Isthmian Canal Commission 
 
 SANITARY CONDITIONS ON THE 
 ISTHMUS OF PANAMA 
 
 REPLY OF THE 
 ISTHMIAN CANAL COMMISSION 
 
 TO THE 
 
 REPORT OF DR, C. A. L, REED 
 
 WITH 
 
 LETTERS OF -THE PRESIDENT AND 
 SECRETARY OF WAR 
 
 IN REFERENCE THERBTO 
 
 WASHINGTON, D. C. 
 1905 
 

TABLE OF CONTENTS. 
 
 1 . Letter of the Secretary of War to the President transmitt- 
 
 ing the reply of the Isthmian Canal Commission to the 
 report of Dr. C. A. L. Reed. 
 
 2. Letter of the President to the Secretary of War in reply 
 
 thereto. 
 
 3. Letter to the Chairman of the Commission from the Sec- 
 
 retary of War transmitting the report of Dr. Reed. 
 
 4. Letter of the Isthmian Canal Commission to the Secretary 
 
 of War in reply to Dr. Reed. 
 
 5. Report of Dr. C. A. L. Reed to the Secretary of War. 
 
t/,S. Isthmian Canal Commission 
 
 SANITARY CONDITIONS ON THE 
 ISTHMUS OF PANAMA 
 
 REPLY OF THE 
 ISTHMIAN CANAL COMMISSION 
 
 TO THE 
 
 REPORT OF DR. C. A. L. REED 
 
 WITH 
 
 LETTERS OF THE PRESIDENT AND 
 SECRETARY OF WAR 
 
 IN REFERENCE THERETO 
 
 WASHINGTON, D. C. 
 1905 
 
l^^ 
 
 
War Department^ 
 Washington^ D. C, March 17 , ^9^5- 
 To THE President : 
 
 I herewith transmit the answer of the Commission to 
 the charges contained in the report of Dr. C. A. L. Reed, 
 to me as to the sanitary provisions made by the Isthmian 
 Canal Commission on the Isthmus. 
 
 I think that a reading of the two documents will show 
 what indeed was apparent on the face of Dr. Reed's 
 statement — that his charges against the Commission 
 were biased and controversial, and not written in the 
 judicial spirit that inspires confidence in their justice and 
 accuracy. 
 
 Dr. Reed visited the Isthmus at my request to act 
 as an assessor of land upon a commission provided by 
 the treaty between Panama and the United States, but 
 as he was the head of the American Medical Association, 
 it seemed to me an opportunity on his return to secure 
 information from one skilled in his profession as to the 
 existing conditions upon the Isthmus. In response to 
 my queries he was so emphatic and so detailed in his 
 charges that I asked him to make his statement in writ- 
 ing, which he did upon the same day by the use of a 
 stenographer. It is probable that had he taken more time 
 he would have been more measured in his criticisms, 
 less extreme in his statements, and less flippant in his 
 references to the action of the Commission. The report 
 of Dr. Reed was published without my knowledge or 
 consent. 
 
 The reply of the Commission seems to show that a 
 large part of the plans and the action of the Commission 
 which Dr. Reed criticises was fully concurred in and 
 
agreed to by Colonel Gorgas and the other medical of- 
 ficers in the employ of the Commission. It is doubtless 
 true that Colonel Gorgas and his staff believed that it 
 would be wiser to give them an entirely free hand in 
 the matter of ordering construction, supplies and the 
 employment of subordinates. It is quite probable that 
 had the approval of the Commission in the matter of 
 ordering construction and supplies been dispensed with 
 there would have been fewer delays and less complaint 
 on this account; but in the expenditure of such large 
 sums as were necessary for the organization of the sani- 
 tary system, the construction of plant and the purchases 
 of supplies, it may well be doubted whether the Com- 
 mission would have been discharging its duty in with- 
 holding supervisory control. 
 
 It is doubtless true that there have been undue delays 
 in the furnishing of what was needed for sanitary pur- 
 poses on the Isthmus, but I venture to think that this is 
 due rather to the inherent clumsiness of the Commission 
 as an executive body than to the neglect or willful non- 
 action of any member of that board. There must be 
 some restraint for purposes of economy upon expendi- 
 tures, by an executive who has in mind the total expendi- 
 tures and obligations being incurred. To allow each 
 department to expend what in its judgment is necessary 
 will certainly lead to extravagances and waste. The 
 remedy for the delays which may have occurred here 
 are, it seems to me, to be found in a rearrangement of 
 the Commission, with a new distribution of powers and 
 the conferring of the executive on one or, at the most, 
 not more than three members of the Commission, with 
 a general supervisory and confirmatory power in the 
 Commission as a body. 
 
 With your permission, I will submit in a day or two a 
 plan for the better carrying on of the work of the Com- 
 
mission which may be embodied in a new series of in- 
 structions. Respectfully yours, 
 
 Wm. H. Taft^ 
 Secretary of War. 
 
 White House, 
 Washington,, March 20, 1905- 
 The Secretary of War : 
 
 I have received your report of March 17th, together 
 with the report of Dr. Reed and the answer thereto made 
 by the Commission. It appears from this that Dr. Reed's 
 report (which, of course, should under no circumstances 
 have been given to the public until you chose so to give 
 it, and until the answer thereto had been made by the 
 Commission) was, without your knowledge, printed in 
 the medical journals. 
 
 It further appears that the statements which he thus 
 published were in many instances unwarranted by the 
 facts, and his accusations in many instances unsupported 
 by proof. 
 
 Dr. Reed has not displayed in this report the qualities 
 of temperament or the power of accurate judicial obser- 
 vation needed to make a report valuable to the Govern- 
 ment. It is true that he was not charged with the duty 
 of making such a report, and that he was appointed to 
 be a commissioner to assess value of real estate. Never- 
 theless, when he assumed to make a report on sanitary 
 conditions at your request as Secretary of War, he was 
 under obligation to speak with care and justice on so 
 important a subject and to observe the proprieties as to 
 its publication. 
 
 Judging from your report, it appears that the chief 
 difficulties that have arisen have come from the inherent 
 faultiness of the law under which the Commission was 
 appointed. It further appears, however, that in view of 
 
6 
 
 our experience with the workings of the Commission, a 
 rearrangement of duties and a change of personnel in 
 view of this rearrangement should be made. I am glad 
 that you are shortly to submit to me a plan with these 
 objects in view. 
 
 Theodore Roosevelt. 
 
 War Department, 
 Washington, March 6, 1903. 
 (confidential.) 
 My Dear Admiral : 
 
 I enclose herewith a report made to me by Dr. C. A. L. 
 Reed, one of the Commissioners whom the President 
 appointed to assess property on the Isthmus. 
 
 Dr. Reed is the president of the American Medical 
 Association, and as such took much interest in the sani- 
 tary provisions for meeting the dangers from disease in 
 Panama. He has accordingly written this report. It 
 is so extreme in many of its statements that, though I 
 should place it on my confidential files only, I feel that 
 in justice to your Commission even there it should be 
 accompanied by such comment as your Commission 
 might desire to make upon it. The bias of Dr. Reed is 
 evident in the tone of the letter, but he makes a number 
 of statements of fact which it is possible you or some 
 member of the Commission may desire to controvert, 
 and which certainly you ought to have an opportunity to 
 deny if existing conditions justify and require it. 
 
 Very sincerely yours, 
 
 Wm. H. Taft. 
 Rear- Admiral John G. Walker, U. S. N. (Retired), 
 Chairman, Isthmian Canal Commission. 
 (enclosure.) 
 P. S. — I ought to have said that I showed this report 
 to the President, and that any answer which it may be 
 thought wise to make to it will also be submitted to him. 
 
K^- 
 
 March i6, 1905. 
 The Hon. Wm. H. Taft^ Secretary of War. 
 
 Sir: — The Commission has given such consideration 
 to the letter addressed to you under date of March 2, 
 1905, by Dr. C. A. L. Reed as time that could be spared 
 from the urgent duties of the office since its receipt on 
 March 7th has permitted. 
 
 The letter is so full of misstatements that it has been 
 thought advisable to answer it at considerable length, 
 even though the tone thereof should be sufficient evi- 
 dence that it is the product of a strangely biased mind. 
 
 The Health Department was preliminarily organized 
 in May, 1904, a few days after the canal properties came 
 into possession of the United States. 
 
 The permanent organization of this department was 
 under consideration during the stay of the Commission 
 on the Isthmus in the summer of 1904, during all of 
 August, having been adopted on September 2d. Com- 
 missioner Grunsky took a special interest in the affairs 
 of the Health Department and the sanitary work on the 
 Isthmus, and assisted the Medical Staff in planning the 
 permanent organization, being in frequent conference 
 with the physicians and submitting to the Commission 
 the result of the deliberations. It was at once apparent 
 to the Commission that it would not be possible to accept 
 in their entirety the recommendations and suggestions 
 made by the Chief Sanitary Officer, which included such 
 matters as the immediate taking over and management 
 by the United States of the San Tomas Hospital, one of 
 the public institutions of the Republic of Panama, lo- 
 cated in Panama; the taking over and management of 
 the poorhouse of Panama called Asilo de Bolivar; the 
 taking over of the Lazaretto, or home of lepers. 
 
 Dr. Reed's assertion that "much of the report on a 
 plan of organization was formulated over the respectful 
 
8 
 
 protest of the medical men" is without any foundation 
 whatever. Modifications of the suggestions submitted 
 by the Medical Staff were made from day to day until a 
 plan acceptable to both the Commission and to the 
 Medical Staff was worked out which must stand on its 
 merits. It may at once be stated that one of its chief 
 merits lies in its elasticity. 
 
 The facilities immediately provided and to be provided 
 were those foreseen to be necessary within the time 
 during which plans of the canal were to be under consid- 
 eration, and during which there would be only a mod- 
 erate force at work on actual canal construction. 
 
