ill 
 
University of California Berkeley 
 
SANITATION IN PANAMA 
 
Concreted Ditch. Ancon. 
 
jurm 
 
 SANITATION 
 IN PANAMA 
 
 BY 
 
 WILLIAM CRAWFORD GORGAS 
 
 CHIEF SANITARY OFFICER, PANAMA CANAL, SURGEON GENERAL, U. 8. 
 UAJOK GENERAL, U. 8. A. 
 
 ILLUSTRATED 
 
 NEW YORK AND LONDON 
 D. APPLETON AND COMPANY 
 
 1915 
 
COPYRIGHT, 1915, BY 
 D. APPLETON AND COMPANY 
 
 Printed in the United States of America 
 
CONTENTS 
 
 I. YELLOW FEVER AND THE DISCOVERIES br 
 
 ITS TRANSMISSION 1 
 
 II. THE EXPERIMENTS OF THE REED BOARD . 18 
 
 III. THE DISCOVERIES OF THE REED BOARD . . 32 
 
 IV. THE SANITARY BOARD OF HAVANA ... 40 
 V. SANITARY WORK AT HAVANA .... 50 
 
 VI. THE RESULTS ACCOMPLISHED IN HAVANA 63 
 
 VII. CORRESPONDENCE WITH DR. REED ... 77 
 
 VIII. HISTORY OF YELLOW FEVER 110 
 
 IX. GEOGRAPHICAL LIMITS OF YELLOW FEVER 124 
 
 X. APPOINTED CHIEF SANITARY OFFICER FOR 
 
 THE ISTHMUS 138 
 
 XL PRELIMINARY ORGANIZATION AND WORK 
 
 AT PANAMA 148 
 
 XII. YELLOW-FEVER WORK AT THE ISTHMUS . 159 
 
 XIII. NOMBRE DE DlOS 175 
 
 XIV. THE WORK OF THE SANITARY INSPECTORS 182 
 XV. THE WORK AT THE HOSPITALS .... 206 
 
 XVI. MALARIA WORK AND THE HOSPITAL SYS- 
 TEM , , 219 
 
CONTENTS 
 
 CHAPTER PAOB 
 
 XVII. MEDICAL AND SURGICAL SERVICE OF ANCON 
 
 HOSPITAL 241 
 
 XVIII. THE SANITARIUM AT TABOGA .... 248 
 
 XIX. THE LEPER COLONY 256 
 
 XX. QUARANTINE SYSTEM 260 
 
 XXI. PLEASURES AGAINST BUBONIC PLAGUE . . 275 
 
 XXII. THE WORK OF THE SANITARY DEPART- 
 MENT OF PANAMA 279 
 
 INDEX 293 
 
LIST OF ILLUSTRATIONS 
 
 FACING 
 PAGE 
 
 Concreted Ditch. Ancon Frontispiece 
 
 Map of the Panama Canal Zone, Showing Hospi- 
 tals of the Sanitary Department .... 1 
 
 Stegomyia Squad. Havana 52 
 
 Screened Water Barrel. Havana 52 
 
 Concreted Ditch. Gatun 112 
 
 Screened Yellow-fever Ward. Ancon Hospital, 
 
 Panama 150 
 
 St. Charles Ward, Ancon Hospital. Building in 
 Which Twelve Hundred Frenchmen Died of 
 
 Yellow Fever 150 
 
 Oilers at Work in Marsh 184 
 
 Burning Out Ditch with Oil Spray 184 
 
 Old French Engine Tender Used as Storage Tank 
 
 for Oil 194 
 
 Mule for Packing Oil to Oilers 194 
 
 Distilled Water Cart. Culebra 220 
 
 Ward at Ancon Hospital 220 
 
 Stoned Ditch near Tivoli Hotel. Ancon, Panama . 234 
 
 Bad Anopheles Breeding-ground on Artificial Fill. 
 
 La Boca . 234 
 
CARIBBEAN 
 
 S E 
 
 F 1 C 
 
 OCEAN 
 
 Map of the Panama Canal Zone, Showing Hospitals of the 
 Sanitary Department. 
 
SANITATION 
 IN PANAMA 
 
 CHAPTER I 
 
 YELLOW FEVER AND THE DISCOVERIES OF ITS TRANS- 
 MISSION 
 
 \^ ELLOW FEVER for two hundred years be- 
 * fore the Spanish- American War caused great 
 loss of life and much destruction of wealth. Every 
 few years portions of the United States would be- 
 come infected with this disease. In the earlier 
 part of this period the disease was more or less 
 local. As the Mississippi valley became more 
 thickly populated, the extent of the disease and the 
 injury caused became very much augmented. The 
 epidemic of 1878 was probably the deadliest and 
 most extensive epidemic of yellow fever which ever 
 affected the United States. In this epidemic over 
 thirteen thousand people in the Mississippi valley 
 alone lost their lives, and the loss of wealth is 
 estimated at considerably more than one hundred 
 millions of dollars. 
 
 It is very difficult to convey to a reader any idea 
 of the conditions which exist during an epidemic 
 of yellow fever. All business is entirely para- 
 
SANITATION IN PANAMA 
 
 lyzed, the quarantines not allowing any communi- 
 cation between the affected districts and those 
 not affected. In an epidemic of any extent this 
 means hundreds of local quarantines. Some idea 
 of the condition of affairs can be obtained by pic- 
 turing what would occur in any community if all 
 the income of that community should entirely 
 cease for six months. And this was the condition 
 of business all over the Mississippi valley every 
 time yellow fever gained entrance. 
 
 The population originally feared yellow fever 
 on account of the poverty, suffering and business 
 depression always caused by the quarantines 
 which had to be enforced to prevent its spread, 
 and in time people came to associate this idea of 
 dread with yellow fever itself. When this disease 
 was announced in a town, everybody left who 
 could. The sick were frequently left without care, 
 and often a great deal of cruelty and cowardice 
 was shown. If a person escaped from an infected 
 region and became sick with the disease, or sick 
 from any other cause, he was generally treated 
 as if he were a leper, and would often be left to 
 starve or die on the roadside. 
 
 It requires continuously warm weather for the 
 yellow-fever mosquito to breed in sufficient num- 
 bers to propagate yellow fever; therefore, this 
 disease never became endemic in the United 
 States, I mean by endemic, existing all the year 
 
 2 
 
YELLOW FEVER AND ITS TRANSMISSION 
 
 round and over a number of years. The frosts 
 of winter, wherever they occur, either destroy all 
 the yellow-fever mosquitoes, or reduce their num- 
 ber below the point at which yellow fever could be 
 propagated. 
 
 It was known in the United States that yellow 
 fever was always brought somewhere from the 
 littoral of either the Gulf of Mexico, or the Carib- 
 bean Sea, and the city of Havana, located on the 
 northern coast of the island of Cuba, was known to 
 be the center of this endemic area. 
 
 Yellow fever in 1898 was looked upon as the 
 example of a filth disease, par excellence, and it 
 was thought that if Havana were put in a proper 
 state of cleanliness, it might cease to be the great 
 point of infection for the United States. It was 
 known that yellow fever had existed in the city 
 of Havana continuously for one hundred and fifty 
 years. It is interesting to note that the endemic 
 infection of Havana occurred in 1762, when Ha- 
 vana was besieged and captured by American 
 troops. 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 was 
 supposed to have been brought by a vessel from 
 Vera Cruz. 
 
 Yellow fever peculiarly affects shipping, and 
 time and again ships in the harbor of Havana 
 
 5 
 
SANITATION IN PANAMA 
 
 have had every living soul of their crew die from 
 this disease, and these vessels would have to lie 
 there for months until another crew could be ob- 
 tained. 
 
 When we went to Havana in 1898 we knew no 
 more of the sanitation of yellow fever than we 
 had known a century before. The army which 
 went to Santiago suffered as severely from yellow 
 fever and other tropical diseases as any military 
 expedition into the tropics had suffered before 
 that time, and its death rate, had it remained, 
 would have been just as high as was that of the 
 French army of similar size, which was exter- 
 minated in the island of Haiti just one hundred 
 years before. 
 
 A very deep impression was made upon me 
 by the condition of our army at the end of two 
 months 1 campaigning in this tropical region. It 
 was utterly used up and of no value whatever as 
 a fighting machine. Fully four-fifths of the men 
 were having fever. This small army of sixteen 
 thousand men was as fine a body of soldiers when 
 they landed at Siboney as could probably be got- 
 ten together, but after two months' campaigning 
 in this tropical jungle, and after several weeks 
 of fever from which no one was free, their stamina 
 and 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 
 
YELLOW FEVER AND ITS TRANSMISSION 
 
 go home. No one could see any need of staying 
 in Cuba, and every individual was perfectly cer- 
 tain that he would die if he remained there a 
 month longer. Officers and men became nervous 
 and hysterical. I commanded the base hospital 
 at Siboney, and it was my disagreeable duty to 
 select from day to day those who would have to 
 remain. Many times every day the poor fellows, 
 officers and men, would break down and cry when 
 told that they could not leave on the next ship. I 
 could form some idea of what it must have been 
 among the French at Haiti when they knew that 
 they 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 of 
 Havana. We arrived there in December, 1898. 
 The military authorities concluded jthat this was 
 the opportunity which the United States had been 
 awaiting for the past two hundred years. Think- 
 ing that yellow fever was a filth disease, they 
 believed that if we could get Havana clean enough, 
 we could free it from yellow fever. It was felt 
 that if we could eliminate Havana as a focus of 
 infection, the United States would cease to be 
 subject to epidemics. This meant so much to the 
 United States, financially and otherwise, that the 
 authorities determined to make all other efforts 
 secondary to this sanitary effort. 
 
 The city was cleaned as well as it was possible 
 
SANITATION IN PANAMA 
 
 to cleanse it. This remark applies as well to the 
 private premises as to the public highways. Ener- 
 getic and capable Army officers were placed at 
 the head of various municipal departments, and 
 these departments were thoroughly organized and 
 made as efficient as possible. By the middle of 
 the year 1900 all the city governments were per- 
 fectly organized, and were accomplishing all that 
 it was possible for them to accomplish. I believe 
 that Havana was cleaner than any other city had 
 ever 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 ever 
 since we had taken possession of the city, and in 
 1900 there were a greater number of cases than 
 there had been for several years. The Cubans 
 twitted us with the fact that all our cleaning up 
 and 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 best 
 kept portions of the city were by far the worst 
 sufferers from yellow fever, and the evidence was 
 so 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 
 
 6 
 
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 the 
 causative agent in yellow fever. 
 
 Drs. Eeed and Carroll had proved that the 
 bacillus icteroides of Sanarelli was identical with 
 the 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 years 
 1897 and 1898, at the laboratory of the Army 
 Medical Museum in Washington. The investiga- 
 tion was undertaken at the request of General 
 Sternberg. 
 
 In 1899 our Public Health Service published the 
 report of a board of medical officers who had been 
 sent 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 the 
 discovery 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 
 
SANITATION IN PANAMA 
 
 received through the respiratory tract, in other 
 words, verifying one discovery and making others 
 of almost equal importance, at the same time 
 eliminating incorrect theories, must be considered 
 a notable achievement in medical science and one 
 of the greatest practical value to the people of the 
 United States and other countries infected, or 
 liable to be infected by yellow fever. 
 
 
 
 In view of the widespread interest which the 
 report will excite and the practical deductions to 
 be drawn therefrom, I have respectfully to re- 
 quest authority to have the same printed. 
 
 The findings of this Commission were : 
 
 First. That the microorganism discovered by 
 Professor Giuseppi Sanarelli, of the University 
 of Bologna, Italy, and by him named "bacillus 
 icteroides" is the cause of yellow fever. 
 
 Second. That yellow fever is naturally infec- 
 tious to certain animals, the degree varying with 
 the species; that in some of the rodents local 
 infection is very quickly followed by blood infec- 
 tion, and that, while in dogs and rabbits there is 
 no evidence of this subsequent invasion of the 
 blood, monkeys react to the infection the same 
 as man. 
 
 Third. That infection takes place by way of the 
 respiratory tract, the primary colonization in this 
 tract giving rise to the earlier manifestations of 
 the disease. 
 
YELLOW FEVER AND ITS TRANSMISSION 
 
 Fourth. That in many cases, probably a major- 
 ity, the primary infection, or colonization, in the 
 lungs is followed by a "secondary infection," or a 
 secondary colonization in the blood of the patient. 
 This secondary infection may be complicated by 
 the coinstantaneous passage of other organisms 
 into the blood, or this complication may arise 
 during the last hours of life. 
 
 Fifth. There is no evidence to support the 
 theory advanced by Professor Sanarelli that this 
 disease is primarily a septicemia, inasmuch as 
 cases do occur in which the bacillus icteroides can- 
 not be found in the blood, or organs in which it 
 might be deposited therefrom. 
 
 Sixth. That there exists no casual relationship 
 between the bacillus X of Sternberg and this 
 highly infectious disease; and that this bacillus 
 X is frequently found in the intestinal contents of 
 normal animals and of man, as well as in the urine 
 and the bronchial secretion. 
 
 Seventh. That, so far as your Commission is 
 aware, the bacillus icteroides has never been found 
 in any body other than of one infected with yellow 
 fever; and that whatever may be the cultural 
 similarities between this and other microorgan- 
 isms, it is characterized by a specificity which is 
 distinctive. 
 
 Eighth. That the bacillus icteroides is very sus- 
 ceptible to the influences injurious to bacterial life, 
 
 9 
 
SANITATION IN PANAMA 
 
 and that its ready control by the processes of dis- 
 infection, chemical and mechanical, is assured. 
 
 Ninth. That the bacillus icteroides produces in 
 vitro as well as in vita a train of the most marked 
 potency; and that, from our present knowledge, 
 there exists a reasonable possibility of the ulti- 
 mate production of an antiserum more potent than 
 that of Professor Sanarelli. 
 
 About the same time an officer of the Public 
 Health Service, Dr. H. K. Carter, was making in 
 Mississippi his epoch-marking observations upon 
 the extrinsic incubation of yellow fever. Meas- 
 ured by the results produced, this was one of the 
 most important papers ever written. Yet as high 
 an authority as the Surgeon-General of the Pub- 
 lic Health Service expected the greatest results to 
 flow from the conclusions reached by this Board, 
 and did not notice the report from his subordinate 
 concerning the extrinsic incubation of yellow 
 fever. The conclusions of his Board turned out to 
 be all wrong and useless as to results. The report 
 of Carter turned out to be pure gold, and was one 
 of the great steps in establishing the true method 
 of the transmission of yellow fever. I do not say 
 this 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 their 
 own time who make these discoveries. 
 
 General George M. Sternberg, the then Surgeon- 
 
 10 
 
YELLOW FEVER AND ITS TRANSMISSION 
 
 General of the Army, was one of the leading bac- 
 teriologists of the profession, and was also one 
 of the best known authorities on yellow fever. He 
 doubted the findings of this Board, and obtained 
 authority from the Secretary of War to appoint 
 a board of Army medical officers to investigate 
 this same subject. He appointed on this now 
 famous and immortal board Eeed, Lazear, Car- 
 roll and Agramonte. They came to Havana, and 
 spent several months in investigating Sanarelli's 
 organism. They proved beyond peradventure that 
 it had no causative relation to yellow fever, and 
 identified it as a well-recognized organism. 
 
 It is an interesting historical fact that one of 
 the yellow-fever patients in whom the Board of 
 Public Health Service found Sanarelli's organism 
 was a patient of mine. He was a soldier, Private 
 Patrick Smith, Eighth Infantry, a non-immune 
 living in an infected part of Havana, so that I 
 thought 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 yellow 
 fever. The symptoms in a case of yellow fever 
 dying on the ninth day are always so well marked 
 that the diagnosis should not be in doubt. But 
 the Board found Sanarelli's organism, and being 
 themselves convinced that this was the organism 
 of yellow fever, they believed the case to be that 
 disease. It shows the necessity in scientific mat- 
 
 H 
 
SANITATION IN PANAMA 
 
 ters of being on one's guard, and of approaching 
 investigation with an open mind. 
 
 The Army Board having satisfied themselves 
 that Sanarelli's organism bore no relation to yel- 
 low fever, but was simply the ordinary hog-cholera 
 bacillus, turned their attention to other matters, 
 though they were always working in relation to 
 yellow fever. They spent a great deal of time in 
 examining the intestinal flora in cases of recog- 
 nized yellow fever, but could find nothing that 
 seemed to have any relation to this disease in a 
 causative sense. 
 
 Being at that time the health officer of the city 
 of Havana, and in that capacity having charge of 
 all cases of yellow fever which occurred in the city. 
 I necessarily came in contact with tliis Board a 
 great deal, and with its various members. I was 
 naturally much interested in the work, and kept 
 in very close touch with it. The Sanitary Depart- 
 ment of Havana had a commission of medical men 
 to whom all cases of yellow fever were referred for 
 diagnosis. I was a member of this Commission, 
 and Dr. Carlos Finlay, Dr. Antonio Albertini and 
 Dr. John Guiteras were the other members. Each 
 of us had had a very large practical experience 
 with yellow fever. It is likely, therefore, that our 
 Commission was as accurate in its diagnosis of 
 this disease as it was possible for fallible doctors 
 to be. Most of Dr. Reed's experimental cases 
 
 12 
 
YELLOW FEVER AND ITS TRANSMISSION 
 
 were seen and passed upon by this Commission. 
 Dr. Eeed requested us to do so, in order that the 
 diagnosis of his cases might be upon the same 
 footing as the diagnosis of the other cases occur- 
 ring in the city of Havana. 
 
 Dr. Carlos Finlay, of Havana, the physician 
 just mentioned as being a member of our Com- 
 mission, had ever since the year 1881 been investi- 
 gating, thinking of and writing about the relation 
 of the mosquito to yellow fever. He had con- 
 vinced himself that this insect was the means 
 whereby the disease was conveyed from person 
 to person. Others before Dr. Finlay's time had 
 referred to the possibility of this being the case, 
 notably Dr. J. C. Nott, of Mobile, Alabama. In 
 March, 1848, he published in the Neiv Orleans 
 Medical Journal an article in which he maintained 
 that the spread of yellow fever could not be ex- 
 plained by the assumption of a diffusible miasm 
 in the atmosphere. But Dr. Finlay had given 
 more attention to this subject than anyone who 
 had gone before him. He had written upon it 
 constantly from the year 1881. His argument 
 from the then known facts with regard to yellow 
 fever, showing from these facts that it was prob- 
 ably the mosquito that conveyed this disease, was 
 movst beautiful and logical. But a still more 
 beautiful piece of reasoning was the induction that 
 it was the stegomyia mosquito, out of the six or 
 
 13 
 
SANITATION IN PANAMA 
 
 seven hundred species of mosquitoes, that con- 
 veyed yellow fever. 
 
 Dr. Finlay, in the twenty years before we 
 went 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 in 
 transmitting the disease. He had no means of 
 knowing that it took the mosquito twelve days 
 from the time when she swallowed the blood of a 
 yellow-fever patient to become herself infectious. 
 Not knowing this fact, it was perfectly natural 
 for Dr. Finlay to use his mosquitoes upon his 
 experimental cases within the first four or five 
 days after they had bitten a yellow-fever patient. 
 At any rate, in a large number of experimental 
 bitings of the human subject he did not have a 
 single case in which the evidence was conclusive 
 that yellow fever had been conveyed by the mos- 
 quito. Eeed says of Finlay: "To Dr. Carlos Fin- 
 lay, of Havana, must be given, however, full 
 credit for the theory of the propagation of yellow 
 fever by means of the mosquito, which he proposed 
 in a paper read before the Royal Academy in that 
 city 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 good 
 deal before he commenced his mosquito work, and 
 
 14 
 
YELLOW FEVER AND ITS TRANSMISSION 
 
 was thoroughly familiar with Dr. Finlay's argu- 
 ments and ideas on the subject. Indeed, we all 
 knew Dr. Finlay well, but were rather inclined to 
 make 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 that 
 every day for more than a year we had more or 
 less discussion on this subject. 
 
 Dr. Finlay is a most lovable man in character 
 and personality, and no one could be constantly 
 thrown with him as I was daily for several years 
 without becoming warmly attached to him and 
 forming the highest estimate of his scientific hon- 
 esty and straightforwardness. Being very famil- 
 iar with yellow fever, both historically and 
 clinically, I was constantly bringing to his notice 
 instances in the past which could not be accounted 
 for on the mosquito theory. He, with the greatest 
 ingenuity, was equally ready to explain how the 
 mosquito theory could be turned so as to meet just 
 this condition. 
 
 Dr. Finlay is still living in retirement and com- 
 fortable old age in the city of Havana. When the 
 American forces were withdrawn from Cuba in 
 1902, Dr. Finlay succeeded me as health officer 
 under the Cuban Government. He has since been 
 retired on a pension by that Government. I called 
 on him in Havana several years ago, and found 
 him enjoying his more than eighty years of age, 
 
 15 
 
SANITATION IN PANAMA 
 
 and the honors that were being heaped upon him. 
 He is one of the few great men who has had his 
 work recognized during his lifetime. 
 
 Dr. Keed got from Dr. Finlay the eggs from 
 which he raised the mosquitoes used in his experi- 
 mental work. Dr. Finlay says on page 1 of his 
 "Agreement between the History of Yellow Fever 
 and Its Transmission by the Culex Mosquito": 
 "The experiments made by Drs. Keed, 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 had 
 handed to him. All the successful experiments 
 have hitherto been made with that particular mos- 
 quito." 
 
 Dr. Eeed says in his paper, "The Etiology of 
 Yellow Fever, Preliminary Note": "We here de- 
 sire to express our sincere thanks to Dr. Finlay 
 who accorded us a most courteous interview and 
 has gladly placed at our disposal his several pub- 
 lications relating to yellow fever, during the past 
 nineteen years; and also for ova of the species of 
 mosquito with which he had made his several in- 
 oculations. An important observation to be here 
 recorded is that according to Finlay's statement, 
 thirty days prior to our visit, these ova had been 
 deposited by a female just at the edge of the water 
 in a small basin, whose contents had been allowed 
 to slightly evaporate ; so that these ova were at 
 
 16 
 
YELLOW FEVER AND ITS TRANSMISSION 
 
 the time of our visit, entirely above contact with 
 the water. Notwithstanding this long interval 
 after deposition, they were promptly converted 
 into the larval stage, after a short period, by rais- 
 ing the level of the water in the basin. With the 
 mosquitoes thus obtained we had been able to con- 
 duct our experiments. Specimens of this mos- 
 quito forwarded to Mr. L. 0. Howard, Entomolo- 
 gist, Department of Agriculture, Washington, 
 D. C., were kindly identified as culex fasciatus 
 Fabr." 
 
CHAPTER II 
 
 THE EXPERIMENTS OF THE EEED BOARD 
 
 A FTEE consultation, the Eeed Board deter- 
 ** mined to experiment to see whether the mos- 
 quito really did convey yellow fever. But it was 
 necessary to have a good deal of money and suffi- 
 cient authority before starting in. The Board had 
 come to Cuba for entirely different investigations, 
 and had not been supplied with sufficient funds for 
 these experiments. Fortunately for the cause of 
 science and of humanity, we had as Governor-Gen- 
 eral of Cuba at that time General Leonard Wood, 
 of the United States Army. General Wood had 
 been educated as a physician, and had a very 
 proper idea of the great advantages which would 
 accrue to the world if we could establish the fact 
 that yellow fever was conveyed by the mosquito, 
 and his medical training made him a very compe- 
 tent judge as to the steps necessary to establish 
 such fact. 
 General Wood during the whole course of the 
 
 18 
 
THE EXPERIMENTS OF THE REED BOARD 
 
 investigations took the greatest interest in the 
 experiments, and assisted the Board in every way 
 he could. Dr. Eeed outlined to General Wood 
 the course he expected to pursue, and General 
 "Wood was so convinced by Dr. Eeed's argument 
 that he authorized the expenditure from Cuban 
 funds of a sufficient sum and gave Dr. Eeed ample 
 powers as to the method of expenditure. 
 
 The Board then went to work in earnest along 
 lines which seemed calculated to develop the facts 
 in the matter. They started a laboratory at 
 Camp Columbia, the American military station a 
 short distance out of Havana. Here they bred 
 their mosquitoes from eggs procured from Dr. 
 Finlay, and here the first three experimental cases 
 occurred. The first case was severe; the second 
 case was that of Dr. Carroll, a member of the 
 Board, and was well marked, and Dr. Lazear, an- 
 other member of the Board, died of the disease. 
 Dr. Lazear visited Las Animas Hospital and was 
 bitten by the mosquito on September 13, 1900; 
 was taken sick September 18th and died Septem- 
 ber 25th. Previously on August 16th, he had 
 been experimentally bitten by a mosquito which 
 had ten days before bitten a yellow-fever patient 
 in the fifth day of the disease. We know now 
 that ten days is too short a time for incubation 
 in the mosquito, and the fifth day a period too late 
 for the yellow-fever patient to be infectious. 
 
 19 
 
SANITATION IN PANAMA 
 
 Dr. Carroll was intentionally bitten. Dr. Lazear 
 told me after he was taken sick, and a day or two 
 before he died, that he recalled being bitten by a 
 stegomyia three or four days before he was taken 
 sick, and while he was at work at Las Animas, our 
 yellow-fever hospital in Havana. He said that 
 he had noticed the mosquito enough to recognize 
 that it was a stegomyia, and had allowed it to fill 
 and fly away without disturbing it. These three 
 cases satisfied the Board that the stegomyia mos- 
 quito was the means of conveying yellow fever, 
 but they determined that they would make such a 
 demonstration of the matter that there could be 
 no doubt in the mind of any reasonable person as 
 to what had been proved. 
 
 With this idea in view they selected a spot a 
 mile or more from the military camp, which was 
 well isolated and had no habitations near it. They 
 agreed that if they established an experimental 
 station here and kept their patients in such a 
 way that there was no possibility of their getting 
 out and contracting the disease elsewhere, then the 
 results obtained in this station would be due to 
 measures taken there. They already had their 
 stegomyia mosquitoes which they had reared from 
 the eggs procured from Dr. Finlay. These mosr 
 quitoes they took to the hospitals in Havana, and 
 allowed them to bite people sick with yellow fever. 
 In the course of time the Board found that the 
 
 20 
 
THE EXPERIMENTS OF THE REED BOARD 
 
 mosquito to become infected with this disease 
 must bite the sick human being within the first 
 three days of his disease. This was a singular 
 and unexpected phenomenon, and is explained in 
 this way. The mosquito injects the yellow-fever 
 parasite into the blood of the human being ; these 
 parasites at once commence ejecting toxins into 
 the blood in which they are circulating; these 
 toxins irritate the human cells with which the 
 poisoned blood comes in contact and they begin 
 to throw into the blood circulation antitoxins. By 
 the end of the third day these antitoxins have 
 become so concentrated in the blood that they al- 
 ways kill the yellow-fever parasite, and after the 
 third day no yellow-fever parasites remain in the 
 human body. 
 
 Yellow fever is a very fatal disease, and on the 
 average kills the patient on the sixth or seventh 
 day. Why then does death occur in yellow fever 
 if on the average the patient lives to the sixth or 
 seventh day, and yet always by the end of the 
 third day the yellow-fever parasites have been 
 routed and destroyed in the great battle which 
 has taken place between them and the body 
 cells? 
 
 Dr. Eeed established this fact by finding that 
 mosquitoes which had bitten a patient more than 
 three days after the patient had developed yellow 
 fever, did not convey the disease to the non-im- 
 
 21 
 
SANITATION IN PANAMA 
 
 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 give 
 these non-immunes yellow fever when he used 
 mosquitoes which had bitten the man sick with 
 yellow fever within the first three days of his 
 symptoms. 
 
 We have followed Dr. Eeed now up to the point 
 of his having infected mosquitoes and being ready 
 to transmit the disease to non-immune human be- 
 ings. A human being, in order that he may be 
 liable to yellow fever, must be non-immune, and 
 by immune I mean a person who either has had 
 yellow fever, or has lived ten or more years in a 
 locality where yellow fever prevails. An attack 
 of yellow fever gives a great immunity to the dis- 
 ease, probably just as much as occurs in the case 
 of smallpox. In practice, it is counted as absolute. 
 In over two thousand cases of yellow fever which 
 I 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 the 
 first attack. I have seen several, however, who 
 believed that they had had a previous attack, and 
 I myself believe that I saw them in their second 
 attack. I have by no means seen a quarter as 
 many cases of smallpox as I have of yellow fever, 
 yet I have seen more cases of second attacks of 
 smallpox than I have of yellow fever. I feel con- 
 
 22 
 
THE EXPERIMENTS OF THE, REED BOARD 
 
 fident, therefore, in stating that yellow fever gives 
 fully as great immunity as does smallpox. 
 
 It is well known that in a yellow-fever endemic 
 center such as was Havana during the nineteenth 
 century native Havanese are not liable to yellow 
 fever. They look upon their immunity as being 
 absolute, and in my experience of fourteen years 
 of life in such endemic centers I am inclined to 
 accept their belief. The immunity of the native 
 is explained by saying that he has probably 
 had yellow fever in childhood when the dis- 
 ease was very mild, and that, at the time, it was 
 overlooked and not recognized. This is the best 
 explanation that, so far as I know, can be made 
 of the facts in the case. 
 
 Certain it is that one of these endemic centers 
 from which yellow fever has been banished for a 
 number of years may have yellow fever as badly 
 as a city in which it has never been endemic. 
 Eighty years ago a native of Mobile, Alabama, or 
 Pensacola, Florida, looked upon himself as being 
 as immune to yellow fever as did the Havanese 
 twenty years ago. But at the present time the 
 native of either of these cities is just as liable to 
 yellow fever as is the man from New York. This 
 is explained by the fact that eighty years ago 
 they had yellow fever so frequently in Mobile and 
 Pensacola that all the natives had this disease in 
 childhood. Within the last fifty years they have 
 
 23 
 
SANITATION IN PANAMA 
 
 had it so infrequently that very few now living in 
 those cities have had this disease. 
 
 Another phase of the same condition is seen in 
 Ecuador. Guayaquil, the port of Ecuador, is lo- 
 cated on Guayas River at sea level, not more than 
 three degrees from the equator. Here yellow 
 fever always prevails, and the native of Guayaquil 
 is 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 the 
 great Andean plateau ten thousand feet above 
 sea level. The stegomyia cannot breed at Quito, 
 so that yellow fever has never occurred there. 
 The native of Quito, therefore, has no immunity 
 to yellow fever, and of this he is well aware. 
 Guayaquil is the only seaport of Ecuador, and 
 everyone leaving the country has to leave through 
 this port. Hundreds of the natives of Quito have 
 died of yellow fever contracted by passing through 
 Guayaquil. The man from Quito dreads Guaya- 
 quil a great deal more than did the American in 
 the early days fear Panama. 
 
 Dr. Reed, therefore, to make his experiments of 
 any value, had to get human beings who had 
 neither suffered from yellow fever itself, nor had 
 lived long enough in an endemic center to acquire 
 immunity. Havana for a number of years had 
 received a considerable Spanish immigration. At 
 the time to which I refer, it amounted to about 
 
 24 
 
THE EXPERIMENTS OP THE REED BOARD 
 
 twenty thousand a year. These immigrants be- 
 lieved that they were going to have yellow fever, 
 and though they knew that a considerable number 
 of them must succumb during the process, they 
 were anxious to have the disease and be done with 
 it. There was a very general belief among the 
 Spaniards in Havana that a person with what they 
 called "thin blood" as contra-distinguished from a 
 robust, plethoric, full-blooded person, was much 
 more likely to recover from yellow fever. They 
 tried, therefore, with their newly arrived friends, 
 relatives and dependents from Spain to bring 
 about this condition of their blood. They kept 
 them confined in a darkened room and fed them on 
 a very limited diet, and certainly succeeded in 
 rapidly reducing the strong, florid, robust Gallego 
 to a very marked condition of anemia and debility. 
 The Spaniard believed that he thus saved many 
 lives. I was convinced that he thus killed a good 
 many of his friends and dependents. 
 
 The newly arrived Spaniard, as soon as he had 
 had yellow fever and could present a certificate 
 of immunity, could command double the wages 
 that he could get before he had the disease. So 
 that when Dr. Keed proposed to some of these men 
 that they should go out to his camp, have a mild 
 case of yellow fever, be well cared for and when 
 recovered be given by him a certificate of immun- 
 ity, he found no difficulty in getting volunteers, and 
 
 25 
 
SANITATION IN PANAMA 
 
 when, in addition to that, he promised each man 
 who had the disease a bonus of two hundred and 
 fifty dollars, the service became exceedingly popu- 
 lar. 
 
 Dr. Eeed had prepared, as I have above men- 
 tioned, a very comfortable camp at an isolated 
 point near Camp Columbia, well separated from 
 all other dwellings. This camp was kept under 
 military guard, so that no one could come and 
 go without Dr. Reed's knowledge. Here he placed 
 his non-immune volunteer Spaniards whom he had 
 gotten from Havana, and kept them under obser- 
 vation for two weeks, taking their temperatures 
 every day so as to be sure that they had not con- 
 tracted yellow fever before they went out to the 
 camp. 
 
 At this point he made another important dis- 
 covery in the mode of yellow-fever propagation. 
 He found that the mosquito herself had to wait 
 from ten to fifteen days after she had bitten a man 
 sick with yellow fever before she herself conveyed 
 the disease. He found that the mosquito for the 
 first week or ten days after she had bitten the 
 yellow-fever patient was entirely harmless though 
 she fed freely on non-immunes. But after the 
 twelfth or fourteenth day she would give the dis- 
 ease to every non-immune whom she bit. I have 
 often seen the non-immune doctors and nurses at 
 Las Animas Hospital put their hands in the jars 
 
 26 
 
THE EXPERIMENTS OF THE REED BOARD 
 
 where infected mosquitoes were kept during the 
 first seven days of their infection and allow them 
 to draw their fill of blood, for the purpose of feed- 
 ing them, but they would not think of doing this 
 after the seventh or eighth day. Two of these 
 nurses afterwards contracted yellow fever from 
 allowing mosquitoes to bite them after the twelfth 
 day, and one of them, Miss Mass, died from the 
 disease so contracted. 
 
 Dr. Carlos Finlay, in his many experiments on 
 the human being, was unaware of these two facts 
 with regard to the transmission of yellow fever: 
 first, that the mosquito could only become infected 
 by biting a human being within the first three days 
 of his disease ; and second, that she could only be- 
 come infectious, that is, transmit the disease, when 
 some twelve or fourteen days had passed since 
 she had bitten the sick man. Dr. Finlay put a 
 great many of his mosquitoes to the sick man after 
 the third day, and in no case did he apply his 
 mosquito to the non-immune twelve or fourteen 
 days after she had bitten the infected person. 
 
 Dr. Henry E. Carter had published a paper on 
 certain observations of his made during the epi- 
 demic of 1898 in the neighborhood of Jackson, 
 Mississippi. It had long been known to men 
 practically familiar with yellow fever that, in gen- 
 eral, when you took a patient suffering from 
 yellow fever into a house where yellow fever had 
 
 27 
 
SANITATION IN PANAMA 
 
 not before existed, the people in that house did not 
 at once develop the fever. We explained this by 
 stating that it was due to the fact that the germs 
 of yellow fever went from the patient to favorable 
 grounds for development about the house, and 
 there underwent some development which enabled 
 them to produce the disease in non-immune man. 
 "We thought that the dirtier and more unhygienic 
 were 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 and 
 the conditions favorable for making the observa- 
 tions, and found that the average time from the 
 introduction of a yellow-fever patient into a house 
 until the first case of yellow fever was contracted 
 in that house, was about seventeen days. These 
 observations were published to the world. 
 
 Dr. Eeed was greatly impressed by this pub- 
 lication of Dr. Carter's. He reasoned that if it 
 were the mosquito which transmitted the disease, 
 this period of extrinsic incubation must be due to 
 a period of incubation in the mosquito. He says : 
 
 We were also much impressed by the valuable 
 observations made at Orwood and Taylor, Missis- 
 sippi, during the year 1898 by Surgeon Henry R. 
 Carter, U. S. Marine Hospital Service, "A Note on 
 the Interval between Infecting and Secondary 
 Cases of Yellow Fever, etc." (Reprint from New 
 
 28 
 
THE EXPERIMENTS OF THE REED BOARD 
 
 Orleans Medical Journal, May, 1900.) We do not 
 believe 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 we 
 had 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 worked 
 were favorable for recording with considerable 
 accuracy the interval between the time of arrival 
 of infecting cases in isolated farmhouses and the 
 occurrence of secondary cases in these houses. 
 According to Carter, "the period from the first (in- 
 fecting) case to the first group of cases infected 
 at these houses, is generally from two to three 
 weeks." 
 
 The house having now become infected, suscep- 
 tible individuals thereafter visiting the houses for 
 a few hours, fall sick with the disease in the usual 
 period of incubation, one to seven days. 
 
 Other observations made by us since our arrival 
 confirmed Carter's conclusions, thus pointing, as 
 it seemed to us, to the presence of an intermediate 
 host, such as the mosquito, which having taken the 
 parasite into the stomach, soon after the entrance 
 of the patient into the non-infected house, was 
 able, 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 from 
 nine to sixteen days (allowing for the period of 
 
 39 
 
SANITATION IN PANAMA 
 
 incubation) which agrees fairly closely with the 
 time required for the passage of the malarial para- 
 site from the stomach of the mosquito to its 
 salivary glands. 
 
 In view of the foregoing observations we con- 
 cluded to test the theory of Finlay on human be- 
 ings. 
 
 Dr. Keed had, however, been working for some 
 time before he came to these conclusions. His 
 first nine cases bitten between August 11 and 
 August 25, were all unsuccessful. The next two, 
 bitten on August 27 and 31, were positive and 
 were 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 or 
 money 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 good 
 reason for this. The stoiy told in Havana was 
 that the American soldiers, who were doing the 
 guard duty for the camp, had found an old lime 
 kiln in the lower part of the grounds. In this 
 kiln 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 the 
 bones of their predecessors in Dr. Reed's camp, 
 and that if they did not leave before they were 
 bitten by Dr. Reed's mosquitoes, their bones would 
 
 30 
 
THE EXPERIMENTS OF THE REED BOARD 
 
 soon be bleaching in the same place. It was use- 
 less for Dr. Keed to argue and explain. This ocu- 
 lar evidence was too strong for any argument by 
 word of mouth, and Dr. Reed had to give it up. 
 
 Our soldiers had seen that the disease was very 
 mild; that the patients while they were in camp 
 had the very best of high living and a mighty good 
 time, and when they left, were presented with a 
 gratification of two hundred and fifty dollars in 
 shining gold coin. They concluded that this was 
 too good for Gallegos, and belonged of right to 
 natural-born Americans. When the Spaniards 
 had decamped, our men came forward and volun- 
 teered. Dr. Reed accepted them, and the work 
 went forward. 
 
CHAPTER III 
 
 THE DISCOVERIES OF THE REED BOARD 
 
 . REED wished to make his demonstrations 
 as 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 most 
 men thought had been their practical experience 
 that it was received with scant consideration. 
 
 He had a small frame house built, fourteen by 
 twenty feet, well screened-in with wire netting, so 
 that mosquitoes could not get in or out. This 
 building he had divided into two compartments by 
 a partition extending down the center, made of 
 wire 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 air 
 conveyed yellow fever. Dr. Reed wished to show 
 that this was not the case. 
 
 He put two non-immunes in this building, one 
 in each room. These two men breathed exactly 
 
 32 
 
THE DISCOVERIES OF THE REED BOARD 
 
 the same air, and had exactly the same surround- 
 ings, with one single exception which I will in a 
 moment point out. But they were entirely sepa- 
 rated by the wire netting. He let them live and 
 sleep in these rooms for several days, so as to 
 demonstrate 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 man 
 in this room for thirty minutes, announcing that 
 the room was now infected. He took the man out 
 of this infected room, but left in the other room 
 two men on the other side of the wire netting. He 
 stated that the man who had stayed thirty min- 
 utes in the infected room would come down with 
 yellow fever within three or four days, and that 
 the other men, who were only separated from him 
 by wire netting, and who breathed and were sur- 
 rounded by exactly the same air, would not get 
 sick. 
 
 He explained that the only difference between 
 the two rooms was that in the infected room, in- 
 fection had been brought about by liberating there 
 fifteen stegomyia mosquitoes which had previously 
 bitten patients sick of yellow fever. The man 
 from the infected room was on the afternoon of 
 the same day again placed in this room for twenty 
 minutes, and on the following day he was a third 
 time put in the room for fifteen minutes. On the 
 first visit he was bitten by seven mosquitoes ; on 
 
 33 
 
SANITATION IN PANAMA 
 
 the second, by five ; on the third, by three. At the 
 end of the fourth (Christmas) day, Eeed showed 
 the man from the infected room down with yellow 
 fever, and the men who had lived and slept in the 
 other room, separated only by wire netting, per- 
 fectly well. He called attention to the fact that 
 the only difference in the exposure of these men 
 was that the sick man had been in a room for thirty 
 minutes, with fifteen infected stegomyia mos- 
 quitoes. He claimed that this was a demonstra- 
 tion that the female stegomyia mosquito could 
 transmit yellow fever, and that the atmosphere 
 alone could not. Many of the visitors to Dr. 
 Heed's camp were clinically familiar with this dis- 
 ease, and the case was sufficiently marked to be 
 easily recognized by all as being a case of yellow 
 fever. 
 
 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 placed 
 a non-immune in each room, left them there for 
 several days, and they remained perfectly well. 
 He explained that he disinfected the room by sim- 
 ply catching all the stegomyia mosquitoes which 
 he had formerly liberated in the room. 
 
