relation toyellow fever. They spent a great deal of time inexamining the intestinal flora in cases of recog-nized yellow fever, but could find nothing thatseemed to have any relation to this disease in acausative sense.

Being at that time the health officer of the cityof Havana, and in that capacity having charge ofall cases of yellow fever which occurred in the city,I necessarily came in contact with this Board agreat deal, and with its various members. I wasnaturally much interested in the work, and keptin very close touch with it. The Sanitary Depart-ment of Havana had a commission of medical mento whom all cases of yellow fever were referred fordiagnosis. I was a member of this Commission,and Dr. Carlos Finlay, Dr. Antonio Albertini andDr. John Guiteras were the other members. Eachof us had had a very large practical experiencewith yellow fever. It is likely, therefore, that ourCommission was as accurate in its diagnosis ofthis disease as it was possible for fallible doctorsto be. Most of Dr. Reed’s experimental cases

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were seen and passed upon by this Commission.Dr. Reed requested us to do so, in order that thediagnosis of his cases might be upon the samefooting as the diagnosis of the other cases occur-ring in the city of Havana.

Dr. Carlos Finlay, of Havana, the physicianjust mentioned as being a member of our Com-mission, had ever since the year 1881 been investi-gating, thinking of and writing about the relationof the mosquito to yellow fever. He had con-vinced himself that this insect was the meanswhereby the disease was conveyed from personto person. Others before Dr. Finlay’s time hadreferred to the possibility of this being the case,notably Dr. J. C. Nott, of Mobile, Alabama. InMarch, 1848, he published in the New OrleansMedical Journal an article in which he maintainedthat the spread of yellow fever could not be ex-plained by the assumption of a difiusible miasmin the atmosphere. But Dr. Finlay had givenmore attention to this subject than anyone whohad gone before him. He had written upon itconstantly from the year 1881. His argumentfrom the then known facts with regard to yellowfever, showing from these facts that it was prob-ably the mosquito that conveyed this disease, wasmost beautiful and logical. But a still morebeautiful piece of reasoning was the induction thatit was the stegomyia mosquito, out of the six or

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seven hundred species of mosquitoes, that con-veyed yellow fever.

Dr. Finlay, in the twenty years before wewent to Havana, had done a great deal of experi-menting on the human subject with regard to yel-low fever. But he had not been successful intransmitting the disease. He had no means ofknowing that it took the mosquito twelve daysfrom the time when she swallowed the blood of ayellow-fever patient to become herself infectious.Not knowing this fact, it was perfectly naturalfor Dr. Finlay to use his mosquitoes upon hisexperimental cases within the first four or fivedays after they had bitten a yellow-fever patient.At any rate, in a large number of experimentalbitings of the human subject he did not have asingle case in which the evidence was conclusivethat yellow fever had been conveyed by the mos-quito. Reed says of Finlay: “To Dr. Carlos Fin-lay, of Havana, must be given, however, fullcredit for the theory of the propagation of yellowfever by means of the mosquito, which he proposedin a paper read before the Royal Academy in thatcity at its session on the 14th day of August, 1881.”

The Reed Board, after many months of incon-clusive work in other directions, turned their at-tention to Dr. Finlay’s mosquito theory. Dr.Reed discussed the matter with Dr. Finlay a gooddeal before he commenced his mosquito work, and

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was thoroughly familiar with Dr. Finlay’s argu-ments and ideas on the subject. Indeed, we allknew Dr. Finlay well, but were rather inclined tomake light of his ideas, and none more so than I.He and I met every day on the yellow-fever Com-mission above referred to, and it is probable thatevery day for more than a year we had more orless discussion on this subject.

Dr. Finlay is a most lovable man in characterand personality, and no one could be constantlythrown with him as I was daily for several yearswithout becoming warmly attached to him andforming the highest estimate of his scientific hon-esty and straightforwardness. Being very famil-iar with yellow fever, both historically andclinically, I was constantly bringing to his noticeinstances in the past which could not be accountedfor on the mosquito theory. He, with the greatestingenuity, was equally ready to explain how themosquito theory could be turned so as to meet justthis condition.

Dr. Finlay is still living in retirement and com-fortable old age in the city of Havana. When theAmerican forces were withdrawn from Cuba in1902, Dr. Finlay succeeded me as health officerunder the Cuban Government. He has since beenretired on a pension by that Government. I calledon him in Havana several years ago, and foundhim enjoying his more than eighty years of age,

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and the honors that were being heaped upon him.He is one of the few great men who has had hiswork recognized during his lifetime.

Dr. Reed got from Dr. Finlay the eggs fromwhich he raised the mosquitoes used in his experi-mental work. Dr. Finlay says on page 1 of his“Agreement between the History of Yellow Feverand Its Transmission by the Culex Mosquito”:“The experiments made by Drs. Reed, Carroll,Agramonte and Lazear were started in June,1900, with a brood hatched from eggs of the iden-tical insect which at Dr. Lazear’s request I hadhanded to him. All the successful experimentshave hitherto been made with that particular mos-quito.”

Dr. Reed says in his paper, “The Etiology ofYellow Fever, Preliminary Note”: “We here de-sire to express our sincere thanks to Dr. Finlaywho accorded us a most courteous interview andhas gladly placed at our disposal his several pub-lications relating to yellow fever, during the pastnineteen years; and also for ova of the species ofmosquito with which he had made his several in-oculations. An important observation to be hererecorded is that according to Finlay’s statement,thirty days prior to our visit, these ova had beendeposited by a female just at the edge of the waterin a small basin, whose contents had been allowedto slightly evaporate; so that these ova were at

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the time of our visit, entirely above contact withthe water. Notwithstanding this long intervalafter deposition, they were promptly convertedinto the larval stage, after a short period, by rais-ing the level of the water in the basin. With themosquitoes thus obtained we had been able to con-duct our experiments. Specimens of this mos-quito forwarded to Mr. L. O. Howard, Entomolo-gist, Department of Agriculture, Washington,D. C., were kindly identified as culex fasciatus—Fabr.”

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CHAPTER II

THE EXPERIMENTS OF THE REED BOARD

AFTER consultation, the Reed Board deter-mined to experiment to see whether the mos-

quito really did convey yellow fever. But it wasnecessary to have a good deal of money and sum-cient authority before starting in. The Board hadcome to Cuba for entirely different investigations,and had not been supplied with sufficient funds forthese experiments. Fortunately for the cause ofscience and of humanity, we had as Governor-Gen-eral of Cuba at that time General Leonard Wood,of the United States Army. General Wood hadbeen educated as a physician, and had a veryproper idea of the great advantages which wouldaccrue to the world if we could establish the factthat yellow fever was conveyed by the mosquito,and his medical training made him a very compe-tent judge as to the steps necessary to establishsuch fact.

General Wood during the whole course of the18

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investigations took the greatest interest in theexperiments, and assisted the Board in every wayhe could. Dr. Reed outlined to General Woodthe course he expected to pursue, and GeneralWood was so convinced by Dr. Reed’s argumentthat he authorized the expenditure from Cubanfunds of a sufficient sum and gave Dr. Reed amplepowers as to the method of expenditure.

The Board then went to work in earnest alonglines which seemed calculated to develop the factsin the matter. They started a laboratory atCamp Columbia, the American military station ashort distance out of Havana. Here they bredtheir mosquitoes from eggs procured from Dr.Finlay, and here the first three experimental casesoccurred. The first case was severe; the secondcase was that of Dr. Carroll, a member of theBoard, and was well marked, and Dr. Lazear, an-other member of the Board, died of the disease.Dr. Lazear visited Las Animas Hospital and wasbitten by the mosquito on September 13, 1900;was taken sick September 18th and died Septem-ber 25th. Previously on August 16th, he hadbeen experimentally bitten by a mosquito whichhad ten days before bitten a yellow-fever patientin the fifth day of the disease. We know nowthat ten days is too short a time for incubationin the mosquito, and the fifth day a period too latefor the yellow-fever patient to be infectious.

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Dr. Carroll was intentionally bitten. Dr. Lazeartold me after he was taken sick, and a day or twobefore he died, that he recalled being bitten by astegomyia three or four days before he was takensick, and while he was at work at Las Animas, ouryellow-fever hospital in Havana. He said thathe had noticed the mosquito enough to recognizethat it was a stegomyia, and had allowed it to filland fly away without disturbing it. These threecases satisfied the Board that the stegomyia mos-quito was the means of conveying yellow fever,but they determined that they would make such ademonstration of the matter that there could beno doubt in the mind of any reasonable person asto what had been proved.

With this idea in view they selected a spot amile or more from the military camp, which waswell isolated and had no habitations near it. Theyagreed that if they established an experimentalstation here and kept their patients in such away that there was no possibility of their gettingout and contracting the disease elsewhere, then theresults obtained in this station would be due tomeasures taken there. They already had theirstegomyia mosquitoes which they had reared fromthe eggs procured from Dr. Finlay. These mos-quitoes they took to the hospitals in Havana, andallowed them to bite people sick with yellow fever.In the course of time the Board found that the

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mosquito to become infected with this diseasemust bite the sick human being within the firstthree days of his disease. This was a singularand unexpected phenomenon, and is explained inthis way. The mosquito injects the yellow-feverparasite into the blood of the human being; theseparasites at once commence ejecting toxins intothe blood in which they are circulating; thesetoxins irritate the human cells with which thepoisoned blood comes in contact and they beginto throw into the blood circulation antitoxins. Bythe end of the third day these antitoxins havebecome so concentrated in the blood that they al-ways kill the yellow-fever parasite, and after thethird day no yellow-fever parasites remain in thehuman body.

Yellow fever is a very fatal disease, and on theaverage kills the patient on the sixth or seventhday. Why then does death occur in yellow feverif on the average the patient lives to the sixth orseventh day, and yet always by the end of thethird day the yellow-fever parasites have beenrouted and destroyed in the great battle whichhas taken place between them and the bodycells?Dr. Reed established this fact by finding that

mosquitoes which had bitten a patient more thanthree days after the patient had developed yellowfever, did not convey the disease to the non-im-

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mune when he attempted to infect these non-im-munes with such mosquitoes. On the other hand,he found that he was almost always able to givethese non-immunes yellow fever when he usedmosquitoes which had bitten the man sick withyellow fever within the first three days of hissymptoms.

We have followed Dr. Reed now up to the pointof his having infected mosquitoes and being readyto transmit the disease to non-immune human be-ings. A human being, in order that he may beliable to yellow fever, must be non-immune, andby immune I mean a person who either has hadyellow fever, or has lived ten or more years in alocality where yellow fever prevails. An attackof yellow fever gives a great immunity to the dis-ease, probably just as much as occurs in the caseof smallpox. In practice, it is counted as absolute.In over two thousand cases of yellow fever whichI have treated personally or seen in consultation,I have never seen a single case with a second at-tack, in which I saw the same individual in thefirst attack. I have seen several, however, whobelieved that they had had a previous attack, andI myself believe that I saw them in their secondattack. I have by no means seen a quarter asmany cases of smallpox as I have of yellow fever,yet I have seen more cases of second attacks ofsmallpox than I have of yellow fever. I feel con-

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fident, therefore, in stating that yellow fever givesfully as great immunity as does smallpox.

It is well known that in a yellow-fever endemiccenter such as was Havana during the nineteenthcentury native Havanese are not liable to yellowfever. They look upon their immunity as beingabsolute, and in my experience of fourteen yearsof life in such endemic centers I am inclined toaccept their belief. The immunity of the nativeis explained by saying that he has probablyhad yellow fever in childhood when the dis-ease was very mild, and that, at the time, it wasoverlooked and not recognized. This is the bestexplanation that, so far as I know, can be madeof the facts in the case.

Certain it is that one of these endemic centersfrom which yellow fever has been banished for anumber of years may have yellow fever as badlyas a city in which it has never been endemic.Eighty years ago a native of Mobile, Alabama, orPensacola, Florida, looked upon himself as beingas immune to yellow fever as did the Havanesetwenty years ago. But at the present time thenative of either of these cities is just as liable toyellow fever as is the man from New York. Thisis explained by the fact that eighty years agothey had yellow fever so frequently in Mobile andPensacola that all the natives had this disease inchildhood. Within the last fifty years they have

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had it so infrequently that very few now living inthose cities have had this disease.

Another phase of the same condition is seen inEcuador. Guayaquil, the port of Ecuador, is lo-cated on Guayas River at sea level, not more thanthree degrees from the equator. Here yellowfever always prevails, and the native of Guayaquilis not liable to the disease and never has it. Quito,the capital of Ecuador, is situated about two hun-dred miles away, right on the equator, and on thegreat Andean plateau ten thousand feet abovesea level. The stegomyia cannot breed at Quito,so that yellow fever has never occurred there.The native of Quito, therefore, has no immunityto yellow fever, and of this he is well aware.Guayaquil is the only seaport of Ecuador, andeveryone leaving the country has to leave throughthis port. Hundreds of the natives of Quito havedied of yellow fever contracted by passing throughGuayaquil. The man from Quito dreads Guaya-quil a great deal more than did the American inthe early days fear Panama.

Dr. Reed, therefore, to make his experiments ofany value, had to get human beings who hadneither suffered from yellow fever itself, nor hadlived long enough in an endemic center to acquireimmunity. Havana for a number of years hadreceived a considerable Spanish immigration. Atthe time to which I refer, it amounted to about

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twenty thousand a year. These immigrants be-lieved that they were going to have yellow fever,and though they knew that a considerable numberof them must succumb during the process, theywere anxious to have the disease and be done withit. There was a very general belief among theSpaniards in Havana that a person with what theycalled “thin blood” as contra-distinguished from arobust, plethoric, full-blooded person, was muchmore likely to recover from yellow fever. Theytried, therefore, with their newly arrived friends,relatives and dependents from Spain to bringabout this condition of their blood. They keptthem confined in a darkened room and fed them ona very limited diet, and certainly succeeded inrapidly reducing the strong, florid, robust Gallegoto a very marked condition of anemia and debility.The Spaniard believed that he thus saved manylives. I was convinced that he thus killed a goodmany of his friends and dependents.

The newly arrived Spaniard, as soon as he hadhad yellow fever and could present a certificateof immunity, could command double the wagesthat he could get before he had the disease. Sothat when Dr. Reed proposed to some of these menthat they should go out to his camp, have a mildcase of yellow fever, be well cared for and whenrecovered be given by him a certificate of immun-ity, he found no difficulty in getting volunteers, and

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when, in addition to that, he promised each manwho had the disease a bonus of two hundred andfifty dollars, the service became exceedingly popu-lar.

Dr. Reed had prepared, as I have above men-tioned, a very comfortable camp at an isolatedpoint near Camp Columbia, well separated fromall other dwellings. This camp was kept undermilitary guard, so that no one could come andgo without Dr. Reed’s knowledge. Here he placedhis non-immune volunteer Spaniards whom he hadgotten from Havana, and kept them under obser-vation for two weeks, taking their temperaturesevery day so as to be sure that they had not con-tracted yellow fever before they went out to thecamp.

At this point he made another important dis-covery in the mode of yellow-fever propagation.He found that the mosquito herself had to waitfrom ten to fifteen days after she had bitten a mansick with yellow fever before she herself conveyedthe disease. He found that the mosquito for thefirst week or ten days after she had bitten theyellow-fever patient was entirely harmless thoughshe fed freely on non-immunes. But after thetwelfth or fourteenth day she would give the dis-ease to every non-immune whom she bit. I haveoften seen the non-immune doctors and nurses atLas Animas Hospital put their hands in the jars

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where infected mosquitoes were kept during thefirst seven days of their infection and allow themto draw their fill of blood, for the purpose of feed-ing them, but they would not think of doing thisafter the seventh or eighth day. Two of thesenurses afterwards contracted yellow fever fromallowing mosquitoes to bite them after the twelfthday, and one of them, Miss Mass, died from thedisease so contracted.

Dr. Carlos Finlay, in his many experiments onthe human being, was unaware of these two factswith regard to the transmission of yellow fever:first, that the mosquito could only become infectedby biting a human being within the first three daysof his disease; and second, that she could only be-come infectious, that is, transmit the disease, whensome twelve or fourteen days had passed sinceshe had bitten the sick man. Dr. Finlay put agreat many of his mosquitoes to the sick man afterthe third day, and in no case did he apply hismosquito to the non-immune twelve or fourteendays after she had bitten the infected person.

Dr. Henry R. Carter had published a paper oncertain observations of his made during the epi-demic of 1898 in the neighborhood of Jackson,Mississippi. It had long been known to menpractically familiar with yellow fever that, in gen-eral, when you took a patient suffering fromyellow fever into a house where yellow fever had

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not before existed, the people in that house did notat once develop the fever. We explained this bystating that it was due to the fact that the germsof yellow fever went from the patient to favorablegrounds for development about the house, andthere underwent some development which enabledthem to produce the disease in non-immune man.We thought that the dirtier and more unhygienicwere the conditions of the house, the more favor-able were the conditions for the further develop-ment of the germs. Dr. Carter recorded a num-ber of cases where the houses were isolated andthe conditions favorable for making the observa-tions, and found that the average time from theintroduction of a yellow-fever patient into a houseuntil the first case of yellow fever was contractedin that house, was about seventeen days. Theseobservations were published to the world.

Dr. Reed was greatly impressed by this pub-lication of Dr. Carter’s. He reasoned that if itwere the mosquito which transmitted the disease,this period of extrinsic incubation must be due toa period of incubation in the mosquito. He says:

We were also much impressed by the valuableobservations made at Orwood and Taylor, Missis-sippi, during the year 1898 by Surgeon Henry R.Carter, U. S. Marine Hospital Service, “A Note onthe Interval between Infecting and SecondaryCases of Yellow Fever, etc.” (Reprint from New

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Orleans Medical Journal, May, 1900.) We do notbelieve that sufficient importance has been accord-ed these painstaking and valuable data. We ob-serve that the members of the yellow-fever com-mission of the Liverpool School of Tropical Medi-cine, Doctors Surham and Meyers, to whom wehad the pleasure of submitting Carter’s observa-tions, have been equally impressed by their impor-tance. (British Medical Journal, Sept. 8, 1900,pp. 656-70.)

The circumstances under which Carter workedwere favorable for recording with considerableaccuracy the interval between the time of arrivalof infecting cases in isolated farmhouses and theoccurrence of secondary cases in these houses.According to Carter, “the period from the first (in-fecting) case to the first group of cases infectedat these houses, is generally from two to threeweeks.”

The house having now become infected, suscep-tible individuals thereafter visiting the houses fora few hours, fall sick with the disease in the usualperiod of incubation, one to seven days.

Other observations made by us since our arrivalconfirmed Carter’s conclusions, thus pointing, asit seemed to us, to the presence of an intermediatehost, such as the mosquito, which having taken theparasite into the stomach, soon after the entranceof the patient into the non-infected house, wasable, after a certain interval, to reconvey the in-fecting agent to other individuals, thereby con-verting a non-infected house into an “infected”house. This interval would appear to be fromnine to sixteen days (allowing for the period of

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incubation) which agrees fairly closely with thetime required for the passage of the malarial para-site from the stomach of the mosquito to itssalivary glands.

In view of the foregoing observations we con-cluded to test the theory of Finlay on human be-ings.

Dr. Reed had, however, been working for sometime before he came to these conclusions. Hisfirst nine cases bitten between August 11 andAugust 25, were all unsuccessful. The next two,bitten on August 27 and 31, were positive andwere well-marked cases of yellow fever.But Dr. Reed’s work was now brought to a stand-

still. He found that all his Spaniards were de-serting, and that he could get no more for love ormoney to come to the camp. The work from be-ing much sought had become very unpopular.For some time he was unable to find any goodreason for this. The story told in Havana wasthat the American soldiers, who were doing theguard duty for the camp, had found an old limekiln in the lower part of the grounds. In thiskiln they had placed a lot of bleached old bones,and here they would take the newly arrived Span-iard and darkly insinuate that these were thebones of their predecessors in Dr. Reed’s camp,and that if they did not leave before they werebitten by Dr. Reed’s mosquitoes, their bones would

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soon be bleaching in the same place. It was use-less for Dr. Reed to argue and explain. This ocu-lar evidence was too strong for any argument byword of mouth, and Dr. Reed had to give it up.

Our soldiers had seen that the disease was verymild; that the patients while they were in camphad the very best of high living and a mighty goodtime, and when they left, were presented with agratification of two hundred and fifty dollars inshining gold coin. They concluded that this wastoo good for Gallegos, and belonged of right tonatural-born Americans. When the Spaniardshad decamped, our men came forward and volun-teered. Dr. Reed accepted them, and the workwent forward.

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CHAPTER III

THE DISCOVERIES OF THE REED BOARD

DR. REED wished to make his demonstrationsas convincing and spectacular as possible. It

was an entirely new idea, and his conclusions ex-cited a great deal of adverse comment and criti-cism. This theory was so contrary to what mostmen thought had been their practical experiencethat it was received with scant consideration.

He had a small frame house built, fourteen bytwenty feet, well screened-in with wire netting, sothat mosquitoes could not get in or out. Thisbuilding he had divided into two compartments bya partition extending down the center, made ofwire netting, and it was known as the infected mos-quito building. It was well ventilated. Most per-sons at this time believed that in some way the airconveyed yellow fever. Dr. Reed wished to showthat this was not the case.

He put two non-immunes in this building, onein each room. These two men breathed exactly

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the same air, and had exactly the same surround-ings, with one single exception which I will in amoment point out. But they were entirely sepa-rated by the wire netting. He let them live andsleep in these rooms for several days, so as todemonstrate that there was no yellow-fever in-fection in the building. He then put fifteen in-fected stegomyia in one of the rooms; left the manin this room for thirty minutes, announcing thatthe room was now infected. He took the man outof this infected room, but left in the other roomtwo men on the other side of the wire netting. Hestated that the man who had stayed thirty min-utes in the infected room would come down withyellow fever within three or four days, and thatthe other men, who were only separated from himby wire netting, and who breathed and were sur-rounded by exactly the same air, would not getsick.

He explained that the only difference betweenthe two rooms was that in the infected room, in-fection had been brought about by liberating therefifteen stegomyia mosquitoes which had previouslybitten patients sick of yellow fever. The manfrom the infected room was on the afternoon ofthe same day again placed in this room for twentyminutes, and on the following day he was a thirdtime put in the room for fifteen minutes. On thefirst visit he was bitten by seven mosquitoes; on

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the second, by five; on the third, by three. At theend of the fourth (Christmas) day, Reed showedthe man from the infected room down with yellowfever, and the men who had lived and slept in theother room, separated only by wire netting, per-fectly well. He called attention to the fact thatthe only difference in the exposure of these menwas that the sick man had been in a room for thirtyminutes, with fifteen infected stegomyia mos-quitoes. He claimed that this was a demonstra-tion that the female stegomyia mosquito couldtransmit yellow fever, and that the atmospherealone could not. Many of the visitors to Dr.Reed’s camp were clinically familiar with this dis-ease, and the case was sufficiently marked to beeasily recognized by all as being a case of yellowfever.

Dr. Reed then announced that he would disin-fect the room so that it would no longer give yel-low fever. When it was prepared, he again placeda non-immune in each room, left them there forseveral days, and they remained perfectly well.He explained that he disinfected the room by sim-ply catching all the stegomyia mosquitoes whichhe had formerly liberated in the room.

This demonstration made a very profound im-pression. Many, however, still urged that whileit was evident that the female stegomyia mosquitocould convey yellow fever, it was equally evident

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from the history of epidemics of this disease thatit could be and was generally conveyed in otherways, such as soiled clothing, bedding, the bodiesof yellow-fever dead, persons sick of the disease,etc.

Dr. Reed had a small house built, made almostair-tight and with scarcely any ventilation. Thisbuilding was known as the infected-clothing build-ing, and was purposely so constructed as to ex-clude anything like efficient ventilation. It wasplaced on the opposite side of a small valley,about eighty yards from the infected mosquitobuilding, and they were both about seventy-fiveyards distant from the camp proper. Both houseswere provided with wire screen windows anddouble screen doors, so that mosquitoes could bekept without or within the building, as the experi-menter might desire.

In this building he placed material obtainedfrom Las Animas, the yellow-fever hospital of theHealth Department of Havana; mattresses onwhich yellow-fever patients had died, soiled bytheir excreta and discharges; sheets, pillows andpillow-cases stained with black vomit; the pajamaswhich patients had worn at the time of their death.It was Dr. Reed’s desire to have this material in-fected if it were possible to become infected in thisway. Dr. John W. Ross, the superintendent ofLas Animas Hospital, therefore gave the matter

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his personal attention, saw to the packing of thismaterial in chests for transportation to CampLazear, and before the chests were closed, hadbasins of black vomit and other excreta from yel-low-fever patients poured over the contents of thechest. If there were any possibility of suchmaterial becoming infected, infection certainlywould have followed such procedure.

Dr. Reed had this material opened up andspread out in the close room I have described.He called for volunteers to sleep in this room.Dr. R. P. Cook of the Army, and several soldiersquickly responded. These men put on the pajamassoiled as described, and slept on the mattressesand bed clothing soiled beyond description. Fora period of twenty days they spent the nights inthis building, but for the sake of general healthwere allowed to go out during the day. All themen remained perfectly well, and no case of yellowfever was developed from such exposure.

This set of experiments was generally acceptedas proving that yellow fever was conveyed fromman to man by the mosquito alone, and that it wasnot transmitted in any other way. A great manypersons, however, were still skeptical. The exper-imental camp had been named “Lazear” in mem-ory of Dr. Lazear, a member of the Board, whohad died a few months before of yellow fever,contracted while prosecuting this work.

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The Board then took the blood of a yellow-feverpatient in the first three days of his sickness, andinjected it with a hypodermic syringe into a non-immune. He promptly developed yellow fever.This proved that the blood of a patient sufferingfrom this disease could transmit yellow fever with-out passing through the body of the mosquito.From this experiment of injecting the blood di-rectly from one person into another it was arguedthat it might not be a yellow-fever parasite thatwas injected, but a toxin.

The Board then took the blood within the firstthree days of sickness from this second patientwho had been given his disease from the blood ofthe first patient, and injected it into a thirdpatient. This third patient developed the diseaseat the proper time. This experiment demon-strated that the virus so conveyed was capable ofmultiplying; that it was a living germ and notmerely a toxin or chemical body which transmittedthe disease.

The Board then took the blood of a patient col-lected in the first three days of his sickness, andpassed it through a Pasteur filter so fine that itwould stop any particle large enough to be seenwith a microscope of the highest power. Thisblood when injected into a non-immune still gaveyellow fever. This demonstrated that the para-site was sub-microscopic; that is, too small to

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be seen by a microscope of even the highestpower.

They then took the blood of a yellow-feverpatient within the first three days of his disease,heated it to 55° C., and injected it into a non-im-mune. The non-immune did not develop yellowfever. This was repeated three times. Thisexperiment proved that the living parasite in theblood of the yellow-fever patient was killed bybeing raised to a temperature of 55° C.

The conclusions announced by the Board wereas follows:

That yellow fever is conveyed from man to manonly by the bite of the female stegomyia mosquito,and that this mosquito, to become infected, mustsuck the blood of the yellow-fever patient withinthe first three days of his disease.

That after biting the patient, twelve to twentydays must elapse before she herself is able to con-vey the infection. This period is known as theperiod of extrinsic incubation. Extrinsic incuba-tion in Havana was found to be considerablylonger during the cool months of winter than dur-ing the warm period of summer.

That after the non-immune human being hadbeen bitten by the infected stegomyia mosquito,an incubation period of from three to six dayselapsed before the man began to show symptomsof yellow fever. The shortest period of incuba-

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tion in Dr. Reed’s cases was two hours less thanthree days, and the longest period, two hours morethan six days.

That the blood, taken at the proper time andinjected into a non-immune, would also cause yel-low fever; that the disease was caused by a para-site, and that the parasite was sub-microscopic.

These discoveries have been of enormous bene-fit to mankind, and upon them has been based thesanitary work against yellow fever which has beenso successful. At first blush, however, it was notevident to what extent it would be of practical useto us.

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CHAPTER IV

THE SANITARY BOARD OF HAVANA

AT this time, February, 1901, I was health offi-cer of the city of Havana. The efforts of the

Department had been concentrated for more thantwo years previous upon controlling yellow feverin that city. Not only had we met with no success,but yellow fever was actually worse than when wecommenced work. Ample funds and power hadbeen given us by General Wood, the military gov-ernor, and we had by far the best and most efficientsanitary organization of whose existence, eitherbefore or since that time, I have any knowledge.

When the work of the Reed Board began topoint to the mosquito as the conveyor of yellowfever, the Sanitary Department of Havana wasat its wits’ end and was glad to receive this dis-covery as a means of possible help. I, as healthofficer of Havana, had nothing to do with the workof the Reed Board in any way whatever, exceptthat I was a very interested spectator and kept in

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close touch with the work as it developed. Weassisted the Board in every way that we could.All the hospitals in the city were under our con-trol, so that we were enabled to furnish themample clinical material.

Neither the Reed Board nor any of its membershad anything to do with the practical working outof the methods whereby their theory was demon-strated, and by means of which yellow fever wasfinally eliminated from Havana. These methodswere first originated and worked out by the Sani-tary Department of Havana during the year 1901.They have since been copied and successfully ap-plied in many parts of the world where yellowfever formerly prevailed.

Dr. Finlay, in a reprint from the Journal of theAmerican Medical Association, April 19, 1902,says:

The final confirmation of the rôle which apper-tains to the culex mosquito deso (now included inthe genus stegomyia of Theobald) in the trans-mission of yellow fever, has now been sanctionedby the experiments of Drs. Reed, Carroll, Agra-monte and the lamented Dr. Lazear, at Que-mados de Marianao, during the winter of 1900,and afterwards by those of Dr. Guiteras at theExperimental Station of Las Animas, last sum-mer, and finally by the splendid practical resultsobtained by the Chief Sanitary Officer of Havana,Major W. C. Gorgas, during the epidemic year

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which has just been completed. With those factsand the ones which I had gathered in former years,it is now possible to determine with some degreeof precision the conditions which are necessaryin order that yellow fever may develop in an epi-demic form in a given locality, not too highly situ-ated above the sea level and where temperaturesbetween 25° and 35° C. (77° and 95° F.) eithertemporarily or habitually prevail.

Dr. Reed and I discussed on several occasionsthe possibility of making practical application ofhis discoveries. It did not seem to us possible todestroy the adult mosquito in sufficient numbers tobe of any practical use. And we were not suf-ficiently familiar at that time with the life historyof the mosquito to think of any other way in whichthe subject could be approached with a fair pros-pect of success.

We, of the Sanitary Department, after a greatdeal of discussion and thought given to the matter,decided that we should adopt all measures thatseemed likely to be useful, being guided in ourplans principally by the life history of the mos-quito.

After the first two cases—in all some twenty-six—all the Board’s cases had been very light.We concluded, therefore, that our strongest meas-ure would be vaccination; that is, to have an in-fected mosquito bite a non-immune and give him a

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light case. If this proved as successful as hadvaccination in smallpox, we could see that thismeasure alone would entirely protect against yel-low fever, just as had vaccination against small-pox. We consulted the military governor, GeneralWood, on the subject, and he agreed to let us tryit as one of the several preventive measures whichwe were putting into effect against yellow fever.

We announced that we were ready at Las Ani-mas Hospital to immunize against this diseaseanyone who wished to be treated in this way.There was no lack of applicants. This was in Feb-ruary, 1901. Most of the work of the Army Boardhad been done during the preceding fall, and atthis time we had only one infected mosquito left,which had been given us by Dr. Reed. This oldlady was a veteran in every sense. She had givenseveral people yellow fever, but her greatest claimto celebrity was the fact that it had been fifty-seven days between the first case of fever and thelast one which she had given.

The weather is cool in Havana during January,February and March, so that the stegomyia underordinary conditions become quite sluggish in theirmovements and a great many die. Mosquitoes de-crease so much during these months that yellowfever becomes more or less rare, and it was verydifficult for us to infect our mosquitoes. Whilefor one hundred and forty years there had never

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been a single month in which there had not beensome reported case of yellow fever in Havana,still only a very small proportion of these caseswas recognized during the first three days, and itmust be remembered that a mosquito has to bitewithin that period of the disease in man to becameinfected. We were, therefore, keeping our onlyinfected mosquito with a great deal of care andtenderness, knowing that we had to depend uponher to start our vaccination work.

In all Havana there is probably not a singlefireplace or other means of artificial heat, so wesent to the United States and imported an oil-stovewherewith to keep her ladyship’s room always atsummer temperature. Her home was a largeglass jar on a table in the center of a sunshinyroom. In this jar was hung a lump of white sugaron which she fed when hungry, and to this wasadded now and then a small piece of banana. Asmall vessel containing water was also kept in thejar. In order that she might have a plentiful sup-ply of fresh air, the glass top was not placed uponthe jar, but a sleeve of mosquito-netting was tiedover its top.Within the last fifteen years a great deal of

study has been given to mosquito life. It is nowknown that there are some seven hundred differentspecies of mosquitoes; that in all species of mos-quitoes the natural food is the various vegetable

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juices. In all species the female has to have afeed of blood before she can lay eggs. Blood doesnot seem to be necessary for life, but merely stim-ulates the function of ovulation. In order thatthe female may get this blood, she is furnishedwith biting apparatus not possessed by the male.The male never bites, not being physically able todo so. The female stegomyia, therefore, is aloneconcerned in the transmission of yellow fever.

Las Animas Hospital being the yellow-feverhospital for the city of Havana was a center ofattraction for most of the doctors of the HealthDepartment. Dr. John W. Ross, Dr. John Gui-teras and myself were at this hospital almostevery day. Dr. Guiteras had charge of the vac-cination work and of the laboratory where themosquitoes for this work were being bred. Ourlady mosquito was therefore directly under hischarge. She had given so many people yellowfever and was therefore so valuable for our pros-pective work that we all when at the hospitalwould drop in to see how she was coming alongand to pay our respects.

One morning about daylight I got a messagestating that her ladyship was in a most critical anddesperate plight, as some time during the nightshe had gotten her wing caught in a mesh of themosquito netting, and had struggled to free her-self for so long a time that when she was discov-

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ered by the attendant in the morning, she was al-most dead. I rapidly dressed and hurried to thehospital. Similar messages had been sent to Dr.Ross and Dr. Guiteras. We found her conditioneven worse than had been represented. Two orthree of the doctors on the staff of the hospital hadbeen promptly called in, and the services of sev-eral of our trained nurses had been likewise ob-tained. Her wing had been gently liberated fromthe mesh of the netting, and her ladyship laid upona soft bed of cotton batting. The oil-stove wasstarted up, and the room brought to a very hotsummer temperature, but it was all of no avail.She finally ceased to kick about nine o’clock in themorning, and died with a larger attendance of doc-tors and nurses around her table than had everbeen present around the deathbed of any merehuman in the city of Havana.

This account may sound somewhat exaggerated,but the scene still comes back to my mind’s eyevery vividly, how earnest and serious we all were.A half-dozen of the leading practitioners ofHavana were sitting around the deathbed of thismosquito, looking and feeling exceedingly mourn-ful and depressed. And it was a very heavy blowto the Health Department of Havana. It was wellon into the summer, the month of July, beforewe succeeded in getting another infected mosquito,and in proceeding with our vaccination work.

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Finally, we succeeded in infecting several mos-quitoes, and bit with these mosquitoes sixteen per-sons, of whom eight developed the disease.

Much to our alarm, several of these cases de-veloped very violent symptoms, much more so thanhad occurred in any of the cases of the ArmyBoard, with the exception of Lazear and Carroll.Three of these eight positive cases vaccinated byDr. Guiteras died; one of those who died was aMiss Maas, a trained nurse from the UnitedStates, who requested to be allowed to get im-munity in this way. Why our cases should havebeen so severe, and all of the cases of the Boardso mild, no one has attempted to explain. It is afact that during the hot summer weather the ex-trinsic period of incubation in the mosquito, thatis, the time after which the mosquito bites the mansick with yellow fever until she herself is able toconvey the disease, is considerably shorter thanthe same period during the cool winter months,this period in the summer months being fromtwelve to fourteen days, and in the winter months,from fifteen to twenty days. I am inclined tothink that there is probably the same difference inthe virulence of the infection developed by themosquito in the hot summer months, and in thecool winter months.

This experience demonstrated to us most for-cibly that vaccination could not take any prom-

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inent part in our preventive measures againstyellow fever. While Dr. Guiteras was going onwith his preparatory work at Las Animas andgetting ready for his vaccinations, he invited tothe hospital some fifteen or twenty members ofthe International Sanitary Congress who had ex-pressed themselves as being particularly skepticalwith regard to the mosquito theory of the trans-mission of yellow fever. This Congress assembledin Havana during the month of February, 1902.The laboratory at Las Animas was the room I havejust described as being the home of the mosquitoknown as “Her Ladyship.” It was carefullyscreened with wire netting at all the windows, andthe single door was protected by a vestibule whichitself had double doors. This vestibule was builtupon a platform some four feet above the groundand just outside the door of the laboratory. Thevisitors pretty well filled the small room. Dr.Guiteras started at one end of his laboratory, ex-plaining that in this jar he had the eggs of thestegomyia mosquito, and invited his visitors toexamine them; in the next jar, the larvæ; in thenext, the pupae; in the next, the young mosquitojust born, and in the last jar, the mosquitoes whichhad passed their period of extrinsic incubation andwere now ready to convey yellow fever.While handling this jar, the sleeve of mosquito-

netting accidentally slipped off, and a dozen or48

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more mosquitoes soared toward the ceiling of theroom. Our visitors stood for a moment dum-founded, open-mouthed and wide-eyed. Then eachone of the twenty, at the same moment, made arush for the door. The vestibule was small andwould hold only about four persons, so that thepressure from behind toppled it over onto theground four feet below, and in a moment, therewere some twenty gentlemen in a pile on theground struggling to get as far as possible fromthese deadly lady mosquitoes.