 In order that the character of modifications of the 
 scheme as submitted by the chief sanitary officer may 
 be understood, one illustration may suffice. He had sug- 
 gested the establishment and equipment of twenty emer- 
 gency hospitals (these being apart from the hospitals 
 at Ancon and Colon), with twenty beds each and the 
 necessary staff of employes, to be located along the line 
 of the canal ; that is, one every two miles between Pan- 
 ama and Colon. Without venturing to pass upon the 
 ultimate necessity for this number of emergency hos- 
 pitals, it was decided that it would be better to establish 
 only three at the outset, each with less than twenty beds. 
 These were to be located at centers of population and 
 to be enlarged, and others were to be established and 
 equipped as should later be found necessary. 
 
 The following from the report on the plan of organi- 
 zation refers to this matter : 
 
 "Emergency hospitals will be required along the line 
 of the canal as soon as large numbers of laborers are 
 concentrated at the points where the work is of greatest 
 magnitude. At each of these hospitals a physician should 
 be stationed. Each emergency hospital should be suit- 
 
9 
 
 ably equipped for emergency service and should have 
 combined v^ith it a dispensary. 
 
 "It is assumed by the Chief Sanitary Officer that there 
 will be need ultimately for twenty of these hospitals, 
 with twenty beds each, but after careful consideration of 
 the matter it was decided that necessity does not exist 
 for more than three at present, and that others can be 
 added as required." 
 
 Other modifications of the submitted scheme of a like 
 character were made in a like spirit, and in every case the 
 matter involved was fully discussed with, and concurred 
 in, by the Medical Staff. 
 
 The joint participation of all the Commissioners in 
 the formulation of the plan of organization is sufficiently 
 evidenced by the adoption of the report upon this matter 
 without modification. The organization of the Depart- 
 ment of Health, as perfected, except possibly the Board 
 of Health feature, which originated with the Commis- 
 sion's general counsel, seemed to be highly satisfactory 
 to the Chief Sanitary Officer and his associates, and met 
 with their entire and full concurrence. 
 
 The spirit which pervades the plan of organization is 
 well illustrated in the first paragraph of the report there- 
 on, which was subsequently adopted. 
 
 ''After repeated conferences with the Chief Sanitary 
 Officer, Dr. Gorgas ; Director of Hospitals, Dr. Ross; 
 the Superinendent of Ancon Hospital, Dr. LaGarde ; 
 Chief Quarantine Officer, Dr. Carter; Chief Sanitary In- 
 spector of the Canal Zone, Mr. LePrince; the Superin- 
 tendent of Colon Hospital, Dr. Spratling, and the Super- 
 vising Architect, Mr. Johnson, it has been agreed to be 
 desirable to perfect an organization of the Department 
 of Health as herein set forth, which will be sufficiently 
 elastic to permit of expansion or contraction as condi- 
 tions on the Isthmus may, from time to time, require. 
 The needs of the first year of service and the conditions 
 
lO 
 
 prevailing during the time of preparation for canal work 
 on a large scale were, therefore, used as a guide in de- 
 termining the scope of the work to be done and the per- 
 sonnel which should be authorized." 
 
 As Dr. Reed comments unfavorably upon the Commis- 
 sion's Department of Material and Supplies, it should be 
 briefly stated that this department was created for the pur- 
 pose of receiving, storing, caring for and issuing supplies 
 and materials, including those for the medical department 
 and for the care of machinery not in use. It naturally 
 works in conjunction with the Commission's Purchasing 
 and Shipping Department. Dr. Reed says that in the 
 resolution creating the Material and Supplies Depart- 
 ment nothing is said about the Sanitary Department, 
 thereby giving the impression that by some oversight 
 a right of inspection accorded other departments has 
 been denied to the Sanitary Department as such, and 
 that the Health Department will be hampered in secur- 
 ing suitable medicines and supplies. Dr. Reed should 
 liave continued his quotation by adding the following, 
 which appears in the printed proceedings of the Com- 
 mission's meeting of August 28, 1904: 
 
 **In the organization of a general purchasing depart- 
 ment provision could well be made for at least one com- 
 petent clerk who is familiar with the requirements of 
 sanitary and hospital service. Purchases of medical sup- 
 plies and instruments could be just as carefully made as 
 through an independent office. All supplies and medical 
 stores should be consigned to the general storekeeper 
 of the Commission, and should by him be at once trans- 
 ferred to a sub-department and possibly a separate store- 
 house, where they could be kept apart from other 
 -stores." 
 
 The Commission, in the making of its first purchase 
 
II 
 
 for the Health Department, gave the Medical Staff au- 
 thority to purchase in open market whatever was neces- 
 sary. In the making of subsequent purchases it called 
 upon Colonel Turrell, Medical Purveyor, U. S. A., at 
 New York, for assistance, chiefly with a view to the is- 
 suance of clear specifications for supplies and medicines, 
 and still later an arrangement was made with Surgeon- 
 General Wyman, of the United States Public Health 
 and Marine Hospital Service, under which all requisi- 
 tions for medicines, surgical instruments and supplies 
 are referred to that department and are filled by it. 
 
 It was that department which made the purchase of 
 the X-ray outfit, in reference to which Dr. Reed makes 
 statements that are quite erroneous. He states that a 
 request was made in Washington by the Health Depart- 
 ment's expert to be allowed to select the Crookes' tubes 
 of an X-ray outfit, and that this request was peremp- 
 torily refused. This statement evidences either woeful 
 ignorance or a willful misstatement of fact, and the 
 Doctor tries to make matters appear still worse by stat- 
 ing that although no X-ray outfit had reached the Isth- 
 mus, the salary of the expert who had been specially 
 employed to do X-ray work in Ancon goes on. This 
 expert is Dr. Herrick, who is the pathologist at Ancon 
 Hospital, and who will have charge of such instruments 
 and appliances as are required in the laboratory, includ- 
 ing the X-ray outfit. Full service is being rendered by 
 Dr. Herrick in his capacity as pathologist for the salary 
 which still goes on. 
 
 No request to assist in the selection of the X-ray outfit 
 or of the Crookes' tubes was denied; on the contrary, 
 Dr. Herrick was told that any service he desired to ren- 
 der in the selection of such apparatus or of microscopes 
 would be welcomed by the Commission. Dr. Herrick, 
 in November, 1904, came to the Washington of^ce with 
 
12 
 
 a letter from Dr. LaGarde, Superintendent of Ancon 
 Hospital, from which the following is an extract: 
 
 "Mr. Herrick leaves here to-morrow for a much- 
 needed rest. He has aided me more than anyone in the 
 organizing of our important hospital. I desire very- 
 much that he should be consulted by the Purchasing 
 Agent in New York in the purchase of microscopic, 
 X-ray, and operating-room supplies, that are costly and 
 that must be of certain standards and quality to suit our 
 needs. No one but an expert like Herrick can intelli- 
 gently do such purchasing, and I write to ask if you will 
 be kind enough to give him a letter to Mr. Anderson, 
 explaining the necessity of such advice, or, in fact, let 
 Herrick do the selecting himself." 
 
 This letter, addressed to the Chairman of the Com- 
 mission, was presented in person to the Acting Chair- 
 man, and Dr. Herrick was told that the Commission 
 would be glad to accede to the request of Dr. LaGarde 
 and requested his assistance in the matter. Dr. Herrick 
 was informed that the matter of soliciting proposals was 
 no longer in the hands of Mr. Anderson. He was refer- 
 red to Mr. Redfern, the Chief Clerk of the Commission, 
 in direct charge, at that time, of the filling of requisi- 
 tions. In this connection Mr. Redfern, upon being 
 requested to state what happened thereafter says, in 
 reference to the purchase of microscopes, apochromatic 
 objectives, and an X-ray outfit, that these comprised one 
 dissecting microscope, Leitz No. 44; three ordinary 
 microscopes for hospital use, and one Zeiss microscope, 
 complete, besides the objectives, compensating eye 
 pieces and a Spencer Lens Co.'s new No. 4 stand. He 
 states that the requisition for these instruments were 
 being handled at the time of Dr. Herrick's visit to Wash- 
 ington; that Dr. Herrick was referred to him (Redfern) 
 by the Acting Chairman, and that he (Redfern) was in- 
 
13 
 
 structed to consult Dr. Herrick and obtain his views as 
 to what he desired to do in the matter before making 
 any purchases or definite arrangements in regard to the 
 Zeiss microscope and X-ray outfit. Mr. Redfern further 
 says that he was present at a part of the interview be- 
 tween the Acting Chairman and Dr. Herrick, and that 
 Dr. Herrick expressed a desire to superintend to a more 
 or less degree the purchase of the instruments referred 
 to; that Dr. Herrick called on him (Redfern) on the 
 following day (as he remembers) and was requested 
 to give the matter of the purchase of the microscope and 
 of the X-ray outfit his attention; that for personal rea- 
 sons it was not convenient for Dr. Herrick to give these 
 purchases the required attention; moreover, that even 
 in the case of the X-ray outfit there were several makes 
 equally as good as the one specified, any one of which 
 would suit him. Mr. Redfern further states that the 
 dissecting microscope, Leitz No. 44, was bought from 
 Ernest Leitz, of New York, after having referred the 
 matter to the Public Health and Marine Hospital for 
 advice. The three ordinary microscopes were purchased 
 for the Commission by the Public Health and Marine 
 Hospital Service, the style purchased being the "Con- 
 tinental," and the firm from whom they were purchased 
 was Bausch and Lomb, of New York. The apochro- 
 matic objectives, the Zeiss microscope and the X-ray 
 outfit were bought by the Public Health and Marine 
 Hospital Service. It was understood that these instru- 
 ments would be tested for the Public Health and Marine 
 Hospital Service by the Director of the Hygienic Labo- 
 ratory of that Service at Washington. 
 
 It is stated by Dr. Reed that the Commission substi- 
 tuted a number of worthless microscope objectives for 
 others carefully specified. The purchase of these has 
 above been explained. The Commission has at no time 
 
14 
 
 authorized the substitution nor the acceptance of any 
 "worthless" instruments. 
 