 This demonstration made a very profound im- 
 pression. Many, however, still urged that while 
 it was evident that the female stegomyia mosquito 
 could convey yellow fever, it was equally evident 
 
 34 
 
THE DISCOVERIES OF THE REED BOARD 
 
 from the history of epidemics of this disease that 
 it could be and was generally conveyed in other 
 ways, such as soiled clothing, bedding, the bodies 
 of yellow-fever dead, persons sick of the disease, 
 etc. 
 
 Dr. Reed had a small house built, made almost 
 air-tight and with scarcely any ventilation. This 
 building was known as the infected-clothing build- 
 ing, and was purposely so constructed as to ex- 
 clude anything like efficient ventilation. It was 
 placed on the opposite side of a small valley, 
 about eighty yards from the infected mosquito 
 building, and they were both about seventy-five 
 yards distant from the camp proper. Both houses 
 were provided with wire screen windows and 
 double screen doors, so that mosquitoes could be 
 kept without or within the building, as the experi- 
 menter might desire. 
 
 In this building he placed material obtained 
 from Las Animas, the yellow-fever hospital of the 
 Health Department of Havana; mattresses on 
 which yellow-fever patients had died, soiled by 
 their excreta and discharges; sheets, pillows and 
 pillow-cases stained with black vomit; the pajamas 
 which 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 this 
 way. Dr. John W. Ross, the superintendent of 
 Las Animas Hospital, therefore gave the matter 
 
 35 
 
SANITATION IN PANAMA 
 
 his personal attention, saw to the packing of this 
 material in chests for transportation to Camp 
 Lazear, and before the chests were closed, had 
 basins of black vomit and other excreta from yel- 
 low-fever patients poured over the contents of the 
 chest. If there were any possibility of sueh 
 material becoming infected, infection certainly 
 would have followed such procedure. 
 
 Dr. Reed had this material opened up and 
 spread out in the close room I have described. 
 He called for volunteers to sloop in this room. 
 Dr. E. P. Cook of the Army, and several soldiers 
 quickly responded. These men put on the pajamas 
 soiled as described, and slept on the mattresses 
 and bed clothing soiled beyond description. For 
 a period of twenty days they spent the nights in 
 this building, but for the sake of general health 
 were allowed to go out during the day. All the 
 men remained perfectly well, and no case of yellow 
 fever was developed from such exposure. 
 
 This set of experiments was generally accepted 
 as proving that yellow fever was conveyed from 
 man to man by the mosquito alone, and that it was 
 not transmitted in any other way. A great many 
 persons, however, were still skeptical. The exper- 
 imental camp had been named "Lazear" in mem- 
 ory of Dr. Lazear, a member of the Board, who 
 had died a few months before of yellow fever, 
 contracted while prosecuting this work, 
 
 36 
 
THE DISCOVERIES OF THE REED BOARD 
 
 The Board then took the blood of a yellow-fever 
 patient in the first three days of his sickness, and 
 injected it with a hypodermic syringe into a non- 
 immune. He promptly developed yellow fever. 
 This proved that the blood of a patient suffering 
 from 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 argued 
 that it might not be a yellow-fever parasite that 
 was injected, but a toxin. 
 
 The Board then took the blood within the first 
 three days of sickness from this second patient 
 who had been given his disease from the blood of 
 the first patient, and injected it into a third 
 patient. This third patient developed the disease 
 at the proper time. This experiment demon- 
 strated that the virus so conveyed was capable of 
 multiplying; that it was a living germ and not 
 merely a toxin or chemical body which transmitted 
 the disease. 
 
 The Board then took the blood of a patient col- 
 lected in the first three days of his sickness, and 
 passed it through a Pasteur filter so fine that it 
 would stop any particle large enough to be seen 
 with a microscope of the highest power. This 
 blood when injected into a non-immune still gave 
 yellow fever. This demonstrated that the para- 
 site was sub-microscopic; that is, too small to 
 
 37 
 
SANITATION IN PANAMA 
 
 be seen by a microscope of even the highest 
 power. 
 
 They then took the blood of a yellow-fever 
 patient 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 yellow 
 fever. This was repeated three times. This 
 experiment proved that the living parasite in the 
 blood of the yellow-fever patient was killed by 
 being raised to a temperature of 55 C. 
 
 The conclusions announced by the Board were 
 as follows : 
 
 That yellow fever is conveyed from man to man 
 only by the bite of the female stegomyia mosquito, 
 and that this mosquito, to become infected, must 
 suck the blood of the yellow-fever patient within 
 the first three days of his disease. 
 
 That after biting the patient, twelve to twenty 
 days must elapse before she herself is able to con- 
 vey the infection. This period is known as the 
 period of extrinsic incubation. Extrinsic incuba- 
 tion in Havana was found to be considerably 
 longer during the cool months of winter than dur- 
 ing the warm period of summer. 
 
 That after the non-immune human being had 
 been bitten by the infected stegomyia mosquito, 
 an incubation period of from three to six days 
 elapsed before the man began to show symptoms 
 of yellow fever. The shortest period of incuba- 
 
 38 
 
THE DISCOVERIES OF THE REED BOARD 
 
 tion in Dr. Keed's cases was two hours less than 
 three days, and the longest period, two hours more 
 than six days. 
 
 That the blood, taken at the proper time and 
 injected 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 the 
 sanitary work against yellow fever which has been 
 so successful. At first blush, however, it was not 
 evident to what extent it would be of practical use 
 to us. 
 
CHAPTER IV 
 
 THE SANITARY BOARD OF HAVANA 
 
 A T this time, February, 1901, I was health offi- 
 ** cer of the city of Havana. The efforts of the 
 Department had been concentrated for more than 
 two years previous upon controlling yellow fever 
 in that city. Not only had we met with no success, 
 but yellow fever was actually worse than when we 
 commenced work. Ample funds and power had 
 been given us by General Wood, the military gov- 
 ernor, and we had by far the best and most efficient 
 sanitary organization of whose existence, either 
 before or since that time, I have any knowledge. 
 When the work of the Reed Board began to 
 point to the mosquito as the conveyor of yellow 
 fever, the Sanitary Department of Havana was 
 at its wits' end and was glad to receive this dis- 
 covery as a means of possible help. T, as health 
 officer of Havana, had nothing to do with the work 
 of the Reed Board in any way whatever, except 
 that I was a very interested spectator and kept in 
 
 40 
 
THE SANITARY BOARD OP HAVANA 
 
 close touch with the work as it developed. We 
 assisted 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 them 
 ample clinical material. 
 
 Neither the Reed Board nor any of its members 
 had anything to do with the practical working out 
 of the methods whereby their theory was demon- 
 strated, and by means of which yellow fever was 
 finally eliminated from Havana. These methods 
 were 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 yellow 
 fever formerly prevailed. 
 
 Dr. Finlay, in a reprint from the Journal of the 
 American Medical Association, April 19, 1902, 
 says: 
 
 The final confirmation of the role which apper- 
 tains to the culex mosquito deso (now included in 
 the genus stegomyia of Theobald) in the trans- 
 mission of yellow fever, has now been sanctioned 
 by the experiments of Drs. Eeed, 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 the 
 Experimental Station of Las Animas, last sum- 
 mer, and finally by the splendid practical results 
 obtained by the Chief Sanitary Officer of Havana, 
 Major W. C. Gorgas, during the epidemic year 
 
 41 
 
SANITATION IN PANAMA 
 
 which has just been completed. With those facts 
 and the ones which I had gathered in former years, 
 it is now possible to determine with some degree 
 of precision the conditions which are necessary 
 in 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 temperatures 
 between 25 and 35 C. (77 and 95 F.) either 
 temporarily or habitually prevail. 
 
 Dr. Eeed and I discussed on several occasions 
 the possibility of making practical application of 
 his discoveries. It- did not seem to us possible to 
 destroy the adult mosquito in sufficient numbers to 
 be of any practical use. And we were not suf- 
 ficiently familiar at that time with the life history 
 of the mosquito to think of any other way in which 
 the subject could be approached with a fair pros- 
 pect of success. 
 
 We, of the Sanitary Department, after a great 
 deal of discussion and thought given to the matter, 
 decided that we should adopt all measures that 
 seemed likely to be useful, being guided in our 
 plans 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 
 
 42 
 
THE SANITARY BOARD OF HAVANA 
 
 light case. If this proved as successful as had 
 vaccination in smallpox, we could see that this 
 measure alone would entirely protect against yel- 
 low fever, just as had vaccination against small- 
 pox. "We consulted the military governor, General 
 Wood, on the subject, and he agreed to let us try 
 it as one of the several preventive measures which 
 we were putting into effect against yellow fever. 
 
 We announced that we were ready at Las Ani- 
 mas Hospital to immunize against this disease 
 anyone 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 Board 
 had been done during the preceding fall, and at 
 this time we had only one infected mosquito left, 
 which had been given us by Dr. Reed. This old 
 lady was a veteran in every sense. She had given 
 several people yellow fever, but her greatest claim 
 to celebrity was the fact that it had been fifty- 
 seven days between the first case of fever and the 
 last one which she had given. 
 
 The weather is cool in Havana during January, 
 February and March, so that the stegomyia under 
 ordinary conditions become quite sluggish in their 
 movements and a great many die. Mosquitoes de- 
 crease so much during these months that yellow 
 fever becomes more or less rare, and it was very 
 difficult for us to infect our mosquitoes. While 
 for one hundred and forty years there had never 
 
 43 
 
SANITATION IN PANAMA 
 
 been a single month in which there had not been 
 some reported case of yellow fever in Havana, 
 still only a very small proportion of these cases 
 was recognized during the first three days, and it 
 must be remembered that a mosquito has to bite 
 within that period of the disease in man to become 
 infected. We were, therefore, keeping our only 
 infected mosquito with a great deal of care and 
 tenderness, knowing that we had to depend upon 
 her to start our vaccination work. 
 
 In all Havana there is probably not a single 
 fireplace or other means of artificial heat, so we 
 sent to the United States and imported an oil-stove 
 wherewith to keep her ladyship's room always at 
 summer temperature. Her home was a large 
 glass jar on a table in the center of a sunshiny 
 room. In this jar was hung a lump of white sugar 
 on which she fed when hungry, and to this was 
 added now and then a small piece of banana. A 
 small vessel containing water was also kept in the 
 jar. In order that she might have a plentiful sup- 
 ply of fresh air, the glass top was not placed upon 
 the jar, but a sleeve of mosquito-netting was tied 
 over its top. 
 
 Within the last fifteen years a great deal of 
 study has been given to mosquito life. It is now 
 known that there are some seven hundred different 
 species of mosquitoes ; that in all species of mos- 
 quitoes the natural food is the various vegetable 
 
 44 
 
THE SANITARY BOARD OF HAVANA 
 
 juices. In all species the female has to have a 
 feed of blood before she can lay eggs. Blood does 
 not seem to be necessary for life, but merely stim- 
 ulates the function of ovulation. In order that 
 the female may get this blood, she is furnished 
 with biting apparatus not possessed by the male. 
 The male never bites, not being physically able to 
 do so. The female stegomyia, therefore, is alone 
 concerned in the transmission of yellow fever. 
 
 Las Animas Hospital being the yellow-fever 
 hospital for the city of Havana was a center of 
 attraction for most of the doctors of the Health 
 Department. Dr. John W. Boss, Dr. John Gui- 
 teras and myself were at this hospital almost 
 every day. Dr. Guiteras had charge of the vac- 
 cination work and of the laboratory where the 
 mosquitoes for this work were being bred. Our 
 lady mosquito was therefore directly under his 
 charge. She had given so many people yellow 
 fever and was therefore so valuable for our pros- 
 pective work that we all when at the hospital 
 would drop in to see how she was coming along 
 and to pay our respects. 
 
 One morning about daylight I got a message 
 stating that her ladyship was in a most critical and 
 desperate plight, as some time during the night 
 she had gotten her wing caught in a mesh of the 
 mosquito netting, and had struggled to free her- 
 self for so long a time that when she was discov- 
 
 45 
 
SANITATION IN PANAMA 
 
 ered by the attendant in the morning, she was al- 
 most dead. I rapidly dressed and hurried to the 
 hospital. Similar messages had been sent to Dr. 
 Eoss and Dr. Guiteras. We found her condition 
 even worse than had been represented. Two or 
 three of the doctors on the staff of the hospital had 
 been promptly called in, and the services of sev- 
 eral of our trained nurses had been likewise ob- 
 tained. Her wing had been gently liberated from 
 the mesh of the netting, and her ladyship laid upon 
 a soft bed of cotton batting. The oil-stove was 
 started up, and the room brought to a very hot 
 summer temperature, but it was all of no avail. 
 She finally ceased to kick about nine o'clock in the 
 morning, and died with a larger attendance of doc- 
 tors and nurses around her table than had ever 
 been present around the deathbed of any mere 
 human in the city of Havana. 
 
 This account may sound somewhat exaggerated, 
 but the scene still comes back to my mind's eye 
 very vividly, how earnest and serious we all were. 
 A half-dozen of the leading practitioners of 
 Havana were sitting around the deathbed of this 
 mosquito, looking and feeling exceedingly mourn- 
 ful and depressed. And it was a very heavy blow 
 to the Health Department of Havana. It was well 
 on into the summer, the month of July, before 
 we succeeded in getting another infected mosquito, 
 and in proceeding with our vaccination work. 
 
 46 
 
THE SANITARY BOARD OF HAVANA 
 
 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 than 
 had occurred in any of the cases of the Army 
 Board, with the exception of Lazear and Carroll. 
 Three of these eight positive cases vaccinated by 
 Dr. Guiteras died; one of those who died was a 
 Miss Maas, a trained nurse from the United 
 States, who requested to be allowed to get im- 
 munity in this way. Why our cases should have 
 been so severe, and all of the cases of the Board 
 so mild, no one has attempted to explain. It is a 
 fact that during the hot summer weather the ex- 
 trinsic period of incubation in the mosquito, that 
 is, the time after which the mosquito bites the man 
 sick with yellow fever until she herself is able to 
 convey the disease, is considerably shorter than 
 the same period during the cool winter months, 
 this period in the summer months being from 
 twelve to fourteen days, and in the winter months, 
 from fifteen to twenty days. I am inclined to 
 think that there is probably the same difference in 
 the virulence of the infection developed by the 
 mosquito in the hot summer months, and in the 
 cool winter months. 
 
 This experience demonstrated to us most for- 
 cibly that vaccination could not take any prom- 
 
 47 
 
SANITATION IN PANAMA 
 
 inent part in our preventive measures against 
 yellow fever. While Dr. Guiteras was going on 
 with his preparatory work at Las Animas and 
 getting ready for his vaccinations, he invited to 
 the hospital some fifteen or twenty members of 
 the International Sanitary Congress who had ex- 
 pressed themselves as being particularly skeptical 
 with regard to the mosquito theory of the trans- 
 mission of yellow fever. This Congress assembled 
 in Havana during the month of February, 1902. 
 The laboratory at Las Animas was the room I have 
 just described as being the home of the mosquito 
 known as "Her Ladyship." It was carefully 
 screened with wire netting at all the windows, and 
 the single door was protected by a vestibule which 
 itself had double doors. This vestibule was built 
 upon a platform some four feet above the ground 
 and just outside the door of the laboratory. The 
 visitors 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 the 
 stegomyia mosquito, and invited his visitors to 
 examine them; in the next jar, the larvae; in the 
 next, the pupae; in the next, the young mosquito 
 just born, and in the last jar, the mosquitoes which 
 had passed their period of extrinsic incubation and 
 were now ready to convey yellow fever. 
 
 While handling this jar, the sleeve of mosquito- 
 netting accidentally slipped off, and a dozen or 
 
 48 
 
THE SANITARY BOARD OF HAA^ANA 
 
 more mosquitoes soared toward the ceiling of the 
 room. Our visitors stood for a moment dum- 
 f ounded, open-mouthed and wide-eyed. Then each 
 one of the twenty, at the same moment, made a 
 rush for the door. The vestibule was small and 
 would hold only about four persons, so that the 
 pressure from behind toppled it over onto the 
 ground four feet below, and in a moment, there 
 were some twenty gentlemen in a pile on the 
 ground struggling to get as far as possible from 
 these deadly lady mosquitoes. 
 
 Dr. Guiteras afterwards assured us that his 
 mosquitoes had never bitten a sick man and were 
 not infected; that he was only demonstrating the 
 processes of mosquito-breeding and infection that 
 would have to be carried out in the vaccination 
 process. Our visitors laughingly acknowledged 
 that, at any rate, their subconscious selves had 
 been convinced of the correctness of the theory of 
 the mosquito transmission of yellow fever. 
 
CHAPTER V 
 
 SANITARY WORK AT HAVANA 
 
 Army Board had demonstrated that the 
 mosquito, to become infected, had always to 
 bite some patient with yellow fever within the first 
 three days of his disease. It was evident, there- 
 fore, that if we could prevent this being done in 
 every case of yellow fever in Havana, the disease 
 would disappear. This measure alone would be 
 sufficient for eliminating yellow fever. 
 
 To accomplish this we required all cases of yel- 
 low fever in the city to be reported to the central 
 office of the Health Department. They were at 
 once seen by the official diagnosis commission, and 
 if pronounced yellow fever, were at once moved 
 to Las Animas Hospital in a carefully screened 
 ambulance and placed in screened wards. The 
 routine at Las Animas Hospital precluded the 
 possibility of any mosquitoes biting the patient. 
 Most of the Americans, and in fact patients of all 
 classes, preferred to go to Las Animas. Under 
 
 50 
 
SANITARY WORK AT HAVANA 
 
 Dr. Boss's care the hospital soon obtained the 
 reputation of saving more yellow-fever patients 
 than could be done at the other hospitals, or at 
 their homes. This reputation was justly acquired. 
 The statistics of this hospital amply bore out the 
 reputation which public opinion gave it. If the 
 patient elected, he could stay in his own home, 
 the room or rooms to be screened were agreed 
 upon, a skilled force of carpenters were sent by 
 the central sanitary office, who thoroughly and 
 carefully screened the designated apartments. 
 Only one point of exit and entrance was left, and 
 this was protected by a vestibule and double door. 
 A number of squads of carpenters, each furnished 
 with its own wagon loaded with the necessary wire 
 netting, lumber, and other material, were always 
 on duty, so that usually within an hour after 
 notice came to the central office night or day, the 
 patient was either removed to the hospital or was 
 being screened at his own home. 
 
 To see that sanitary regulations were carried 
 out and that only authorized persons were ad- 
 mitted within the screened quarters of the patient, 
 an officer of the Sanitary Department was always 
 on duty. He sat in the vestibule and required 
 that one door should be closed always before the 
 second was opened. He was changed every eight 
 hours, that is, he was on duty only eight hours 
 in each twenty-four. We soon found that this 
 
 51 
 
SANITATION IN PANAMA 
 
 method could not be carried out in its entirety; 
 that it was the exception that we could get hold of 
 a patient during his initial chill. Generally the 
 patient had been sick one or two days before he 
 came under our observation. 
 
 It was evident, therefore, that a number of 
 mosquitoes might have bitten him before he was 
 discovered and cared for. As it would be twelve 
 or fourteen days before these mosquitoes would 
 become infectious, we had plenty of time to attend 
 to them. From the known habits of the stego- 
 myia mosquito we did not think they would leave 
 the house in which they had become infected, 
 though in an individual case this might occur, and 
 a mosquito wander into a contiguous house. 
 
 To meet this condition of affairs, as soon as the 
 case was concluded, the house in which the patient 
 had been sick and all the contiguous houses were 
 fumigated with such material as would kill the 
 mosquitoes. In order that the fumigation might 
 be effective the house had to be carefully gone 
 over and all cracks and crevices stopped, so as to 
 make the building as nearly air-tight as in the 
 nature of things it could be made. This was a 
 very laborious process and required care and 
 expert supervision. Most of the stopping of 
 crevices was done with paper and paste. Sulphur 
 is probably the most effective substance in killing 
 the mosquito. The rolled sulphur was used at 
 
 52 
 
Stegomyia Squad. Havana. 
 
 Screened Water Barrel. Havana. 
 
SANITARY WORK AT HAVANA 
 
 the rate of about a pound to the thousand cubic 
 feet of space to be fumigated. "We generally used 
 the Dutch oven placed in a box of sand or vessel 
 of water, so that in case of a leak, or in case of the 
 oven's getting too hot, the floor would not catch 
 on fire. With a large force of ignorant men en- 
 gaged in this work constant watchfulness has to 
 be used to see that fires do not occur. The proper 
 amount of sulphur is placed in the Dutch oven, a 
 little alcohol poured over the sulphur, and a match 
 applied. The sulphur will burn for three or four 
 hours, and will produce very dense fumes which 
 will fill the building and kill all the mosquitoes. 
 The fumes of sulphur in a building which has been 
 well prepared will kill not only all mosquitoes, 
 but all insect and animal life, and is by far the best 
 material to use for this purpose. It is generally 
 somewhat difficult to start the sulphur burning 
 with alcohol alone, and I have noticed that the 
 men got in the habit of using an ounce or two of 
 pyrethrum placed on top of the sulphur for the 
 purpose of starting the fire. The pyrethrum was 
 moistened with the alcohol and would burn for a 
 considerable time after the alcohol was consumed, 
 in almost every instance starting the sulphur 
 burning. 
 
 The fumes of sulphur will tarnish gilt metals 
 of all kinds, and injure most light-colored fabrics. 
 This occurs particularly where the air is heavily 
 
 53 
 
SANITATION IN PANAMA 
 
 charged with moisture. In cases in which sulphur 
 was likely to do damage, we used pyrethrum pow- 
 der. This powder does not tarnish or injure 
 fabrics 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. The 
 fumes of pyrethrum do not generally kill the mos- 
 quito, but simply intoxicate her. In the course 
 of time she revives and eventually entirely re- 
 covers. For this reason the building should be 
 opened up within a couple of hours after the burn- 
 ing of the pyrethrum, and all mosquitoes carefully 
 gathered and burned. 
 
 In almost all dwellings of the better class of 
 tenants there are fixtures and fabrics which will 
 be injured by the fumes of sulphur. Therefore, 
 in this class of buildings we generally used py- 
 rethrum. For fumigating in this same class of 
 buildings where pyrethrum was used we found a 
 mixture of camphor and carbolic acid, one part of 
 camphor to three of carbolic acid, very useful. 
 This should be placed in a tin dish and vaporized 
 with a spirit lamp. The same procedure should 
 be observed as a precaution against fire as is taken 
 with sulphur. The mixture when vaporized gives 
 off dense white fumes which kill the mosquito. 
 Generally, where care has to be taken for fear of 
 injuring fixtures and fabrics, this mixture is 
 
 5* 
 
SANITARY WORK AT HAVANA 
 
 preferable to pyrethrum. Pyrethrum should be 
 used at the rate of one pound to the thousand 
 cubic feet, and the camphor mixture at the rate 
 of 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, nor 
 the camphor mixture, as they all affected the deli- 
 cate flavor of the tobacco. At first we used to 
 move all tobacco out of a building to be fumigated. 
 This was very laborious and added largely to the 
 cost of fumigation and also tended to drive out 
 from the building the infected mosquitoes before 
 they had been reached by fumigation. Mr. Jos- 
 eph Le Prince, who was in charge of this work, 
 after much experimenting found that the fumes 
 from tobacco stems did not hurt the flavor of to- 
 bacco, and were almost as deadly to the mosquito 
 as was sulphur. We could therefore fumigate 
 with this material buildings where tobacco was 
 stored without injury to the tobacco. The stems 
 were a waste product in cigar manufacturing, and 
 could be obtained in large quantities at little cost. 
 They should be used at the rate of two pounds 
 to the thousand cubic feet, and with the same pre- 
 cautions against fire as are taken in other cases. 
 
 Formalin we found useless. It has apparently 
 little effect upon insect life. 
 
 From our general knowledge of the life history 
 
 55 
 
SANITATION IN PANAMA 
 
 of all species of mosquitoes, we knew they had to 
 spend eight or nine days in a larval stage, and 
 that while in this larval stage they lived in water. 
 Therefore, collections of water were necessary 
 for the development of the mosquito. The stego- 
 myia mosquito we knew preferred clear, clean 
 water, 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 a 
 small portion of its area. By far the larger por- 
 tion of the population obtained its water supply 
 from 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 sanitary 
 inspector. This inspector was required to get 
 around to each house in his district once a month 
 and make a careful inspection with regard to mos- 
 quito-breeding, and report to the central office 
 on a printed blank the conditions found. If this 
 report indicated that the condition of the premises 
 amounted to a sanitary nuisance, the householder 
 was proceeded against. An order had been 
 promulgated making it a sanitary nuisance for 
 any householder to have mosquito larvae on his 
 premises. The health officer was given authority 
 to impose a fine for such nuisance ; the fine was col- 
 lected by the Cuban courts, and the proceeds of 
 
 56 
 
SANITARY WORK AT HAVANA 
 
 the fine deposited in the Cuban treasury. The 
 health officer had authority to remit the fine at any 
 stage of the proceedings. In practice, it came 
 about that the whole matter was settled in the 
 Sanitary Department. We employed a lawyer to 
 whom cases of fines were referred. When a 
 householder was reported by the sanitary inspec- 
 tor as having larvae on his premises, he was noti- 
 fied that under the sanitary ordinance he was fined 
 five dollars for having this nuisance on his prem- 
 ises, but that if the nuisance were abated, the fine 
 would be remitted. This usually brought the man 
 promptly to the office with the statement that the 
 nuisance had been abated. An inspector was sent 
 around, and if the householder's statement was 
 found to be correct, the fine was remitted. 
 
 In a certain number of cases this notice caused 
 no action on the part of the householder. In these 
 cases the fine was sent to the judge of the district 
 for collection by him. In the few cases in which 
 the first notice had not brought the householder to 
 terms, this action by the court did. If he reported 
 that he had abated the nuisance and the inspector 
 when sent to investigate found this to be the case, 
 the fine was withdrawn. In this way we did very 
 little fining. Out of about twenty-five hundred 
 fines levied in the last nine months of 1901, only 
 fifty were finally imposed and deposited in the 
 treasury. 
 
 57 
 
SANITATION IN PANAMA 
 
 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 power 
 of assessing and remitting fines that was the prin- 
 cipal cause of our popularity. The Cuban had 
 been accustomed to looking upon laws and ordi- 
 nances as devices for filling the pockets of the 
 officials, and fines as the legitimate perquisites of 
 those officials. When a fine was remitted, he 
 looked upon it as a personal present from the 
 pocket of the chief sanitary officer to himself, and 
 was grateful accordingly. Why the chief sani- 
 tary officer should take so great an interest in mos- 
 quito larvae he could not comprehend. But that 
 officer evidently did take a most decided interest 
 in the matter, and had he not demonstrated his 
 friendship by taking five dollars, which was as 
 good as in his pocket, and giving it to him, the 
 offender? His loyalty was appealed to and gen- 
 erally he remained ever afterwards the friend of 
 the Department. 
 
 Cisterns, barrels and receptacles for containing 
 and storing rain water for drinking and domestic 
 purposes were absolutely necessary in the case of 
 the larger part of the population. It was neces- 
 sary that we prepare these receptacles so that 
 they could not breed mosquitoes. If it were ar- 
 ranged so that mosquitoes could not lay their eggs 
 on the surface of the water, this object would be 
 
 68 
 
SANITARY WORK AT HAVANA 
 
 accomplished. It was therefore provided that all 
 receptacles should be covered in such a manner 
 that mosquitoes could not have access to them. 
 The tops were covered, a small hole being left in 
 the top by means of which water could enter. This 
 hole was covered with wire netting, and a spigot 
 was placed in the bottom whereby the water could 
 be drawn off. This was done at public expense. 
 At the central office squads of carpenters with 
 material loaded in wagons were always on hand 
 to go out for this work. If the sanitary inspector 
 reported 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 into 
 eight 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. Every 
 family had an earthen vessel in which drinking- 
 water was kept for daily use. This always had 
 larvae in it. It was the inspector's duty to empty 
 this vessel, point out the larvae to the housekeeper, 
 and explain that if the vessel were emptied once 
 a day and the larvae washed out, mosquito develop- 
 ment could not occur. All sorts of vessels in a 
 house which might contain water had to be con- 
 sidered as possible breeding-places for mos- 
 quitoes. Every housekeeper in Havana, when we 
 started work there, had a number of breeding- 
 
 59 
 
SANITATION IN PANAMA 
 
 places for mosquitoes in her domestic establish- 
 ment. Among these may be mentioned flower-pots 
 in which a little too much water had been used; 
 cans filled with water, in which the legs of tables 
 had 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 of 
 oil to pour upon any pools or puddles about the 
 premises that might need oiling. They picked up 
 old bottles and cans which might contain water 
 and become breeding-places, and generally looked 
 after the yards. The district inspector, at the 
 same time, made a general report on the premises 
 in writing, and on this report the owner was called 
 to account if unsanitary conditions were found 
 existing. 
 
 Next to cisterns and water barrels, roof gutters 
 were found to be the most general breeding-places 
 for the stegomyia mosquitoes. Leaves and trash 
 fall upon the roofs, are washed into the gutters, 
 and these make little dams behind which water 
 collects and remains after the rain has ceased. 
 At other times the gutter sags and thus forms a 
 collection of water. In the tropics you can always 
 count upon roof gutters as being places for mos- 
 quito-breeding, and being inaccessible and difficult 
 to inspect, such breeding-places are seldom dis- 
 turbed, 
 
 60 
 
SANITARY WORK AT HAVANA 
 
 During its larval stage the mosquito lives en- 
 tirely in water, but has to come to the surface 
 frequently for the purpose of getting air. This 
 necessity is seized upon by man for the purpose of 
 destroying the larvae. If kerosene oil is poured 
 upon the water, it spreads in a very thin film over 
 the surface. Now when the larvae rise to breathe, 
 the oil gets into their breathing-tubes when they 
 attempt to force them through the thin film of oil 
 spread 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 how 
 rapidly such a system will free a city of mos- 
 quitoes, and how after a few months of such work 
 you cease to be annoyed by them. In yellow-fever 
 work this system of destroying mosquito larvae is 
 the 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 become 
 more frequent, and this character of mosquito 
 breeding-places becomes more important than con- 
 tainers. Wherever possible these breeding-places 
 should be drained, though oiling in this class of 
 work has a very useful field. In the suburbs, in 
 these pools and puddles, the anopheles, the 
 malarial mosquito, becomes common and this dis- 
 ease has to be looked after. We had fifty men 
 
 61 
 
SANITATION IN PANAMA 
 
 engaged in this work, under a different set of 
 inspectors from those doing the stegomyia work. 
 This was made necessary, as the men doing the 
 anopheles work were occupied almost entirely in 
 the suburbs of the city. The details I will describe 
 in another place. 
 
CHAPTER VI 
 
 THE RESULTS ACCOMPLISHED IN HAVANA 
 
 FROM the account already given of yellow fever 
 it is evident that the parasite has to be intro- 
 duced into a locality, either in the body of a human 
 being 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 the 
 health authorities can keep out these two sources 
 of infection, yellow fever can never occur in that 
 locality. 
 
 With this object in view we established a mod- 
 ern quarantine at Havana. Any ship coming in 
 with yellow fever aboard was placed in quarantine. 
 The vessel itself was fumigated so as to kill all 
 the mosquitoes. This rendered the ship safe. 
 All the non-immune crew were taken off, carried 
 to quarantine station, where they were cared for 
 during a period of six days. If no sickness de- 
 veloped during this period, it was concluded that 
 the infected mosquitoes aboard the ship had not 
 
 63 
 
SANITATION IN PANAMA 
 
 bitten these non-immunes up to the time of their 
 departure. They were therefore released and al- 
 lowed to return. The immunes were not consid- 
 ered liable to yellow fever, even if they had been 
 bitten by the infected mosquitoes. 
 
 One attack of yellow fever gives such great 
 protection that, in practice, a man who can prove 
 that he has once had the disease is looked upon 
 as entirely safe. But of course he has to prove 
 this to the satisfaction of tho quarantine physician. 
 It is considered so certain that everyone exposed 
 to yellow fever will have the disease that proof 
 that a man has lived in an endemic center for ten 
 years is accepted as proof of his immunity. No 
 quarantine 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 the 
 disease after they had been released from quar- 
 antine. But a quarantine greatly lessens the 
 number of times and the frequency with which 
 infection is introduced into a locality. 
 
 For some reason yellow fever, in the minds of 
 people generally, is covered with a cloak of mys- 
 tery. In communities where it prevails there are 
 hundreds of remedies and courses of treatment 
 that are vaunted as being infallible cures, and the 
 more ignorant and uneducated the possessors of 
 
 64 
 
THE RESULTS ACCOMPLISHED IN HAVANA 
 
 these specifics, the more readily they seem to be 
 accepted by the people generally. But yellow 
 fever, like every other acute disease, has its own 
 natural history, and man at present knows no 
 remedy that can shorten or change its course. 
 Many a time I have found myself completely 
 routed in cases of yellow fever by the old 
 negro mammy, who would insist that if the pa- 
 tient would take orange-leaf tea and adopt cer- 
 tain other procedures which she advocated, the 
 patient would certainly get well. Now, on the 
 average with severe yellow fever, seventy-five per 
 cent, will recover and twenty-five per cent, will 
 die. The negro mammy did not know this, but 
 was firmly convinced that it was the orange-leaf 
 tea which caused the recovery in the cases of 
 those who recovered, and some departure from 
 her directions that caused death in the case of 
 those who died. She believed that if her routine 
 had been carried out in the fatal cases, they 
 would have recovered. I must confess, however, 
 that in my experience the measures generally 
 advocated by the negro mammy did little or no 
 harm, and in looking back over a yellow-fever ex- 
 perience of thirty years, I cannot by any means 
 make so strong a statement with regard to my 
 professional brethren. 
 
 One of the most general superstitions with re- 
 gard to yellow fever was that all air must be kept 
 
 65 
 
SANITATION IN PANAMA 
 
 from the patient. With this in view, the room in 
 which the patient was treated was kept closed and 
 entirely dark. No water for washing the face and 
 hands, 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 had 
 been ill five or six days can be better imagined 
 than described. 
 
 I was once called into consultation by a medical 
 friend of very high standing in one of the best 
 and most aristocratic Havanese families. The 
 patient was a young American teacher who had 
 been brought to Havana a few months before in 
 connection with the education of a large family of 
 children. She had been sick with yellow fever 
 some five or six days when I saw her, and I recog- 
 nized without much examination that she was 
 fatally ill and had but a few hours to live. Her 
 Cuban friends were devoted to her, and were will- 
 ing to do anything for her comfort and recovery 
 that their wealth could command. As is generally 
 the case in yellow fever, her mental faculties were 
 perfectly clear, and her physical strength good, 
 although she died within six hours after I saw 
 her. She was delighted to see me, and begged me 
 earnestly to induce her friends to let her bathe 
 her face and hands and have clean clothing; for 
 neither of these luxuries had been granted her 
 since she was taken sick. I urged my medical 
 
 66 
 
THE RESULTS ACCOMPLISHED IN HAVANA 
 
 friend who had called me into the case to allow the 
 poor girl to have these things, and I knew that 
 he agreed with me that they could do no possible 
 harm. He said that he would try, but that prob- 
 ably the only result would be that he would lose 
 the confidence of the family and do the poor girl 
 no good. We both urged this upon the family, 
 but so strong was their belief that such a measure 
 would deprive their friend of such little chance 
 of recovery as was left that they would not con- 
 sent. 
 
 In times of stress and danger such as come 
 about as the result of an epidemic of yellow fever, 
 many tragic and cruel phases of human nature are 
 brought out, as well as many brave and unselfish 
 ones. Some tragedies stand out prominently in 
 my recollection. 
 
 When yellow fever was at its height in Havana, 
 our chief commissary, an officer of the regular 
 Army, was taken sick and his disease was soon 
 recognized as being yellow fever. His wife had 
 left Havana a few weeks before to make a short 
 visit to her home in Cincinnati. I had promised 
 that if my friend should get yellow fever, I would 
 cable his wife. I did so, and the wife received the 
 cable while at a dinner-party. She started for 
 Havana 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- 
 
 07 
 
SANITATION IN PANAMA 
 
 usually strong, and as she was assured that hope 
 was departing, her grief was very great. This 
 was before we knew that the mosquito alone could 
 convey the disease, and when we had some general 
 idea that it was infectious, and in some way con- 
 tracted by contact with fomites, and with those 
 who were sick of the disease. 
 
 The wife as she saw death approaching de- 
 termined, if possible, herself to contract the dread 
 disease. I heard her appeal to her husband in 
 most moving terms not to die and leave her alone. 
 She was with her husband at the moment of his 
 death, and held him in her arms at the time. One 
 who is familiar with a deathbed scene from yellow 
 fever can appreciate what this means. It is a very 
 gruesome death, and the young wife was covered 
 with "vomito negro." 
 
 I felt myself more or less responsible, and 
 thought that she was going into the jaws of death 
 by this kind of exposure. I therefore called for 
 the assistance of one of the nurses, and used some 
 force in getting her into the next room. She at 
 first reproached me, but as soon as we got her 
 into 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 so 
 that she could take her husband's body with her 
 when she sailed on the next vessel for the United 
 States. 
 
 68 
 
THE RESULTS ACCOMPLISHED IN HAVANA 
 
 Mrs. Gorgas and I walked with her to her room 
 and gave certain directions with regard to her 
 care and comfort for the night. She asked me for 
 a sleeping dose which she might take in case she 
 was unable to sleep. I recollect that I put this 
 up 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 she 
 asked about the location of persons in the adjoin- 
 ing rooms. 
 
 About two A. M. Mrs. Gorgas and I went to our 
 quarters. We had been home just a short time 
 when I was aroused by a hurried step and a knock 
 at the door. I found it was a messenger summon- 
 ing me to the hospital, with the information that 
 the lady had killed herself. 
 
 When the door of her room was forced, we 
 entered and found our friend apparently in a 
 peaceful, quiet sleep. One arm had dropped 
 naturally to the side, and the right arm was lying 
 across the chest, the hand still holding the pistol 
 with which she had killed herself. The appear- 
 ance was exactly that of a piece of marble. She 
 had 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 pistol 
 in her trunk which she had procured in the United 
 States at the time she started for Havana. She 
 
 69 
 
SANITATION IN PANAMA 
 
 had placed fresh clothing on a chair by the bed- 
 side, apparently with the intention of being robed 
 in it after death. 
 
 In looking back I could see various things in her 
 actions and conversation that indicated the inten- 
 tion of taking her life. At other times she had 
 entirely forgotten this, and was preparing for her 
 sad future in this life. She had apparently been 
 dazed by her grief and was temporarily un- 
 balanced, unable for any length of time to follow 
 in her mind any definite plan of action. 
 
 The Major having been our chief commissary 
 and a man with whom we were in daily contact, 
 this tragedy profoundly affected the military com- 
 munity. The next day we took husband and wife 
 out to the little military cemetery at Camp Colum- 
 bia where the American troops were cantoned, 
 some five miles from Havana, and laid them to rest 
 in the presence of a large concourse, military and 
 civil. 
 
 While there, a member of the Commanding 
 General's staff, Captain Page, had a chill, returned 
 home sick, developed a severe case of yellow fever 
 and died within a week. This was looked upon by 
 all the community as evidence that the disease 
 had been contracted by contagion from the Cap- 
 tain's having attended the funeral. 
 
 From the table on page 71 it will be seen that 
 for ten years preceding our occupation of Havana 
 
 70 
 
THE RESULTS ACCOMPLISHED IN HAVANA 
 
 Tf 30 TJ< O O O 00 O 
 rH ^H i-l rt i-t i-l O 
 
 
 OOOSTfi O<N OOOOi W Tf rf O I O 
 
 CO * 1C 1> 10 M ,-1 
 
 CO 
 
 r-.^o^<NcoQC^oc^ I n 
 
 2 I 
 
 || S^^i^ggSS:: || 
 
 ocoTmot^r-Ho^icoo^i^. 
 
 i-l 1-1 C^ CO CO O CO CC 1-1 
 
 H CO Tj< ^ <N IN -1 
 
 .-i CO CO CO -i - 10 
 
 CO^Cvl^HfN 
 
 II-H eotocSeooi^S! 001 ^ ^ 
 
 ri Tj< oo ^f o 10 co o co to ^r I Ci 
 
 CO CO CO I 00 
 
 
 i : s 
 
 71 
 
SANITATION IN PANAMA 
 
 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 yellow 
 fever. A further search of the mortality statistics 
 shows that yellow fever had existed in Havana 
 continuously from the year 1762. This was the 
 year during which Havana was besieged and cap- 
 tured by the English forces. The troops were 
 largely made up of colonials from the North 
 American colonies, and they suffered severely 
 from yellow fever. For two hundred years before 
 this time Havana had been subject to epidemics 
 of yellow fever, but from 1762 up to the year 1901, 
 there was probably not a single day when Havana 
 did not have a case of this disease within its 
 bounds. 
 
 In February, 1901, the measures above de- 
 scribed were begun. Under these measures yellow 
 fever rapidly disappeared, and in September of 
 that year, the last case of yellow fever occurred. 
 With one exception there has been no case of this 
 disease in Havana since that date. 
 
 The work directed against mosquitoes had an 
 equally good effect upon malaria. While the work 
 done with the view of getting rid of the stegomyia 
 was effective to a certain extent against the anoph- 
 eles, the principal , anti-anopheles work was 
 executed in the suburbs of the city. It is a gen- 
 
 72 
 
THE RESULTS ACCOMPLISHED IN HAVANA 
 
 eral rule that malaria does not occur in the heart 
 of a city, but generally in its outlying districts. 
 The reasons for this will become evident when I 
 describe anti-malarial work in one of our future 
 chapters. 
 
 DEATHS FROM MALARIA IN THE CITY OF HAVANA 
 
 Year No. Year No. Year No. Year No. 
 