Dr. Guiteras afterwards assured us that hismosquitoes had never bitten a sick man and werenot infected; that he was only demonstrating theprocesses of mosquito-breeding and infection thatwould have to be carried out in the vaccinationprocess. Our visitors laughingly acknowledgedthat, at any rate, their subconscious selves hadbeen convinced of the correctness of the theory ofthe mosquito transmission of yellow fever.

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CHAPTER V

SANITARY WORK AT HAVANA

THE Army Board had demonstrated that themosquito, to become infected, had always to

bite some patient with yellow fever within the firstthree days of his disease. It was evident, there-fore, that if we could prevent this being done inevery case of yellow fever in Havana, the diseasewould disappear. This measure alone would besufficient for eliminating yellow fever.

To accomplish this we required all cases of yel-low fever in the city to be reported to the centraloffice of the Health Department. They were atonce seen by the official diagnosis commission, andif pronounced yellow fever, were at once movedto Las Animas Hospital in a carefully screenedambulance and placed in screened wards. Theroutine at Las Animas Hospital precluded thepossibility of any mosquitoes biting the patient.Most of the Americans, and in fact patients of allclasses, preferred to go to Las Animas. Under

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Dr. Ross’s care the hospital soon obtained thereputation of saving more yellow-fever patientsthan could be done at the other hospitals, or attheir homes. This reputation was justly acquired.The statistics of this hospital amply bore out thereputation which public opinion gave it. If thepatient elected, he could stay in his own home,the room or rooms to be screened were agreedupon, a skilled force of carpenters were sent bythe central sanitary office, who thoroughly andcarefully screened the designated apartments.Only one point of exit and entrance was left, andthis was protected by a vestibule and double door.A number of squads of carpenters, each furnishedwith its own wagon loaded with the necessary wirenetting, lumber, and other material, were alwayson duty, so that usually within an hour afternotice came to the central office night or day, thepatient was either removed to the hospital or wasbeing screened at his own home.

To see that sanitary regulations were carriedout and that only authorized persons were ad-mitted within the screened quarters of the patient,an officer of the Sanitary Department was alwayson duty. He sat in the vestibule and requiredthat one door should be closed always before thesecond was opened. He was changed every eighthours, that is, he was on duty only eight hoursin each twenty-four. We soon found that this

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method could not be carried out in its entirety;that it was the exception that we could get hold ofa patient during his initial chill. Generally thepatient had been sick one or two days before hecame under our observation.

It was evident, therefore, that a number ofmosquitoes might have bitten him before he wasdiscovered and cared for. As it would be twelveor fourteen days before these mosquitoes wouldbecome infectious, we had plenty of time to attendto them. From the known habits of the stego-myia mosquito we did not think they would leavethe house in which they had become infected,though in an individual case this might occur, anda mosquito wander into a contiguous house.To meet this condition of affairs, as soon as the

case was concluded, the house in which the patienthad been sick and all the contiguous houses werefumigated with such material as would kill themosquitoes. In order that the fumigation mightbe effective the house had to be carefully goneover and all cracks and crevices stopped, so as tomake the building as nearly air-tight as in thenature of things it could be made. This was avery laborious process and required care andexpert supervision. Most of the stopping ofcrevices was done with paper and paste. Sulphuris probably the most effective substance in killingthe mosquito. The rolled sulphur was used at

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Stegomyia Squad. Havana.

Screened Water Barrel. Havana.

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the rate of about a pound to the thousand cubicfeet of space to be fumigated. We generally usedthe Dutch oven placed in a box of sand or vesselof water, so that in case of a leak, or in case of theoven’s getting too hot, the floor would not catchon fire. With a large force of ignorant men en-gaged in this work constant watchfulness has tobe used to see that fires do not occur. The properamount of sulphur is placed in the Dutch oven, alittle alcohol poured over the sulphur, and a matchapplied. The sulphur will burn for three or fourhours, and will produce very dense fumes whichwill fill the building and kill all the mosquitoes.The fumes of sulphur in a building which has beenwell prepared will kill not only all mosquitoes,but all insect and animal life, and is by far the bestmaterial to use for this purpose. It is generallysomewhat difficult to start the sulphur burningwith alcohol alone, and I have noticed that themen got in the habit of using an ounce or two ofpyrethrum placed on top of the sulphur for thepurpose of starting the fire. The pyrethrum wasmoistened with the alcohol and would burn for aconsiderable time after the alcohol was consumed,in almost every instance starting the sulphurburning.

The fumes of sulphur will tarnish gilt metalsof all kinds, and injure most light-colored fabrics.This occurs particularly where the air is heavily

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charged with moisture. In cases in which sulphurwas likely to do damage, we used pyrethrum pow-der. This powder does not tarnish or injurefabrics of any kind. The building must be pre-pared in the same way as for sulphur, and the ves-sel in which the pyrethrum is burned must be ar-ranged as above described for sulphur. Thefumes of pyrethrum do not generally kill the mos-quito, but simply intoxicate her. In the courseof time she revives and eventually entirely re-covers. For this reason the building should beopened up within a couple of hours after the burn-ing of the pyrethrum, and all mosquitoes carefullygathered and burned.

In almost all dwellings of the better class oftenants there are fixtures and fabrics which willbe injured by the fumes of sulphur. Therefore,in this class of buildings we generally used py-rethrum. For fumigating in this same class ofbuildings where pyrethrum was used we found amixture of camphor and carbolic acid, one part ofcamphor to three of carbolic acid, very useful.This should be placed in a tin dish and vaporizedwith a spirit lamp. The same procedure shouldbe observed as a precaution against fire as is takenwith sulphur. The mixture when vaporized givesoff dense white fumes which kill the mosquito.Generally, where care has to be taken for fear ofinjuring fixtures and fabrics, this mixture is

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preferable to pyrethrum. Pyrethrum should beused at the rate of one pound to the thousandcubic feet, and the camphor mixture at the rateof an ounce for the same space.

In Havana we had to deal with cigar manufac-tories and tobacco storehouses on a large scale.Here we could use neither sulphur, pyrethrum, northe camphor mixture, as they all affected the deli-cate flavor of the tobacco. At first we used tomove all tobacco out of a building to be fumigated.This was very laborious and added largely to thecost of fumigation and also tended to drive outfrom the building the infected mosquitoes beforethey had been reached by fumigation. Mr. Jos-eph Le Prince, who was in charge of this work,after much experimenting found that the fumesfrom tobacco stems did not hurt the flavor of to-bacco, and were almost as deadly to the mosquitoas was sulphur. We could therefore fumigatewith this material buildings where tobacco wasstored without injury to the tobacco. The stemswere a waste product in cigar manufacturing, andcould be obtained in large quantities at little cost.They should be used at the rate of two poundsto the thousand cubic feet, and with the same pre-cautions against fire as are taken in other cases.

Formalin we found useless. It has apparentlylittle effect upon insect life.

From our general knowledge of the life history55

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of all species of mosquitoes, we knew they had tospend eight or nine days in a larval stage, andthat while in this larval stage they lived in water.Therefore, collections of water were necessaryfor the development of the mosquito. The stego-myia mosquito we knew preferred clear, cleanwater, such as is supplied by the various collec-tions of rain water needed for domestic purposes.The city of Havana had pipe water over only asmall portion of its area. By far the larger por-tion of the population obtained its water supplyfrom rain water stored in cisterns, tanks and re-ceptacles of all kinds. We resolved to stop mos-quito-breeding in all such places.

The city was divided into twenty inspection dis-tricts, each district under the charge of a sanitaryinspector. This inspector was required to getaround to each house in his district once a monthand make a careful inspection with regard to mos-quito-breeding, and report to the central officeon a printed blank the conditions found. If thisreport indicated that the condition of the premisesamounted to a sanitary nuisance, the householderwas proceeded against. An order had beenpromulgated making it a sanitary nuisance forany householder to have mosquito larvæ on hispremises. The health officer was given authorityto impose a fine for such nuisance; the fine was col-lected by the Cuban courts, and the proceeds of

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the fine deposited in the Cuban treasury. Thehealth officer had authority to remit the fine at anystage of the proceedings. In practice, it cameabout that the whole matter was settled in theSanitary Department. We employed a lawyer towhom cases of fines were referred. When ahouseholder was reported by the sanitary inspec-tor as having larvæ on his premises, he was noti-fied that under the sanitary ordinance he was finedfive dollars for having this nuisance on his prem-ises, but that if the nuisance were abated, the finewould be remitted. This usually brought the manpromptly to the office with the statement that thenuisance had been abated. An inspector was sentaround, and if the householder’s statement wasfound to be correct, the fine was remitted.

In a certain number of cases this notice causedno action on the part of the householder. In thesecases the fine was sent to the judge of the districtfor collection by him. In the few cases in whichthe first notice had not brought the householder toterms, this action by the court did. If he reportedthat he had abated the nuisance and the inspectorwhen sent to investigate found this to be the case,the fine was withdrawn. In this way we did verylittle fining. Out of about twenty-five hundredfines levied in the last nine months of 1901, onlyfifty were finally imposed and deposited in thetreasury.

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The Sanitary Department was said to be de-cidedly the most popular of the American depart-ments with the Cubans, and it was this very powerof assessing and remitting fines that was the prin-cipal cause of our popularity. The Cuban hadbeen accustomed to looking upon laws and ordi-nances as devices for filling the pockets of theofficials, and fines as the legitimate perquisites ofthose officials. When a fine was remitted, helooked upon it as a personal present from thepocket of the chief sanitary officer to himself, andwas grateful accordingly. Why the chief sani-tary officer should take so great an interest in mos-quito larvæ he could not comprehend. But thatofficer evidently did take a most decided interestin the matter, and had he not demonstrated hisfriendship by taking five dollars, which was asgood as in his pocket, and giving it to him, theoffender? His loyalty was appealed to and gen-erally he remained ever afterwards the friend oftheDepartment.Cisterns, barrels and receptacles for containing

and storing rain water for drinking and domesticpurposes were absolutely necessary in the case ofthe larger part of the population. It was neces-sary that we prepare these receptacles so thatthey could not breed mosquitoes. If it were ar-ranged so that mosquitoes could not lay their eggson the surface of the water, this object would be

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accomplished. It was therefore provided that allreceptacles should be covered in such a mannerthat mosquitoes could not have access to them.The tops were covered, a small hole being left inthe top by means of which water could enter. Thishole was covered with wire netting, and a spigotwas placed in the bottom whereby the water couldbe drawn off. This was done at public expense.At the central office squads of carpenters withmaterial loaded in wagons were always on handto go out for this work. If the sanitary inspectorreported that such work was necessary, it was im-mediately attended to by one of these squads.

For carrying into execution the orders pertain-ing to mosquito work the city was divided intoeight districts, each district in charge of a mos-quito inspector. A great deal of stegomyia breed-ing went on in the interior of the dwellings. Everyfamily had an earthen vessel in which drinking-water was kept for daily use. This always hadlarvæ in it. It was the inspector’s duty to emptythis vessel, point out the larvæ to the housekeeper,and explain that if the vessel were emptied oncea day and the larvæ washed out, mosquito develop-ment could not occur. All sorts of vessels in ahouse which might contain water had to be con-sidered as possible breeding-places for mos-quitoes. Every housekeeper in Havana, when westarted work there, had a number of breeding-

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places for mosquitoes in her domestic establish-ment. Among these may be mentioned flower-potsin which a little too much water had been used;cans filled with water, in which the legs of tableshad been placed as a protection against ants,etc.

Each mosquito inspector had with him five men,and one of these men carried a sufficient amount ofoil to pour upon any pools or puddles about thepremises that might need oiling. They picked upold bottles and cans which might contain waterand become breeding-places, and generally lookedafter the yards. The district inspector, at thesame time, made a general report on the premisesin writing, and on this report the owner was calledto account if unsanitary conditions were foundexisting.

Next to cisterns and water barrels, roof gutterswere found to be the most general breeding-placesfor the stegomyia mosquitoes. Leaves and trashfall upon the roofs, are washed into the gutters,and these make little dams behind which watercollects and remains after the rain has ceased.At other times the gutter sags and thus forms acollection of water. In the tropics you can alwayscount upon roof gutters as being places for mos-quito-breeding, and being inaccessible and difficultto inspect, such breeding-places are seldom dis-turbed.

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During its larval stage the mosquito lives en-tirely in water, but has to come to the surfacefrequently for the purpose of getting air. Thisnecessity is seized upon by man for the purpose ofdestroying the larvæ. If kerosene oil is pouredupon the water, it spreads in a very thin film overthe surface. Now when the larvæ rise to breathe,the oil gets into their breathing-tubes when theyattempt to force them through the thin film of oilspread over the surface of the water. This suffo-cates and kills the insect and is very effective.

It is very surprising and impressive to see howrapidly such a system will free a city of mos-quitoes, and how after a few months of such workyou cease to be annoyed by them. In yellow-feverwork this system of destroying mosquito larvæ isthe essential; everything else is secondary to it.In the built-up portions of a city such as Havana,caring for the cisterns, water barrels and con-tainers is the essential work, but as you ap-proach the suburbs, pools and puddles becomemore frequent, and this character of mosquitobreeding-places becomes more important than con-tainers. Wherever possible these breeding-placesshould be drained, though oiling in this class ofwork has a very useful field. In the suburbs, inthese pools and puddles, the anopheles, themalarial mosquito, becomes common and this dis-ease has to be looked after. We had fifty men

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engaged in this work, under a different set ofinspectors from those doing the stegomyia work.This was made necessary, as the men doing theanopheles work were occupied almost entirely inthe suburbs of the city. The details I will describein another place.

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CHAPTER VI

THE RESULTS ACCOMPLISHED IN HAVANA

FROM the account already given of yellow feverit is evident that the parasite has to be intro-

duced into a locality, either in the body of a humanbeing sick of yellow fever, or in the body of a fe-male stegomyia mosquito which has become in-fected by the parasite. It is evident that if thehealth authorities can keep out these two sourcesof infection, yellow fever can never occur in thatlocality.

With this object in view we established a mod-ern quarantine at Havana. Any ship coming inwith yellow fever aboard was placed in quarantine.The vessel itself was fumigated so as to kill allthe mosquitoes. This rendered the ship safe.All the non-immune crew were taken off, carriedto quarantine station, where they were cared forduring a period of six days. If no sickness de-veloped during this period, it was concluded thatthe infected mosquitoes aboard the ship had not

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bitten these non-immunes up to the time of theirdeparture. They were therefore released and al-lowed to return. The immunes were not consid-ered liable to yellow fever, even if they had beenbitten by the infected mosquitoes.

One attack of yellow fever gives such greatprotection that, in practice, a man who can provethat he has once had the disease is looked uponas entirely safe. But of course he has to provethis to the satisfaction of the quarantine physician.It is considered so certain that everyone exposedto yellow fever will have the disease that proofthat a man has lived in an endemic center for tenyears is accepted as proof of his immunity. Noquarantine is, however, absolute in any disease,in any locality, or carried out by any authority.Some people now and then will pass the quaran-tine who are either so slightly sick that the dis-ease is not recognized, or who developed thedisease after they had been released from quar-antine. But a quarantine greatly lessens thenumber of times and the frequency with whichinfection is introduced into a locality.

For some reason yellow fever, in the minds ofpeople generally, is covered with a cloak of mys-tery. In communities where it prevails there arehundreds of remedies and courses of treatmentthat are vaunted as being infallible cures, and themore ignorant and uneducated the possessors of

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these specifics, the more readily they seem to beaccepted by the people generally. But yellowfever, like every other acute disease, has its ownnatural history, and man at present knows noremedy that can shorten or change its course.Many a time I have found myself completelyrouted in cases of yellow fever by the oldnegro mammy, who would insist that if the pa-tient would take orange-leaf tea and adopt cer-tain other procedures which she advocated, thepatient would certainly get well. Now, on theaverage with severe yellow fever, seventy-five percent. will recover and twenty-five per cent. willdie. The negro mammy did not know this, butwas firmly convinced that it was the orange-leaftea which caused the recovery in the cases ofthose who recovered, and some departure fromher directions that caused death in the case ofthose who died. She believed that if her routinehad been carried out in the fatal cases, theywould have recovered. I must confess, however,that in my experience the measures generallyadvocated by the negro mammy did little or noharm, and in looking back over a yellow-fever ex-perience of thirty years, I cannot by any meansmake so strong a statement with regard to myprofessional brethren.

One of the most general superstitions with re-gard to yellow fever was that all air must be kept

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from the patient. With this in view, the room inwhich the patient was treated was kept closed andentirely dark. No water for washing the face andhands, no change of body or bed clothing was al-lowed during the course of the disease. The con-ditions, therefore, as to filth when a patient hadbeen ill five or six days can be better imaginedthan described.

I was once called into consultation by a medicalfriend of very high standing in one of the bestand most aristocratic Havanese families. Thepatient was a young American teacher who hadbeen brought to Havana a few months before inconnection with the education of a large family ofchildren. She had been sick with yellow feversome five or six days when I saw her, and I recog-nized without much examination that she wasfatally ill and had but a few hours to live. HerCuban friends were devoted to her, and were will-ing to do anything for her comfort and recoverythat their wealth could command. As is generallythe case in yellow fever, her mental faculties wereperfectly clear, and her physical strength good,although she died within six hours after I sawher. She was delighted to see me, and begged meearnestly to induce her friends to let her batheher face and hands and have clean clothing; forneither of these luxuries had been granted hersince she was taken sick. I urged my medical

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friend who had called me into the case to allow thepoor girl to have these things, and I knew thathe agreed with me that they could do no possibleharm. He said that he would try, but that prob-ably the only result would be that he would losethe confidence of the family and do the poor girlno good. We both urged this upon the family,but so strong was their belief that such a measurewould deprive their friend of such little chanceof recovery as was left that they would not con-sent.

In times of stress and danger such as comeabout as the result of an epidemic of yellow fever,many tragic and cruel phases of human nature arebrought out, as well as many brave and unselfishones. Some tragedies stand out prominently inmy recollection.

When yellow fever was at its height in Havana,our chief commissary, an officer of the regularArmy, was taken sick and his disease was soonrecognized as being yellow fever. His wife hadleft Havana a few weeks before to make a shortvisit to her home in Cincinnati. I had promisedthat if my friend should get yellow fever, I wouldcable his wife. I did so, and the wife received thecable while at a dinner-party. She started forHavana at once and reached Las Animas Hos-pital a day or two before the Major, her husband.died. The tie between husband and wife was un-

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usually strong, and as she was assured that hopewas departing, her grief was very great. Thiswas before we knew that the mosquito alone couldconvey the disease, and when we had some generalidea that it was infectious, and in some way con-tracted by contact with fomites, and with thosewho were sick of the disease.

The wife as she saw death approaching de-termined, if possible, herself to contract the dreaddisease. I heard her appeal to her husband inmost moving terms not to die and leave her alone.She was with her husband at the moment of hisdeath, and held him in her arms at the time. Onewho is familiar with a deathbed scene from yellowfever can appreciate what this means. It is a verygruesome death, and the young wife was coveredwith “vomito negro.”

I felt myself more or less responsible, andthought that she was going into the jaws of deathby this kind of exposure. I therefore called forthe assistance of one of the nurses, and used someforce in getting her into the next room. She atfirst reproached me, but as soon as we got herinto the adjoining room she seemed at once to re-gain her mental balance, spoke rationally to Mrs.Gorgas, and asked me to arrange the details sothat she could take her husband’s body with herwhen she sailed on the next vessel for the UnitedStates.

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Mrs. Gorgas and I walked with her to her roomand gave certain directions with regard to hercare and comfort for the night. She asked me fora sleeping dose which she might take in case shewas unable to sleep. I recollect that I put thisup in such quantity that she could not hurt her-self even if she took it all. The rooms were sep-arated by very thin wooden partitions, and sheasked about the location of persons in the adjoin-ing rooms.

About two a. m. Mrs. Gorgas and I went to ourquarters. We had been home just a short timewhen I was aroused by a hurried step and a knockat the door. I found it was a messenger summon-ing me to the hospital, with the information thatthe lady had killed herself.When the door of her room was forced, we

entered and found our friend apparently in apeaceful, quiet sleep. One arm had droppednaturally to the side, and the right arm was lyingacross the chest, the hand still holding the pistolwith which she had killed herself. The appear-ance was exactly that of a piece of marble. Shehad shot herself behind the ear, and the hemor-rhage had been so sharp that the body was en-tirely blanched. From where we stood the hemor-rhage did not show. She had concealed a pistolin her trunk which she had procured in the UnitedStates at the time she started for Havana. She

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had placed fresh clothing on a chair by the bed-side, apparently with the intention of being robedin it after death.

In looking back I could see various things in heractions and conversation that indicated the inten-tion of taking her life. At other times she hadentirely forgotten this, and was preparing for hersad future in this life. She had apparently beendazed by her grief and was temporarily un-balanced, unable for any length of time to followin her mind any definite plan of action.

The Major having been our chief commissaryand a man with whom we were in daily contact,this tragedy profoundly affected the military com-munity. The next day we took husband and wifeout to the little military cemetery at Camp Colum-bia where the American troops were cantoned,some five miles from Havana, and laid them to restin the presence of a large concourse, military andcivil.

While there, a member of the CommandingGeneral’s staff, Captain Page, had a chill, returnedhome sick, developed a severe case of yellow feverand died within a week. This was looked upon byall the community as evidence that the diseasehad been contracted by contagion from the Cap-tain’s having attended the funeral.

From the table on page 71 it will be seen thatfor ten years preceding our occupation of Havana

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DEATHS FROM YELLOW FEVER IN THE CITY OF HAVANAYears 1856 1857 1858 1859 1860 1861 1862 1863 1864 1865 1866 1867 1868 1869 1870 1871 1872 1873 1874 1875 1876 1877 1878

MonthsJanuary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 20 32 7 16 24 8 26February . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 13 23 4 16 24 9 13March . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 4 27 18 32 29 11 5April . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 4 37 22 34 33 8 28May . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 13 127 85 32 103 16 53June. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 68 378 172 142 292 143 184July . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 68 416 361 187 675 249 504August . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 70 127 416 144 250 285 374September . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 59 35 186 102 97 234 179October. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 38 28 91 109 42 185 106November . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 85 5 42 105 31 150 53December . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 73 9 21 82 19 76 34

Total . . 1309 2058 1396 1193 439 1020 1386 550 555 238 51 591 290 1000 572 991 515 1244 1425 1001 1619 1374 1559

Years 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901Months

January . . 11 16 7 9 14 26 4 4 5 8 17 10 10 15 15 7 15 10 69 7 1 8 7February . 13 9 3 11 9 16 3 0 6 8 5 4 3 10 6 4 4 7 24 1 0 9 5March . . . . 6 20 3 14 21 5 1 0 8 14 5 4 4 1 4 2 2 3 30 2 1 4 1April . . . . . 13 44 6 18 34 32 2 1 22 24 8 13 5 8 8 4 6 14 71 1 2 0 0May . . . . . . 40 40 6 84 75 55 3 1 84 26 17 23 7 7 23 16 10 27 88 4 0 2 0June. . . . . . 237 50 37 176 162 66 4 14 128 36 37 38 41 13 69 31 16 46 174 3 1 8 0July . . . . . . 475 179 90 195 177 131 13 33 102 74 48 67 66 27 118 77 88 116 168 16 2 30 1August . . . 417 48 127 73 148 97 34 39 73 113 73 60 66 67 100 73 120 262 102 16 13 49 2September 148 75 94 56 50 41 32 37 36 63 37 33 65 70 68 76 135 166 56 34 18 52 2October. . . 44 32 39 33 72 24 41 16 33 48 21 32 48 54 46 40 102 240 42 26 25 74 0November 31 21 38 36 45 8 22 13 20 33 21 15 24 52 28 23 35 244 26 13 18 54 0December 9 11 35 24 42 7 6 9 15 21 14 9 17 33 11 29 20 147 8 13 22 20 0

Total . . 1444 645 485 729 849 511 165 167 532 468 303 308 356 357 496 382 553 1282 858 136 103 310 18

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there had been an average of more than five hun-dred deaths per year from this disease in the city;that in 1900, two years after we had taken posses-sion of the city there were 310 deaths from yellowfever. A further search of the mortality statisticsshows that yellow fever had existed in Havanacontinuously from the year 1762. This was theyear during which Havana was besieged and cap-tured by the English forces. The troops werelargely made up of colonials from the NorthAmerican colonies, and they suffered severelyfrom yellow fever. For two hundred years beforethis time Havana had been subject to epidemicsof yellow fever, but from 1762 up to the year 1901,there was probably not a single day when Havanadid not have a case of this disease within itsbounds.

In February, 1901, the measures above de-scribed were begun. Under these measures yellowfever rapidly disappeared, and in September ofthat year, the last case of yellow fever occurred.With one exception there has been no case of thisdisease in Havana since that date.

The work directed against mosquitoes had anequally good effect upon malaria. While the workdone with the view of getting rid of the stegomyiawas effective to a certain extent against the anoph-eles, the principal anti-anopheles work wasexecuted in the suburbs of the city. It is a gen-

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eral rule that malaria does not occur in the heartof a city, but generally in its outlying districts.The reasons for this will become evident when Idescribe anti-malarial work in one of our futurechapters.

Deaths From Malaria in the City of HavanaYear No. Year No. Year No. Year No.1871 262 1882 223 1893 246 1904 441872 316 1883 183 1894 201 1905 321873 329 1884 196 1895 206 1906 261874 288 1885 101 1986 450 1907 231875 284 1886 135 1897 811 1908 191876 334 1887 269 1898 1907 1909 61877 422 1888 208 1899 909 1910 151878 453 1889 228 1900 325 1911 121879 343 1890 256 1901 151 1912 41880 384 1891 292 1902 771881 251 1892 286 1903 51

It will be seen from this table that before theyear 1901 Havana had yearly from 300 to 500deaths from malaria, rising as high in 1898 as1,900 deaths. Since 1901 there has been a steadydecrease in the malarial death rate until the lastyear of the table, 1912, when there were only fourdeaths. Four deaths from malaria in a city ofthe size of Havana, about 300,000 population,means the extinction of malaria in that city. Forthe island of Cuba is in the tropics, and there aremany malarious localities through the country dis-tricts. Havana is the metropolis of Cuba, and hasin its environs the largest and best equipped hos-

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pitals of the country, as well as the most dis-tinguished surgeons and physicians. The sick,therefore, are brought from the country in consid-erable numbers, and a great many cases of malariaare brought in among these outside sick. Thetables quoted above include all persons who diedwithin the limits of the city of Havana, whetherthey came from the outside, or were residents ofthe city; whether they died in the large hospitalsof the city, or in private houses.

Four deaths in one year from malaria can verysafely be put down as coming from the outside,and it can with equal safety be said that by 1912,malaria had become as completely extinguishedin Havana, as had yellow fever in 1902.

The extinction of malaria, however, did not at-tract anything like the attention that the extinc-tion of yellow fever had aroused. The work ofDr. Ronald Ross and his co-workers with theanopheles mosquito, and of Reed and his asso-ciates with the stegomyia, undoubtedly gave theknowledge whereby the practical extinction ofmalaria and yellow fever was accomplished atHavana, but the accomplishment of this work withregard to yellow fever was the event which at-tracted the greatest attention. It seems almostprovidential that we had all the machinery at handwhereby the discoveries of the Reed Board couldbe immediately tested and demonstrated. Here

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was a large city of 250,000 inhabitants in whichyellow fever had been endemic for one hundredand fifty years. The American Army had been incontrol of the city for two years, and the HealthDepartment was thoroughly organized andequipped and under the charge of a medical officerof the regular Army. Dr. Reed himself wasstrongly impressed with the advantage it had beento him to have his discoveries given so thoroughand conspicuous a test, and wrote me to that effectmany times.

There has been a great deal of discussion as towho deserves the credit for this great discovery.Undoubtedly Reed and his Board brought all thethreads together and actually made the great dis-covery, but Finlay, Sternberg, Carter and others,started the spinning of many of these threads.Like all great discoveries everywhere it was grad-ually led up to by many workers.Nothing is more true than the following quota-

tion from one of Huber’s papers:

And let me premise here, that in science at least,great names are landmarks; and the owners ofthese names have traversed and gleaned in fieldswhere many a devoted laborer had delved andsown, and pathetically sweated blood in his al-truistic zeal. In science at least no man works invain. Full many an one, worthy of an elegy, hasgiven his whole life to establishing a fact, or in-

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deed only an item to a fact; his work unrealized,ridicule and even persecution ofttimes his onlycompensation, throughout perhaps in the meanestdestitution, yet his life and his work have beenabsolutely essential to the building of a mightyfabric. Martyrs have been many among such—dying from the diseases from which they soughtto defend others; knowing, too, full well, whattheir own fate would be. Nor does it in any wisedetract from the gratitude due the great man thathe has profited by the labors of others, addingwhat he can of his own, scrutinizing every detail,every datum, permeating and illuminating withhis own genius, cementing the mass with his owndeductions.

And from Flexner:

Remarkable achievements are never unique oc-currences in nature. Even the greatest men reston the shoulders of a multitude of smaller oneswho have preceded them; and epochal discoveriesemerge out of a period of intellectual restlessnessthat affects many minds.

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CHAPTER VII

CORRESPONDENCE WITH DR. REED

AS illustrating the way in which we looked atconditions at Havana at the time that our

mosquito work was first begun, I will quote cor-respondence which took place between Dr. Reedand myself at this time.

(1)War Department, Surgeon General’s Office,

Army Medical Museum and Library,Washington, May 16, 1901.

My dear Gorgas:Briefly speaking, how is the yellow-fever situa-

tion in Havana? I got your report for April andnoted, with much pleasure and satisfaction, yourenthusiasm in tackling C. fasciatus and her numer-ous cousins. Later, I think on May 4th, I read of“a serious outbreak” in your town, to the extent oftwo cases. Since then I have heard nothing con-cerning the progress of your epidemic. How manycases have you at the present writing, and what

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are your prospects of prognostications for thefuture? I ask for this information particularlybecause Dr. Durham, of the English Commission,in a letter recently received, has proposed to joinus in Cuba for the purpose of trying to reconcilehis work, or rather the results of his work, atPara, Brazil, with our observations at Quemados,and as he will reach here during the last week inMay, it is barely within the bounds of possibilitythat you may again see us back in our old hauntsby July 1st. Everything will depend upon Dr.Sternberg’s decision. . . . As much as I should liketo see you and other friends, I would prefer tospend the summer in the United States. I hearthat my friend, Kean, has been promoted to bethe head of Charities and Correction for theIsland. Who, then, is Post Surgeon at ColumbiaBarracks? How does Dr. Guiteras succeed at hispropagating station? I trust that your own andMrs. Gorgas’ health is very good. Please remem-ber me very kindly to the latter and to Col. HavardandGlennan.

Sincerely yours,Walter Reed.

(2)Havana, Cuba, May 22, 1901.

My dear Reed:Yours of the 16th received. I wrote you a day

or two ago, but I have forgotten whether or notI answered your question.

The fever situation is all that could be desired,I think. The last death from yellow fever oc-

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curred on March 13th. Since that time we have hada case April 21st; another on April 22d. We hadno more cases then till May 6th, when we had one;and on May 7th, three more. Since that time, twoweeks, we have had no more; and as the conditions,as far as non-immunes are concerned, seem morefavorable for the spread of yellow fever, I am inhigh fettle.

I am inclined to attribute our freedom to theway in which we killed the mosquitoes. We havefifty men at this work, oiling and draining smallcollections of water in every house and puttingoil in all the sinks and closets so that it will rundown into the cesspools. During the winter andcool periods of the year, up to this time say, thecesspools are the great places for breeding mos-quitoes. All the cesspools, so far, have larvæ inthem; when water barrels and cisterns in sameyard have none. I am inclined to think that Dr.Guiteras, and other mosquito breeders, would getmuch more vigorous larvæ if they would use bloodor some richer food than mere bread. We havebeen trying them side by side and find that sewerwater develops much more hardy and large larvæthan rain water with bread alone in it.

I have had all the little streams and ditches inthe suburbs cleaned and oiled; and we have killeda great number of larvæ.

You can go to any sewer mouth now and seethe dead larvæ running out in considerable num-bers, coming principally, I think, from the foso-mauros, where they have been killed by the oilwhich would no doubt remain upon them for sev-eral hours.

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But we have evidently had some tough old in-fected fellows, who have hibernated through thewinter. For instance, on the two cases that oc-curred on the 21st and 22d of April (in differentparts of the city, however), the mosquitoes werekilled as thoroughly as we knew how. Everyroom in the house was closed; and a pound ofpyrethrum powder burned to 1,000 cubic feet, andoil used everywhere, sewers and everywhere else.Not only was this done in the infected house, butin the fifteen or twenty contiguous houses. Oneach case we used 50 pounds of pyrethrum powderand something like 40 gallons of oil. I think theresults show that we probably got hold of the in-fected mosquito or mosquitoes. We did the samething on May 6th and 7th; and it now looks asthough we had gotten hold of the infected mos-quito there.

The prospect of getting infected mosquitoesnow is poor. So far we know of none in Las Ani-mas; all the cases this year having been exceed-ingly mild. It takes a Board with decided “amary-lic” to diagnose them.Would like very much to see you, Durham and

Carroll down this summer, that is if you did notobject to coming.Dr. Gaylor, of the New York Pathological Lab-

oratory, wants to take a whack at yellow fever,after his success at cancer. He asked me to lethim know when I could get him some moreautopsies of yellow fever, and he would come downat once.We have things nicely fixed at Las Animas now;

and I think we would do good work if we only80

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had yellow fever; but of course we can do nothingif we don’t have.

Mrs. Gorgas has just returned from the “States”and joins me in kindest regards. I got weak inthe knees and was afraid to keep our small girldown here, even though we had no infected mos-quitoes.

Very truly yours,W. C. Gorgas.

(3)War Department, Surgeon General’s Office,

Army Medical Museum and Library,Washington, May 23, 1901.

My dear Gorgas:I had only just penned you a short note, inquir-

ing into the yellow-fever situation, when herecomes your most welcome and interesting letterof May 15th. I was so much interested in Gui-teras’ results. One positive case in nine inocula-tions is better than we had at first. We only suc-ceeded with our tenth individual. Of course, youwere biting often with non-contaminated mos-quitoes, as your fever cases were doubtful. Cases3 and 6 should have failed. I expect better resultsfrom your May-infected mosquitoes. I see thatFinlay and Guiteras continue to harp on the harm-lessness of a single mosquito’s bite, drawing theconclusion that ordinarily y. f. is due to multiplebites. After some poor devil dies, they maychange their minds. Carroll’s severe illness wasdue to a single insect and poor Lazear died froma single bite. Why are not malarial fevers gener-

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ally double or multiple infections? We know thatthe opposite—single infections, as shown by onegroup of parasites—is the rule. . . . What’s theneed for us to return, if you have no y. f.?Havana should get a more accommodating ChiefSanitary Officer! Hurry up your new infections.

Again thanking you for your letter and the copyof G.’s report, and with best regards to your wife,believe me,

Sincerely yours,W. Reed.

(4)War Department, Surgeon General’s Office,

Army Medical Museum and Library,Washington, June 5, 1901.

My dear Gorgas:Your very kind letters of May 22d and 23d have

both been received. Please say to Dr. Finlay thatI will send a copy of our last paper just as soonas we can get it from “American Medicine.” Ithasn’t been published yet. I hope to have it soon.You shall certainly have a Reprint. What you tellme about the y.-f. situation is certainly very en-couraging, but were not the results just as encour-aging in 1899, at the same season? I will admitthat you must have more non-immunes in Havananow than in 1899. Of course, you understand,my dear Doctor, that the control of yellow feverduring this epidemic season, is to me the all-ab-sorbing and important question, and it is on thisvery account that I am afraid that you and I mightbe led, in our enthusiasm, to think that moreshould be attributed to the sanitary measures now

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being carried out, than to the season, or some otherconditions of which we might be ignorant. It issimply a delight to read that you are “in highfettle,” and I consider the city fortunate in havinga Health Officer who believes that he can masterthe problem. I am astonished at the strength ofyour mosquito-destroying sanitary squad. Whatyou say about the cesspools as breeding-placesis intensely interesting. We got our first goodsupply of larvæ from an old can containing somefeces at Columbia Barracks, and since then wehave added a little fecal material to our breedingjars and have found that larvæ thus fed grewmuch more vigorously than those in ordinarywater. Your experiments agree fully with ours.You are certainly doing effective work towardtheir destruction. I was astonished at the amountof pyrethrum that you are burning to the 1,000cubic feet. Is such a large amount necessary, doyou think? Won’t you soon exhaust the supply?At Mount Vernon B’ks, where culex was veryabundant, I used to find that about 2 or 3 ounceswould intoxicate every mosquito in a room of some3,500 cubic feet, so that I could sweep them upand burn them before they “sobered up.” Cer-tainly your plan of destroying insects in the sur-rounding houses is worthy of all commendation.However, be sure that your sanitary measures donot prove obnoxious to the Cuban doctors and lay-men, or otherwise they will certainly conceal theirmilder cases. While the destruction of the mos-quitoes is very desirable, I consider the thoroughprotection of the patient against their bites as ofeven greater importance. I cannot believe that

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in so large a city . . . that you can possibly ac-complish this. The undertaking, to me, seemswell-nigh impossible. They will conceal theircases, do what you may; and these cases will bethe foci for other cases. I can see no other al-ternative for this summer, at least. Still, you willundoubtedly be able to control the spread of thedisease better than ever. . . . Pardon this longletter. Good luck attend your well-conceived reg-ulations. Health and happiness attend you andyours.