 Dr. Reed says that one medicine is substituted for an- 
 other in practically every requisition for medicine that 
 has reached the hospital. The Commission knows of 
 no such substitution. It has been aided, as explained, 
 by Col. Turrell, the Medical Purveyor for the U. S. A., 
 and by the Public Health and U. S. Marine Hospital 
 Service, and it has no grounds for assuming that either 
 of these departments should have sanctioned the pur- 
 chase of medicines other than those asked for, nor have 
 its medical officers ever reported such a substitution. 
 
 The statements of Dr. Reed that a request to have an 
 expert select Crookes' tubes, was denied; that no X-ray 
 outfit was purchased; that worthless apparatus was sub- 
 stituted by the Commission for that specified; that the 
 Commission foisted remedies upon the medical service, 
 other than those specified, are all absolutely false. 
 
 Relating to Dr. Reed's statement that the Commis- 
 sion wants cheap doctors on the Isthmus, only $50 per 
 month being allowed for the internes, the fact is that 
 graduates from medical colleges, without experience, 
 are useful as internes in the hospital organization on the 
 Isthmus as they are in hospital organization in the 
 United States. In the United States they serve a year 
 without pay. It was thought proper to allow them 
 transportation to the Isthmus from the United States 
 port, and to allow them $50 per monh during their year 
 of service, and to return them free of expense to the 
 United States at the end of the year or in case of dis- 
 ability due to sickness. Should it be found that an in- 
 terne desires to remain in the Isthmian service, the as- 
 signment to further duty carries with it pay of 
 at least $125 per month. To the above compensation for 
 internes there is added quarters, board and some laun- 
 
15 
 
 dry. Nor is there any reason why a doctor promoted 
 from an interneship should not, if he is deserving, be 
 recommended at once for higher pay than $125 per 
 month, which has been named as a minimum. It is true 
 that internes are expected to remain a year to entitle 
 them to free return transportation, but after six months 
 of satisfactory service they are entitled to any reduced 
 rates of transportation available to the Commission 
 ($25 to New York or New Orleans). That the Com- 
 mission does not seek cheap medical service is further 
 answered by quoting the salaries fixed six months ago 
 for such service: Chief Sanitary Officer, $7,500 per year; 
 Executive Officer in the Office of the Sanitary Officer (a 
 physician), $2,400; Director of Hospitals, $7,000; Super- 
 intendent of Ancon Hospital, $6,000; Pathologist and 
 X-ray Specialist at Ancon, $4,000; Physiological Chem- 
 ist at Ancon, $3,000; two other physicians at $2,400 and 
 two at $1,500; and internes at $600; Superintendent of 
 Colon Hospital, $4,000; Surgeon and Pathologist at 
 Colon, $3,000; three other physicians, $2,400; internes, 
 $600; Physicians at Emergency Hospitals along the line 
 of the Canal, $2,400; at Dispensaries, $1,800; Chief 
 Quarantine Officer, $6,000; other Quarantine Officers, 
 two at $3,500, two at $2,400; Panama Health Officer, 
 $3,000; Assistant Health Officer, $1,800; Colon Health 
 Officer, $2,400. In addition to this, all physicians are 
 allowed quarters, or, in commutation of quarters, 15 per 
 cent, of their pay, and the Commission's principal repre- 
 sentatives on the Isthmus are allowed carriages. 
 
 In the matter of Director of Hospitals, which you are 
 told was abolished, there has been no abolishment of the 
 office, although the Commission did request from its 
 Chief Sanitary Officer, after the resignation of Dr. John 
 Ross, because of ill health, a suggestion for the reor- 
 ganization of his office, which reorganization should 
 
i6 
 
 provide for an Assistant Chief Sanitary Officer in lieu 
 of the Director of Hospitals. In view of the fact that 
 the laws of the Canal Zone creating the office of Di- 
 rector of Hospitals can no longer be amended by the 
 Commission, it is not likely that further steps in this 
 matter will be taken. 
 
 The non-allowance of twenty sanitary inspectors to 
 serve in the Canal Zone under the Chief Inspector was 
 one of the modifications of the suggestions of the Chief 
 Sanitary Officer, already alluded to. On this subject 
 the report on the plan of organization may be quoted : 
 
 "No work to be done by the Sanitary Force upon the 
 Isthmus is of greater importance than that which, by 
 restricting the breeding of anopheles and stegomezia 
 mosquitos, will reduce the danger of malarial and yel- 
 low fever infection. This work is now in charge of a 
 Chief Sanitary Inspector, under whom there are four 
 assistant inspectors, more being at once required. . . . 
 An efficient beginning can be made with eight inspectors 
 in the Canal Zone, and these should be provided." 
 
 These were provided, together with i6 sanitary fore- 
 men, their number to be increased from time to time as 
 shown to be necessary by experience. To this time no 
 request for an increase has been made by the officers 
 whose experience would guide the Commission in such 
 matters. • 
 
 It is stated by Dr. Reed that screens were asked for 
 for all the buildings in the Canal Zone; that the Com- 
 mission concluded this to be a totally unwarranted ex- 
 pense, and eliminated the proposition. The Commis- 
 sion has reached no such conclusion; moreover, feels 
 itself under obligation not only to provide screens for 
 all buildings owned or controlled by it, but would like 
 to see all buildings where screens would be of any serv- 
 ice suitably screened. 
 
17 
 
 The original proposition of the Chief Sanitary Officer 
 to construct screens entirely around the verandas or 
 porches surrounding the Ancon Hospital buildings was 
 modified, as stated by Dr. Reed, but with the consent 
 and full approval of the Medical Staff, so far as screen- 
 ing only that part of the galleries which will be in use 
 by the patients is concerned. The boarding below the 
 railing, or some other means of protecting the screen- 
 ing against accident, remains as a suggestion, and the 
 Commission has no information of its final acceptance 
 or rejection by its representatives on the Isthmus. 
 
 The statement made by Dr. Reed, that such a propo- 
 sition would carry about ten times the expense of 
 screening, is in error. The reduction of aggregate cost 
 resulting from the plan of screening, as adopted, would 
 amount to many thousands of dollars, and would place 
 a large amount of screening under the protection of 
 porches where increased length of serviceability is to be 
 assumed. The cost of boards in the place of screens, 
 instead of being ten times greater, should be compared 
 on the basis of about six (6) cents per square foot for 
 screens, as against three (3) cents for boards, apart in 
 each case from the cost of placing these materials. 
 
 In the matter of compensation allowed its clerks, 
 which Dr. Reed criticizes, the Commission has endeav- 
 ored to secure a fair and uniform classification in its 
 several departments, and the salaries fixed were the out- 
 come of long discussion and deliberation, the intention 
 being to fix salaries for all such service at about 25 per 
 cent, in excess of the amount which like service would 
 command in the United States. 
 
 The Doctor states in this connection that "Colonel 
 Gorgas asked for a Chief Clerk at $1,800, with the ob- 
 ject of getting a man who had had experience with him 
 in Cuba; he was allowed only $1,500, for which he could 
 
i8 
 
 get only an inexperienced man.'' The salary fixed in 
 the plan of organization for the Chief Clerks of the 
 Chief Sanitary Officer (see page 171 of the printed pro- 
 ceedings of the Commission) is $1,800; the salary of the 
 Clerk in the office of Director of Hospitals, called by 
 courtesy Chief Clerk, is $1,500; the salary of the Chief 
 Clerk of Ancon Hospital is $1,800 per year. 
 
 It should be stated that the fixing of salaries of the 
 officers of the Health Department has received careful 
 consideration by the Commission. Salaries, in connec- 
 tion with all other matters relating to the organization 
 of the Health Department, were discussed and agreed 
 upon in conference with the Medical Staff, and they re- 
 main subject to revision. There are, in fact, frequent 
 changes, and it is needless to say that a change invaria- 
 bly means increase. Some of these salaries have herein- 
 before been enumerated. 
 
 In the matter of the use of movable vessels for night 
 soil, it may be stated that those called for have been pur- 
 chased. On this subject, after discussing the advan- 
 tages and disadvantages of disposal by water carriage 
 in sewers, as against the use of a bucket system, Dr. 
 Gorgas, under date of January 7th, concluded : *T would, 
 therefore, recommend that in general, for the strip, the 
 bucket system be adopted, and that the Sanitary Depart- 
 ment be authorized to install the same as necessity 
 arises." Hereupon Governor Davis took up the ques- 
 tion, writing under date of January 17th, among other 
 things : **It seems to me that it should not be a very diffi- 
 cult matter to arrange that each house, or group of two 
 or three houses, should be provided with a small privy, 
 constructed of boards, over a pit dug in the earth, and 
 provided with steps and seats, and that the Sanitarians 
 should inspect these privies occasionally, and see that 
 they are kept in proper condition, and removed from 
 
19 
 
 time to time to other pits when it shall appear neces- 
 sary." 
 
 The Commission thereupon, at its meeting on the 4th 
 of February, 1905, adopted a report of its Committee on 
 Sanitation, which was sent to the Isthmus for further 
 comment by the Governor of the Canal Zone and the 
 Chief Sanitary Officer. 
 
 Referring to this resolution, Governor Davis, under 
 date of February 25th, writes : "It will be observed that 
 Col. Gorgas sees no necessity for any action by the 
 Commission in this matter, and I have not, myself, been 
 able to think of any phase of the case that requires such 
 action." 
 
 "Since my letter of January 17th, the subject of the 
 use along the Canal line of privies and privy vaults for 
 night soil, and before the receipt of the Secretary's com- 
 munication now at hand, was taken up by me with Col. 
 Gorgas and Mr. Le Prince, and I personally made a 
 sketch of a privy vault, or pit, that I thought would 
 meet the case, and the instructions I gave to prevent 
 the vault or pit from being flooded were almost exactly 
 the same as those suggested in the memorandum of the 
 Committee on Sanitation. . . . The Commission 
 will be kept advised as to the experience in this matter, 
 and if any necessity arises for action by resolution or in 
 a legislative way, the fact will be made known." 
 
 On the same subject, under date of February 24th, 
 Chief Sanitary Officer Col. W. C Gorgas writes : . . . 
 "In my opinion no special regulation by the Commis- 
 sion is necessary for carrying out the views expressed 
 in this resolution. . . . The scheme seems to me 
 good and to fulfill the requirements. If upon trial it is 
 not found satisfactory, I shall report the circumstances 
 to the proper authorities." 
 