 1871 262 1882 223 1893 246 1904 44 
 
 1872 
 
 316 
 
 1883 
 
 183 
 
 1894 
 
 201 
 
 1905 
 
 32 
 
 1873 
 
 329 
 
 1884 
 
 196 
 
 1895 
 
 206 
 
 1906 
 
 26 
 
 1874 
 
 288 
 
 1885 
 
 101 
 
 1986 
 
 450 
 
 1907 
 
 23 
 
 1875 
 
 284 
 
 1886 
 
 135 
 
 1897 
 
 811 
 
 1908 
 
 19 
 
 1876 
 
 334 
 
 1887 
 
 269 
 
 1898 
 
 1907 
 
 1909 
 
 6 
 
 1877 
 
 422 
 
 1888 
 
 208 
 
 1899 
 
 909 
 
 1910 
 
 15 
 
 1878 
 
 453 
 
 1889 
 
 228 
 
 1900 
 
 325 
 
 1911 
 
 12 
 
 1879 
 
 343 
 
 1890 
 
 256 
 
 1901 
 
 151 
 
 1912 
 
 4 
 
 1880 
 
 384 
 
 1891 
 
 292 
 
 1902 
 
 77 
 
 
 
 1881 
 
 251 
 
 1892 
 
 286 
 
 1903 
 
 51 
 
 
 
 It will be seen from this table that before the 
 year 1901 Havana had yearly from 300 to 500 
 deaths from malaria, rising as high in 1898 as 
 1,900 deaths. Since 1901 there has been a steady 
 decrease in the malarial death rate until the last 
 year of the table, 1912, when there were only four 
 deaths. Four deaths from malaria in a city of 
 the size of Havana, about 300,000 population, 
 means the extinction of malaria in that city. For 
 the island of Cuba is in the tropics, and there are 
 many malarious localities through the country dis- 
 tricts. Havana is the metropolis of Cuba, and has 
 in its environs the largest and best equipped hos- 
 
 73 
 
SANITATION IN PANAMA 
 
 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 malaria 
 are brought in among these outside sick. The 
 tables quoted above include all persons who died 
 within the limits of the city of Havana, whether 
 they came from the outside, or were residents of 
 the city; whether they died in the large hospitals 
 of the city, or in private houses. 
 
 Four deaths in one year from malaria can very 
 safely be put down as coming from the outside, 
 and it can with equal safety be said that by 1912, 
 malaria had become as completely extinguished 
 in 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 of 
 Dr. Eonald Ross and his co-workers witli the 
 anopheles mosquito, and of Eeed and his asso- 
 ciates with the stegomyia, undoubtedly gave the 
 knowledge whereby the practical extinction of 
 malaria and yellow fever was accomplished at 
 Havana, but the accomplishment of this work with 
 regard to yellow fever was the event which at- 
 tracted the greatest attention. It seems almost 
 providential that we had all the machinery at hand 
 whereby the discoveries of the Reed Board could 
 be immediately tested and demonstrated. Here 
 
 74 
 
THE RESULTS ACCOMPLISHED IN HAVANA 
 
 was a large city of 250,000 inhabitants in which 
 yellow fever had been endemic for one hundred 
 and fifty years. The American Army had been in 
 control of the city for two years, and the Health 
 Department was thoroughly organized and 
 equipped and under the charge of a medical officer 
 of the regular Army. Dr. Eeed himself was 
 strongly impressed with the advantage it had been 
 to him to have his discoveries given so thorough 
 and conspicuous a test, and wrote me to that effect 
 many times. 
 
 There has been a great deal of discussion as to 
 who deserves the credit for this great discovery. 
 Undoubtedly Reed and his Board brought all the 
 threads 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 Huberts papers : 
 
 And let me premise here, that in science at least, 
 great names are landmarks; and the owners of 
 these names have traversed and gleaned in fields 
 where many a devoted laborer had delved and 
 sown, and pathetically sweated blood in his al- 
 truistic zeal. In science at least no man works in 
 vain. Full many an one, worthy of an elegy, has 
 given his whole life to establishing a fact, or in- 
 
 75 
 
SANITATION IN PANAMA 
 
 deed only an item to a fact ; his work unrealized, 
 ridicule and even persecution ofttimes his only 
 compensation, throughout perhaps in the meanest 
 destitution, yet his life and his work have been 
 absolutely essential to the building of a mighty 
 fabric. Martyrs have been many among such 
 dying from the diseases from which they sought 
 to defend others; knowing, too, full well, what 
 their own fate would be. Nor does it in any wise 
 detract from the gratitude due the great man that 
 he has profited by the labors of others, adding 
 what he can of his own, scrutinizing every detail, 
 every datum, permeating and illuminating with 
 his own genius, cementing the mass with his own 
 deductions. 
 
 And from Flexner : 
 
 Remarkable achievements are never unique oc- 
 currences in nature. Even the greatest men rest 
 on the shoulders of a multitude of smaller ones 
 who have preceded them ; and epochal discoveries 
 emerge out of a period of intellectual restlessness 
 that affects many minds. 
 
CHAPTER VII 
 
 CORRESPONDENCE WITH DR. REED 
 
 A S illustrating the way in which we looked at 
 ** conditions at Havana at the time that our 
 mosquito work was first begun, I will quote cor- 
 respondence which took place between Dr. Eeed 
 and myself at this time. 
 
 War Department, Surgeon General's Office, 
 Army Medical Museum and Library, 
 
 Washington, May 16, 1901. 
 
 MY DEAR GORGAS I 
 
 Briefly speaking, how is the yellow-fever situa- 
 tion in Havana? I got your report for April and 
 noted, with much pleasure and satisfaction, your 
 enthusiasm in tackling C. f asciatus and her numer- 
 ous cousins. Later, I think on May 4th, I read of 
 "a serious outbreak" in your town, to the extent of 
 two cases. Since then I have heard nothing con- 
 cerning the progress of your epidemic. How many 
 cases have you at the present writing, and what 
 
 77 
 
SANITATION IN PANAMA 
 
 are your prospects of prognostications for the 
 future! I ask for this information particularly 
 because Dr. Durham, of the English Commission, 
 in a letter recently received, has proposed to join 
 us in Cuba for the purpose of trying to reconcile 
 his work, or rather the results of his work, at 
 Para, Brazil, with our observations at Quemados, 
 and as he will reach here during the last week in 
 May, it is barely within the bounds of possibility 
 that you may again see us back in our old haunts 
 by July 1st. Everything will depend upon I>r. 
 Sternberg's decision. ... As much as I should liko 
 to see you and other friends, I would prefer to 
 spend the summer in the United States. I hear 
 that my friend, Kean, has been promoted to be 
 the head of Charities and Correction for tlio 
 Island. Who, then, is Post Surgeon at Columbia 
 Barracks? How does Dr. Guiteras succeed at his 
 propagating station? I trust that your own and 
 Mrs. Gorgas' health is very good. Please remem- 
 ber me very kindly to the latter and to Col. Havard 
 and Glennan. 
 
 Sincerely yours, 
 
 WALTER KEED. 
 
 (2) 
 
 Havana, Cuba, May 22, 1901. 
 MY DEAR KEED: 
 
 Yours of the 16th received. I wrote you a day 
 or two ago, but I have forgotten whether or not 
 I answered your question. 
 
 The fever situation is all that could be desired, 
 I think. The last death from yellow fever oc- 
 
 78 
 
CORRESPONDENCE WITH DR. REED 
 
 cur red on March 13th. Since that time we have had 
 a case April 21st ; another on April 22d. We had 
 no more cases then till May 6th, when we had one ; 
 and on May 7th, three more. Since that time, two 
 weeks, we have had no more ; and as the conditions, 
 as far as non-immunes are concerned, seem more 
 favorable for the spread of yellow fever, I am in 
 high fettle. 
 
 I am inclined to attribute our freedom to the 
 way in which we killed the mosquitoes. We have 
 fifty men at this work, oiling and draining small 
 collections of water in every house and putting 
 oil in all the sinks and closets so that it will run 
 down into the cesspools. During the winter and 
 cool periods of the year, up to this time say, the 
 cesspools are the great places for breeding mos- 
 quitoes. All the cesspools, so far, have larvae in 
 them; when water barrels and cisterns in same 
 yard have none. I am inclined to think that Dr. 
 Guiteras, and other mosquito breeders, would get 
 much more vigorous larvae if they would use blood 
 or some richer food than mere bread. We have 
 been trying them side by side and find that sewer 
 water develops much more hardy and large larvae 
 than rain water with bread alone in it. 
 
 I have had all the little streams and ditches in 
 the suburbs cleaned and oiled ; and we have killed 
 a great number of larvae. 
 
 You can go to any sewer mouth now and see 
 the dead larvae running out in considerable num- 
 bers, coming principally, I think, from the foso- 
 mauros, where they have been killed by the oil 
 which would no doubt remain upon them for sev- 
 eral hours, 
 
 79 
 
SANITATION IN PANAMA 
 
 But we have evidently had some tough old in- 
 fected fellows, who have hibernated through the 
 winter. For instance, on the two cases that oc- 
 curred on the 21st and 22d of April (in different 
 parts of the city, however), the mosquitoes were 
 killed as thoroughly as we knew how. Every 
 room in the house was closed; and a pound of 
 pyrethrum powder burned to 1,000 cubic feet, and 
 oil used everywhere, sewers and everywhere else. 
 Not only was this done in the infected house, but 
 in the fifteen or twenty contiguous houses. On 
 each case we used 50 pounds of pyrethrum powder 
 and something like 40 gallons of oil. I think the 
 results show that we probably got hold of the in- 
 fected mosquito or mosquitoes. We did the same 
 thing on May 6th and 7th; and it now looks as 
 though we had gotten hold of the infected mos- 
 quito there. 
 
 The prospect of getting infected mosquitoes 
 now 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 not 
 object 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 let 
 him know when I could get him some more 
 autopsies of yellow fever, and he would come down 
 at once. 
 
 We have things nicely fixed at Las Animas now; 
 and I think we would do good work if we only 
 
 80 
 
CORRESPONDENCE WITH DR. REED 
 
 had yellow fever; but of course we can do nothing 
 if we don't have. 
 
 Mrs. Gorgas has just returned from the "States" 
 and joins me in kindest regards. I got weak in 
 the knees and was afraid to keep our small girl 
 down 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 here 
 comes your most welcome and interesting letter 
 of 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, you 
 were biting often with non-contaminated mos- 
 quitoes, as your fever cases were doubtful. Cases 
 3 and 6 should have failed. I expect better results 
 from your May-infected mosquitoes. I see that 
 Finlay and Guiteras continue to harp on the harm- 
 lessness of a single mosquito's bite, drawing the 
 conclusion that ordinarily y. f. is due to multiple 
 bites. After some poor devil dies, they may 
 change their minds. Carroll's severe illness was 
 due to a single insect and poor Lazear died from 
 a singly bite. Why are not malarial fevers gener- 
 
 81 
 
SANITATION IN PANAMA 
 
 ally double or multiple infections f We know that 
 the opposite single infections, as shown by one 
 group of parasites is the rule. . . . What's the 
 need for us to return, if you have no y. f.f 
 Havana should get a more accommodating Chief 
 Sanitary Officer ! Hurry up your new infections. 
 Again thanking you for your letter and the copy 
 of G.'s report, and with best regards to your wife, 
 believe me, sincerely yours, 
 
 W. KEED. 
 
 (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 that 
 I will send a copy of our last paper just as soon 
 as we can get it from "American Medicine." It 
 hasn't been published yet. I hope to have it soon. 
 You shall certainly have a Reprint. What you tell 
 me 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 admit 
 that you must have more non-immunes in Havana 
 now than in 1899. Of course, you understand, 
 my dear Doctor, that the control of yellow fever 
 during this epidemic season, is to me the all-ab- 
 sorbing and important question, and it is on this 
 very account that I am afraid that you and I might 
 be led, in our enthusiasm, to think that more 
 should be attributed to the sanitary measures, now 
 
 62 
 
CORRESPONDENCE WITH DR. REED 
 
 being carried out, than to the season, or some other 
 conditions of which we might be ignorant. It is 
 simply a delight to read that you are "in high 
 fettle," and I consider the city fortunate in having 
 a Health Officer who believes that he can master 
 the problem, I am astonished at the strength of 
 your mosquito-destroying sanitary squad. What 
 you say about the cesspools as breeding-places 
 is intensely interesting. We got our first good 
 supply of larvae from an old can containing some 
 feces at Columbia Barracks, and since then we 
 have added a little fecal material to our breeding 
 jars and have found that larvae thus fed grew 
 much more vigorously than those in ordinary 
 water. Your experiments agree fully with ours. 
 You are certainly doing effective work toward 
 their destruction. I was astonished at the amount 
 of pyrethrum that you are burning to the 1,000 
 cubic feet. Is such a large amount necessary, do 
 you think? Won't you soon exhaust the supply? 
 At Mount Vernon B'ks, where culex was very 
 abundant, I used to find that about 2 or 3 ounces 
 would intoxicate every mosquito in a room of some 
 3.500 cubic feet, so that I could sweep them up 
 and 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 do 
 not prove obnoxious to the Cuban doctors and lay- 
 men, or otherwise they will certainly conceal their 
 milder cases. While the destruction of the mos- 
 quitoes is very desirable, I consider the thorough 
 protection of the patient against their bites as of 
 even greater importance. I cannot believe that 
 
 33 
 
SANITATION IN PANAMA 
 
 in so large a city . . . that you can possibly ac- 
 complish this. The undertaking, to me, seems 
 well-nigh impossible. They ivill conceal their 
 cases, do what you may; and these cases will be 
 the foci for other cases. I can see no other al- 
 ternative for this summer, at least. Still, you will 
 undoubtedly be able to control the spread of the 
 disease better than ever. . . . Pardon this long 
 letter. Good luck attend your well-conceived reg- 
 ulations. Health and happiness attend you and 
 
 Sincerely, your friend, 
 
 EEED. 
 
 Dr. Eeed here considers a squad of fifty mon 
 doing sanitary work in a city of two hundred 
 thousand inhabitants at large. Four years after- 
 wards, in the city of Panama, a place of twenty 
 thousand inhabitants, we had six hundred men 
 doing the same work. Major Reed is inclined to 
 think fifty pounds of pyrethrum to a case a large 
 amount. In 1905 in Panama we used two hundred 
 and forty thousand pounds during the year. I call 
 attention to this as showing how little any of us 
 appreciated the magnitude of the job when we first 
 started in. 
 
 (5) 
 
 Havana, Cuba, June 13, 1901. 
 MY DEAR REED : 
 
 Yours of June 5th received. I inclose yon a 
 copy of Dr. Guiteras' report for May. 
 
 84 
 
CORRESPONDENCE WITH DR. REED 
 
 We see still no success from our inoculations in 
 twenty-two cases, but the great "but" comes in. 
 I am not sure that any of the cases bitten were 
 yellow fever. One of the last, from Tampico, I 
 thought a pretty well marked case, though not 
 dangerously ill, but his mosquitoes, on the 20th 
 day, did not infect. I am disappointed beyond 
 measure. I had hoped by this time to have Las 
 Animas full to overflowing with inoculated cases, 
 and be turning out immunes at the rate of some 
 two hundred a month. But may be it is well as it 
 is ; in our enthusiasm we might have infected the 
 city. 
 
 No case of yellow fever since May 7th, and still 
 none on hand. The Board diagnosed one early 
 in the month, but it turned out a well-marked case 
 of typhoid fever. Of course I agree with you that 
 nothing very definite can be deduced from our re- 
 sults this early in the season, though personally I 
 am very much impressed by them. Our condition 
 now is very much better than it was even in '99, 
 with regard to yellow fever, and of course our 
 liability 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 in 
 Havana, and they would not have had yellow fever 
 no matter what the condition of infection would 
 have been. I except of course, the latter part 
 of '99. 
 
 From the 1st of March to the 16th of June in 
 '99 (and mind you this has been far and away the 
 best record Havana ever made), we had four 
 deaths from yellow fever. In the same period 
 this year, we have had one, which occurred March 
 
 85 
 
SANITATION IN PANAMA 
 
 16th. The deaths in '99 occurred scattered over 
 this period. It seems to me that the present con- 
 dition of affairs indicates that we have been doing 
 something that has had a great effect upon infec- 
 tion; and of course the only thing we have done 
 this year that we did not do last year is the de- 
 struction of the mosquito. We commenced this 
 work about the middle of February, just about the 
 time that yellow fever practically disappears. 
 
 On the 12th of June, 1899, we had had for the 
 month two cases of yellow fever, and in 1900, six. 
 If you consider the amount of work there was to 
 be done, to put oil in all the cesspools, all the wat-r 
 barrels and all the cisterns, once a mouth, and 
 then keep the streams and pools in the suburbs 
 drained, you will understand that seventy-five men 
 is not at all a large force. I think I could use to 
 advantage more. As you say, we could use less 
 pyrethrum. We arrived at the rate of a pound 
 per 1,000 cubic feet by experiments at Las Ani- 
 mas. We found that in this ratio we could kill 
 mosquitoes in one and a half hours. It would 
 probably be just as well to intoxicate them and 
 sweep them up, and I shall probably cut down the 
 quantity in a short time. A\ V have to sweep them 
 up anyway. But feeling that it may be possible 
 that we have no infected mosquitoes in Havana I 
 want to do everything I can think of, when a case 
 occurs, to increase the chances of killing the in- 
 fected mosquito in the neighborhood of where the 
 patient 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 
 
CORRESPONDENCE WITH DR. REED 
 
 the patient's home. There is less objection raised 
 to this than to the ordinary disinfection. It dam- 
 ages nothing, only keeps them out of their room 
 for an hour or two, and kills the mosquitoes. I 
 think there is much less opposition to us on this 
 account than there was last year. 
 
 I feel confident that there is very little conceal- 
 ment of cases, and I do not feel much anxiety on 
 this score. We cannot have many light cases with- 
 out having a death now and then, and deaths would 
 almost certainly be reported. 
 
 But what gives me the greatest confidence is 
 that our non-immunes are made up entirely of 
 Spaniards and Americans. The Americans 
 promptly report themselves where there is any- 
 thing suspicious, for the sake of the better care 
 that they get at Las Animas. The Spaniards are 
 all matriculated at one of the three "quintas," and 
 go there as soon as they are sick from any cause. 
 These "quintas" are all very anxious to try and 
 catch up to the record of Las Animas, and report 
 every case that they think, by any possibility, will 
 pass the Board. And then, too, I can control the 
 "quintas" by frequent inspections. So it seems to 
 me that there is very little probability of cases be- 
 ing concealed to any extent. Still, we can speak 
 more definitely on this subject about the 1st of 
 December than we can now. 
 
 All well. With kindest regards, I remain, 
 
 Very sincerely yours, 
 
 W. C. GORGAS, 
 
 To Maj. Walter Eeed, Maj. & Surg., U. S. A. 
 Washington, D. C. Chief Sanitary Officer. 
 
 87 
 
SANITATION IN PANAMA 
 
 (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 dear 
 Dr., in spite of a few disagreeable things and 
 people, when I think of the absence of yellow fever 
 from Havana for a period of fifty days, I begin to 
 feel like rejoicing that I ever was born! You are 
 doing a splendid work for your corps and profes- 
 sion in Havana. 
 
 Sincerely, your friend, 
 
 KEED. 
 
 (7) 
 
 Army Med. Museum, Washington, July 29. 
 MY DEAR GORGAS : 
 
 I was on the eve of writing to you, when your 
 kind favor of the 20th inst. reached me. The news 
 from Havana is simply delightful. I am willing 
 to confess that my fears that physicians would fail 
 to report cases of yellow fever to your office, and 
 thus maintain foci of infection, were groundless. 
 It shows that your acquaintance with the local con- 
 ditions were much better than mine. That you 
 have succeeded in throttling the epidemic appears 
 to be beyond question, and is to your everlasting 
 credit as an energetic Health Officer, who saw his 
 opportunity and grasped it. A man of less dis- 
 cretion, enthusiasm and energy would have made 
 
 88 
 
CORRESPONDENCE WITH DR. REED 
 
 a fiasco of it. Whereas, you, my dear Gorgas, 
 availing yourself of the results of the work at 
 Camp Lazear, have rid that pest hole, Havana, 
 of her yellow plague ! All honor to you my dear 
 boy! Thank God that the Medical Department 
 of the U. S. Army, which got such "a black eye" 
 during the Spanish- American war, has during the 
 past year accomplished work that will always re- 
 main to its eternal credit! I had seen in the 
 papers report of the cases at Santiago de las 
 Vegas. I am delighted that you have taken charge 
 of the suppression of this outbreak. Of course, 
 you will soon stamp it out, if you can enforce your 
 regulations. I shall look forward with the great- 
 est interest to your work there. Please keep me 
 posted. I did not get your June Eeport, which I 
 should like to have very much. Apropos of the 
 outbreak 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 yellow 
 fever, of making a few observations on human 
 beings, which will be a valuable guide to us at 
 the present stage of our search for the parasite. I 
 sincerely hope that he can succeed in getting hold 
 of a few recently arrived immigrants for this pur- 
 pose. I especially ask your kind assistance in this 
 matter. I see that Gen. Wood has left Havana 
 so that I am afraid that Carroll cannot get any 
 money with which to pay the subjects of experi- 
 mentation. Have you any funds with which they 
 could be paid $1.00 per day ? I think that you said 
 that 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 
 
 89 
 
SANITATION IN PANAMA 
 
 his return by Sept. 20th, if possible. So that he 
 has but little time in which to accomplish the task 
 before. Still if he can draw blood from a few 
 undoubted cases and can get a few subjects, it 
 won't take him long to decide the point. I' wanted 
 to come very much, but I have work here which I 
 feel that I should not neglect. Else I should 
 have certainly come down. I have been intend- 
 ing to ask you whether, in dealing with y. f. in 
 Havana, this year, you have confined your work 
 to simply protecting the sick against bites and 
 destruction of mosquitoes; and have omitted all 
 disinfection of bedding and clothing. I sincerely 
 hope that this is true. I shall probably present, 
 with Carroll, a paper to the next meeting of the 
 American Public Health Association on the man- 
 agement and prevention of yellow fever, and I 
 would so like to be able to say that the great work 
 in Havana was accomplished without the disinfec- 
 tion of any bedding or clothing. Carroll leaves 
 New York, with Pvt. Springer, on Ward Line 
 leaving on Wednesday, August 6th. Pardon this 
 lengthy letter. Please present my kindest regards 
 to Mrs. Gorgas. Keep me informed of your 
 progress at S. de las Vegas. 
 
 Sincerely yours, 
 
 KEED. 
 
 The parasite has not yet been discovered. Dr. 
 Carroll proved by the experiments which Dr. Eeed 
 here refers to that the parasite of yellow fever is 
 sub-microscopic. 
 
 90 
 
CORRESPONDENCE WITH DR. REED 
 
 (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 child 
 twelve years old who had never been out of 
 Havana. Personally, I have not seen a case since 
 March, belonging to Havana, with which I was 
 perfectly satisfied as being yellow fever, but I 
 am more confirmed in my suspicions since we have 
 had the Santiago de las Vegas cases. 
 
 You recollect we bit some thirty-four subjects at 
 the time when I last wrote you without being able 
 to transmit the disease in a single instance. These 
 mosquitoes we tried to infect on some dozen of 
 these supposed Havana cases. 
 
 We all agreed that the Santiago de las Vegas 
 cases were yellow fever. While they were not 
 severe, they were well-marked cases of yellow 
 fever. "We bit one man with eleven mosquitoes. 
 He was a well-marked case, but not dangerously 
 ill at any time. These eleven mosquitoes have 
 since bitten seven subjects, six of whom have 
 gone down with yellow fever. Three have re- 
 covered and three died. Carroll will no doubt 
 give you details in these cases, and Guiteras will 
 publish the matter in detail. 
 
 I am very much disappointed. I had hope that 
 through the mosquito we had a means of giving 
 mild cases which would protect, but these cases 
 
 91 
 
SANITATION IN PANAMA 
 
 show that the severest form of yellow fever can be 
 transmitted 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 year 
 has 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 is 
 settled. The discovery that it is the mosquito 
 alone that conveys the disease will enable us to 
 manage it. 
 
 I cannot but think that the freedom of Havana 
 from yellow fever on the 24th of August, a thing 
 never before known, must be due to the fact that 
 we got the infected mosquito nearly every time. 
 The disease has been introduced freely from the 
 outside, and yet has not spread among our thirty 
 thousand non-immunes. I believe that our system 
 gets them nearly every time. I think wo will soon 
 have Santiago de las Vegas under control. We 
 are inspecting and keeping track of all the non- 
 immune travelers coming to Havana. They are 
 seen by one of our doctors every three days of 
 their stay in Havana, up to six. We have gotten 
 hold of several in this way, and the town is being 
 regularly gone over with the same system that 
 we have in Havana. 
 
 We had a case on the 20th from Las Vegas, but 
 it was from a part of that town that had not 
 been disinfected. I feel confident that we will 
 have no more cases from Las Vegas after Sep- 
 
 92 
 
CORRESPONDENCE WITH DR. REED 
 
 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 last 
 year, plus using the pyrethrum powder and oil 
 in the infected house and in all the neighboring 
 houses. Formaline was used in the infected room 
 and the clothing was sent to Las Animas Hospital, 
 and the patient quarantined. I did it because it 
 could not decrease the effectiveness of disinfection, 
 and would relieve me from criticism in case we 
 were not able to control yellow fever, and had as 
 much 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 how 
 they were coming out I might have discontinued 
 the disinfection of clothing long ago. But in 
 order that the cases may be reported as generally 
 as possible, I am doing everything that I think I 
 safely can to make the routine as little burdensome 
 to the people, as possible. In accordance with 
 this, I have this month issued an order that in 
 yellow-fever cases the only disinfection was to be 
 with pyrethrum; that the clothing was not to be 
 taken to Las Animas, and that after the fifth day 
 the patients were not to be quarantined or 
 screened. 
 
 I have been designated by the Military Governor 
 to represent the Department at the Public Health 
 Association next month at Buffalo, and also the 
 Board of Health at the meeting at Niagara which 
 is scheduled to occur on the 13th. I hope to see 
 you there if I go. If things are as quiet as they 
 are now, I will probably go; but if I have any 
 
 93 
 
SANITATION IN PANAMA 
 
 yellow fever on hand I would rather send some- 
 body else. 
 
 Yes, I agree with you. I think this yellow fever 
 work will reflect great credit upon our corps. Cer- 
 tainly the work of proving the mosquito to be the 
 transmitter of yellow fever is as important a piece 
 of work as has been done since Jenner's time, and 
 as far as the United States is concerned, probably 
 of more importance; and as yours was the guiding 
 hand in the whole matter, I hope that some suitable 
 reward will come to you, more substantial than the 
 general professional recognition which you are 
 now getting from all quarters. I am very happy 
 to shine in the more humble role of being the first 
 to put your discovery to extensive, practical appli- 
 cation. 
 
 Mrs. Gorgas joins me in kindest regards. 
 
 Very sincerely yours, 
 
 \V. C. GORGAS, 
 Major & Surgeon, U. S. A., 
 
 Chief Sanitarv Officer. 
 
 War Department, Surgeon General'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 already 
 written to me about the unfortunate termination of 
 
 9* 
 
CORRESPONDENCE WITH DR. REED 
 
 some of Guiteras' cases. I was very, very sorry 
 to hear of Guiteras' bad luck and can appreciate 
 fully his mental distress over this loss of life. 
 Perhaps, after all, the sacrifice of a few will lead 
 to the more effectual protection of the many. I 
 think that we had best look at the matter in this 
 light. That eleven mosquitoes could and did in- 
 fect six persons, causing the death of three, is in- 
 deed, very strong confirmatory evidence of our 
 observations of last fall and winter. I have been 
 particularly anxious to learn of your results at 
 Santiago de las Vegas, hoping to incorporate them 
 in a paper on the prevention of yellow fever, which 
 I hope to read at Buffalo ; but since the good news 
 comes that you will be there "in persona vera," you 
 can give the figures better than anyone else. I 
 will, however, show by chart, the occurrence of 
 yellow fever in Havana during the present year, 
 and would be so glad if you would give me your 
 cases and deaths for August. To Aug. 26th, you 
 report 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 would 
 not have been obtained by a less energetic and 
 enthusiastic Health Officer. You, therefore, my 
 dear Gorgas, deserve all manner of praise for your 
 thorough work. I hope that Carroll is meeting 
 with success. Please let me hear from you by re- 
 turn mail, if possible, about your August cases and 
 deaths. A line will do. With kindest regards to 
 Mrs. Gorgas, 
 
 Sincerely, your friend, 
 
 REED. 
 
 9$ 
 
SANITATION IN PANAMA 
 
 (10) 
 
 "War Department, Surgeon General's Office, 
 Army Medical Museum and Library, 
 
 Washington, October 3rd. 
 
 MY DEAR GORGAS I 
 
 I have been hoping to see you and Mrs. Gorgas 
 in Washington and wondered what you found at 
 Buffalo to keep you so long; but a letter from 
 Carroll just received, mentions your return to 
 Havana. So you have, indeed, given us the "glad 
 go-bye!" Well, as Columbia has just won from 
 Shamrock, I'll have to forgive you this time ! But 
 you 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 the 
 No. of cases and deaths for September, so that I 
 could have included them in our paper, but it is 
 too late now. Don't forget to keep me on your 
 exchange list. I had a letter from your brother in 
 answer to one I wrote you for which please give 
 him my best thanks. You were saying, if I re- 
 member, that you would like to have your former 
 assistants, Lyster and Shockley, back again. If 
 you haven't them, and still want somebody, I only 
 mention the fact that Asst. Surgeon Deverenx, 
 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 well 
 as an assistant. . . . Borden says that he has made 
 a very good assistant. You might have your eye 
 
 96 
 
CORRESPONDENCE WITH DR. HEED 
 
 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 with 
 you over your superb paper, and arguments with 
 Wadsin. Nothing could have been clearer, it 
 seems to me. I congratulate you upon being the 
 First Vice-President; I think you ought to have 
 been President but that matter had been arranged 
 beforehand as going to the retiring Treasurer, 
 who had held that office so long. Other names as 
 First Vice-President had been proposed to the 
 Committee, 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 deaths 
 for September. We have had a little focus about 
 the "Mercado del Vapor," but I think we have 
 squashed it. Our last case occurred Sept. 26th. 
 Ten days without a case, this time of the year, is 
 pretty good. But our general death rate took a 
 most remarkable drop. We had only 339 deaths 
 in September, a rate of 15.64 per thousand. 
 
 You had better move down to Havana with your 
 family. I am getting so that I am afraid to go 
 
 97 
 
SANITATION IN PANAMA 
 
 back to the United States and run all the risks of 
 infection and bad hygiene that you are constantly 
 subjected to in cities such as Washington, New 
 York, etc. 
 
 I looked into it carefully, and am positive that 
 there is no error in the figures. I don't believe it 
 is possible for a person to be buried in Havana 
 without my knowledge, and I know that these fig- 
 ures are correct. 
 
 Carroll seems to be hard at work; looks very 
 mysterious, and can't get him to tell anything. He 
 had better hurry up; yellow fever in Havana will 
 soon be a thing of the past. 
 
 I left Mrs. Gorgas and Aileen in New York, but 
 expect them to leave for Havana, Wednesday, 
 the 9th. 
 With kindest regards, I remain, 
 
 Yours very sincerely, 
 
 \V. C. GORGAS, 
 Major & Surgeon, U. S. A., 
 
 Chief Sanitary Officer. 
 Major Walter C. Eeed, 
 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. Of 
 course we did not know it at the time, but this case 
 marked the first conquest of yellow fever in an 
 endemic center; the first application of the mos- 
 quito theory to practical sanitary work in any 
 disease, 
 
 93 
 
CORRESPONDENCE WITH DR. REED 
 
 (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 very 
 much your kind words about my paper and my 
 selection for First Vice-President of the Associa- 
 tion. The latter was a very great surprise, as I 
 didn'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 more 
 satisfactory? Certainly five deaths in seven 
 months is a good record for the city of Havana, 
 in this year of our Lord 1901! I hope that you 
 no 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 really 
 don't blame you for being a little nervous about 
 your health when you come to the United States, 
 for you are certainly making Havana one of the 
 healthiest cities in the world. I think that I will 
 take your advice, come down and build me a house ; 
 that is, after I retire ! Remember me very kindly 
 to Mrs. Gorgas and your daughter. ... I will be 
 glad to get your monthly report for September. 
 
 With best wishes, 
 
 Sincerely yours, 
 
 WALTER REED. 
 
 99 
 
SANITATION IN PANAMA 
 
 (13) 
 
 War Department, Surgeon General's Office, 
 Army Medical Museum and Library, 
 
 Washington, Dec. 21, 1901. 
 
 MY DEAR OOEGAS:. 
 
 Many thanks for your October report. The 
 November report has not been received yet, but 
 hope to get it later. I got your kind letter of 
 Dec. 6th. Certainly the results for October and 
 November could hardly be beaten. J think that 
 we should thank Heaven and be satisfied. An- 
 other experimental ease of yellow fever! Look 
 here, Mr. Sanitary Officer, if you don't stop apply 
 ing stegomyia to willing Cjistilians, there will be 
 trouble yet! Carroll fairly grinned all over when 
 I read it to him! He wishes to be very kindly 
 remembered to you. I am glad that l>r. Kinlay 
 still finds his Tetragenus. Please remember me 
 to him. What a splendid paper that was of (iiii- 
 teras in American Mcdirhic! I was delighted 
 with it. Make my best regards to him, also, pi* 
 The weather here is so very cold that I long for 
 the balminess of the Cuban atmosphere. Why 
 men and women will persist in living in cold 
 climates is something that [ can't possibly under- 
 stand. Stay where you are. hon'f permit even 
 the 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 since 
 left the office. I must hurry home in an open 
 street-car and thereby chill my very marrow. My 
 best regards to Mrs. Gorgas. . . . 
 
 100 
 
CORRESPONDENCE WITH DR. REED 
 
 With all manner of greetings for a Merry Xmas 
 and happy 1902, believe me, 
 
 Sincerely, your friend, 
 
 KEED. 
 
 (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 French 
 Consul with my compliments. I was just about to 
 write to you, to ask at what time during 1901 you 
 omitted to disinfect bedding or clothing. I think 
 that you wrote that about August 15th, you no 
 longer required such disinfection, but I cannot find 
 your letter. Again : Can you not give me some of 
 the data with regard to your fight for control of 
 epidemic in Santiago de las Vegas? Did your 
 show by the prompt suppression of the 
 in that town that you were adopting the 
 right, measures? I have just been asked to write 
 an article for the English Journal of Hygiene, 
 setting forth our observations, as well as the work 
 of the Medical Department in Cuba, and I should 
 like to mention Santiago de las Vegas as well as 
 Havana, ( ji\ in-^ you, of course, full credit for the 
 results obtained. I haven't your December report 
 as yet. Please send me a copy of it. I never was 
 quite so busy in all of my life and sigh for the 3d 
 of April, when I can get this class off my hands. 
 
 101 
 
SANITATION IN PANAMA 
 
 How is your epidemic in Havana? How I would 
 like to run away from my present surroundings 
 and go on a "toot" with you and Kean! 
 
 Please let me hear from you promptly, as I 
 must prepare my paper by the end of February. 
 Eemember me very kindly to Mrs. Gorgas. . . . 
 Sincerely yours, 
 
 REED. 
 
 (15) 
 
 Havana, Cuba, January 22, 1902. 
 Major Walter Eeed, 
 
 Surgeon General's Office, 
 
 Washington, D. C. 
 MY DEAR REED : 
 
 Yours of January 14th received. The sending 
 of clothing and bedding for disinfection to Las 
 Animas, in yellow- fever cases, was stopped about 
 
 . The official order was 
 
 issued August 21, 1901. A\V hnvo a large disin- 
 fecting plant at Las Animas to which everything 
 of this kind is sent. When a house is disinfected 
 for diphtheria or any similar disease, the room it- 
 self is infected with formaline gas and washed 
 down with a bi-chloride solution "and all fabrics 
 and clothing of every kind are sent to the disin- 
 fection plant. Up to the time mentioned this had 
 been done in the case of yellow fever, but, bavini-; 
 become convinced that the mosquito was the only 
 way of transmitting the disease and that no good 
 could be obtained from this process, we stopped 
 this method. 
 
 From my experience here in municipal sanita- 
 
 102 
 
CORRESPONDENCE WITH DR. REED 
 
 tion, I think this is of the greatest importance, viz : 
 to put people to as little inconvenience and loss 
 as 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 fomites 
 causes a great deal of inconvenience and some 
 loss. 
 
 The all important matter in yellow fever is to 
 get your cases reported as thoroughly as possible 
 and this can only be done with the co-operation of 
 the people. I am therefore of the opinion that the 
 great element of our success was due to the fact 
 that we did away with the attempted destruction 
 of fomites. You can readily see how one unre- 
 ported case might start an epidemic. 
 
 The Santiago de las Vegas case is a very good 
 illustration of the efficiency of our methods in 
 stamping out a focus. Santiago de las Vegas is 
 practically a suburb of Havana, distant about 
 twelve miles with a considerable non-immune pop- 
 ulation, constantly having communication with 
 Havana. The infection of 1900 evidently re- 
 mained over. Some cases occurred in January, 
 some in June and more in July. The cases of July 
 were taken and the houses all gone over, and the 
 mosquitoes 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 considerable 
 appropriation and started a brigade systemati- 
 cally fumigating, block by block, around the in- 
 fected areas. With this we were successful and 
 got rid of the focus. This was the most difficult 
 disinfection we have attempted. The infection 
 
 103 
 
SANITATION IN PANAMA 
 
 had evidently got pretty widely spread and new 
 cases kept occurring outside of the area in which 
 we were working. I send you a few papers on the 
 subject. Please return them when you have fin- 
 ished as they form a part of our records on the 
 subject. 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. 31st. 
 MY DEAR GORGAS : 
 
 Your kind letter of January 22d was received a 
 few days ago. I am very much obliged for the 
 information concerning Santiago de las Vegas. I 
 have made a copy of several of the enclosed papers 
 and return them herewith with many thanks for 
 the opportunity of seeing them. I would like to 
 know in how many cases of y. f. since July 1, 1900, 
 you have omitted disinfection of clothing. llmv 
 many cases under observation in Havana since 
 that time? Tliere were five deaths I notice after 
 that date and these probably cover say twenty 
 cases. Can you give me the exact number of cases 
 by months for 1900 and 19011 I want to make a 
 curve for these years of cases to accompany my 
 next article to be published in the Journal of 
 Hygiene (English). . . . 
 
 104 
 
CORRESPONDENCE WITH DR. REED 
 
 Another thing. Can you possibly obtain from 
 Dr. Guiteras, some eggs of stegomyia and send 
 them to me dried on filter paper? I have no in- 
 sects nor eggs at present, and am so very anxious 
 to obtain some as soon as possible. 
 
 Kemember me very kindly to Mrs. Gorgas. 
 With best wishes, 
 
 Sincerely yours, 
 
 WALTER SEED. 
 
 (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. The 
 Army Examining Board of which I am a member 
 is not now in session, but undoubtedly will be set 
 at work just as soon as the school session ends, 
 April 3d, and I should venture the opinion that 
 the Board will remain in session until November 
 1st, except during a brief summer vacation in July 
 and 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 see 
 if I can't soften the hearts of some of the stoniest- 
 hearted members. ... I hear that you are going 
 to have a y. f. "picnic" down in Havana this month. 
 Talk "right from the shoulder" to those South 
 Americans, and make them begin the work of 
 exterminating the disease in their respective coun- 
 
 105 
 
SANITATION IN PANAMA 
 
 tries. I think that Mexico is alright on this ques- 
 tion. 
 
 
 
 Faithfully yours, 
 
 KEED. 
 
 (18) 
 
 War Department, Surgeon General's Office, 
 Army Medical Museum and Library, 
 
 Washington, Feb. 12, 1902. 
 
 MY DEAR GORGAS I 
 
 Just a line to say that I have your kind letter 
 of Feb. 6th, containing the information that I 
 so much wanted. I thank you very much for it. 
 I am trying very hard to put together an article 
 for the Journal of Hygiene, as I wrote you, but 
 between the class and other work, it's deuced hard 
 to accomplish a half hour's work on it daily. Did 
 you see Souchon's reply to Carroll and myself in 
 the Eecord for January 8th? ... If I can get a 
 little time, after awhile, I may reply to him. . . . 
 This should reach you in the midst of the meeting 
 of the Congress. Do, pray, persuade them to ac- 
 cept the mosquito transmission and change their 
 sanitation 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 you 
 are going to remain in Havana for awhile. You 
 should stay during the whole summer and fall. . . . 
 
 Good-bye. 
 
 x Sincerely yours, 
 
 REED. 
 
 106 
 
CORRESPONDENCE WITH DR. REED 
 
 (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 Ke- 
 port. What a glorious record! No wonder, my 
 dear boy, that you should grow eloquent, as you 
 did, in your closing paragraph. It made my heart 
 beat faster as I read it. You have done a splen- 
 did work in Havana, my dear Gorgas, one that 
 should always give you the greatest pleasure to 
 look back upon. You have my sincere admiration 
 and congratulations. We will really and truly 
 liar* to go on that Toot ivhen you land on your 
 native heath, once more! I But if I had my way, 
 you would remain in charge of sanitary matters 
 in Havana for another summer! I have told 
 Gen. Sternberg so. It would be such a ,pity 
 to have this splendid work all undone, for the lack 
 of 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, 
 
 EEED. 
 
 107 
 
SANITATION IN PANAMA 
 
 (20) 
 
 War Department, Surgeon General's Office, 
 Army Medical Museum arid Library, 
 
 Washington, May 14, 1902. 
 