Sincerely, your friend,Reed.

Dr. Reed here considers a squad of fifty mendoing sanitary work in a city of two hundredthousand inhabitants at large. Four years after-wards, in the city of Panama, a place of twentythousand inhabitants, we had six hundred mendoing the same work. Major Reed is inclined tothink fifty pounds of pyrethrum to a case a largeamount. In 1905 in Panama we used two hundredand forty thousand pounds during the year. I callattention to this as showing how little any of usappreciated the magnitude of the job when we firststarted in.

(5)Havana, Cuba, June 13, 1901.

My dear Reed:Yours of June 5th received. I inclose you a

copy of Dr. Guiteras’ report for May.84

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We see still no success from our inoculations intwenty-two cases, but the great “but” comes in.I am not sure that any of the cases bitten wereyellow fever. One of the last, from Tampico, Ithought a pretty well marked case, though notdangerously ill, but his mosquitoes, on the 20thday, did not infect. I am disappointed beyondmeasure. I had hoped by this time to have LasAnimas full to overflowing with inoculated cases,and be turning out immunes at the rate of sometwo hundred a month. But may be it is well as itis; in our enthusiasm we might have infected thecity.

No case of yellow fever since May 7th, and stillnone on hand. The Board diagnosed one earlyin the month, but it turned out a well-marked caseof typhoid fever. Of course I agree with you thatnothing very definite can be deduced from our re-sults this early in the season, though personally Iam very much impressed by them. Our conditionnow is very much better than it was even in ’99,with regard to yellow fever, and of course ourliability to it is very much better. ’98 and ’99,with regard to yellow fever, should be left out,as in these years there were no non-immunes inHavana, and they would not have had yellow feverno matter what the condition of infection wouldhave been. I except of course, the latter partof ’99.

From the 1st of March to the 16th of June in’99 (and mind you this has been far and away thebest record Havana ever made), we had fourdeaths from yellow fever. In the same periodthis year, we have had one, which occurred March

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16th. The deaths in ’99 occurred scattered overthis period. It seems to me that the present con-dition of affairs indicates that we have been doingsomething that has had a great effect upon infec-tion; and of course the only thing we have donethis year that we did not do last year is the de-struction of the mosquito. We commenced thiswork about the middle of February, just about thetime that yellow fever practically disappears.

On the 12th of June, 1899, we had had for themonth two cases of yellow fever, and in 1900, six.If you consider the amount of work there was tobe done, to put oil in all the cesspools, all the waterbarrels and all the cisterns, once a month, andthen keep the streams and pools in the suburbsdrained, you will understand that seventy-five menis not at all a large force. I think I could use toadvantage more. As you say, we could use lesspyrethrum. We arrived at the rate of a poundper 1,000 cubic feet by experiments at Las Ani-mas. We found that in this ratio we could killmosquitoes in one and a half hours. It wouldprobably be just as well to intoxicate them andsweep them up, and I shall probably cut down thequantity in a short time. We have to sweep themup anyway. But feeling that it may be possiblethat we have no infected mosquitoes in Havana Iwant to do everything I can think of, when a caseoccurs, to increase the chances of killing the in-fected mosquito in the neighborhood of where thepatient got his infection.We are using now from one hundred to two

hundred pounds to the patient, killing the mos-quitoes everywhere within half a dozen houses of

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the patient’s home. There is less objection raisedto this than to the ordinary disinfection. It dam-ages nothing, only keeps them out of their roomfor an hour or two, and kills the mosquitoes. Ithink there is much less opposition to us on thisaccount than there was last year.

I feel confident that there is very little conceal-ment of cases, and I do not feel much anxiety onthis score. We cannot have many light cases with-out having a death now and then, and deaths wouldalmost certainly be reported.

But what gives me the greatest confidence isthat our non-immunes are made up entirely ofSpaniards and Americans. The Americanspromptly report themselves where there is any-thing suspicious, for the sake of the better carethat they get at Las Animas. The Spaniards areall matriculated at one of the three “quintas,” andgo there as soon as they are sick from any cause.These “quintas” are all very anxious to try andcatch up to the record of Las Animas, and reportevery case that they think, by any possibility, willpass the Board. And then, too, I can control the“quintas” by frequent inspections. So it seems tome that there is very little probability of cases be-ing concealed to any extent. Still, we can speakmore definitely on this subject about the lst ofDecember than we can now.All well. With kindest regards, I remain,

Very sincerely yours,W. C. Gorgas,

To Maj. Walter Reed, Maj. & Surg., U. S. A.Washington, D. C. Chief Sanitary Officer.

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(6)Army Med. Museum, June 27, 1901.

My dear Gorgas:I thank you so much for your last kind and most

interesting letter of June 13th. Really, my dearDr., in spite of a few disagreeable things andpeople, when I think of the absence of yellow feverfrom Havana for a period of fifty days, I begin tofeel like rejoicing that I ever was born! You aredoing a splendid work for your corps and profes-sion in Havana.

. . . . . .Sincerely, your friend,

Reed.

(7)

Army Med. Museum, Washington, July 29.My dear Gorgas:

I was on the eve of writing to you, when yourkind favor of the 20th inst. reached me. The newsfrom Havana is simply delightful. I am willingto confess that my fears that physicians would failto report cases of yellow fever to your office, andthus maintain foci of infection, were groundless.It shows that your acquaintance with the local con-ditions were much better than mine. That youhave succeeded in throttling the epidemic appearsto be beyond question, and is to your everlastingcredit as an energetic Health Officer, who saw hisopportunity and grasped it. A man of less dis-cretion, enthusiasm and energy would have made

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a fiasco of it. Whereas, you, my dear Gorgas,availing yourself of the results of the work atCamp Lazear, have rid that pest hole, Havana,of her yellow plague! All honor to you my dearboy! Thank God that the Medical Departmentof the U. S. Army, which got such “a black eye”during the Spanish-American war, has during thepast year accomplished work that will always re-main to its eternal credit! I had seen in thepapers report of the cases at Santiago de lasVegas. I am delighted that you have taken chargeof the suppression of this outbreak. Of course,you will soon stamp it out, if you can enforce yourregulations. I shall look forward with the great-est interest to your work there. Please keep meposted. I did not get your June Report, which Ishould like to have very much. Apropos of theoutbreak at Santiago de las Vegas, I have con-cluded to have Carroll go to Havana, for the pur-pose, if he can get hold of any cases of yellowfever, of making a few observations on humanbeings, which will be a valuable guide to us atthe present stage of our search for the parasite. Isincerely hope that he can succeed in getting holdof a few recently arrived immigrants for this pur-pose. I especially ask your kind assistance in thismatter. I see that Gen. Wood has left Havanaso that I am afraid that Carroll cannot get anymoney with which to pay the subjects of experi-mentation. Have you any funds with which theycould be paid $1.00 per day? I think that you saidthat subjects could be obtained at that price. Car-roll would like to do his work at Las Animas Hos-pital. Can that be arranged? He must start on

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his return by Sept. 20th, if possible. So that hehas but little time in which to accomplish the taskbefore. Still if he can draw blood from a fewundoubted cases and can get a few subjects, itwon’t take him long to decide the point. I wantedto come very much, but I have work here which Ifeel that I should not neglect. Else I shouldhave certainly come down. I have been intend-ing to ask you whether, in dealing with y. f. inHavana, this year, you have confined your workto simply protecting the sick against bites anddestruction of mosquitoes; and have omitted alldisinfection of bedding and clothing. I sincerelyhope that this is true. I shall probably present,with Carroll, a paper to the next meeting of theAmerican Public Health Association on the man-agement and prevention of yellow fever, and Iwould so like to be able to say that the great workin Havana was accomplished without the disinfec-tion of any bedding or clothing. Carroll leavesNew York, with Pvt. Springer, on Ward Lineleaving on Wednesday, August 6th. Pardon thislengthy letter. Please present my kindest regardsto Mrs. Gorgas. Keep me informed of yourprogress at S. de las Vegas.

Sincerely yours,Reed.

The parasite has not yet been discovered. Dr.Carroll proved by the experiments which Dr. Reedhere refers to that the parasite of yellow fever issub-microscopic.

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(8)Havana, Cuba, August 26, 1901.

My dear Reed:Yours of July 29th received. You will see by

the last report that our conditions continue good.So far this month we have had only two cases be-longing to Havana, one of these a Cuban childtwelve years old who had never been out ofHavana. Personally, I have not seen a case sinceMarch, belonging to Havana, with which I wasperfectly satisfied as being yellow fever, but Iam more confirmed in my suspicions since we havehad the Santiago de las Vegas cases.You recollect we bit some thirty-four subjects at

the time when I last wrote you without being ableto transmit the disease in a single instance. Thesemosquitoes we tried to infect on some dozen ofthese supposed Havana cases.

We all agreed that the Santiago de las Vegascases were yellow fever. While they were notsevere, they were well-marked cases of yellowfever. We bit one man with eleven mosquitoes.He was a well-marked case, but not dangerouslyill at any time. These eleven mosquitoes havesince bitten seven subjects, six of whom havegone down with yellow fever. Three have re-covered and three died. Carroll will no doubtgive you details in these cases, and Guiteras willpublish the matter in detail.

I am very much disappointed. I had hope thatthrough the mosquito we had a means of givingmild cases which would protect, but these cases

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show that the severest form of yellow fever can betransmitted by one or two mosquito bites.

I suppose I ought to be thankful for the im-mense good that the discovery so far has done,and for the great success that our work this yearhas had, but the death of these patients, just now,makes all success taste of gall and wormwood,and casts a gloom over the Sanitary Depart-ment.

From a practical standpoint though I am in-clined to think that the yellow-fever question issettled. The discovery that it is the mosquitoalone that conveys the disease will enable us tomanage it.

I cannot but think that the freedom of Havanafrom yellow fever on the 24th of August, a thingnever before known, must be due to the fact thatwe got the infected mosquito nearly every time.The disease has been introduced freely from theoutside, and yet has not spread among our thirtythousand non-immunes. I believe that our systemgets them nearly every time. I think we will soonhave Santiago de las Vegas under control. Weare inspecting and keeping track of all the non-immune travelers coming to Havana. They areseen by one of our doctors every three days oftheir stay in Havana, up to six. We have gottenhold of several in this way, and the town is beingregularly gone over with the same system thatwe have in Havana.We had a case on the 20th from Las Vegas, but

it was from a part of that town that had notbeen disinfected. I feel confident that we willhave no more cases from Las Vegas after Sep-

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tember 1st. This will be a very nice demonstra-tion of what can be done by our system of mos-quito killing.

Heretofore we have disinfected exactly as lastyear, plus using the pyrethrum powder and oilin the infected house and in all the neighboringhouses. Formaline was used in the infected roomand the clothing was sent to Las Animas Hospital,and the patient quarantined. I did it because itcould not decrease the effectiveness of disinfection,and would relieve me from criticism in case wewere not able to control yellow fever, and had asmuch as we had last year.

I must confess that our results this year are en-tirely unexpected to me, and if I had any idea howthey were coming out I might have discontinuedthe disinfection of clothing long ago. But inorder that the cases may be reported as generallyas possible, I am doing everything that I think Isafely can to make the routine as little burdensometo the people, as possible. In accordance withthis, I have this month issued an order that inyellow-fever cases the only disinfection was to bewith pyrethrum; that the clothing was not to betaken to Las Animas, and that after the fifth daythe patients were not to be quarantined orscreened.

I have been designated by the Military Governorto represent the Department at the Public HealthAssociation next month at Buffalo, and also theBoard of Health at the meeting at Niagara whichis scheduled to occur on the 13th. I hope to seeyou there if I go. If things are as quiet as theyare now, I will probably go; but if I have any

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yellow fever on hand I would rather send some-body else.

Yes, I agree with you. I think this yellow feverwork will reflect great credit upon our corps. Cer-tainly the work of proving the mosquito to be thetransmitter of yellow fever is as important a pieceof work as has been done since Jenner’s time, andas far as the United States is concerned, probablyof more importance; and as yours was the guidinghand in the whole matter, I hope that some suitablereward will come to you, more substantial than thegeneral professional recognition which you arenow getting from all quarters. I am very happyto shine in the more humble role of being the firstto put your discovery to extensive, practical appli-cation.

Mrs. Gorgas joins me in kindest regards.Very sincerely yours,

W. C. Gorgas,Major & Surgeon, U. S. A.,

Chief Sanitary Officer.

(9)War Department, Surgeon Gcneral’s Office,

Army Medical Museum and Library,Washington, Sept. 2, 1901.

My dear Gorgas:Upon returning to town, from a two weeks’ rest

in the mountains, I find your very interesting let-ter of Aug. 26th. Of course, Carroll had alreadywritten to me about the unfortunate termination of

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some of Guiteras’ cases. I was very, very sorryto hear of Guiteras’ bad luck and can appreciatefully his mental distress over this loss of life.Perhaps, after all, the sacrifice of a few will leadto the more effectual protection of the many. Ithink that we had best look at the matter in thislight. That eleven mosquitoes could and did in-fect six persons, causing the death of three, is in-deed, very strong confirmatory evidence of ourobservations of last fall and winter. I have beenparticularly anxious to learn of your results atSantiago de las Vegas, hoping to incorporate themin a paper on the prevention of yellow fever, whichI hope to read at Buffalo; but since the good newscomes that you will be there “in persona vera,” youcan give the figures better than anyone else. Iwill, however, show by chart, the occurrence ofyellow fever in Havana during the present year,and would be so glad if you would give me yourcases and deaths for August. To Aug. 26th, youreport only two cases. Were there any others?I have the cases and deaths for the other months.Is not the record a glorious one? But it wouldnot have been obtained by a less energetic andenthusiastic Health Officer. You, therefore, mydear Gorgas, deserve all manner of praise for yourthorough work. I hope that Carroll is meetingwith success. Please let me hear from you by re-turn mail, if possible, about your August cases anddeaths. A line will do. With kindest regards toMrs. Gorgas,

Sincerely, your friend,Reed.

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(10)

War Department, Surgeon General’s Office,Army Medical Museum and Library,

Washington, October 3rd.My dear Gorgas:I have been hoping to see you and Mrs. Gorgas

in Washington and wondered what you found atBufialo to keep you so long; but a letter fromCarroll just received, mentions your return toHavana. So you have, indeed, given us the “gladgo-bye!” Well, as Columbia has just won fromShamrock, I’ll have to forgive you this time! Butyou mustn’t do so any more, or there will be“trouble on the old man’s mind.”I trust that you found the yellow-fever situation

satisfactory. I wish that I could have known theNo. of cases and deaths for September, so that Icould have included them in our paper, but it istoo late now. Don’t forget to keep me on yourexchange list. I had a letter from your brother inanswer to one I wrote you for which please givehim my best thanks. You were saying, if I re-member, that you would like to have your formerassistants, Lyster and Shockley, back again. Ifyou haven’t them, and still want somebody, I onlymention the fact that Asst. Surgeon Devereux,who has been on duty with Borden at the Genl.Hospital here, leaves in a day or two for Havana,to report for duty, and might suit you very wellas an assistant. . . . Borden says that he has madea very good assistant. You might have your eye

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open for him. Give my kindest regards to Mrs.Gorgas. Good-bye.

Sincerely, your friend,Reed.

(11)Havana, Cuba, Oct. 8, 1901.

My dear Reed:I was sorry that I did not see you before leaving

Buffalo, and have an opportunity of talking withyou over your superb paper, and arguments withWadsin. Nothing could have been clearer, itseems to me. I congratulate you upon being theFirst Vice-President; I think you ought to havebeen President but that matter had been arrangedbeforehand as going to the retiring Treasurer,who had held that office so long. Other names asFirst Vice-President had been proposed to theCommittee, but when your name was mentioned,they all voluntarily withdrew, and you were nom-inated without a single dissenting voice.You will see from the report how we are coming

along. The record is just as good; two deathsfor September. We have had a little focus aboutthe “Mercado del Vapor,” but I think we havesquashed it. Our last case occurred Sept. 26th.Ten days without a case, this time of the year, ispretty good. But our general death rate took amost remarkable drop. We had only 339 deathsin September, a rate of 15.64 per thousand.You had better move down to Havana with your

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back to the United States and run all the risks ofinfection and bad hygiene that you are constantlysubjected to in cities such as Washington, NewYork, etc.

I looked into it carefully, and am positive thatthere is no error in the figures. I don’t believe itis possible for a person to be buried in Havanawithout my knowledge, and I know that these fig-ures are correct.

Carroll seems to be hard at work; looks verymysterious, and can’t get him to tell anything. Hehad better hurry up; yellow fever in Havana willsoon be a thing of the past.

I left Mrs. Gorgas and Aileen in New York, butexpect them to leave for Havana, \Vednesday,the 9th.

With kindest regards, I remain,Yours very sincerely,

W. C. Gorgas,Major & Surgeon, U. S. A.,

Chief Sanitary Officer.Major Walter C. Reed,

Office of the Surgeon General,Washington, D. C.

This case which I report on September 26, 1901,was really the last which occurred in Havana. Ofcourse we did not know it at the time, but this casemarked the first conquest of yellow fever in anendemic center; the first application of the mos-quito theory to practical sanitary work in anydisease.

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(12)

War Department, Surgeon General’s Office,Army Medical Museum and Library,

Washington, Oct. 17, 1901.My dear Gorgas:

I have yours of the 8th inst., and appreciate verymuch your kind words about my paper and myselection for First Vice-President of the Associa-tion. The latter was a very great surprise, as Ididn’t dream that I would be considered as a can-didate for any office.

. . . . . .I am indeed delighted to hear that you only had

two deaths in September. What could be moresatisfactory? Certainly five deaths in sevenmonths is a good record for the city of Havana,in this year of our Lord 1901! I hope that youno longer destroy fomites but are careful to pro-tect your cases until fever subsides or death en-sues. Good luck to you and your work! I reallydon’t blame you for being a little nervous aboutyour health when you come to the United States,for you are certainly making Havana one of thehealthiest cities in the world. I think that I willtake your advice, come down and build me a house;that is, after I retire! Remember me very kindlyto Mrs. Gorgas and your daughter. . . . I will beglad to get your monthly report for September.

With best wishes,Sincerely yours,

Walter Reed.99

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(13)War Department, Surgeon General’s Office,

Army Medical Museum and Library,Washington, Dec. 21, 1901.

My dear Gorgas:Many thanks for your October report. The

November report has not been received yet, buthope to get it later. I got your kind letter ofDec. 6th. Certainly the results for October andNovember could hardly be beaten. I think thatwe should thank Heaven and be satisfied. An-other experimental case of yellow fever? Lookhere, Mr. Sanitary Officer, if you don’t stop apply-ing stegomyia to willing Castilians, there will betrouble yet! Carroll fairly grinned all over whenI read it to him! He wishes to be very kindlyremembered to you. I am glad that Dr. Finlaystill finds his Tetragenus. Please remember meto him. What a splendid paper that was of Gui-teras in American Medicine! I was delightedwith it. Make my best regards to him, also, please.The weather here is so very cold that I long forthe balmincss of the Cuban atmosphere. Whymen and women will persist in living in coldclimates is something that I can’t possibly under-stand. Stay where you are. Don’t permit eventhe evacuation of the Island to bring you away.We need you as a defence against yellow Jack!Well, the hour is five P. M. and all have long sinceleft the office. I must hurry home in an openstreet-car and thereby chill my very marrow. Mybest regards to Mrs. Gorgas. . . .

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With all manner of greetings for a Merry Xmasand happy 1902, believe me,

Sincerely, your friend,Reed.

(14)War Department, Surgeon General’s Office,

Army Medical Museum and Library,Washington, Jan. 14, 1902.

My dear Gorgas:In response to your request just received, I

have forwarded to you a copy of each of our Re-ports which I will ask you to hand to the FrenchConsul with my compliments. I was just about towrite to you, to ask at what time during 1901 youomitted to disinfect bedding or clothing. I thinkthat you wrote that about August 15th, you nolonger required such disinfection, but I cannot findyour letter. Again: Can you not give me some ofthe data with regard to your fight for control ofthe epidemic in Santiago de las Vegas? Did yourresults show by the prompt suppression of theepidemic in that town that you were adopting theright measures? I have just been asked to writean article for the English Journal of Hygiene,setting forth our observations, as well as the workof the Medical Department in Cuba, and I shouldlike to mention Santiago de las Vegas as well asHavana, giving you, of course, full credit for theresults obtained. I haven’t your December reportas yet. Please send me a copy of it. I never wasquite so busy in all of my life and sigh for the 3dof April, when I can get this class off my hands.

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How is your epidemic in Havana? How I wouldlike to run away from my present surroundingsand go on a “toot” with you and Kean!

Please let me hear from you promptly, as Imust prepare my paper by the end of February.Remember me very kindly to Mrs. Gorgas. . . .

Sincerely yours,Reed.

(15)Havana, Cuba, January 22, 1902.

Major Walter Reed,Surgeon General’s Office,

Washington, D. C.My dear Reed:

Yours of January 14th received. The sendingof clothing and bedding for disinfection to LasAnimas, in yellow-fever cases, was stopped about

. The official order wasissued August 21, 1901. We have a large disin-fecting plant at Las Animas to which everythingof this kind is sent. When a house is disinfectedfor diphtheria or any similar disease, the room it-self is infected with formaline gas and washeddown with a bi-chloride solution, and all fabricsand clothing of every kind are sent to the disin-fection plant. Up to the time mentioned this hadbeen done in the case of yellow fever, but, havingbecome convinced that the mosquito was the onlyway of transmitting the disease and that no goodcould be obtained from this process, we stoppedthis method.

From my experience here in municipal sanita-102

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tion, I think this is of the greatest importance, viz:to put people to as little inconvenience and lossas possible by methods of disinfection. The de-struction of mosquitoes in a building can be ac-complished with very little annoyance to the in-mates but the thorough destruction of fomitescauses a great deal of inconvenience and someloss.

The all important matter in yellow fever is toget your cases reported as thoroughly as possibleand this can only be done with the co-operation ofthe people. I am therefore of the opinion that thegreat element of our success was due to the factthat we did away with the attempted destructionof fomites. You can readily see how one unre-ported case might start an epidemic.

The Santiago de las Vegas case is a very goodillustration of the efficiency of our methods instamping out a focus. Santiago de las Vegas ispractically a suburb of Havana, distant abouttwelve miles with a considerable non-immune pop-ulation, constantly having communication withHavana. The infection of 1900 evidently re-mained over. Some cases occurred in January,some in June and more in July. The cases of Julywere taken and the houses all gone over, and themosquitoes killed, but it was evident that the in-fection had gotten away from us by this method,so on the 24th of July we got a considerableappropriation and started a brigade systemati-cally fumigating, block by block, around the in-fected areas. With this we were successful andgot rid of the focus. This was the most difficultdisinfection we have attempted. The infection

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had evidently got pretty widely spread and newcases kept occurring outside of the area in whichwe were working. I send you a few papers on thesubject. Please return them when you have fin-ished as they form a part of our records on thesubject. Please excuse this hurried letter.

Sincerely yours,W. C. Gorgas,

Major and Surgeon, U. S. A.Chief Sanitary Officer.

(16)

War Department, Surgeon General’s Office,Army Medical Museum and Library,

Washington, Jan. 3lst.My dear Gorgas:Your kind letter of January 22d was received a

few days ago. I am very much obliged for theinformation concerning Santiago de las Vegas. Ihave made a copy of several of the enclosed papersand return them herewith with many thanks forthe opportunity of seeing them. I would like toknow in how many cases of y. f. since July 1, 1900,you have omitted disinfection of clothing. Howmany cases under observation in Havana sincethat time? There were five deaths I notice afterthat date and these probably cover say twentycases. Can you give me the exact number of casesby months for 1900 and 1901? I want to make acurve for these years of cases to accompany mynext article to be published in the Journal ofHygiene (English). . . .

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Another thing. Can you possibly obtain fromDr. Guiteras, some eggs of stegomyia and sendthem to me dried on filter paper? I have no in-sects nor eggs at present, and am so very anxiousto obtain some as soon as possible.Remember me very kindly to Mrs. Gorgas.

With best wishes,Sincerely yours,

Walter Reed.

(17)

War Department, Surgeon General’s Office,Army Medical Museum and Library,

Washington, Feb. 4, 1902.My dear Gorgas:

Yours of January 31st is just to hand. TheArmy Examining Board of which I am a memberis not now in session, but undoubtedly will be setat work just as soon as the school session ends,April 3d, and I should venture the opinion thatthe Board will remain in session until November1st, except during a brief summer vacation in Julyand August. I hope that your friend will appear.Give him a note to me, or a general recommen-dation for the use of the Board, and I will seeif I can’t soften the hearts of some of the stoniest-hearted members. . . . I hear that you are goingto have a y. f. “picnic” down in Havana this month.Talk “right from the shoulder” to those SouthAmericans, and make them begin the work ofexterminating the disease in their respective coun-

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tries. I think that Mexico is alright on this ques-tion.

. . . . . .Faithfully yours,

Reed.

(18)War Department, Surgeon General’s Office,

Army Medical Museum and Library,Washington, Feb. 12, 1902.

My dear Gorgas:Just a line to say that I have your kind letter

of Feb. 6th, containing the information that Iso much wanted. I thank you very much for it.I am trying very hard to put together an articlefor the Journal of Hygiene, as I wrote you, butbetween the class and other work, it’s deuced hardto accomplish a half hour’s work on it daily. Didyou see Souchon’s reply to Carroll and myself inthe Record for January 8th? . . . If I can get alittle time, after awhile, I may reply to him. . . .This should reach you in the midst of the meetingof the Congress. Do, pray, persuade them to ac-cept the mosquito transmission and change theirsanitation accordingly. I trust to you, Havard,Kean and Guiteras to do this. Make my kind re-gards to Mrs. Gorgas. I am so glad that youare going to remain in Havana for awhile. Youshould stay during the whole summer and fall. . . .

Good-bye.Sincerely yours,

Reed.106

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(19)

War Department, Surgeon General’s Office,Army Medical Museum and Library,

Washington, April 3, 1902.My dear Gorgas:Yours of March 28th reached me yester-

day. . . .I was simply delighted with your Annual Re-

port. What a glorious record! No wonder, mydear boy, that you should grow eloquent, as youdid, in your closing paragraph. It made my heartbeat faster as I read it. You have done a splen-did work in Havana, my dear Gorgas, one thatshould always give you the greatest pleasure tolook back upon. You have my sincere admirationand congratulations. We will really and trulyhave to go on that Toot when you land on yournative heath, once more!! I But if I had my way,you would remain in charge of sanitary mattersin Havana for another summer! I have toldGen. Sternberg so. It would be such a pityto have this splendid work all undone, for the lackof an enlightened Health Official. Who will suc-ceed you? His position will be the most impor-tant on the Island. . . .

Adios, my dear friend. May Heaven bless you.Your friend,

Reed.

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(20)War Department, Surgeon General’s Olfice,

Army Medical Museum and Library,Washington, May 14, 1902.

My dear Gorgas:I received your reprints and was very much

pleased with them and to know that you are doingsuch good missionary work. Modification ofquarantine will come slowly but surely. Am de-lighted to know that you will be here on your wayfrom Saratoga. . . .

So you have really applied stegomyia again toy. f.! Dear me! Haven’t you had experienceenough? If you are going to do this thing muchmore, Carroll and I will join you on your way backto Havana. There are several problems to beworked out, from a scientific point of view. . . .Are you not a delegate to the Assoc. of Mili-tary Surgeons? I thought that you were. If youshould arrive before May 28th, you could join usin the dinner to Gen. and Mrs. Sternberg.Wish so much that you could be here with Mrs.Gorgas, as I know that you would both enjoy theoccasion. . . .

Sincerely yours,Reed.

(21)War Department, Surgeon General’s Office,

Army Medical Museum and Library,Washington, July 21, 1902.

My dear Gorgas:It was like the good fellow that you are to sit

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down and write me that nice letter of congratu-lation. Harvard did indeed do me very greathonor in conferring the degree of Master of Arts,and the audience was so very enthusiastic that Ifelt that Boston, at least, had some appreciation ofwhat the Army had done in Cuba. . . . The Uni-versity of Michigan, not to be outdone by Har-vard, gave me the following week the degree ofL.L.D! . . .

There is another way in which to look at thismatter. Instead of simply being satisfied to makefriends and draw your pay, it is worth doing yourduty, to the best of your ability, for duty’s sake;and in doing this, while the indolent sleep, youmay accomplish something that will be of realbenefit to humanity and worth more than all thehigh places that could be bestowed by shrewdpoliticians. Nor you nor I have reason to beashamed of our work of the past two years, norwould we think of exchanging places with any ofthe luckier members of the Corps. “Verbum sap.”I am having Mr. Meyers look up Panama andNicaragua literature. Do you want articles inGerman and French, or only in English? Howshall they be addressed?

With warmest regards to Mrs. Gorgas, . . . be-lieve me, always,

Your good friend,Reed.

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CHAPTER VIII

HISTORY OF YELLOW FEVER

FROM the dawn of history man has made someattempt to prevent disease. He saw on all

sides evidences of the fact that he had sufferedfrom disease through no fault of his own; that oc-casionally disease would occur with unusual vio-lence and exterminate whole communities.

The cause of such mortality not being evidentto his senses was attributed by him to spirits, orto powerful gods. These spirits being superiorto himself in power, he attempted to propitiatethem by presents and prayers. These were hisfirst efforts at preventive medicine and sanitation.He would try to drive off the evil spirits of dis-ease with loud and disagreeable noises made bytom-toms and similar instruments. He attemptedto prevent the ingress of these same spirits bysigns and incantations. The gods were lookedupon as beings influenced by the same love andpassions as himself, and be appealed to them with

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supplications or bribes, as seemed likely to bemost effective. In his reasoning during this bar-barous age concerning the cause of disease, hewas really nearer the truth than subsequentlyduring a much more refined age, or even up to themiddle of the nineteenth century. We now knowthat spirits and gods do not directly cause diseasein man, but we have found out that living beings,germs, are the direct cause of all infectious dis-eases.

A great many of our sanitary measures, if nowwitnessed by our ancestors of three thousandyears ago, would probably seem perfectly naturaland proper. The fumigation of ships and build-ings would seem a very proper mode of burningincense to the hostile god who was causing yellowfever. The modern man, his descendant, is burn-ing the pyrethrum to kill the living spirit, themosquito, which he has found by experiment reallycauses the disease. Our ancestor would accept asa perfectly natural explanation the use of oil onthe stagnant waters if he were told that this was alibation to propitiate the angry god who was in-flicting on man malarial fevers. His descendantis using the oil really to kill the living beings, mos-quito larvæ, which cause malaria.

As man advanced in intelligence and civilizationhe threw aside his belief in spirits and numberlesshigher beings as causes of disease among his fel-

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lowmen. He now began to attribute disease toabnormal conditions in the blood and tissues of thebody, caused by unfavorable environment, such asfilth, food, clothing, climatic conditions, etc. Hisefforts for the prevention of disease during allthis period had little or no effect. It is probablethat through long ages the human race remainedstationary in numbers or increased very slowly,due principally to the fact that men were unableto affect favorably their sanitary condition, or toward off in any way the fearful epidemic scourgesthat every now and then swept through the ranksof mankind.

Up to the time of the discovery of America,Europeans had been making no attempt whateverto prevent disease and with our present knowledgeand point of view, we can see that any sanitaryattempt on their part would necessarily havefailed. They had an entirely wrong conception ofdisease and an erroneous theory of its cause. Themortality rates in most parts of Europe at thistime were as high as its birth rates. In England,the population had not increased for several cen-turies, or if it had increased, the increment wasso slight that it could not easily be measured.Every now and then virulent epidemics wouldsweep through Europe and carry off a large por-tion of the population. The figures as given insome of these epidemics are almost inconceivable.

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Concreted Ditch. Gatun.

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For instance, it is stated by Hecker that theepidemic of plague in the fourteenth century car-ried off from Europe some twenty-five millions ofthe population, and from China alone, thirteenmillions. That again, in the fourteenth and fif-teenth centuries, millions of the population ofGermany and other countries were carried off bythe “sweating sickness.”

Such instances of mortality could be adducedad infinitum. Leprosy in the fourteenth centurywas more common in England than it is now inPalestine, so common that every county had alazaretto where lepers were strictly confined, andlaws are still on the statute books prescribing themethod of their confinement, and the dispositionof their property.

The inhabitants of Europe at this time weresubject to all the contagious and infectious dis-eases to which, with one or two exceptions, theyare now subject, but most of these diseases, forsome reason, were vastly more virulent than theyare at the present time.In the fifteenth century when America was dis-

covered by the Europeans, the Indians undoubt-edly suffered from disease. They probably hadsome diseases from which Europeans, up to thattime, had not suffered, and the Europeans, nodoubt, brought with them some diseases fromwhich the Indians had not suflered. Yellow fever

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is a good example of the first, and syphilis of thesecond. And this must necessarily have been thecase if we give a little thought to the matter.

According to generally accepted scientific be-lief, the buffalo developed from the first createdcell from which we have all descended. If hisancestry could be traced, the line would runstraight back to this first cell. But he developedinto the present buffalo in a limited area in NorthAmerica. The ox, at some period in the distantpast, branched off from the same line of descentfrom which the buffalo came, yet he developedinto the present ox within a very limited area inCentral Asia. These animals were originallynative to a very small area of country, and thisseems to have been the case in the development ofall animal life.

The yellow-fever germ is primarily an animalvery much like the buffalo or ox, and must havecome from the first created cell just as did alllife, and must have developed as did other animalsin a very limited area or territory. Exactly thesame could be said of the tuberculosis germ. Itis, therefore, just as natural that the westernhemisphere should have had its peculiar diseasesas that it should have had its peculiar animals.

Everywhere that the European attempted tocolonize he suffered from disease, and this alwaysoccurred within the first two or three years. In

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Columbus’ settlement on Santo Domingo, he lostwithin the first three years a very large numberof the colonists settled there. When the Englishcolonized Virginia at Jamestown, they lost fromdisease about one-half of the total number ofcolonists, and the same is true of the settlers atPlymouth. Everywhere that settlements were at-tempted, the settlers were so nearly destroyed bydisease that, in many instances, the few survivorscould not be persuaded to remain.

Yellow fever is an acute specific, very fatal,febrile disease, lasting about a week, and char-acterized by fever, vomiting, muscular pains andalbuminuria, and in the graver cases by blackvomit and hematogenous jaundice. It is trans-mitted from person to person by the female steg-omyia mosquito. The sick person does not infectthe biting mosquito after the third day of the dis-case: One attack gives immunity against a sec-ond attack.

Like all other diseases, its origin is envelopedin a cloud of obscurity. The yellow-fever organ-ism, like the horse or the dog, developed in someparticular locality. The horse had his whole life-time in which to wander from place to place, andso spread very rapidly and widely as comparedwith the yellow-fever organism. The yellow-fever organism was dependent upon the mosquitoand man for his locomotion. On the average, he

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had not more than a week in which to travel. Ipresume that a week would be long for the aver-age life of a stegomyia mosquito, and the travel-ing ability of the organism would be limited bythe life of the mosquito. For while the femalestegomyia mosquito has to live two weeks aftershe has bitten the yellow-fever patient before shecan convey the disease to another non-immunehuman being, still the average length of life inthe mosquito cannot be as great as this. Thevarious conditions of unfavorable environment,the natural enemies of all kinds, wind, etc., mustkill a large proportion of mosquitoes within thefirst week. If we consider the total number ofstegomyia mosquitoes in an infected locality, wemust see that only an infinitesimal proportionsucceed in biting a yellow-fever patient within thefirst three days. This small proportion, however,has the best protection and is more likely to havea long life than the average of the female stego-myia, for they necessarily bite inside of the houses,and in such places have the best protection fromthe wind and sun, their greatest enemies.

In this other host, man, the parasite had onlythree days to travel. During these three days theman would be sick and not likely to move aboutmuch. During man’s savage state he traveledvery little more than did the mosquito. We wouldexpect, therefore, the yellow-fever organism’s

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rate of spread to be very much less rapid than thespread of the horse.

When America was discovered, the horse hadnot yet reached that continent. The evidencewith regard to the yellow-fever organism seemsto me to indicate that, at this same time, it had notspread further than a limited area about VeraCruz. It is probably the latest disease to whichman has been subject.

There are very many beliefs as to the localityat which yellow fever developed; that it origi-nated among the earliest nations of the world in-habiting Asia Minor; that it originated in Africa.in connection with the slave trade; that it origi-nated in America, and was not known to Euro-peans until the discoveries of Columbus.

A recent writer on yellow fever, Augustin,suggests that its origin can be traced back to thesiege of Troy, and that the Greeks and Trojanssuffered severely from this disease during theprosecution of the war. Mr. Augustin arguesquite forcibly in favor of the idea that many ofthe great epidemics of Europe and Asia, beforeand since the Christian era, were yellow fever.He thinks that the population became immunefrom the fact that all at some time suffered fromthe disease, and thus, in the course of time, itdied out from want of material on which to feed.I consider Mr. Augustin one of the most compe-

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tent authorities that we have on the history ofyellow fever, and anyone writing on that diseasein any of its phases would do well to consult hismonumental work.