20 
 
 Dr. Reed tells you that the establishment of a con- 
 valescent hospital on the Island of Taboga, with a doc- 
 tor and a head nurse, was refused. Taboga is located 
 about twelve miles down the Bay of Panama, and the 
 use of the island as a hospital will involve the keeping 
 of a suitable steamer in service. It should be stated 
 that the Commission resolved in August, 1904, as fol- 
 lows : "The large two-story structure on Taboga Island, 
 usually referred to as the 'Convalescent Hospital,' is 
 suitable for a convalescent station to be made use of 
 whenever the hospital facilities at Ancon prove inade- 
 quate. There is no immediate need of providing a 
 medical staff for this station. It is estimated that $8,500 
 will be required to put the building in a suitable condi- 
 tion of repair." This expenditure was authorized by 
 resolution on September 2, 1904, and the Commission 
 has, since that time, upon recommendation of the Chief 
 Sanitary Officer, authorized the furnishing and use of 
 this station by canal employes who need a change of 
 air and of surroundings to recuperate their energies. 
 
 Another of the Doctor's misstatements relates to 
 Miraflores Hospital. The establishment of this hos- 
 pital was authorized immediately it was asked for. The 
 transfer of personnel was authorized, and no obstruction 
 has been interposed by the Commission to the filling of 
 any vacancies created by such transfer. 
 
 You are told by Dr. Reed that the Commission de- 
 clined to give the Chief Sanitary Officer some oppor- 
 tunity to exercise his judgment as to qualification of 
 personnel and quality of material furnished his depart- 
 ment. The present medical staff is of his own selection. 
 He has been restricted only by civil service regulations. 
 The method followed in purchasing medicines and sup- 
 plies has already been explained. 
 
21 
 
 You are told that the Health Department is hampered 
 in its efforts to suppress yellow fever. In this connec- 
 tion it is only necessary to call attention to the fact that 
 materials for use in disinfecting have been purchased as 
 required, the following aggregate amounts of materials, 
 principally used, purchased and forwarded : 
 
 14 tons of insect powder in 16 shipments. 
 52 tons of sulphur in 17 shipments. 
 2 tons of sulphate of iron. 
 23 tons of chloride of lime. 
 500 lbs. of sulphate of copper. 
 
 Regular shipments of insect powder and roll sulphur 
 are being made, and will be continued until notice is 
 received from the Sanitary Department that they are no 
 longer needed. 
 
 The Commission has at all times met every request 
 for such material promptly. If some allowance be now 
 made for misunderstandings as to what was required, 
 and on the other hand for some duplication of pur- 
 chases resulting from the use of the cable, it must be 
 apparent that any difference in the amount of a single 
 shipment from the amount named in a requisition should 
 not be used as a reflection upon the earnest effort of the 
 Commission to do effective sanitary work. 
 
 The following two letters from the Chairman of the 
 Commission, one under date of January 5, 1905, to Gen- 
 eral Davis, the other under date of February 14, 1905, 
 to Mr. E. C. Tobey, Chief of Material and Supplies De- 
 partment, will sufficiently illustrate the attention given 
 to such matters. 
 
 The addresses and signatures being omitted, these 
 letters are as follows : 
 
22 
 
 *'Sir: 
 
 ^'I this morning received your cable of yesterday as 
 follows : 
 
 "Health Department will systematically fumigate 
 Panama; require 2,000 pounds insect powder weekly 
 for six weeks; present supply exhausted January 15th; 
 can I depend upon required shipments." 
 
 To which I have replied : 
 
 "Will send 2,000 pounds insect powder weekh^ 
 "In this connection I have to inform you that the 
 steamer sailing yesterday took two orders of disinfecting 
 material — one for eight (8) tons of rolled sulphur and 
 one (i) ton of insect powder, and the other for 5,000 
 pounds of rolled sulphur and 4,000 pounds of insect 
 powder. 
 
 "The 2,000 pounds of insect powder which you request 
 weekly for six successive weeks, will be forwarded you, 
 beginning Tuesday, the loth inst." 
 
 And the letter to Mr. Tobey: 
 
 "Dear Sir: 
 
 "Referring to cable sent by General Davis, received at 
 this office on the 5th day of January, 1905, requesting 
 that six weekly shipments be made of insect powder in 
 2,000 pound lots : 
 
 "I wish to bring to your attention that under this 
 order the shipments would cease on the 14th day of 
 February. To guard against possible chance that the 
 supply should become exhausted, I have this day 
 directed that two more consignments of 2,000 pounds 
 each be made, bringing the total quantity up to 16,000 
 pounds and to the 28th day of this month. Upon receipt 
 of this letter should the conditions warrant the con- 
 tinuing of these weekly shipments, you are directed to 
 cable such request." 
 
 In further evidence of the earnest desire to facilitate 
 
23 
 
 the work of the Health Department in preventing and 
 suppressing epidemics the Commission enacted the fol- 
 lowing in Act No. 8, of the Laws of the Canal Zone : 
 
 "But in case of emergency created by threatened or 
 imminent danger to the public health, extraordinary 
 expenditures by the Board of Health may be authorized 
 by the Governor of the Canal Zone." 
 
 Under this authorization medical and sanitary sup- 
 plies have been and can be purchased as required. 
 
 The Commission on September 2, 1904, also passed 
 the following resolution: 
 
 ''Resolved, That in case of any great public calamity, 
 emergency, or urgent necessity, the member or mem- 
 bers of the Commission on the Isthmus of Panama be, 
 and they hereby are authorized to act for the Commis- 
 sion, taking such measures as may be necessary to meet 
 the conditions as they arise, and to purchase materials 
 and to do any work or make any expenditures, which 
 they deem necessary to avert such calamity or to meet 
 such emergency and urgent necessity." 
 
 You are told by Dr. Reed that the Commission de- 
 clared that screens for hospitals along the line of the 
 canal were unnecessary. This is also a misstatement, 
 the exact reverse being the case. 
 
 Building repairs are made under the direction and 
 supervision of the Chief Engineer. The Commission 
 has not been advised that this arrangement is the cause 
 of any embarrassment. The Commission has not, as 
 Dr. Reed desires that you should believe, required that 
 estimates should first be submitted to the Commission 
 before repairs to buildings are made. The making of 
 these repairs rests with the Commission's representa- 
 tives on the Isthmus. 
 
24 
 
 The Commission has not denied a request for a house 
 at a quarantine station. Full authorization for all build- 
 ings asked for, for the quarantine service, has been 
 given. 
 
 The Commission maintains a laboratory at Ancon 
 Hospital. Even if the Commission v^ere clear that the 
 establishment of a laboratory for purely scientific re- 
 search would be a proper feature of expenditure, it does 
 not believe the time to have come for establishing one, 
 and denied a request for such laboratory. Dr. Herrick 
 is the Commission's pathologist at Ancon Hospital and 
 X-ray specialist, and it is expected that at the Ancon 
 Hospital laboratory, for the present, such scientific work 
 as may be necessary will be done. 
 
 The keeping of the Ancon Hospital ambulance at the 
 Section stable, instead of at a separate hospital stable, is 
 referred to by Dr. Reed as making it impossible to get 
 the ambulance on ready call at times of an emergency. 
 No arrangement for stabling the ambulance has been 
 made which does not give the hospital officials com- 
 plete control over its movements. It should be stated 
 in this connection that the Section stable is on a tract 
 of land as fully under the control of the Commission as 
 the hospital site in contact therewith and less than 200 
 yards from the hospital gate and connected by tele- 
 phone. 
 
 The combination of scattered stables into one estab- 
 lishment is a feature of efficient administration. 
 
 It is charged by Dr. Reed that the Commission's 
 hospitals are opened to all the world. No other answer 
 seems necessary than a reference to the plan of organiza- 
 tion and to the health regulations as set forth in the 
 Laws of the Canal Zone. (See Acts Nos. 8 and 9.) 
 The medical staff should have power to order into hos- 
 pitals all persons suspected of being ill with infectious 
 
or contagious diseases, and this has been given. The 
 Commission foresaw that restrictions would be neces- 
 sary to prevent competition by the hospitals with physi- 
 cians in private practice. The admission of patients as 
 pay or charity patients is only permitted where the 
 hospital authorities determine such admission to be 
 desirable. It was not intended that any sick person not 
 an employe of the Commission should be admitted upon 
 mere application, and so far as the Commission has been 
 advised no other construction has been placed upon the 
 paragraphs of the plan of organization relating to ad- 
 mission of patients. 
 
 To establish a proper relation between the Commis- 
 sion's hospitals and their medical staffs, on the one hand, 
 and the private physicians practicing on the Isthmus, on 
 the other, the Commission will always be ready to take 
 suitable action. 
 
 It has recently, upon the receipt of a suggestion, 
 relating to this matter, passed the following resolution 
 which was suggested by the Chief Sanitary Officer : 
 
 ^'Resolved, That any pay patient can employ any phy- 
 sician desired by such patient, and such physician can 
 have access to such patient and use of all supplies and 
 conveniences of the hospital, under regulations to be 
 prescribed. A charge of not less than $5.00 and not 
 more than $10.00 will be made for the use of operating 
 room. 
 
 "In case a pay patient in a hospital elects to have a 
 physician employed by the Commission attend him or 
 her, the Superintendent shall charge for such attend- 
 ance or surgical operation in accordance with the scale 
 of fees, to be agreed upon between the Chief Sanitary 
 Officer, on the one hand, and the legally qualified medi- 
 cal men of Panama and Colon, on the other." 
 
 This resolution was adopted at the request of Dr. 
 
26 
 
 Gorgas. The Commission is by no means certain that it 
 will not soon require further modification, which will 
 be made when asked for, but for the present accepts the 
 view of Col. Gorgas, who, under date of December 6, 
 1904, referring thereto, says : "I have discussed this 
 with a committee appointed to represent the physicians 
 (referring to the medical profession of Panama), and 
 they express themselves as being satisfied with the 
 arrangements. This will give them access to the hos- 
 pital and the advantages of the hospital, and they will 
 make such arrangements as they please with their 
 patients, just as if the patient were in a hotel." 
 