 MY DEAR GORGAS I 
 
 I received your reprints and was very much 
 pleased with them and to know that you are doing 
 such good missionary work. Modification of 
 quarantine will come slowly but surely. Am de- 
 lighted to know that you will be here on your way 
 from Saratoga. . . . 
 
 So you have really applied stegomyia again to 
 y. f. ? Dear me! Haven't you had experience 
 enough? If you are going to do this thing imn-h 
 more, Carroll and I will join you on your way hack 
 to Havana. There are several problems to be 
 worked out, from a scientific point of view. . . . 
 Are you not a delegate to the Assoc. of Mill 
 tary Surgeons? I though that you were. If you 
 should arrive before May 28th, you could join us 
 in 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 the 
 occasion. . . . 
 
 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 
 
 108 
 
CORRESPONDENCE WITH DR. REED 
 
 down and write me that nice letter of congratu- 
 lation. Harvard did indeed do me very great 
 honor in conferring the degree of Master of Arts, 
 and the audience was so very enthusiastic that I 
 felt that Boston, at least, had some appreciation of 
 what 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 of 
 L.L.D! . . . 
 
 There is another way in which to look at this 
 matter. Instead of simply being satisfied to make 
 friends and draw your pay, it is worth doing your 
 duty, to the best of your ability, for duty's sake; 
 and in doing this, while the indolent sleep, you 
 may accomplish something that will be of real 
 benefit to humanity and worth more than all the 
 high places that could be bestowed by shrewd 
 politicians. Nor you nor I have reason to be 
 ashamed of our work of the past two years, nor 
 would we think of exchanging places with any of 
 the luckier members of the Corps. "Verbum sap" 
 I am having Mr. Meyers look up Panama and 
 Nicaragua literature. Do you want articles in 
 German and French, or only in English? How 
 shall they be addressed? 
 
 With warmest regards to Mrs. Gorgas, . . . be- 
 lieve me, always, 
 
 Your good friend, 
 
 REED. 
 
CHAPTER VIII 
 
 HISTORY OF YELLOW FEVER 
 
 ROM the dawn of history man has made some 
 attempt to prevent disease. He saw on all 
 sides evidences of the fact that he had suffered 
 from 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 evident 
 to his senses was attributed by him to spirits, or 
 to powerful gods. These spirits being superior 
 to himself in power, he attempted to propitiate 
 them by presents and prayers. These were his 
 first efforts at preventive medicine and sanitation. 
 He would try to drive off the evil spirits of dis- 
 ease with loud and disagreeable noises made by 
 tom-toms and similar instruments. He attempted 
 to prevent the ingress of these same spirits by 
 signs and incantations. The gods were looked 
 upon as beings influenced by the same love and 
 passions as himself, and he appealed to them with 
 
 no 
 
HISTORY OF YELLOW FEVER 
 
 supplications or bribes, as seemed likely to be 
 most effective. In his reasoning during this bar- 
 barous age concerning the cause of disease, he 
 was really nearer the truth than subsequently 
 during a much more refined age, or even up to the 
 middle of the nineteenth century. We now know 
 that spirits and gods do not directly cause disease 
 in 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 now 
 witnessed by our ancestors of three thousand 
 years ago, would probably seem perfectly natural 
 and proper. The fumigation of ships and build- 
 ings would seem a very proper mode of burning 
 incense to the hostile god who was causing yellow 
 fever. The modern man, his descendant, is burn- 
 ing the pyrethrum to kill the living spirit, the 
 mosquito, which he has found by experiment really 
 causes the disease. Our ancestor would accept as 
 a perfectly natural explanation the use of oil on 
 the stagnant waters if he were told that this was a 
 libation to propitiate the angry god who was in- 
 flicting on man malarial fevers. His descendant 
 is using the oil really to kill the living beings, mos- 
 quito larvae, which cause malaria. 
 
 As man advanced in intelligence and civilization 
 he threw aside his belief in spirits and numberless 
 higher beings as causes of disease among his fel- 
 
 m 
 
SANITATION IN PANAMA 
 
 lowmen. He now began to attribute disease to 
 abnormal conditions in the blood and tissues of the 
 body, caused by unfavorable environment, such as 
 filth, food, clothing, climatic conditions, etc. His 
 efforts for the prevention of disease during all 
 this period had little or no effect. It is probable 
 that through long ages the human race remained 
 stationary in numbers or increased very slowly, 
 due principally to the fact that men were unable 
 to affect favorably their sanitary condition, or to 
 ward off in any way the fearful epidemic scourges 
 that every now and then swept through the ranks 
 of mankind. 
 
 Up to the time of the discovery of America, 
 Europeans had been making no attempt whatever 
 to prevent dsease and with our present knowlt <hc 
 and point of view, we can see that any sanitary 
 attempt on their part would necessarily have 
 failed. They had an entirely wrong conception of 
 disease and an erroneous theory of its cause. The 
 mortality rates in most parts of Europe at this 
 time 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 was 
 so slight that it could not easily be measured. 
 Every now and then virulent epidemics would 
 sweep through Europe and carry off a large por- 
 tion of the population. The figures as given in 
 some of these epidemics are almost inconceivable. 
 
 112 
 
Concreted Ditch. Gatun. 
 
HISTORY OF YELLOW FEVER 
 
 For instance, it is stated by Hecker that the 
 epidemic of plague in the fourteenth century car- 
 ried off from Europe some twenty-five millions of 
 the population, and from China alone, thirteen 
 millions. That again, in the fourteenth and fif- 
 teenth centuries, millions of the population of 
 Germany and other countries were carried off by 
 the "sweating sickness." 
 
 Such instances of mortality could be adduced 
 ad infinitum. Leprosy in the fourteenth century 
 was more common in England than it is now in 
 Palestine, so common that every county had a 
 lazaretto where lepers were strictly confined, and 
 laws are still on the statute books prescribing the 
 method of their confinement, and the disposition 
 of their property. 
 
 The inhabitants of Europe at this time were 
 subject to all the contagious and infectious dis- 
 eases to which, with one or two exceptions, they 
 are now subject, but most of these diseases, for 
 some reason, were vastly more virulent than they 
 are 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 had 
 some diseases from which Europeans, up to that 
 time, had not suffered, and the Europeans, no 
 doubt, brought with them some diseases from 
 which the Indians had not suffered. Yellow fever 
 
SANITATION IN PANAMA 
 
 is a good example of the first, and syphilis of the 
 second. And this must necessarily have been the 
 case if we give a little thought to the matter. 
 
 According to generally accepted scientific be- 
 lief, the buffalo developed from the first created 
 cell from which we have all descended. If his 
 ancestry could be traced, the line would run 
 straight back to this first cell. But he developed 
 into the present buffalo in a limited area in North 
 America. The ox, at some period in the distant 
 past, branched off from the same line of descent 
 from which the buffalo came, yet he developed 
 into the present ox within a very limited area in 
 Central Asia. These animals were originally 
 native to a very small area of country, and this 
 seems to have been the case in the development of 
 all animal life. 
 
 The yellow-fever germ is primarily an animal 
 very much like the buffalo or ox, and must have 
 come from the first created cell just as did all 
 life, and must have developed as did other animals 
 in a very limited area or territory. Exactly the 
 same could be said of the tuberculosis germ. It 
 is, therefore, just as natural that the western 
 hemisphere should have had its peculiar diseases 
 as that it should have had its peculiar animals. 
 
 Everywhere that the European attempted to 
 colonize he suffered from disease, and this always 
 occurred within the first two or three years. In 
 
HISTORY OF YELLOW FEVER 
 
 Columbus' settlement on Santo Domingo, lie lost 
 within the first three years a very large number 
 of the colonists settled there. When the English 
 colonized Virginia at Jamestown, they lost from 
 disease about one-half of the total number of 
 colonists, and the same is true of the settlers at 
 Plymouth. Everywhere that settlements were at- 
 tempted, the settlers were so nearly destroyed by 
 disease that, in many instances, the few survivors 
 could 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 and 
 albuminuria, and in the graver cases by black 
 vomit and hematogenous jaundice. It is trans- 
 mitted from person to person by the female steg- 
 omyia mosquito. The sick person does not infect 
 the biting mosquito after the third day of the dis- 
 ease? One attack gives immunity against a sec- 
 ond attack. , 
 
 Like all other diseases, its origin is enveloped 
 in a cloud of obscurity. The yellow-fever organ- 
 ism, like the horse or the dog, developed in some 
 particular locality. The horse had his whole life- 
 time in which to wander from place to place, and 
 so spread very rapidly and widely as compared 
 with the yellow-fever organism. The yellow- 
 fever organism was dependent upon the mosquito 
 and man for his locomotion. On the average, he 
 
 115 
 
SANITATION IN PANAMA 
 
 had not more than a week in which to travel. I 
 presume 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 by 
 the life of the mosquito. For while the female 
 stegomyia mosquito has to live two weeks after 
 she has bitten the yellow-fever patient before she 
 can convey the disease to another non-immune 
 human being, still the average length of life in 
 the mosquito cannot be as great as this. The 
 various conditions of unfavorable environment, 
 the natural enemies of all kinds, wind, etc., must 
 kill a large proportion of mosquitoes within the 
 first week. If we consider the total number of 
 stegomyia mosquitoes in an infected locality, we 
 must see that only an infinitesimal proportion 
 succeed in biting a yellow-fever patient within the 
 first three days. This small proportion, however, 
 has the best protection and is more likely to have 
 a 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 from 
 the wind and sun, their greatest enemies. 
 
 In this other host, man, the parasite had only 
 three days to travel. During these three days the 
 man would be sick and not likely to move about 
 much. During man's savage state he traveled 
 very little more than did the mosquito. ~\Ye would 
 expect, therefore, the yellow-fever organism's 
 
 116 
 
HISTORY OF YELLOW FEVER 
 
 rate of spread to be very much less rapid than the 
 spread of the horse. 
 
 When America was discovered, the horse had 
 not yet reached that continent. The evidence 
 with regard to the yellow-fever organism seems 
 to me to indicate that, at this same time, it had not 
 spread further than a limited area about Vera 
 Cruz. It is probably the latest disease to which 
 man has been subject. 
 
 There are very many beliefs as to the locality 
 at 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 the 
 siege of Troy, and that the Greeks and Trojans 
 suffered severely from this disease during the 
 prosecution of the war. Mr. Augustin argues 
 quite forcibly in favor of the idea that many of 
 the great epidemics of Europe and Asia, before 
 and since the Christian era, were yellow fever. 
 He thinks that the population became immune 
 from the fact that all at some time suffered from 
 the disease, and thus, in the course of time, it 
 died out from want of material on which to feed. 
 I consider Mr. Augustin one of the most compe- 
 
 117 
 
SANITATION IN PANAMA 
 
 cent authorities that we have on the history of 
 yellow fever, and anyone writing on that disease 
 in any of its phases would do well to consult his 
 monumental work. 
 
 It seems to me, however, that the evidence is 
 against yellow fever having occurred in Europe 
 before the fifteenth century. If it had been gen- 
 eral in southern Europe, semi-tropical Asia Mi- 
 nor and semi-tropical Africa, it would be there 
 now, just as it is in similar localities in tropical 
 and semi-tropical America. If the Phoenicians 
 had suffered from yellow fever during the time 
 of Abraham, and the great epidemics of Smyrna, 
 Thebes, Athens, Eome and Carthago had Itccu 
 yellow fever, this disease would be in those coun- 
 tries now. History does not show that yellow 
 fever can immunize a whole country, but merely 
 the locality in which it prevails endemieally. 
 While the old inhabitant of Havana was immune 
 to yellow fever, the man from the interior of 
 Cuba where yellow fever had not been endemic 
 knew that he was just as liable to contract yellow 
 fever when he visited Havana as was the man 
 who came from the United States, and he feared 
 the disease just as much. 
 
 The native of the city of Panama was immune 
 to yellow fever, but the soldier coming from the 
 mountains of the interior knew that he would 
 catch the disease, and this actually occurred 
 
 118 
 
HISTORY OP YELLOW FEVER 
 
 many times whenever a fresh regiment was 
 brought to Panama. At present, Guayaquil in 
 Ecuador is the seaport of Quito, the capital of the 
 country. Quito is situated some three hundred 
 miles up in the mountains, and is connected by 
 rail with Guayaquil. Yellow fever is at present 
 endemic in Guayaquil and has been so for many 
 years. The old resident of Guayaquil is immune 
 to yellow fever, but the natives of Quito dread 
 Quayaquil as they do death. They never go there 
 when they can avoid it, and when they have to 
 visit the outside world, they remain in Quayaquil 
 just as few hours as will enable them to catch 
 their ship. And the fear is well founded. Very 
 many Ecuadorians of high position have lost 
 their lives from yellow fever contracted in pass- 
 ing through Quayaquil. But all these years of 
 endemicity of yellow fever in these cities, the in- 
 habitants of the respective countries in which 
 they 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 at 
 present. While the native of Memphis who la- 
 bored on the pyramids of Cheops would have been 
 immune to yellow fever, enough fresh material 
 from up the Nile would have continued coming 
 into Memphis to have kept the disease going. 
 
 119 
 
SANITATION IN PANAMA 
 
 And the hundred thousand men whom old Cheops 
 kept at work on his pyramids for twenty years 
 would have died in such numbers that he would 
 either have had to give up this work, or would 
 have exhausted the population of his kingdom; 
 but the interior of Egypt would never have be- 
 come immune any more than has the interior of 
 Cuba, or Panama, or Brazil in our own time. 
 
 Had Athens been subject to yellow fever in the 
 time of Alcibiades, yellow fever would certainly 
 be there to-day. All the citizens of the city of 
 Athens would have become immune, but a suffi- 
 cient number of Greeks would have been con- 
 stantly coming into the city from the interior to 
 have 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 the 
 original source of yellow fever. 
 
 Another theory of the origin of yellow fever is 
 that it originated in Africa and was carried to 
 America in connection with the slave trade. Next 
 to that of the origin in America, this is the most 
 generally accepted explanation. But the argu- 
 ments against this belief are unanswerable. 
 
 According to Lind, the first yellow fever that 
 appeared in Africa was in Senegal, in 1759. If 
 yellow fever had existed along the coast, it would 
 certainly have spread in the two hundred and 
 fifty years during which this coast had been oc- 
 
 120 
 
HISTORY OF YELLOW FEVER 
 
 cupied by Europeans since its settlement by the 
 Portuguese in the year 1415. As a matter of fact, 
 it was recognized many times in America before 
 it appeared in Africa. The American origin of 
 yellow 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 of 
 evidence points toward its having originated in 
 America at some period prior to its discovery by 
 Columbus. 
 
 Dr. Carlos Finlay, in a paper published in The 
 Climatologist, of Philadelphia, in July, 1892, 
 gives very clear proof that the disease existed in 
 America before the discovery by Columbus. It 
 seems to have been endemic in the neighborhood 
 of Vera Cruz, Mexico, and to have been very well 
 known to the Aztec authorities. The Govern- 
 ment, before the arrival of the Spaniards, had 
 many times caused a forced emigration from the 
 interior to the neighborhood of Vera Cruz, to re- 
 populate a country that had been depopulated by 
 an epidemic disease known to the Aztecs as "co- 
 colitzle." To induce them to stay, these people 
 were given many privileges, such as exemption 
 from taxation, etc. This cocolitzle was known 
 among the Mayos of Yucatan as "black vomit." 
 The Spanish historian, Father Lapey, gives a 
 very clear account of cocolitzle as it occured in 
 Yucatan in 1648. It is such a clear description 
 
SANITATION IN PANAMA 
 
 of yellow fever that I think it instructive to quote 
 from 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, that 
 in less than eight days the whole population of 
 the 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 patients 
 were taken with a most severe and intense head- 
 ache, and pains in all the bones of their bodies, so 
 violent that their limbs felt as if torn asunder, 
 or squeezed in a press. A few moments after the 
 pains, there came on a very intense fever, which 
 in most instances produced delirium, though not 
 in 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 in 
 the bones without any other symptoms. In the 
 majority the fever seemed to remit completely on 
 the third day; they would say that they felt no 
 pains whatever, the delirium would cease, the pa- 
 tients conversing in their full senses, but they were 
 unable 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, they 
 rxj tired. A great number did not pass the third 
 day, the majority died on the fifth, and very few 
 reached the seventh. The most healthy and ro- 
 bust of the young men were most violently at- 
 tacked and died soonest. When the laity began 
 to improve, the disease broke out among the 
 priests. Of the eight members of the Jesuit Col- 
 
 122 
 
HISTORY OF YELLOW FEVER 
 
 lege, six died; of our own order (Franciscan) 
 twenty died in the city. Almost all the heads of 
 institutions and persons of highest rank, both 
 ecclesiastics and seculars, were carried away by 
 the epidemic. The disease continued over the 
 whole country during the space of two years. 
 Few that then lived in this land, or visited it, in 
 the 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 who 
 were attacked by the peste in Yucatan, only few 
 had died, as compared with the adults. 
 
CHAPTER IX 
 
 GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 geographical limits of yellow fever, when 
 first encountered by the white man, were not 
 very wide. They were contained within a zone 
 limited on the north by the twentieth parallel of 
 latitude, on the south by the eighth, on the east by 
 the sixtieth meridian, and on the west by the one 
 hundredth. Practically, the disease was confined 
 to the shores of the Caribbean and the southern 
 shores of the Gulf of Mexico. Within these re- 
 gions it was practically endemic at the time Col- 
 umbus discovered America. The arrival of the 
 whito man with his sailing ships made the disease 
 much easier of transmission from place to place, 
 because man traveled much more frequently and 
 much farther, and also because sailing ships, with 
 their fresh-water tanks, bred the stegomyia ex- 
 tensively. Under these influences the endemic 
 area began slowly to spread. Toward the north 
 the endemic area never extended far beyond the 
 
GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 limits it occupied when Columbus made his first 
 voyage. Havana, in latitude 23, is the northern 
 endemic limit in the western hemisphere. This 
 is rather strange, as the city is located so near 
 the original endemic focus. The arrival of a con- 
 siderable number of non-immunes in a locality 
 is necessary for yellow fever to become endemic, 
 and this supply has to be fairly constant. Dur- 
 ing the first hundred years after the founding of 
 Havana, in 1511, the city was considered very 
 healthy. In 1G20, an epidemic of yellow fever 
 occurred, the disease having been introduced 
 from Panama (Porto Bello) by the treasure fleet 
 on its way to Spain. In 1649 another epidemic 
 occurred, which was extremely severe and spread 
 to many other towns of Cuba. This epidemic 
 lasted more or less until 1655. For a hundred 
 years 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 troops 
 from the North American colonies, the disease 
 again 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 the 
 name of "black vomit." It became endemic, and 
 did 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- 
 
SANITATION IN PANAMA 
 
 lish troops, and after their departure, to the fact 
 that the port was thrown open to general com- 
 merce, and to a continuous supply of immigrants 
 from Spain. 
 
 It would seem, then, that Havana, after remain- 
 ing in the epidemic area for some two hundred 
 and fifty years, finally, about the year 1762, 
 passed permanently into the endemic area. 
 
 Havana is the most northern point to which the 
 endemic area ever extended. Toward the south 
 the endemic area spread much farther from the 
 original endemic focus than on the north. AYhile 
 in distance from the original endemic area the 
 disease spread further south than north, it did 
 not in point of latitude. Eio Janeiro and Santos, 
 the furthest points south to which the endemic 
 area spread, are about latitude 23, much tho 
 same as Havana on the north. Para, Manaos, 
 Pernambuco and Bahia gradually came within the 
 endemic area, until finally, in 1849, yellow fever 
 took up its permanent habitat in Rio and Santos. 
 During the year 1850, forty-one hundred and 
 sixty persons died of yellow fever in Rio. 
 
 These cities, like Havana, were subject to epi- 
 demics of yellow fever years before they became 
 endemic centers. Endemicity did not spread 
 regularly over this area from north to south. 
 The disease became endemic in Rio thirty or forty 
 years before it did in Manaos. Other factors 
 
 126 
 
GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 proved more potent than location as to latitude. 
 The large emigration to Brazil, which set in about 
 the middle of the nineteenth century, gave a con- 
 stant and large supply of non-immunes to Eio, 
 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 eastern 
 coast of Brazil, about longitude 35 west, is the 
 point 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 on 
 the -west coast of Africa, from St. Paul de Lo- 
 anda on the south to the Canary Islands on the 
 north, yellow fever has been present all the time 
 at some point or points, ever since its introduc- 
 tion in 1494, though on this coast it has never 
 manifested itself continuously in the same town 
 or city for any considerable number of years. 
 But it is endemic on the coast in the sense that 
 it no longer has to be re-introduced from the 
 outside, but is always present at some point. We 
 have 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 ever 
 become endemic is its original home, Vera Cruz, 
 Mexico. It has been endemic at both Panama 
 and Guayaquil, on the west coast of America, 
 
 127 
 
SANITATION IN PANAMA 
 
 While these points are on the west coast, and 
 Vera Cruz is on the east coast, still, Vera Cruz 
 is some sixteen degrees of latitude west of either 
 Panama or Guayaquil. 
 
 The endemic limits of yellow fever at its period 
 of greatest extent would be defined by a line 
 drawn from Havana, commencing on the north, 
 to the Canary Islands, down the west coast of 
 Africa to Loanda, from Loanda west to Bio 
 Janeiro, Brazil, from Bio Janeiro to Guayaquil, 
 Ecuador, from Guayaquil to Panama, from Pan- 
 ama to Vera Cruz, Mexico, and from Vera Cruz 
 back to Havana, a very restricted area compared 
 with other infectious diseases. 
 
 But it is as an epidemic disease that it has 
 caused most alarm and loss. The United St.- 
 Spain, and the West Indies have suffered most 
 severely in this respect. It has been epidemic 
 as far north as Quebec in North America. In 
 1805, some fifty-five cases occurred among the 
 English troops stationed there. In Europe, it has 
 been epidemic as far north as Swansea, Wales. 
 In the year 1865, the sailing ship Hecla from 
 Cuba, introduced yellow fever into Swansea, 
 and twenty-two cases developed in the town in 
 persons who had no communication with the 
 vessel. 
 
 France has never had a yellow-fever epidemic 
 of any consequence, though it has been demon- 
 
 128 
 
GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 strated that under favorable conditions, the dis- 
 ease might become epidemic. At St. Nazaire, in 
 the year 1861, yellow fever was introduced by the 
 sailing 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 extended 
 further east. Leghorn is the most eastern point 
 to which yellow fever has ever reached. There 
 in 1804 a severe epidemic occurred in which some 
 two thousand persons died. 
 
 On the west coast of Africa epidemics have oc- 
 curred as far south as St. Paul de Loanda. The 
 island of Ascension, about the same latitude as 
 St. Paul but in the mid-Atlantic, has suffered 
 very severely. In 1823, the British sloop Bann 
 brought yellow fever from Sierra Leon to Ascen- 
 sion. Ninety-nine cases occurred on the Bann, 
 with thirty-four deaths, and on the island itself 
 twenty-eight cases occurred with fifteen deaths. 
 
 Yellow fever has been epidemic on the east 
 coast 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 as 
 Guaymas, Mexico. 
 
 The epidemic area of yellow fever has been 
 very much more extensive than the endemic area. 
 This epidemic area would then be bounded by a 
 line commencing on the north at Quebec, Canada, 
 
 129 
 
SANITATION IN PANAMA 
 
 extending east to Swansea, Wales; from Swan- 
 sea south to St. Nazaire, France; from St. Naz- 
 aire southeast to Leghorn, Italy; from Leghorn 
 south to Loanda, on the west coast of Africa; 
 from Loanda west across the Atlantic to the isl- 
 and of Ascension; from Ascension still west 
 across 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 to 
 Quebec. 
 
 By lines of latitude and longitude the epidemic 
 area would be bounded on the north by the forty- 
 fifth degree, north latitude; on the south by the 
 thirty-fifth degree, south latitude; on the east by 
 the tenth degree, east from Greenwich, and on the 
 west by the one hundred and tenth degree, west 
 from Greenwich. 
 
 In point of area its period of greatest extent 
 was during the first half of the nineteenth cen- 
 tury. Since the middle of the nineteenth century 
 its area has been decreasing rapidly, until at the 
 present time this disease is confined to a half 
 dozen centers in South America. 
 
 Within the epidemic area the loss of human life 
 from this disease has been very great, the United 
 States and Spain being the most populous coun- 
 tries affected. 
 
 South America lies generally well east of North 
 
 ISO 
 
GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 America, and its northern coast is about opposite 
 the southern part of North America, so that the 
 neck of land which connects the two runs east and 
 west and is known as the Isthmus of Panama. 
 Most of this isthmus is embraced in the present 
 Eepublic of Panama. 
 
 Columbus was the first white man to visit Pan- 
 ama. On his third expedition he entered the Bay 
 of Bocas del Toro, and spent some time there. 
 On this same expedition he also visited Limon 
 Bay, into which the northern end of the Panama 
 Canal at present empties. He also visited Porto 
 Bello, which afterwards became rich, famous and 
 populous, and which is located on the northern 
 extremity of the royal paved highway running 
 north from the old city of Panama. He left more 
 than one hundred men under his brother, Diego, 
 at Belen, some fifty miles west of the present 
 town of Colon. After several years of sickness, 
 hardships and deprivations, this colony was final- 
 ly destroyed by the Indians. Spain afterwards 
 ennobled Columbus' grandson, Luis, under the 
 title of Duke of Veragua, and granted to him a 
 large tract of land in the neighborhood of this 
 old colony, to which was given the name "Duke- 
 dom of Veragua." One of the provinces of the 
 Eepublic of Panama which covers about the same 
 area as did the tract referred to, is known as the 
 Province of Veragua. The old royal highway 
 
 131 
 
SANITATION IN PANAMA 
 
 just referred to, running between Panama and 
 Porto Bello, lies from five to fifteen miles east of 
 the Canal. Columbus' third voyage was made in 
 1498. A few years later, Balboa, with a party 
 of Spanish adventurers, under the authority of 
 the Captain-General from Santo Domingo, ar- 
 rived in the eastern part of Panama and made 
 permanent settlements, at first on the north 
 coast, and discovered the Pacific. 
 
 A few years later, in 1519, the city of old Pan- 
 ama was founded. Balboa was the best type of 
 the Spanish conquistador. He was brave, hardy 
 and determined, qualities very common to the 
 early Spanish adventurers, but Balboa was more 
 able and had much broader views of government 
 and colonization than either Pizarro or Cortez. 
 He was displaced as governor of Panama by 
 Pedrarias, a man inferior to him in every re- 
 spect. Balboa was beheaded by Pedrarias in 
 1517. He had heard of the Inca empire to the 
 south, and was getting together a fleet on the 
 south coast with the intention of invading tins 
 empire. Pedrarias became jealous of his power, 
 and feared he was getting together a force for 
 the purpose of overthrowing his government. As 
 far as historical data show, there was no reason 
 for this jealousy. 
 
 Tradition has it that the cause of the enmity 
 between Balboa and Pedrarias was due to the fact 
 
GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 that Balboa, being betrothed to the daughter of 
 Pedrarias, became involved in an affair with the 
 daughter of an Indian chief while absent on the 
 south coast building the fleet with which he hoped 
 to conquer the Inca empire. Pedrarias' daugh- 
 ter, hearing rumors of this affair, became very 
 jealous, and influenced her father's mind against 
 Balboa, even to the extent of having him behead- 
 ed. This is, however, probably pure romance. 
 
 The facts seem to be that Pedrarias, being a 
 narrow-minded man and jealous in disposition, 
 gradually became hostile to Balboa on account of 
 the latter's popularity with the Spanish colonists, 
 as well as with the Indians. Balboa, for a con- 
 quistador, was humane in his attitude toward the 
 Indians. For this reason Pedrarias began to 
 make charges against and quarrel with Balboa. 
 Pedrarias, being governor, had absolute power 
 in the Province of Panama, and Balboa, to be 
 successful in fitting out his expedition, knew that 
 he had to have the support of Pedrarias. In his 
 endeavor to placate him and insure his support, 
 Balboa married Pedrarias' daughter, a child of 
 six years of age. The marriage ceremony was 
 performed by proxy, Pedrarias' daughter being 
 absent in Spain. Balboa never saw his wife. 
 
 Pizarro was one of the lieutenants of Balboa, 
 though as an officer of Pedrarias' government 
 he was actually in charge of the party that ar- 
 
 133 
 
SANITATION IN PANAMA 
 
 rested Balboa. Balboa's death was a great loss 
 to Spain and to Panama. He would in all prob- 
 ability have made a much more humane con- 
 queror of Peru than did Pizarro, and certainly 
 would have made a much abler ruler of that coun- 
 try. He was beheaded at Acla, the capital of 
 Panama at that time, situated on the north coast 
 on Caledonia Bay. All trace of this town has 
 now disappeared. 
 
 Panama when first known to the Spaniards, in 
 the early part of the sixteenth century, was a 
 thickly inhabited country, peopled by a mild-man- 
 nered Indian population, who lived principally 
 by agriculture. Las Casas makes the statement 
 that during the twenty years in which Pedrarias 
 governed Panama he caused the death of three 
 million Indians. I am inclined to think this a 
 very great exaggeration, but it is evident from 
 the accounts one reads of Balboa's expeditions 
 that there was a considerable population in the 
 country. As day after day he makes marches 
 from town to town, Balboa describes getting sup- 
 plies from these towns, and that he was able to 
 procure from five hundred to a thousand porters 
 for carrying the baggage of the expedition. In 
 every town he secured some gold, and none but a 
 very populous country could have furnished the 
 supplies of men and amounts of gold which he 
 describes. 
 
 1M 
 
GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 The Eepublic of Panama is something over 
 half the size of the state of Alabama, containing 
 some 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 present 
 all the population of the Republic. The eastern 
 half has no population at all, with the exception 
 of a few wild Indians. In Balboa's time this east- 
 ern half was thickly populated, and contained 
 most of the inhabitants. Columbus looked upon 
 Panama as the richest portion of his American 
 discoveries, particularly from a gold-producing 
 standpoint, and the Spaniards generally shared 
 this opinion. This was such a widespread belief 
 that the country was known as Castilla del Oro. 
 
 The importance of Panama was vastly in- 
 creased by the discovery and conquest of the Inca 
 empire about 1530. Vast quantities of gold and 
 silver bullion passed through Panama on its way 
 to Europe. It seems to be an historical fact, 
 mentioned by Prescott and other Writers, that 
 Pizarro exacted from the Inca emperor, Atahu- 
 allpa, for his ransom, a room full of gold, the 
 dimensions of which are stated as being twenty- 
 two feet long, seventeen feet wide and nine feet 
 high. An adjoining room of somewhat smaller 
 dimensions Atahuallpa agreed to fill twice over 
 with silver. Such quantities of bullion were in- 
 troduced into Europe as had never before been 
 
 155 
 
SANITATION IN PANAMA 
 
 dreamed of, and prices rose to what was then con- 
 sidered an extraordinary figure. 
 
 The city of Panama became the commercial 
 metropolis of the western hemisphere. The high- 
 way between Porto Bello and old Panama became 
 a road over which there was a constant stream 
 of people traveling. All the merchants, officials 
 and colonists going to Peru, western Mexico, and 
 the Spanish possessions in the East Indies used 
 this route, and there was a steady and constant 
 stream of such people going between -the colonies 
 and mother country. 
 
 About the beginning of the seventeenth cen- 
 tury Panama was the chief port for the Spanish 
 trade of the Pacific. This large travel and large 
 business was fortunate for her from a commer- 
 cial point of view, but it was the cause of her evil 
 reputation as to health. Her location was in the 
 tropics, where the stegomyia mosquito could 
 breed freely all the year round. Yellow fever 
 was early introduced by the Spanish conquista- 
 dor. Then the constant stream of unacclimated 
 Europeans passing for four hundred years 
 through her borders made conditions ideal for 
 the development and maintenance of yellow fever. 
 And for four hundred years this region has been 
 known as the most unhealthy in Amerioa. 
 
 As Panama grew in wealth and importance, 
 and it became known what great amounts of 
 
 136 
 
GEOGRAPHICAL LIMITS OF YELLOW FEVER 
 
 treasure were passing through her borders, she 
 became attractive -to the English soldiers of for- 
 tune. Drake was one of the earliest of these, and 
 his name and fame are intimately associated with 
 the early history of Panama. He first came to 
 the north coast in 1572, and remained in the coun- 
 try nearly two years. He secreted his ships in 
 remote places among the beautiful San Bias 
 Islands, and it was not discovered by the Span- 
 iards just where he was. From this point he 
 made frequent expeditions against the various 
 Spanish 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 bitterly 
 hostile to the Spaniards, who, whenever they 
 could get hold of them, were their harsh and cruel 
 taskmasters. Consequently, the Indians were 
 friendly to the English whom they knew to be the 
 enemies of Spain. 
 
CHAPTER X 
 
 APPOINTED CHIEF SANITARY OFFICER FOR THE 
 ISTHMUS 
 
 ARLY in the year 1902, while still stationed at 
 Havana, I wrote to Surgeon-General Stern- 
 berg concerning the discoveries made by the Reed 
 Board, and the application made of these discov- 
 eries to the eradication of yellow fever in Havana, 
 and invited attention to the fact that they would 
 have a most important bearing upon the work of 
 the construction of the Panama Canal. 
 
 I invited General Sternberg's attention to the 
 enormous loss of life that had been caused among 
 the French working at Panama, due to tropical 
 diseases; that by far the most important of the 
 diseases were yellow fever and malaria; that if 
 we could protect our laborers on the Canal as \ve 
 had the people of Havana, we should be able to 
 build the Canal without anything like such losses 
 as had occurred to the French. I also invited his 
 attention to the fact that while there was a con- 
 siderable difference in the conditions and environ- 
 
 138 
 
APPOINTED CHIEF SANITARY OFFICER 
 
 ment at Havana, still I believed tliat tlie methods 
 worked out at Havana could be so modified as to 
 be applied successfully at the Isthmus. 
 
 General Sternberg approved the idea, and 
 recommended that, on account of my experience in 
 similar work at Havana, I be placed in charge of 
 the sanitary work on the Isthmus. 
 
 In all discussion with regard to canal construc- 
 tion at this time Nicaragua was looked upon as 
 the point where the United States would build its 
 canal. Delays entirely unexpected to the authori- 
 ties occurred on account of the failure of the treaty 
 with Colombia, and it was not until the fall of 
 1903 that it was settled that we were to build a 
 canal at Panama, under a concession from the Ee- 
 public of Panama. 
 
 I was relieved from duty at Havana in the fall 
 of 1902 and ordered to the United States, in order 
 that I might be in personal contact with the prepa- 
 rations for canal work on the Isthmus. "While 
 waiting for the organization to commence, I was 
 sent to Egypt as the representative of the Medi- 
 cal Department of the United States Army to the 
 first Egyptian Medical Congress, and I was di- 
 rected while on this duty to examine into what had 
 been 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 
 
 139 
 
SANITATION IN PANAMA 
 
 useful to us at Panama. The conditions were so 
 entirely different at the Isthmus of Suez from 
 the conditions at the Isthmus of Panama from a 
 sanitary point of view that there was no similarity 
 in the sanitary measures applicable to the two 
 places. The route of the Suez Canal was through 
 a dry, sandy desert, where, at the time of con- 
 struction, they suffered from neither yellow fever 
 nor malaria. The route of the Panama Canal lay 
 through a low, swampy country, alternating with 
 rugged mountainous regions, where the rainfall 
 was excessive, and yellow fever and malaria pre- 
 vailed to an alarming extent. 
 
 During my visit there, however, I found that they 
 were suffering severely from malaria at Ismalia. 
 a town on the canal about halfway across the 
 Isthmus, 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. They 
 were obliged to carry this on camel-back a number 
 of miles from the nearest branch of the Nile. I 
 was 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 the 
 Israelites, leading up from the Nile through the 
 land of Goshen. This old canal came within a 
 few miles of the present route of the Suez Canal. 
 
 no 
 
APPOINTED CHIEF SANITARY OFFICER 
 
 The French extended it to the Suez Canal, and 
 then made a small canal parallel with the route 
 of the Suez, which conveyed fresh water all along 
 this route. Wherever in the desert fresh water 
 is applied to the soil, the land becomes very fruit- 
 ful and productive. At Ismalia, this sweet-water 
 canal, just described (the Arabs usually refer to 
 fresh water as sweet water), was used for irriga- 
 tion purposes. When I saw the canal in 1902, 
 the town and neighborhood were covered with a 
 beautiful growth of trees and shrubbery, and 
 vegetation appeared on every side. Unfortu- 
 nately, the water which produced this wonderful 
 oasis in the desert also bred the malarial mosquito 
 freely and Ismalia had become a hotbed for 
 malaria. 
 
 Sir Ronald Ross, the great English sanitarian, 
 who had taken so prominent a part in discovering 
 that malaria was carried by the anopheles mos- 
 quito, was employed by the French Company to 
 advise them how they should protect themselves 
 against this plague. The plans which he advised 
 were carried into execution, and Ismalia in a 
 short time was entirely free from malaria. 
 
 When I returned from Egypt, I found the canal 
 project still being delayed. Pending organization, 
 I was sent to Paris, France, as the representative 
 of the United States Army Medical Department 
 to the Hygiene Congress which met in Paris in 
 
 141 
 
SANITATION IN PANAMA 
 
 October, 1903. I was directed to get while there 
 such sanitary information as might be obtained 
 from the Paris offices of the French Panama Canal 
 Company. Besides having a very agreeable and 
 delightful stay, I collected a great deal of valuable 
 data with regard to the sanitary conditions which 
 had existed under the French at Panama. 
 
 Finally, in January, 1904, the Isthmian Canal 
 Commission was organized by the President under 
 the Spooner Act. The President was very 
 strongly urged by the medical profession generally 
 to make a medical man one of the commissioners. 
 It was pointed out to him that sanitation at 
 Panama was fully as important as engineering; 
 that if our force suffered as much from disease as 
 had the French fifteen years before we should havo 
 great difficulty in ca'rrying through our project. 
 His attention was invited to the fact that in this 
 Commission of seven men, where the sanitary 
 phase of the work to be controlled by them 
 was just as important as the engineering phase, 
 there were five engineers and not a single phy- 
 sician. 
 
 The American Medical Association took a most 
 active part in urging this matter upon the atten- 
 tion of the President, and hundreds of telegrams 
 came in to him on this subject from all parts of 
 the country. The President was not convinced 
 by these arguments as they were presented to 
 
APPOINTED CHIEF SANITARY OFFICER 
 
 him, and organized the Commission of seven mem- 
 bers without putting a physician on it. 
 
 During the latter part of March, 1904, I was 
 ordered to accompany the Commission to Panama 
 as their sanitary adviser, and for the purpose of 
 drawing up a scheme of sanitation whereby the 
 force might be protected during the construction 
 of the Canal. I requested that Medical Director 
 John W. Ross, United States Navy, Major Louis 
 A. La Garde, Surgeon, United States Army, and 
 Major Cassius E. Gillette, Corps of Engineers, 
 United States Army, be detailed to assist me. 
 
 We went to Panama with the Commission, and 
 were absent on this trip about a month looking 
 into conditions and examining the locality. After 
 much study and careful consideration, we sub- 
 mitted a report which embodied the organization 
 which 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 we 
 made this visit. They treated us very hospitably, 
 and we were their guests during our stay on the 
 Isthmus. We were housed on the Atlantic side, 
 in the building known as the De Lesseps Palace. 
 There was, however, nothing palatial about this 
 building. It was simply a good, comfortable, 
 frame building, such as can be found on many of 
 
 143 
 
SANITATION IN PANAMA 
 
 the well-to-do plantations in our southern states. 
 De Lesseps is accused of having erected it at a 
 cost of more than $100,000. As I afterwards came 
 to be more familiar with the history of the French 
 regime at Panama, I found that this was on a par 
 with most of the other stories of French extrava- 
 gance on the Isthmus, and had no more foundation 
 in fact than many of the other tales that fill the 
 books of a few of our American writers concerning 
 the Canal, to the discredit of the French. 
 
 On one occasion we were invited across the 
 Isthmus to dine with the Administrator who was 
 in charge of the work. It is somewhat startling 
 to an inhabitant of the United States to contem- 
 plate traveling from the Atlantic to the Pacific 
 to keep a dinner engagement, but at Panama this 
 was not unusual. We not only left the Atlantic 
 in the afternoon and dined on the shores of the 
 Pacific the same evening, but we returned from 
 the Pacific and slept on the shores of the Atlantic 
 that same night. I was familiar with the history 
 of the house in which the French Director lived, 
 where we dined that night. I could not help re- 
 calling the sad story of Monsieur Dingier, the 
 great French Director, who first attempted canal 
 construction on the Isthmus. In this house had 
 died his wife, daughter and son-in-law, and scores 
 of other French engineers of prominence. The 
 French butler who waited on us at dinner that 
 
 144 
 
APPOINTED CHIEF SANITARY OFFICER 
 
 evening and presided over the servants who at- 
 tended us, remained with the Americans in the 
 same 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 Canal 
 Commission. 
 
 We spent a delightful evening, and returned to 
 the "North Sea" after dinner, reaching Colon 
 about one o'clock in the morning. An amusing in- 
 cident of our stay on the Isthmus occurred on our 
 return. One of the commissioners was sick, and 
 for this reason did not attend the dinner. In my 
 business of looking up sanitary matters at Colon I 
 had come to know the Mayor of the town quite 
 well. Much to my surprise I found him at this 
 late hour of the night awaiting our return. He 
 took me aside and told me in a whisper that the 
 Commissioner whom we had left behind sick had 
 appeared on the street most uproariously drunk, 
 had fought the Colon police to a finish, and was 
 at that moment in the Colon jail raising pande- 
 monium. The Mayor said that he had endeavored 
 in every way to keep the matter quiet and protect 
 the honor of the American Commission, but that 
 the Commissioner himself had been so noisy and 
 pugnacious that he feared the matter had gotten 
 pretty well noised about the town. 
 