It seems to me, however, that the evidence isagainst yellow fever having occurred in Europebefore the fifteenth century. If it had been gen-eral in southern Europe, semi-tropical Asia Mi-nor and semi-tropical Africa, it would be therenow, just as it is in similar localities in tropicaland semi-tropical America. If the Phoenicianshad suffered from yellow fever during the timeof Abraham, and the great epidemics of Smyrna,Thebes, Athens, Rome and Carthage had beenyellow fever, this disease would be in those coun-tries now. History does not show that yellowfever can immunize a whole country, but merelythe locality in which it prevails endemically.While the old inhabitant of Havana was immuneto yellow fever, the man from the interior ofCuba where yellow fever had not been endemicknew that he was just as liable to contract yellowfever when he visited Havana as was the manwho came from the United States, and he fearedthe disease just as much.

The native of the city of Panama was immuneto yellow fever, but the soldier coming from themountains of the interior knew that he wouldcatch the disease, and this actually occurred

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many times whenever a fresh regiment wasbrought to Panama. At present, Guayaquil inEcuador is the seaport of Quito, the capital of thecountry. Quito is situated some three hundredmiles up in the mountains, and is connected byrail with Guayaquil. Yellow fever is at presentendemic in Guayaquil and has been so for manyyears. The old resident of Guayaquil is immuneto yellow fever, but the natives of Quito dreadQuayaquil as they do death. They never go therewhen they can avoid it, and when they have tovisit the outside world, they remain in Quayaquiljust as few hours as will enable them to catchtheir ship. And the fear is well founded. Verymany Ecuadorians of high position have losttheir lives from yellow fever contracted in pass-ing through Quayaquil. But all these years ofendemicity of yellow fever in these cities, the in-habitants of the respective countries in whichthey are situated have never become immune.

The same is true of Europe, Asia and Africa.If Memphis, in Egypt, had been an endemic cen-ter of yellow fever in the dim dawn of man’s civ-ilization, the disease would be endemic there atpresent. While the native of Memphis who la-bored on the pyramids of Cheops would have beenimmune to yellow fever, enough fresh materialfrom up the Nile would have continued cominginto Memphis to have kept the disease going.

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And the hundred thousand men whom old Cheopskept at work on his pyramids for twenty yearswould have died in such numbers that he wouldeither have had to give up this work, or wouldhave exhausted the population of his kingdom;but the interior of Egypt would never have be-come immune any more than has the interior ofCuba, or Panama, or Brazil in our own time.

Had Athens been subject to yellow fever in thetime of Alcibiades, yellow fever would certainlybe there to-day. All the citizens of the city ofAthens would have become immune, but a suffi-cient number of Greeks would have been con-stantly coming into the city from the interior tohave kept the disease endemic, exactly as has oc-curred in our own time at Havana. I think, then,that we can throw aside Europe and Asia as theoriginal source of yellow fever.

Another theory of the origin of yellow fever isthat it originated in Africa and was carried toAmerica in connection with the slave trade. Nextto that of the origin in America, this is the mostgenerally accepted explanation. But the argu-ments against this belief are unanswerable.

According to Lind, the first yellow fever thatappeared in Africa was in Senegal, in 1759. Ifyellow fever had existed along the coast, it wouldcertainly have spread in the two hundred andfifty years during which this coast had been oc-

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cupied by Europeans since its settlement by thePortuguese in the year 1415. As a matter of fact,it was recognized many times in America beforeit appeared in Africa. The American origin ofyellow fever impresses me as being the most rea-sonable and the one most in accord with the re-corded facts. But it seems to me that the bulk ofevidence points toward its having originated inAmerica at some period prior to its discovery byColumbus.

Dr. Carlos Finlay, in a paper published in TheClimatologist, of Philadelphia, in July, 1892,gives very clear proof that the disease existed inAmerica before the discovery by Columbus. Itseems to have been endemic in the neighborhoodof Vera Cruz, Mexico, and to have been very wellknown to the Aztec authorities. The Govern-ment, before the arrival of the Spaniards, hadmany times caused a forced emigration from theinterior to the neighborhood of Vera Cruz, to re-populate a country that had been depopulated byan epidemic disease known to the Aztecs as “co-colitzle.” To induce them to stay, these peoplewere given many privileges, such as exemptionfrom taxation, etc. This cocolitzle was knownamong the Mayos of Yucatan as “black vomit.”The Spanish historian, Father Lapey, gives avery clear account of cocolitzle as it occured inYucatan in 1648. It is such a clear description

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of yellow fever that I think it instructive to quotefrom his report as given in Dr. Finlay’s paper:

With such violence and rapidity were the peo-ple attacked, big and small, rich and poor, thatin less than eight days the whole population ofthe city (Campeche) were sick at the same time,and many citizens of the highest rank and au-thority died. In most of the cases the patientswere taken with a most severe and intense head-ache, and pains in all the bones of their bodies, soviolent that their limbs felt as if torn asunder,or squeezed in a press. A few moments after thepains, there came on a very intense fever, whichin most instances produced delirium, though notin all. This was followed by vomiting of blood,as if putrified, and of such cases very few sur-vived—and many suffered the fever and pain inthe bones without any other symptoms. In themajority the fever seemed to remit completely onthe third day; they would say that they felt nopains whatever, the delirium would cease, the pa-tients conversing in their full senses, but they wereunable to eat or drink anything; they would con-tinue thus for several days, and while still talk-ing and saying that they were quite well, theyexpired. A great number did not pass the thirdday, the majority died on the fifth, and very fewreached the seventh. The most healthy and ro-bust of the young men were most violently at-tacked and died soonest. When the laity beganto improve, the disease broke out among thepriests. Of the eight members of the Jesuit Col-

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lege, six died; of our own order (Franciscan)twenty died in the city. Almost all the heads ofinstitutions and persons of highest rank, bothecclesiastics and seculars, were carried away bythe epidemic. The disease continued over thewhole country during the space of two years.Few that then lived in this land, or visited it, inthe course of those two years, escaped being sick,and it rarely happened that anyone died of a sec-ond attack after having recovered from the first.I then reflected that of the young children whowere attacked by the peste in Yucatan, only fewhad died, as compared with the adults.

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CHAPTER IX

GEOGRAPHICAL LIMITS OF YELLOW FEVER

THE geographical limits of yellow fever, whenfirst encountered by the white man, were not

very wide. They were contained within a zonelimited on the north by the twentieth parallel oflatitude, on the south by the eighth, on the east bythe sixtieth meridian, and on the west by the onehundredth. Practically, the disease was confinedto the shores of the Caribbean and the southernshores of the Gulf of Mexico. Within these re-gions it was practically endemic at the time Col-umbus discovered America. The arrival of thewhite man with his sailing ships made the diseasemuch easier of transmission from place to place,because man traveled much more frequently andmuch farther, and also because sailing ships, withtheir fresh-water tanks, bred the stegomyia ex-tensively. Under these influences the endemicarea began slowly to spread. Toward the norththe endemic area never extended far beyond the

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limits it occupied when Columbus made his firstvoyage. Havana, in latitude 23°, is the northernendemic limit in the western hemisphere. Thisis rather strange, as the city is located so nearthe original endemic focus. The arrival of a con-siderable number of non-immunes in a localityis necessary for yellow fever to become endemic,and this supply has to be fairly constant. Dur-ing the first hundred years after the founding ofHavana, in 1511, the city was considered veryhealthy. In 1620, an epidemic of yellow feveroccurred, the disease having been introducedfrom Panama (Porto Bello) by the treasure fleeton its way to Spain. In 1649 another epidemicoccurred, which was extremely severe and spreadto many other towns of Cuba. This epidemiclasted more or less until 1655. For a hundredyears after this, nothing in the nature of an epi-demic occurred. In 1762, at the time of the cap-ture of Havana by the English colonial troopsfrom the North American colonies, the diseaseagain became epidemic, and after that time re-mained constantly in Havana as an endemic dis-ease. At this time it was recognized as being in-troduced from Vera Cruz, Mexico, under thename of “black vomit.” It became endemic, anddid not disappear as on former occasions, on ac-count of the large and constant supply of non-immune persons, due to the presence of the Eng-

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lish troops, and after their departure, to the factthat the port was thrown open to general com-merce, and to a continuous supply of immigrantsfrom Spain.

It would seem, then, that Havana, after remain-ing in the epidemic area for some two hundredand fifty years, finally, about the year 1762,passed permanently into the endemic area.

Havana is the most northern point to which theendemic area ever extended. Toward the souththe endemic area spread much farther from theoriginal endemic focus than on the north. Whilein distance from the original endemic area thedisease spread further south than north, it didnot in point of latitude. Rio Janeiro and Santos,the furthest points south to which the endemicarea spread, are about latitude 23°, much thesame as Havana on the north. Para, Manaos,Pernambuco and Bahia gradually came within theendemic area, until finally, in 1849, yellow fevertook up its permanent habitat in Rio and Santos.During the year 1850, forty-one hundred andsixty persons died of yellow fever in Rio.

These cities, like Havana, were subject to epi-demics of yellow fever years before they becameendemic centers. Endemicity did not spreadregularly over this area from north to south.The disease became endemic in Rio thirty or fortyyears before it did in Manaos. Other factors

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proved more potent than location as to latitude.The large emigration to Brazil, which set in aboutthe middle of the nineteenth century, gave a con-stant and large supply of non-immunes to Rio,while Manaos did not get this supply until rail-road construction commenced in the interior,about the beginning of the present century.

Strictly speaking, Pernambuco, on the easterncoast of Brazil, about longitude 35° west, is thepoint farthest east where yellow fever really be-came endemic, in the sense of remaining continu-ously in one city for a number of years. But onthe west coast of Africa, from St. Paul de Lo-anda on the south to the Canary Islands on thenorth, yellow fever has been present all the timeat some point or points, ever since its introduc-tion in 1494, though on this coast it has nevermanifested itself continuously in the same townor city for any considerable number of years.But it is endemic on the coast in the sense thatit no longer has to be re-introduced from theoutside, but is always present at some point. Wehave a pretty accurate account of its first intro-duction into the Canary Islands in 1494 by Span-iards returning from Hispanola.

The farthest point west at which it has everbecome endemic is its original home, Vera Cruz,Mexico. It has been endemic at both Panamaand Guayaquil, on the west coast of America.

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While these points are on the west coast, andVera Cruz is on the east coast, still, Vera Cruzis some sixteen degrees of latitude west of eitherPanama or Guayaquil.

The endemic limits of yellow fever at its periodof greatest extent would be defined by a linedrawn from Havana, commencing on the north,to the Canary Islands, down the west coast ofAfrica to Loanda, from Loanda west to RioJaneiro, Brazil, from Rio Janeiro to Guayaquil,Ecuador, from Guayaquil to Panama, from Pan-ama to Vera Cruz, Mexico, and from Vera Cruzback to Havana, a very restricted area comparedwith other infectious diseases.

But it is as an epidemic disease that it hascaused most alarm and loss. The United States,Spain, and the West Indies have suffered mostseverely in this respect. It has been epidemicas far north as Quebec in North America. In1805, some fifty-five cases occurred among theEnglish troops stationed there. In Europe, it hasbeen epidemic as far north as Swansea, Wales.In the year 1865, the sailing ship Hecla fromCuba, introduced yellow fever into Swansea,and twenty-two cases developed in the town inpersons who had no communication with thevessel.

France has never had a yellow-fever epidemicof any consequence, though it has been demon-

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strated that under favorable conditions, the dis-ease might become epidemic. At St. Nazaire, inthe year 1861, yellow fever was introduced by thesailing ship Anne-Marie, and forty cases resulted,with twenty-three deaths.Yellow fever has appeared in epidemic form

several times in Italy, but has never extendedfurther east. Leghorn is the most eastern pointto which yellow fever has ever reached. Therein 1804 a severe epidemic occurred in which sometwo thousand persons died.

On the west coast of Africa epidemics have oc-curred as far south as St. Paul de Loanda. Theisland of Ascension, about the Same latitude asSt. Paul but in the mid-Atlantic, has sufferedvery severely. In 1823, the British sloop Bannbrought yellow fever from Sierra Leon to Ascen-sion. Ninety-nine cases occurred on the Bann,with thirty-four deaths, and on the island itselftwenty-eight cases occurred with fifteen deaths.

Yellow fever has been epidemic on the eastcoast of South America as far south as Monte-video, and on the west coast as far south as Val-paraiso, and on this same coast as far north asGuaymas, Mexico.

The epidemic area of yellow fever has beenvery much more extensive than the endemic area.This epidemic area would then be bounded by aline commencing on the north at Quebec, Canada,

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extending east to Swansea, Wales; from Swan-sea south to St. Nazaire, France; from St. Naz-aire southeast to Leghorn, Italy; from Leghornsouth to Loanda, on the west coast of Africa;from Loanda west across the Atlantic to the isl-and of Ascension; from Ascension still westacross the Atlantic to Montevideo; from Monte-video still west across South America to Valpa-raiso, Chili; from Valparaiso northwest to Guay-mas, and from Guaymas northeast back toQuebec.

By lines of latitude and longitude the epidemicarea would be bounded on the north by the forty-fifth degree, north latitude; on the south by thethirty-fifth degree, south latitude; on the east bythe tenth degree, east from Greenwich, and on thewest by the one hundred and tenth degree, westfrom Greenwich.

In point of area its period of greatest extentwas during the first half of the nineteenth cen-tury. Since the middle of the nineteenth centuryits area has been decreasing rapidly, until at thepresent time this disease is confined to a halfdozen centers in South America.

Within the epidemic area the loss of human lifefrom this disease has been very great, the UnitedStates and Spain being the most populous coun-tries affected.

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America, and its northern coast is about oppositethe southern part of North America, so that theneck of land which connects the two runs east andwest and is known as the Isthmus of Panama.Most of this isthmus is embraced in the presentRepublic of Panama.

Columbus was the first white man to visit Pan-ama. On his third expedition he entered the Bayof Bocas del Toro, and spent some time there.On this same expedition he also visited LimonBay, into which the northern end of the PanamaCanal at present empties. He also visited PortoBello, which afterwards became rich, famous andpopulous, and which is located on the northernextremity of the royal paved highway runningnorth from the old city of Panama. He left morethan one hundred men under his brother, Diego,at Belen, some fifty miles west of the presenttown of Colon. After several years of sickness,hardships and deprivations, this colony was final-ly destroyed by the Indians. Spain afterwardsennobled Columbus’ grandson, Luis, under thetitle of Duke of Veragua, and granted to him alarge tract of land in the neighborhood of thisold colony, to which was given the name “Duke-dom of Veragua.” One of the provinces of theRepublic of Panama which covers about the samearea as did the tract referred to, is known as theProvince of Veragua. The old royal highway

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just referred to, running between Panama andPorto Bello, lies from five to fifteen miles east ofthe Canal. Columbus’ third voyage was made in1498. A few years later, Balboa, with a partyof Spanish adventurers, under the authority ofthe Captain-General from Santo Domingo, ar-rived in the eastern part of Panama and madepermanent settlements, at first on the northcoast, and discovered the Pacific.

A few years later, in 1519, the city of old Pan-ama was founded. Balboa was the best type ofthe Spanish conquistador. He was brave, hardyand determined, qualities very common to theearly Spanish adventurers, but Balboa was moreable and had much broader views of governmentand colonization than either Pizarro or Cortez.He was displaced as governor of Panama byPedrarias, a man inferior to him in every re-spect. Balboa was beheaded by Pedrarias in1517. He had heard of the Inca empire to thesouth, and was getting together a fleet on thesouth coast with the intention of invading thisempire. Pedrarias became jealous of his power,and feared he was getting together a force forthe purpose of overthrowing his government. Asfar as historical data show, there was no reasonfor this jealousy.

Tradition has it that the cause of the enmitybetween Balboa and Pedrarias was due to the fact

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that Balboa, being betrothed to the daughter ofPedrarias, became involved in an affair with thedaughter of an Indian chief while absent on thesouth coast building the fleet with which he hopedto conquer the Inca empire. Pedrarias’ daugh-ter, hearing rumors of this affair, became veryjealous, and influenced her father’s mind againstBalboa, even to the extent of having him behead-ed. This is, however, probably pure romance.

The facts seem to be that Pedrarias, being anarrow-minded man and jealous in disposition,gradually became hostile to Balboa on account ofthe latter’s popularity with the Spanish colonists,as well as with the Indians. Balboa, for a con-quistador, was humane in his attitude toward theIndians. For this reason Pedrarias began tomake charges against and quarrel with Balboa.Pedrarias, being governor, had absolute powerin the Province of Panama, and Balboa, to besuccessful in fitting out his expedition, knew thathe had to have the support of Pedrarias. In hisendeavor to placate him and insure his support,Balboa married Pedrarias’ daughter, a child ofsix years of age. The marriage ceremony wasperformed by proxy, Pedrarias’ daughter beingabsent in Spain. Balboa never saw his wife.Pizarro was one of the lieutenants of Balboa,

though as an officer of Pedrarias’ governmenthe was actually in charge of the party that ar-

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rested Balboa. Balboa’s death was a great lossto Spain and to Panama. He would in all prob-ability have made a much more humane con-queror of Peru than did Pizarro, and certainlywould have made a much abler ruler of that coun-try. He was beheaded at Acla, the capital ofPanama at that time, situated on the north coaston Caledonia Bay. All trace of this town hasnow disappeared.

Panama when first known to the Spaniards, inthe early part of the sixteenth century, was athickly inhabited country, peopled by a mild-man-nered Indian population, who lived principallyby agriculture. Las Casas makes the statementthat during the twenty years in which Pedrariasgoverned Panama he caused the death of threemillion Indians. I am inclined to think this avery great exaggeration, but it is evident fromthe accounts one reads of Balboa’s expeditionsthat there was a considerable population in thecountry. As day after day he makes marchesfrom town to town, Balboa describes getting sup-plies from these towns, and that he was able toprocure from five hundred to a thousand portersfor carrying the baggage of the expedition. Inevery town be secured some gold, and none but avery populous country could have furnished thesupplies of men and amounts of gold which hedescribes.

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The Republic of Panama is something overhalf the size of the state of Alabama, containingsome 31,571 square miles of territory, and is di-vided into two parts near its center by the Pan-ama Canal. The western half contains at presentall the population of the Republic. The easternhalf has no population at all, with the exceptionof a few wild Indians. In Balboa’s time this east-ern half was thickly populated, and containedmost of the inhabitants. Columbus looked uponPanama as the richest portion of his Americandiscoveries, particularly from a gold-producingstandpoint, and the Spaniards generally sharedthis opinion. This was such a widespread beliefthat the country was known as Castilla del Oro.

The importance of Panama was vastly in-creased by the discovery and conquest of the Incaempire about 1530. Vast quantities of gold andsilver bullion passed through Panama on its wayto Europe. It seems to be an historical fact,mentioned by Prescott and other writers, thatPizarro exacted from the Inca emperor, Atahu-allpa, for his ransom, a room full of gold, thedimensions of which are stated as being twenty-two feet long, seventeen feet wide and nine feethigh. An adjoining room of somewhat smallerdimensions Atahuallpa agreed to fill twice overwith silver. Such quantities of bullion were in-troduced into Europe as had never before been

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dreamed of, and prices rose to what was then con-sidered an extraordinary figure.

The city of Panama became the commercialmetropolis of the western hemisphere. The high-way between Porto Bello and old Panama becamea road over which there was a constant streamof people traveling. All the merchants, officialsand colonists going to Peru, western Mexico, andthe Spanish possessions in the East Indies usedthis route, and there was a steady and constantstream of such people going between the coloniesand mother country.

About the beginning of the seventeenth cen-tury Panama was the chief port for the Spanishtrade of the Pacific. This large travel and largebusiness was fortunate for her from a commer-cial point of view, but it was the cause of her evilreputation as to health. Her location was in thetropics, where the stegomyia mosquito couldbreed freely all the year round. Yellow feverwas early introduced by the Spanish conquista-dor. Then the constant stream of unacclimatedEuropeans passing for four hundred yearsthrough her borders made conditions ideal forthe development and maintenance of yellow fever.And for four hundred years this region has beenknown as the most unhealthy in America.

As Panama grew in wealth and importance,and it became known what great amounts of

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treasure were passing through her borders, shebecame attractive to the English soldiers of for-tune. Drake was one of the earliest of these, andhis name and fame are intimately associated withthe early history of Panama. He first came tothe north coast in 1572, and remained in the coun-try nearly two years. He secreted his ships inremote places among the beautiful San BlasIslands, and it was not discovered by the Span-iards just where he was. From this point hemade frequent expeditions against the variousSpanish possessions.

From Drake’s accounts there was still a con-siderable Indian population in the country,though not by any means as numerous as in Bal-boa’s day. This Indian population was bitterlyhostile to the Spaniards, who, whenever theycould get hold of them, were their harsh and crueltaskmasters. Consequently, the Indians werefriendly to the English whom they knew to be theenemies of Spain.

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CHAPTER X

APPOINTED CHIEF SANITARY OFFICER FOR THEISTHMUS

EARLY in the year 1902, while still stationed atHavana, I wrote to Surgeon-General Stern-

berg concerning the discoveries made by the ReedBoard, and the application made of these discov-eries to the eradication of yellow fever in Havana,and invited attention to the fact that they wouldhave a most important bearing upon the work ofthe construction of the Panama Canal.

I invited General Sternberg’s attention to theenormous loss of life that had been caused amongthe French working at Panama, due to tropicaldiseases; that by far the most important of thediseases were yellow fever and malaria; that ifwe could protect our laborers on the Canal as wehad the people of Havana, we should be able tobuild the Canal without anything like such lossesas had occurred to the French. I also invited hisattention to the fact that while there was a con-siderable difference in the conditions and environ-

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ment at Havana, still I believed that the methodsworked out at Havana could be so modified as tobe applied successfully at the Isthmus.

General Sternberg approved the idea, andrecommended that, on account of my experience insimilar work at Havana, I be placed in charge ofthe sanitary work on the Isthmus.

In all discussion with regard to canal construc-tion at this time Nicaragua was looked upon asthe point where the United States would build itscanal. Delays entirely unexpected to the authori-ties occurred on account of the failure of the treatywith Colombia, and it was not until the fall of1903 that it was settled that we were to build acanal at Panama, under a concession from the Re-public of Panama.

I was relieved from duty at Havana in the fallof 1902 and ordered to the United States, in orderthat I might be in personal contact with the prepa-rations for canal work on the Isthmus. Whilewaiting for the organization to commence, I wassent to Egypt as the representative of the Medi-cal Department of the United States Army to thefirst Egyptian Medical Congress, and I was di-rected while on this duty to examine into what hadbeen the sanitary conditions during the construc-tion of the Suez Canal.

This turned out to be a very interesting trip,though I did not get much information that was

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useful to us at Panama. The conditions were soentirely different at the Isthmus of Suez fromthe conditions at the Isthmus of Panama from asanitary point of view that there was no similarityin the sanitary measures applicable to the twoplaces. The route of the Suez Canal was througha dry, sandy desert, where, at the time of con-struction, they suffered from neither yellow fevernor malaria. The route of the Panama Canal laythrough a low, swampy country, alternating withrugged mountainous regions, where the rainfallwas excessive, and yellow fever and malaria pre-vailed to an alarming extent.

During my visit there, however, I found that theywere suffering severely from malaria at Ismalia,a town on the canal about halfway across theIsthmus, and the headquarters of the Canal Com-pany. During the early period of their construc-tion work they had a great deal of trouble supply-ing their laborers with drinking water. Theywere obliged to carry this on camel-back a numberof miles from the nearest branch of the Nile. Iwas informed that, at one time, they had to em-ploy some sixteen hundred camels in this work.

In order to obviate this expense and inconveni-ence, De Lesseps reopened the old canal of theIsraelites, leading up from the Nile through theland of Goshen. This old canal came within afew miles of the present route of the Suez Canal.

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The French extended it to the Suez Canal, andthen made a small canal parallel with the routeof the Suez, which conveyed fresh water all alongthis route. Wherever in the desert fresh wateris applied to the soil, the land becomes very fruit-ful and productive. At Ismalia, this sweet-watercanal, just described (the Arabs usually refer tofresh water as sweet water), was used for irriga-tion purposes. When I saw the canal in 1902,the town and neighborhood were covered with abeautiful growth of trees and shrubbery, andvegetation appeared on every side. Unfortu-nately, the water which produced this wonderfuloasis in the desert also bred the malarial mosquitofreely and Ismalia had become a hotbed formalaria.

Sir Ronald Ross, the great English sanitarian,who had taken so prominent a part in discoveringthat malaria was carried by the anopheles mos-quito, was employed by the French Company toadvise them how they should protect themselvesagainst this plague. The plans which he advisedwere carried into execution, and Ismalia in ashort time was entirely free from malaria.

When I returned from Egypt, I found the canalproject still being delayed. Pending organization,I was sent to Paris, France, as the representativeof the United States Army Medical Departmentto the Hygiene Congress which met in Paris in

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October, 1903. I was directed to get while theresuch sanitary information as might be obtainedfrom the Paris offices of the French Panama CanalCompany. Besides having a very agreeable anddelightful stay, I collected a great deal of valuabledata with regard to the sanitary conditions whichhad existed under the French at Panama.

Finally, in January, 1904, the Isthmian CanalCommission was organized by the President underthe Spooner Act. The President was verystrongly urged by the medical profession generallyto make a medical man one of the commissioners.It was pointed out to him that sanitation atPanama was fully as important as engineering;that if our force suffered as much from disease ashad the French fifteen years before we should havegreat difficulty in carrying through our project.His attention was invited to the fact that in thisCommission of seven men, where the sanitaryphase of the work to be controlled by themwas just as important as the engineering phase,there were five engineers and not a single phy-sician.

The American Medical Association took a mostactive part in urging this matter upon the atten-tion of the President, and hundreds of telegramscame in to him on this subject from all parts ofthe country. The President was not convincedby these arguments as they were presented to

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him, and organized the Commission of seven mem-bers without putting a physician on it.

During the latter part of March, 1904, I wasordered to accompany the Commission to Panamaas their sanitary adviser, and for the purpose ofdrawing up a scheme of sanitation whereby theforce might be protected during the constructionof the Canal. I requested that Medical DirectorJohn W. Ross, United States Navy, Major LouisA. La Garde, Surgeon, United States Army, andMajor Cassius E. Gillette, Corps of Engineers,United States Army, be detailed to assist me.

We went to Panama with the Commission, andwere absent on this trip about a month lookinginto conditions and examining the locality. Aftermuch study and careful consideration, we sub-mitted a report which embodied the organizationwhich we thought necessary to accomplish the de-sired ends. The report also gave detailed esti-mate of the cost of this organization.The French Company still had possession, and

their representatives were in charge when wemade this visit. They treated us very hospitably,and we were their guests during our stay on theIsthmus. We were housed on the Atlantic side,in the building known as the De Lesseps Palace.There was, however, nothing palatial about thisbuilding. It was simply a good, comfortable,frame building, such as can be found on many of

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the well-to-do plantations in our southern states.De Lesseps is accused of having erected it at acost of more than $100,000. As I afterwards cameto be more familiar with the history of the Frenchregime at Panama, I found that this was on a parwith most of the other stories of French extrava-gance on the Isthmus, and had no more foundationin fact than many of the other tales that fill thebooks of a few of our American writers concerningthe Canal, to the discredit of the French.

On one occasion we were invited across theIsthmus to dine with the Administrator who wasin charge of the work. It is somewhat startlingto an inhabitant of the United States to contem-plate traveling from the Atlantic to the Pacificto keep a dinner engagement, but at Panama thiswas not unusual. We not only left the Atlanticin the afternoon and dined on the shores of thePacific the same evening, but we returned fromthe Pacific and slept on the shores of the Atlanticthat same night. I was familiar with the historyof the house in which the French Director lived,where we dined that night. I could not help re-calling the sad story of Monsieur Dingler, thegreat French Director, who first attempted canalconstruction on the Isthmus. In this house haddied his wife, daughter and son-in-law, and scoresof other French engineers of prominence. TheFrench butler who waited on us at dinner that

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evening and presided over the servants who at-tended us, remained with the Americans in thesame capacity during the whole period of construc-tion on the Isthmus, and is still there as the major-domo of the Chairman of the Isthmian CanalCommission.

We spent a delightful evening, and returned tothe “North Sea” after dinner, reaching Colonabout one o’clock in the morning. An amusing in-cident of our stay on the Isthmus occurred on ourreturn. One of the commissioners was sick, andfor this reason did not attend the dinner. In mybusiness of looking up sanitary matters at Colon Ihad come to know the Mayor of the town quitewell. Much to my surprise I found him at thislate hour of the night awaiting our return. Hetook me aside and told me in a whisper that theCommissioner whom we had left behind sick hadappeared on the street most uproariously drunk,had fought the Colon police to a finish, and wasat that moment in the Colon jail raising pande-monium. The Mayor said that he had endeavoredin every way to keep the matter quiet and protectthe honor of the American Commission, but thatthe Commissioner himself had been so noisy andpugnacious that he feared the matter had gottenpretty well noised about the town.

I was, of course, much chagrined at this accountof the Commissioner’s conduct. I knew well his

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reputation in the United States, and knew that hehad lived a perfectly correct life for fifty years,enjoying the respect and consideration of the com-munity, and that at home he was known as a soberand abstemious gentleman as far as alcoholicdrink was concerned.

I took the Chairman of the Commission asideand unfolded to him the astounding story whichthe Mayor had just confided to me. We got intoa carriage with the Mayor and hurried to the jail.As we neared this building our worst fears wereconfirmed; pandemonium seemed let loose. Wecould hear our honored Commissioner swear-ing and shouting, to the great delight andamusement of the crowd outside. We hurriedin to see what we could do with our friend.Upon being ushered into the room in whichhe was raising such an uproar, we foundthat it was not the Commissioner, but oneof our clerks. He had developed delirium tremensas the result of too much French hospitality, andinsisted that he was the Commissioner above men-tioned. The Mayor was never quite convincedthat this was not the case. The Commissionerrather rose in the estimation of the townspeople,as being a jolly good fellow, but the Mayor alwaysthought that he had carried things a little too farfor a man occupying such a dignified position.In April, 1904, I was finally ordered to report

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to the Commission as the chief sanitary officer forthe Isthmus. Having been there, we had a verygood idea of how great the difficulties would be ingetting either supplies or personnel. We there-fore requested the Commission to authorize ourtaking down a certain number of men and a certainquantity of supplies. They authorized our spend-ing $50,000 for these purposes, and this we did,taking the men and supplies with us to the Isthmusearly in June, 1904.

As I have before stated, when we visited theIsthmus in March, 1904, the French were still inpossession of the property and we were theirguests. On May 4, 1904, the property was for-mally transferred to the representatives of theUnited States, so that when we reached theIsthmus in June we were at once able to take pos-session of such sanitary equipment as there was,and to begin our organization.

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CHAPTER XI

PRELIMINARY ORGANIZATION AND WORK AT PANAMA

FROM the very beginning insuperable difficul-ties arose in the way of getting supplies.

Very little could be obtained on the Isthmus, andthe supply departments in the United States wereso slow in being organized that, during the firstyear, very few requisitions that were sent to theUnited States were filled.

The attempt of the first Commission to managefrom Washington the work at Panama in all itsdetails was fatal, and the arrangement wherebythe Sanitary Department was made one of thebureaus of the Government, having no access tothe Chairman, the real executive, except throughthe Governor, was equally fatal. In June, 1904,however, we all commenced work with a great dealof enthusiasm, determined to do the best we couldunder the circumstances.

The $50,000 worth of supplies taken down, andthe personnel brought along at the same time, en-

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abled us to make a good start in all branches ofthe Sanitary Department, as outlined in the recom-mendations made in March. If it had not beenfor the supplies and personnel taken down at thistime, we could have made no better showing thandid the Engineering Department or the Quarter-master Department during the same period.We realized that the subject of yellow fever was

by far the most important phase of sanitationwith which we had to deal. We appreciated that,if the Americans were subject to this disease toany considerable extent, we should have greatdifficulty in keeping them at Panama, and in orderto induce them to stay, we should have to increasewages to such an extent that the cost of the workwould be very greatly increased. That even if weshould find a white American force which wouldbe willing to stay, and if we could afford to paysufficiently high wages to induce them to stay,Congress, in all probability, would not sanctionthe continuance of the work, if we lost from yellowfever fifteen or sixteen hundred Americans everyyear.

From the best statistics which I could get onthe Isthmus, I found that the French lost yearlyby death from yellow fever about one-third oftheir white force. If we lost in the same ratio itwould give us about thirty-five hundred deathsamong our Americans yearly. We, therefore, dur-

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ing the first year made yellow fever the first con-sideration, and gave it the most attention.

The two principal foci of infection for yellowfever were the towns at either end of the railroad,Colon at the northern end, on the Caribbean Sea,and Panama at the southern end, on the PacificOcean.As I have mentioned in a former chapter, when

we got through at Havana, we all thoroughly be-lieved that the great virtue of our work there layin the killing of infected mosquitoes by fumigation.So when we commenced work in the city of Pan-ama, we relied principally upon this method. Wecarried fumigation in Panama, however, much fur-ther than we had ever dreamed of doing atHavana. Beside carrying out the method whichwe had developed at Havana of fumigating thehouse where a case of yellow fever had occurred,together with all the contiguous houses, weadopted the following plan.

Panama compared with Havana was a verysmall town. Havana in 1904 had a population of250,000; Panama, about 20,000. Instead of wait-ing for the slow process of fumigating the housewhere a yellow-fever case occurred, with the con-tiguous houses, and thereby killing the infectedmosquitoes concerned in that particular case, weought to be able, we said, in a small town likePanama to fumigate every house in the city within

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Screened Yellow-fever Ward. Ancon Hospital, Panama.

St. Charles Ward, Ancon Hospital. Building in WhichTwelve Hundred Frenchmen Died of Yellow Fever.

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a comparatively short time, and thereby get ridof all the infected mosquitoes at one fell swoop.

This would certainly have been the result if ourpremises had been correct, namely, that it was thefumigation that had caused the disappearance ofyellow fever at Havana. With this object in view,we commenced at one end of the city and fumi-gated every building. It took us about a monthto get over the whole town. Cases of yellow feverstill continued to occur after we had finished. Wetherefore went through the procedure a second,time. Still other cases occurred, and we wentover the city a third time. We used up in thesefumigations in the course of about a year somehundred and twenty tons of insect powder, andsome three hundred tons of sulphur. These quan-tities of material give some idea of the amount offumigation.

This draft of one hundred and twenty tons ofinsect powder represented the whole supply ofthe United States for a year, and we actually usedup at Panama all the insect powder that could befound in the market of the United States.

An interesting incident occurred during thisfirst year with regard to insect powder. Knowingthat there would be some yellow fever to be dealtwith in Colon and Panama, we estimated andmade requisition for eight tons of insect powder.The reviewing authorities were very much shocked

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and surprised at the size of our requisition, andseized upon this one item of eight tons of insectpowder to demonstrate the wildness of our esti-mates. It was some satisfaction to us for theCommission to see that we had not only not beenwild and extravagant in our estimates, but thatwe had been obliged to use actually fifteen timesas much as we had estimated for.

From the very beginning the Commission un-derestimated the magnitude of the sanitary oper-ations, as well as their cost, and when the sanitaryauthorities urged upon them more extensivepreparation and larger expenditure, they thoughtus visionary and more or less lost confidence inus. This was very unfortunate both for the sani-tary authorities, and for the Commission, andcame very near being the cause of the completecollapse of sanitation.

General George W. Davis, the governor, was theonly member of the Commission who lived con-tinuously on the Isthmus. He was the only mem-ber of the Commission who had any adequate ideaof the difficulties with which the Sanitary Depart-ment was confronted. He gave us his heartiestsupport.

Our force of unacclimated whites liable to yellowfever rapidly increased during the winter of 1904and spring of 1905. Yellow fever increased withstill greater rapidity. The authorities became

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more and more alarmed. In January, 1905, thefirst Commission was asked to resign, and a newCommission was appointed.

Even after this change the Sanitary Depart-ment was in no better condition than it had beenunder the former Commission. The chief sani-tary officer was still subordinate to the governorof the Canal, and had no means of access to thechairman, except through the governor. Suchsanitary measures were carried through the im-portance of which the chief sanitary officer couldimpress upon the governor. Those, the impor-tance of which the governor could not see, werewith great difficulty carried into effect.

This condition of affairs was unfortunate. Theauthorities had no sanitary training, and as theylooked upon the ideas of the sanitary officials withregard to the method of conveyance of yellowfever by the mosquito as being wild and visionary,they could not be expected to have rose-coloredviews as to what would be the results of attempt-ing to carry these views into effect.

The sanitary authorities had no doubt of theirultimate success, and felt confident that they coulderadicate yellow fever in Panama, as they hadjust done in Havana, if they could only hold onlong enough and get reasonable support from thesuperior authorities.

Conditions with regard to yellow fever kept go-

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ing from bad to worse during the first six monthsof 1905. In April, 1905, several of the higherofficials died of yellow fever. This caused wide-spread panic among the whites, and very greatdemoralization to the work itself. A considerablesprinkling of our white force had either been inCuba with us, or knewwhat had been accomplishedthere with regard to yellow fever, but the rankand file of the men began to believe that they weredoomed just as had been the French before them.

Finally, in June, 1905, the Governor and ChiefEngineer, members of the Executive Committeeof the Commission, united in a recommendationto the Secretary of War that the Chief SanitaryOfficer and Dr. Carter and those who believedwith them in the mosquito theory, should be re-lieved, and men with more practical views be ap-pointed in their stead. They stated that the sani-tary authorities had visionary ideas with regardto the cause of yellow fever, and no practicalmethods even for carrying these ideas into exe-cution.