 In reference to the admission of all the world to the 
 hospitals, it may be stated that the views of Col. Gorgas 
 were so extreme in August, 1904, that his original sug- 
 gestion included the taking over and management, as 
 already stated, of the hospitals and poorhouse of the 
 Republic of Panama. 
 
 Dr. Reed is again in error when he says that it was 
 "made a part of the Laws of the Canal Zone 'that sur- 
 gical operations shall be charged for according to their 
 importance and the financial ability of the patient to 
 pay, but no charge in excess of $50.00. shall be made 
 without the approval of the Director of Hospitals.' " 
 This is a quotation from page 166 of the minutes of the 
 proceedings of the Commission; it forms no part of the 
 Laws of the Canal Zone. It has, as just stated, been 
 already changed, based on the experience and recom- 
 mendation of the medical staff. 
 
 The purpose of the requirement that a charge be 
 made under certain circumstances for attendance upon 
 sick at their homes was to encourage the persons enti- 
 tled to hospital treatment, and to free rriedical treat- 
 ment, to seek medical advice at the dispensaries and at 
 
27 
 
 the hospitals, thereby reducing the number of outside 
 calls to be made by the Commission's physicians. The 
 charge for such attendance is in no sense, as Dr. Reed 
 would have you believe, a charge in competition v^ith 
 private practitioners, or in compensation for the services 
 rendered. He has quoted only enough to mislead, from 
 the report on the plan of hospital organization. The full 
 statement in that report relating to this matter as taken 
 from the printed proceedings of the Commission is as 
 follows : 
 
 ^'Visits made by physicians to the residence of any 
 person entitled to free hospital treatment, or to the 
 residence of a railroad employe, or to the residence of 
 any other person entitled to treatment at the hospital at 
 a fixed daily rate of pay, should be charged for at the 
 rate of one-half dollar for each visit, but no such charge 
 is to be made for emergency calls nor in the case of per- 
 sons entitled to free hospital treatment until after the 
 person has been ordered into a hospital." 
 
 It is true that the Commission has declared that all 
 money realized at hospitals from charges for board, med- 
 ical attendance, surgical operations and the like, and 
 from visits at residences, should be considered public 
 funds. This is covered by the Laws of the Canal Zone 
 in the following words : 
 
 "All money collected for the United States by the 
 Department of Health, or any of its several branches 
 or services, or by any officer or employe thereof, shall be 
 turned over to the Government of the Canal Zone as 
 soon as practicable after the date of its receipt." 
 
 Two of the members of the present Commission have 
 repeatedly visited the Isthmus in the last five years, and 
 
 ^B'^.A -pj. 
 
28 
 
 they know that the Isthmus during this entire time was 
 never free from yellow fever. Why does Dr. Reed now 
 venture such a statement, referring to the last days of 
 June, 1904, as the following: 'Tanama was then ap- 
 parently free from yellow fever?" 
 
 Yellow fever being still endemic in the city of Panama, 
 the Commission has taken vigorous measures to stamp 
 it out. It is considered of prime importance to exter- 
 minate the stegomeyia mosquito in Panama. The Com- 
 mission at once recognized the importance of bringing 
 into Panama a wholesome water supply, and no time 
 has been lost in selecting a source of supply and pur- 
 chasing material. Only after water is thus made avail- 
 able can the use of water containers, the favorite breed- 
 ing place of this particular mosquito, be prohibited. 
 
 In the meanwhile the Commission appointed a Health 
 Officer for the City of Panama, its Board of Health took 
 charge of all suspected cases of yellow fever wherever 
 found, and provision was made to have funds in any 
 amount at its disposal in case of an emergency, as 
 already hereinbefore stated. 
 
 It is true that the Treaty between the United States 
 and Panama gives to the United States certain rights in 
 the matter of prescribing and enforcing sanitary regula- 
 tions in the Cities of Panama and Colon. The follow- 
 ing is from Article VI of the Treaty : 
 
 'The Republic of Panama agrees that the Cities of 
 Panama and Colon shall comply in perpetuity with sani- 
 tary ordinances whether of a preventive or curative 
 character prescribed by the United States, and in case 
 the Government of Panama is unable or fails in its 
 duty to enforce this compliance by the Cities of Panama 
 and Colon, with the sanitary ordinances of the United 
 States, the Republic of Panama grants to the United 
 States the right and authority to enforce the same." 
 
29 
 
 The Commission gave its Health Department a tem- 
 porary organization by formal action at its session on 
 May 8, 1904. At this meeting: "The Chief Sanitary 
 Officer and the Director of Hospitals, in addition to 
 other duties, were designated as the Health Board for 
 Colon and Panama," and the Chief Sanitary Officer took 
 such steps as he thought justified to improve the sani- 
 tary conditions in these cities. He asked for, and was 
 given, certain powers in this matter by the Government 
 of the Republic of Panama, and continued to exercise 
 these until the scheme for a permanent organization of 
 the Health Department took definite shape. About the 
 same time the Commission adopted sanitary rules and 
 regulations for the Cities of Panama and Colon and 
 quarantine regulations for the ports and harbors of these 
 cities. 
 
 At the Commission's meeting of September 2, 1904, 
 the Chairman was directed to transmit a copy of these 
 rules and regulations to the proper authorities of the 
 Republic of Panama, with the request that such action 
 betakenby competent authorities as might be necessary 
 to give the rules and regulations the force of law. This 
 was done, and suitable action was subsequently taken 
 by the Government of Panama. 
 
 Not until January, 1905, was the Commission advised 
 by the authorities of Panama of its inability to properly 
 enforce these regulations, and the Commission imme- 
 diately took full charge of the work of cleaning and 
 sanitation in Panama. In this matter the Commission 
 acted up to the entire limit of its authority, as is shown 
 by the following extract from a decision of the Comp- 
 troller of the United States Treasury, in which he says : 
 *Tt requires no extended argument to demonstrate that 
 until Panama confessed its inability or failed to execute 
 
30 
 
 these regulations, the Government of the United States 
 was not authorized so to do, and not being authorized 
 to execute them could not legally, under such circum- 
 stances, pay for their execution.'' 
 
 It should be further stated in this connection that a 
 Health Office for Panama, with a physician in charge, 
 an assistant, two clerks, and three inspectors are in- 
 cluded in the Health Department organization, and 
 were stationed there long before the United States took 
 charge of the enforcement of health ordinances. A 
 similar staff, except the assistant health officer, was 
 provided in the plan of organization for Colon. Dr. 
 Reed lays great stress upon the subordination of the 
 Chief Sanitary Officer to the seventh degree, enumer- 
 ating even the President, and a single member of the 
 Commission to accomplish this subordination. In the 
 discharge of his duties as a sanitary officer Dr. Gorgas 
 has been absolutely free and has absolute freedom of 
 action. 
 
 The providing of water for Panama received the at- 
 tention of the Commission in April, 1904, before the 
 canal properties had passed into possession of the 
 United States, it having been resolved on April 12 that 
 parties be organized as soon as practicable for the doing 
 of the following field work : . . . "Surveys for 
 water supply and sewerage systems for Colon and 
 Panama." 
 
 Under this resolution an engineer of experience was 
 engaged and entered upon his duties as soon as he could 
 arrange his private affairs, on June 20, 1904. His duties 
 included the design of water works for Panama, sewers 
 for Panama, and water works and sewers for Colon. 
 
 The cleaning of the streets, including the disposal of 
 night-soil, was placed in the hands of Col. Gorgas, with 
 
31 
 
 full powers so far as the Commission could confer them, 
 on May 8, 1904. 
 
 Compare also this statement of Dr. Reed with the 
 facts. He says, referring to the water works for Pan- 
 ama : ''Mr. Wallace had drawn the plans and specifica- 
 tions in July previous and had taken care to specify only 
 such pipe as manufacturers keep in stock, and that could,, 
 therefore, be procured without a moment's delay."" 
 The facts are that the recommendation of the Chief 
 Engineer that the selection of the Rio Grande as a source 
 of water for Panama be approved, bearing date August 
 6th (not July), and that the specifications for pipe sub- 
 mitted by him bear date of August 15th, and were ap- 
 proved by the Commission on August 19th as sub- 
 mitted. 
 
 The specifications as prepared had no reference to 
 stock on hand by manufacturers. All delay in the deliv- 
 ery of this cast iron pipe has been due to a default of the 
 contractor in making shipment. The pipe was manu- 
 factured in time for shipment as required by contract, 
 but the second (final) installment did not get off within 
 the contract time. 
 
 The Doctor's ignorance as to the forms of water 
 pipe and their method of manufacture has led him into 
 a silly statement as to their details. The Commission 
 never asked the Chief Engineer for any explanation as 
 to eastern or western patterns, as they exist only in the 
 Doctor's imagination. 
 
 Every reasonable step is being and will be taken to 
 reduce malaria. To this end an efificient sanitary corps 
 for the Canal Zone has been organized and a vast 
 amount of good work has been accomplished. Any one 
 who knew the Isthmus before May 4, 1904, and who 
 visits it now, can testify to the changed conditions. 
 
32 
 
 Ponds were drained and oiled, ditches constructed and 
 cleaned out, and brush has been cut out, improving the 
 surroundings of the several clusters of buildings in the 
 Canal Zone. 
 
 The statement that the Commission thought some- 
 thing like 20 laborers too many for the Health De- 
 partment, and allowed only one-half of that number, is 
 absolutely false. Laborers have been allowed as re- 
 quired and as necessary, and have been numbered by 
 hundreds in the Health Department. 
 
 Dr. Reed says that a call for 2,500 yards of wire 
 screening was cut by the Commission to 500 yards. The 
 Commission has made four purchases of wire screen, ag- 
 gregating upwards of 17,000 square yards, besides enter- 
 ing into a $4,700 contract for screens suitably framed 
 for door and window openings. None of the calls for 
 screens was for the amount of 2,500 yards as claimed by 
 Dr. Reed. 
 
 No requisition for quinine was ever reduced or denied. 
 