 I was, of course, much chagrined at this account 
 of the Commissioner's conduct. I knew well his 
 
 14$ 
 
SANITATION IN PANAMA 
 
 reputation in the United States, and knew that he 
 had 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 sober 
 and abstemious gentleman as far as alcoholic 
 drink was concerned. 
 
 I took the Chairman of the Commission aside 
 and unfolded to him the astounding story which 
 the Mayor had just confided to me. We got into 
 a carriage with the Mayor and hurried to the jail. 
 As we neared this building our worst fears were 
 confirmed; pandemonium seemed let loose. We 
 could hear our honored Commissioner swear- 
 ing and shouting, to the great delight and 
 amusement of the crowd outside. We hurried 
 in to see what we could do with our friend. 
 Upon being ushered into the room in which 
 he was raising such an uproar, we found 
 that it was not the Commissioner, but one 
 of our clerks. He had developed delirium tremens 
 as the result of too much French hospitality, and 
 insisted that he was the Commissioner above men- 
 tioned. The Mayor was never quite convinced 
 that this was not the case. The Commissioner 
 rather rose in the estimation of the townspeople, 
 as being a jolly good fellow, but the Mayor always 
 thought that he had carried things a little too far 
 for a man occupying such a dignified position. 
 
 In April, 1904, I was finally ordered to report 
 
 146 
 
APPOINTED CHIEF SANITARY OFFICER 
 
 to the Commission as the chief sanitary officer for 
 the Isthmus. Having been there, we had a very 
 good idea of how great the difficulties would be in 
 getting either supplies or personnel. We there- 
 fore requested the Commission to authorize our 
 taking down a certain number of men and a certain 
 quantity 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 Isthmus 
 early in June, 1904. 
 
 As I have before stated, when we visited the 
 Isthmus in March, 1904, the French were still in 
 possession of the property and we were their 
 guests. On May 4, 1904, the property was for- 
 mally transferred to the representatives of the 
 United States, so that when we reached the 
 Isthmus in June we were at once able to take pos- 
 session of such sanitary equipment as there was, 
 and to begin our organization. 
 
CHAPTER XI 
 
 PRELIMINARY ORGANIZATION AND WORK AT PANAMA 
 
 ROM the very beginning insuperable difficul- 
 ties arose in the way of getting supplies. 
 Very little could be obtained on the Isthmus, and 
 the supply departments in the United States were 
 so slow in being organized that, during the first 
 year, very few requisitions that were sent to the 
 United States were filled. 
 
 The attempt of the first Commission to manage 
 from Washington the work at Panama in all its 
 details was fatal, and the arrangement whereby 
 the Sanitary Department was made one of the 
 bureaus of the Government, having no access to 
 the Chairman, the real executive, except through 
 the Governor, was equally fatal. In June, 1904, 
 however, we all commenced work with a great deal 
 of enthusiasm, determined to do the best we could 
 under the circumstances. 
 
 The $50,000 worth of supplies taken down, and 
 the personnel brought along at the same time, en- 
 
PRELIMINARY ORGANIZATION 
 
 abled us to make a good start in all branches of 
 the Sanitary Department, as outlined in the recom- 
 mendations made in March. If it had not been 
 for the supplies and personnel taken down at this 
 time, we could have made no better showing than 
 did 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 sanitation 
 with which we had to deal. We appreciated that, 
 if the Americans were subject to this disease to 
 any considerable extent, we should have great 
 difficulty in keeping them at Panama, and in order 
 to induce them to stay, we should have to increase 
 wages to such an extent that the cost of the work 
 would be very greatly increased. That even if we 
 should find a white American force which would 
 be willing to stay, and if we could afford to pay 
 sufficiently high wages to induce them to stay, 
 Congress, in all probability, would not sanction 
 the continuance of the work, if we lost from yellow 
 fever fifteen or sixteen hundred Americans every 
 year. 
 
 From the best statistics which I could get on 
 the Isthmus, I found that the French lost yearly 
 by death from yellow fever about one-third of 
 their white force. If we lost in the same ratio it 
 would give us about thirty-five hundred deaths 
 among our Americans yearly. We, therefore, dur- 
 
 149 
 
SANITATION IN PANAMA 
 
 ing the first year made yellow fever the first con- 
 sideration, and gave it the most attention. 
 
 The two principal foci of infection for yellow 
 fever 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 Pacific 
 Ocean. 
 
 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 lay 
 in the killing of infected mosquitoes by fumigation. 
 So when we commenced work in the city of Pan- 
 ama, we relied principally upon this method. We 
 carried fumigation in Panama, however, much fur- 
 ther than we had ever dreamed of doing at 
 Havana. Beside carrying out the method which 
 we had developed at Havana of fumigating the 
 house where a case of yellow fever had occurred, 
 together with all the contiguous houses, we 
 adopted the following plan. 
 
 Panama compared with Havana was a very 
 small town. Havana in 1904 had a population of 
 250,000; Panama, about 20,000. Instead of wait- 
 ing for the slow process of fumigating the house 
 where a yellow-fever case occurred, with the con- 
 tiguous houses, and thereby killing the infected 
 mosquitoes concerned in that particular case, we 
 ought to be able, we said, in a small town like 
 Panama to fumigate every house in the city within 
 
 150 
 
Screened Yellow-fever Ward. Ancon Hospital, Panama. 
 
 St. Charles Ward, Ancon Hospital. Building in Which 
 Twelve Hundred Frenchmen Died of Yellow Fever. 
 
PRELIMINARY ORGANIZATION 
 
 a comparatively short time, and thereby get rid 
 of all the infected mosquitoes at one fell swoop. 
 
 This would certainly have been the result if our 
 premises had been correct, namely, that it was the 
 fumigation that had caused the disappearance of 
 yellow 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 month 
 to get over the whole town. Cases of yellow fever 
 still continued to occur after we had finished. We 
 therefore went through the procedure a second 
 time. Still other cases occurred, and we went 
 over the city a third time. We used up in these 
 fumigations in the course of about a year some 
 hundred and twenty tons of insect powder, and 
 some three hundred tons of sulphur. These quan- 
 tities of material give some idea of the amount of 
 fumigation. 
 
 This draft of one hundred and twenty tons of 
 insect powder represented the whole supply of 
 the United States for a year, and we actually used 
 up at Panama all the insect powder that could be 
 found in the market of the United States. 
 
 An interesting incident occurred during this 
 first year with regard to insect powder. Knowing 
 that there would be some yellow fever to be dealt 
 with in Colon and Panama, we estimated and 
 made requisition for eight tons of insect powder. 
 The reviewing authorities were very much shocked 
 
 151 
 
SANITATION IN PANAMA 
 
 and surprised at the size of our requisition, and 
 seized upon this one item of eight tons of insect 
 powder to demonstrate the wildness of our esti- 
 mates. It was some satisfaction to us for the 
 Commission to see that we had not only not been 
 wild and extravagant in our estimates, but that 
 we had been obliged to use actually fifteen times 
 as 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 sanitary 
 authorities urged upon them more extensive 
 preparation and larger expenditure, they thought 
 us visionary and more or less lost confidence in 
 us. This was very unfortunate both for the sani- 
 tary authorities, and for the Commission, and 
 came very near being the cause of the complete 
 collapse of sanitation. 
 
 General George W. Davis, the governor, was the 
 only member of the Commission who lived con- 
 tinuously on the Isthmus. He was the only mem- 
 ber of the Commission who had any adequate idea 
 of the difficulties with which the Sanitary Depart- 
 ment was confronted. He gave us his heartiest 
 support. 
 
 Our force of unacclimated whites liable to yellow 
 fever rapidly increased during the winter of 1904 
 and spring of 1905. Yellow fever increased with 
 still greater rapidity. The authorities became 
 
 152 
 
PRELIMINARY ORGANIZATION 
 
 more and more alarmed. In January, 1905, the 
 first Commission was asked to resign, and a new 
 Commission was appointed. 
 
 Even after this change the Sanitary Depart- 
 ment was in no better condition than it had been 
 under the former Commission. The chief sani- 
 tary officer was still subordinate to the governor 
 of the Canal, and had no means of access to the 
 chairman, except through the governor. Such 
 sanitary measures were carried through the im- 
 portance of which the chief sanitary officer could 
 impress upon the governor. Those, the impor- 
 tance of which the governor could not see, were 
 with great difficulty carried into effect. 
 
 This condition of affairs was unfortunate. The 
 authorities had no sanitary training, and as they 
 looked upon the ideas of the sanitary officials with 
 regard to the method of conveyance of yellow 
 fever by the mosquito as being wild and visionary, 
 they could not be expected to have rose-colored 
 views as to what would be the results of attempt- 
 ing to carry these views into effect. 
 
 The sanitary authorities had no doubt of their 
 ultimate success, and felt confident that they could 
 eradicate yellow fever in Panama, as they had 
 just done in Havana, if they could only hold on 
 long enough and get reasonable support from the 
 superior authorities. 
 
 Conditions with regard to yellow fever kept go- 
 
 153 
 
SANITATION IN PANAMA 
 
 ing from bad to worse during the first six months 
 of 1905. In April, 1905, several of the higher 
 officials died of yellow fever. This caused wide- 
 spread panic among the whites, and very great 
 demoralization to the work itself. A considerable 
 sprinkling of our white force had either been in 
 Cuba with us, or knew what had been accomplished 
 there with regard to yellow fever, but the rank 
 and file of the men began to believe that they were 
 doomed just as had been the French before them. 
 
 Finally, in June, 1905, the Governor and Chief 
 Engineer, members of the Executive Committee 
 of the Commission, united in a recommendation 
 to the Secretary of "War that the Chief Sanitary 
 Officer and Dr. Carter and those who believed 
 with 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 regard 
 to the cause of yellow fever, and no practical 
 methods even for carrying these ideas into exe- 
 cution. 
 
 Fortunately for the cause of sanitation, the then 
 President of the United States had been in office 
 when the work at Havana had been done by us. 
 He told the Commission that the mosquito theory 
 had been established beyond peradventure ; that 
 its application had been entirely successful at 
 Havana, where yellow fever had been more firmly 
 
 IM 
 
PRELIMINARY ORGANIZATION 
 
 established and established for a longer time than 
 at Panama. He declined to sanction the change 
 recommended, and directed that every possible 
 support and assistance be extended to the sanitary 
 officials. It was really fortunate for the sanitary 
 work that matters were brought to a head in this 
 way. 
 
 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 caused 
 by the resignation of the former Chief Engineer. 
 From his arrival on the Isthmus Mr. Stevens 
 expressed confidence in the Sanitary Department, 
 and gave us his undivided support. The moral 
 effect of so high an official taking such a stand at 
 this 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 on 
 the Isthmus owes to this gentleman for its sub- 
 sequent success. 
 
 During the fall of 1905 the Chairman of the 
 Commission recommended that the Sanitary De- 
 partment be made an independent bureau, report- 
 ing directly to himself. This enabled the chief 
 sanitary officer to make known directly to the 
 chairman 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 sanitary 
 
 155 
 
SANITATION IN PANAMA 
 
 efficiency on the Isthmus, and more sanitation was 
 done at this time than during any other period of 
 the construction of the Canal. 
 
 During the fall of 1905 yellow fever rapidly 
 decreased, and by November, the last case of this 
 disease had occurred in Panama. This fact 
 quieted alarm on the Isthmus, and gave the sani- 
 tary officials great prestige, not only among the 
 now large body of Canal employees, but also 
 among 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 halcyon 
 days for the Sanitary Department. It was really 
 during this period that our work was accom- 
 plished. By the fall of 1907 about all of our 
 sanitary work had been completed. Our fight 
 against disease in Panama had been won, and 
 from that time on our attention was given to hold- 
 ing what had been accomplished. 
 
 One more case of yellow fever occurred in Colon 
 during the following May, but since May, 1906, 
 now more than eight years, not a case of yellow 
 fever has originated on the Isthmus. 
 
 It is interesting to speculate upon what might 
 have been the result if the recommendation in 
 regard to changing the sanitary officials had been 
 carried into effect. At that time, in June, 1905, 
 most of the physicians who had had experience 
 with yellow fever had not been won over to the 
 
 156 
 
PRELIMINARY ORGANIZATION 
 
 truth of the theory of its transmission by the mos- 
 quito. It was reported on the Isthmus that one 
 of the most prominent and ablest of these physi- 
 cians, who did not believe that the mosquito trans- 
 mission of yellow fever had been proved, and 
 who was convinced that he himself had controlled 
 yellow fever acting upon the filth theory of its 
 causation, had been settled upon as my successor. 
 Had this been the case he would undoubtedly have 
 stopped mosquito work and devoted his attention 
 entirely to cleaning up, as is indicated by the 
 filth theory of the causation of the disease. He 
 would have been the more inclined to this course, 
 as it accorded with the beliefs and prejudices of 
 the authorities on the Isthmus. 
 
 This would probably have been kept up for two 
 or three years, and there is no reason for believing 
 that our condition on the Isthmus in 1908 would 
 have been any better than was that of the French 
 at the height of their work, when they were hav- 
 ing a death-rate of 250 per thousand per year of 
 their employees. 
 
 It would apparently have been demonstrated 
 that nothing could control yellow fever on the 
 Isthmus, and the belief then generally held that 
 it was the most unhealthy place in the world would 
 have been still further confirmed. And while it 
 is probable that eventually the mosquito theory, 
 of yellow fever would have become established 
 
 157 
 
SANITATION IN PANAMA 
 
 somewhere else, its apparent failure at Panama 
 would have given it a blow from which it would 
 have taken years to recover. 
 
 It seems singular that, after the demonstration 
 at Havana, there should have been any doubt in 
 the mind of anyone with regard to the mosquito 
 transmission of yellow fever. 
 
 Moreover, the reputation of Dr. Carter, Dr. 
 Eoss, Mr. Le Prince and myself, as sanitary 
 officials, would have been irretrievably ruined. 
 We took a tremendous risk and came very near 
 failing from causes hinted at in the foregoing 
 pages. 
 
 Even if the dangers had been as groat as they 
 were under the French, and the deaths as numer- 
 ous, I believe we would have found a sufficient 
 number of men who were willing to go to tho 
 Isthmus, just as did the French. Thoro is nlways 
 a certain element which is attracted by daimvr 
 and adventure, and to whom exposure to risk is a 
 sufficient reward for their labor. This character- 
 istic I have always found particularly strong 
 among the Americans. But if we had lost from 
 disease thirty-five hundred of our Americans 
 every year (for the French lost in about this 
 ratio), I am inclined to think that public opinion 
 would not have backed any work involving such 
 loss of life, and that Congress would not have 
 made the appropriations for continuing the work. 
 
 108 
 
CHAPTER XII 
 
 YELLOW-FEVER WORK AT THE ISTHMUS 
 
 AT the same time that yellow-fever work was 
 commenced, an attack was also made upon 
 malaria. Mr. Joseph L. Le Prince, who was in 
 charge of similar work in Havana, was placed in 
 charge of this work. 
 
 The anti-malarial work in the towns of Colon 
 and Panama was exactly similar to that in the 
 city of Havana. But the country along the line 
 of the Canal between the two termini, Colon and 
 Panama, was entirely different, and the problem 
 was much more extensive than it had been in 
 Havana. 
 
 The anopheles, the malarial mosquito, is peculi- 
 arly a country mosquito. In general, he likes 
 clear, fresh water in which grass and algae are 
 plentiful, such as is found along the banks of the 
 small mountain streams of Panama, or the fresh 
 water ponds and pools. The grass and algae give 
 protection to the larvae from the fish. Wherever 
 
SANITATION IN PANAMA 
 
 the small fish can easily gain access, there mos- 
 quitoes cannot breed. 
 
 For the purpose of looking after malaria along 
 this fifty miles of country district, the region was 
 divided into twenty-four sanitary districts, known 
 as Panama, La Boca, Ancon, Corozal, Miraflores, 
 Pedro Miguel, Paraiso, Culebra, Empire, Las Cas- 
 cadas, Bohio, Matachin, Gorgona, Juan Grande, 
 San Pablo, Tabernilla, Frijoles, Largarto, Lion 
 Hill, Gatun, Mount Hope, Colon, Nombre de Dios 
 and Toro Point. Some years after, when the rail- 
 road was being relocated, we had an additional 
 sanitary district, embracing the town of Lirio and 
 a working force in that neighborhood for several 
 miles up and down the road. Later, a quarry was 
 established at the old city of Porto Bello, for the 
 purpose of getting stone for the Gatun locks, and 
 here we had another sanitary district. 
 
 Porto Bello is about twenty miles north of 
 Colon, on the Caribbean Sea, and in our time was 
 accessible to Canal employees only by water. It 
 was 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 road 
 had become entirely overgrown and was impass- 
 able even to a man on foot. It was originally well 
 paved and well graded. I spent a great deal of 
 time in trying to cross the Isthmus on this road, 
 and succeeded in getting as far north from Pan- 
 
 160 
 
YELLOW-FEVER WORK AT THE ISTHMUS 
 
 ama as San Juan, a town of about one thousand 
 inhabitants, on the Pequini Eiver, and on the 
 royal road about half-way across the Isthmus. 
 There had been some travel between this town 
 and Panama which had kept the royal highway 
 sufficiently 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 on 
 the road from San Juan to Porto Bello. 
 
 Porto Bello has a /beautiful landlocked harbor, 
 decidedly the best for hundreds of miles up and 
 down 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 for 
 several 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 to 
 get up steam and go to sea on account of the 
 severity of these northers. The harbor of Porto 
 Bello is entirely protected from these northers by 
 a mountain which runs out into the sea. Behind 
 this mountain is a spacious and deep harbor. 
 
 About the beginning of the seventeenth century 
 Porto Bello enjoyed one of the largest export 
 trades in the then commercial world, though it 
 was never a very populous town in its halcyon 
 
SANITATION IN PANAMA 
 
 days, probably not having more than fourteen 
 or 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 population 
 dropped to a couple of thousands. 
 
 Professor William K. Shepherd, of Columbia 
 University, estimates that the bullion shipped 
 from Porto Bello amounted to about forty-two 
 million dollars ($42,000,000) per year. If we take 
 into account the value of gold then as compared 
 with the present time, we can see that the export 
 commerce of Porto Bello during the sixteenth cen- 
 tury and early seventeenth was very little under 
 two hundred million dollars ($200,000,000) per 
 year. 
 
 Porto Bello had such a reputation for bad health 
 that merchants, shipmasters, sailors and every- 
 body got away as soon as possible after the fair 
 was over. Indeed, I have seen it stated that it 
 was the health conditions that limited the length 
 of the fair; that the shipmasters would stay as 
 long 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 decree 
 when the Spaniards abandoned Nombre de Dios, 
 a town on the Caribbean coast about twenty miles 
 east of Porto Bello. Porto Bello was strongly 
 
 162 
 
YELLOW-FEVER WORK AT THE ISTHMUS 
 
 fortified by the Spaniards. Four different large 
 and extensive stone forts were erected at various 
 points about the harbor. These masonry struc- 
 tures were considered very strong for their day, 
 and were well armed and well manned. One of 
 the largest was built well up the side of the moun- 
 tain which formed the protection for the harbor on 
 the north, and where we afterwards established 
 our quarry, above referred to. 
 
 Drake in his last expedition attempted to cap- 
 ture Porto Bello. He was repulsed in his attempt 
 to storm the forts, but succeeded in capturing the 
 Spanish 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 body 
 in the flagship of the Spanish fleet, took the ship 
 to the mouth of the harbor and there scuttled her. 
 The island at the mouth of the harbor is still 
 known locally as Drake's Island. I cannot imag- 
 ine a more appropriate burial place for Drake 
 than this spot, nor a more fitting tomb than the 
 Spanish flagship. For this was the scene of some 
 of his greatest triumphs over the Spaniards. 
 
 Morgan, about seventy years later, succeeded in 
 storming the forts and capturing the town, and 
 Admiral Vernon again captured it in 1730. 
 
 In its prosperous days Porto Bello was every 
 fall the scene of the great fair. This was one of 
 the great fairs of the world. The merchants from 
 
 163 
 
SANITATION IN PANAMA 
 
 Spain and Europe, Cuba and Santo Domingo 
 brought their goods to Porto Bello, and at the 
 same time the Spanish treasure fleet collected here 
 for the purpose of starting on its trip to Spain. 
 The merchants from Peru and all the western 
 coast of South America, the western coast of 
 Mexico and the Philippine Islands collected here 
 for the purpose of purchasing from and exchang- 
 ing with their confreres from the east. All the 
 bullion, gold, silver and precious stones which had 
 been collected at Panama during the year from 
 these same places was now brought on pack mules 
 across the Isthmus on the royal highway, and 
 placed 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 north 
 from Panama to Cruces on the Chagres River, and 
 from 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, in 
 ordinary times, was willing to take. these chances, 
 but when it came to the Imperial treasure collected 
 for a whole year, and to the whole year's supply 
 of merchandise, they would not risk the attack 
 of the buccaneers, but came across the old high- 
 way. 
 
 Porto Bello rapidly lost its importance after 
 the revolt of the Spanish colonies in the early part 
 
 16* 
 
YELLOW-FEVER WORK AT THE ISTHMUS 
 
 of the nineteenth century. There was no longer 
 any treasure tribute to be shipped to Spain. The 
 building of the railroad in 1855 entirely deprived 
 Porto Bello of the little importance left it by the 
 Spanish colonial revolution, and when we first 
 occupied it, we found nothing but a fishing village 
 of a couple of hundred natives, who lived by fish- 
 ing and some agriculture. There was a very 
 marked contrast between the squalid native and 
 the carved stone building which made his resi- 
 dence. The walls of many of the public buildings 
 and some of the more opulent private buildings are 
 still standing, and are used by the natives. And 
 the frowning old forts are in an excellent state of 
 preservation. 
 
 We placed a large force here which worked the 
 quarry. At first our malarial rate was exces- 
 sively high, but in a very few months malaria was 
 controlled and the force here got along about as 
 well as at the other places of employment. It was 
 always the case that when our forces occupied a 
 locality, for the first three or four months the 
 malarial rate was high. Of course we could have 
 avoided this if we had been notified two or three 
 weeks beforehand and had sent up a sanitary force 
 to do preliminary work, but such notification was 
 not always possible in the exigencies of construc- 
 tion work. 
 
 Porto Bello at first gave us considerable anx- 
 
 165 
 
SANITATION IN PANAMA 
 
 iety ; we knew its ancient history, and feared that 
 we might not be able to control disease there. But 
 the difficulties appeared no greater there than at 
 several other points occupied by us. 
 
 Our laborers and working forces occupied the 
 side of the mountain on the north side of the bay 
 opposite the old town of Porto Bello, and the 
 quarry was worked first where the old fort stood. 
 We soon found that our employees were so much 
 in the town of Porto Bello that they contracted 
 malaria there, and that though we were able to 
 control it in our own village on the mountain side, 
 we could not prevent our people from contracting 
 malaria from the natives in the town of Porto 
 Bello. The town was located outside the Canal 
 Zone, in the jurisdiction of the Republic of Pan- 
 ama. We therefore requested the Panaman Gov- 
 ernment to appoint the chief sanitary officer the 
 health officer of the town of Porto Bello. It had 
 been generally agreed that wherever it was neces- 
 sary for the protection of the health of the Canal 
 employees the Panaman Government would sur- 
 render this authority to the chief sanitary officer 
 of the Isthmian Canal Commission. 
 
 We introduced the same health measures as in 
 the other sanitary districts, which we expect soon 
 to describe, and in a few months had malaria here 
 completely under control. Porto Bello was lo- 
 cated well within the San Bias country. Though 
 
 166 
 
YELLOW-FEVER WORK AT THE ISTHMUS 
 
 the inhabitants of the town were Panamanians and 
 recognized the authority of the Bepublic of Pan- 
 ama, all of the Kepublic east of this point, in 
 area about one-half of the state of Panama, 
 was entirely uninhabited, except by a few 
 San Bias Indians, not more than thirty thousand 
 all 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 Porto 
 Bello. They carried on their trade as far east 
 as the Gulf of Atrato, and the city of Cartagena, 
 in Colombia. There was, therefore, a probability 
 of the introduction of infectious disease to the 
 Canal Zone by this route. 
 
 To protect ourselves against this disease we had 
 to establish a quarantine station at Porto Bello. 
 The Panaman Government was asked to appoint 
 the chief sanitary officer of the Canal Zone quar- 
 antine officer for the port of Porto Bello. This 
 they promptly did. 
 
 The San Bias Indians who inhabited this coun- 
 try east of Porto Bello, are a peculiar and inter- 
 esting people. This was the region first occupied 
 by Balboa and his Spanish companions. They 
 found here a pretty dense population of Indians, 
 Carib in language and probably in descent. Their 
 habits were agricultural and their character rather 
 
 167 
 
SANITATION IN PANAMA 
 
 warlike. They were thoroughly subjugated and 
 were worked by the Spaniards under their aparta- 
 miento system. Las Casas states that the gover- 
 nor, Pedro Arias, during his governorship of some 
 twenty years, caused the death of three million 
 Indians in the present state of Panama. I have 
 no doubt that such a figure is a very great exagger- 
 ation, but it shows what a very good old Spanish 
 priest thought of the destruction of Indian life 
 due to the cruelties of the conquistador. 
 
 Fifty years later when Sir Francis Drake ap- 
 peared upon the scene, this Indian population had 
 almost disappeared. Sir Francis Drake, in 1572, 
 secreted his three ships in one of the sheltered and 
 well concealed bays among the San Bias Islands, 
 and marched his one hundred Englishmen through 
 all parts of the present San Bias country. His 
 narrative shows that the Indian population was 
 very much less than that described sixty years 
 before by Balboa, marching through the same 
 country. They had been treated so cruelly by the 
 Spaniards that they thoroughly hated them. As 
 they knew that the English were fighting the Span- 
 iards, they were always ready to help the English 
 and give information. 
 
 The governor of Panama, all through the colo- 
 nial period, was constantly trying to overrun this 
 country, and though at various times forts were 
 built in many localities, and these forts garrisoned 
 
 168 
 
YELLOW-FEVER WORK AT THE ISTHMUS 
 
 for a considerable length of time, the country was 
 never conquered, and the Indians after their orig- 
 inal conquest by Balboa never recognized the 
 authority of the Spaniards. They early adopted 
 the policy of not allowing, under any pretext what- 
 ever, a white man to come into their country. This 
 law they have enforced up to the present time, and 
 still enforce it. Many white men have lost their 
 lives in trying to explore the interior of the San 
 Bias country. 
 
 For generations there has been a good deal of 
 commerce in light-draft schooners along the north- 
 e % n coast of the San Bias country. The San Bias 
 Lidian himself, like all the other Carib tribes, is a 
 natural-born sailor. You see him miles from 
 shore in his frail dugout, in the roughest sort of 
 weather. It has been his custom for generations 
 to ship aboard sailing-vessels visiting his country, 
 occasionally for very long voyages, as far even as 
 London or New York, so that when you meet him, 
 he is very likely to speak English, and on occasions 
 of state, %ear European clothes. In the ten years 
 that we have been at work on the Isthmus the San 
 Bias Indians have acquired considerable confidence 
 in us, and have become quite friendly. They come 
 to the hospitals very freely for treatment and 
 surgical operations, and the men can now be seen 
 almost any day in Colon trading. Whenever they 
 come up to Colon, they wear European clothing. 
 
 169 
 
SANITATION IN PANAMA 
 
 This is of every variety and style, but the hat is 
 always the same, a derby! 
 
 The present government of the Eepublic of 
 Panama has induced the old Chief to recognize 
 formally the authority of the Eepublic. This has 
 not been brought about by force, but principally 
 by 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 Panaman 
 Government. 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 end 
 of the northern coast of the Eepublic. The Presi- 
 dent of the Eepublic took occasion to inspect this 
 post, and went down on the only war vessel the 
 Eepublic possessed, a twenty-ton steam launch. 
 As they passed the island in San Bias Bay on 
 which was located the principal town of the In- 
 dians, the old Chief ran up the Colombian flair, 
 and notified the President that he had changed his 
 allegiance from Panama to Colombia. As the old 
 fellow controlled a full quarter of the territory of 
 Panama, this meant a good deal to the Eepublic, 
 but the President very wisely made no attempt at 
 force. He granted the few unimportant requests 
 of the Indians ; increased the old Chief in his rank ; 
 
 170 
 
YELLOW-FEVER WORK AT THE ISTHMUS 
 
 gave him a new coat with more lace than the for- 
 mer, and the flag of Panama now floats serenely; 
 where the Colombian flag then floated. 
 
 While the Indians recognize the overlordship of 
 the Republic of Panama, I doubt if the President, 
 or any other white official, would be allowed to 
 spend a night in the San Bias country, nor would 
 they during our whole stay on the Isthmus allow 
 any official of the Canal Commission to spend a 
 night in this domain. 
 
 Some years ago the Indians reported to me that 
 they had yellow fever among their people, and 
 requested my help. As their territory came di- 
 rectly up to the Canal Zone, it was important for 
 us to know whether or not this was really true. A 
 party of sanitary officials, consisting of Dr. Carter, 
 Major Lyster, myself and others, went down on a 
 steamer to investigate. We went by appointment 
 to the principal town. The Indians were very glad 
 to see us, and received us most hospitably. It was 
 a very picturesque scene as we approached the 
 landing. The whole population was drawn up on 
 the beach in their gala attire, to do us honor. The 
 women, who had probably never before seen a 
 white man, were dressed very much as described 
 by the earlier explorers in the middle of the 
 seventeenth century; a skirt of some bright 
 material and a scarf of brilliant red around the 
 shoulders ; gold ornaments in great profusion ; nose 
 
 171 
 
SANITATION IN PANAMA 
 
 rings, ear-rings, heavy bracelets on the upper arm 
 and around the ankles. A most peculiar custom 
 among the young women was that of binding very 
 tightly around the calves of both legs a band of 
 beadwork, from four to six inches broad. Some 
 had the same band on the upper arm. This band 
 had been worn so long and was so tight that it had 
 made a deep, permanent depression in the mus- 
 cular tissue ; enough I should have thought to can -c 
 some lameness, but in no case could I see that it 
 interfered with locomotion. The early explorers 
 also refer to this custom. 
 
 Another custom which I have seen referred to 
 and which attracted our attention among these 
 Indians, is the manner in which the women smoke 
 their cigars. I saw many of them putting the 
 lighted end in their mouths and smoking the cigar 
 by drawing the air through it that way. 
 
 After seeing the display of gold ornaments I 
 could well understand how Balboa collected such 
 large quantities of gold as he describes, in his 
 expeditions through the country. I estimate that 
 the women I saw on this occasion averaged in 
 their rings and bracelets ten or fifteen ounces of 
 gold apiece. The conquistadors, no doubt, wln-n 
 they entered a town seized all this gold. 
 
 The Indians, as I have said, received us very 
 cordially, and brought to us all their sick, and 
 apparently wanted us to give some medicine to 
 
 172 
 
YELLOW-FEVER WORK AT THE ISTHMUS 
 
 everyone in the village. This we cheerfully did, 
 giving them the best advice we could, but when 
 evening came, they politely notified us of their 
 national 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 suffering 
 we found to be not yellow fever, but pneumonia. 
 While ashore, we had noticed a Jamaican negro 
 paddling around in a dugout. Upon inquiry, we 
 were 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 told 
 that the custom among the San Bias Indians was 
 to execute the doctor whenever his patient died, 
 and that our unfortunate rival, the Jamaican 
 negro, had been executed for this cause a few days 
 after we left. We had prescribed for one or two 
 patients in the last stages of consumption who 
 evidently had not many days to live. We have, 
 therefore, been very chary about returning to the 
 San Bias country, and strongly suspect that we 
 are marked in the national archives for execution 
 under the San Bias law for the practice of medi- 
 cine. 
 
 The San Bias Indian was very independent in 
 all his ideas, and considered his government as 
 the political equal of the Canal Government, the 
 United States, or any other government. 
 
 173 
 
SANITATION IN PANAMA 
 
 In looking about for a place in which to get 
 sand to make concrete for the Gatun locks, Colonel 
 Sibert, with a party of engineers, visited this same 
 Chief. They found here what they considered 
 suitable sand, and tried to purchase from the old 
 Chief the right to use it. He was, however, very 
 short with them ; told them that the San Bias In- 
 dians had need of all the sand the Almighty had 
 given them and hinted very broadly that it would 
 be healthy for Colonel Sibert and his party to 
 return to their boats and leave the country. 
 
CHAPTER XIII 
 
 NOMBRE DE DIGS 
 
 A NOTHER sanitary district had to be estab- 
 ** lished about twenty miles east of Porto Bello, 
 at Nombre de Dios. Here we had a force of some 
 two hundred men who dredged the sand that was 
 used 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 not 
 more than one hundred people, on the old site of 
 Nombre de Dios, and we found that to protect 
 our 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 Nombre 
 de Dios is even better known in the wild history 
 of 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 northern 
 terminus of the paved royal highway leading 
 from Panama. Afterwards, when Porto Bello 
 
 '175 
 
SANITATION IN PANAMA 
 
 was built, the highway forked about thirty miles 
 south of Nombre de Dios, one branch leading to 
 Porto Bello, and the other to Nombre de Dios. 
 
 The roadstead at Nombre de Dios was entirely 
 open and exposed to the full force of the north 
 wind, locally known as the "norther," so trouble- 
 some along this coast during the winter months. 
 It was so exposed that it was difficult for the 
 Spaniards to fortify it. The fabulous amount of 
 treasure which the Spaniards were bringing up 
 from Peru rapidly became known throughout the 
 world. The Spaniards, during their earlier colo- 
 nial period, collected their treasure from time to 
 time during the year, in preparation of the sail- 
 ing of the fleet. For this reason, Nombre de Dios 
 was constantly being threatened by adventurers 
 of all nationalities, who frequented the seas wash- 
 ing the shores of the Spanish Main. 
 
 Drake, in his expedition of 1572, made a most 
 romantic attack upon Nombre de Dios. With one 
 hundred men in small boats he attacked the town 
 and took the garrison entirely by surprise. They 
 were 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 were 
 in the hands of the English, and there seemed 
 very little chance for the Governor and his few 
 
 176 
 
NOMBRE DE BIOS 
 
 brave followers. The silver bullion, the accumu- 
 lations of a year from the countries tributary to 
 Spain in this part of the world, was in one of the 
 buildings already in the hands of the English. 
 Drake describes it as being piled in bars of solid 
 silver, and 'states that the pile was some eighty 
 feet long, twenty feet broad and ten feet high. 
 The old Governor and his companions were still 
 bravely holding the palace, and Drake led a 
 charge in person. While they were battering in 
 the main gate, Drake received a bullet wound in 
 the head and fell to the ground unconscious. His 
 men became demoralized, thinking that he had 
 been 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 treasure 
 which the English had gone through so much suf- 
 fering and privation to possess. 
 
 The Spanish garrison was immediately rein- 
 forced from Panama. Though Drake remained 
 with his ships concealed among the San Bias Isl- 
 ands in the beautiful tropical bay of San Bias, 
 he never had another opportunity of surprising 
 with any chance of success the fort and garrison 
 of Nombre de Dios. 
 
 About a year later, however, he surprised and 
 captured a treasure train on the royal highway 
 coming across from Panama to Nombre de Dios. 
 
 177 
 
SANITATION IN PANAMA 
 
 The fight took place just about where the royal 
 highway to Porto Bello branches off from that to 
 Nombre de Dios. Drake's men after the capture 
 were some fifty or sixty miles from their ships. 
 There was no trail nor road of any kind leading 
 in that direction, so that they could not take the 
 pack mules. Drake therefore directed that the 
 gold 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 the 
 treasure should be buried and concealed as well 
 as it could be in the immediate neighborhood. 
 
 Drake and his men succeeded in getting to their 
 ships safely with the treasure they had captured, 
 and this was enough to pay the expense of their 
 whole trip and besides make each one of them 
 rich for life, according to the standards of that 
 day. The Spanish garrison from Nombre de 
 Dios was on the ground within a few hours after 
 the capture of the pack train, and spent several 
 days in searching for hidden buried treasure. 
 They found a great deal, and thought they had 
 found all that was left. About two weeks after- 
 wards Drake and his men returned and due: up 
 enough to give again to each man all that he 
 could carry, but as this was principally silver, 
 it was not so valuable as had been their previous 
 load. 
 
 In 1598, Nombre de Dios, by order of the Span- 
 
NOMBRE DE DIGS 
 
 ish king, was abandoned and everything moved 
 to Porto Bello. As I before remarked, our men 
 were located right among the ruins of the old city 
 of Nombre de Dios, and our sand-digging opera- 
 tions were carried on near the shore line right in 
 front of the town. In the three hundred years 
 since Nombre de Dios had been abandoned the 
 harbor had silted up and filled in to a consider- 
 able extent. In excavating for sand our men 
 found the frame of an old ship of considerable 
 size ten or fifteen feet under the surface of the 
 ground, and some two hundred yards from the 
 present coast line. She was evidently an old 
 Spanish ship that had been abandoned at the then 
 shore line of the city of Nombre de Dios, and had 
 gradually been covered by the action of the water 
 with sand and silt. 
 
 The Spanish officers and soldiers of 1650 
 seemed to have lost the initiative and energy 
 which they had so wonderfully exhibited two gen- 
 erations before in this same country under Bal- 
 boa, Pizarro, Almargo, and other leaders of that 
 stamp. But they did not lack bravery and dogged 
 determination, when it came to the defensive, as 
 was illustrated in the case of the Spanish Gov- 
 ernor at Nombre de Dios, when summoned by 
 Drake to surrender, although his condition was 
 apparently hopeless. His courage and devotion 
 were most unexpectedly rewarded by success, 
 
 179 
 
SANITATION IN PANAMA 
 
 which he had not the slightest right to expect, due 
 to 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 stormed 
 and carried one stronghold after another until 
 nothing but the palace was left to the Spaniards. 
 In the palace the Governor had placed the women 
 and children, with himself and about ten men, 
 and had barricaded all the entrances as well as 
 possible. He steadily refused all summons which 
 Morgan made on him to surrender. AVhen the 
 main door was battered down and Morgan en- 
 tered sword in hand at the head of more than one 
 hundred men, he found the old Governor standing 
 with drawn sword, his ten men behind him and tlio 
 women and children behind them. The Governor 
 was even then a man of over sixty years of age. It 
 was not the custom in those days for either Span- 
 iards or buccaneers to ask or give quarter. Sir 
 Henry Morgan is not ordinarily credited with 
 much soft-heartedness even from the standpoint 
 of a buccaneer. According to accounts, he was 
 touched by the scene that presented itself to his 
 view as he and his men poured into the court 
 the white-haired old Governor unflinchingly sup- 
 
 180 
 
NOMBRE DE BIOS 
 
 ported by his brave little garrison of ten men, 
 and the frightened and crying women and chil- 
 dren standing behind. By a gesture he waved 
 back his men, and told the Governor that he 
 wished to spare his life and the lives of those de- 
 pendent upon him. Though his wife entreated 
 the Governor to accept Morgan's terms and 
 pointed out to him the uselessness of resistance, 
 as all the town and the forts were in the hands of 
 six or seven hundred buccaneers, and that there 
 were but ten Spaniards left, the doughty old Gov- 
 ernor refused to yield and told Morgan that he 
 was 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 would 
 never yield it as long as he had a drop of blood 
 left. 
 
 This is the only recorded instance that I know 
 of in which Morgan was touched by the bravery 
 of 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 his 
 brave men had gone to the land where the souls 
 of 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. 
 
CHAPTER XIV 
 
 THE WORK OF THE SANITARY INSPECTORS 
 
 T7 ACH of the twenty-five districts into which the 
 * ^ Zone was divided, as far as the general sani- 
 tary work was concerned, was in the charge of a 
 sanitary inspector. The sanitary inspector had 
 under him a force of from twenty to one hundred 
 laborers, with assistants and foremen as neces- 
 sary. The districts varied considerably in the 
 number of people living in them. Some of the 
 districts had as many as eight or ten thousand 
 people ; some only a few hundred. The area of the 
 district varied between fifteen and thirty-five 
 square miles. The Zone extends for five miles 
 on each side of the Canal, that is, a strip ten miles 
 broad and fifty miles long. Most of the population 
 was located on each side of the Canal, within about 
 a mile of its axis, while a few houses and cabins 
 were scattered through all parts of the Canal Zone. 
 Sanitary work, generally speaking, was done 
 only within a mile or so of the Canal itself. All 
 
 182 
 
WORK OP THE SANITARY INSPECTORS 
 
 brush and undergrowth were cleared within two 
 hundred yards of houses and villages, and the 
 ground carefully drained within the same area. 
 There was no object in carrying sanitary work 
 beyond the populated area. Even if mosquitoes 
 bred where no human beings were living, no harm 
 would be done, as there would be no one to infect. 
 
 All told, the country under the jurisdiction of 
 the Isthmian Canal Commission amounted in 
 area to about five hundred square miles, and only 
 a hundred of this was affected by the work of the 
 Sanitary Department. The great work of the 
 sanitary inspector was his anti-mosquito work. 
 In the early days he paid most attention to the 
 stegomyia mosquito, but after the fall of 1905 
 when yellow fever had been conquered, attention 
 was concentrated on the anopheles, the malarial 
 mosquito. 
 