Fortunately for the cause of sanitation, the thenPresident of the United States had been in officewhen the work at Havana had been done by us.He told the Commission that the mosquito theoryhad been established beyond peradventure; thatits application had been entirely successful atHavana, where yellow fever had been more firmly

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established and established for a longer time thanat Panama. He declined to sanction the changerecommended, and directed that every possiblesupport and assistance be extended to the sanitaryofficials. It was really fortunate for the sanitarywork that matters were brought to a head in thisway.

Mr. John F. Stevens about this time was ap-pointed chief engineer and member of the Com-mission, to fill a vacancy which had been causedby the resignation of the former Chief Engineer.From his arrival on the Isthmus Mr. Stevensexpressed confidence in the Sanitary Department,and gave us his undivided support. The moraleffect of so high an official taking such a stand atthis period, when the fortunes of the Sanitary De-partment were at so low an ebb, was very great,and it is hard to estimate how much sanitation onthe Isthmus owes to this gentleman for its sub-sequent success.

During the fall of 1905 the Chairman of theCommission recommended that the Sanitary De-partment be made an independent bureau, report-ing directly to himself. This enabled the chiefsanitary officer to make known directly to thechairman of the Commission the needs of the de-partment. The chairman, also, when thus in-formed of our needs, gave us loyal support.

This period was the high-water mark of sanitary155

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efficiency on the Isthmus, and more sanitation wasdone at this time than during any other period ofthe construction of the Canal.During the fall of 1905 yellow fever rapidly

decreased, and by November, the last case of thisdisease had occurred in Panama. This factquieted alarm on the Isthmus, and gave the sani-tary officials great prestige, not only among thenow large body of Canal employees, but alsoamong the native population living on the Isthmus.

In looking back over our ten years of work,these two years of 1905 and 1906 seem the halcyondays for the Sanitary Department. It was reallyduring this period that our work was accom-plished. By the fall of 1907 about all of oursanitary work had been completed. Our fightagainst disease in Panama had been won, andfrom that time on our attention was given to hold-ing what had been accomplished.

One more case of yellow fever occurred in Colonduring the following May, but since May, 1906,now more than eight years, not a case of yellowfever has originated on the Isthmus.

It is interesting to speculate upon what mighthave been the result if the recommendation inregard to changing the sanitary officials had beencarried into effect. At that time, in June, 1905,most of the physicians who had had experiencewith yellow fever had not been won over to the

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truth of the theory of its transmission by the mos-quito. It was reported on the Isthmus that oneof the most prominent and ablest of these physi-cians, who did not believe that the mosquito trans-mission of yellow fever had been proved, andwho was convinced that he himself had controlledyellow fever acting upon the filth theory of itscausation, had been settled upon as my successor.Had this been the case he would undoubtedly havestopped mosquito work and devoted his attentionentirely to cleaning up, as is indicated by thefilth theory of the causation of the disease. Hewould have been the more inclined to this course,as it accorded with the beliefs and prejudices ofthe authorities on the Isthmus.

This would probably have been kept up for twoor three years, and there is no reason for believingthat our condition on the Isthmus in 1908 wouldhave been any better than was that of the Frenchat the height of their work, when they were hav-ing a death-rate of 250 per thousand per year oftheir employees.

It would apparently have been demonstratedthat nothing could control yellow fever on theIsthmus, and the belief then generally held thatit was the most unhealthy place in the world wouldhave been still further confirmed. And while itis probable that eventually the mosquito theoryof yellow fever would have become established

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somewhere else, its apparent failure at Panamawould have given it a blow from which it wouldhave taken years to recover.

It seems singular that, after the demonstrationat Havana, there should have been any doubt inthe mind of anyone with regard to the mosquitotransmission of yellow fever.

Moreover, the reputation of Dr. Carter, Dr.Ross, Mr. Le Prince and myself, as sanitaryofficials, would have been irretrievably ruined.We took a tremendous risk and came very nearfailing from causes hinted at in the foregoingpages.

Even if the dangers had been as great as theywere under the French, and the deaths as numer-ous, I believe we would have found a sufficientnumber of men who were willing to go to theIsthmus, just as did the French. There is alwaysa certain element which is attracted by dangerand adventure, and to whom exposure to risk is asufficient reward for their labor. This character-istic I have always found particularly strongamong the Americans. But if we had lost fromdisease thirty-five hundred of our Americansevery year (for the French lost in about thisratio), I am inclined to think that public opinionwould not have backed any work involving suchloss of life, and that Congress would not havemade the appropriations for continuing the work.

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CHAPTER XII

YELLOW-FEVER WORK AT THE ISTHMUS

AT the same time that yellow-fever work wascommenced, an attack was also made upon

malaria. Mr. Joseph L. Le Prince, who was incharge of similar work in Havana, was placed incharge of this work.

The anti-malarial work in the towns of Colonand Panama was exactly similar to that in thecity of Havana. But the country along the lineof the Canal between the two termini, Colon andPanama, was entirely different, and the problemwas much more extensive than it had been inHavana.

The anopheles, the malarial mosquito, is peculi-arly a country mosquito. In general, he likesclear, fresh water in which grass and algæ areplentiful, such as is found along the banks of thesmall mountain streams of Panama, or the freshwater ponds and pools. The grass and algæ giveprotection to the larvæ from the fish. Wherever

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the small fish can easily gain access, there mos-quitoes cannot breed.

For the purpose of looking after malaria alongthis fifty miles of country district, the region wasdivided into twenty-four sanitary districts, knownas Panama, La Boca, Ancon, Corozal, Miraflores,Pedro Miguel, Paraiso, Culebra, Empire, Las Cas-cadas, Bohio, Matachin, Gorgona, Juan Grande,San Pablo, Tabernilla, Frijoles, Largarto, LionHill, Gatun, Mount Hope, Colon, Nombre de Diosand Toro Point. Some years after, when the rail-road was being relocated, we had an additionalsanitary district, embracing the town of Lirio anda working force in that neighborhood for severalmiles up and down the road. Later, a quarry wasestablished at the old city of Porto Bello, for thepurpose of getting stone for the Gatun locks, andhere we had another sanitary district.

Porto Bello is about twenty miles north ofColon, on the Caribbean Sea, and in our time wasaccessible to Canal employees only by water. Itwas the northern terminus of the old royal high-way, built by the Spaniards in the sixteenth cen-tury, and a good road at that time. This roadhad become entirely overgrown and was impass-able even to a man on foot. It was originally wellpaved and well graded. I spent a great deal oftime in trying to cross the Isthmus on this road,and succeeded in getting as far north from Pan-

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ama as San Juan, a town of about one thousandinhabitants, on the Pequini River, and on theroyal road about half-way across the Isthmus.There had been some travel between this townand Panama which had kept the royal highwaysufficiently open to be traversed by pack animals.The Alcalde, a man of about seventy years of age,told me that no one in his memory had crossed onthe road from San Juan to Porto Bello.

Porto Bello has a beautiful landlocked harbor,decidedly the best for hundreds of miles up anddown the Caribbean coast. This coast is not sub-ject to hurricanes and severe storms of that kind,but during the winter months the north wind,locally known as a “norther,” blows sharply forseveral days at a time, and makes it very un-comfortable for vessels lying in the open road-steads which characterize all the other harbors.Two or three times every winter all the vessels ly-ing at the docks in the harbor of Colon have toget up steam and go to sea on account of theseverity of these northers. The harbor of PortoBello is entirely protected from these northers bya mountain which runs out into the sea. Behindthis mountain is a spacious and deep harbor.

About the beginning of the seventeenth centuryPorto Bello enjoyed one of the largest exporttrades in the then commercial world, though itwas never a very populous town in its halcyon

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days, probably not having more than fourteenor fifteen thousand inhabitants, and this only dur-ing the period when the great fair was going on.As soon as the fair was over, the populationdropped to a couple of thousands.

Professor William R. Shepherd, of ColumbiaUniversity, estimates that the bullion shippedfrom Porto Bello amounted to about forty-twomillion dollars ($42,000,000) per year. If we takeinto account the value of gold then as comparedwith the present time, we can see that the exportcommerce of Porto Bello during the sixteenth cen-tury and early seventeenth was very little undertwo hundred million dollars ($200,000,000) peryear.

Porto Bello had such a reputation for bad healththat merchants, shipmasters, sailors and every-body got away as soon as possible after the fairwas over. Indeed, I have seen it stated that itwas the health conditions that limited the lengthof the fair; that the shipmasters would stay aslong as they had crew enough to work their ships.When sickness had reduced the crew to the mini-mum which was able to work the ship, the ship-master sailed away and thus broke up the fair.

Porto Bello was established by royal decreewhen the Spaniards abandoned Nombre de Dios,a town on the Caribbean coast about twenty mileseast of Porto Bello. Porto Bello was strongly

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fortified by the Spaniards. Four different largeand extensive stone forts were erected at variouspoints about the harbor. These masonry struc-tures were considered very strong for their day,and were well armed and well manned. One ofthe largest was built well up the side of the moun-tain which formed the protection for the harbor onthe north, and where we afterwards establishedour quarry, above referred to.

Drake in his last expedition attempted to cap-ture Porto Bello. He was repulsed in his attemptto storm the forts, but succeeded in capturing theSpanish fleet in the harbor. He died in the har-bor of Porto Bello a few days after the fight,January 28, 1596. His followers placed his bodyin the flagship of the Spanish fleet, took the shipto the mouth of the harbor and there scuttled her.The island at the mouth of the harbor is stillknown locally as Drake’s Island. I cannot imag-ine a more appropriate burial place for Drakethan this spot, nor a more fitting tomb than theSpanish flagship. For this was the scene of someof his greatest triumphs over the Spaniards.

Morgan, about seventy years later, succeeded instorming the forts and capturing the town, andAdmiral Vernon again captured it in 1730.

In its prosperous days Porto Bello was everyfall the scene of the great fair. This was one ofthe great fairs of the world. The merchants from

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Spain and Europe, Cuba and Santo Domingobrought their goods to Porto Bello, and at thesame time the Spanish treasure fleet collected herefor the purpose of starting on its trip to Spain.The merchants from Peru and all the westerncoast of South America, the western coast ofMexico and the Philippine Islands collected herefor the purpose of purchasing from and exchang-ing with their confrères from the east. All thebullion, gold, silver and precious stones which hadbeen collected at Panama during the year fromthese same places was now brought on pack mulesacross the Isthmus on the royal highway, andplaced aboard the treasure fleet. The royal high-way was not much used at other times; the ordi-nary route of travel across the Isthmus was northfrom Panama to Cruces on the Chagres River, andfrom the mouth of the river by sea to Porto Bello.But this thirty miles of sea trip exposed the trav-eler to possible capture by the buccaneers who in-fested these waters. The ordinary merchant, inordinary times, was willing to take these chances,but when it came to the Imperial treasure collectedfor a whole year, and to the whole year’s supplyof merchandise, they would not risk the attackof the buccaneers, but came across the old high-way.

Porto Bello rapidly lost its importance afterthe revolt of the Spanish colonies in the early part

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of the nineteenth century. There was no longerany treasure tribute to be shipped to Spain. Thebuilding of the railroad in 1855 entirely deprivedPorto Bello of the little importance left it by theSpanish colonial revolution, and when we firstoccupied it, we found nothing but a fishing villageof a couple of hundred natives, who lived by fish-ing and some agriculture. There was a verymarked contrast between the squalid native andthe carved stone building which made his resi-dence. The walls of many of the public buildingsand some of the more opulent private buildings arestill standing, and are used by the natives. Andthe frowning old forts are in an excellent state ofpreservation.

We placed a large force here which worked thequarry. At first our malarial rate was exces-sively high, but in a very few months malaria wascontrolled and the force here got along about aswell as at the other places of employment. It wasalways the case that when our forces occupied alocality, for the first three or four months themalarial rate was high. Of course we could haveavoided this if we had been notified two or threeweeks beforehand and had sent up a sanitary forceto do preliminary work, but such notification wasnot always possible in the exigencies of construc-tion work.Porto Bello at first gave us considerable anx-

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iety; we knew its ancient history, and feared thatwe might not be able to control disease there. Butthe difficulties appeared no greater there than atseveral other points occupied by us.

Our laborers and working forces occupied theside of the mountain on the north side of the bayopposite the old town of Porto Bello, and thequarry was worked first where the old fort stood.We soon found that our employees were so muchin the town of Porto Bello that they contractedmalaria there, and that though we were able tocontrol it in our own village on the mountain side,we could not prevent our people from contractingmalaria from the natives in the town of PortoBello. The town was located outside the CanalZone, in the jurisdiction of the Republic of Pan-ama. We therefore requested the Panaman Gov-ernment to appoint the chief sanitary officer thehealth officer of the town of Porto Bello. It hadbeen generally agreed that wherever it was neces-sary for the protection of the health of the Canalemployees the Panaman Government would sur-render this authority to the chief sanitary officerof the Isthmian Canal Commission.We introduced the same health measures as in

the other sanitary districts, which we expect soonto describe, and in a few months had malaria herecompletely under control. Porto Bello was lo-cated well within the San Blas country. Though

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the inhabitants of the town were Panamanians andrecognized the authority of the Republic of Pan-ama, all of the Republic east of this point, inarea about one-half of the state of Panama,was entirely uninhabited, except by a fewSan Blas Indians, not more than thirty thousandall told.

The largest product of these Indians was cocoa-nuts, and this cocoanut trade employed a consider-able number of light draft schooners and canoes.These fleets rendezvoused in the harbor of PortoBello. They carried on their trade as far eastas the Gulf of Atrato, and the city of Cartagena,in Colombia. There was, therefore, a probabilityof the introduction of infectious disease to theCanal Zone by this route.

To protect ourselves against this disease we hadto establish a quarantine station at Porto Bello.The Panaman Government was asked to appointthe chief sanitary officer of the Canal Zone quar-antine officer for the port of Porto Bello. Thisthey promptly did.

The San Blas Indians who inhabited this coun-try east of Porto Bello, are a peculiar and inter-esting people. This was the region first occupiedby Balboa and his Spanish companions. Theyfound here a pretty dense population of Indians,Carib in language and probably in descent. Theirhabits were agricultural and their character rather

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warlike. They were thoroughly subjugated andwere worked by the Spaniards under their aparta-miento system. Las Casas states that the gover-nor, Pedro Arias, during his governorship of sometwenty years, caused the death of three millionIndians in the present state of Panama. I haveno doubt that such a figure is a very great exagger-ation, but it shows what a very good old Spanishpriest thought of the destruction of Indian lifedue to the cruelties of the conquistador.

Fifty years later when Sir Francis Drake ap-peared upon the scene, this Indian population hadalmost disappeared. Sir Francis Drake, in 1572,secreted his three ships in one of the sheltered andwell concealed bays among the San Blas Islands,and marched his one hundred Englishmen throughall parts of the present San Blas country. Hisnarrative shows that the Indian population wasvery much less than that described sixty yearsbefore by Balboa, marching through the samecountry. They had been treated so cruelly by theSpaniards that they thoroughly hated them. Asthey knew that the English were fighting the Span-iards, they were always ready to help the Englishand give information.

The governor of Panama, all through the colo-nial period, was constantly trying to overrun thiscountry, and though at various times forts werebuilt in many localities, and these forts garrisoned

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for a considerable length of time, the country wasnever conquered, and the Indians after their orig-inal conquest by Balboa never recognized theauthority of the Spaniards. They early adoptedthe policy of not allowing, under any pretext what-ever, a white man to come into their country. Thislaw they have enforced up to the present time, andstill enforce it. Many white men have lost theirlives in trying to explore the interior of the SanBlas country.

For generations there has been a good deal ofcommerce in light-draf t schooners along the north-ern coast of the San Blas country. The San BlasIndian himself, like all the other Carib tribes, is anatural-born sailor. You see him miles fromshore in his frail dugout, in the roughest sort ofweather. It has been his custom for generationsto ship aboard sailing-vessels visiting his country,occasionally for very long voyages, as far even asLondon or New York, so that when you meet him,he is very likely to speak English, and on occasionsof state, wear European clothes. In the ten yearsthat we have been at work on the Isthmus the SanBlas Indians have acquired considerable confidencein us, and have become quite friendly. They cometo the hospitals very freely for treatment andsurgical operations, and the men can now be seenalmost any day in Colon trading. Whenever theycome up to Colon, they wear European clothing.

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This is of every variety and style, but the hat isalways the same, a derby!

The present government of the Republic ofPanama has induced the old Chief to recognizeformally the authority of the Republic. This hasnot been brought about by force, but principallyby freeing the trade with the Indians of all duties,and by flattering the old Chief.As an official of the Panaman Government, the

Chief is authorized to wear a most splendid gold-laced uniform coat, furnished by the PanamanGovernment. This will not, however, always re-tain the allegiance of the old man.

Not very long ago the Panaman Government es-tablished a small police station at the extreme endof the northern coast of the Republic. The Presi-dent of the Republic took occasion to inspect thispost, and went down on the only war vessel theRepublic possessed, a twenty-ton steam launch.As they passed the island in San Blas Bay onwhich was located the principal town of the In-dians, the old Chief ran up the Colombian flag,and notified the President that he had changed hisallegiance from Panama to Colombia. As the oldfellow controlled a full quarter of the territory ofPanama, this meant a good deal to the Republic,but the President very wisely made no attempt atforce. He granted the few unimportant requestsof the Indians; increased the old Chief in his rank;

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gave him a new coat with more lace than the for-mer, and the flag of Panama now floats serenelywhere the Colombian flag then floated.

While the Indians recognize the overlordship ofthe Republic of Panama, I doubt if the President,or any other white official, would be allowed tospend a night in the San Blas country, nor wouldthey during our whole stay on the Isthmus allowany official of the Canal Commission to spend anight in this domain.

Some years ago the Indians reported to me thatthey had yellow fever among their people, andrequested my help. As their territory came di-rectly up to the Canal Zone, it was important forus to know whether or not this was really true. Aparty of sanitary officials, consisting of Dr. Carter,Major Lyster, myself and others, went down on asteamer to investigate. We went by appointmentto the principal town. The Indians were very gladto see us, and received us most hospitably. It wasa very picturesque scene as we approached thelanding. The whole population was drawn up onthe beach in their gala attire, to do us honor. Thewomen, who had probably never before seen awhite man, were dressed very much as describedby the earlier explorers in the middle of theseventeenth century; a skirt of some brightmaterial and a scarf of brilliant red around theshoulders; gold ornaments in great profusion; nose

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rings, ear-rings, heavy bracelets on the upper armand around the ankles. A most peculiar customamong the young women was that of binding verytightly around the calves of both legs a band ofbeadwork, from four to six inches broad. Somehad the same band on the upper arm. This bandhad been worn so long and was so tight that it hadmade a deep, permanent depression in the mus-cular tissue; enough I should have thought to causesome lameness, but in no case could I see that itinterfered with locomotion. The early explorersalso refer to this custom.

Another custom which I have seen referred toand which attracted our attention among theseIndians, is the manner in which the women smoketheir cigars. I saw many of them putting thelighted end in their mouths and smoking the cigarby drawing the air through it that way.

After seeing the display of gold ornaments Icould well understand how Balboa collected suchlarge quantities of gold as he describes, in hisexpeditions through the country. I estimate thatthe women I saw on this occasion averaged intheir rings and bracelets ten or fifteen ounces ofgold apiece. The conquistadors, no doubt, whenthey entered a town seized all this gold.

The Indians, as I have said, received us verycordially, and brought to us all their sick, andapparently wanted us to give some medicine to

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everyone in the village. This we cheerfully did,giving them the best advice we could, but whenevening came, they politely notified us of theirnational custom with regard to white men spend-ing a night on shore. We took the hint and re-turned aboard our steamer.

This disease from which they were sufferingwe found to be not yellow fever, but pneumonia.While ashore, we had noticed a Jamaican negropaddling around in a dugout. Upon inquiry, wewere told that he was our professional rival pre-scribing various patent medicines for the Indians.A short time after our return to Colon I was toldthat the custom among the San Blas Indians wasto execute the doctor whenever his patient died,and that our unfortunate rival, the Jamaicannegro, had been executed for this cause a few daysafter we left. We had prescribed for one or twopatients in the last stages of consumption whoevidently had not many days to live. We have,therefore, been very chary about returning to theSan Blas country, and strongly suspect that weare marked in the national archives for executionunder the San Blas law for the practice of medi-cine.

The San Blas Indian was very independent inall his ideas, and considered his government asthe political equal of the Canal Government, theUnited States, or any other government.

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In looking about for a place in which to getsand to make concrete for the Gatun locks, ColonelSibert, with a party of engineers, visited this sameChief. They found here what they consideredsuitable sand, and tried to purchase from the oldChief the right to use it. He was, however, veryshort with them; told them that the San Blas In-dians had need of all the sand the Almighty hadgiven them and hinted very broadly that it wouldbe healthy for Colonel Sibert and his party toreturn to their boats and leave the country.

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CHAPTER XIII

NOMBRE DE DIOS

ANOTHER sanitary district had to be estab-lished about twenty miles east of Porto Bello,

at Nombre de Dios. Here we had a force of sometwo hundred men who dredged the sand that wasused in making concrete for the locks at Gatun.The conditions were very much the same as at Por-to Bello. There was a small native town of notmore than one hundred people, on the old site ofNombre de Dios, and we found that to protectour own force we had to take charge of these na-tives, just as we did at Porto Bello.

Nombre de Dios has even a more romantic his-tory than Porto Bello, and the name of Nombrede Dios is even better known in the wild historyof the Spanish Main than is that of Porto Bello.It was founded about 1520, soon after the settle-ment of old Panama, and became the northernterminus of the paved royal highway leadingfrom Panama. Afterwards, when Porto Bello

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was built, the highway forked about thirty milessouth of Nombre de Dios, one branch leading toPorto Bello, and the other to Nombre de Dios.

The roadstead at Nombre de Dios was entirelyopen and exposed to the full force of the northwind, locally known as the “norther,” so trouble-some along this coast during the winter months.It was so exposed that it was difficult for theSpaniards to fortify it. The fabulous amount oftreasure which the Spaniards were bringing upfrom Peru rapidly became known throughout theworld. The Spaniards, during their earlier colo-nial period, collected their treasure from time totime during the year, in preparation of the sail-ing of the fleet. For this reason, Nombre de Dioswas constantly being threatened by adventurersof all nationalities, who frequented the seas wash-ing the shores of the Spanish Main.

Drake, in his expedition of 1572, made a mostromantic attack upon Nombre de Dios. With onehundred men in small boats he attacked the townand took the garrison entirely by surprise. Theywere driven in every direction and many cap-tured. The Governor, with a handful of men,defended the palace where the gold and more val-uable treasures were stored, with desperate valor,but the town and all other public buildings werein the hands of the English, and there seemedvery little chance for the Governor and his few

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brave followers. The silver bullion, the accumu-lations of a year from the countries tributary toSpain in this part of the world, was in one of thebuildings already in the hands of the English.Drake describes it as being piled in bars of solidsilver, and states that the pile was some eightyfeet long, twenty feet broad and ten feet high.The old Governor and his companions were stillbravely holding the palace, and Drake led acharge in person. While they were battering inthe main gate, Drake received a bullet wound inthe head and fell to the ground unconscious. Hismen became demoralized, thinking that he hadbeen killed, and though they had the prize en-tirely within their grasp, they fled to their boats,carrying with them the insensible form of Drake,and left to the defeated Spaniards the treasurewhich the English had gone through so much suf-fering and privation to possess.

The Spanish garrison was immediately rein-forced from Panama. Though Drake remainedwith his ships concealed among the San Blas Isl-ands in the beautiful tropical bay of San Blas,he never had another opportunity of surprisingwith any chance of success the fort and garrisonof Nombre de Dios.

About a year later, however, he surprised andcaptured a treasure train on the royal highwaycoming across from Panama to Nombre de Dios.

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The fight took place just about where the royalhighway to Porto Bello branches off from that toNombre de Dios. Drake’s men after the capturewere some fifty or sixty miles from their ships.There was no trail nor road of any kind leadingin that direction, so that they could not take thepack mules. Drake therefore directed that thegold and most valuable treasure should be divid-ed up among the men as much as each could carry,and that the silver and least valuable part of thetreasure should be buried and concealed as wellas it could be in the immediate neighborhood.

Drake and his men succeeded in getting to theirships safely with the treasure they had captured,and this was enough to pay the expense of theirwhole trip and besides make each one of themrich for life, according to the standards of thatday. The Spanish garrison from Nombre deDios was on the ground within a few hours afterthe capture of the pack train, and spent severaldays in searching for hidden buried treasure.They found a great deal, and thought they hadfound all that was left. About two weeks after-wards Drake and his men returned and dug upenough to give again to each man all that hecould carry, but as this was principally silver,it was not so valuable as had been their previousload.

In 1598, Nombre de Dios, by order of the Span-178

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ish king, was abandoned and everything movedto Porto Bello. As I before remarked, our menwere located right among the ruins of the old cityof Nombre de Dios, and our sand-digging opera-tions were carried on near the shore line right infront of the town. In the three hundred yearssince Nombre de Dios had been abandoned theharbor had silted up and filled in to a consider-able extent. In excavating for sand our menfound the frame of an old ship of considerablesize ten or fifteen feet under the surface of theground, and some two hundred yards from thepresent coast line. She was evidently an oldSpanish ship that had been abandoned at the thenshore line of the city of Nombre de Dios, and hadgradually been covered by the action of the waterwith sand and silt.

The Spanish officers and soldiers of 1650seemed to have lost the initiative and energywhich they had so wonderfully exhibited two gen-erations before in this same country under Bal-boa, Pizarro, Almargo, and other leaders of thatstamp. But they did not lack bravery and doggeddetermination, when it came to the defensive, aswas illustrated in the case of the Spanish Gov-ernor at Nombre de Dios, when summoned byDrake to surrender, although his condition wasapparently hopeless. His courage and devotionwere most unexpectedly rewarded by success,

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which he had not the slightest right to expect, dueto purely accidental conditions.

This bravery and devotion of the Spanish cav-alier was again illustrated eighty years later,when Sir Henry Morgan, the English buccaneer,stormed the works at Porto Bello. The circum-stances were somewhat the same as above de-scribed at Nombre de Dios. The English stormedand carried one stronghold after another untilnothing but the palace was left to the Spaniards.In the palace the Governor had placed the womenand children, with himself and about ten men,and had barricaded all the entrances as well aspossible. He steadily refused all summons whichMorgan made on him to surrender. When themain door was battered down and Morgan en-tered sword in hand at the head of more than onehundred men, he found the old Governor standingwith drawn sword, his ten men behind him and thewomen and children behind them. The Governorwas even then a man of over sixty years of age. Itwas not the custom in those days for either Span-iards or buccaneers to ask or give quarter. SirHenry Morgan is not ordinarily credited withmuch soft-heartedness even from the standpointof a buccaneer. According to accounts, he wastouched by the scene that presented itself to hisview as he and his men poured into the court—the white-haired old Governor unflinchingly sup-

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ported by his brave little garrison of ten men,and the frightened and crying women and chil-dren standing behind. By a gesture he wavedback his men, and told the Governor that hewished to spare his life and the lives of those de-pendent upon him. Though his wife entreatedthe Governor to accept Morgan’s terms andpointed out to him the uselessness of resistance,as all the town and the forts were in the hands ofsix or seven hundred buccaneers, and that therewere but ten Spaniards left, the doughty old Gov-ernor refused to yield and told Morgan that hewas not placed there by his king to surrender,but to fight, and that if he wanted his sword, he(Morgan) would have to take it, as he wouldnever yield it as long as he had a drop of bloodleft.

This is the only recorded instance that I knowof in which Morgan was touched by the braveryof his enemy. But his patience now entirely ex-hausted, he gave the signal, and in a few mo-ments the brave old Governor and ten of hisbrave men had gone to the land where the soulsof soldiers, good and true, are known to go.

This picture has always affected me strongly.I have often stood on the ground and tried to re-habilitate the old court as it appeared that mem-orable May afternoon.

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CHAPTER XIV

ETHE WORK OF THE SANITARY INSPECTORS

ACH of the twenty-five districts into which theZone was divided, as far as the general sani-

tary work was concerned, was in the charge of asanitary inspector. The sanitary inspector hadunder him a force of from twenty to one hundredlaborers, with assistants and foremen as neces-sary. The districts varied considerably in thenumber of people living in them. Some of thedistricts had as many as eight or ten thousandpeople; some only a few hundred. The area of thedistrict varied between fifteen and thirty-fivesquare miles. The Zone extends for five mileson each side of the Canal, that is, a strip ten milesbroad and fifty miles long. Most of the populationwas located on each side of the Canal, within abouta mile of its axis, while a few houses and cabinswere scattered through all parts of the Canal Zone.

Sanitary work, generally speaking, was doneonly within a mile or so of the Canal itself. All

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brush and undergrowth were cleared within twohundred yards of houses and villages, and theground carefully drained within the same area.There was no object in carrying sanitary workbeyond the populated area. Even if mosquitoesbred where no human beings were living, no harmwould be done, as there would be no one to infect.

All told, the country under the jurisdiction ofthe Isthmian Canal Commission amounted inarea to about five hundred square miles, and onlya hundred of this was affected by the work of theSanitary Department. The great work of thesanitary inspector was his anti-mosquito work.In the early days he paid most attention to thestegomyia mosquito, but after the fall of 1905when yellow fever had been conquered, attentionwas concentrated on the anopheles, the malarialmosquito.

For the elimination of the stegomyia, the in-spector in these country districts took the samemeasures as described in Colon and Panamaagainst these mosquitoes, though of course on avery much smaller scale. Against malaria, hehad a sufficient number of laborers under one ormore foremen, according to the size of the dis-trict, who cut the brush and undergrowth withintwo hundred yards of all villages, houses anddwellings, and who also cut the grass within thisarea whenever it reached a foot in height. This

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was done for several reasons. The adult mos-quito is destroyed by wind or sunlight, and heseeks all sorts of shrubbery, grass and foliagefor protection against both of these enemies.Therefore, if the brush, shrubbery and high grassis cleared off within two hundred yards arounda dwelling, there is no shelter for the mosquitofrom either the wind or sunlight, and there aretherefore no mosquitoes within this area.

The anopheles, the malarial mosquito, is not amosquito of strong flight; two hundred yards is,in general, a good long flight for her. If therewere trees and shrubs and bushes every fewyards, the anopheles mosquito might travel verylong distances and not be much exposed to eitherthe sun or the wind. But if an area of two hun-dred yards around each building is kept clear,she will not often be able to cross such a zonewithout destruction, either by sun or wind. Clear-ing this zone exposes the ground to both sun andwind, and by these forces alone many of thesmaller pools will be dried up and made unfitfor mosquito breeding. I have often seen thismeasure alone, that is, clearing the zone, cause aswampy place which I had expected to have todrain, to become dry and cease to breed mos-quitoes.

It was also the inspector’s duty to see to thedrainage. For this purpose he had a properly

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Oilers at Work in Marsh.

Burning Out Ditch With Oil Spray.

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trained body of men under his control. Thedrainage was, of course, very much more exten-sive in area than the grass and bush cutting, fornot only had the cleared zone itself to be drained,but all the area within that zone, and also thewater-courses leading off from the drained areashad to receive attention. Many times we foundthat anopheles were breeding very much beyondthe two-hundred-yard limit and still coming intothe village. In one case we had a very largeflight of anopheles which lasted for two or threeweeks, and they were found to be breeding morethan a mile from the village of Gatun. So, as amatter of fact, our work was very many timescarried beyond the two-hundred-yard zone.

The inspector used several methods of drain-ing, being governed in his choice by local con-ditions.

One of these methods was the open ditch, suchas the farmer used for the ordinary draining inagricultural work. At Panama, there were sev-eral objections to this method. While the ditchdrained the surrounding ground and stoppedmosquito-breeding at this point, it became a mostexcellent breeding-place itself, as the grass grewin the bed of the ditch. At Panama, rain felldaily for eight months of the year, and the tem-perature was always high enough from one year’send to another to encourage vegetable growth.

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The grass, therefore, grew so rapidly that theditch had to be cleaned out every two or threeweeks. The cost of keeping open a surface drainof this kind we found to be very high.

Another system of drainage which the inspec-tors used very freely and found very useful, wasthat of filling the ditch, after it had been exca-vated, with broken stone. This largely preventedthe growing of grass, and also prevented anydevelopment of mosquitoes in the ditch itself.Another form much resorted to was that of liningthe ditch with concrete. This entirely preventedthe growth of grass and did away with the ex-pense of up-keep. The only expense involved incaring for such a ditch was that of a man goingover it now and then and removing such obstruc-tions as may have gotten in. Mr. Le Prince andhis inspectors became very expert in this style ofconcrete work, and finally, by the use of chickenwire as a framework for strengthening the con-crete, were enabled to lay a ditch of this typevery cheaply. Wherever the drainage was ex-pected to be used for a year or more, we found itmore efficient and economical to use concreterather than the open ditch.

Mr. Le Prince and his staff devised severalprocesses whereby the cleaning of these ditchesof grass was much cheapened. Several solutionsof arsenic were found which, when applied to the

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grass, killed it. Such a process kept the grassdown for a much longer time than that of simplycutting it out with a hoe. A burner was devisedwhich atomized oil under air pressure, makinga very hot flame which destroyed the grass roots.After once clearing a piece of ground the in-

spector had to keep it in such condition that itwould not protect adult mosquitoes. He had,therefore, not only to keep it clear of brush, butalso must not allow the grass to grow more thana foot in height. For grass-cutting, there was agreat economy in using the horse-mower wher-ever we could. Numerous open ditches inter-fered with the use of a horse-mower. To meetthis difficulty, the inspector used sub-soil tileddrainage wherever it was feasible. This is theideal anti-mosquito drainage. It carries off thewater, so that there is no formation of breeding-places on the surface. After it is once laid itrequires no work or expense for up-keep, and ahorse-mower can be used just as freely over itssurface as if there were no ditch there.

With the various methods just mentioned wedrained pretty well about one hundred squaremiles of territory, constructing in all some fivemillion feet of open ditch, some one and a halfmillion feet of concrete ditch, some one millionfeet of rock-filled ditch, and about one million feetof sub-soil tile.

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For doing this ditching, each inspector had agang of men under a competent foreman. Inmany instances, where the work was extensiveand required unusual skill, such as tile-laying,the gangs especially experienced in this workwere transferred from district to district. Oftenit is not possible to drain—for instance, a largeswamp area, or where the locality is to be occu-pied so short a time that it is not economical todrain. In such an extensive engineering work aswas being carried out on the Isthmus, the con-struction work was constantly interfering withthe drainage and making pools and puddles whichhad to be looked after. In these instances, andmany others of similar character, the use of kero-sine oil was our only resource. The oil was dis-tributed from a can on a man’s back, by a pumpwhich he worked with his hand, forcing the oilthrough a nozzle to the place which he wished toaffect. In general, we used crude oil of com-merce, not because it was the best, but because itwas so cheap that we could use it much moreextensively than the rectified oil. It was sothick, however, that we had to thin it with vari-ous mixtures before we could spray it throughthe nozzle. This cost us a fraction over twocents a gallon, and we used about fifty thousandgallons a month over the hundred square miles ofterritory we were treating. It is not necessary

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to look after all collections of water in order thatmosquito-breeding may be prevented. If thewater is sufficiently deep and clear of grass, sothat the fish can have free access, these fish willdestroy all the larvæ, and mosquitoes will not de-velop. But all natural collections of water in awarm climate such as Panama have grass andalgæ freely growing on its edges, and these ob-structions protect mosquito larvæ, particularlythe larvæ of the malarial mosquito, the anopheles.

Gatun Lake, the large lake made by the dam-ming of the Chagres River, gave us a great dealof trouble on this account during the last twoyears of construction. Not only would the an-opheles breed freely around the edges of the lake,but wherever trees or vegetable matter were float-ing, there algæ grew freely and anopheles larvæwere found in abundance. We found that the an-opheles larvæ on the Isthmus developed justabout as freely in the mountains as they did inthe lowlands. The clear mountain torrent seemedto be just as acceptable a home for the anophelesas the edge of the lowland swamp. At Panama,the temperature remains the same all the yearround. The water of the mountain stream is suf-ficiently warm for his development, just as in theswamp. The stream, as it winds down the moun-tain, grows grass and algæ freely on both sidesof its tortuous course, and here the larvæ of the

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anopheles find safe harbor. Into this grass andalgæ oil will not spread. We had to find some-thing that would dissolve in the water and poisonthe larvæ protected by the grass and algæ.

Dr. Samuel Darling, of the laboratory, finallyworked out a mixture of carbolic acid, resin andalkali, which would emulsify in water and ac-complish this purpose. The mixture was knownas larvacide. The method of its manufacture wasas follows:

One hundred and fifty gallons of crude car-bolic acid are heated in an iron tank having asteam coil, with steam at fifty pounds pressure.Two hundred pounds of finely crushed and siftedcommon resin are dissolved in the heated acid,and thirty pounds of caustic soda dissolved insix gallons of water are added. There is a me-chanical stirring rod attached to the tank. Theproduct is ready in a few minutes, yielding aboutthree and one-half barrels.