 Dr. Reed is also in error when he states that the 
 Isthmian Canal Commission, in its report of December, 
 1904, states: 
 
 *'A11 cases of employes sick with malaria are taken 
 to Colon and Ancon Hospitals and so screened that 
 mosquitoes cannot reach them." 
 
 Dr. Reed calls this "an absolute and unqualified false- 
 hood." 
 
 The words quoted by Dr. Reed are not those of the 
 Commission; they are not in the Commission's report, 
 but appear in a report of the Governor of the Canal 
 Zone, and probably have reference to the use of mos- 
 quito bars in the hospitals. Moreover, if mosquitoes are 
 not kept away from malarial patients at Colon and An- 
 
33 
 
 con Hospitals by the use of mosquito netting, the 
 responsibility falls upon the medical officers of these 
 hospitals. 
 
 You are asked by Dr. Reed to consider the authoriza- 
 tion by the Commission, with the approval of its medical 
 staff, to accept student nurses at Ancon Hospital as a 
 mere subterfuge to secure cheap nursing. 
 
 The idea that a training school for nurses might prove 
 a success was suggested by the application of a young 
 woman of Panama, a member of one of the foremost 
 families of that Republic, who offered to render such 
 service as she might, without pay, being desirous of hav- 
 ing an opportunity to gain experience as a nurse, and 
 by the statement made by herself and friends that other 
 young women of Panama would probably avail them- 
 selves of any suitable opportunity to enter the hospital 
 as student nurses. On this subject the report on a plan of 
 organization says : "Attention should also be called to 
 the fact that young women, some from Panama, others 
 from the United States, will be desirous of entering a 
 hospital so well equipped as Ancon, as student nurses. 
 This should be encouraged. Climate and environment 
 are not unpleasant, and a good training school for 
 nurses should prove attractive, and would add materially 
 to the hospital service.*' The scheme as authorized 
 would allow students compensation at the rate of $12 
 per month during the first year, $15 during the second, 
 and $18 during the third. The students would receive 
 traveling expenses to the Ithmus from New York, New 
 Orleans or San Francisco, and free return expenses to 
 one of these cities in case of service for at least one year 
 or in case of disability by reason of illness. 
 
 The making of purchases of supplies and materials for 
 use on the Isthmus has not been a simple problem. It 
 
34 
 
 has been and is the desire of the Commission, so far as 
 practicable, to make purchases on the basis of proposals 
 submitted on advertisement. The following resolution 
 relating to this matter was passed on August i8, 1904: 
 
 ''Resolved, That hereafter, so far as practicable, all 
 purchases of machinery, material and supplies shall be 
 made after due advertisement and competition." 
 
 It was on the other hand necessary, at the outset, to 
 send to the Isthmus such amounts of material and sup- 
 plies as were required for the work of the Commission, 
 and to prevent loss of time and money to the Govern- 
 ment. Open market purchases were, therefore, neces- 
 sary, but the making of open market purchases was stop- 
 ped and restricted as soon as it seemed wise to do this. 
 
 In making purchases by advertising for proposals 
 careful specifications had to take the place of the judg- 
 ment of the Purchasing Agent and of experts, and the 
 descriptions contained in requisitions had to be amplified 
 before a call for proposals could be made. In other 
 words, the requisitions were only a general evidence of 
 the requirement; specifications had in many cases to be 
 subsequently prepared. It has been the plan of the 
 Commission to have the needs of its several departments 
 foreseen for half year or full year periods in order that 
 purchases would be in sufficient quantities to avoid as 
 far as possible emergency calls and to afford the pur- 
 chasing officer ample time to prepare papers to call for 
 proposals with a reasonable time allowance to permit 
 intending bidders in all parts of the country to prepare 
 their proposals, and to permit of the delivery, or manu- 
 facture and delivery, as the case might be, of the articles 
 required. 
 
 We quote in connection with the delivery of material 
 
35 
 
 to the Isthmus from the report of the Subcommittee 
 of the Committee on Interstate and Foreign Commerce 
 of the House of Representatives: "In fact, supplies 
 were received in such quantities and so much more rap- 
 idly than needed that the terminal facilities of the rail- 
 road were inadequate to care for them." . . . This, 
 when read in connection with Dr. Reed's letter, may 
 illustrate the difference which the standpoint makes 
 from which the Commission's affairs are discussed. 
 
 The Commission, on its first visit to the Isthmus, in 
 April, 1904, was accompanied by the three chief mem- 
 bers of the Sanitary Corps of the Canal. They returned 
 together and were in conference in Washington concern- 
 ing the preliminary organization of the Health Depart- 
 ment for the Zone. The views and propositions pre- 
 sented by the chief and associate sanitary officers were 
 then discussed, and, with slight modification, accepted 
 by the Commission. These officers returned in June 
 to the Isthmus, with full authority to inaugurate their 
 work by selecting their personnel and providing their 
 supplies. 
 
 The Commission returned to the Canal Zone early in 
 August, when the necessity of immediate and perma- 
 nent sanitary organization was at once apparent. A 
 great part of the five weeks during which the Commis- 
 sion remained there was spent in conference with the 
 heads of that department, after their experience of 
 three months, concerning the scope and details of an 
 organization which should give them all necessary 
 authority and opportunity to perform their most impor- 
 tant duty. The discussion was full and free and resulted 
 in the adoption of the project, which forms part of the 
 minutes of the Commission for August 28, 1904. It 
 was the clear understanding at the time, and has been 
 since, that this scheme of organization was satisfactory. 
 
36 
 
 not only to the Commission, but to the officers upon 
 whom the responsibility for the sanitation of the Isth- 
 mus devolved. Since that time, much correspondence 
 on sanitary subjects has passed and many interviews 
 with members of the Sanitary Staff have been held, but 
 the Commission has not learned from either source that 
 the plan of organization has failed or has become un- 
 acceptable to those charged with its execution. Nota- 
 bly, a committee of the Commission, recently returned 
 from the Isthmus, unreservedly states the full satisfac- 
 tion of the Sanitary Staff with the successful operation 
 of the organization and the health conditions on the 
 Isthmus. 
 
 Of course, during the inception of this great work, 
 there have been occasions when the filling of requisi- 
 tions has been delayed, or where other annoyances have 
 temporarily existed, but the Commission has no reason 
 to believe that the scheme of sanitary administration 
 has not been wisely devised, or that it has not been 
 effective in operation. 
 
 The Commission understands the immense impor- 
 tance of the sanitation of the Isthmus as a factor in the 
 building of the canal. It is certain that the Chiefs of the 
 Sanitary Department are aware of the grave responsi- 
 bility resting upon them. If the statements of Dr. 
 Reed were true, either in detail or in the general im- 
 pression they are intended to convey of sanitary condi- 
 tions on the Isthmus, they would convict the Sanitary 
 Staff of a gross abandonment of duty in failure to in- 
 form the Commission thereof. Neither from official 
 conferences, nor from correspondence, nor from inter- 
 views with members of the Staff, has it been learned 
 that the plan is defective in scope or elasticity, or that 
 troubles have occurred, except such as inevitably attend 
 the organization of great enterprises. 
 
37 
 
 It remains to be stated that the action of the Com- 
 mission as expressed in its reports, and in the resolutions 
 found in the record of its proceedings, is to be accepted 
 as the action of the Commission, and represents a con- 
 sensus of opinion often arrived at before a report or a 
 resolution was written. The fact that any Commis- 
 sioner may have been more frequently noted than 
 others as presenting resolutions, is no reason why 
 greater responsibility for the Commission's action 
 should fall upon him than upon the other Commis- 
 sioners. 
 
 In conclusion, the Commission desires to express its 
 appreciation of the courtesy of your act in giving it 
 early opportunity to file a reply to the letter of Dr. 
 Reed. 
 
 The report of Dr. Reed was transmitted to this Com- 
 mission by you as a confidential document. The Com- 
 mission has learned, however, that within the last few 
 days it has appeared, in full, in the Journal of the Amer- 
 ican Medical Association, published in Chicago, and 
 that synopses thereof have been published in a num- 
 ber of newspapers. The Commission would, therefore, 
 most respectfully suggest that this reply be not treated 
 as a confidential document, but that a copy thereof be 
 transmitted, with a request for publication in full, to 
 the Journal of the American Medical Association, and 
 that the public press be requested to give it extended 
 notice. 
 
 Very respectfully, 
 
 J. G. Walker, Chairman; 
 Wm. Barclay Parsons, 
 Wm. H. Burr, 
 
 B. M. Harrod, 
 
 C. E. Grunsky. 
 
38. 
 
 Isthmian Canal Commission, 
 Washington,, D. C, March i8, 1905. 
 
 Hon. Wm. H. Taft, Secretary of War, Washington, D. C. 
 
 Sir: 
 
 The Commission desires, in addition to the reply to 
 Dr. C. A. L. Reed, forwarded to you on March 17th, to 
 call attention to the Doctor's charge that *'The re- 
 sponsibility for the present existence of yellow fever on 
 the Isthmus can be placed no where else than upon the 
 Isthmian Canal Commission." 
 
 This charge is sufficiently refuted by the following 
 extracts from a letter addressed to the Governor of the 
 Canal Zone, under date of February ist, by Col. W. C. 
 Gorgas, the Chief Sanitary Officer of the Commission: 
 
 *'In answer to conversation with yourself this morn- 
 ing and enclosed extract from letter of the Secretary of 
 War, I desire to state that I do not think the delays in 
 getting medical supplies on the Isthmus have had any- 
 thing whatever to do with the yellow fever at present 
 in Panama. ... I would also like to state that 
 there is every evidence that the work is being entirely 
 successful, just as it was in Havana. Of course, I am 
 referring entirely to the yellow fever work." 
 Very respectfully, 
 
 J. G. Walker, 
 
 Chairman. 
 
 Washington, D, C, March 2, 1905. 
 Honorable William H. Taft, Secretary of War. 
 
 Dear Sir : 
 
 Pursuant to your request I have the honor herewith 
 to submit the report of my observations relative to the 
 status of sanitation and of the Sanitary Department in 
 the Canal Zone and in the Cities of Colon and Panama. 
 