 For the elimination of the stegomyia, the in- 
 spector in these country districts took the same 
 measures as described in Colon and Panama 
 against these mosquitoes, though of course on a 
 very much smaller scale. Against malaria, he 
 had a sufficient number of laborers under one or 
 more foremen, according to the size of the dis- 
 trict, who cut the brush and undergrowth within 
 two hundred yards of all villages, houses and 
 dwellings, and who also cut the grass within this 
 area whenever it reached a foot in height. This 
 
 183 
 
SANITATION IN PANAMA 
 
 was done for several reasons. The adult mos- 
 quito is destroyed by wind or sunlight, and he 
 seeks all sorts of shrubbery, grass and foliage 
 for protection against both of these enemies. 
 Therefore, if the brush, shrubbery and high grass 
 is cleared off within two hundred yards around 
 a dwelling, there is no shelter for the mosquito 
 from either the wind or sunlight, and there are 
 therefore no mosquitoes within this area. 
 
 The anopheles, the malarial mosquito, is not a 
 mosquito of strong flight; two hundred yards is, 
 in general, a good long flight for her. If there 
 were trees and shrubs and bushes every few 
 yards, the anopheles mosquito miirht travel very 
 long distances and not be much exposed to either 
 the 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 zone 
 without destruction, either by sun or wind. Clear- 
 ing this zone exposes the ground to both sun and 
 wind, and by these forces alone many of the 
 smaller pools will be dried up and made unfit 
 for mosquito breeding. I have often seen this 
 measure alone, that is, clearing the zone, cause a 
 swampy place which I had expected to have to 
 drain, to become dry and cease to breed mos- 
 quitoes. 
 
 It was also the inspector's duty to see to the 
 drainage. For this purpose he had a properly 
 
 184 
 
Oilers at Work in Marsh. 
 
 
 
 Burning Out Ditch With Oil Spray. 
 
WORK OF THE SANITARY INSPECTORS 
 
 trained body of men under his control. The 
 drainage was, of course, very much more exten- 
 sive in area than the grass and bush cutting, for 
 not only had the cleared zone itself to be drained, 
 but all the area within that zone, and also the 
 water-courses leading off from the drained areas 
 had to receive attention. Many times we found 
 that anopheles were breeding very much beyond 
 the two-hundred-yard limit and still coming into 
 the village. In one case we had a very large 
 flight of anopheles which lasted for two or three 
 weeks, and they were found to be breeding more 
 than a mile from the village of Gatun. So, as a 
 matter of fact, our work was very many times 
 carried 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, such 
 as the farmer used for the ordinary draining in 
 agricultural work. At Panama, there were sev- 
 eral objections to this method. While the ditch 
 drained the surrounding ground and stopped 
 mosquito-breeding at this point, it became a most 
 excellent breeding-place itself, as the grass grew 
 in the bed of the ditch. At Panama, rain fell 
 daily for eight months of the year, and the tem- 
 perature was always high enough from one year's 
 end to another to encourage vegetable growth. 
 
 185 
 
SANITATION IN PANAMA 
 
 The grass, therefore, grew so rapidly that the 
 ditch had to be cleaned out every two or three 
 weeks. The cost of keeping open a surface drain 
 of this kind we found to be very high. 
 
 Another system of drainage which the inspec- 
 tors used very freely and found very useful, was 
 that of filling the ditch, after it had been exca- 
 vated, with broken stone. This largely prevented 
 the growing of grass, and also prevented any 
 development of mosquitoes in the ditch itself. 
 Another form much resorted to was that of lining 
 the ditch with concrete. This entirely prevented 
 the growth of grass and did away with the ex- 
 pense of up-keep. The only expense involved in 
 caring for such a ditch was that of a man going 
 over it now and then and removing such obstruc- 
 tions as may have gotten in. Mr. Le Prince and 
 his inspectors became very expert in this style of 
 concrete work, and finally, by the use of chicken 
 wire as a framework for strengthening the con- 
 crete, were enabled to lay a ditch of this type 
 very cheaply. Wherever the drainage was ex- 
 pected to be used for a year or more, we found it 
 more efficient and economical to use concrete 
 rather than the open ditch. 
 
 Mr. Le Prince and his staff devised several 
 processes whereby the cleaning of these ditches 
 of grass was much cheapened. Several solutions 
 of arsenic were found which, when applied to the 
 
 186 
 
WORK OP THE SANITARY INSPECTORS 
 
 grass, killed it. Such a process kept the grass 
 down for a much longer time than that of simply 
 cutting it out with a hoe. A burner was devised 
 which atomized oil under air pressure, making 
 a 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 it 
 would not protect adult mosquitoes. He had, 
 therefore, not only to keep it clear of brush, but 
 also must not allow the grass to grow more than 
 a foot in height. For grass-cutting, there was a 
 great economy in using the horse-mower wher- 
 ever we could. Numerous open ditches inter- 
 fered with the use of a horse-mower. To meet 
 this difficulty, the inspector used sub-soil tiled 
 drainage wherever it was feasible. This is the 
 ideal anti-mosquito drainage. It carries off the 
 water, so that there is no formation of breeding- 
 places on the surface. After it is once laid it 
 requires no work or expense for up-keep, and a 
 horse-mower can be used just as freely over its 
 surface as if there were no ditch there. 
 
 With the various methods just mentioned we 
 drained pretty well about one hundred square 
 miles of territory, constructing in all some five 
 million feet of open ditch, some one and a half 
 million feet of concrete ditch, some one million 
 feet of rock-filled ditch, and about one million feet 
 of sub-soil tile. 
 
 187 
 
SANITATION IN PANAMA 
 
 For doing this ditching, each inspector had a 
 gang of men under a competent foreman. In 
 many instances, where the work was extensive 
 and required unusual skill, such as tile-laying, 
 the gangs, especially experienced in this work 
 were transferred from district to district. Often 
 it is not possible to drain for instance, a large 
 swamp area, or where the locality is to be occu- 
 pied so short a time that it is not economical to 
 drain. In such an extensive engineering work as 
 was being carried out on the Isthmus, the con- 
 struction work was constantly interfering with 
 the drainage and making pools and puddles which 
 had to be looked after. In these instances, and 
 many 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 pump 
 which he worked with his hand, forcing the oil 
 through a nozzle to the place which he wished to 
 affect. In general, we used crude oil of com- 
 merce, not because it was the best, but because it 
 was so cheap that we could use it much more 
 extensively than the rectified oil. It was so 
 thick, however, that we had to thin it with vari- 
 ous mixtures before we could spray it through 
 the nozzle. This cost us a fraction over two 
 cents a gallon, and we used about fifty thousand 
 gallons a month over the hundred square miles of 
 territory we were treating. It is not necessary 
 
 188 
 
WORK OF THE SANITARY INSPECTORS 
 
 to look after all collections of water in order that 
 mosquito-breeding may be prevented. If the 
 water is sufficiently deep and clear of grass, so 
 that the fish can have free access, these fish will 
 destroy all the larvae, and mosquitoes will not de- 
 velop. But all natural collections of water in a 
 warm climate such as Panama have grass and 
 algae freely growing on its edges, and these ob- 
 structions protect mosquito larvae, particularly 
 the larvae of the malarial mosquito, the anopheles. 
 Gatun Lake, the large lake made by the dam- 
 ming of the Chargres River, gave us a great deal 
 of trouble on this account during the last two 
 years 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 algae grew freely and anopheles larvae 
 were found in abundance. We found that the an- 
 opheles larvae on the Isthmus developed just 
 about as freely in the mountains as they did in 
 the lowlands. The clear mountain torrent seemed 
 to be just as acceptable a home for the anopheles 
 as the edge of the lowland swamp. At Panama, 
 the temperature remains the same all the year 
 round. The water of the mountain stream is suf- 
 ficiently warm for his development, just as in the 
 swamp. The stream, as it winds down the moun- 
 tain, grows grass and algae freely on both sides 
 of its tortuous course, and here the larvae of the 
 
 189 
 
SANITATION IN PANAMA 
 
 anopheles find safe harbor. Into this grass and 
 algae oil will not spread. We had to find some- 
 thing that would dissolve in the water and poison 
 the larvae protected by the grass and algae. 
 
 Dr. Samuel Darling, of the laboratory, finally 
 worked out a mixture of carbolic acid, resin and 
 alkali, which would emulsify in water and ac- 
 complish this purpose. The mixture was known 
 as larvacide. The method of its manufacture was 
 as follows: 
 
 One hundred and fifty gallons of crude car- 
 bolic acid are heated in an iron tank ha vino: a 
 steam coil, with steam at fifty pounds pressure. 
 Two hundred pounds of finely crushed and sifted 
 common resin are dissolved in the heated acid, 
 and thirty pounds of caustic soda dissolved in 
 six gallons of water are added. There is a me- 
 chanical stirring rod attached to the tank. The 
 product is ready in a few minutes, yielding about 
 three 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. $1,512.00 
 
 12,300 pounds rosin at $2.48 per hundred 305.04 
 
 2,550 pounds caustic soda at $3.70 per hundred 94 .35 
 
 2 tons coal at $5.00 per ton 10.00 
 
 Labor 94.46 
 
 Supervision 50 . 00 
 
 Total $2,065.85 
 
 Cost per gallon 14 . 14 
 
 190 
 
WORK OF THE SANITARY INSPECTORS 
 
 To insure the manufacture of a uniform prod- 
 uct, requisitions called for crude carbolic acid 
 of a specific gravity not greater than 0.97, and 
 to contain not less than 15 per cent tar acids. 
 Each consignment of crude carbolic acid received 
 was assayed at the laboratory to determine its 
 specific gravity and percentage of tar acids, for 
 it is necessary to keep the product of a specific 
 gravity approximately that of water, so that it 
 will diffuse rapidly and neither sink to the bot- 
 tom, nor remain at the surface. 
 
 In a hundred square miles of territory treated 
 we used about two hundred barrels of this mix- 
 ture a month. The cost of manufacture was 
 about seventeen cents a gallon. In the early days 
 we had used various proprietary articles for this 
 purpose, for which we generally had to pay about 
 fifty cents per gallon. Larvacide came in the 
 course of time to be used on the Isthmus for dis- 
 infectant purposes of many kinds, and also for 
 the prevention of fly-breeding. We found it most 
 excellent for all rough purposes of this kind, 
 such as disinfecting and deodorizing around privy 
 vaults and similar places. 
 
 A sanitary inspector, when malaria is rife, has 
 to be thoroughly familiar with the life history of 
 the mosquito, and particularly with the life his- 
 tory of the anopheles. There are some six or 
 seven hundred species of mosquitoes, and many 
 
 191 
 
SANITATION IN PANAMA 
 
 of these differ widely in their habits of flight. 
 The stegomyia mosquito is one of the feeblest 
 species in its ability for flight, and it is at once 
 blown away and destroyed when it gets into a 
 breeze. It therefore seldom wanders from the 
 house in which it is bred. The culex solicitans is 
 very strong and bold in flight, and can fly twenty 
 miles in one night before a favoring breeze. This 
 has been demonstrated by Dr. J. B. Smith, of 
 New Jersey. Dr. Smith was the entomologist of 
 the state of New Jersey, and one of the most 
 faithful 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 to 
 their breeding-places, some species breeding in 
 brackish water, some only in fresh water. Other 
 species breed freely in dirty and muddy water, 
 and still others can apparently live only in froli, 
 clean water. The two species with which we are 
 most concerned as being disease-carrying mos- 
 quitoes are very particular as to their habits, al- 
 ways seeking fresh, clean, clear water in which 
 their larvae can develop. 
 
 The stegomyia likes clean rain water such as is 
 found in cisterns and water barrels. As these 
 collections are found principally around the 
 dwellings of man in towns and cities, this mos- 
 
 192 
 
WORK OF THE SANITARY INSPECTORS 
 
 quito is known as a town mosquito. The larvae 
 of the anopheles, the malarial mosquito, also likes 
 clear, clean, fresh water, but it requires algae and 
 grass for its protection. These conditions are 
 best furnished by the edges of ponds and running 
 streams. This mosquito is, therefore, essentially 
 a country mosquito. 
 
 Generally, in any one locality, there are only 
 three or four species of mosquito occurring in 
 any abundance, so that when the inspector has 
 learned to differentiate these, he is pretty well 
 educated for work in that particular locality. 
 Each species usually has some prominent trait; 
 the anopheles, for instance, has the hind legs very 
 much longer than the fore legs, which gives her 
 when at rest the appearance of standing on her 
 head. The stegomyia has prominent white mark- 
 ings on its body and white bands around the 
 joints of its legs, and while these cannot readily 
 be distinguished by the naked eye, they give it a 
 gray appearance which easily distinguishes it 
 from other species in such a locality as Panama. 
 
 The culex solicitans and stegomyia look very 
 much alike to the naked eye, so much so that one 
 of our most experienced inspectors at Panama, 
 on returning from a vacation spent on Long Isl- 
 and, told me that the stegomyia was the common 
 mosquito on Long Island. As a matter of fact, 
 the stegomyia never appears farther north than 
 
 193 
 
SANITATION IN PANAMA 
 
 Norfolk, Virginia, unless as a matter of acciden- 
 tal introduction during warm summer weather. 
 
 As the inspector deals with the mosquito in the 
 larval stage principally, he must be familiar with 
 the habits of the larvae, and the habits of the dif- 
 ferent larvae differ about as much as the habits 
 of the adult mosquitoes. They also differ much 
 in size and shape; for instance, the larvae of the 
 anopheles can readily be recognized by the way 
 it comes to the surface to breathe. During this 
 process it lies horizontal to and in contact with 
 the surface of the water. The culex larvae, when 
 breathing, lies with its tail up and head down. 
 The anopheles is a long, very slender larva; the 
 culex, short and chunky. The anopheles larva is 
 most noticeable from its superior intelligence. It 
 will dive and seek shelter in the grass at any 
 sound or shadow thrown upon the water; the 
 culex larva is sluggish and pays little attention 
 to such things. 
 
 The inspector must become very familiar with 
 the half-dozen most frequently occurring laiv;r 
 in his district; he must recognize them easily 
 when he sees them, and must know the kind of 
 locality in which to seek for them. He must learn 
 the peculiarity of ditching as applied to drainage 
 intended to prevent mosquito breeding. This is 
 quite an art in itself. Take, for instance, an or- 
 dinary depression between two small hills; if we 
 
Old French Engine Tender Used as Storage Tank for Oil. 
 
 Mule for Packing Oil to Oilers. 
 
WORK OF THE SANITARY INSPECTORS 
 
 want merely to get the water away for ordinary 
 drainage purposes, a ditch through the center 
 will accomplish this, but sometimes where the 
 water is oozing through the surface on the hill- 
 side, you still have soft moist places on each side 
 of your ditch which makes most excellent breed- 
 ing-places for mosquitoes. 
 
 Mr. Le Prince discovered that for mosquito 
 work ditches would have to be run along the hill- 
 side to cut off the water from this soft ground 
 and to catch it when it came to the surface. 
 Where the ordinary engineer does ditching, such 
 a 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 employed 
 directly by himself and under his orders and 
 supervision. I think it is of the utmost impor- 
 tance in mosquito work that the health officer 
 should have direct control of the men doing this 
 work. The ordinary engineer has no special 
 knowledge of the life history of the mosquito, and 
 as the ditching and brush-cutting are done to pre- 
 vent mosquito-breeding, it is not surprising that 
 it is not successfully done by a man who has no 
 knowledge of the mosquito. 
 
 All the work at Havana was done by men 
 trained and instructed as to the life habits of the 
 mosquito, and the same was the case for the first 
 
 195 
 
SANITATION IN PANAMA 
 
 three years at Panama, when the effective mos- 
 quito work was done. Whenever speaking or 
 writing on this subject I have insisted upon the 
 necessity of having the execution of the work in 
 the hands of men who have been trained in anti- 
 malarial procedure. 
 
 Another duty of the inspector was to see that 
 the houses were properly screened, and that the 
 screens were kept in effective condition. The Com- 
 mission had several thousand buildings scattered 
 in thirty or more towns, and it endeavored to 
 keep all these buildings mosquito-proof with who 
 netting. Mr. Wright, the architect of the Com- 
 mission, developed several very useful types of 
 houses, well adapted to a tropical country and 
 for the use of wire netting. The general plan 
 was 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 the 
 doors being left open. Mr. Wright therefore 
 planned his houses so that they were screened 
 in, having only one door of entrance. A house 
 screened in this way is very thoroughly protected 
 against the mosquito. The housekeeper, with 
 very little attention, can keep closed the one 
 screen door that gives entrance to the house. 
 
 Another great advantage of such screening is 
 that there is very little interference with the cir- 
 
 196 
 
WORK OF THE SANITARY INSPECTORS 
 
 dilation of the air. We used a wire netting of 
 sixteen strands to the inch. In the case of a win- 
 dow screened with such wire, a large part of the 
 air that would ordinarily enter is kept out, and 
 the interior of the house is made hot and uncom- 
 fortable in a warm climate. With the whole side 
 of the veranda screened the amount of air kept 
 out is not appreciable, and at Panama there was 
 no complaint that the screening interfered with 
 the ventilation. 
 
 Another very great advantage of this style of 
 building was that the galleries could be used as 
 living- and sleeping-rooms, and this at Panama 
 was very generally the case. It was found that 
 the cost of screening the gallery was very little 
 more than that of screening the doors and win- 
 dows. While screening the whole gallery re- 
 quired much more wire netting, the work itself 
 was very simple. Making the window and door 
 frames brought up the cost of screening them to 
 about the cost of screening the galleries. 
 
 Care must be taken as to the quality of the wire 
 netting. We were put to a great deal of expense 
 at Panama by sometimes getting wire netting 
 that would last only two or three months. We 
 finally adopted a specification requiring that our 
 netting 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 
 
 197 
 
SANITATION IN PANAMA 
 
 to see that it came within these specifications. It 
 was the very general opinion on the Isthmus that 
 houses thus screened protected us much more 
 thoroughly from insect life than is the case in 
 most parts of the United States during the sum- 
 mer months. The dwellers in these houses habit- 
 ually sat on the galleries, with electric lights 
 burning, and would read for a whole evening 
 without being disturbed by any kind of insect. 
 
 The inspector had a man constantly employed 
 patching holes and looking after the condition of 
 this wire screening. In our barracks, in which 
 forty or fifty Jamaican negroes lived, it was 
 much more difficult to keep the wire netting in 
 repair, and to keep the screened door of entrance 
 closed, and some mosquitoes would always get 
 in, if there were any mosquitoes around. In 
 many of our stations we succeeded in entirely 
 eliminating the mosquito, as in the district of 
 Ancon. In such districts it made little difference 
 as to the condition of the wire netting; in other 
 districts where the anti-malarial work had been 
 curtailed, mosquitoes were troublesome, and 
 every day some would get into such barracks as I 
 have described. 
 
 For these cases Mr. Le Prince and his assis- 
 tants developed a very effective method. They 
 took an ordinary test tube, put at the bottom of 
 it a few pieces of ordinary rubber, dropped on 
 
 198 
 
WORK OF THE SANITARY INSPECTORS 
 
 this rubber a few drops of chloroform and placed 
 a small layer of absorbent cotton over it to keep 
 it in place. When the mouth of this test tube is 
 placed over the mosquito, she in a few seconds 
 becomes narcotized by the chloroform and dies. 
 
 This method of killing infected mosquitoes was 
 developed 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 of 
 the other anti-malarial measures is possible. 
 
 For instance, at one time we had railroad con- 
 struction going on near Diablo Hill. This hill is 
 surrounded by fresh-water swamps on three 
 sides. We put a force of several hundred men 
 to work on this. They were fairly comfortably 
 housed in ordinary box cars, the doors and win- 
 dows of which had been carefully screened with 
 wire netting. These cars were located at the foot 
 of Diablo Hill, on the edge of the swamp. No 
 anti-malarial work having been done here up to 
 this time, anopheles were very numerous. The 
 swamp was so extensive that efficient anti-mala- 
 rial work was not considered then practicable. 
 Prophylactic quinin in five-grain doses was being 
 taken by these men, but we knew from a recent 
 experience in this same locality that infection 
 was so severe that prophylactic quinin alone would 
 not protect our men. We knew, also, that a cer- 
 tain number of mosquitoes would get by the 
 
 199 
 
SANITATION IN PANAMA 
 
 screens every night. With a number of men liv- 
 ing in a car and using one door, we knew that on 
 the average that door would be open a large por- 
 tion of the time. From inspections, we had found 
 that there were always a considerable number of 
 mosquitoes in the cars. Mr. Le Prince reasoned 
 that while the mosquito-catcher could not by any 
 possibility catch all the mosquitoes in every car 
 every day, he would catch most of them. It was 
 therefore extremely improbable that any individ- 
 ual mosquito would escape the mosquito-catcher 
 for ten successive days". As it takes ten days 
 from the time at which the female anopheles mos- 
 quito bites the man sick with malaria until she 
 herself becomes able to transmit the disease, no 
 mosquito would live long enough under these 
 conditions to become disease-bearing. And in 
 practice this proved to be the case. The mos- 
 quito-catcher went through the cars every day 
 and caught all the mosquitoes he could find, and 
 continued this day after day as long as the cars 
 remained in this swamp. The force was kept 
 here for several months without suffering appre- 
 ciably from malaria. 
 
 This was the more impressive from the fact 
 that just before we had our negro employees in 
 cars on the edge of the swamp, we had kept a 
 considerable force of marines for several weeks 
 camped in tents on top of Diablo Hill. These 
 
 200 
 
WORK OF THE SANITARY INSPECTORS 
 
 marines suffered very severely from malarial 
 fever, very few of them escaping. The tents not 
 being screened, we could not carry out the same 
 naethod of catching infected mosquitoes which 
 was so successful in the case of our negro labor- 
 ers, a couple of hundred yards distant from this 
 same camp. One of the medical officers reported 
 to me one day that, under a mosquito-bar which 
 he had kept over a sick man during the preceding 
 night, he caught in the morning quite a large 
 number of anopheles about fifty, as I recall it. 
 We used this method more and more during the 
 later years of our work on the Isthmus. 
 
 It is quite feasible everywhere, by proper 
 drainage, to eliminate entirely the anopheles mos- 
 quito, and in several of our towns and villages 
 we succeeded in doing this, and could have done 
 it everywhere if it had been thought desirable by 
 the authorities to apply the same methods, which 
 had been successful at these places, and previous- 
 ly at Havana. 
 
 At stations where mosquitoes were more or less 
 troublesome, the mosquito-catching method above 
 described was very useful in the barracks of the 
 laborers. In a barrack building which quarters 
 forty or fifty men the best screening will not alto- 
 gether keep out mosquitoes, if there are many 
 mosquitoes around. Holes will continually be 
 punched in the wire netting, but mosquitoes enter 
 
 201 
 
SANITATION IN PANAMA 
 
 principally through the constant opening of the 
 door, and through the door being carelessly left 
 open. We found that at such stations we could 
 keep malaria down by catching malarial mos- 
 quitoes. 
 
 Occasionally, at a station where we had con- 
 trolled mosquitoes for several years, a great 
 swarm would appear for reasons which we could 
 not explain. These swarms would not remain 
 for a long time, and usually they were not made 
 up of anopheles. While they lasted, we used the 
 method of catching infected mosquitoes for the 
 protection of our force. On one occasion, how- 
 ever, we had a large flight of anopheles. They 
 swarmed everywhere about the station, and we 
 could not account for them, or discover wlure 
 they came from. The sanitary inspectors' de- 
 partment devoted all its spare force to investi- 
 gating this point, and for a considerable period 
 Mr. Le Prince devoted all his time to the subject. 
 He finally located the breeding area in a small 
 swamp about a mile from the town. This swamp 
 had existed there during the preceding years 
 when Gatun had been comparatively free from 
 mosquitoes. At this particular time when the 
 anopheles were so troublesome, the engineers had 
 begun to pump silt from the channel of the Canal 
 into this swamp. This silt was carried by salt 
 water, which made the water of the swamp brack- 
 
 202 
 
WORK OP THE SANITARY INSPECTORS 
 
 ish. This brackish water apparently favored the 
 development of the anopheles, and they were pro- 
 duced in enormous numbers. The engineers were 
 requested to pump sea water into the swamp area 
 for a few days. This soon made the water of the 
 swamp too salty for the breeding of the anopheles, 
 and in a few days the mosquitoes disappeared 
 from the town. 
 
 It is remarkable that anopheles should have 
 bred in this brackish water, as it is a mosquito 
 which generally seeks fresh water. It is probable 
 that the brackish water made some advantageous 
 change in the food supply of the larvae, and that 
 when the swamp was filled with pure sea water, 
 this food supply was stopped. This is the longest 
 flight of anopheles which we discovered on the 
 Isthmus. 
 
 The method worked out by Mr. Le Prince and 
 his assistants was original with them. They 
 would take a screened cage containing a large 
 number of anopheles mosquitoes, and spray them 
 with a solution of analine blue; take them down 
 at night and release them at the suspected spot. 
 They would erect a tent at some convenient place 
 in the town to be examined, put a mosquito-bar 
 in this tent with a man under it as a bait for the 
 lady anopheles, leave the bar open during the 
 night, closing it early in the morning before the 
 anopheles which had bitten during the night had 
 
 203 
 
SANITATION IN PANAMA 
 
 an opportunity to escape. The mosquitoes under 
 the bar were caught and carefully examined. If 
 any blue-stained mosquitoes were found, it was 
 proof that they had come from the point at which 
 the stained mosquitoes had been released the 
 evening before. 
 
 The job of acting as bait for the mosquitoes 
 during these investigations was a position much 
 sought after by our negro employees. They were 
 paid by the hour the same wages that the day- 
 laborers received. To be paid full wages for 
 sleeping in a comfortable bed struck the Jamai- 
 can as being as near complete bliss as was to be 
 found in this world. 
 
 Mr. Le Prince did a great deal of work in ex- 
 perimenting upon the flight of the anopheles at 
 other stations, and during his investigations came 
 across many curious things as to the habits and 
 tastes of the anopheles. He found that the 
 anopheles would show a marked preference for a 
 particular horse; though there might be several 
 other horses near and accessible, they would bite 
 this one horse almost exclusively, the taste of 
 whose blood they seemed to prefer. The same 
 thing was true of men. We had one inspector of 
 whom the mosquitoes were excessively fond. 
 When they were not very numerous, they would 
 scarcely trouble his companions at all, devoting 
 all their attention to him. This poor fellow died 
 
 204 
 
WORK OF THE SANITARY INSPECTORS 
 
 as a result of this kind of work. He was Mr. Le 
 Prince's main dependence for investigations of 
 this kind. He did not suffer particularly from 
 malarial fever while on the Isthmus, but a short 
 time after his return to his northern home, he 
 died of an attack of pernicious malarial fever. 
 
 These various methods of combating malaria 
 were very successful. In some of the towns, as I 
 have already said, they were just as successful 
 as they had been in the city of Havana, and I 
 myself have no doubt that, if we could have con- 
 tinued the methods which we inaugurated on the 
 Isthmus, we should have been just as successful 
 with malaria at Panama as we had previously 
 been with the disease at Havana, and at no 
 greater cost. As it was, we succeeded in so pro- 
 tecting the force against malaria that it did not 
 interfere to any appreciable degree with its work- 
 ing capacity. 
 
CHAPTER XV 
 
 THE WORK AT THE HOSPITALS 
 
 . JOHN W. ROSS, of the United States 
 Navy, Major Louis A. La Garde, of the Army, 
 and I had all had a large experience in tropical 
 military service. We were, therefore, thoroughly 
 imbued with the idea that from the very beginning 
 we must make ample and liberal provision for the 
 care of a large number of sick. We were im- 
 pressed with the fact that the constant sick rate of 
 the Army in the Philippines had been ninety per 
 thousand during the year 1898; that it had been 
 even larger with our Army at Santiago, Cuba. 
 We therefore thought that we should prepare to 
 have at least fifty per thousand of our employees 
 on the Isthmus constantly sick. 
 
 Our estimates were based upon fifty thousand 
 employees. If, as occurred with our Army in the 
 Philippines, we should have three hundred per 
 thousand constantly sick, we would need a bed 
 capacity, equipment and personnel for the care 
 
 206 
 
THE WORK AT THE HOSPITALS 
 
 of fifteen thousand sick. If, as we hoped, it might 
 not exceed fifty per thousand of our employees 
 sick, we should only need a bed capacity of twenty- 
 five hundred beds. We determined to keep at least 
 fifty beds per thousand for our actual force ; that 
 this should be the minimum number, and that the 
 number of beds should be increased as the force 
 increased. 
 
 It is a matter of interest to note the fact that 
 during the year that our force was at its maxi- 
 mum, fifty-eight thousand men during the calendar 
 year 1913, we had a hospital capacity of just about 
 twenty-five hundred beds, though the constant sick 
 rate of our employees at this time was only about 
 twenty-two per thousand. The hospital service 
 had become so popular, and had acquired such a 
 reputation for the skillful service and good care 
 which could be obtained there, that a large number 
 of people came to seek its benefits from various 
 Spanish American countries north and south 
 of us. 
 
 We had at this time some eight hundred in- 
 dividuals in the hospitals who were not Canal 
 employees. Dr. Boss was determined that our 
 hospital 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 just 
 as skillful, and just as good care, as he could com- 
 mand in our largest centers in the United States. 
 
 207 
 
SANITATION IN PANAMA 
 
 With this object in view ^he hospitals were 
 equipped with bedding and other hospital sup- 
 plies of the very best kind. Very little was ex- 
 pended upon buildings. In general we used the 
 buildings that had been erected by the French 
 some twenty years before, and which were still 
 standing in fairly usable condition. 
 
 Dr. Eoss impressed upon everyone with whom 
 he came in contact that the hospital department 
 was organized primarily for the care of the sick, 
 and that the comfort and happiness of the sick 
 must always have the first consideration. This 
 department retained this principle as its most 
 marked characteristic during the whole period of 
 its existence. 
 
 The very best equipment in all directions was 
 obtained, and the very best class of youn^ phy- 
 sicians and surgeons was secured from the United 
 States. At our maximum we had, all told, one hun- 
 dred and two physicians in the Sanitary Depart- 
 ment. Our nursing force was as enthusiastic, as 
 good and as efficient as could be found anywhere. 
 At our maximum we had one hundred and thirty 
 trained nurses from the best training-schools in 
 the United States. 
 
 As I have mentioned before, the Canal extended 
 from northwest to southeast some fifty miles, the 
 city of Colon being at the northern end and Pan- 
 ama at the southern. The working force was 
 
 208 
 
THE WORK AT THE HOSPITALS 
 
 scattered, more or less, along this line between 
 these two points. 
 
 The French had left two large hospitals, Ancon 
 Hospital at Panama on the southern end, and 
 Colon Hospital at Colon on the northern end. We 
 determined to utilize these two hospitals as base 
 hospitals, and to bring as many patients as pos- 
 sible from along the line to these institutions. We 
 divided the territory between Panama and Colon 
 into as many medical districts as we had sanitary 
 districts, and in each of these districts a small hos- 
 pital was erected, from twenty to one hundred beds 
 in size, where a certain number of sick could 
 be treated, whom we thought it would not be 
 advantageous to transport to the two base hos- 
 pitals. 
 
 Many of the districts had several villages within 
 their borders where the laborers lived. Each of 
 these villages had in it a small hospital of from five 
 to fifteen beds where the sick were kept until they 
 could be moved to the district hospital. We had 
 some forty of these sub-district hospitals, which 
 were generally known as rest camps. This gave 
 us, all told, some sixty hospitals. 
 
 It was evident that we could not afford to make 
 all these sixty hospitals first-class hospitals, and 
 we therefore decided to concentrate upon our two 
 base hospitals and make them first-class in every 
 respect. For instance, in the surgical line we de- 
 
 209 
 
SANITATION IN PANAMA 
 
 termined to have all the instruments, equipment 
 and personnel that could be obtained in the best 
 equipped hospitals in our large cities. The 
 eighteen district hospitals were well equipped to 
 care for emergency patients, both medical and 
 surgical, and for such as it was thought would be 
 injured by being moved to the base hospitals. 
 The sub-district hospitals, or rest camps, were not 
 equipped at all for the care of surgical cases, but 
 merely for the care of medical cases until they 
 could be moved to the district hospitals. 
 
 The sub-district hospitals were used a great deal 
 for the care of men who were sick only for a day 
 or two. It was believed that there would be a 
 certain amount of injury done in transporting 
 the wounded by train. Some of the stations were 
 twenty-five miles from either Ancon or Colon, but 
 at the same time it was thought that the better 
 care, skill and attention that the patient could get 
 in the large and well-equipped hospitals, such as 
 Ancon and Colon, would a great deal more than 
 counterbalance the injury done by the long rail- 
 way haul. 
 
 For the purpose of transporting the sick and 
 wounded from the various district hospitals to the 
 base hospitals, hospital cars were run over the 
 road morning and evening, in both directions. 
 The hospital cars were of local manufacture, 
 gotten up by Dr. Carter, the then director of hos- 
 
 210 
 
THE WORK AT THE HOSPITALS 
 
 pitals. He took the ordinary baggage car, rigged 
 up iron frames over which canvas was stretched, 
 and these frames were secured to the walls with 
 hinges, so that when not in use they could be 
 folded down on the side of the car, out of the way. 
 There were sixteen of these beds in each car. The 
 car was also arranged so that when the beds were 
 not left down there was a row of seats available all 
 around the car. Ordinarily, in transportation 
 there would be five or six stretcher cases occupy- 
 ing beds in the car, but the large majority of the 
 cases would be sitting up. Each car was provided 
 with a toilet, a small supply of medicines and 
 surgical dressings, and two small closets in which 
 such things were stored. The car was manned by 
 a trained white male nurse and a negro assistant. 
 The car was screened. 
 
 The trains at Ancon and Colon were met by the 
 necessary number of ambulances, and the patient 
 in this way was carried to the hospital. Cases of 
 pressing emergency were brought on special 
 trains. The district physician could generally get 
 a special train if he certified that there was neces- 
 sity for it. 
 
 This method of transportation for the sick 
 proved eminently satisfactory, and during our ten 
 years of construction work on the Isthmus, it ful- 
 filled every need. "We transported a great many 
 thousand patients in this way without a mishap 
 
 211 
 
SANITATION IN PANAMA 
 
 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 to 
 wheeled vehicles. So the patients who could not 
 walk had to be carried to the hospital car on 
 stretchers. But long before the period of con- 
 struction was half through roads had been built 
 to all these district hospitals. 
 
 In charge of the medical matters in each of our 
 twenty districts was a district physician. This 
 physician had charge of the district hospital, and 
 looked after the patients there. It was also his 
 duty to look after the families of employees. No 
 charge 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 send 
 any employee he thought best to the hospital. If 
 the employee preferred to stay at home for treat- 
 ment he was charged one dollar for each visit of 
 the physician. These fees reverted to the Commis- 
 sion. The physician was paid a fixed salary by 
 the Commission, and was not allowed to make any 
 charge for his services. Members of families of 
 employees were charged one dollar a day for hos- 
 pital care, and could be admitted on the order of 
 the district physician. Families of employees 
 who received less than fifty dollars a month were 
 
 212 
 
THE WORK AT THE HOSPITALS 
 
 charged only thirty cents per day for hospital 
 treatment. As a rule, both employees and their 
 families preferred to come into the hospital when 
 sick, rather than to be treated at home. The class 
 of employees receiving less than fifty dollars a 
 month was almost exclusively Jamaican negroes. 
 During the earlier years of our Isthmian work the 
 negroes were afraid of the hospitals and did not 
 like to come in. This applied particularly to the 
 women and children. But as years went by we 
 gained their confidence entirely, and during the 
 last years of construction, the hospital accommo- 
 dation for negro women and children was always 
 full, though we were constantly extending this 
 branch of our hospital. 
 
 In each district one or more dispensaries were 
 maintained. In immediate charge of the dispen- 
 sary was a competent druggist who had one or 
 more men under him for assisting him about the 
 dispensary. The district physician presided over 
 the dispensary and advised without charge anyone 
 who applied for treatment, and furnished him with 
 medicines if he were unable to pay. Quinin was 
 given at the dispensary to anyone who applied. 
 In some of the larger districts where the popula- 
 tion amounted to eight or ten thousand, the district 
 physician had as many as four assistants. All the 
 doctors on the Isthmus had to be graduates of 
 medical schools in good standing, and, except for 
 
 213 
 
SANITATION IN PANAMA 
 
 the first few years of construction, had to pass 
 a civil service examination. 
 
 There was a very great sanitary advantage in 
 our giving in this way to the whole population free 
 medical 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 earliest 
 information with regard to such diseases as yel- 
 low fever and plague, and they were enabled to 
 take the proper sanitary precautions at the time 
 when they would be most efficacious. Many times 
 information obtained in this way enabled us to 
 stamp out these diseases in their incipiency and 
 before they could get started as epidemics. 
 
 The district physician also had inspectorial con- 
 trol of all buildings within his district. He was 
 directed to pay particular attention to hotels, 
 eating-houses, etc. He was required to make a 
 monthly report on these subjects. Faults reported 
 by the district physician were carefully looked 
 after 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 the 
 cemeteries in the Zone, which were twenty-odd 
 in number. Each of the districts had a ceme- 
 tery, and no burials were allowed except in these 
 cemeteries. The inspector kept a register of all 
 
 214 
 
THE WORK AT THE HOSPITALS 
 
 burials, and any death which was at all suspi- 
 cious was investigated by the authorities of the 
 Sanitary Department. The charge for prepar- 
 ing the grave was just about enough to cover 
 the expense of digging. The control of the 
 cemeteries by the Sanitary Department we con- 
 sidered very important from a sanitary point of 
 view, as in this way we could keep an absolute 
 register of all deaths occurring, and no death from 
 a 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 were 
 buried quite a number of our naval officers and 
 sailors who had died of yellow fever on our war 
 vessels while in the bay of Panama during the 
 preceding fifty years. Here were buried, also, 
 patients who died at the nearby quaran- 
 tine station. The site was beautifully located 
 about half-way up Flemenco Hill, in a dense 
 tropical forest, with just below it, at the water 
 line, the vine-covered ruins of an old Span- 
 ish fort. At the present time the top of Flemenco 
 Hill has been cut away for the location of one of 
 our batteries. The old fort has been razed for 
 the location of another battery and the tombs and 
 monuments of the old cemetery have been moved 
 to the grounds of Ancon Hospital. 
 
 In the grounds of this hospital was located the 
 
 215 
 
SANITATION* IN PANAMA 
 
 cemetery where most of the employees and 
 laborers who had died during the period of con- 
 struction were buried. This also was a very pic- 
 turesque place, situated on the side of Ancon 
 mountain, looking to the north, with Culebra Cut 
 instinctively in view. The grounds were prettily 
 laid out and artistically planted with tropical trees 
 and shrubbery. Here we had some two thousand 
 interments. 
 
 But the principal cemetery was that located at 
 Mount Hope. This was the cemetery for the city 
 of Colon, and in all the writings of the early days 
 on the Isthmus, it is known as "Monkey Hill." It 
 has 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 died 
 during the construction of the Panama Railroad, 
 and many others well known on the Isthmus during 
 the fifty years of the existence of the railroad as 
 a transcontinental route. Dr. Connor, health offi- 
 cer of Colon, gave a great deal of attention and 
 thought to the beautifying of this piece of ground, 
 and it is now as pretty a garden of tropical trees 
 and shrubbery as can be seen anywhere. 
 
 At Porto Bello we used the principal fort on 
 the north side of the harbor as a cemetery. This 
 structure, though built of brick some two hundred 
 years before, was in a very good state of preserva- 
 tion. The mountain rose several hundred feet on 
 
 216 
 
THE WORK AT THE HOSPITALS 
 
 this side of the harbor, and on the side of this 
 mountain, to the seaward from the old fort, was 
 located our great Porto Bello quarry, from which 
 was obtained the stone for building the Gatun 
 locks and the Colon breakwaters. The fort was a 
 very strong and complete military structure for 
 its time, and it was located at the foot of the moun- 
 tain, near the water's edge. When I first visited 
 the ruin, it was completely covered with jungle, to 
 such an extent that it could not be entered or 
 recognized as a structure built by human hands. 
 I reached it and made an entrance by having a 
 native machete-man cut out the jungle enough for 
 me to force my way through behind him. Large 
 trees 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 jungle 
 and arranged so that it could be used as a ceme- 
 tery, and here are buried the employees who died 
 at Porto Bello within the six or seven years dur- 
 ing which we operated the quarry. I selected it 
 as the cemetery site, because it struck me as be- 
 ing appropriate that this old fort, which had seen 
 so much of war, should finally be used for so 
 peaceful a purpose as the last resting-place of 
 the laborers engaged in the construction of a com- 
 mercial enterprise like the Panama Canal, for 
 which so much is hoped for the benefit of the whole 
 
 217 
 
SANITATION IN PANAMA 
 
 human race. The old fort had been built by one 
 set of pirates, the old Spaniards, to protect the 
 plunder which they had wrung from the Incas and 
 other natives of America, from that other set of 
 pirates who infested the Spanish main, and were 
 constantly attempting to wrest from the Spaniards 
 this plunder. 
 
CHAPTER XVI 
 
 MALARIA WORK AND THE HOSPITAL SYSTEM 
 
 T N the early years of our construction malaria 
 " was very common and gave a great deal of 
 trouble. As I have explained before, malaria is 
 caused by a small animal parasite which lives in 
 the blood of man and feeds upon the red globules. 
 The excretions of this parasite poison man and 
 cause the fever and other symptoms which we know 
 as malarial fever. This parasite is transferred 
 from the sick man to the well man by the bite of the 
 mosquito. Now it is quite evident that if in any 
 way we can kill the parasites as they exist in man, 
 we not only cure the individual man of malarial 
 fever, but at the same time prevent his being a 
 means of infection for other men who have not yet 
 acquired the disease. In a purely empirical man- 
 ner, some one hundred and fifty years ago a drug 
 was discovered which man could take without in- 
 jury to himself, and which, when absorbed into 
 the circulating blood was deadly to the malarial 
 
 219 
 
SANITATION IN PANAMA 
 
 parasite there swimming about. It is somewhat 
 singular that this drug should have been discov- 
 ered not very far from Panama. A Peruvian 
 Catholic priest found that the Indians in certain 
 parts of Peru cured themselves of the fevers 
 native to that country by the use of the bark of a 
 certain forest tree common to that region. Its 
 benefits 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 of 
 this wonderful bark, and introduced it into the 
 mother country and other parts of Europe. This 
 lady was the Marchioness of Cinchona. No drug 
 ever discovered has been as useful to mankind as 
 quinin, and it remains up to the present time one 
 of the few specifics known to the medical profes- 
 sion. 
 