Cost of Manufacture, August, 1909.Amount manufactured: 14,600 gallons (292 barrels)

12,600 gallons crude carbolic acid at 12 cents per gal. $1,512.0012,300 pounds rosin at $2.48 per hundred . . . . . . . . . 305.042,550 pounds caustic soda at $3.70 per hundred . . . . 94.352 tons coal at $5.00 per ton . . . . . . . . . . . . . . . . . . . . . . . 10.00Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.46Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.00

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,065.85Cost per gallon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.14

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To insure the manufacture of a uniform prod-uct, requisitions called for crude carbolic acidof a specific gravity not greater than 0.97, andto contain not less than 15 per cent tar acids.Each consignment of crude carbolic acid receivedwas assayed at the laboratory to determine itsspecific gravity and percentage of tar acids, forit is necessary to keep the product of a specificgravity approximately that of water, so that itwill diffuse rapidly and neither sink to the bot-tom, nor remain at the surface.

In a hundred square miles of territory treatedwe used about two hundred barrels of this mix-ture a month. The cost of manufacture wasabout seventeen cents a gallon. In the early dayswe had used various proprietary articles for thispurpose, for which we generally had to pay aboutfifty cents per gallon. Larvacide came in thecourse of time to be used on the Isthmus for dis-infectant purposes of many kinds, and also forthe prevention of fly-breeding. We found it mostexcellent for all rough purposes of this kind,such as disinfecting and deodorizing around privyvaults and similar places.A sanitary inspector, when malaria is rife, has

to be thoroughly familiar with the life history ofthe mosquito, and particularly with the life his-tory of the anopheles. There are some six orseven hundred species of mosquitoes, and many

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of these differ widely in their habits of flight.The stegomyia mosquito is one of the feeblestspecies in its ability for flight, and it is at onceblown away and destroyed when it gets into abreeze. It therefore seldom wanders from thehouse in which it is bred. The culex solicitans isvery strong and bold in flight, and can fly twentymiles in one night before a favoring breeze. Thishas been demonstrated by Dr. J. B. Smith, ofNew Jersey. Dr. Smith was the entomologist ofthe state of New Jersey, and one of the mostfaithful and successful mosquito workers.

The culex solicitans is the common gray mos-quito which breeds so abundantly in the salt-water marshes of our Atlantic coast. The dif-ferent species of mosquitoes differ widely as totheir breeding-places, some species breeding inbrackish water, some only in fresh water. Otherspecies breed freely in dirty and muddy water,and still others can apparently live only in fresh,clean water. The two species with which we aremost concerned as being disease-carrying mos-quitoes are very particular as to their habits, al-ways seeking fresh, clean, clear water in whichtheir larvæ can develop.

The stegomyia likes clean rain water such as isfound in cisterns and water barrels. As thesecollections are found principally around thedwellings of man in towns and cities, this mos-

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quito is known as a town mosquito. The larvaof the anopheles, the malarial mosquito, also likesclear, clean, fresh water, but it requires algæ andgrass for its protection. These conditions arebest furnished by the edges of ponds and runningstreams. This mosquito is, therefore, essentiallya country mosquito.

Generally, in any one locality, there are onlythree or four species of mosquito occurring inany abundance, so that when the inspector haslearned to differentiate these, he is pretty welleducated for work in that particular locality.Each species usually has some prominent trait;the anopheles, for instance, has the hind legs verymuch longer than the fore legs, which gives herwhen at rest the appearance of standing on herhead. The stegomyia has prominent white mark-ings on its body and white bands around thejoints of its legs, and while these cannot readilybe distinguished by the naked eye, they give it agray appearance which easily distinguishes itfrom other species in such a locality as Panama.

The culex solicitans and stegomyia look verymuch alike to the naked eye, so much so that oneof our most experienced inspectors at Panama,on returning from a vacation spent on Long Isl-and, told me that the stegomyia was the commonmosquito on Long Island. As a matter of fact,the stegomyia never appears farther north than

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Norfolk, Virginia, unless as a matter of acciden-tal introduction during warm summer weather.

As the inspector deals with the mosquito in thelarval stage principally, he must be familiar withthe habits of the larvæ, and the habits of the dif-ferent larvæ differ about as much as the habitsof the adult mosquitoes. They also differ muchin size and shape; for instance, the larva of theanopheles can readily be recognized by the wayit comes to the surface to breathe. During thisprocess it lies horizontal to and in contact withthe surface of the water. The culex larva, whenbreathing, lies with its tail up and head down.The anopheles is a long, very slender larva; theculex, short and chunky. The anopheles larva ismost noticeable from its superior intelligence. Itwill dive and seek shelter in the grass at anysound or shadow thrown upon the water; theculex larva is sluggish and pays little attentionto such things.

The inspector must become very familiar withthe half-dozen most frequently occurring larvæin his district; he must recognize them easilywhen he sees them, and must know the kind oflocality in which to seek for them. He must learnthe peculiarity of ditching as applied to drainageintended to prevent mosquito breeding. This isquite an art in itself. Take, for instance, an or-dinary depression between two small hills; if we

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OldFrenchEngine TenderUsedas Storage Tank forOil.

Mule for Packing Oil to Oilers.

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want merely to get the water away for ordinarydrainage purposes, a ditch through the centerwill accomplish this, but sometimes where thewater is oozing through the surface on the hill-side, you still have soft moist places on each sideof your ditch which makes most excellent breed-ing-places for mosquitoes.

Mr. Le Prince discovered that for mosquitowork ditches would have to be run along the hill-side to cut off the water from this soft groundand to catch it when it came to the surface.Where the ordinary engineer does ditching, sucha detail as this is overlooked by him.

Wherever possible, I insisted upon the sani-tary inspector who was instructed in these mat-ters doing his own work, using men employeddirectly by himself and under his orders andsupervision. I think it is of the utmost impor-tance in mosquito work that the health officershould have direct control of the men doing thiswork. The ordinary engineer has no specialknowledge of the life history of the mosquito, andas the ditching and brush-cutting are done to pre-vent mosquito-breeding, it is not surprising thatit is not successfully done by a man who has noknowledge of the mosquito.

All the work at Havana was done by mentrained and instructed as to the life habits of themosquito, and the same was the case for the first

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three years at Panama, when the effective mos-quito work was done. Whenever speaking orwriting on this subject I have insisted upon thenecessity of having the execution of the work inthe hands of men who have been trained in anti-malarial procedure.

Another duty of the inspector was to see thatthe houses were properly screened, and that thescreens were kept in effective condition. The Com-mission had several thousand buildings scatteredin thirty or more towns, and it endeavored tokeep all these buildings mosquito-proof with wirenetting. Mr. Wright, the architect of the Com-mission, developed several very useful types ofhouses, well adapted to a tropical country andfor the use of wire netting. The general planwas not to attempt to screen the doors and win-dows; such screening is more or less imperfect,and with several entrances to a house, it is im-possible with any ordinary care to prevent thedoors being left open. Mr. Wright thereforeplanned his houses so that they were screenedin, having only one door of entrance. A housescreened in this way is very thoroughly protectedagainst the mosquito. The housekeeper, withvery little attention, can keep closed the onescreen door that gives entrance to the house.

Another great advantage of such screening isthat there is very little interference with the cir-

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culation of the air. We used a wire netting ofsixteen strands to the inch. In the case of a win-dow screened with such wire, a large part of theair that would ordinarily enter is kept out, andthe interior of the house is made hot and uncom-fortable in a warm climate. With the whole sideof the veranda screened the amount of air keptout is not appreciable, and at Panama there wasno complaint that the screening interfered withthe ventilation.

Another very great advantage of this style ofbuilding was that the galleries could be used asliving- and sleeping-rooms, and this at Panamawas very generally the case. It was found thatthe cost of screening the gallery was very littlemore than that of screening the doors and win-dows. While screening the whole gallery re-quired much more wire netting, the work itselfwas very simple. Making the window and doorframes brought up the cost of screening them toabout the cost of screening the galleries.

Care must be taken as to the quality of the wirenetting. We were put to a great deal of expenseat Panama by sometimes getting wire nettingthat would last only two or three months. Wefinally adopted a specification requiring that ournetting should be at least ninety per cent copper,allowing not more than ten per cent of non-cor-rosive metals. All netting was carefully tested

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to see that it came within these specifications. Itwas the very general opinion on the Isthmus thathouses thus screened protected us much morethoroughly from insect life than is the case inmost parts of the United States during the sum-mer months. The dwellers in these houses habit-ually sat on the galleries, with electric lightsburning, and would read for a whole eveningwithout being disturbed by any kind of insect.

The inspector had a man constantly employedpatching holes and looking after the condition ofthis wire screening. In our barracks, in whichforty or fifty Jamaican negroes lived, it wasmuch more difficult to keep the wire netting inrepair, and to keep the screened door of entranceclosed, and some mosquitoes would always getin, if there were any mosquitoes around. Inmany of our stations we succeeded in entirelyeliminating the mosquito, as in the district ofAncon. In such districts it made little differenceas to the condition of the wire netting; in otherdistricts where the anti-malarial work had beencurtailed, mosquitoes were troublesome, andevery day some would get into such barracks as Ihave described.

For these cases Mr. Le Prince and his assis-tants developed a very effective method. Theytook an ordinary test tube, put at the bottom ofit a few pieces of ordinary rubber, dropped on

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this rubber a few drops of chloroform and placeda small layer of absorbent cotton over it to keepit in place. When the mouth of this test tube isplaced over the mosquito, she in a few secondsbecomes narcotized by the chloroform and dies.

This method of killing infected mosquitoes wasdeveloped by Mr. Le Prince and his sanitary in-spectors into one of our most effective anti-ma-larial measures. It can be used where none ofthe other anti-malarial measures is possible.

For instance, at one time we had railroad con-struction going on near Diablo Hill. This hill issurrounded by fresh-water swamps on threesides. We put a force of several hundred mento work on this. They were fairly comfortablyhoused in ordinary box cars, the doors and win-dows of which had been carefully screened withwire netting. These cars were located at the footof Diablo Hill, on the edge of the swamp. Noanti-malarial work having been done here up tothis time, anopheles were very numerous. Theswamp was so extensive that efficient anti-mala-rial work was not considered then practicable.Prophylactic quinin in five-grain doses was beingtaken by these men, but we knew from a recentexperience in this same locality that infectionwas so severe that prophylactic quinin alone wouldnot protect our men. We knew, also, that a cer-tain number of mosquitoes would get by the

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screens every night. With a number of men liv-ing in a car and using one door, we knew that onthe average that door would be open a large por-tion of the time. From inspections, we had foundthat there were always a considerable number ofmosquitoes in the cars. Mr. Le Prince reasonedthat while the mosquito-catcher could not by anypossibility catch all the mosquitoes in every carevery day, he would catch most of them. It wastherefore extremely improbable that any individ-ual mosquito would escape the mosquito-catcherfor ten successive days. As it takes ten daysfrom the time at which the female anopheles mos-quito bites the man sick with malaria until sheherself becomes able to transmit the disease, nomosquito would live long enough under theseconditions to become disease-bearing. And inpractice this proved to be the case. The mos-quito-catcher went through the cars every dayand caught all the mosquitoes he could find, andcontinued this day after day as long as the carsremained in this swamp. The force was kepthere for several months without suffering appre-ciably from malaria.

This was the more impressive from the factthat just before we had our negro employees incars on the edge of the swamp, we had kept aconsiderable force of marines for several weekscamped in tents on top of Diablo Hill. These

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marines suffered very severely from malarialfever, very few of them escaping. The tents notbeing screened, we could not carry out the samemethod of catching infected mosquitoes whichwas so successful in the case of our negro labor-ers, a couple of hundred yards distant from thissame camp. One of the medical officers reportedto me one day that, under a mosquito-bar whichhe had kept over a sick man during the precedingnight, he caught in the morning quite a largenumber of anopheles—about fifty, as I recall it.We used this method more and more during thelater years of our work on the Isthmus.

It is quite feasible everywhere, by properdrainage, to eliminate entirely the anopheles mos-quito, and in several of our towns and villageswe succeeded in doing this, and could have doneit everywhere if it had been thought desirable bythe authorities to apply the same methods, whichhad been successful at these places, and previous-ly at Havana.

At stations where mosquitoes were more or lesstroublesome, the mosquito-catching method abovedescribed was very useful in the barracks of thelaborers. In a barrack building which quartersforty or fifty men the best screening will not alto-gether keep out mosquitoes, if there are manymosquitoes around. Holes will continually bepunched in the wire netting, but mosquitoes enter

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principally through the constant opening of thedoor, and through the door being carelessly leftopen. We found that at such stations we couldkeep malaria down by catching malarial mos-quitoes.

Occasionally, at a station where we had con-trolled mosquitoes for several years, a greatswarm would appear for reasons which we couldnot explain. These swarms would not remainfor a long time, and usually they were not madeup of anopheles. While they lasted, we used themethod of catching infected mosquitoes for theprotection of our force. On one occasion, how-ever, we had a large flight of anopheles. Theyswarmed everywhere about the station, and wecould not account for them, or discover wherethey came from. The sanitary inspectors’ de-partment devoted all its spare force to investi-gating this point, and for a considerable periodMr. Le Prince devoted all his time to the subject.He finally located the breeding area in a smallswamp about a mile from the town. This swamphad existed there during the preceding yearswhen Gatun had been comparatively free frommosquitoes. At this particular time when theanopheles were so troublesome, the engineers hadbegun to pump silt from the channel of the Canalinto this swamp. This silt was carried by saltwater, which made the water of the swamp brack-

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ish. This brackish water apparently favored thedevelopment of the anopheles, and they were pro-duced in enormous numbers. The engineers wererequested to pump sea water into the swamp areafor a few days. This soon made the water of theswamp too salty for the breeding of the anopheles,and in a few days the mosquitoes disappearedfrom the town.

It is remarkable that anopheles should havebred in this brackish water, as it is a mosquitowhich generally seeks fresh water. It is probablethat the brackish water made some advantageouschange in the food supply of the larvæ, and thatwhen the swamp was filled with pure sea water,this food supply was stopped. This is the longestflight of anopheles which we discovered on theIsthmus.

The method worked out by Mr. Le Prince andhis assistants was original with them. Theywould take a screened cage containing a largenumber of anopheles mosquitoes, and spray themwith a solution of aniline blue; take them downat night and release them at the suspected spot.They would erect a tent at some convenient placein the town to be examined, put a mosquito-barin this tent with a man under it as a bait for thelady anopheles, leave the bar open during thenight, closing it early in the morning before theanopheles which had bitten during the night had

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an opportunity to escape. The mosquitoes underthe bar were caught and carefully examined. Ifany blue-stained mosquitoes were found, it wasproof that they had come from the point at whichthe stained mosquitoes had been released theevening before.

The job of acting as bait for the mosquitoesduring these investigations was a position muchsought after by our negro employees. They werepaid by the hour the same wages that the day-laborers received. To be paid full wages forsleeping in a comfortable bed struck the Jamai-can as being as near complete bliss as was to befound in this world.

Mr. Le Prince did a great deal of work in ex-perimenting upon the flight of the anopheles atother stations, and during his investigations cameacross many curious things as to the habits andtastes of the anopheles. He found that theanopheles would show a marked preference for aparticular horse; though there might be severalother horses near and accessible, they would bitethis one horse almost exclusively, the taste ofwhose blood they seemed to prefer. The samething was true of men. We had one inspector ofwhom the mosquitoes were excessively fond.When they were not very numerous, they wouldscarcely trouble his companions at all, devotingall their attention to him. This poor fellow died

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as a result of this kind of work. He was Mr. LePrince’s main dependence for investigations ofthis kind. He did not suffer particularly frommalarial fever while on the Isthmus, but a shorttime after his return to his northern home, hedied of an attack of pernicious malarial fever.

These various methods of combating malariawere very successful. In some of the towns, as Ihave already said, they were just as successfulas they had been in the city of Havana, and Imyself have no doubt that, if we could have con-tinued the methods which we inaugurated on theIsthmus, we should have been just as successfulwith malaria at Panama as we had previouslybeen with the disease at Havana, and at nogreater cost. As it was, we succeeded in so pro-tecting the force against malaria that it did notinterfere to any appreciable degree with its work-ing capacity.

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CHAPTER XV

THE WORK AT THE HOSPITALS

DR. JOHN W. ROSS, of the United StatesNavy, Major Louis A. La Garde, of the Army,

and I had all had a large experience in tropicalmilitary service. We were, therefore, thoroughlyimbued with the idea that from the very beginningwe must make ample and liberal provision for thecare of a large number of sick. We were im-pressed with the fact that the constant sick rate ofthe Army in the Philippines had been ninety perthousand during the year 1898; that it had beeneven larger with our Army at Santiago, Cuba.We therefore thought that we should prepare tohave at least fifty per thousand of our employeeson the Isthmus constantly sick.

Our estimates were based upon fifty thousandemployees. If, as occurred with our Army in thePhilippines, we should have three hundred perthousand constantly sick, we would need a bedcapacity, equipment and personnel for the care

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of fifteen thousand sick. If, as we hoped, it mightnot exceed fifty per thousand of our employeessick, we should only need a bed capacity of twenty-five hundred beds. We determined to keep at leastfifty beds per thousand for our actual force; thatthis should be the minimum number, and that thenumber of beds should be increased as the forceincreased.

It is a matter of interest to note the fact thatduring the year that our force was at its maxi-mum, fifty-eight thousandmen during the calendaryear 1913, we had a hospital capacity of just abouttwenty-five hundred beds, though the constant sickrate of our employees at this time was only abouttwenty-two per thousand. The hospital servicehad become so popular, and had acquired such areputation for the skillful service and good carewhich could be obtained there, that a large numberof people came to seek its benefits from variousSpanish American countries north and southof us.

We had at this time some eight hundred in-dividuals in the hospitals who were not Canalemployees. Dr. Ross was determined that ourhospital service should be first-class in every re-spect; that a sick employee of the Canal Commis-sion on the Zone should be able to command justas skillful, and just as good care, as he could com-mand in our largest centers in the United States.

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With this object in view the hospitals wereequipped with bedding and other hospital sup-plies of the very best kind. Very little was ex-pended upon buildings. In general we used thebuildings that had been erected by the Frenchsome twenty years before, and which were stillstanding in fairly usable condition.

Dr. Ross impressed upon everyone with whomhe came in contact that the hospital departmentwas organized primarily for the care of the sick,and that the comfort and happiness of the sickmust always have the first consideration. Thisdepartment retained this principle as its mostmarked characteristic during the whole period ofits existence.

The very best equipment in all directions wasobtained, and the very best class of young phy-sicians and surgeons was secured from the UnitedStates. At our maximum we had, all told, one hun-dred and two physicians in the Sanitary Depart-ment. Our nursing force was as enthusiastic, asgood and as efficient as could be found anywhere.At our maximum we had one hundred and thirtytrained nurses from the best training-schools inthe United States.

As I have mentioned before, the Canal extendedfrom northwest to southeast some fifty miles, thecity of Colon being at the northern end and Pan-ama at the southern. The working force was

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scattered, more or less, along this line betweenthese two points.

The French had left two large hospitals, AnconHospital at Panama on the southern end, andColon Hospital at Colon on the northern end. Wedetermined to utilize these two hospitals as basehospitals, and to bring as many patients as pos-sible from along the line to these institutions. Wedivided the territory between Panama and Coloninto as many medical districts as we had sanitarydistricts, and in each of these districts a small hos-pital was erected, from twenty to one hundred bedsin size, where a certain number of sick couldbe treated, whom we thought it would not beadvantageous to transport to the two base hos-pitals.

Many of the districts had several villages withintheir borders where the laborers lived. Each ofthese villages had in it a small hospital of from fiveto fifteen beds where the sick were kept until theycould be moved to the district hospital. We hadsome forty of these sub-district hospitals, whichwere generally known as rest camps. This gaveus, all told, some sixty hospitals.

It was evident that we could not afford to makeall these sixty hospitals first-class hospitals, andwe therefore decided to concentrate upon our twobase hospitals and make them first-class in everyrespect. For instance, in the surgical line we de-

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termined to have all the instruments, equipmentand personnel that could be obtained in the bestequipped hospitals in our large cities. Theeighteen district hospitals were well equipped tocare for emergency patients, both medical andsurgical, and for such as it was thought would beinjured by being moved to the base hospitals.The sub-district hospitals, or rest camps, were notequipped at all for the care of surgical cases, butmerely for the care of medical cases until theycould be moved to the district hospitals.

The sub-district hospitals were used a great dealfor the care of men who were sick only for a dayor two. It was believed that there would be acertain amount of injury done in transportingthe wounded by train. Some of the stations weretwenty-five miles from either Ancon or Colon, butat the same time it was thought that the bettercare, skill and attention that the patient could getin the large and well-equipped hospitals, such asAncon and Colon, would a great deal more thancounterbalance the injury done by the long rail-way haul.

For the purpose of transporting the sick andwounded from the various district hospitals to thebase hospitals, hospital cars were run over theroad morning and evening, in both directions.The hospital cars were of local manufacture,gotten up by Dr. Carter, the then director of hos-

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pitals. He took the ordinary baggage car, riggedup iron frames over which canvas was stretched,and these frames were secured to the walls withhinges, so that when not in use they could befolded down on the side of the car, out of the way.There were sixteen of these beds in each car. Thecar was also arranged so that when the beds werenot left down there was a row of seats available allaround the car. Ordinarily, in transportationthere would be five or six stretcher cases occupy-ing beds in the car, but the large majority of thecases would be sitting up. Each car was providedwith a toilet, a small supply of medicines andsurgical dressings, and two small closets in whichsuch things were stored. The car was manned bya trained white male nurse and a negro assistant.The car was screened.

The trains at Ancon and Colon were met by thenecessary number of ambulances, and the patientin this way was carried to the hospital. Cases ofpressing emergency were brought on specialtrains. The district physician could generally geta special train if he certified that there was neces-sity for it.

This method of transportation for the sickproved eminently satisfactory, and during our tenyears of construction work on the Isthmus, it ful-filled every need. We transported a great manythousand patients in this way without a mishap

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of any kind due to the method of transportation.The country along the Canal route was exceed-

ingly rugged, and many of the district hospitals,for the first few years, were inaccessible towheeled vehicles. So the patients who could notwalk had to be carried to the hospital car onstretchers. But long before the period of con-struction was half through roads had been builtto all these district hospitals.

In charge of the medical matters in each of ourtwenty districts was a district physician. Thisphysician had charge of the district hospital, andlooked after the patients there. It was also hisduty to look after the families of employees. Nocharge was made for the medical care of an em-ployee, or for medicine furnished him, or for sur-gical operations performed upon him.

The district physician had the authority to sendany employee he thought best to the hospital. Ifthe employee preferred to stay at home for treat-ment he was charged one dollar for each visit ofthe physician. These fees reverted to the Commis-sion. The physician was paid a fixed salary bythe Commission, and was not allowed to make anycharge for his services. Members of families ofemployees were charged one dollar a day for hos-pital care, and could be admitted on the order ofthe district physician. Families of employeeswho received less than fifty dollars a month were

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charged only thirty cents per day for hospitaltreatment. As a rule, both employees and theirfamilies preferred to come into the hospital whensick, rather than to be treated at home. The classof employees receiving less than fifty dollars amonth was almost exclusively Jamaican negroes.During the earlier years of our Isthmian work thenegroes were afraid of the hospitals and did notlike to come in. This applied particularly to thewomen and children. But as years went by wegained their confidence entirely, and during thelast years of construction, the hospital accommo-dation for negro women and children was alwaysfull, though we were constantly extending thisbranch of our hospital.

In each district one or more dispensaries weremaintained. In immediate charge of the dispen-sary was a competent druggist who had one ormore men under him for assisting him about thedispensary. The district physician presided overthe dispensary and advised without charge anyonewho applied for treatment, and furnished him withmedicines if he were unable to pay. Quinin wasgiven at the dispensary to anyone who applied.In some of the larger districts where the popula-tion amounted to eight or ten thousand, the districtphysician had as many as four assistants. All thedoctors on the Isthmus had to be graduates ofmedical schools in good standing, and, except for

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the first few years of construction, had to passa civil service examination.

There was a very great sanitary advantage inour giving in this way to the whole population freemedical service and medicines. It kept the dis-trict physician accurately informed of what char-acter of sickness was occurring in his district.The sanitary authorities thus had the very earliestinformation with regard to such diseases as yel-low fever and plague, and they were enabled totake the proper sanitary precautions at the timewhen they would be most efficacious. Many timesinformation obtained in this way enabled us tostamp out these diseases in their incipiency andbefore they could get started as epidemics.

The district physician also had inspectorial con-trol of all buildings within his district. He wasdirected to pay particular attention to hotels,eating-houses, etc. He was required to make amonthly report on these subjects. Faults reportedby the district physician were carefully lookedafter by the central sanitary office, and were usu-ally promptly corrected by the responsible sani-tary official.

The sanitary inspector had the care of all thecemeteries in the Zone, which were twenty-oddin number. Each of the districts had a ceme-tery, and no burials were allowed except in thesecemeteries. The inspector kept a register of all

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burials, and any death which was at all suspi-cious was investigated by the authorities of theSanitary Department. The charge for prepar-ing the grave was just about enough to coverthe expense of digging. The control of thecemeteries by the Sanitary Department we con-sidered very important from a sanitary point ofview, as in this way we could keep an absoluteregister of all deaths occurring, and no death froma contagious or infectious disease could occur with-out the authorities being informed.

On Flemenco Island was located one of our old-est cemeteries, though small in size. Here wereburied quite a number of our naval officers andsailors who had died of yellow fever on our warvessels while in the bay of Panama during thepreceding fifty years. Here were buried, also,patients who died at the nearby quaran-tine station. The site was beautifully locatedabout half-way up Flemenco Hill, in a densetropical forest, with just below it, at the waterline, the vine-covered ruins of an old Span-ish fort. At the present time the top of FlemencoHill has been cut away for the location of one ofour batteries. The old fort has been razed forthe location of another battery and the tombs andmonuments of the old cemetery have been movedto the grounds of Ancon Hospital.In the grounds of this hospital was located the

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cemetery where most of the employees andlaborers who had died during the period of con-struction were buried. This also was a very pic-turesque place, situated on the side of Anconmountain, looking to the north, with Culebra Cutinstinctively in view. The grounds were prettilylaid out and artistically planted with tropical treesand shrubbery. Here we had some two thousandinterments.

But the principal cemetery was that located atMount Hope. This was the cemetery for the cityof Colon, and in all the writings of the early dayson the Isthmus, it is known as “Monkey Hill.” Ithas been in use ever since the foundation of Colon,about 1850, and contains a large number of in-terments. Here sleep most of the men who diedduring the construction of the Panama Railroad,andmany others well known on the Isthmus duringthe fifty years of the existence of the railroad asa transcontinental route. Dr. Connor, health offi-cer of Colon, gave a great deal of attention andthought to the beautifying of this piece of ground,and it is now as pretty a garden of tropical treesand shrubbery as can be seen anywhere.

At Porto Bello we used the principal fort onthe north side of the harbor as a cemetery. Thisstructure, though built of brick some two hundredyears before, was in a very good state of preserva-tion. The mountain rose several hundred feet on

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this side of the harbor, and on the side of thismountain, to the seaward from the old fort, waslocated our great Porto Bello quarry, from whichwas obtained the stone for building the Gatunlocks and the Colon breakwaters. The fort was avery strong and complete military structure forits time, and it was located at the foot of the moun-tain, near the water’s edge. When I first visitedthe ruin, it was completely covered with jungle, tosuch an extent that it could not be entered orrecognized as a structure built by human hands.I reached it and made an entrance by having anative machete-man cut out the jungle enough forme to force my way through behind him. Largetrees were growing in all parts of the old struc-ture, some of them six or eight feet in diameter,and more than one hundred feet in height.

The interior of the fort was cleared of jungleand arranged so that it could be used as a ceme-tery, and here are buried the employees who diedat Porto Bello within the six or seven years dur-ing which we operated the quarry. I selected itas the cemetery site, because it struck me as be-ing appropriate that this old fort, which had seenso much of war, should finally be used for sopeaceful a purpose as the last resting-place ofthe laborers engaged in the construction of a com-mercial enterprise like the Panama Canal, forwhich so much is hoped for the benefit of the whole

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human race. The old fort had been built by oneset of pirates, the old Spaniards, to protect theplunder which they had wrung from the Incas andother natives of America, from that other set ofpirates who infested the Spanish main, and wereconstantly attempting to wrest from the Spaniardsthis plunder.

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CHAPTER XVI

MALARIA WORK AND THE HOSPITAL SYSTEM

IN the early years of our construction malariawas very common and gave a great deal of

trouble. As I have explained before, malaria iscaused by a small animal parasite which lives inthe blood of man and feeds upon the red globules.The excretions of this parasite poison man andcause the fever and other symptoms which we knowas malarial fever. This parasite is transferredfrom the sick man to the well man by the bite of themosquito. Now it is quite evident that if in anyway we can kill the parasites as they exist in man,we not only cure the individual man of malarialfever, but at the same time prevent his being ameans of infection for other men who have not yetacquired the disease. In a purely empirical man-ner, some one hundred and fifty years ago a drugwas discovered which man could take without in-jury to himself, and which, when absorbed intothe circulating blood was deadly to the malarial

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parasite there swimming about. It is somewhatsingular that this drug should have been discov-ered not very far from Panama. A PeruvianCatholic priest found that the Indians in certainparts of Peru cured themselves of the feversnative to that country by the use of the bark of acertain forest tree common to that region. Itsbenefits were so evident that the wife of the Cap-tain-General of Peru became interested in the mat-ter, and spread about a knowledge of the virtue ofthis wonderful bark, and introduced it into themother country and other parts of Europe. Thislady was the Marchioness of Cinchona. No drugever discovered has been as useful to mankind asquinin, and it remains up to the present time oneof the few specifics known to the medical profes-sion.

Besides curing the malarial patient after he hadgotten the parasite into his blood, it was the desireof the Sanitary Department to have the blood ofall persons on the Isthmus in such condition thatit would not harbor the parasite. We believed thatif everybody would take five grains of quinin aday, this quinin would be absorbed into the bloodand render the blood so poisonous to the malarialparasite that when the parasite was injected intothe blood by the mosquito it could not thrive anddevelop, but would die.

With the object of getting as many people as

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Distilled Water Cart. Culebra.

Ward at Ancon Hospital.

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possible to take quinin every day, each districtphysician had attached to his staff one or morequinin dispensers. This quinin dispenser was aman furnished with quinin in various forms, whospent the day going about among the laborersoffering them quinin. It was the endeavor of thedistrict physician to have each laborer once a dayoffered quinin. The dispenser carried with himwhat was known on the Isthmus as quinin tonic.This was a quinin solution made up so that eachounce should contain five grains of quinin. Otheringredients were added so as to make it attractivein smell, taste and appearance. The quinin dis-penser also carried with him quinin pills, capsulesand tablets, and the patient was allowed his choice.

The Commission ran a large number of hotelsand eating-houses, where all classes of employeeswere fed. Quinin tonic and quinin tablets wereplaced on the tables of all these eating-houses andmesses, and an educational campaign was vigor-ously pushed among the employees, with the ideaof teaching them what was aimed at by takingquinin in this way. No attempt was ever made toforce anyone to take this prophylactic quinin, butexplanation and persuasion were used to theirfullest extent.

By these methods we succeeded, when the useof quinin was at its maximum, in getting our forceto take about forty thousand doses per day. The

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men responded very heartily and loyally to thissystem of education. I was very much gratifiedat the results, and feel confident that no systemof compulsion could have been as successful. Iam satisfied that during the early years of con-struction, before our other anti-malarial work hadproduced results, this giving of prophylactic qui-nin on so large a scale was of the very greatestuse to us.

Under some circumstances we required our em-ployees to take quinin. At Taboga, down in Pan-ama Bay, we had a convalescent hospital wherethe men were sent to spend a week or two whenconvalescing from the severer forms of malarialfever. A man with malarial parasites in his bloodwas a source of infection and of danger to his wellcompanions. With the idea of being certain tokill all the parasites in his blood, he was requiredto continue large doses of quinin for a week orten days after the stoppage of his fever. Butsuch is the nature of man that as soon as youbegin to force him to do a thing, from that momenthe begins to seek ways by which he can avoiddoing the thing you are trying to force upon him.A certain number of men, when they were given

their daily dose of quinin in the dispensary, wouldmanage to throw their tablets out of the dispen-sary window. The old turkey-gobbler that wasthe pet of the hospital seemed to like the stimu-

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lating effect of the quinin and gobbled up all thetablets he could find. He became so dissipated inthis way that he finally developed quinin ambly-opia. This amblyopia is a species of blindnessthat is sometimes caused by too much quinin. Thedoctor finally had to confine his old gobbler andkeep him away from quinin tablets until he recov-ered his sight. I cannot vouch for this story, butI was often twitted with it as an illustration ofhow the men were treating prophylactic quinin.Even if this story were true, it could not be usedas an argument against prophylactic quinin on theIsthmus. In general, no attempt was made at com-pulsion, and there would therefore be no objectin a man taking quinin and throwing it away.

I have noted before that our hospital system wasplanned upon the scheme of some forty sub-dis-trict hospitals, or rest camps, which fed abouttwenty district hospitals. These twenty districthospitals, by means of hospital trains, fed twobase hospitals, situated respectively at the north-ern and southern end of the Canal, Colon andPanama. The one at the southern end was muchour largest hospital, containing at its maximumabout fifteen hundred beds.

The city of Panama is situated on a peninsula,stretching into the bay of Panama. Just northof the city rises Ancon mountain, some six hun-dred and fifty feet in height. This mountain is

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only accessible to a pedestrian; the trail is toorough and precipitous for horse or mule. Thenorthern suburb of the city of Panama is knownas Ancon, and this village nestles about the south-ern foot of Ancon mountain. The line dividingUnited States territory from Panama passes be-tween Ancon and the city of Panama. Ancon istherefore under the jurisdiction of the UnitedStates.

Ancon Hospital is beautifully located along thesouthern and eastern front of Ancon mountain.The French early in their construction period,about 1882, commenced building their main hos-pital there. The side of the mountain was gradedfor roads and laid off in the most beautiful andpicturesque manner. Every variety of tropicalshrub and plant was introduced from other partsof the tropical world and planted around thegrounds. Every opportunity for picturesque lo-cation of buildings was seized, and over thirtyhospital buildings of various kinds were locatedover a large area, extending along the northernand eastern sides of Ancon mountain.

The maximum bed capacity under the Frenchwas about seven hundred beds. The hospital builtby them was well manned and equipped, and wasa very much better institution than any hospital inAmerica that I know of at the same period car-ried on by a firm or corporation. The French did

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most of their work by contract so that almost allof their patients were employees of the variouscontractors. Each contractor was made respon-sible for sick employees whom he sent to the hos-pital, and was charged one dollar a day for eachsick employee as long as he remained in the hos-pital. A dollar a day was a very moderate chargefor the care and attention given a sick man inAncon Hospital, and I know that the charge didnot cover the cost to the old company.

It is the general belief among the people on theIsthmus, who were there during the general con-struction work of the old French Company, thata very small portion of the employees of the con-tractors came into the hospital. Notable amongthese is Sir Claude Mallet, who was the Englishrepresentative in the city of Panama during theperiod referred to, and who is at present the Brit-ish minister to the Panaman Government. Frommy knowledge of human nature I feel sure thatthe French contractors did not send a large pro-portion of their sick to Ancon Hospital. I am sur-prised that under these circumstances the hospitalever contained seven hundred patients. If we hadbeen doing the work and had twenty-five or thirtyAmerican contractors employing sixteen or sev-enteen thousand men, I should be very much sur-prised if we at any time had seven hundred pa-tients in the hospital, if the contractors were re-

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quired to pay one dollar per day for each of theseven hundred patients.

Attached to the hospital the French had a dairywith a very complete set of dairy buildings. Inconnection with this dairy was a farm of somethree or four hundred acres. The water supplyfor the hospital during the French occupationcame from three or four beautiful springs whichissued from the side of Ancon mountain. Nightsoil was taken care of by a bucket system of closets.

The hospital system, on account of thetopography, was necessarily the pavilion system.This system was probably the best that could beadopted for both the local and climatic conditions.The cooking was done at one central kitchen, andthe cooked food distributed to the wards, where itwas consumed.

The nursing force was composed of CatholicSisters, assisted by negro maids and orderlies.These orderlies and maids did the manual workand rough nursing, under the supervision of theSisters.

The medical staff consisted of a sufficient num-ber of French physicians. The superintendentduring most of the period of construction of theold company and up to the time that we took chargein 1904 was Dr. La Crosade. He remained with usfor several years, and did for us most valuableand useful work.

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The hospital was not popular among the Frenchemployees. The mortality there was very high,and it was soon recognized that men contractedyellow fever there; for instance, a man, otherwisewell, would break his leg, be sent to the hospital,in the course of four or five days develop yellowfever, and within ten days be dead. This fear ofthe hospital was another reason why French em-ployees did not go there. Most of the whites andthe better class of French employees, when theywere taken sick, remained in their boarding-housesand homes in the city of Panama.

In making these remarks I do not intend to re-flect in any way upon the management of AnconHospital by the French. If we had had this hos-pital in 1884 we should probably have obtainedno better results than they did. At that time theydid not know that the mosquito transmitted yellowfever from man to man, nor did we know it then.Still, the hospital records show that in the nineyears of construction under the old French Com-pany, twelve hundred patients died in Ancon Hos-pital from yellow fever. These were mostlyFrenchmen, and they died in the building used forwhite employees, the Saint Charles. This build-ing was occupied for the first few years of ourconstruction of the Canal by Dr. Carter and my-self, with our families. The fact that we werewilling to place our families in such a building,

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located in one of the worst yellow-fever centers,shows how thoroughly we believed that yellowfever was not infectious in the ordinary sense ofthe term.