 I arrived at Colon on the 7th of Febuary and sailed 
 
39 
 
 from that city on the 226. of the same month, thus 
 affording me fifteen days in which to study, with more 
 or less care, the conditions of organization and the de- 
 tails of administration as they relate to the public health 
 interest. 
 
 I was given every facility in this regard by General 
 Davis, the Governor of the Zone; by Mr. Wallace, the- 
 Chief Engineer; by Colonel Gorgas, the Chief Sanitary 
 Officer; as well as by his associates, Major La Garde, 
 Lieutenant Lyster and Dr. Carter. As a result of this 
 investigation I became impressed with the efficiency 
 and the zeal of the Sanitary Staff; with the fact that 
 very much has been accomplished in the way of sanita- 
 tion under exceedingly adverse circumstances; that 
 much remains to be done which cannot be done unless 
 better facilities are afforded; and that very much more 
 ought to be done and would have been done if the facili- 
 had been properly furnished. 
 
 I was forced to this conclusion not only by what I 
 saw and heard while on the Isthmus, but by a careful 
 study of the published proceedings of the Isthmian 
 Canal Commission, by a study of the laws of the Canal 
 Zone formulated by that Commission, and by a careful 
 consideration of their first annual report, submitted 
 under date of December i, 1904. 
 
 The situation became all the more impressive from 
 the fact that the question of sanitation on the Isthmus 
 was considered of so much importance that it was made 
 a subject of special provision in the Canal Convention 
 entered into between the Republic of Panama and the 
 United States. There is, in fact, no stipulated cession 
 to the United States that does not carry with it the 
 expressed right of sanitation. This is true not only of 
 the Zone proper, but it is likewise agreed "That the 
 
40 
 
 Cities of Panama and Colon," which lie outside of the 
 Canal Zone, ''shall comply in perpetuity with the sani- 
 tary ordinances, whether of a preventive or curative 
 character, prescribed by the United States, and in case 
 the Government of Panama, is unable or fails in its duty 
 to enforce this compliance by the Cities of Panama and 
 Colon with the sanitary ordinances of the United States, 
 the Republic of Panama grants to the United States 
 the right and authority to enforce the same." 
 
 This provision of treaty entered into by the two coun- 
 tries was the logical result of the disastrous experiences, 
 first, of the Panama Railroad under the three companies 
 that were successively identified with its construction, 
 and later by the two French companies that had at- 
 tempted to dig the canal. That sanitation was, indeed, 
 the fundamental problem to be solved before even the 
 engineering question could be subjected to successful 
 solution had been reduced to a demonstration. 
 
 This view of the case was manifestly accepted by the 
 President, who, on the formal installation of the Isth- 
 mian Canal Commission, addressed that body, in part, 
 as follows: 
 
 ''There is one matter to which I wish to ask your 
 special attention — the question of sanitation and 
 hygiene. You will take measures to secure the best 
 medical experts for this purpose whom you can obtain, 
 and you will, of course, make the contractors submit as 
 implicitly as your own employes to all the rules and 
 regulations of the medical department under you. / 
 presume you will find it best to have one head for this medi- 
 cal department, but that I shall leave to your own judg- 
 
 The italics by the writer indicate the views of the 
 President, subsequently expressed to the writer, that 
 
41 
 
 by having Colonel Gorgas placed in full charge of the 
 sanitary work, instead of on the Commission itself, as 
 had been urged by the medical profession of the United 
 States, he would be untrammeled with extraneous 
 duties, and would consequently have better opportunity 
 to make his work effective than if he were actually a 
 member of the executive board. 
 
 THE ORGANIZATION OF THE HEALTH DEPARTMENT. 
 
 At the meeting of the Commission, held at Ancon, 
 August 28, 1904, Mr. Grunsky, as the Committee on the 
 proposed Health Department, presented a report which 
 began by stating that "after repeated conferences with'* 
 Colonel Gorgas and practically the entire sanitary 
 staff, "it has been agreed," but which should have 
 stated that "in certain important particulars Mr. Grun- 
 sky has agreed with himself ;'* for as a matter of fact 
 much of the report was formulated over the respectful 
 protest of the medical men who were invited to the 
 conference. By this report the Commission, more 
 especially Mr. Grunsky, provided for the creation of a 
 board of health, with power to formulate regulations 
 which would become effective only after approval by 
 the Commission, or in cases of emergency only on the 
 approval of the Governor of the Canal Zone. The Chief 
 Sanitary Officer was sent to the Zone to clear it up and 
 to make it ready for the actual work of the engineers. 
 Thus, however, his discretion was limited to the en- 
 forcement of regulations that had first been adopted by 
 the Commission or by a Board of Health; in which lat- 
 ter event it had to be sent generally to Washington to 
 be endorsed by the Commission, or in cases of emer- 
 gency it had to receive the approval of the Governor 
 of the Zone. 
 
42 
 
 It thus came about that the Chief Sanitary Officer, 
 whom and whose department the medical profession 
 had asked to be made largely autonomous; whom and 
 which the President himself had obviously intended 
 should be largely autonomous, was by the action of 
 the Commission, more especially Mr. Grunsky, subordi- 
 nated to the Governor of the Zone; to the Chief Dis- 
 bursing Officer; to the Chief of the Bureau of Material 
 and Supplies; to Mr. Grunsky; to the Commission; to 
 the Secretary of War; to the President; subordinated, 
 in fact, in the seventh degree from the original source 
 of authority. And this is the state of affairs on the 
 Isthmus to-day. One cannot but be impressed with the 
 anomalous condition by which a man of Colonel Gor- 
 gas' distinction, the foremost authority in the world in 
 solving the peculiar problems that are connected with 
 sanitation on the Isthmus, being made an instrument of 
 a whole series of men who confessedly are ignorant of 
 the very questions with which he is most familiar. 
 
 THE SANITARY DEPARTMENT DENIED THE RIGHT TO DECIDE 
 UPON THE SUITABILITY OF ITS OWN SUPPLIES. 
 
 The Commission at Ancon last August adopted a 
 resolution creating a department of the Zone Govern- 
 ment to be known as the Material and Supplies Depart- 
 ment, the chief of which is ''charged with the receipt, 
 inspection on the Isthmus, custody, care, shipment, 
 transfer, issue and disposition of all supplies, material, 
 equipage and floating equipment unissued and not in 
 actual use." It is, however, specifically provided that 
 **the Governor of the Canal Zone, acting for the Execu- 
 tive Branch of the Government of the Zone, and the 
 Chief Engineer, acting for the Department of Engineer- 
 ing and Construction, shall have authority to decide on 
 
43 
 
 the suitability of any and all supplies furnished, and 
 their requisitions for such materials as are on the Isth- 
 mus shall be promptly filled without reference to a 
 higher authority." 
 
 There is nothing said about the Sanitary Department, 
 and as that which is not included is excluded, it follows 
 that the right very justly accorded to the Engineering 
 Department is denied to the Sanitary Department as 
 such. It is obvious, of course, that the Sanitary Depart- 
 ment, being made subordinate to "the Executive 
 Branch of the Government of the Zone," can get sup- 
 plies, but subject only to the judgment of the Governor, 
 who by this resolution is empowered to pass upon the 
 suitability of any or all supplies for the Medical Depart- 
 ment or the Department of Public Health." 
 
 An example of the working of this rule was shown 
 in the recent purchase of an X-ray outfit for the Ancon 
 Hospital. The requisition went in several months ago 
 and was pending before the Commission, more espe- 
 cially Mr. Grunsky, when the expert, who had been 
 specially employed to do X-ray work in Ancon, hap- 
 pened in Washington and requested the privilege of 
 selecting the Crookes' tubes; the request was perempto- 
 rily refused; the expert urged that his knowledge would 
 enable him to make better selections than would be 
 probable by an unskilled purchasing agent, and went so 
 far as to urge as an additional reason the distance to the 
 Isthmus, the time involved in transportation, to say 
 nothing of the expense involved, only, however, to be 
 informed that if the tubes did not suit they could be 
 returned. They came after a long delay; were found 
 worthless and were returned; other ones have not yet 
 been sent to replace them, and, as a consequence, An- 
 con Hospital is to-day without X-ray service, while the 
 
44 
 
 salary of the expert goes on. In another instance 
 objectives for a number of microscopes were carefully 
 specified by the chief of the laboratory, who would 
 naturally be presumed to know most about them, but 
 the Commission, more especially Mr. Grunsky, assumed 
 to possess superior knowledge of the subject, and sub- 
 stituted others, with the result that when they arrived 
 upon the Isthmus they, too, were found to be worthless. 
 The foregoing are but two examples of what is con- 
 stantly occurring. The matter becomes really very 
 serious when it involves questions of medicines, and in 
 this particular furnishes a strange inconsistency with 
 the laws laid down by the Commission for the govern- 
 ment of everybody else but themselves. Thus, by the 
 laws of the Canal Zone, a severe penalty is imposed 
 upon druggists and purveyors in general for substitut- 
 ing one medicine for another that may have been 
 ordered, yet instance after instance is coming to the 
 front in which the Commission, either through Mr. 
 Grunsky or through an unqualified purchasing agent, 
 is foisting upon the medical service remedies other than 
 those specified in the requisitions. This, I believe, holds 
 true in practically every requisition for medicine that 
 has reached Ancon Hospital, and the same principle 
 may probably account for the fact that the majority of 
 all of the requisitions for medical supplies have been 
 either ignored or suppressed by the Commission at 
 Washington. 
 
 CHEAP DOCTORS FOR THE ISTHMUS. 
 