 Besides curing the malarial patient after he had 
 gotten the parasite into his blood, it was the desire 
 of the Sanitary Department to have the blood of 
 all persons on the Isthmus in such condition that 
 it would not harbor the parasite. We believed that 
 if everybody would take five grains of quinin a 
 day, this quinin would be absorbed into the blood 
 and render the blood so poisonous to the malarial 
 parasite that when the parasite was injected into 
 the blood by the mosquito it could not thrive and 
 develop, but would die. 
 
 With the object of getting as many people as 
 
 220 
 
Distilled Water Cart. Culebra. 
 
 Ward at Ancon Hospital. 
 
MALARIA WORK 
 
 possible to take quinin every day, each district 
 physician had attached to his staff one or more 
 quinin dispensers. This quinin dispenser was a 
 man furnished with quinin in various forms, who 
 spent the day going about among the laborers 
 offering them quinin. It was the endeavor of the 
 district physician to have each laborer once a day 
 offered quinin. The dispenser carried with him 
 what was known on the Isthmus as quinin tonic. 
 This was a quinin solution made up so that each 
 ounce should contain five grains of quinin. Other 
 ingredients were added so as to make it attractive 
 in smell, taste and appearance. The quinin dis- 
 penser also carried with him quinin pills, capsules 
 and tablets, and the patient was allowed his choice. 
 
 The Commission ran a large number of hotels 
 and eating-houses, where all classes of employees 
 were fed. Quinin tonic and quinin tablets were 
 placed on the tables of all these eating-houses and 
 messes, and an educational campaign was vigor- 
 ously pushed among the employees, with the idea 
 of teaching them what was aimed at by taking 
 quinin in this way. No attempt was ever made to 
 force anyone to take this prophylactic quinin, but 
 explanation and persuasion were used to their 
 fullest extent. 
 
 By these methods we succeeded, when the use 
 of quinin was at its maximum, in getting our force 
 to take about forty thousand doses per day. The 
 
SANITATION IN PANAMA 
 
 men responded very heartily and loyally to this 
 system of education. I was very much gratified 
 at the results, and feel confident that no system 
 of compulsion could have been as successful. I 
 am satisfied that during the early years of con- 
 struction, before our other anti-malarial work had 
 produced results, this giving of prophylactic qui- 
 nin on so large a scale was of the very greatest 
 use 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 whoro 
 the men were sent to spend a week or two when 
 convalescing from the severer forms of malarial 
 fever. A man with malarial parasites in his blood 
 was a source of infection and of danger to his well 
 companions. AVith the idea of being certain to 
 kill all the parasites in his blood, he was required 
 to continue large doses of quinin for a week or 
 ten days after the stoppage of his fever. But 
 such is the nature of man that as soon as you 
 begin to force him to do a thing, from that moment 
 he begins to seek ways by which he can avoid 
 doing 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, would 
 manage to throw their tablets out of the dispen- 
 sary window. The old turkey-gobbler that was 
 the pet of the hospital seemed to like the stimu- 
 
 223 
 
MALARIA WORK 
 
 lating effect of the quinin and gobbled up all the 
 tablets he could find. He became so dissipated in 
 this way that he finally developed quinin ambly- 
 opia. This amblyopia is a species of blindness 
 that is sometimes caused by too much quinin. The 
 doctor finally had to confine his old gobbler and 
 keep him away from quinin tablets until he recov- 
 ered his sight. I cannot vouch for this story, but 
 I was often twitted with it as an illustration of 
 how the men were treating prophylactic quinin. 
 Even if this story were true, it could not be used 
 as an argument against prophylactic quinin on the 
 Isthmus. In general, no attempt was made at com- 
 pulsion, and there would therefore be no object 
 in a man taking quinin and throwing it away. 
 
 I have noted before that our hospital system was 
 planned upon the scheme of some forty sub-dis- 
 trict hospitals, or rest camps, which fed about 
 twenty district hospitals. These twenty district 
 hospitals, by means of hospital trains, fed two 
 base hospitals, situated respectively at the north- 
 ern and southern end of the Canal, Colon and 
 Panama. The one at the southern end was much 
 our largest hospital, containing at its maximum 
 about fifteen hundred beds. 
 
 The city of Panama is situated on a peninsula, 
 stretching into the bay of Panama. Just north 
 of the city rises Ancon mountain, some six hun- 
 dred and fifty feet in height. This mountain is 
 
 223 
 
SANITATION IN PANAMA 
 
 only accessible to a pedestrian; the trail is too 
 rough and precipitous for horse or mule. The 
 northern suburb of the city of Panama is known 
 as Ancon, and this village nestles about the south- 
 ern foot of Ancon mountain. The line dividing 
 United States territory from Panama passes be- 
 tween Ancon and the city of Panama. Ancon is 
 therefore under the jurisdiction of the United 
 States. 
 
 Ancon Hospital is beautifully located along the 
 southern 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 graded 
 for roads and laid off in the most beautiful and 
 picturesque manner. Every variety of tropical 
 shrub and plant was introduced from other parts 
 of the tropical world and planted around the 
 grounds. Every opportunity for picturesque lo- 
 cation of buildings was seized, and over thirty 
 hospital buildings of various kinds were located 
 over a large area, extending along the northern 
 and eastern sides of Ancon mountain. 
 
 The maximum bed capacity under the French 
 was about seven hundred beds. The hospital built 
 by them was well manned and equipped, and was 
 a very much better institution than any hospital in 
 America that I know of at the same period car- 
 ried on by a firm or corporation. The French did 
 
 224 
 
MALARIA WORK 
 
 most of their work by contract so that almost all 
 of their patients were employees of the various 
 contractors. Each contractor was made respon- 
 sible for sick employees whom he sent to the hos- 
 pital, and was charged one dollar a day for each 
 sick employee as long as he remained in the hos- 
 pital. A dollar a day was a very moderate charge 
 for the care and attention given a sick man in 
 Ancon Hospital, and I know that the charge did 
 not cover the cost to the old company. 
 
 It is the general belief among the people on the 
 Isthmus, who were there during the general con- 
 struction work of the old French Company, that 
 a very small portion of the employees of the con- 
 tractors came into the hospital. Notable among 
 these is Sir Claude Mallet, who was the English 
 representative in the city of Panama during the 
 period referred to, and who is at present the Brit- 
 ish minister to the Panaman Government. From 
 my knowledge of human nature I feel sure that 
 the French contractors did not send a large pro- 
 portion of their sick to Ancon Hospital. I am sur- 
 prised that under these circumstances the hospital 
 ever contained seven hundred patients. If we had 
 been doing the work and had twenty-five or thirty 
 American 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- 
 
SANITATION IN PANAMA 
 
 quired to pay one dollar per day for each of the 
 seven hundred patients. 
 
 Attached to the hospital the French had a dairy 
 with a very complete set of dairy buildings. In 
 connection with this dairy was a farm of some 
 three or four hundred acres. The water supply 
 for the hospital during the French occupation 
 came from three or four beautiful springs which 
 issued from the side of Ancon mountain. Night 
 soil was taken care of by a bucket system of closets. 
 
 The hospital system, on account of the 
 topography, was necessarily the pavilion system. 
 This system was probably the best that could be 
 adopted for both the local and climatic conditions. 
 The cooking was done at one central kitchen, and 
 the cooked food distributed to the wards, where it 
 was consumed. 
 
 The nursing force was composed of Catholic 
 Sisters, assisted by negro maids and orderlies. 
 These orderlies and maids did the manual work 
 and rough nursing, under the supervision of the 
 Sisters. 
 
 The medical staff consisted of a sufficient num- 
 ber of French physicians. The superintendent 
 during most of the period of construction of the 
 old company and up to the time that we took charge 
 in 1904 was Dr. La Crosade. He remained with us 
 for several years, and did for us most valuable 
 and useful work. 
 
MALARIA WORK 
 
 The hospital was not popular among the French 
 employees. The mortality there was very high, 
 and it was soon recognized that men contracted 
 yellow fever there ; for instance, a man, otherwise 
 well, would break his leg, be sent to the hospital, 
 in the course of four or five days -develop yellow 
 fever, and within ten days be dead. This fear of 
 the hospital was another reason why French em- 
 ployees did not go there. Most of the whites and 
 the better class of French employees, when they 
 were taken sick, remained in their boarding-houses 
 and homes in the city of Panama. 
 
 In making these remarks I do not intend to re- 
 flect in any way upon the management of Ancon 
 Hospital by the French. If we had had this hos- 
 pital in 1884 we should probably have obtained 
 no better results than they did. At that time they 
 did not know that the mosquito transmitted yellow 
 fever from man to man, nor did we know it then. 
 Still, the hospital records show that in the nine 
 years of construction under the old French Com- 
 pany, twelve hundred patients died in Ancon Hos- 
 pital from yellow fever. These were mostly 
 Frenchmen, and they died in the building used for 
 white employees, the Saint Charles. This build- 
 ing was occupied for the first few years of our 
 construction of the Canal by Dr. Carter and my- 
 self, with our families. The fact that we were 
 willing to place our families in such a building, 
 
SANITATION IN PANAMA! 
 
 located in one of the worst yellow-fever centers, 
 shows how thoroughly we believed that yellow 
 fever was not infectious in the ordinary sense of 
 the 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 side 
 of the mountain looking to the northeast. A 
 macadam road skirted the building on the down 
 side, and the masonry retaining-wall supported 
 this road on the lower side. Between the border 
 of the road and the retaining-wall was a superb 
 row of stately royal palms. Behind the building 
 rose the mountain for four hundred feet, covered 
 by a perfectly impenetrable tropical forest, giving 
 to the picture the deepest possible dark green 
 background. The view to the north and east ex- 
 tended for miles and miles. To the east, over 
 the bay of Panama, dotted with its forest-clad 
 islands, I have many times watched from the gal- 
 lery of this building that anomaly, so generally 
 remarked at Panama, the sun rising out of the 
 Pacific. 
 
 To the north and east were in view the various 
 ranges of Andean Mountains which make up the 
 backbone of the Isthmus. From this point, four 
 or five ranges of mountains could be seen, and in 
 the evening, when the sun was setting behind the 
 Ancon mountain at one's back, the play of colors 
 
 1*1 
 
MALARIA WORK 
 
 was superb: light green upon the nearer ranges, 
 changing into deep azure upon the farther ranges, 
 with the mountain tops and higher valleys covered 
 here and there with a robe of white mist. 
 
 For the fourteen years after the failure of the 
 old French Company in 1889, Ancon Hospital had 
 financially a most straightened time, and the Sis- 
 ters who were in charge had to reach out in all 
 directions to make both ends meet. They deserve 
 a great deal of credit for the brave and successful 
 struggle which they made in supplying the wants 
 of 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 and 
 successfully proceeded to organize the hospital on 
 such a basis that it was always able to care prop- 
 erly for all patients who presented themselves. 
 
 For the first year there were almost insuperable 
 difficulties in the way of getting supplies of all 
 kinds, but gradually these troubles were corrected. 
 We used all the old French buildings in much the 
 same manner as had the French. As the number 
 of patients increased, the old French buildings 
 were enlarged, generally by adding a second story, 
 and a few new buildings were added, until finally 
 the capacity of the hospital had risen to fifteen 
 hundred beds. 
 
 Into all these buildings a piped water supply 
 
 229 
 
SANITATION IN PANAMA 
 
 was introduced, and the bucket system for night 
 soil was everywhere replaced by modern flush 
 closets. Bathing facilities were also supplied 
 wherever needed. A good sewage system con- 
 nected all these buildings with the sewers of the 
 city of Panama. The old lighting system of 
 candles and lamps were replaced by electric lights. 
 All the buildings were thoroughly screened with 
 wire netting. This precaution was almost essen- 
 tial in the early years before we got mosquito- 
 breeding as thoroughly under control as it later 
 became. 
 
 In 1904 and 1905 we treated a good deal of yel- 
 low fever in this hospital, and in the wards where 
 we treated yellow fever we had to be particularly 
 careful. Most of the patients in these wards were 
 non-immunes, that is, were patients who had not 
 had yellow fever. The nurses and doctors were 
 also generally non-immunes, who were liable to 
 yellow fever. We had, therefore, to be absolutely 
 certain that no mosquito which could carry yellow 
 fever from patient to patient, or to the doctors and 
 nurses, got into these wards. 
 
 The screening was very carefully done under the 
 supervision of Mr. Le Prince, who formerly had 
 charge of similar work at Havana. Only one en- 
 trance was used for each ward, and this entrance 
 was closed by a screened vestibule, with double 
 doors. A watchman was always on duty in this 
 
 230 
 
MALARIA WORK 
 
 vestibule, whose business it was to see that any 
 person 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 of 
 Ancon Hospital in the years 1904 and 1905, and 
 in spite of the fact that in these wards were a con- 
 siderable number of non-immune patients who did 
 not have yellow fever, and the further fact that 
 most of the doctors and nurses were non-immunes, 
 not a single case of yellow fever developed in 
 Ancon Hospital during American control of that 
 institution. I wish to except from this statement 
 one of the female nurses. This nurse did have a 
 very severe case, and came very near dying. The 
 evidence seemed very strong that she had not con- 
 tracted the disease in the hospital. She was in 
 the habit of going down frequently into the city of 
 Panama in the evening after sunset where infec- 
 tion was very rife. Soon after her recovery she 
 married one of the young doctors connected with 
 the hospital upon whom public opinion settled 
 the blame for her contracting the disease, because 
 he had so frequently inveigled her into taking 
 trips into town. 
 
 That no case of yellow-fever infection occurred 
 in the hospital is the greatest possible compliment 
 to the efficiency of the system established by the 
 authorities for its prevention. It made a very 
 
 2*1 
 
SANITATION IN PANAMA 
 
 strong impression both upon the Americans and 
 Panamans. All could see that we had done some- 
 thing that had radically changed conditions as 
 they had existed before in Ancon Hospital. For- 
 merly, nearly every white non-immune who was 
 taken to the hospital developed yellow fever. 
 Now, they could see that the yellow-fever wards of 
 Ancon Hospital were safer for a non-immune than 
 was any part of the city of Panama. When it 
 was explained to them that there was no mystery 
 about this ; that it had been discovered that yellow 
 fever 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 to 
 propagate yellow fever, they could not have pro- 
 vided conditions better adapted for this purpose 
 than the conditions which they did establish with 
 an entirely different object. The stegomyia were 
 bred everywhere about the Ancon Hospital 
 grounds in the usual numbers found in almost 
 every tropical community, due to old cans, bottles, 
 rain-water barrels, roof gutters, etc. As I have 
 mentioned before, the grounds were most beauti- 
 fully laid Off and every kind of tropical bush and 
 shrub carefully fostered in the various plots about 
 the grounds. There is down there a large ant, 
 known as the umbrella ant, thai is very destruc- 
 tive to most shrubs and plants. A colony of these 
 
 232 
 
MALARIA WORK 
 
 ants will, in the course of a single night, cut every 
 leaf from a good-sized orange tree. The leaf is 
 cut into a piece about half an inch in diameter and 
 carried off by the ant in his nippers, and when 
 you 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 looks 
 very 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 was 
 placed in the large hole in the center. This thor- 
 oughly protected the plant, as the ant was unable 
 to cross the water. But the water in the ring was 
 an ideal breeding-place for the stegomyia mos- 
 quito, and as there were several thousand of these 
 earthenware rings about the grounds, close to the 
 wards, 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 of 
 the 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 
 
 233 
 
SANITATION IN PANAMA 
 
 many years carefully nurtured and cared for by 
 our French predecessors, ruthlessly destroyed. 
 
 But our work was successful, and in the course 
 of time we got rid of mosquitoes entirely in the 
 grounds of Ancon Hospital. AVe continued to 
 keep the buildings well screened, however, though 
 I feel sure that we could now treat cases of yellow 
 fever in Ancon Hospital in unscreened wards and 
 still not have the disease transmitted to the non- 
 immunes in the ward, for the reason that there are 
 no stegomyia there to transmit the disease. This 
 statement is not altogether theory on my part. 
 
 On the next hill, about a quarter of a mile from 
 the old yellow- fever wards of Ancon Hospital, is 
 the Tivoli Hotel. This hotel is owned and oper- 
 ated by the Canal Commission, and for the last few 
 years has been filled with visitors from abroad, 
 principally from the United States, who were of 
 course entirely unacclimated. During the months 
 of the dry season the hotel is crowded, and for 
 the last two years it has been kept full nearly all 
 the year round. During these last two years 
 about thirty thousand sight-seers have visited the 
 Isthmus. 
 
 This hotel is practically unscreened. AVhile the 
 doors and windows are provided with screens, such 
 screening, where there are many doors and win- 
 dows, is so imperfect that in the tropics it gives 
 little protection against yellow fever and malaria. 
 
 234 
 
Stoned Ditch near Tivoli Hotel. Ancon, Panama. 
 
 Bad Anopheles Breeding-ground on Artificial Fill. La Boca. 
 
MALARIA WORK 
 
 No attempt at all was made to screen the galleries 
 of this hotel. Hundreds of visitors spent the 
 whole evening on these galleries until twelve and 
 one o'clock at night, yet we had no cases of yellow 
 fever or malaria developing from such exposure. 
 If this had occurred ten years before and three 
 hundred of these unacclimated visitors from the 
 United States had sat for an hour or two after 
 sunset on this gallery, exposed to the deadly night 
 air, it would probably have meant that every single 
 one of them would have contracted fever, and a 
 considerable number of them would have died. 
 The only difference between now and then is that 
 we have drained and cleaned the country around 
 this hotel, so that now there are no pools or 
 puddles, or places of any kind within two hundred 
 yards of the hotel where mosquitoes can breed, 
 and consequently there are no mosquitoes. 
 
 The fact that unacclimated non-immunes can 
 live in the Tivoli Hotel without contracting fever 
 is evidence that we could do without screening in 
 our wards at the hospital, but we thought it un- 
 wise to do away with the wire netting there. We 
 thought it equally unwise not to screen the Tivoli 
 Hotel, but the expense was large, and the architect 
 thought it would mar the appearance of the build- 
 ing, so it was left off by the authorities, in spite 
 of my advice on the subject. The first guests in 
 the Tivoli Hotel were President Eoosevelt and his 
 
 235 
 
SANITATION IN PANAMA 
 
 party, who were there in November, 1906. I suc- 
 ceeded in getting the authorities to screen thor- 
 oughly the portion of the building occupied by 
 the President. 
 
 As time went on and we found that we had 
 freed the hospital grounds from mosquitoes, we 
 began to replace the flowers and shrubbery which 
 we 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 at 
 once destroyed. AVhile the methods used by the 
 French for this purpose had been entirely suc- 
 cessful and efficient as far as protection from ants 
 was concerned, we could not use it on account of 
 its mosquito-breeding qualities. 
 
 The umbrella ant, in leaving its nest on its 
 foraging expeditions, makes a very distinct trail 
 some four or five inches wide between its nest and 
 the tree to be attacked. Next morning, by follow- 
 ing the trail, you can easily find the nest. Colonel 
 Phillips, the superintendent of the hospital, found 
 that by pouring a little bisulphid of carbon into 
 the ant-hole, allowing it to vaporize for a few 
 minutes and then exploding it, the gas would pene- 
 trate into every part of the nest and kill all the 
 ants. In this way, all the umbrella ants around 
 Ancon Hospital were killed off. At first it was 
 very laborious, and took the entire time of one 
 man, but in the course of time all the nests in the 
 
 236 
 
MALARIA WORK 
 
 neighborhood were destroyed, and it is now only 
 at long intervals that a new colony comes in and 
 has to be killed off. 
 
 At the present time the grounds are even more 
 filled with shrubbery and flowers and tropical 
 plants generally, than they were under the French, 
 and they present as beautiful and attractive an 
 appearance as can be found anywhere in the 
 tropics. Entomologists tell us that this ant does 
 not collect the leaf for food, but chews it up into 
 a pasty mass, places it in the storehouses of its 
 nest, and grows upon it a fungus which he uses 
 for food. 
 
 The food for this large hospital of over two 
 thousand people was cooked in a large and airy 
 kitchen, situated about the center of the grounds. 
 This kitchen was equipped with every modern 
 convenience both for good and economical cooking. 
 Cooking by steam was used in part, and cooking 
 on the range, for such things as were best pre- 
 pared in that way. The food when prepared was 
 sent to the various wards, the receptacles being 
 carried in hand carts. 
 
 The wards were so arranged that every two of 
 them had a dining-room and diet kitchen in com- 
 mon. In each diet kitchen the heating apparatus 
 was so arranged that the food brought from the 
 center kitchen could be re-heated before being used. 
 
 On a spur of the mountain near the center of 
 
 237 
 
SANITATION IN PANAMA 
 
 the grounds was located the operating-room, with 
 seven or eight surgical wards grouped around. 
 This operating-room was erected by the French 
 about the year 1882. We repaired the building 
 and enlarged it somewhat. Dr. A. Herrick, the 
 chief surgeon, equipped this building with every 
 modern surgical appliance, such as x-ray machine, 
 etc., etc. The results of the surgery at Ancon 
 compare 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 variety 
 of 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 great 
 deal of useful original work has been done. The 
 pathological work of the hospital was done in 
 this laboratory. 
 
 From the peculiarity and isolation of our posi- 
 tion on the Isthmus, many things were done by 
 the Sanitary Department which in the United 
 States are done by other branches of the Govern- 
 ment, or by individuals. In the early days, when 
 there was a great deal of fear and alarm on the 
 Isthmus among the Americans with regard to 
 health conditions, the Commission promised their 
 American employees that all who died on the 
 Isthmus should have their bodies returned to their 
 
 338 
 
MALARIA WORK 
 
 friends in the United States, at the expense of the 
 Commission. The fulfilling of this promise was 
 turned over to the Sanitary Department, and to 
 carry it out, an undertaking department was es- 
 tablished and attached to the laboratory. The ex- 
 pense of this department is one of the very many 
 items that bear no relation to sanitation, merely 
 because the officers of the Sanitary Department 
 supervised the work, and the employees were 
 carried on the rolls of this Department. 
 
 There being nothing else of this kind on the 
 Isthmus, it gradually came about that whenever 
 anyone died and his friends wished to have the 
 body embalmed, we were called upon to do it, 
 and in later years, as the non-employee population 
 increased, there was a great deal of this outside 
 work. Strange to say, in our rather complicated 
 and involved accounts on the Isthmus, when the 
 President of the Eepublic of Panama died, the 
 Sanitary Department was called upon to embalm 
 the body. The considerable cost of this opera- 
 tion, $100 or more, is charged to sanitation on the 
 Isthmus, and while the Commission was a good 
 deal more than reimbursed by the family from this 
 expenditure, the reimbursement was not credited 
 to sanitation, but went, under the law, to engineer- 
 ing and construction. 
 
 It seems all through as though the laws were 
 framed with the idea of making sanitation appear 
 
 239 
 
SANITATION IN PANAMA 
 
 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 came 
 down, in June, 1904, we purchased in New York 
 and took with us $50,000 worth of supplies. 
 Among these supplies were a certain number of 
 coffins. When they were unloaded on the dock at 
 Colon, the fact was considerably commented on. 
 Among these coffins were six metallic cases, of a 
 quality much superior to the others. These metal- 
 lic cases were piled by themselves. The Commis- 
 sion, the governing body at that time on the 
 Isthmus, was composed of seven men, of whom six 
 on that date were present on the Isthmus. 
 
 Major La Garde was superintending the unload- 
 ing of the ship. One of these six commissioners 
 happened to be passing at this particular time, and 
 he 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 better 
 kind and quality than the ordinary coffin?" Major 
 La Garde promptly replied : "Mr. Commissioner, 
 you know that Commissioner Blank is not on the 
 Isthmus, and that only six commissioners are 
 down here." The inference was so obvious that 
 the Commissioner is said to have returned home 
 and to have taken to his bed at once. I am glad 
 to say, however, that none of the Commission ever 
 had any use for those caskets. 
 
 240 
 
CHAPTER XVII 
 
 MEDICAL AND SURGICAL SERVICE OF ANCON HOSPITAL 
 
 HPHE medical and surgical service of Ancon 
 ** Hospital rapidly developed so as to win the 
 confidence of the civil population all around. Not 
 only did patients come to us from the Zone and the 
 Eepublic of Panama, but patients also applied for 
 admission, and many of them, from the west coast 
 as far south as Chili, and as far north as Mexico. 
 Many hundreds of people who formerly went to 
 Europe and the United States for surgical care 
 and treatment, now go to the Ancon Hospital. 
 
 The charges for this treatment are so arranged 
 that it costs the Commission nothing, but is actu- 
 ally a source of considerable profit. Hundreds of 
 patients who can never hope to have means enough 
 to go to Europe or the United States for medical 
 or surgical relief, are able to go to Ancon and pay 
 the very moderate charges there. 
 
 This is another item of peculiar charge on the 
 Isthmus. If it costs $30,000 a year to care for 
 
SANITATION IN PANAMA 
 
 these patients, in our accounts tbis $30,000 is 
 charged to sanitation, but the $50,000 which the 
 Commission receives for these patients is not 
 credited to sanitation, but to construction and 
 engineering. 
 
 An eye department was also established at 
 Ancon by Major Theodore C. Lyster, of the United 
 States Army, and was equipped with all modern 
 appliances for eye, ear, nose and throat work. 
 This department developed along the same lines 
 as did the surgical work of the hospital, and was 
 soon attracting patients from all the west coast 
 north and south of us. 
 
 The hospital also had a well-appointed depart- 
 ment for the insane. This grew from very small 
 dimensions to considerable size. In 1913, we had 
 two hundred and fifty patients in this section of the 
 hospital. 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, and 
 cared for with the ordinary prisoners. Knowing 
 that, as time went on, we would have a consider- 
 able number of insane from the people in the Zone 
 for whom we had to make provision, we proposed 
 to the Panaman Government that we should take 
 care of their insane in our institution, at a per 
 capita cost of seventy-five cents per day. This 
 they readily agreed to, and at present, consider- 
 ably more than half of these two hundred and 
 
ANCON HOSPITAL 
 
 fifty patients are sent in by the Panaman Govern- 
 ment. 
 
 The cost of caring for these Panaman patients 
 was charged to the Department of Sanitation, but 
 the seventy-five cents per day which was received 
 by 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 merely 
 to do hospital work, but it was so difficult for 
 employees to get washing done that the functions 
 of the laundry were gradually extended and work 
 was done for Canal employees other than those 
 sick in hospitals. A reasonable charge was made 
 for this outside work, and it finally came about 
 that the income from this outside work went a con- 
 siderable way in paying the expenses of the 
 laundry. 
 
 Under Colonel Mason, who succeeded Colonel 
 Phillips in the management of the hospital, the 
 waste fats and tallow from the kitchen were saved, 
 and enough soap made not only to supply the 
 laundry, but in good part to supply the hospital. 
 
 The amount of surgical work in this hospital 
 was very large, and the quantity of surgical dress- 
 ings enormous. A considerable portion of these 
 surgical dressings were not at all soiled, or very 
 
 243 
 
SANITATION IN PANAMA 
 
 little so. Colonel Mason had these picked over, 
 washed and sterilized, and found that he could thus 
 make a large saving in his surgical dressings. 
 
 In the early years of the hospital we bought 
 such milk as we could get from the surrounding 
 country at one dollar and twenty cents a gallon. 
 Colonel Phillips brought cows from the United 
 States and established a dairy on the hospital 
 grounds, which accommodated about one hundred 
 cows. After the dairy was well under way, he 
 found that his milk cost him only from thirty to 
 forty cents per gallon. 
 
 I merely mention these items to show how much 
 can be saved by care and attention to details in 
 a large institution like Ancon Hospital. I could 
 mention many other items, but these suffice to 
 show that the hospital was very economically as 
 well as efficiently run. 
 
 All the adjuncts of a large and well-managed 
 farm could be found on the Ancon Hospital 
 grounds 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 two 
 thousand 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. Out 
 of compliment to the Church, the French Company 
 
ANCON HOSPITAL 
 
 erected for the Bishop of the Diocese of Panama 
 a residence just within the hospital gates, and fixed 
 up 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 a 
 broad flight of some thirty-five or forty steps led 
 from the main roadway directly up to the building 
 itself. A noble row of fifteen or twenty royal 
 palms partially screened the building in front. 
 This building was used by us as quarters for the 
 superintendent of Ancon Hospital. 
 
 The laboratory for original research, which I 
 described above, was located across the roadway 
 some fifty or sixty yards in front of this house. 
 I have also mentioned that part of the function 
 of the laboratory was that of an undertaking es- 
 tablishment, and many of the funeral services for 
 those who died took place in a small chapel con- 
 nected with this laboratory. At one time in the 
 early days when a number of the Americans were 
 dying of yellow fever, the Governor of the Zone, 
 like many of the others one day felt cold chills 
 creeping down his spine. He went over to the 
 laboratory to consult Major La Garde. The 
 Major took his temperature, felt his pulse, made 
 a careful examination and looked exceedingly 
 grave. He insisted upon the Governor's going up 
 into his (Major La Garde's) house, the one I have 
 just described as overlooking the laboratory. 
 
 245 
 
SANITATION IN PANAMA 
 
 While the Governor was undressing and getting 
 ready for bed, a hearse drove up to the laboratory, 
 but from the location of the building, the hearse 
 was also immediately at the foot of the broad flight 
 of steps leading to the Bishop's house. The Gov- 
 ernor was naturally much depressed at the turn 
 affairs seemed to be taking. Evening was draw- 
 ing on, and the sun was sinking to rest. He knew 
 from the history of yellow fever that many a poor 
 fellow who had gone to bed as he was doing had 
 not lived to see the sun rise again. So he ma<lo 
 up his mind that he would take one more look at 
 the sun, the trees and the outside world before 
 he turned in. He went to the window, drew asi<K> 
 the curtains and looked out, and there at the foot 
 of the steps, right at his front door, stood the 
 hearse. With a groan he turned to his bed, sure 
 now that Major La Garde regarded the case as 
 one of those short and fatal ones, and had ordered 
 the hearse so that it would be on hand and con- 
 venient when the Governor had need of it. But I 
 am glad to say that the Governor was all right next 
 morning, and the hearse had been ordered not for 
 the Governor, but for some poor fellow in the 
 morgue at the laboratory. This is not my story, 
 but the Governor's, and I wish I could tell it in 
 the inimitable way I have many times heard it 
 from him. 
 
 As stated previously, any sick employee was 
 
 246 
 
ANCON HOSPITAL 
 
 cared for in Ancon Hospital, or any other Depart- 
 ment hospital, free of charge. If he were on the 
 gold roll, he was allowed pay for thirty days' sick- 
 ness in each year. The gold roll practically meant 
 white Americans, of whom there were about five 
 thousand. The families of employees receiving 
 more than fifty dollars per month were charged 
 one dollar a day for treatment in the wards. If 
 they asked for special consideration, such as 
 private rooms, or private nurses, they were 
 charged accordingly. No charge was made for 
 surgical operations on members of the families 
 of employees. If the employee received less than 
 fifty dollars a month, a member of his family was 
 charged 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, and 
 an additional charge for all extras, such as private 
 rooms, special nurses, etc. 
 
 On October 31, 1913, we had in our hospitals 
 three hundred and twenty-nine white employees, 
 four hundred and forty-five negro employees, one 
 hundred and ninety-nine white non+employee pay 
 patients, 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 cared 
 for in the hospitals. 
 
 247 
 
CHAPTER XVIII 
 
 THE SANITARIUM AT TABOGA 
 
 "J3ANAMA BAY runs straight south from An- 
 * con mountain about one hundred miles. It is 
 filled with a great number of islands, which are evi- 
 dently the tops of mountains projecting above the 
 surface of the water. One of these islands is 
 Taboga, situated in the bay about twelve miles 
 south of the city of Panama. It rises abruptly 
 from the surface of the ocean about a thousand 
 feet, and at the present time is very thoroughly 
 cultivated, the principal product being pineapples 
 which have a great local reputation for size and 
 flavor. It was inhabited by the Indians when the 
 city of Panama was first founded by the Span- 
 iards, and the wealthy inhabitants of the city of 
 Panama early made it a resort, as being pleas- 
 anter, cooler and more healthy than the mainland. 
 The water was considered unusually pure, and the 
 island had the reputation of not being liable to 
 yellow fever. 
 
 248 
 
THE SANITARIUM AT TABOGA 
 
 A quaint little village, Taboga, nestles on the 
 beach at the foot of the mountain. This village 
 is now some four hundred years old, and the 
 church there is reputed to be about that age. A 
 gruesome thing about the pretty little church is 
 the fact that in the outer wall a human skull is im- 
 bedded in the masonry. A glass cover is placed 
 over the front, and the skull can be plainly seen. 
 I was told that this was the skull of one of the 
 early padres, who had been a very good man, and 
 to whom the people were greatly devoted. And 
 when he died, they took this method of perpetuat- 
 ing his memory and showing their veneration. 
 
 For the reason that Taboga was considered so 
 much more healthy than Panama, the French lo- 
 cated there a sanitarium. It was very prettily 
 situated outside the limits of the village of Taboga, 
 and the grounds about the sanitarium had been 
 beautified and improved by the French just as 
 had the grounds of Ancon Hospital. In their 
 sanitarium they could accommodate about one 
 hundred people. We enlarged this institution, 
 and made it a convalescent hospital of about one 
 hundred and twenty beds, and patients were re- 
 ceived here on the same terms as in our other 
 hospitals. 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 got 
 
SANITATION IN PANAMA 
 
 sick, he became very much depressed and made 
 up his mind that he was going to die, and usually 
 determined that he would go back home to the 
 United States if he ever again became able to 
 travel. 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 to 
 the convalescent hospital there until he was able 
 to travel, or until his ship sailed. He usually im- 
 proved so rapidly at Taboga that by the time a 
 ship was ready to sail, he had gotten over his 
 homesickness and depression. In this way a 
 large number of useful employees were saved to 
 the Commission. 
 
 I think the bay of Panama, looking north from 
 Taboga, compares very favorably with the bay of 
 Naples, and reminds one somewhat of that fam- 
 ous sheet of water. A most romantic dell leads 
 up to the top of the mountain from the convales- 
 cent hospital. Down this dell runs the only 
 stream of water on the island, fed by springs 
 near the top of the mountain, by way of this ra- 
 vine. When one has finally reached the crest of 
 the mountain a thousand feet above the level of 
 the sea, the view on all sides is superb. To the 
 north the mouth of the Canal, defended by the 
 fortified islands of Naos, Perico and Flemenco; 
 the city of Panama, Ancon mountain, and in the 
 distance the continental divide of Culebra. To 
 
 250 
 
THE SANITARIUM AT TABOGA 
 
 the south, the bay, extending some fifty or sixty 
 miles, dotted with islands, large and small, and 
 in the distance, the historic group of the Pearl 
 Islands. 
 
 The trail referred to gave access to the dozens 
 of small pineapple farms located on each side 
 of the ravine. Just as the trail reaches the top 
 of the mountain there are three or four crosses, 
 locating an equal number of graves. Every fall, 
 in September, the whole village of Taboga turns 
 out and has a religious procession which goes 
 up to these graves and decorates them. The tra- 
 dition among the natives is that when Sir Henry 
 Morgan captured old Panama in 1670, he sent 
 an expedition down to Taboga. The townsmen 
 made a very brave resistance, but were slowly 
 driven back by the pirates up the trail to the top 
 of the mountain, where they made their final 
 stand, and at last succeeded in beating off their 
 enemies. The little burying-ground was the point 
 where they made this stand, and the townsmen 
 who were killed in the fight were buried where 
 they fell. The yearly religious ceremony which 
 I saw was kept up in commemoration of their 
 brave fight. 
 
 The bay north of Taboga is pretty well inclosed 
 by the mainland on the northeast and west, and 
 Taboga on the south. This piece of water is a 
 favorite place for the collection of large schools 
 
 251 
 
SANITATION IN PANAMA 
 
 of fish, and when these schools are in, all species 
 of 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 a 
 favorite nook for whales. I recollect on one oc- 
 casion seeing as many as six in this little bay at 
 the same time. They did not seem to be particu- 
 larly shy, allowing us to approach them in the 
 steam launch to within twenty-five or thirty 
 yards. 
 
 This bay was the scene of one of the most re- 
 markable naval battles of history. About ten 
 years after Sir Henry Morgan's sacking of Pan- 
 ama, another buccaneering expedition crossed 
 the Isthmus. They struck the South Sea about 
 opposite the Pearl Islands, camping on the bay 
 of San Miguel. Here they collected enough In- 
 dian dugouts to carry their force of three hun- 
 dred men. This Indian dugout is very much like 
 the one made by our Indians in the southern 
 states, an exceedingly unstable and easily cap- 
 sized boat, as anyone knows who has ever at- 
 tempted to navigate one. It is much better 
 adapted to the smooth inland waters than to the 
 rough open sea. The Pearl Islands are about 
 forty miles south of Taboga, and Sharp, with the 
 bulk of his men, undertook a foraging expedition 
 
 252 
 
THE SANITARIUM AT TABOGA 
 
 to these islands. Hawkins with sixty men went 
 northward along the coast toward the city of 
 Panama. 
 
 When they reached the island of Chepo, they 
 heard that the Spanish fleet was anchored at 
 Taboga. Chepo is easily visible from Taboga. 
 The Spanish fleet consisted of the flagship, the 
 Santa Maria, whose armament was twenty guns, 
 and whose crew consisted of one hundred men. 
 She was accompanied by two tenders of a couple 
 of guns each, and crews of about thirty men. 
 Hawkins, having accurate information of the ar- 
 mament and strength of the Spaniards, wished 
 to be reenforced by the main body before going 
 any further. After waiting several days, he 
 thought it unwise to delay any longer, and deter- 
 mined to attack the Spaniards with the force he 
 then had sixty men. So he started his canoes 
 paddling toward Taboga, some fifteen miles off. 
 When the Spaniards discovered the buccaneering 
 fleet approaching, they got under sail, expecting 
 to have no difficulty in running down and sinking 
 in the open sea the canoes of the buccaneers. 
 
 Now the buccaneer, like our frontiersman, was 
 dependent upon his gun for his food. Most of 
 them had spent many years hunting wild cattle 
 in Haiti, and the cured beef of cattle killed in 
 this way was their principal support, and also 
 their principal article of export and commerce, 
 
 333 
 
SANITATION IN PANAMA 
 
 under the name of "buccan." And this is how 
 they got their generic title of buccaneer, a person 
 who produces buccan. This wild life on the coast 
 caused them to become equally expert in handling 
 the dugout. 
 
 King Rose commanded the leading division of 
 six canoes, and described the fight most graph- 
 ically. As the large Spanish vessel bore down 
 upon the canoes of the buccaneers, under full sail, 
 the latter found no difficulty in avoiding tho l>iir 
 vessel by a few strokes of the paddles. As the 
 great ship passed, the expert marksman in the 
 canoe shot down the man at the wheel. This 
 caused the big ship to yaw, lose headway and be- 
 come stationary. 
 
 The buccaneers in the same way would shoot 
 down any other man who tried to get hold of 
 the wheel, and so the vessel was unable to get 
 under sail again. AVith the vessel stationary, it 
 was very easy for the canoes to lie close in out 
 of range of the big guns, and the superior marks- 
 manship of the buccaneers, with their small arms, 
 enabled them to keep down entirely small arm 
 fire 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 boarded 
 the Santa Maria to accept the surrender, of the 
 one hundred men of the crew who had commenced 
 
 25* 
 
THE SANITARIUM AT TABOGA 
 
 the fight, ninety-two had been shot down, and 
 only eight were left standing. Everyone of these 
 eight was, however, wounded. 
 
 I call it one of the most extraordinary naval 
 battles of history, from the fact that sixty men 
 in dugouts, armed only with small arms, were 
 able in the open sea to capture this man-of-war 
 and her tenders, having an armament of over 
 twenty great guns, and crews of over one hun- 
 dred and fifty men. And this was accomplished 
 not by surprise or stealth, but in an open, stand- 
 up fight. The Spaniards saw them coming for 
 miles, and sailed out to meet them. 
 
 The Santa Maria had, under the pirates, a most 
 extraordinary history for three years. She sailed 
 up and down the west coast, bidding defiance to 
 anything the Spaniards sent against her. She 
 finally doubled the Horn, reached the Barbadoes, 
 and was there sold by the pirates for a good 
 round sum. 
 
CHAPTER XIX 
 
 THE LEPER COLONY 
 
 A NOTHER sanitary precaution that the Health 
 ^~* 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 many 
 years that it was unable to bear the expense 
 of any careful enforcement of this law. Some 
 twelve or thirteen lepers had been living in huts 
 down 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 for 
 a long time before our arrival had fallen entirely 
 upon Mr. Espinosa, one of the leading citizens 
 of Panama. 
 
 Knowing that we would have a certain number 
 of lepers in the Zone, we made the same propo- 
 sition to the Panaman Government with regard to 
 lepers that we had made with regard to the in- 
 sane ; that is, that we would care for their lepers 
 
 256 
 
THE LEPER COLONY 
 
 at the rate of seventy-five cents per day per 
 capita. 
 
 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 on 
 an 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 are 
 living contented and happy. We have a white 
 male trained nurse in general charge; a white 
 female trained nurse in charge of the women, 
 and some four or five other employees. We have 
 a teacher for the children, and the lepers are al- 
 ways employed for any work of which they are 
 capable, and are paid for this work so as to en- 
 courage them to seek it. 
 