This building was about the center of the hos-pital grounds, and occupied a most attractive site.It was situated about two hundred feet up the sideof the mountain looking to the northeast. Amacadam road skirted the building on the downside, and the masonry retaining-wall supportedthis road on the lower side. Between the borderof the road and the retaining-wall was a superbrow of stately royal palms. Behind the buildingrose the mountain for four hundred feet, coveredby a perfectly impenetrable tropical forest, givingto the picture the deepest possible dark greenbackground. The view to the north and east ex-tended for miles and miles. To the east, overthe bay of Panama, dotted with its forest-cladislands, I have many times watched from the gal-lery of this building that anomaly, so generallyremarked at Panama, the sun rising out of thePacific.To the north and east were in view the various

ranges of Andean Mountains which make up thebackbone of the Isthmus. From this point, fouror five ranges of mountains could be seen, and inthe evening, when the sun was setting behind theAncon mountain at one’s back, the play of colors

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was superb: light green upon the nearer ranges,changing into deep azure upon the farther ranges,with the mountain tops and higher valleys coveredhere and there with a robe of White mist.

For the fourteen years after the failure of theold French Company in 1889, Ancon Hospital hadfinancially a most straightened time, and the Sis-ters who were in charge had to reach out in alldirections to make both ends meet. They deservea great deal of credit for the brave and successfulstruggle which they made in supplying the wantsof the sick intrusted to them.

Major La Garde, of the United States Army,was appointed Superintendent of Ancon Hospital,and took charge in June, 1904. He rapidly andsuccessfully proceeded to organize the hospital onsuch a basis that it was always able to care prop-erly for all patients who presented themselves.

For the first year there were almost insuperabledifficulties in the way of getting supplies of allkinds, but gradually these troubles were corrected.We used all the old French buildings in much thesame manner as had the French. As the numberof patients increased, the old French buildingswere enlarged, generally by adding a second story,and a few new buildings were added, until finallythe capacity of the hospital had risen to fifteenhundred beds.

Into all these buildings a piped water supply229

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was introduced, and the bucket system for nightsoil was everywhere replaced by modern flushclosets. Bathing facilities were also suppliedwherever needed. A good sewage system con-nected all these buildings with the sewers of thecity of Panama. The old lighting system ofcandles and lamps were replaced by electric lights.All the buildings were thoroughly screened withwire netting. This precaution was almost essen-tial in the early years before we got mosquito-breeding as thoroughly under control as it laterbecame.

In 1904 and 1905 we treated a good deal of yel-low fever in this hospital, and in the wards wherewe treated yellow fever we had to be particularlycareful. Most of the patients in these wards werenon-immunes, that is, were patients who had nothad yellow fever. The nurses and doctors werealso generally non-immunes, who were liable toyellow fever. We had, therefore, to be absolutelycertain that no mosquito which could carry yellowfever from patient to patient, or to the doctors andnurses, got into these wards.

The screening was very carefully done under thesupervision of Mr. Le Prince, who formerly hadcharge of similar work at Havana. Only one en-trance was used for each ward, and this entrancewas closed by a screened vestibule, with doubledoors. A watchman was always on duty in this

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vestibule, whose business it was to see that anyperson entering the vestibule from the outer door,closed the outer door before opening the inner.Notwithstanding the large number of cases of yel-low fever treated in the yellow-fever wards ofAncon Hospital in the years 1904 and 1905, andin spite of the fact that in these wards were a con-siderable number of non-immune patients who didnot have yellow fever, and the further fact thatmost of the doctors and nurses were non-immunes,not a single case of yellow fever developed inAncon Hospital during American control of thatinstitution. I wish to except from this statementone of the female nurses. This nurse did have avery severe case, and came very near dying. Theevidence seemed very strong that she had not con-tracted the disease in the hospital. She was inthe habit of going down frequently into the city ofPanama in the evening after sunset where infec-tion was very rife. Soon after her recovery shemarried one of the young doctors connected withthe hospital upon whom public opinion settledthe blame for her contracting the disease, becausehe had so frequently inveigled her into takingtrips into town.

That no case of yellow-fever infection occurredin the hospital is the greatest possible complimentto the efficiency of the system established by theauthorities for its prevention. It made a very

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strong impression both upon the Americans andPanamans. All could see that we had done some-thing that had radically changed conditions asthey had existed before in Ancon Hospital. For-merly, nearly every white non-immune who wastaken to the hospital developed yellow fever.Now, they could see that the yellow-fever wards ofAncon Hospital were safer for a non-immune thanwas any part of the city of Panama. When itwas explained to them that there was no mysteryabout this; that it had been discovered that yellowfever could not be conveyed from man to man ex-cept by the stegomyia mosquito, they were pre-pared to accept this as the proper explanation.

Probably, if the French had been trying topropagate yellow fever, they could not have pro-vided conditions better adapted for this purposethan the conditions which they did establish withan entirely different object. The stegomyia werebred everywhere about the Ancon Hospitalgrounds in the usual numbers found in almostevery tropical community, due to old cans, bottles,rain-water barrels, roof gutters, etc. As I havementioned before, the grounds were most beauti-fully laid off and every kind of tropical bush andshrub carefully fostered in the various plots aboutthe grounds. There is down there a large ant,known as the umbrella ant, that is very destruc-tive to most shrubs and plants. A colony of these

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ants will, in the course of a single night, cut everyleaf from a good-sized orange tree. The leaf iscut into a piece about half an inch in diameter andcarried off by the ant in his nippers, and whenyou see a column of these ants crossing the path,hundreds and thousands of them, with these cir-cular pieces of leaves in their nippers, it looksvery much as if they were carrying them for pro-tection against the sun. Hence their name, “um-brella ant.”

Now, in order to raise any vegetation at Ancon,the plant has to be protected from these ants.The French used for this purpose a pottery ring.The ring was filled with water and the plant wasplaced in the large hole in the center. This thor-oughly protected the plant, as the ant was unableto cross the water. But the water in the ring wasan ideal breeding-place for the stegomyia mos-quito, and as there were several thousand of theseearthenware rings about the grounds, close to thewards, a more perfect arrangement for the propa-gation of yellow fever could not have been adopted,if the authorities had this object in view.

Knowing that shrubbery protected and har-bored mosquitoes, we cleared off, as was our rule,everything within two hundred yards of any ofthe buildings. It looked very much like vandal-ism on our part to see all the beautiful plants,rose bushes, flowers, etc., which had been for so

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many years carefully nurtured and cared for byour French predecessors, ruthlessly destroyed.

But our work was successful, and in the courseof time we got rid of mosquitoes entirely in thegrounds of Ancon Hospital. We continued tokeep the buildings well screened, however, thoughI feel sure that we could now treat cases of yellowfever in Ancon Hospital in unscreened wards andstill not have the disease transmitted to the non-immunes in the ward, for the reason that there areno stegomyia there to transmit the disease. Thisstatement is not altogether theory on my part.

On the next hill, about a quarter of a mile fromthe old yellow-fever wards of Ancon Hospital, isthe Tivoli Hotel. This hotel is owned and oper-ated by the Canal Commission, and for the last fewyears has been filled with visitors from abroad,principally from the United States, who were ofcourse entirely unacclimated. During the monthsof the dry season the hotel is crowded, and forthe last two years it has been kept full nearly allthe year round. During these last two yearsabout thirty thousand sight-seers have visited theIsthmus.

This hotel is practically unscreened. While thedoors and windows are provided with screens, suchscreening, where there are many doors and win-dows, is so imperfect that in the tropics it giveslittle protection against yellow fever and malaria.

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Stoned Ditch near Tivoli Hotel. Ancon, Panama.

BadAnopheles Breeding-ground onArtificial Fill. LaBoca.

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No attempt at all was made to screen the galleriesof this hotel. Hundreds of visitors spent thewhole evening on these galleries until twelve andone o’clock at night, yet we had no cases of yellowfever or malaria developing from such exposure.If this had occurred ten years before and threehundred of these unacclimated visitors from theUnited States had sat for an hour or two aftersunset on this gallery, exposed to the deadly nightair, it would probably have meant that every singleone of them would have contracted fever, and aconsiderable number of them would have died.The only difference between now and then is thatwe have drained and cleaned the country aroundthis hotel, so that now there are no pools orpuddles, or places of any kind within two hundredyards of the hotel where mosquitoes can breed,and consequently there are no mosquitoes.

The fact that unacclimated non-immunes canlive in the Tivoli Hotel without contracting feveris evidence that we could do without screening inour wards at the hospital, but we thought it un-wise to do away with the wire netting there. Wethought it equally unwise not to screen the TivoliHotel, but the expense was large, and the architectthought it would mar the appearance of the build-ing, so it was left off by the authorities, in spiteof my advice on the subject. The first guests inthe Tivoli Hotel were President Roosevelt and his

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party, who were there in November, 1906. I suc-ceeded in getting the authorities to screen thor-oughly the portion of the building occupied bythe President.As time went on and we found that we had

freed the hospital grounds from mosquitoes, webegan to replace the flowers and shrubbery whichwe had swept away in the early sanitary work.But we realized that we had to protect all vege-tation from the ants; if we did not, it would be atonce destroyed. While the methods used by theFrench for this purpose had been entirely suc-cessful and efficient as far as protection from antswas concerned, we could not use it on account ofits mosquito-breeding qualities.

The umbrella ant, in leaving its nest on itsforaging expeditions, makes a very distinct trailsome four or five inches wide between its nest andthe tree to be attacked. Next morning, by follow-ing the trail, you can easily find the nest. ColonelPhillips, the superintendent of the hospital, foundthat by pouring a little bisulphid of carbon intothe ant-hole, allowing it to vaporize for a fewminutes and then exploding it, the gas would pene-trate into every part of the nest and kill all theants. In this way, all the umbrella ants aroundAncon Hospital were killed off. At first it wasvery laborious, and took the entire time of oneman, but in the course of time all the nests in the

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neighborhood were destroyed, and it is now onlyat long intervals that a new colony comes in andhas to be killed off.

At the present time the grounds are even morefilled with shrubbery and flowers and tropicalplants generally, than they were under the French,and they present as beautiful and attractive anappearance as can be found anywhere in thetropics. Entomologists tell us that this ant doesnot collect the leaf for food, but chews it up intoa pasty mass, places it in the storehouses of itsnest, and grows upon it a fungus which he usesfor food.

The food for this large hospital of over twothousand people was cooked in a large and airykitchen, situated about the center of the grounds.This kitchen was equipped with every modernconvenience both for good and economical cooking.Cooking by steam was used in part, and cookingon the range, for such things as were best pre-pared in that way. The food when prepared wassent to the various wards, the receptacles beingcarried in hand carts.

The wards were so arranged that every two ofthem had a dining-room and diet kitchen in com-mon. In each diet kitchen the heating apparatuswas so arranged that the food brought from thecenter kitchen could be re-heated before being used.

On a spur of the mountain near the center of237

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the grounds was located the operating-room, withseven or eight surgical wards grouped around.This operating-room was erected by the Frenchabout the year 1882. We repaired the buildingand enlarged it somewhat. Dr. A. Herrick, thechief surgeon, equipped this building with everymodern surgical appliance, such as x-ray machine,etc., etc. The results of the surgery at Anconcompare favorably with the results obtained any-where else.

A medical clinic was built up under the super-vision of Dr. W. W. Deeks, where every varietyof tropical disease could be seen in all its phases.

A laboratory for original research was also at-tached to the hospital. This laboratory was de-veloped by Dr. Samuel Darling, and in it a greatdeal of useful original work has been done. Thepathological work of the hospital was done inthis laboratory.

From the peculiarity and isolation of our posi-tion on the Isthmus, many things were done bythe Sanitary Department which in the UnitedStates are done by other branches of the Govern-ment, or by individuals. In the early days, whenthere was a great deal of fear and alarm on theIsthmus among the Americans with regard tohealth conditions, the Commission promised theirAmerican employees that all who died on theIsthmus should have their bodies returned to their

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friends in the United States, at the expense of theCommission. The fulfilling of this promise wasturned over to the Sanitary Department, and tocarry it out, an undertaking department was es-tablished and attached to the laboratory. The ex-pense of this department is one of the very manyitems that bear no relation to sanitation, merelybecause the officers of the Sanitary Departmentsupervised the work, and the employees werecarried on the rolls of this Department.

There being nothing else of this kind on theIsthmus, it gradually came about that wheneveranyone died and his friends wished to have thebody embalmed, we were called upon to do it,and in later years, as the non-employee populationincreased, there was a great deal of this outsidework. Strange to say, in our rather complicatedand involved accounts on the Isthmus, when thePresident of the Republic of Panama died, theSanitary Department was called upon to embalmthe body. The considerable cost of this opera-tion, $100 or more, is charged to sanitation on theIsthmus, and while the Commission was a gooddeal more than reimbursed by the family from thisexpenditure, the reimbursement was not creditedto sanitation, but went, under the law, to engineer-ing and construction.

It seems all through as though the laws wereframed with the idea of making sanitation appear

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to have cost as much as possible, and the construc-tion of the Canal as little as possible.

In a former chapter I stated that when we camedown, in June, 1904, we purchased in New Yorkand took with us $50,000 worth of supplies.Among these supplies were a certain number ofcoffins. When they were unloaded on the dock atColon, the fact was considerably commented on.Among these coffins were six metallic cases, of aquality much superior to the others. These metal-lic cases were piled by themselves. The Commis-sion, the governing body at that time on theIsthmus, was composed of seven men, of whom sixon that date were present on the Isthmus.

Major La Garde was superintending the unload-ing of the ship. One of these six commissionershappened to be passing at this particular time, andhe was very much impressed by what he saw.Stepping up to Major La Garde, he said: “Doctor,why do you bring six caskets of so much betterkind and quality than the ordinary coffin?” MajorLa Garde promptly replied: “Mr. Commissioner,you know that Commissioner Blank is not on theIsthmus, and that only six commissioners aredown here.” The inference was so obvious thatthe Commissioner is said to have returned homeand to have taken to his bed at once. I am gladto say, however, that none of the Commission everhad any use for those caskets.

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CHAPTER XVII

MEDICAL AND SURGICAL SERVICE OF ANCON HOSPITAL

THE medical and surgical service of AnconHospital rapidly developed so as to win the

confidence of the civil population all around. Notonly did patients come to us from the Zone and theRepublic of Panama, but patients also applied foradmission, and many of them, from the west coastas far south as Chili, and as far north as Mexico.Many hundreds of people who formerly went toEurope and the United States for surgical careand treatment, now go to the Ancon Hospital.

The charges for this treatment are so arrangedthat it costs the Commission nothing, but is actu-ally a source of considerable profit. Hundreds ofpatients who can never hope to have means enoughto go to Europe or the United States for medicalor surgical relief, are able to go to Ancon and paythe very moderate charges there.

This is another item of peculiar charge on theIsthmus. If it costs $30,000 a year to care for

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these patients, in our accounts this $30,000 ischarged to sanitation, but the $50,000 which theCommission receives for these patients is notcredited to sanitation, but to construction andengineering.

An eye department was also established atAncon by Major Theodore C. Lyster, of the UnitedStates Army, and was equipped with all modernappliances for eye, ear, nose and throat work.This department developed along the same linesas did the surgical work of the hospital, and wassoon attracting patients from all the west coastnorth and south of us.

The hospital also had a well-appointed depart-ment for the insane. This grew from very smalldimensions to considerable size. In 1913, we hadtwo hundred and fifty patients in this section of thehospital. When we first went to Panama, the in-sane of the Republic were very poorly cared for.In most parts they were confined in the jails, andcared for with the ordinary prisoners. Knowingthat, as time went on, we would have a consider-able number of insane from the people in the Zonefor whom we had to make provision, we proposedto the Panaman Government that we should takecare of their insane in our institution, at a percapita cost of seventy-five cents per day. Thisthey readily agreed to, and at present, consider-ably more than half of these two hundred and

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fifty patients are sent in by the Panaman Govern-ment.

The cost of caring for these Panaman patientswas charged to the Department of Sanitation, butthe seventy-five cents per day which was receivedby the Isthmian Canal Commission from the Pan-aman Government, was turned over to the con-struction of the Canal.A large and well-equipped laundry was at-

tached to Ancon Hospital, furnished with all mod-ern appliances. It was originally intended merelyto do hospital work, but it was so difficult foremployees to get washing done that the functionsof the laundry were gradually extended and workwas done for Canal employees other than thosesick in hospitals. A reasonable charge was madefor this outside work, and it finally came aboutthat the income from this outside work went a con-siderable way in paying the expenses of thelaundry.

Under Colonel Mason, who succeeded ColonelPhillips in the management of the hospital, thewaste fats and tallow from the kitchen were saved,and enough soap made not only to supply thelaundry, but in good part to supply the hospital.

The amount of surgical work in this hospitalwas very large, and the quantity of surgical dress-ings enormous. A considerable portion of thesesurgical dressings were not at all soiled, or very

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little so. Colonel Mason had these picked over,washed and sterilized, and found that he could thusmake a large saving in his surgical dressings.

In the early years of the hospital we boughtsuch milk as we could get from the surroundingcountry at one dollar and twenty cents a gallon.Colonel Phillips brought cows from the UnitedStates and established a dairy on the hospitalgrounds, which accommodated about one hundredcows. After the dairy was well under way, hefound that his milk cost him only from thirty toforty cents per gallon.

I merely mention these items to show how muchcan be saved by care and attention to details ina large institution like Ancon Hospital. I couldmention many other items, but these suffice toshow that the hospital was very economically aswell as efficiently run.

All the adjuncts of a large and well-managedfarm could be found on the Ancon Hospitalgrounds—a poultry yard, a piggery, a large gar-den, all of which contributed largely to the com-fort of the patients, and to the economy of admin-istration. The poultry yard contained some twothousand hens; also, pigeons, ducks, etc.

Ancon being in the suburbs of the city of Pan-ama, and on the mountainside, was always con-sidered a most desirable place of residence. Outof compliment to the Church, the French Company

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erected for the Bishop of the Diocese of Panamaa residence just within the hospital gates, and fixedup the approaches to this residence in very hand-some style. A macadam road led from the hos-pital gate up to the front of the building, and abroad flight of some thirty-five or forty steps ledfrom the main roadway directly up to the buildingitself. A noble row of fifteen or twenty royalpalms partially screened the building in front.This building was used by us as quarters for thesuperintendent of Ancon Hospital.

The laboratory for original research, which Idescribed above, was located across the roadwaysome fifty or sixty yards in front of this house.I have also mentioned that part of the functionof the laboratory was that of an undertaking es-tablishment, and many of the funeral services forthose who died took place in a small chapel con-nected with this laboratory. At one time in theearly days when a number of the Americans weredying of yellow fever, the Governor of the Zone,like many of the others one day felt cold chillscreeping down his spine. He went over to thelaboratory to consult Major La Garde. TheMajor took his temperature, felt his pulse, madea careful examination and looked exceedinglygrave. He insisted upon the Governor’s going upinto his (Major La Garde’s) house, the one I havejust described as overlooking the laboratory.

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While the Governor was undressing and gettingready for bed, a hearse drove up to the laboratory,but from the location of the building, the hearsewas also immediately at the foot of the broad flightof steps leading to the Bishop’s house. The Gov-ernor was naturally much depressed at the turnaffairs seemed to be taking. Evening was draw-ing on, and the sun was sinking to rest. He knewfrom the history of yellow fever that many a poorfellow who had gone to bed as he was doing hadnot lived to see the sun rise again. So he madeup his mind that he would take one more look atthe sun, the trees and the outside world beforehe turned in. He went to the window, drew asidethe curtains and looked out, and there at the footof the steps, right at his front door, stood thehearse. With a groan he turned to his bed, surenow that Major La Garde regarded the case asone of those short and fatal ones, and had orderedthe hearse so that it would be on hand and con-venient when the Governor had need of it. But Iam glad to say that the Governor was all right nextmorning, and the hearse had been ordered not forthe Governor, but for some poor fellow in themorgue at the laboratory. This is not my story,but the Governor’s, and I wish I could tell it inthe inimitable way I have many times heard itfrom him.

As stated previously, any sick employee was

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cared for in Ancon Hospital, or any other Depart-ment hospital, free of charge. If he were on thegold roll, he was allowed pay for thirty days’ sick-ness in each year. The gold roll practically meantwhite Americans, of whom there were about fivethousand. The families of employees receivingmore than fifty dollars per month were chargedone dollar a day for treatment in the wards. Ifthey asked for special consideration, such asprivate rooms, or private nurses, they werecharged accordingly. No charge was made forsurgical operations on members of the familiesof employees. If the employee received less thanfifty dollars a month, a member of his family wascharged only thirty cents a day in the hospital.Any person not an employee was charged two dol-lars per day for ordinary treatment in wards, andan additional charge for all extras, such as privaterooms, special nurses, etc.

On October 31, 1913, we had in our hospitalsthree hundred and twenty-nine white employees,four hundred and forty-five negro employees, onehundred and ninety-nine white non-employee paypatients, and four hundred and fifty-six black non-employee pay patients.The income of the Department from all sources

during the calendar year of 1913 was about $250,-000. This came principally from persons caredfor in the hospitals.

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CHAPTER XVIII

THE SANITARIUM AT TABOGA

ANAMA BAY runs straight south from An-P con mountain about one hundred miles. It isfilled with a great number of islands, which are evi-dently the tops of mountains projecting above thesurface of the water. One of these islands isTaboga, situated in the bay about twelve milessouth of the city of Panama. It rises abruptlyfrom the surface of the ocean about a thousandfeet, and at the present time is very thoroughlycultivated, the principal product being pineappleswhich have a great local reputation for size andflavor. It was inhabited by the Indians when thecity of Panama was first founded by the Span-iards, and the wealthy inhabitants of the city ofPanama early made it a resort, as being pleas-anter, cooler and more healthy than the mainland.The water was considered unusually pure, and theisland had the reputation of not being liable toyellow fever.

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A quaint little village, Taboga, nestles on thebeach at the foot of the mountain. This villageis now some four hundred years old, and thechurch there is reputed to be about that age. Agruesome thing about the pretty little church isthe fact that in the outer wall a human skull is im-bedded in the masonry. A glass cover is placedover the front, and the skull can be plainly seen.I was told that this was the skull of one of theearly padres, who had been a very good man, andto whom the people were greatly devoted. Andwhen he died, they took this method of perpetuat-ing his memory and showing their veneration.

For the reason that Taboga was considered somuch more healthy than Panama, the French lo-cated there a sanitarium. It was very prettilysituated outside the limits of the village of Taboga,and the grounds about the sanitarium had beenbeautified and improved by the French just ashad the grounds of Ancon Hospital. In theirsanitarium they could accommodate about onehundred people. We enlarged this institution,and made it a convalescent hospital of about onehundred and twenty beds, and patients were re-ceived here on the same terms as in our otherhospitals. It has proved to be to us a most use-ful institution.In the early days, the Isthmus had such a bad

reputation for health that when an American got249

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sick, he became very much depressed and madeup his mind that he was going to die, and usuallydetermined that he would go back home to theUnited States if he ever again became able totravel. The island of Taboga had such a repu-tation for salubrity that we could generally per-suade him, when in this frame of mind, to go tothe convalescent hospital there until he was ableto travel, or until his ship sailed. He usually im-proved so rapidly at Taboga that by the time aship was ready to sail, he had gotten over hishomesickness and depression. In this way alarge number of useful employees were saved tothe Commission.

I think the bay of Panama, looking north fromTaboga, compares very favorably with the bay ofNaples, and reminds one somewhat of that fam-ous sheet of water. A most romantic dell leadsup to the top of the mountain from the convales-cent hospital. Down this dell runs the onlystream of water on the island, fed by springsnear the top of the mountain, by way of this ra-vine. When one has finally reached the crest ofthe mountain a thousand feet above the level ofthe sea, the view on all sides is superb. To thenorth the mouth of the Canal, defended by thefortified islands of Naos, Perico and Flemenco;the city of Panama, Ancon mountain, and in thedistance the continental divide of Culebra. To

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the south, the bay, extending some fifty or sixtymiles, dotted with islands, large and small, andin the distance, the historic group of the PearlIslands.

The trail referred to gave access to the dozensof small pineapple farms located on each sideof the ravine. Just as the trail reaches the topof the mountain there are three or four crosses,locating an equal number of graves. Every fall,in September, the whole village of Taboga turnsout and has a religious procession which goesup to these graves and decorates them. The tra-dition among the natives is that when Sir HenryMorgan captured old Panama in 1670, he sentan expedition down to Taboga. The townsmenmade a very brave resistance, but were slowlydriven back by the pirates up the trail to the topof the mountain, where they made their finalstand, and at last succeeded in beating off theirenemies. The little burying-ground was the pointwhere they made this stand, and the townsmenwho were killed in the fight were buried wherethey fell. The yearly religious ceremony whichI saw was kept up in commemoration of theirbrave fight.

The bay north of Taboga is pretty well inclosedby the mainland on the northeast and west, andTaboga on the south. This piece of water is afavorite place for the collection of large schools

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of fish, and when these schools are in, all speciesof birds and fish follow in innumerable myriads.It is a very interesting sight to stand on the gal-lery of the convalescent hospital and see the thou-sands of pelicans and other species of birds div-ing and plunging after their prey. This is also afavorite nook for whales. I recollect on one oc-casion seeing as many as six in this little bay atthe same time. They did not seem to be particu-larly shy, allowing us to approach them in thesteam launch to within twenty-five or thirtyyards.

This bay was the scene of one of the most re-markable naval battles of history. About tenyears after Sir Henry Morgan’s sacking of Pan-ama, another buccaneering expedition crossedthe Isthmus. They struck the South Sea aboutopposite the Pearl Islands, camping on the bayof San Miguel. Here they collected enough In-dian dugouts to carry their force of three hun-dred men. This Indian dugout is very much likethe one made by our Indians in the southernstates, an exceedingly unstable and easily cap-sized boat, as anyone knows who has ever at-tempted to navigate one. It is much betteradapted to the smooth inland waters than to therough open sea. The Pearl Islands are aboutforty miles south of Taboga, and Sharp, with thebulk of his men, undertook a foraging expedition

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to these islands. Hawkins with sixty men wentnorthward along the coast toward the city ofPanama.When they reached the island of Chepo, they

heard that the Spanish fleet was anchored atTaboga. Chepo is easily visible from Taboga.The Spanish fleet consisted of the flagship, theSanta Maria, whose armament was twenty guns,and whose crew consisted of one hundred men.She was accompanied by two tanders of a coupleof guns each, and crews of about thirty men.Hawkins, having accurate information of the ar-mament and strength of the Spaniards, wishedto be reënforced by the main body before goingany further. After waiting several days, hethought it unwise to delay any longer, and deter-mined to attack the Spaniards with the force hethen had-sixty men. So he started his canoespaddling toward Taboga, some fifteen miles off.When the Spaniards discovered the buccaneeringfleet approaching, they got under sail, expectingto have no difficulty in running down and sinkingin the open sea the canoes of the buccaneers.

Now the buccaneer, like our frontiersman, wasdependent upon his gun for his food. Most ofthem had spent many years hunting wild cattlein Haiti, and the cured beef of cattle killed inthis way was their principal support, and alsotheir principal article of export and commerce,

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under the name of “buccan.” And this is howthey got their generic title of buccaneer, a personwho produces buccan. This wild life on the coastcaused them to become equally expert in handlingthe dugout.

Ring Rose commanded the leading division ofsix canoes, and described the fight most graph-ically. As the large Spanish vessel bore downupon the canoes of the buccaneers, under full sail,the latter found no difficulty in avoiding the bigvessel by a few strokes of the paddles. As thegreat ship passed, the expert marksman in thecanoe shot down the man at the wheel. Thiscaused the big ship to yaw, lose headway and be-come stationary.

The buccaneers in the same way would shootdown any other man who tried to get hold ofthe wheel, and so the vessel was unable to getunder sail again. With the vessel stationary, itwas very easy for the canoes to lie close in outof range of the big guns, and the superior marks-manship of the buccaneers, with their small arms,enabled them to keep down entirely small-armfire from the Santa Maria. Here they lay all day,picking off any Spaniard who dared show him-self. When evening came, the Spaniards surren-dered. Ring Rose states that when he boardedthe Santa Maria to accept the surrender, of theone hundred men of the crew who had commenced

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the fight, ninety-two had been shot down, andonly eight were left standing. Everyone of theseeight was, however, wounded.

I call it one of the most extraordinary navalbattles of history, from the fact that sixty menin dugouts, armed only with small arms, wereable in the open sea to capture this man-of–warand her tenders, having an armament of overtwenty great guns, and crews of over one hun-dred and fifty men. And this was accomplishednot by surprise or stealth, but in an open, stand-up fight. The Spaniards saw them coming formiles, and sailed out to meet them.

The Santa Maria had, under the pirates, a mostextraordinary history for three years. She sailedup and down the west coast, bidding defiance toanything the Spaniards sent against her. Shefinally doubled the Horn, reached the Barbadoes,and was there sold by the pirates for a goodround sum.

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CHAPTER XIX

THE LEPER COLONY

NOTHER sanitary precaution that the HealthA Department determined upon was the segre-gation of the lepers. The Republic of Panama re-quired by law the segregation of these people,but the community had been so poor for so manyyears that it was unable to bear the expenseof any careful enforcement of this law. Sometwelve or thirteen lepers had been living in hutsdown on the bay for a number of years, sup-ported by the charity of such individuals as,moved by pity, could afford it. This burden fora long time before our arrival had fallen entirelyupon Mr. Espinosa, one of the leading citizensof Panama.

Knowing that we would have a certain numberof lepers in the Zone, we made the same propo-sition to the Panaman Government with regard tolepers that we had made with regard to the in-sane; that is, that we would care for their lepers

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at the rate of seventy-five cents per day percapita.

We established a colony on a beautifully lo-cated peninsula running out into the bay of Pan-ama, and almost as much isolated as if it were onan island. Here they could have their gardens,chickens, fruit-trees, etc. The location is natur-ally one of the prettiest on the bay.

We now have there some fifty lepers, who areliving contented and happy. We have a whitemale trained nurse in general charge; a whitefemale trained nurse in charge of the women,and some four or five other employees. We havea teacher for the children, and the lepers are al-ways employed for any work of which they arecapable, and are paid for this work so as to en-courage them to seek it.

Dr. Henry R. Carter devoted a great deal oftime and attention to the establishment of thiscolony, and it was due to his painstaking personalcare that the matter turned out so successfully.

The history of the spread of leprosy is peculiarin that those who live with lepers in institutionsand are constantly in contact with them do not asa general thing contract the disease. I refer tosuch peeple as doctors, nurses and attendants.On the other hand, people who have never knownof any contact with a leper sometimes developthe disease. Such a case was that of the English

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Consul, about 1850, who found himself with symp-toms of leprosy, without, as far as he knew, everhaving come in personal contact with a suffererfrom this disease.

On one of the smaller islands of the bay, Flem-enco, there was an old Spanish fort, which hadbeen long unoccupied—not a very large work, in-tended to contain a garrison of some thirty orforty men. Just behind the fort was a pretty,cool, clean spring, which at some period longpassed had been walled up and covered in for theuse of the garrison. The island of Flemenco isat the mouth of the present Canal, and rises somethree hundred and forty feet above the surfaceof the water. It is at present being fortified forthe protection of the Canal. The English Consul,when he found he was a leper, determined that hewould never return home, bought Flemenco Isl-and, fixed up the old fort comfortably as a resi-dence for himself, and there, with a few faithfulattendants, he spent the rest of his life, a volun-tary prisoner, and there he died and was buried.

A few hundred yards north of Flemenco wasthe scene of another naval battle during the revo-lution of 1903. The Government forces in thestate of Panama under General Alban hadbrought the country into subjection to the fed-eral government of Colombia. The rebels stillhad a gunboat, manned and equipped, lying at

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Taboga. General Alban, the governor, seized oneof the merchant steamers lying in the harbor atPanama, armed her, put a crew aboard with aconsiderable number of soldiers, and determinedto attack the smaller rebel gunboat.

He sailed down to Flemenco Island, where heanchored for the night. During the night therebel gunboat came up under the shelter of Flem-enco Island. As day broke she steamed out frombehind Flemenco; ranged herself along the sternof Governor Alban’s ship where no guns couldbear upon her, but where all of her broadsidescould bear upon the Government ship, which hadno steam up, and which could not, therefore, man-euver.

The rebel commander called upon the braveold Governor to surrender, representing that hewas entirely at his mercy, but this the Governorrefused to do. The rebel ship then opened fire,and continued to fire without any possibility ofinjury to herself, until the Government vessel wassunk. The survivors reported that Governor Al-ban and most of his men were killed by the hostilefire before the ship went down. For many yearsthe masts and upper works of this vessel couldbe seen at low tide projecting above the water.

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CHAPTER XX

QUARANTINE SYSTEM

PANAMA, from its situation and location, waspeculiarly liable to infection from other

places in both North and South America. It wasthe gateway through which a large traffic passed,and through which a continuous stream of trav-elers had been entering and departing for theprevious four hundred years. After we had oncefreed it from yellow fever, it was very importantthat we should keep it free, and to do this we hadto take such measures as would prevent a personin the early stages of yellow fever coming intoPanama, and infecting the mosquitoes there, andthus starting an epidemic.

It was possible, also, for a ship to come intoa port with infected mosquitoes aboard. These in-fected mosquitoes might escape to the shore andin this way start the disease, or they might bitesome non-immune visiting the ship, and causethis non-immune to develop yellow fever at his

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house in from three to six days after he hadvisited the ship.

To protect ourselves against the introductionof yellow fever in the above ways, quarantineregulations were established. Any ship that haddeveloped a case of yellow fever aboard was con-sidered infected. We knew that if the case weredeveloped aboard, she must have had infectedmosquitoes there which had bitten the patientand caused the disease. The ship was, therefore,fumigated in such a way as to kill all mosquitoes.After she had been fumigated, we considered hersafe. But though the ship could be rendered safeby the fumigation, some of the passengers orcrew might have been bitten by the infected mos-quitoes just before the fumigation of the ship,and such person might develop yellow fever dur-ing the succeeding six days. We therefore tookall the non-immunes to our quarantine station,and kept them for six days. At the end of sixdays we allowed them to return to the ship. Thevessel itself, with all the immunes aboard, wasreleased from quarantine as soon as the fumiga-tion had been completed.

As I have said before, a person who has oncehad yellow fever is not liable to a second attack.Such person is known as an immune. To proveimmunity, a passenger or member of the crewwas required to present a written statement from

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some recognized authority stating that the writerknew that the person under consideration had suf-fered from an attack of yellow fever.

Wherever yellow fever is endemic, it is a well-recognized fact that the native of the endemicarea is not subject to this disease. This is ex-plained on the theory that he had a mild attack inchildhood, which, though not recognized, giveshim protection in after life. This statement maystrike one with surprise at first. We have, how-ever, an exactly similar state of affairs amongcattle. The beef native to a Texas fever regiondoes not suffer from the disease, but an animalbrought from anywhere outside this region al-ways contracts the disease, and generally dies.The calf of the native cow is believed to have amild attack which does not make it seriously sick,but protects it from Texas fever all through life.If the calf of the foreign cow is born in the en-demic area, it seems to survive just as does thenative calf, though the mother may have died ofTexas fever.

An adult human being frequently has yellowfever in so mild a form that it is not recognizedas yellow fever. Many Europeans are found ina yellow-fever endemic center such as Havana,who have lived there for years and not had yel-low fever, as far as they themselves were aware.If, therefore, an individual could prove that he

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had lived for ten years continuously in a yellow-fever center, his immunity was accepted by thequarantine authorities.

If a ship had touched at a port where yellowfever prevailed, before coming to Panama, therewas a possibility of infected stegomyia havinggotten aboard, even though no cases of yellowfever had developed on the ship. For by chancethe infected mosquitoes may not have bitten any-one, or if they had bitten persons on the ship, thebiting may not have taken place a sufficient lengthof time for the development of the disease, beforethe arrival of the ship at Panama. Such a shipwas considered as possibly infected, and wastreated at quarantine exactly in the same wayas above described in case of a ship known to beinfected.

The fumigation of a ship was generally accom-plished by burning sulphur, as above describedin the case of fumigating a house. In the partsof a ship, such as the engine-room, where therewas valuable machinery which would be injuredby sulphur fumes, pyrethrum was used, just asin similar circumstances it was used in fumigat-ing dwelling-houses. We had more elaboratemachinery than the pots and pans described inthe fumigation of houses, with which sulphurfumes could be developed much more rapidly andin much larger volume. This was used by us on

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special occasions where its use seemed desirable.In the history of yellow fever, many curious

cases of ship infection from this disease haveoccurred. During the fall of 1904, one of ourwarships, the Boston, spent several months inPanama Bay. While down the coast on gun prac-tice, in January, 1905, she developed seven casesof yellow fever. She had been away from Pan-ama such a length of time that the doctor knewthat the cases must have received their infectionaboard, and that therefore the ship was infected.The cases were well marked and most of them weresevere, the doctor and one of the men dying ofthe disease. Nothing could be found in the sickrecords of the ship which would indicate thatanyone belonging to the ship had contracted yel-low fever ashore and developed a mild case, andthus infected the ship. All the cases were con-nected, directly or indirectly, with the ward-room, three of them being commissioned officers.As we were having at the time some yellow feverin Panama, the crew had not been allowed ashore.One or two of the officers, only, had been per-mitted to come into Panama for the transactionof necessary business.