 Dr. Henry K. Carter devoted a great deal of 
 time and attention to the establishment of this 
 colony, and it was due to his painstaking personal 
 care that the matter turned out so successfully. 
 
 The history of the spread of leprosy is peculiar 
 in that those who live with lepers in institutions 
 and are constantly in contact with them do not as 
 a general thing contract the disease. I refer to 
 such people as doctors, nurses and attendants. 
 On the other hand, people who have never known 
 of any contact with a leper sometimes develop 
 the disease. Such a case was that of the English 
 
 257 
 
SANITATION IN PANAMA 
 
 Consul, about 1850, who found himself with symp- 
 toms of leprosy, without, as far as he knew, ever 
 having come in personal contact with a sufferer 
 from this disease. 
 
 On one of the smaller islands of the bay, Flem- 
 enco, there was an old Spanish fort, which had 
 been long unoccupied not a very large work, in- 
 tended to contain a garrison of some thirty or 
 forty men. Just behind the fort was a pretty, 
 cool, clean spring, which at some period long 
 passed had been walled up and covered in for the 
 use of the garrison. The island of Flemenco is 
 at the mouth of the present Canal, and rises some 
 three hundred and forty feet above the surface 
 of the water. It is at present being fortified for 
 the protection of the Canal. The English Consul, 
 when he found he was a leper, determined that he 
 would never return home, bought Flemenco Isl- 
 and, fixed up the old fort comfortably as a resi- 
 dence for himself, and there, with a few faithful 
 attendants, 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 was 
 the scene of another naval battle during the revo- 
 lution of 1903. The Government forces in the 
 state of Panama under General Alban had 
 brought the country into subjection to the fed- 
 eral government of Colombia. The rebels still 
 had a gunboat, manned and equipped, lying at 
 
 258 
 
THE LEPER COLONY 
 
 Taboga. General Alban, the governor, seized one 
 of the merchant steamers lying in the harbor at 
 Panama, armed her, put a crew aboard with a 
 considerable number of soldiers, and determined 
 to attack the smaller rebel gunboat. 
 
 He sailed down to Flemenco Island, where he 
 anchored for the night. During the night the 
 rebel gunboat came up under the shelter of Flem- 
 enco Island. As day broke she steamed out from 
 behind Flemenco; ranged herself along the stern 
 of Governor Alban's ship where no guns could 
 bear upon her, but where all of her broadsides 
 could bear upon the Government ship, which had 
 no steam up, and which could not, therefore, man- 
 euver. 
 
 The rebel commander called upon the brave 
 old Governor to surrender, representing that he 
 was entirely at his mercy, but this the Governor 
 refused to do. The rebel ship then opened fire, 
 and continued to fire without any possibility of 
 injury to herself, until the Government vessel was 
 sunk. The survivors reported that Governor Al- 
 ban and most of his men were killed by the hostile 
 fire before the ship went down. For many years 
 the masts and upper works of this vessel could 
 be seen at low tide projecting above the water. 
 
CHAPTER XX 
 
 QUAKANTINE SYSTEM 
 
 PANAMA, from its situation and location, was 
 peculiarly liable to infection from other 
 places in both North and South America. It was 
 the gateway through which a large traffic passed, 
 and through which a continuous stream of trav- 
 elers had been entering and departing for the 
 previous four hundred years. After we had once 
 freed it from yellow fever, it was very important 
 that we should keep it free, and to do this we had 
 to take such measures as would prevent a person 
 in the early stages of yellow fever coming into 
 Panama, and infecting the mosquitoes there, and 
 thus starting an epidemic. 
 
 It was possible, also, for a ship to come into 
 a port with infected mosquitoes aboard. These in- 
 fected mosquitoes might escape to the shore and 
 in this way start the disease, or they might bite 
 some non-immune visiting the ship, and cause 
 this non-immune to develop yellow fever at his 
 
QUARANTINE SYSTEM 
 
 house in from three to six days after he had 
 visited the ship. 
 
 To protect ourselves against the introduction 
 of yellow fever in the above ways, quarantine 
 regulations were established. Any ship that had 
 developed a case of yellow fever aboard was con- 
 sidered infected. "VVe knew that if the case were 
 developed aboard, she must have had infected 
 mosquitoes there which had bitten the patient 
 and caused the disease. The ship was, therefore, 
 fumigated in such a way as to kill all mosquitoes. 
 After she had been fumigated, we considered her 
 safe. But though the ship could be rendered safe 
 by the fumigation, some of the passengers or 
 crew 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 took 
 all the non-immunes to our quarantine station, 
 and kept them for six days. At the end of six 
 days we allowed them to return to the ship. The 
 vessel itself, with all the immunes aboard, was 
 released from quarantine as soon as the fumiga- 
 tion had been completed. 
 
 As I have said before, a person who has once 
 had yellow fever is not liable to a second attack. 
 Such person is known as an immune. To prove 
 immunity, a passenger or member of the crew 
 was required to present a written statement from 
 
 261 
 
SANITATION IN PANAMA 
 
 some recognized authority stating that the writer 
 knew 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 endemic 
 area is not subject to this disease. This is ex- 
 plained on the theory that he had a mild attack in 
 childhood, which, though not recognized, gives 
 him protection in after life. This statement may 
 strike one with surprise at first. We have, how- 
 ever, an exactly similar state of affairs among 
 cattle. The beef native to a Texas fever region 
 does not suffer from the disease, but an animal 
 brought from anywhere outside this region al- 
 ways contracts the disease, and generally dies. 
 The calf of the native cow is believed to have a 
 mild 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 the 
 native calf, though the mother may have died of 
 Texas fever. 
 
 An adult human being frequently has yellow 
 fever in so mild a form that it is not recognized 
 as yellow fever. Many Europeans are found in 
 a 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 
 
 262 
 
QUARANTINE SYSTEM 
 
 had lived for ten years continuously in a yellow- 
 fever center, his immunity was accepted by the 
 quarantine authorities. 
 
 If a ship had touched at a port where yellow 
 fever prevailed, before coming to Panama, there 
 was a possibility of infected stegomyia having 
 gotten aboard, even though no cases of yellow 
 fever had developed on the ship. For by chance 
 the infected mosquitoes may not have bitten any- 
 one, or if they had bitten persons on the ship, the 
 biting may not have taken place a sufficient length 
 of time for the development of the disease, before 
 the arrival of the ship at Panama. Such a ship 
 was considered as possibly infected, and was 
 treated at quarantine exactly in the same way 
 as above described in case of a ship known to be 
 infected. 
 
 The fumigation of a ship was generally accom- 
 plished by burning sulphur, as above described 
 in the case of fumigating a house. In the parts 
 of a ship, such as the engine-room, where there 
 was valuable machinery which would be injured 
 by sulphur fumes, pyrethrum was used, just as 
 in similar circumstances it was used in fumigat- 
 ing dwelling-houses. We had more elaborate 
 macliinery than the pots and pans described in 
 the fumigation of houses, with which sulphur 
 fumes could be developed much more rapidly and 
 in much larger volume. This was used by us on 
 
 263 
 
SANITATION IN PANAMA 
 
 special occasions where its use seemed desirable. 
 
 In the history of yellow fever, many curious 
 cases of ship infection from this disease have 
 occurred. During the fall of 1904, one of our 
 warships, the Boston, spent several months in 
 Panama Bay. While down the coast on gun prac- 
 tice, in January, 1905, she developed seven cases 
 of yellow fever. She had been away from Pan- 
 ama such a length of time that the doctor knew 
 that the cases must have received their infection 
 aboard, and that therefore the ship was infected. 
 The cases were well marked and most of them were 
 severe, the doctor and one of the men dying of 
 the disease. Nothing could be found in the >i k 
 records of the ship which would indicate that 
 anyone belonging to the ship had contracted yel- 
 low fever ashore and developed a mild case, and 
 thus 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 fever 
 in 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 transaction 
 of necessary business. 
 
 A short time before the ship had left the har- 
 bor, New Year's Eve, 1904, they had given a ball 
 aboard, which had been attended by a large num- 
 ber of the citizens of Panama. After a careful in- 
 
 264 
 
QUARANTINE SYSTEM 
 
 vestigation of the matter, we concluded that some 
 one of these persons was in the initial stages of 
 a mild case of yellow fever. It is quite possible 
 for such a person to be up and around without 
 appreciating that he has the disease. This per- 
 son, we concluded, was bitten by some of the 
 stegomyia aboard. At the end of two weeks these 
 stegomyia 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 a 
 small flat tub under the steps going down from 
 the wardroom, in which stegomyia were breeding 
 freely. This was the only place on the ship where 
 larvae were found, and this one piece of careless- 
 ness was responsible for the epidemic on the ship. 
 All the mosquitoes aboard ship undoubtedly bred 
 here. We could never find out why this tub was 
 kept here, as the wardroom steward who was 
 responsible, contracted the fever and died. The 
 surgeon of the ship also died. 
 
 The ship was carefully fumigated, under the 
 supervision of Dr. Henry E. Carter, and no more 
 cases occurred, though the ship immediately went 
 to sea with all of her crew aboard, with the ex- 
 ception of the sick, who were brought to Ancon 
 Hospital. 
 
 As an instance of what a man sick with yellow 
 fever may do in the way of going about, I will 
 
 265 
 
SANITATION IN PANAMA 
 
 narrate here the case of one of our patients which 
 will well illustrate this point. 
 
 An American machinist, coming from San 
 Francisco to Panama, got off the steamer at Co- 
 rinto, Nicaragua, got on a spree and was locked up 
 in the Corinto jail. lie was left there by the 
 steamer, but was released from jail in time to 
 catch the next steamer going to Panama. He 
 reached Panama at the end of five days, went to 
 work for the Commission, and worked one day, 
 but being taken sick, he quit work, though he did 
 not 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, and 
 placed in jail as being drunk and disorderly. He 
 was released on the third day of his disease and 
 continued his debauch. He was again arrested 
 on the fourth day, put in jail, and was then dis- 
 covered by one of our inspectors who recognized 
 that he was sick as well as drunk. He had him 
 brought to Ancon Hospital, where he died on the 
 sixth day from the beginning of his attack. 
 
 The symptoms of the disease were well- 
 marked, black vomit being profuse. An autopsy 
 confirmed the diagnosis. Here was a man suffer- 
 ing from a case of yellow fever, of which he finally 
 died on the sixth day, who, for the first five days 
 of the disease, was about town, going from saloon 
 to saloon, drinking immoderately, eating what 
 
 266 
 
QUARANTINE SYSTEM 
 
 came to hand, and sleeping where convenient. 
 Twenty-four hours before he died, he rode up to 
 the hospital in a cab and walked into the ward. He 
 was having black vomit before he left the jaiL 
 
 It is often extremely difficult to trace a case of 
 yellow 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 had 
 apparently been contracted in the city of Pan- 
 ama, and developed there. 
 
 A young Englishman had boarded the Eoyal 
 Mail steamship at Southampton, bound for 
 Colon. While the ship had touched at several 
 points en route, the Captain certified that no one 
 had left the ship at Cartagena, the only infected 
 port at which she had touched. He arrived in. 
 Panama January 6, and after being in Panama 
 six days, he developed yellow fever, of which he 
 died on January 24. The symptoms were well 
 marked, and an autopsy confirmed the diagnosis. 
 
 As far as we knew, there had not been a case of 
 this disease in Panama for four years, and the 
 stegomyia were so scarce that we did not believe 
 that yellow fever could be transmitted. The poor 
 fellow, just before he died, told Dr. William 
 Deeks, his attending physician, that on the night 
 during which they were anchored in the Bay of 
 Cartagena, the first mate and himself had slipped 
 off unobserved in one of the ship's boats, spent 
 
 267 
 
SANITATION IN PANAMA 
 
 the night in Cartagena, and had gotten back to 
 the ship before daylight. This confession at once 
 cleared up the case. He had evidently been bit- 
 ten by a stegorayia mosquito while in Cartagena. 
 Had it not been for his confession, the evidence 
 would have been very strong that in some way 
 the disease had been contracted in Panama. 
 
 During 1899 we had the most curious case in 
 Havana of infection in the person of a nun, Sister 
 Maria de los Angeles, a Dominican nun, and a 
 native of France. She had come direct to New 
 York from Europe, on the steamship Celtic, re- 
 mained there two days, and then took the AVaid 
 Line steamer Vigilancia for Havana. The trip 
 from New York to Havana by this steamer oc- 
 cupies four days. 
 
 The nun reached Havana September 8. She 
 was feeling badly, though she did not give up her 
 duties on that account. On September 11 slu* was 
 taken sick with a chill, and died with well-marked 
 yellow fever on the sixteenth. 
 
 The circumstances were such that the Board 
 was convinced that she had contracted the disease 
 on board ship, and not in Havana. She must have 
 gotten it in some way between New York ami 
 Havana. She could not have been infected in 
 New York, as there had been no yellow fever there 
 during the preceding twenty years. The steamer 
 under discussion plied between Vera Cruz, Mex- 
 
 268 
 
QUARANTINE SYSTEM 
 
 ico and New York City, touching at Havana both 
 going and coming. 
 
 We found that the records of the ship showed 
 that the last case of yellow fever aboard had oc- 
 curred on the second trip before the one under 
 consideration, antedating the time the nun was 
 aboard by about a month. This was in the person 
 of a passenger from Vera Cruz, who was taken 
 off at the quarantine station at New York. He 
 occupied the stateroom that afterwards was occu- 
 pied by the nun on her trip to Havana. Such an 
 instance twenty years before would very readily 
 have been explained as an instance of infection 
 from the room, but we now know that yellow fever 
 can be contracted only through the bite of an in- 
 fected female stegomyia mosquito. No other case 
 had 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 passenger 
 sick with yellow fever during the trip up to New 
 York; that this mosquito remained in this room 
 for nearly a month, biting the unfortunate nun 
 soon after she got aboard. 
 
 As no other cases occurred afterwards, it is 
 quite probable that the nun killed the mosquito 
 at the time of the biting. It is also probable that 
 some immune occupied this room on the trip up 
 from Vera Cruz to New York City, who would 
 
 269 
 
SANITATION IN PANAMA 
 
 not be injured even if the mosquito bit him. On 
 the preceding trip down from New York to Vera 
 Cruz the person occupying the room would not 
 have been injured by the biting of the mosquito, 
 even if the person had been a non-immune, as the 
 mosquito requires two weeks from the time she 
 bites a yellow-fever patient before she herself be- 
 comes infectious. The preceding trip down was 
 within this two weeks' period of non-infectious- 
 ness in the mosquito. At first blush, the case cer- 
 tainly appeared very mysterious. How was it 
 possible for a person coming from France via 
 New York to Havana, to have yellow fever when 
 she reached Havana ! 
 
 In 1904, when we first reached Panama, yellow 
 fever 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. On 
 the Caribbean Sea, within from one to three days' 
 sail, Cartagena, Colombia, Porto Caballo, La 
 Guira, Venezuela, the port of Caracas, and other 
 ports were having yellow fever. On the Gulf of 
 Mexico, Vera Cruz, Mexico, was an endemic center. 
 Progreso, the capital of Yucatan, was also having 
 this disease. In 1905, New Orleans, Louisiana, 
 had a sharp epidemic of yellow fever. With all 
 these places we had frequent and close commercial 
 
 270 
 
QUARANTINE SYSTEM 
 
 relations. In 1906, Cuba had some yellow fever 
 at 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 coast 
 of South America, and this disease occurred spo- 
 radically at ports on the Caribbean Sea and the 
 Gulf of Mexico. Quite a number of cases of 
 plague developed in New Orleans during 1914. 
 Our quarantines had to look after this disease in 
 the same manner that yellow fever was guarded 
 against. 
 
 I have already mentioned that in 1905 plague 
 established itself at La Boca and Ancon, in spite 
 of our quarantines. This is no reflection upon our 
 quarantine system. I am glad to say that under 
 the administration of Dr. Henry E. Carter and Dr. 
 James A. Perry, our quarantines were as efficient 
 as could be found anywhere, but the very best 
 quarantine will at some time allow a case of in- 
 fectious disease to pass. Such accidents cannot 
 be entirely prevented, except by the entire aboli- 
 tion of commerce. 
 
 For the care of passengers and ships under 
 quarantine, we built two quarantine stations, one 
 at the north end of the Canal on the Caribbean 
 Sea, the other at the south end on an island in the 
 bay of Panama. 
 
 Culebra Island, on which was located the Pan- 
 
 271 
 
SANITATION IN PANAMA 
 
 ama quarantine station, is an island of four or five 
 acres in extent, the center of the group of islands 
 on which are now located the fortifications pro- 
 tecting the southern mouth of the Canal. These 
 islands are mountain tops projecting from fifty 
 to three hundred and fifty feet above the surface 
 of the waters of the bay of Panama. They are 
 heavily wooded, and are very picturesque in ap- 
 pearance. They are now connected with each 
 other and with the mainland by an artificial cause- 
 way, built during the period of Canal construc- 
 tion by dumping here the spoil from Culebra 
 Cut. 
 
 On Culebra Island, nine or ten comfortable and 
 substantial frame buildings were erected, capable 
 of caring for some three or four hundred persons. 
 They consisted of two small hospitals, divided so 
 that five or six different kinds of contagious dis- 
 eases could be cared for, if necessary, at the same 
 time ; a large barrack building with a capacity of 
 two hundred beds for the care of steerage pas- 
 sengers, divided into a male and female side; a 
 large 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 the 
 employees of the station; a smaller building for 
 the dispensary, doctor's office and administration, 
 
 272 
 
QUARANTINE SYSTEM 
 
 and a comfortable residence for the doctor and 
 his family. 
 
 The station was well equipped for making the 
 different classes of passengers comfortable, and 
 for the care of the sick. In connection with the 
 station we kept equipped a self-propelling barge 
 of about one hundred tons capacity. This vessel 
 was named the Walter Reed, and was supplied 
 with modern machinery for generating sulphur 
 fumes and pumping these fumes aboard the ship to 
 be fumigated. 
 
 These islands are about three miles from the 
 mainland. There was no more desirable place 
 about Panama in which to spend a week than the 
 quarantine station. The site was as picturesque 
 and attractive as could be desired, and its location, 
 three miles out in the bay, made the temperature 
 cool and agreeable. I have to confess that, as a 
 general thing, the passengers quarantined at 
 Culebra 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 held 
 at the quarantine station for several days, in 
 order that his quarantine period might be com- 
 pleted. When the time had expired, he came to 
 the city of Panama, took a look around, remem- 
 bered the beauty and comfort of Culebra Island 
 and the quarantine station, and concluded that he 
 
 273 
 
SANITATION IN PANAMA 
 
 would like to take his family, return to the island, 
 and stay there until his ship sailed. This we 
 gave him permission to do, and he and his family 
 remained at Culebra about a week after his quar- 
 antine period had expired. This established the 
 reputation of the Panama quarantine as being a 
 salubrious, delightful and desirable place in which 
 to be detained. 
 
CHAPTER XXI 
 
 MEASURES AGAINST BUBONIC PLAGUE 
 
 T N 1906, when our malarial rate was highest, 
 * we had eight hundred out of every thousand of 
 our employees admitted to hospitals on account 
 of malaria. In 1913 we had only seventy out of 
 every one thousand of our laborers admitted for 
 this disease. The yearly table for malarial rate 
 is as given below : 
 
 1906 821 per 1,000 
 
 1907 
 
 426 
 
 " 1 000 
 
 1908 
 
 282 
 
 " 1,000 
 
 1909 
 
 215 
 
 " 1 000 
 
 1910 
 
 187 
 
 " 1,000 
 
 1911 . 
 
 184 
 
 " 1 000 
 
 1912 
 
 110 
 
 " 1 000 
 
 1913.. 
 
 76 
 
 " 1.000 
 
 Yellow fever was entirely eradicated. In 1904 
 we had a few cases, and in 1905, a sharp epidemic. 
 In November, 1905, the last case occurred in the 
 city of Panama, and in May, 1906, the last case in 
 
 275 
 
SANITATION IN PANAMA 
 
 the town of Colon. Since that time no cases have 
 originated 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 the 
 hospital with symptoms of bubonic plague. The 
 name 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, a 
 quarantine was placed against La Boca. Dr. 
 James Perry, of the United States Public Health 
 Service, was placed in charge. He was supplied 
 with a force of four foremen and one hundred 
 laborers, who under his direction did the neces- 
 sary cleaning and fumigation. This quarantine 
 was kept up until July 15, when it was raised, as 
 there was no further indication of plague or 
 plague-infected rats. 
 
 Dr. Perry deserves the greatest credit for the 
 efficient way in which he managed to stamp out 
 this infection, so threatening and dangerous to the 
 work. 
 
 Plague is an infectious disease caused by a well- 
 known germ, the bacillus pestis. It is a disease 
 of the rat, and is transferred from the rat to a 
 human being by the rat flea. Anti-plague meas- 
 ures are, therefore, almost entirely directed to- 
 ward the destruction of rats. Eigid quarantines 
 are also kept up, so as to prevent human beings 
 
 276 
 
MEASURES AGAINST BUBONIC PLAGUE 
 
 sick with the disease from going to uninfected 
 places, and there starting new foci of infection. 
 
 The measures used against rats are poisons of 
 various kinds, but the rat is one of the most in- 
 telligent of animals, and soon learns to avoid 
 poisons. The same thing is true with regard to 
 traps. Eats so rapidly learn about poisons and 
 traps that some writers on anti-plague measure^ 
 advise that these measures be used only during 
 emergencies, when plague is either present, or 
 there is imminent danger of an outbreak, the argu- 
 ment being that if you use these measures con- 
 tinuously, the rats will become so knowing that 
 you cannot kill them when plague is upon you 
 and 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 in 
 a rat runway gave no notice to the rat whatever, 
 and always killed him. But it requires some skill 
 to manipulate such a trap, and our Jamaican 
 darkies were so often shocked in trying to arrange 
 it 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 principally 
 to rat-proofing the houses. In a general way, these 
 measures consist in making a concrete floor, and 
 in putting six or eight inches of concrete in the 
 
 277 
 
SANITATION IN PANAMA 
 
 wall around this floor. With the whole town fixed 
 up in this way, you would have no rats. At the 
 same time, disposal of garbage should be carefully 
 looked after, with the object of limiting the food 
 supply of rats. 
 
 Dr. Connor, of Colon, invented an excellent gar- 
 bage stand, so arranged that a lid automatically 
 closed the garbage can whenever the lid had been 
 raised and released. If, however, a town has been 
 made entirely rat-proof, that town is pretty secure 
 from plague. If there are no rats there, no liana 
 will be done, even if cases of plague come in, for 
 there would be no means of transmitting it from 
 man to man. If you have plenty of rats in a com- 
 mercial city, such as Panama, in direct commercial 
 relation with cities having plague, you are sure, 
 in the course of time, to get in plague cases, no 
 matter how good your quarantine, and if plague 
 once gets in where there are plenty of rats it is 
 very apt to spread. 
 
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 has 
 enabled this work to be carried through with a 
 minimum of loss, both in regard to sickness and 
 death among employees engaged in construction 
 work in the Canal Zone. We have no means of 
 telling what was the sick rate with the French 
 during the period of construction under the old 
 French Company, from 1881 to 1889, but we know 
 that it was very large. 
 
 Our Army in Cuba during the Santiago cam- 
 paign had during the last two months of our stay 
 there a constant sick rate of over six hundred per 
 thousand. Undoubtedly, the French rate approxi- 
 mated this during their period of active work, and 
 we can safely calculate that their constant sick 
 rate was at least three hundred and thirty-three 
 per thousand, or one-third their force. 
 
 279 
 
SANITATION IN PANAMA 
 
 Our force during the ten years of construction 
 averaged thirty-nine thousand men. If we had 
 had a similar constant sick rate, we should have 
 had 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 per 
 thousand sick each day, a total of nine hundred 
 for the whole force; that is, we had about twelve 
 thousand fewer men sick every day than had the 
 French. This twelve thousand men per day saved 
 from sickness must be credited to the sanitary 
 work 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, and 
 for the ten years 3,285,000 days of sickness. If 
 our rate had been 300 per 1,000, a very moderate 
 figure compared with what it was under the 
 French, we should have had 11,700 sick every day. 
 For th'e year, this would have given us 4,270,500 
 days of sickness and for the ten years, 42,705,000, 
 a saving of 39,420,000 days of sickness during this 
 period. This saving must justly be credited to 
 sanitation. 
 
 It cost us about one dollar a day to care for a 
 sick man on the Isthmus. The Commission cared 
 for the sick free of charge. Every day, therefore, 
 of sickness prevented on the Isthmus lessened the 
 expense which the Commission had to bear by one 
 
 280 
 
THE SANITARY DEPARTMENT OF PANAMA 
 
 dollar. The Commission was therefore saved by 
 this sanitary work, if we consider the whole ten 
 years of construction, $39,420,000. 
 
 This represents only one phase of the saving due 
 to sanitation, merely the saving due to decrease 
 in the numbers of sick who had to be cared for. 
 But the sanitary work really saved much more 
 than this. If three hundred men out of every one 
 thousand of our employees had been sick every 
 day, the efficiency of the other seven hundred would 
 have been correspondingly decreased. The other 
 seven hundred would have been more or less de- 
 bilitated, and more or less depressed, and the 
 amount of work turned out daily by each man 
 would have been considerably less than it actually 
 was for the employee enjoying good health and 
 cheerful surroundings. We should have had to 
 pay considerably higher wages, if the Isthmus had 
 continued to bear the reputation during our period 
 of construction which it had always borne during 
 the years preceding 1904; if, for instance, it had 
 been known that three out of every ten men going 
 to 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 end 
 of five years. 
 
 Great loss was caused to us in the first years 
 on the Isthmus by the demoralization among the 
 working force, and almost stoppage of work which 
 
 281 
 
SANITATION IN PANAMA 
 
 took place during periods of exacerbation in the 
 yellow-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 condition 
 of his force as the result of such conditions. Mr. 
 Bunau-Varilla was one of the most prominent of 
 the French engineers for the old French Company, 
 and was their chief engineer from 1885 to 1887. 
 
 I do not think that anyone familiar with the 
 conditions would question the statement that a 
 larger sum in dollars and cents was saved to the 
 Commission in these ways than \vas saved by the 
 direct decrease in the number of sick. 
 
 Considering all these factors, it will not be con- 
 sidered an exaggerated estimate to state that 
 eighty million dollars was saved to the United 
 States Government by the sanitary work done on 
 the Isthmus during the ten years of construction. 
 That is, granting that the construction work could 
 have been accomplished under such conditions as 
 had existed during the construction period of the 
 old French Company, or which existed on the 
 Isthmus of Panama at any time prior to 1904, and 
 granting that public sentiment in the United 
 States would have allowed the prosecution of the 
 work with such mortality among the laboring force 
 as had previously occurred, it would have cost the 
 United States eighty million dollars more than it 
 
 282 
 
THE SANITARY DEPARTMENT OF PANAMA 
 
 actually did cost to accomplish the results it has 
 attained on the Isthmus. 
 
 I go into these figures to demonstrate that there 
 is great financial profit resulting from money spent 
 on such sanitary measures as we inaugurated on 
 the Isthmus. This is the purely commercial side 
 of the question. Of much greater importance is 
 the moral argument that can be adduced from the 
 saving of life and suffering that results from such 
 measures. 
 
 During the ten years of construction, we lost by 
 death seventeen out of every thousand of our 
 employees each year. That is, from the whole 
 force of 39,000 men, 663 died each year, and for 
 the whole construction period we lost 6,630 men. 
 If sanitary conditions had remained as they had 
 been previous to 1904, and we had lost, as did the 
 French, two hundred of our employees out of each 
 one thousand on the work, we should have lost 
 7,800 men each year, and 78,000 during the whole 
 construction 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 one 
 man died, probably three would have returned 
 home broken in health, with months and years of 
 suffering and invalidism ahead of them. Sanita- 
 tion on the Isthmus has saved this heavy toll to 
 the devoted people engaged in this great work, 
 
 283 
 
SANITATION IN PANAMA 
 
 and was, therefore a most wise and lucrative in- 
 vestment to our Government, and played a most 
 important part in aiding the construction work in 
 that great enterprise. 
 
 But I believe that this aiding in the construction 
 of the Canal is not the most important function 
 that the sanitary work at Panama has played. The 
 Canal Zone, for the past four hundred years, ever 
 since it has been known by the white man, has been 
 one of the most unhealthy spots in all the tropical 
 world, and this fact has been generally known and 
 recognized 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 man 
 could not live and thrive with such conditions and 
 surroundings as existed there. It seemed to be 
 demonstrated that there was* something in the 
 climate that sapped his constitution and broke his 
 health. This statement applies to white children 
 to an even greater extent than to the adult. 
 
 The great colonizing nations had been the Span- 
 iards, the Portuguese, the Dutch, the French and 
 the English. Their experience had all been ex- 
 actly similar from the beginning of the sixteenth 
 century to the present time that the white man 
 could not live and thrive in the tropics, nor could 
 he leave behind him in those regions a healthy 
 
 2S4 
 
THE SANITARY DEPARTMENT OF PANAMA 
 
 progeny. By all men everywhere it was believed 
 that this was due to tropical climatic conditions, 
 which could not be combated, and that therefore 
 the white man was permanently barred from 
 building up any great civilization in these regions. 
 
 Man, like all other animals, must necessarily 
 have developed in one locality. If we accept the 
 modern explanation, generally received by edu- 
 cated persons, Darwinism, all life at present on 
 the globe must have descended from one single 
 cell. If we take some individual animal at present 
 living, a dog, for instance, we could trace his an- 
 cestry back to the first cell, if we could obtain all 
 the facts in the case. By very slow changes, genus 
 after genus and species after species developed 
 from this first cell, each genus and each species 
 differing slightly from the one preceding. 
 
 An individual varying very slightly from the 
 other individual of his species, becomes the pro- 
 genitor of a new species, provided the variation 
 accords with his surroundings so as to fit him 
 better for the struggle of life. But all of the 
 new species must descend directly from the one 
 pair which produces these favorable variations 
 in their progeny. Every species, therefore, such 
 as the dog, must originate in some one locality. 
 If at any time this species of animal is found in 
 all parts of the world, it must have slowly spread 
 from the locality in which it originated. The dog, 
 
 885 
 
SANITATION IN PANAMA 
 
 therefore, came to his present development in 
 some one part of the world. As he is now found 
 in all parts of the world, he must have spread 
 from this one locality in which he originated. 
 
 Exactly the same argument applies to man. If 
 we consider man's condition in his earlier stages, 
 we can see that there must have been a period 
 when he had neither fire nor clothing. At this time 
 he must have lived in parts of the world where 
 the temperature was that now found between tho 
 tropics of Cancer and Capricorn. As we know 
 him now, he could survive the year around with- 
 out fire and clothing only within this region. Ho 
 might 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 to 
 spend a winter in the latitude of Washington, 
 without either fire or clothing, would be alive 
 when the warm weather of spring returned. It 
 is pretty certain, therefore, that man lived exclu- 
 sively in the tropics, up to the discovery of fire 
 and clothing. 
 
 There was a period, then, in man's existence 
 when the environment found in the tropics was 
 better suited to his life than that found in the 
 present temperate zones. Conditions gradually 
 changed, until affairs were exactly reversed, and 
 the temperate regions became better suited for 
 man's healthy life than the tropical regions. This 
 
 286 
 
THE SANITARY DEPARTMENT OF PANAMA 
 
 was the condition of affairs when we first begin 
 to get some knowledge of man, at the early dawn 
 of history. When we first begin to learn any- 
 thing about him historically, the most vigorous 
 and healthy races, mentally and physically, were 
 to be found in the temperate zones. The condi- 
 tions that brought about this change of habitat 
 in man were probably the spread of the various 
 infectious diseases within the tropics. The hot 
 tropical regions were much better fitted for the 
 life of the germs which caused these infectious 
 diseases than were the temperate regions, for ex- 
 actly the same reasons that these tropical regions 
 better suited the life and development of man. 
 Due to his superior intelligence and superior 
 powers of locomotion, man was enabled to spread 
 through and occupy the tropical regions long be- 
 fore the germs of the various infectious diseases 
 were able to do so. 
 
 Yellow fever, for instance, was able to extend 
 very little beyond the region where it originally 
 developed, until man came along with his ships, 
 and in this way enabled the yellow-fever germ 
 to begin its travels about the world. As yellow 
 fever developed in America, the germ did not 
 begin its travels until Columbus brought his ships 
 into the Caribbean Sea. As the infections spread 
 through the tropics, the environment in those re- 
 gions became unfavorable to man, to such an ex- 
 
 287 
 
SANITATION IN PANAMA 
 
 tent that he ceased to be able to improve in his 
 mental and physical characteristics. But as the 
 environment of regions outside the tropics was 
 still more unfavorable, actually deadly, he had no 
 escape. 
 
 At this period, then, man found himself inhab- 
 iting tropical regions where sanitary conditions, 
 the infections, were very unfavorable to him, and 
 he was unable to migrate to the temperate zones, 
 because the sanitary conditions there, cold, wcro 
 deadly 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 our 
 tropical ancestors. The greatest sanitarian that 
 the human race has ever produced was probably 
 the individual who discovered fire, and next in 
 importance, the individual who first wore some 
 kind of clothing. These two discoveries enabled 
 man to overcome the hitherto insurmountable 
 sanitary obstacle of the temperate regions, name- 
 ly, cold. With the application of these two sani- 
 tary discoveries, the human race was enabled to 
 migrate from the tropics and continue healthy 
 development in the temperate regions. 
 
 At the present time, we have just reversed tho 
 process; we have just made sanitary discoveries 
 that will enable man to return from the temper- 
 ate regions to which he was forced to migrate 
 
 288 
 
THE SANITARY DEPARTMENT OF PANAMA 
 
 long ages ago, and again live and develop in his 
 natural home, the tropics. These sanitary dis- 
 coveries are those that have enabled us to control 
 yellow 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 the 
 first demonstration with regard to either disease. 
 But the conditions were such at Panama that 
 they have attracted the attention of the whole 
 world, and probably the general knowledge that 
 the white man can live and thrive in the tropics 
 will date in future times from the construction of 
 this great work. 
 
 A given amount of labor applied to land will 
 produce a very much larger amount of wealth 
 than will the same labor applied in the same way 
 produce in the temperate regions. The white 
 man, of all the races of the human family, is the 
 most eager in his pursuit of wealth. As it be- 
 comes generally known that he can live in the 
 tropics and maintain his health, necessarily a 
 large emigration will occur from the present 
 civilized temperate regions to the tropics. The 
 largest areas of land suitable for cultivation lie 
 in the tropics, and much the largest bodies of rich 
 alluvial lands, such as the valleys of the Amazon 
 and the Congo. Not only are these lands more 
 productive than the lands of the temperate zone, 
 
 289 
 
SANITATION IN PANAMA 
 
 but climatic conditions enable the farmer to pro- 
 duce several crops a year. The tropics, when 
 occupied and cultivated by the white man, will 
 produce many times the amount of food now pro- 
 duced in the temperate regions. 
 
 The great civilizations of man are now already 
 established and developed in the temperate zones 
 of Europe and America, and it is probable that, 
 for centuries to come, these great empires will be 
 located where they are at present, and that the 
 tropics will be the agricultural, food-producing 
 regions from which these centers of civilization 
 will be supplied. 
 
 In the early stages of the development of man- 
 kind it was all that each individual could do to 
 supply his own necessities. As he advanced in 
 civilization, he produced more than he himself 
 needed, and thereby had a surplus to exchange 
 with his neighbors for things which he desired. 
 As his productive capacity increased, a larger 
 number of men were enabled to apply themselves 
 to the arts and sciences. The degree of civiliza- 
 tion to which a community can reach is in the 
 main governed by the amount of the necessities 
 of life that the labor of one man applied to the 
 land can produce. If one man's labor can pro- 
 duce enough of the necessities to support himself 
 and one other man, we have a certain degree of 
 civilization and refinement. If his labor produces 
 
 290 
 
THE SANITARY DEPARTMENT OF PANAMA 
 
 enough to support himself and two other men, a 
 higher 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 same 
 amount of labor applied in any other part of the 
 world. In the long run, therefore, the great civ- 
 ilizations of the future will be located in the. 
 tropics. 
 
 No doubt the great centers of civilization will 
 remain for centuries much as they are at present. 
 The white settlers will go to the valleys of the 
 Amazon and Congo, building up large agricul- 
 tural communities which will supply the Euro- 
 pean and American centers located as they are at 
 present with their food supply. But in the course 
 of ages the centers of civilization will move to 
 where a given amount of labor will produce the 
 largest amount of food. Of course, other things 
 must be equal. I am assuming that the govern- 
 ment in these new communities is as good as the 
 government with which we are comparing it in 
 the temperate zone. When this great migration 
 of population has fully commenced, I believe that 
 the peoples of that day will look back upon the 
 sanitary work done at the Canal Zone as the first 
 great demonstration that the white man could live 
 as 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 
 
 291 
 
SANITATION IN PANAMA 
 
 important than the actual construction of the 
 Canal itself, as important to the world as this 
 great waterway now is, and will be for genera- 
 tions to come. 
 
 The discovery of the Americas was a great 
 epoch in the history of the white man, and threw 
 large areas of fertile and healthy country open 
 to hi^ settlement. The demonstration made at 
 Panama that he can live a healthy life in the 
 tropics will be an equally important milestone in 
 the history of the race, and will throw just as 
 large an area of the earth's surface open to man's 
 settlement, and a very much more productive 
 area. 
 
INDEX 
 
 Agramonte, Dr., 11, 16, 41. 
 Albertini, Dr. Antonio, 12. 
 American Medical Associa- 
 tion, interest of, in 
 Panama 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. 
 
 Augustin, on yellow fever, 
 
 117. 
 Avila, Pedro Arias de. See 
 
 Pedrarias. 
 
 Balboa in Panama, 132, 133, 
 
 134, 135, 168. 
 Bubonic plague in Panama, 
 
 271, 276-278. 
 
 Camp Columbia, yellow-fever 
 experiments 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, against 
 mosquitoes, 199. 
 
 Coffin story, 240. 
 
 293 
 
INDEX 
 
 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. Samuel, 190, 
 
 238. 
 Davis, George W., General, 
 
 152. 
 
 Decks, Dr. W. W., 238. 
 Dispensaries in Panama, 213, 
 
 220-2:23. 
 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. 
 
 Emergency and temporary 
 
 hospitals in Panama, 
 
 210. 
 Emigration, effect of control 
 
 of tropical disease on, 
 
 289, 293. 
 
 Finlay, Dr. Carlos, mosquito 
 theory of, 13, 14, 27. 
 
 Flemenco Island cemetery, 
 
 215. 
 French Panama Canal Co., 
 
 hospital service of, 224- 
 
 227. 
 yellow fever and malaria 
 
 under, 138, 149, 227. 
 Fumigation for yellow fever, 
 
 52, 53, 54/55, 150, 151, 
 
 261, 263. 
 
 Garbage disposal as anti- 
 plague measure, 278. 
 
 Gillette, Cussius E., Major 
 143. 
 
 Grass-cutting in anti-malarial 
 work, 187. 
 
 Guiteras, Dr. John, 12, 41, 45, 
 48. 
 
 Havana, sanitary measures in, 
 
 5, 6, 5C 
 yellow fever in, 3-7, 22, 23, 
 
 41, 125. 
 
 "Her ladyship," 43-46. 
 Herrick, Dr. A., 238. 
 Hospital system in Panama, 
 
 207-1214, 223. 
 dispensaries in, 213-214, 
 
 220-223. 
 
 equipment in, 207-210. 
 medical districts in, 212- 
 
 214. 
 transportation of sick in, 
 
 210, 211. 
 
 Hospitals, emergency and 
 temporary, in Panama, 
 210. 
 Hygiene Congress, Gorgas, 
 
 Win. C., at, 141. 
 value of certificate of, 25. 
 
 294 
 
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 of 
 mosquito theory at, 48. 
 
 Kerosene oil, in anti-malarial 
 
 work, 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's 
 
 researches, 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 board 
 experiments 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 
 
INDEX 
 
 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, different species 
 compared, 191-195. 
 
 Mount Hope cemetery, 216. 
 
 Mott, Dr. J. C., 13. 
 
 Panama, fumigation for yel- 
 low fever throughout, 
 150, 151. 
 hospital service in, 207-21 -1, 
 
 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, Board 
 of, 10. 
 
 Pyrethrum, fumigation with, 
 54, 263. 
 
 Quarantine, for bubonic 
 
 plague, 276. 
 for vellow fever in Havana, 
 
 *63, 64, 72. 
 in Panama, 260. 
 Quinin, dispensation of, 220- 
 223. 
 
 Rats, relation of, to bubonic 
 plague, 276-278. 
 
 Reed, Dr. Walter, mosquito 
 experiments of, 16, 19- 
 21, 26, 30-36, 38, 41. 
 on Sanan-lli 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 Bias Indians, 167-174. 
 Sanarelli, Giuseppi, \vllo\v- 
 fever researches of, 7- 
 11. 
 
 Sanarelli's organism, Army 
 board 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 
 
INDEX 
 
 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 for 
 yellow fever and, 52- 
 55. 
 
 screens and, 50-52. 
 water supply and, 56-62. 
 in Panama, drainage and, 
 
 184-195, 201. 
 fumigation for yellow 
 fever 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, to 
 
 human race, 289-293. 
 in Africa, 127. 
 in Brazil, 126. 
 incubation period for, 10, 
 
 27-30, 38. 
 in Ecuador, 24, 119. 
 
 297 
 
INDEX 
 
 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 infection 
 
 cases 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. See 
 Mosquito, yellow-fever. 
 Yellow-fever vaccination, 42, 
 47. 
 
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 II