A short time before the ship had left the bar-bor, New Year’s Eve, 1904, they had given a ballaboard, which had been attended by a large num-ber of the citizens of Panama. After a careful in-

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vestigation of the matter, we concluded that someone of these persons was in the initial stages ofa mild case of yellow fever. It is quite possiblefor such a person to be up and around withoutappreciating that he has the disease. This per-son, we concluded, was bitten by some of thestegomyia aboard. At the end of two weeks thesestegomyia became infectious and gave the dis-ease to the crew.

Dr. G. A. Perry, of the Public Health Service,who had immediate charge of the work, found asmall flat tub under the steps going down fromthe wardroom, in which stegomyia were breedingfreely. This was the only place on the ship wherelarvæ were found, and this one piece of careless-ness was responsible for the epidemic on the ship.All the mosquitoes aboard ship undoubtedly bredhere. We could never find out why this tub waskept here, as the wardroom steward who wasresponsible, contracted the fever and died. Thesurgeon of the ship also died.

The ship was carefully fumigated, under thesupervision of Dr. Henry B. Carter, and no morecases occurred, though the ship immediately wentto sea with all of her crew aboard, with the ex-ception of the sick, who were brought to AnconHospital.As an instance of what a man sick with yellow

fever may do in the way of going about, I will265

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narrate here the case of one of our patients whichwill well illustrate this point.

An American machinist, coming from SanFrancisco to Panama, got off the steamer at Co-rinto, Nicaragua, got on a spree and was locked upin the Corinto jail. He was left there by thesteamer, but was released from jail in time tocatch the next steamer going to Panama. Hereached Panama at the end of five days, went towork for the Commission, and worked one day,but being taken sick, he quit work, though he didnot report to the doctor. Instead, he again com-menced drinking. On the second day of his dis-ease, he was arrested by the Panaman police, andplaced in jail as being drunk and disorderly. Hewas released on the third day of his disease andcontinued his debauch. He was again arrestedon the fourth day, put in jail, and was then dis-covered by one of our inspectors who recognizedthat he was sick as well as drunk. He had himbrought to Ancon Hospital, where he died on thesixth day from the beginning of his attack.

The symptoms of the disease were well-marked, black vomit being profuse. An autopsyconfirmed the diagnosis. Here was a man suffer-ing from a case of yellow fever, of which he finallydied on the sixth day, who, for the first five daysof the disease, was about town, going from saloonto saloon, drinking immoderately, eating what

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came to hand, and sleeping where convenient.Twenty-four hours before he died, he rode up tothe hospital in a cab and walked into the ward. Hewas having black vomit before he left the jail.

It is often extremely difficult to trace a case ofyellow fever and discover the source of infection.In 1909 we were very much startled by what ap-peared to be a case of this disease, which hadapparently been contracted in the city of Pan-ama, and developed there.

A young Englishman had boarded the RoyalMail steamship at Southampton, bound forColon. While the ship had touched at severalpoints en route, the Captain certified that no onehad left the ship at Cartagena, the only infectedport at which she had touched. He arrived inPanama January 6, and after being in Panamasix days, he developed yellow fever, of which hedied on January 24. The symptoms were wellmarked, and an autopsy confirmed the diagnosis.

As far as we knew, there had not been a case ofthis disease in Panama for four years, and thestegomyia were so scarce that we did not believethat yellow fever could be transmitted. The poorfellow, just before he died, told Dr. WilliamDeeks, his attending physician, that on the nightduring which they were anchored in the Bay ofCartagena, the first mate and himself had slippedoff unobserved in one of the ship’s boats, spent

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the night in Cartagena, and had gotten back tothe ship before daylight. This confession at oncecleared up the case. He had evidently been bit-ten by a stegomyia mosquito while in Cartagena.Had it not been for his confession, the evidencewould have been very strong that in some waythe disease had been contracted in Panama.During 1899 we had the most curious case in

Havana of infection in the person of a nun, SisterMaria de los Angeles, a Dominican nun, and anative of France. She had come direct to NewYork from Europe, on the steamship Celtic, re-mained there two days, and then took the WardLine steamer Vigilancia for Havana. The tripfrom New York to Havana by this steamer oc-cupies four days.

The nun reached Havana September 8. Shewas feeling badly, though she did not give up herduties on that account. On September 11 she wastaken sick with a chill, and died with well-markedyellow fever on the sixteenth.

The circumstances were such that the Boardwas convinced that she had contracted the diseaseon board ship, and not in Havana. She must havegotten it in some way between New York andHavana. She could not have been infected inNew York, as there had been no yellow fever thereduring the preceding twenty years. The steamerunder discussion plied between Vera Cruz, Mex-

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ico and New York City, touching at Havana bothgoing and coming.7 We found that the records of the ship showedthat the last case of yellow fever aboard had oc-curred on the second trip before the one underconsideration, antedating the time the nun wasaboard by about a month. This was in the personof a passenger from Vera Cruz, who was takenoff at the quarantine station at New York. Heoccupied the stateroom that afterwards was occu-pied by the nun on her trip to Havana. Such aninstance twenty years before would very readilyhave been explained as an instance of infectionfrom the room, but we now know that yellow fevercan be contracted only through the bite of an in-fected female stegomyia mosquito. No other casehad occurred on the ship during the month follow-ing this case, in the passengers from Vera Cruz.It is probable, therefore, that a stegomyia mos-quito in this room must have bitten the passengersick with yellow fever during the trip up to NewYork; that this mosquito remained in this roomfor nearly a month, biting the unfortunate nunsoon after she got aboard.

As no other cases occurred afterwards, it isquite probable that the nun killed the mosquitoat the time of the biting. It is also probable thatsome immune occupied this room on the trip upfrom Vera Cruz to New York City, who would

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not be injured even if the mosquito bit him. Onthe preceding trip down from New York to VeraCruz the person occupying the room would nothave been injured by the biting of the mosquito,even if the person had been a non-immune, as themosquito requires two weeks from the time shebites a yellow-fever patient before she herself be-comes infectious. The preceding trip down waswithin this two weeks’ period of non-infectious-ness in the mosquito. At first blush, the case cer-tainly appeared very mysterious. How was itpossible for a person coming from France viaNew York to Havana, to have yellow fever whenshe reached Havana!

In 1904, when we first reached Panama, yellowfever surrounded us in all directions. Guayaquil,Ecuador, on the west coast of South America,three days’ sail from Panama, was badly infected.On the west coast to the north, Corinto in Nicara-gua and other ports, we knew to be infected. Onthe Caribbean Sea, within from one to three days’sail, Cartagena, Colombia, Porto Caballo, LaGuira, Venezuela, the port of Caracas, and otherports were having yellow fever. On the Gulf ofMexico, Vera Cruz, Mexico, was an endemic center.Progreso, the capital of Yucatan, was also havingthis disease. In 1905, New Orleans, Louisiana,had a sharp epidemic of yellow fever. With allthese places we had frequent and close commercial

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relations. In 1906, Cuba had some yellow feverat many points. All these places had to be care-fully guarded against by our quarantines.Bubonic plague existed endemically at Guaya-

quil, and several other ports on the west coastof South America, and this disease occurred spo-radically at ports on the Caribbean Sea and theGulf of Mexico. Quite a number of cases ofplague developed in New Orleans during 1914.Our quarantines had to look after this disease inthe same manner that yellow fever was guardedagainst.

I have already mentioned that in 1905 plagueestablished itself at La Boca and Ancon, in spiteof our quarantines. This is no reflection upon ourquarantine system. I am glad to say that underthe administration of Dr. Henry R. Carter and Dr.James A. Perry, our quarantines were as efficientas could be found anywhere, but the very bestquarantine will at some time allow a case of in-fectious disease to pass. Such accidents cannotbe entirely prevented, except by the entire aboli-tion of commerce.

For the care of passengers and ships underquarantine, we built two quarantine stations, oneat the north end of the Canal on the CaribbeanSea, the other at the south end on an island in thebay of Panama.

Culebra Island, on which was located the Pan-

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ama quarantine station, is an island of four or fiveacres in extent, the center of the group of islandson which are now located the fortifications pro-tecting the southern mouth of the Canal. Theseislands are mountain tops projecting from fiftyto three hundred and fifty feet above the surfaceof the waters of the bay of Panama. They areheavily wooded, and are very picturesque in ap-pearance. They are now connected with eachother and with the mainland by an artificial cause-way, built during the period of Canal construc-tion by dumping here the spoil from CulebraCut.

On Culebra Island, nine or ten comfortable andsubstantial frame buildings were erected, capableof caring for some three or four hundred persons.They consisted of two small hospitals, divided sothat five or six different kinds of contagious dis-eases could be cared for, if necessary, at the sametime; a large barrack building with a capacity oftwo hundred beds for the care of steerage pas-sengers, divided into a male and female side; alarge building of a capacity of seventy-two beds,for the care of first and second-class passengers,divided into small wards and rooms for the sep-arate care of the two classes of passengers; an-other large building for the housing of theemployees of the station; a smaller building forthe dispensary, doctor’s office and administration,

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and a comfortable residence for the doctor andhis family.

The station was well equipped for making thedifferent classes of passengers comfortable, andfor the care of the sick. In connection with thestation we kept equipped a self-propelling bargeof about one hundred tons capacity. This vesselwas named the Walter Reed, and was suppliedwith modern machinery for generating sulphurfumes and pumping these fumes aboard the ship tobe fumigated.

These islands are about three miles from themainland. There was no more desirable placeabout Panama in which to spend a week than thequarantine station. The site was as picturesqueand attractive as could be desired, and its location,three miles out in the bay, made the temperaturecool and agreeable. I have to confess that, as ageneral thing, the passengers quarantined atCulebra did not appreciate its beauties and com-forts sufficiently to stay an hour after their quaran-tine period. One of our ministers, however, com-ing up the west coast with his family, was heldat the quarantine station for several days, inorder that his quarantine period might be com-pleted. When the time had expired, he came tothe city of Panama, took a look around, remem-bered the beauty and comfort of Culebra Islandand the quarantine station, and concluded that he

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would like to take his family, return to the island,and stay there until his ship sailed. This wegave him permission to do, and he and his familyremained at Culebra about a week after his quar-antine period had expired. This established thereputation of the Panama quarantine as being asalubrious, delightful and desirable place in whichto be detained.

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CHAPTER XXI

MEASURES AGAINST BUBONIC PLAGUE

IN 1906, when our malarial rate was highest,we had eight hundred out of every thousand of

our employees admitted to hospitals on accountof malaria. In 1913 we had only seventy out ofevery one thousand of our laborers admitted forthis disease. The yearly table for malarial rateis as given below:

1906 . . . . . . . . . . . . . . . . . . . . 821 per 1,0001907 . . . . . . . . . . . . . . . . . . . . 426 “ 1,0001908 . . . . . . . . . . . . . . . . . . . . 282 “ 1,0001909 . . . . . . . . . . . . . . . . . . . . 215 “ 1,0001910 . . . . . . . . . . . . . . . . . . . . 187 “ 1,0001911 . . . . . . . . . . . . . . . . . . . . 184 “ 1,0001912 . . . . . . . . . . . . . . . . . . . . 110 “ 1,0001913 . . . . . . . . . . . . . . . . . . . . 76 “ 1,000

Yellow fever was entirely eradicated. In 1904we had a few cases, and in 1905, a sharp epidemic.In November, 1905, the last case occurred in thecity of Panama, and in May, 1906, the last case in

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the town of Colon. Since that time no cases haveoriginated on the Isthmus.On June 20, 1905, Nehemiah Morgan, a Ja-

maican negro, employed at La Boca, the south-ern terminus of the Canal, was admitted to thehospital with symptoms of bubonic plague. Thename La Boca has since been changed to Balboa.This man died on June 23, and the autopsy con-firmed the diagnosis. On the twenty-sixth, aquarantine was placed against La Boca. Dr.James Perry, of the United States Public HealthService, was placed in charge. He was suppliedwith a force of four foremen and one hundredlaborers, who under his direction did the neces-sary cleaning and fumigation. This quarantinewas kept up until July 15, when it was raised, asthere was no further indication of plague orplague-infected rats.

Dr. Perry deserves the greatest credit for theefficient way in which he managed to stamp outthis infection, so threatening and dangerous to thework.

Plague is an infectious disease caused by a well-known germ, the bacillus pestis. It is a diseaseof the rat, and is transferred from the rat to ahuman being by the rat flea. Anti-plague meas-ures are, therefore, almost entirely directed to-ward the destruction of rats. Rigid quarantinesare also kept up, so as to prevent human beings

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sick with the disease from going to uninfectedplaces, and there starting new foci of infection.

The measures used against rats are poisons ofvarious kinds, but the rat is one of the most in-telligent of animals, and soon learns to avoidpoisons. The same thing is true with regard totraps. Rats so rapidly learn about poisons andtraps that some writers on anti-plague measuresadvise that these measures be used only duringemergencies, when plague is either present, orthere is imminent danger of an outbreak, the argu-ment being that if you use these measures con-tinuously, the rats will become so knowing thatyou cannot kill them when plague is upon youand they are actually infected.

Mr. Le Prince arranged a very successful rat-trap which killed the rat by short-circuiting be-tween two electric wires. Such a trap placed ina rat runway gave no notice to the rat whatever,and always killed him. But it requires some skillto manipulate such a trap, and our Jamaicandarkies were so often shocked in trying to arrangeit that Mr. Le Prince gave it up.Undoubtedly, the best anti-plague measures are

those calculated to free the town from rats per-manently, and these measures relate principallyto rat-proofing the houses. In a general way, thesemeasures consist in making a concrete floor, andin putting six or eight inches of concrete in the

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wall around this floor. With the whole town fixedup in this way, you would have no rats. At thesame time, disposal of garbage should be carefullylooked after, with the object of limiting the foodsupply of rats.

Dr. Connor, of Colon, invented an excellent gar-bage stand, so arranged that a lid automaticallyclosed the garbage can whenever the lid had beenraised and released. If, however, a town has beenmade entirely rat-proof, that town is pretty securefrom plague. If there are no rats there, no harmwill be done, even if cases of plague come in, forthere would be no means of transmitting it fromman to man. If you have plenty of rats in a com-mercial city, such as Panama, in direct commercialrelation with cities having plague, you are sure,in the course of time, to get in plague cases, nomatter how good your quarantine, and if plagueonce gets in where there are plenty of rats it isvery apt to spread.

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CHAPTER XXII

THE WORK OF THE SANITARY DEPARTMENT OF PANAMA

THE work of the Sanitary Department of Pan-ama has without question been a most useful

adjunct in the construction of the Canal. It hasenabled this work to be carried through with aminimum of loss, both in regard to sickness anddeath among employees engaged in constructionwork in the Canal Zone. We have no means oftelling what was the sick rate with the Frenchduring the period of construction under the oldFrench Company, from 1881 to 1889, but we knowthat it was very large.

Our Army in Cuba during the Santiago cam-paign had during the last two months of our staythere a constant sick rate of over six hundred perthousand. Undoubtedly, the French rate approxi-mated this during their period of active work, andwe can safely calculate that their constant sickrate was at least three hundred and thirty-threeper thousand, or one-third their force.

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Our force during the ten years of constructionaveraged thirty-nine thousand men. If we hadhad a similar constant sick rate, we should havehad thirteen thousand sick employees in our hos-pitals every day during the ten years of construc-tion. As it was, we had only twenty-three perthousand sick each day, a total of nine hundredfor the whole force; that is, we had about twelvethousand fewer men sick every day than had theFrench. This twelve thousand men per day savedfrom sickness must be credited to the sanitarywork done on the Isthmus.

Now let us consider the totals: We had an aver-age of 900 men sick every day. For the year,this would give us 328,500 days of sickness, andfor the ten years 3,285,000 days of sickness. Ifour rate had been 300 per 1,000, a very moderatefigure compared with what it was under theFrench, we should have had 11,700 sick every day.For the year, this would have given us 4,270,500days of sickness and for the ten years, 42,705,000,a saving of 39,420,000 days of sickness during thisperiod. This saving must justly be credited tosanitation.

It cost us about one dollar a day to care for asick man on the Isthmus. The Commission caredfor the sick free of charge. Every day, therefore,of sickness prevented on the Isthmus lessened theexpense which the Commission had to bear by one

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dollar. The Commission was therefore saved bythis sanitary work, if we consider the whole tenyears of construction, $39,420,000.

This represents only one phase of the saving dueto sanitation, merely the saving due to decreasein the numbers of sick who had to be cared for.But the sanitary work really saved much morethan this. If three hundred men out of every onethousand of our employees had been sick everyday, the efficiency of the other seven hundred wouldhave been correspondingly decreased. The otherseven hundred would have been more or less de-bilitated, and more or less depressed, and theamount of work turned out daily by each manwould have been considerably less than it actuallywas for the employee enjoying good health andcheerful surroundings. We should have had topay considerably higher wages, if the Isthmus hadcontinued to bear the reputation during our periodof construction which it had always borne duringthe years preceding 1904; if, for instance, it hadbeen known that three out of every ten men goingto work on the Canal would be sick all the time,and that two out of every ten would die each year,and that the whole ten would be dead at the endof five years.

Great loss was caused to us in the first yearson the Isthmus by the demoralization among theworking force, and almost stoppage of work which

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took place during periods of exacerbation in theyellow-fever condition, or when prominent em-ployees died of that disease. Great loss also oc-curred to the French on this account. Mr. Bunau-Varilla described very graphically the conditionof his force as the result of such conditions. Mr.Bunau-Varilla was one of the most prominent ofthe French engineers for the old French Company,and was their chief engineer from 1885 to 1887.

I do not think that anyone familiar with theconditions would question the statement that alarger sum in dollars and cents was saved to theCommission in these ways than was saved by thedirect decrease in the number of sick.

Considering all these factors, it will not be con-sidered an exaggerated estimate to state thateighty million dollars was saved to the UnitedStates Government by the sanitary work done onthe Isthmus during the ten years of construction.That is, granting that the construction work couldhave been accomplished under such conditions ashad existed during the construction period of theold French Company, or which existed on theIsthmus of Panama at any time prior to 1904, andgranting that public sentiment in the UnitedStates would have allowed the prosecution of thework with such mortality among the laboring forceas had previously occurred, it would have cost theUnited States eighty million dollars more than it

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actually did cost to accomplish the results it hasattained on the Isthmus.

I go into these figures to demonstrate that thereis great financial profit resulting from money spenton such sanitary measures as we inaugurated onthe Isthmus. This is the purely commercial sideof the question. Of much greater importance isthe moral argument that can be adduced from thesaving of life and suffering that results from suchmeasures.

During the ten years of construction, we lost bydeath seventeen out of every thousand of ouremployees each year. That is, from the wholeforce of 39,000 men, 663 died each year, and forthe whole construction period we lost 6,630 men.If sanitary conditions had remained as they hadbeen previous to 1904, and we had lost, as did theFrench, two hundred of our employees out of eachone thousand on the work, we should have lost7,800 men each year, and 78,000 during the wholeconstruction period.We therefore claim for the work of the Sanitary

Department the saving of 71,370 human lives dur-ing the building of the Panama Canal. Where oneman died, probably three would have returnedhome broken in health, with months and years ofsuffering and invalidism ahead of them. Sanita-tion on the Isthmus has saved this heavy toll tothe devoted people engaged in this great work,

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and was, therefore a most wise and lucrative in-vestment to our Government, and played a mostimportant part in aiding the construction work inthat great enterprise.

But I believe that this aiding in the constructionof the Canal is not the most important functionthat the sanitary work at Panama has played. TheCanal Zone, for the past four hundred years, eversince it has been known by the white man, has beenone of the most unhealthy spots in all the tropicalworld, and this fact has been generally known andrecognized by all nations which have had any com-mercial importance.

About the time of the discovery of America,Europeans began to visit and colonize the tropics,but it was early discovered that the white mancould not live and thrive with such conditions andsurroundings as existed there. It seemed to bedemonstrated that there was something in theclimate that sapped his constitution and broke hishealth. This statement applies to white childrento an even greater extent than to the adult.

The great colonizing nations had been the Span-iards, the Portuguese, the Dutch, the French andthe English. Their experience had all been ex-actly similar from the beginning of the sixteenthcentury to the present time—that the white mancould not live and thrive in the tropics, nor couldhe leave behind him in those regions a healthy

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progeny. By all men everywhere it was believedthat this was due to tropical climatic conditions,which could not be combated, and that thereforethe white man was permanently barred frombuilding up any great civilization in these regions.

Man, like all other animals, must necessarilyhave developed in one locality. If we accept themodern explanation, generally received by edu-cated persons, Darwinism, all life at present onthe globe must have descended from one singlecell. If we take some individual animal at presentliving, a dog, for instance, we could trace his an-cestry back to the first cell, if we could obtain allthe facts in the case. By very slow changes, genusafter genus and species after species developedfrom this first cell, each genus and each speciesdiffering slightly from the one preceding.

An individual varying very slightly from theother individual of his species, becomes the pro-genitor of a new species, provided the variationaccords with his surroundings so as to fit himbetter for the struggle of life. But all of thenew species must descend directly from the onepair which produces these favorable variationsin their progeny. Every species, therefore, suchas the dog, must originate in some one locality.If at any time this species of animal is found inall parts of the world, it must have slowly spreadfrom the locality in which it originated. The dog,

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therefore, came to his present development insome one part of the world. As he is now foundin all parts of the world, he must have spreadfrom this one locality in which he originated.

Exactly the same argument applies to man. Ifwe consider man’s condition in his earlier stages,we can see that there must have been a periodwhen he had neither fire nor clothing. At this timehe must have lived in parts of the world wherethe temperature was that now found between thetropics of Cancer and Capricorn. As we knowhim now, he could survive the year around with-out fire and clothing only within this region. Hemight live a little north and south of these paral-lels of latitude, but not very far. Very few in-dividuals of a community which attempted tospend a winter in the latitude of Washington,without either fire or clothing, would be alivewhen the warm weather of spring returned. Itis pretty certain, therefore, that man lived exclu-sively in the tropics, up to the discovery of fireand clothing.

There was a period, then, in man’s existencewhen the environment found in the tropics wasbetter suited to his life than that found in thepresent temperate zones. Conditions graduallychanged, until affairs were exactly reversed, andthe temperate regions became better suited forman’s healthy life than the tropical regions. This

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was the condition of affairs when we first beginto get some knowledge of man, at the early dawnof history. When we first begin to learn any-thing about him historically, the most vigorousand healthy races, mentally and physically, wereto be found in the temperate zones. The condi-tions that brought about this change of habitatin man were probably the spread of the variousinfectious diseases within the tropics. The hottropical regions were much better fitted for thelife of the germs which caused these infectiousdiseases than were the temperate regions, for ex-actly the same reasons that these tropical regionsbetter suited the life and development of man.Due to his superior intelligence and superiorpowers of locomotion, man was enabled to spreadthrough and occupy the tropical regions long be-fore the germs of the various infectious diseaseswere able to do so.

Yellow fever, for instance, was able to extendvery little beyond the region where it originallydeveloped, until man came along with his ships,and in this way enabled the yellow-fever germto begin its travels about the world. As yellowfever developed in America, the germ did notbegin its travels until Columbus brought his shipsinto the Caribbean Sea. As the infections spreadthrough the tropics, the environment in those re-gions became unfavorable to man, to such an ex-

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tent that he ceased to be able to improve in hismental and physical characteristics. But as theenvironment of regions outside the tropics wasstill more unfavorable, actually deadly, he had noescape.

At this period, then, man found himself inhab-iting tropical regions where sanitary conditions,the infections, were very unfavorable to him, andhe was unable to migrate to the temperate zones,because the sanitary conditions there, cold, weredeadly to him.

About this time, two great sanitary discoveries,the most important ever made by man, namely,fire and clothing, came to the knowledge of ourtropical ancestors. The greatest sanitarian thatthe human race has ever produced was probablythe individual who discovered fire, and next inimportance, the individual who first wore somekind of clothing. These two discoveries enabledman to overcome the hitherto insurmountablesanitary obstacle of the temperate regions, name-ly, cold. With the application of these two sani-tary discoveries, the human race was enabled tomigrate from the tropics and continue healthydevelopment in the temperate regions.

At the present time, we have just reversed theprocess; we have just made sanitary discoveriesthat will enable man to return from the temper-ate regions to which he was forced to migrate

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long ages ago, and again live and develop in hisnatural home, the tropics. These sanitary dis-coveries are those that have enabled us to controlyellow fever and malaria.

The practical application of these great discov-eries has just been demonstrated during the con-struction of the Panama Canal. This was not thefirst demonstration with regard to either disease.But the conditions were such at Panama thatthey have attracted the attention of the wholeworld, and probably the general knowledge thatthe white man can live and thrive in the tropicswill date in future times from the construction ofthis great work.

A given amount of labor applied to land willproduce a very much larger amount of wealththan will the same labor applied in the same wayproduce in the temperate regions. The whiteman, of all the races of the human family, is themost eager in his pursuit of wealth. As it be-comes generally known that he can live in thetropics and maintain his health, necessarily alarge emigration will occur from the presentcivilized temperate regions to the tropics. Thelargest areas of land suitable for cultivation liein the tropics, and much the largest bodies of richalluvial lands, such as the valleys of the Amazonand the Congo. Not only are these lands moreproductive than the lands of the temperate zone,

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but climatic conditions enable the farmer to pro-duce several crops a year. The tropics, whenoccupied and cultivated by the white man, willproduce many times the amount of food now pro-duced in the temperate regions.

The great civilizations of man are now alreadyestablished and developed in the temperate zonesof Europe and America, and it is probable that,for centuries to come, these great empires will belocated where they are at present, and that thetropics will be the agricultural, food-producingregions from which these centers of civilizationwill be supplied.

In the early stages of the development of man-kind it was all that each individual could do tosupply his own necessities. As he advanced incivilization, he produced more than he himselfneeded, and thereby had a surplus to exchangewith his neighbors for things which he desired.As his productive capacity increased, a largernumber of men were enabled to apply themselvesto the arts and sciences. The degree of civiliza-tion to which a community can reach is in themain governed by the amount of the necessitiesof life that the labor of one man applied to theland can produce. If one man’s labor can pro-duce enough of the necessities to support himselfand one other man, we have a certain degree ofcivilization and refinement. If his labor produces

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enough to support himself and two other men, ahigher degree of civilization results. In the trop-ics one man’s labor applied to natural opportu-nities is able to support more men than the sameamount of labor applied in any other part of theworld. In the long run, therefore, the great civ~ilizations of the future will be located in thetropics.

No doubt the great centers of civilization willremain for centuries much as they are at present.The white settlers will go to the valleys of theAmazon and Congo, building up large agricul-tural communities which will supply the Euro-pean and American centers located as they are atpresent with their food supply. But in the courseof ages the centers of civilization will move towhere a given amount of labor will produce thelargest amount of food. Of course, other thingsmust be equal. I am assuming that the govern-ment in these new communities is as good as thegovernment with which we are comparing it inthe temperate zone. When this great migrationof population has fully commenced, I believe thatthe peoples of that day will look back upon thesanitary work done at the Canal Zone as the firstgreat demonstration that the white man could liveas well in the tropics as in the temperate zone.

I am inclined to think that at this time the sani-tary phase of the work will be considered more

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important than the actual construction of theCanal itself, as important to the world as thisgreat waterway now is, and will be for genera-tions to come.

The discovery of the Americas was a greatepoch in the history of the white man, and threwlarge areas of fertile and healthy country opento his settlement. The demonstration made atPanama that he can live a healthy life in thetropics will be an equally important milestone inthe history of the race, and will throw just aslarge an area of the earth’s surface open to man’ssettlement, and a very much more productivearea.

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INDEX

Agramonte, Dr., 11, 16, 41.Albertini, Dr. Antonio, 12.American Medical Associa-

tion, interest of, inPanama sanitation,142.

Ancon Hospital, 209, 224-234, 236-238, 241-247.

care of insane at, 242.clinic for tropical diseases

at, 238.equipment at, 241.eye department at, 242.management of, 243, 244.organized by La Garde,

229-232.records of, under French

company, 227.researches at, 238.services of, to Canal em-

ployees, 247.sewage system installed at,

230.statistics of, 247.treatment of yellow fever

at, 230-231.Angeles, Sister Maria de los,

268.Anopheles. See Mosquito,

malarial.

293

Augustin, on yellow fever,117.

Avila, Pedro Arias de.Pedrarias.

See

Balboa in Panama, 132, 133,134, 135, 168.

Bubonic plague in Panama,271,276-278.

Camp Columbia, yellow-feverexperiments at, 19, 20,25, 26, 30.

Camphor fumigation, 54, 55.Carroll, Dr., on Sanarelli’s

researches, 7, 11.mosquito experiments of,

16, 19, 41.Carter, Dr. Henry R., quar-

antine work of, 271.system of, for transporta-

tion of sick in Panama,210-212.

yellow-fever researches of,10, 27, 28, 29.

Cemeteries in Panama, 214-217.

Chloroform, use of, againstmosquitoes,199.

Coffin story, 240.

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Colon Hospital, 209.Colon, yellow fever in, 150.Colonization and disease, 114,

284.Columbus in Panama, 131.Concrete floors, as anti-plague

measure,277-278.Cook, Dr. R. P., yellow-fever

experiments of, 36.Correspondence, Reed-Gor-

gas, 77-109.Cost of sanitary measures in

Panama, 148, 151, 152,239, 240, 241.

Culebra Island, quarantine at,271-274.

Darling, Dr.238.

Davis, George W., General,152.

Deeks, Dr. W. W., 238.Dispensaries in Panama, 213,

220-223.District physician, duties of,

212-214.Drainage as anti-malarial

measure, 184-189, 194-196, 201, 235.

Drake in Panama, 137, 163,168, 176, 177, 178,179.

Samuel, 190,

Emergency and temporaryhospitals in Panama,210.

Emigration, effect of controlof tropical disease on,289,293.

Finlay, Dr. Carlos, mosquitotheory of, 13, 14, 27.

Flemenco Island cemetery,215.

French Panama Canal Co.,hospital service of, 224-227.

yellow fever and malariaunder, 138, 149, 227.

Fumigation for yellow fever,52, 53, 54, 55, 150, 151,261, 263.

Garbage disposal as anti-plague measure, 278.

Gillette, Cassius E., Major143.

Grass-cutting in anti-malarialwork, 187.

Guiteras, Dr. John, 12, 41, 45,48.

Havana, sanitarymeasures in,5, 6, 56-61.

yellow fever in, 3-7, 22, 23,41,125.

“Her ladyship,” 43-46.Herrick, Dr. A., 238.Hospital system in Panama,

207-214,223.dispensaries in,

220-223.equipment in,207-210.medical districts in, 212.

213-214,

214.transportation of sick in,

210, 211.Hospitals, emergency and

temporary, in Panama,210.

Hygiene Congress, Gorgas,Wm. C., at, 141.

value of certificate of, 25.

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INDEX

Immunity, yellow-fever, 22-24, 64, 118, 119, 261-263.

Insane, care of, in Panama,242.

Inspection. See Sanitary in-spection.

International Sanitary Con-gress, demonstration ofmosquito theory at, 48.

Kerosene oil, in anti-malarialwork, 188.

in yellow-fever work, 61.

La Boca, bubonic plague in,276.

La Crosade, Dr., 226.La. Garde, Louis A., Major,

143,206.organizes Ancon Hospital,

229.Larvacide in anti-malarial

work,190-191.Las Animas Hospital, yellow-

fever experiments in,19, 26, 41, 43, 45.

yellow-fever treatment in,50-51.

Lazear, Dr., on Sanarelli’sresearches,11.

mosquito experiments of,16, 19.

Leper colony in Panama, 256.Le Prince, Joseph, anti-mala-

rial work of, 159, 186,198-200, 202, 203, 204.

fumigation experiments of,55.

rat trap devised by, 277.in Ancon Hospital, 230-231.

Lyster, Theodore C., Major,242.

Malaria, importance of con-trol of, to human race,289-293.

at Ismalia, 140.at Porto Bello, 165, 166.preventive work in, drain-

age and, 183-189.kerosene oil and, 188.quinin dispensation and,

220.sanitary districts organ-

ized for, 160.screens and, 196-198.

statistics of, 73, 275.transmission of, 219.

Malarial mosquito. See Mos-quito, malarial.

Mason, Colonel, 243.Medical districts organized in

Panama, 209, 212, 213.Medical practice, ancient and

modern,110-113.Medical service in Panama,

sanitary advantage of,212-214.

Mosquito, malarial, at Isma-lia, 141.

sanitary control of, 61,159, 183-191, 194-196,198-205.

yellow fever, Army boardexperiments on, 16-20,26, 30-36, 38, 41-49.

breeding conditions of, 2,56, 58, 59, 60, 192, 204,233, 265.

fumigation and, 52, 53,54, 55.

295

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Mosquito, yellow fever, in An-con Hospital grounds,232-234.

kerosene oil, use of, and,61.

Mosquito-catcher in anti-ma-larial work, 198-202.

Mosquito theory of yellow-fever transmission, 13,14, 32, 36, 48, 157.

Mosquitoes, difierent speciescompared, 191-195.

Mount Hope cemetery, 216.Mott, Dr. J. C., 13.

Panama, fumigation for yel-low fever throughout,150, 151.

hospital service in, 207-214,223.

medical districts in, 209.Sanitary Department of,

148,153,154.sick rate statistics at, 280,

281.Spanish rule in, 134-135,

168,176-180.yellow fever in, 136, 150.

Pedrarias in Panama, 132,133.

Perry, Dr. James A., 265, 271,276.

Phillips, Colonel, 244.Pizarro in Panama, 133, 135.Porto Bello, cemetery at, 216,

217.commerce and fair at, 161-

162, 163, 164.malaria in, 165, 166.

Public Health Service, Boardof, 10.

Pyrethrum, fumigation with,54, 263.

Quarantine, for bubonicplague, 276.

for yellow fever in Havana,63, 64, 72.

in Panama, 260.Quinin, dispensation of, 220-

223.

Rats, relation of, to bubonicplague, 276-278.

Reed, Dr. Walter, mosquitoexperiments of, 16, 19-21, 26, 30-36, 38, 41.

on Sanarelli researches, 7,11.

Reed-Gorgas correspondence,77-109.

Ross, Dr. John W., 35, 45,143, 206.

Ross, Dr. Ronald, anti-mala-ria work of, 74, 141.

San Blas Indians, 167-174.Sanarelli, Giuseppi, yellow-

fever researches of, 7-11.

Sanarelli’s organism, Armyboard investigation of,11, 12.

Sanitary Department in Pan-ama, accounts of, 239,241.

cemeteries under control of,214-216.

changes in, 153, 154.financial and moral value

of, 280-284.free medical service of, 214.

296

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Sanitary department in Pan-ama, organization of,148.

undertaking and, 239-240.Sanitary districts for anti-

malarial work, 160,182, 183.

Sanitary inspection, in Ha-vana, fumigation foryellow fever and, 52-55.

screens and, 50-52.water supply and, 56-62.

in Panama, drainage and,184-195, 201.

fumigation for yellowfever and, 150, 151,261, 263.

grass-cutting and, 183-184.

mosquito - catching and,198-202.

screens and, 196-198.Screens, as anti-malaria

measure,196-198.in treatment of yellow fe-

ver, 50–51, 230, 231.Smith, Patrick, Private, San-

arelli’s organism and,11.

Stegomyia. See Mosquito,yellow-fever.

Sternberg, George M., Gen-eral, 7, 138.

Stevens, John F., 155.Suez Canal, sanitation at, 139,

140.Sulphur fumigation, 53, 263.

Taboga, sanitarium at, 248,249.

Tobacco fumigation, 55.Transportation of sick in Pan-

ama,210-212.

Umbrella ants at Ancon Hos-pital, 232-234, 236-237.

U. S. Army, sick rate in, 4,206, 279.

Vaccination, yellow-fever, 42,47.

Water supply, at Ancon Hos-pital, 229.

in Havana, and mosquito-breeding, 56, 58, 59, 60.

at Suez Canal, 140.Wood, Gen. Leonard, 19, 40.

Yellow fever, description of,21, 115, 122.

direct transmission of, 37-38.

effect of, on shipping, 3.endemic areas of, 125-126,

127, 128, 270.epidemic area of, 129, 130.epidemics of, 1, 128, 129,

130.experiments at Camp Co-

lumbia, 19, 20, 21, 25,26, 27, 30.

fumigation for, 52-55, 150,151, 261, 263.

importance of control of, tohuman race, 289-293.

in Africa, 127.in Brazil, 126.incubation period for, 10,

27-30, 38.in Ecuador, 24, 119.

297

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Yellow fever in French Pan-ama Canal Co., 138,149, 227.

in Havana, 3-7, 22, 23, 41,125.

in U. S. Army, 4.in Vera Cruz, 3, 117, 121,

127, 128.investigation of, by Army

board, 11, 12, 16-20,26, 30-36, 38, 41-46.

old treatment of, 65, 66, 67,68, 69, 70.

origin of, 117-118, 119,120, 121, 287.

quarantine regulations for,63, 64, 72, 260.

Sanarelli’s researches in, 7-11.

Yellow fever, ship infectioncases of, 264-269.

spread of, 115, 116, 124,125, 126, 127.

statistics of, 71, 72.transmission of, 13, 14, 21,

27, 32-36, 37-38.treatment of, at Ancon Hos-

pital, 230-232, 233, 234.screens in, 50-51, 230,

231.Yellow-fever immunity, 22-24,

64, 118, 119, 261-263.value of certificate of, 25.

Yellow-fever mosquito. SeeMosquito, yellow-fever.

Yellow-fever vaccination, 42,47.

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