 The Commission in every effort that it has made to 
 secure service upon the Isthmus has tacitly acknowl- 
 edged the unhealthfulness of the region by holding out 
 as an inducement that fact that employes will be fur- 
 
45 
 
 nished free medical service, including the service of the 
 hospitals. The fact that medical men in the Zone v^ould 
 have much executive v^ork to do ; that they would have 
 to deal with large bodies of workmen, and that their 
 duties would require the exercise of trained judgment 
 in a very broad sense prompted Colonel Gorgas to ad- 
 vise that only relatively mature men be brought to the 
 Isthmus in the capacity of physicians. He advised, 
 furthermore, that the minimum salary to be paid to 
 medical men in the Zone be the same as the minimum 
 salary paid in the Army for contract surgeons, namely, 
 $i,8oo. This plan did not, however, commend itself to 
 the Commission, more especially to Mr. Grunsky, who, 
 in the interest of alleged economy, conceived the bril- 
 liant scheme of establishing interneships in the hospitals 
 of the Zone, the incumbents to receive $50 per month, 
 the same salary that is paid to nurses. The verbal justi- 
 fication of the plan offered by Mr. Grunsky, and subse- 
 quently adopted by the Commission, is that young men 
 will thereby receive a preliminary training in tropical 
 diseases, which is to be accepted by them as part pay 
 for their services, after which, that is, after a year, if 
 they so desire, they will be at liberty to return to the 
 States. But Mr. Grunsky takes pains not to say that 
 the incidental service to be rendered by these internes 
 is to represent the bone and sinew of the medical service 
 on the Isthmus, and likewise fails to make clear how he 
 expects to establish a stable medical service if, after the 
 expiration of a year, his internes are at liberty to return 
 to the North, which they would doubtless do in the ab- 
 sence of inducements to remain upon the Isthmus. But 
 what if they should desire to return before the end of a 
 year? This question brings us face to face with Mr. 
 Grunsky's trap to get cheap medical service for the 
 
46 
 
 Zone. Once upon the Isthmus, these young men, find- 
 ing themselves on the salaried basis of nurses, with 
 incidental expenses that cannot be evaded and that v^ill 
 eat up the last penny of their beggarly stipend, desir- 
 ing to leave their humiliating positions, v^ill find the 
 door closed against egress. It is even to-day easy for 
 an employe to get to the Isthmus, but it is already ex- 
 ceedingly difficult for him to get away from it. And 
 what is true to-day will be more emphatically true in 
 the future, a fact that the Commission, more especially 
 Mr. Grunsky, takes great care to leave in the back- 
 ground. But the Commission, more especially Mr. 
 Grunsky, holds up the prospect of promotion. This, 
 in any event, under Mr. Grunsky's rules, cannot be 
 granted under one year, and then, if granted, which it 
 may not be, the salary is placed at $125.00 per month, or 
 $300.00 per year less than the minimum salary paid to 
 contract surgeons in the army. What is there about the 
 medical service in the Canal Zone that should render it 
 less entitled to compensation than the same medical 
 service when rendered in the Army? What is there 
 about the personnel of the Zone Government; about 
 the employes; about the laborers that they should be 
 furnished with a cheaper grade of medical service than 
 the officers, soldiers and enlisted men of the Army? 
 Why should not the Commission, more especially Mr. 
 Grunsky, follow the example of both the Army and the 
 Navy and accept men who have already served interne- 
 ships in the hospitals of the States, give them decent 
 salaries, and then, after sending them to the Isthmus, 
 give them additional opportunities for the preliminary 
 study of tropical diseases at the hospitals at Ancon and 
 Colon? And why should this not be done at once, that 
 a competent medical staff may be at the Isthmus when 
 
47 
 
 the large bodies of workmen shall have arrived. This 
 could not but be gratifying to the Chief Sanitary Ofifiicer, 
 whose wishes, however, it would seem not only to be 
 expressed to have them vetoed by the Commission, 
 more especially by Mr, Grunsky, in what seems to be a 
 fatuous desire, regardless of consequences, to give every 
 detail the impress of his overpowering personality. 
 
 THE commission's PETTY ANTAGONISMS TO THE SANITARY 
 DEPARTMENT. 
 
 That the opinion just expressed, viz., that the Com- 
 mission, more especially Mr. Grunsky, visits upon 
 Colonel Gorgas and upon the Sanitary Department not 
 only unnecessary and unreasonable restraints and confronts 
 it with petty, almost despicable antagonisms, is shown by 
 reference to a series of unrelated facts. Thus, Colonel 
 Gorgas asked the Commission to invest him with indi- 
 vidual authority in carrying out views which had 
 matured not only from his long professional study, but 
 as a result of his highly successful experience in Cuba; 
 the reply was the establishment of a Board of Health, 
 followed by his subordination successively, under the 
 immediate control of practically every feature of gov- 
 ernment in the Zone. He asked for a department of 
 hospitals, with an officer at its head; this was tempo- 
 rarily granted; but the office was soon abolished and 
 was forced into Colonel Gorgas' own office without any 
 compensatory addition to his executive force. Colonel 
 Gorgas sent in numerous requisitions, many of which, 
 as I shall have occasion to allude more in detail, were 
 disregarded; he followed them with letters of respect- 
 ful protest about the slowness of receiving supplies; 
 the reply was the statement made to him verbally and 
 under humiliating surroundings that he was disrespect- 
 
48 
 
 ful to his superior officers. Colonel Gorgas submitted 
 an estimate for the establishment of emergency hos- 
 pitals along the line. This estimate was reduced by 
 the Commission; Colonel Gorgas wanted to begin 
 drainage and other important mosquito work simulta- 
 neously at other points along the line, and for this pur- 
 pose asked for twenty inspectors; the Commission, 
 more especially Mr. Grunsky, took the matter under 
 serious advisement, and reduced the estimate to eight 
 inspectors. Colonel Gorgas asked for screens for all 
 the buildings in the Zone; the Commission, more espe- 
 cially Mr. Grunsky, concluded that this was a totally 
 unwarranted expense, and eliminated the proposition. 
 Colonel Gorgas then urged that mosquito screening be 
 furnished for all of the buildings at the Ancon Hospital, 
 the screens to be placed around the galleries ; the Com- 
 mission, more especially Mr. Grunsky, concluded, how- 
 ever, that only one-half of the gallery space ought to be 
 enclosed; that the windows might possibly be screened 
 with advantage, and that even in that part of the gal- 
 leries where screening was applicable it might be well 
 to board up the part of them below the railing, utterly 
 unmindful that such a proposition would carry about 
 ten times the expense of screening. Colonel Gorgas 
 asked for a chief clerk at $1,800.00, with the object of 
 getting a man who had had experience with him in 
 Cuba; he was allowed only $1,500.00, for which he could 
 get only an inexperienced man. He asked for $5,000.00 
 for a health officer for Panama, a most important office, 
 with the hope that he might fill it with a man of Cuban 
 experience; the Commission, more especially Mr. 
 Grunsky, allowed $3,000.00, with which it was possible 
 to secure only the services of a previously inexperi- 
 
49 
 
 enced man. Colonel Gorgas asked for one hundred 
 female nurses, duly qualified for service at Ancon and 
 Colon hospitals, on a basis of a normal bed capacity of 
 those two institutions ; the Commission, more especially 
 Mr. Grunsky, replied by furnishing him forty female 
 nurses, but by authorizing the establishment of a train- 
 ing school, by which, as in the instance of the interne- 
 ships, it was hoped to get the services of inexperienced 
 nurses for comparatively little money. Colonel Gorgas 
 asked for $50.00 per month for trained men for orderlies 
 in the hospitals ; it would be impossible to get them for 
 less money. The Commission, more especially Mr. 
 Grunsky, replied by cutting the allowance down to 
 $25.00 per month for the trained wardmen and $15.00 
 per month for orderlies, with the result that the medical 
 staff is being subjected to serious confusion by the inef- 
 ficiency of the natives, who alone will accept these small 
 wages. Colonel Gorgas recommended to the Commis- 
 sion the prompt control of both Colon and Panama, to 
 which I shall have subsequent occasion to allude; the 
 Commission, more especially Mr. Grunsky, found a con- 
 venient pretext in totally imaginary diplomatic com- 
 plications to defer this step until forced to it by the 
 development of yellow fever. Colonel Gorgas recom- 
 mended a sysem of movable latrines, which is used in 
 the larger labor camps as a preventive of ankylosto- 
 miasis or hook-worm, with which the natives are 
 already infected, and which is one of the most pestilen- 
 tial diseases of the tropics; the Commission did not 
 consider this, only one member of which taking any 
 notice of the suggestion, and that to the extent of ex- 
 pressing his disapproval, coupling with his disapproval 
 the suggestion that in certain tropical countries with 
 
50 
 
 which he is familiar hogs and buzzards have been suc- 
 cessfully relied upon to dispose of night-soil. Colonel 
 Gorgas asked in his original scheme that the institution 
 at Taboga be set aside for the accommodation of con- 
 convalescents from the hospitals at Ancon, and at other 
 points in the Zone, and asked for the privilege to nomi- 
 nate a doctor and head nurse for the place and to equip 
 the institution; the Commission, more especially Mr. 
 Grunsky, replied that while they would repair the insti- 
 tution they would not put it in commission. (As a 
 matter of fact some repairs have been made, the institu- 
 tion is now in the charge of a caretaker, while the hos- 
 pital at Ancon is overcrowded with convalescents and 
 with the personnel of the institution, thus materially 
 reducing the real hospital capacity of the institution.) 
 Colonel Gorgas asked in November for the personnel 
 for the hospital at Meriflores, which, in accordance with 
 the understanding had with Secretary Taft during his 
 stay on the Isthmus, was set aside for the accommoda- 
 tion of the insane and the lepers of the Republic; the 
 Commission, more especially Mr. Grunsky, authorized 
 that a doctor and an assistant, with a nurse, be transfer- 
 red to the institution, but furnished no person to take 
 the places from which they had been detached. 
 Colonel Gorgas asked that he be given some oppor- 
 tunity to exercise his judgment as to the qualifications 
 of the personnel, and as to the quality of supplies to be 
 furnished his department; the Commission, more espe- 
 cially Mr. Grunsky, declined to give him this important 
 supervision over the selecton of his personnel, while the 
 Disbursing Officer declined to give him the opportunity 
 to inspect supplies before they were actually issued to 
 the Sanitary Department. Colonel Gorgas at the first 
 
51 
 
 outbreak of yellow fever in July of last year asked for a 
 general appropriation to be disbursed at his discretion 
 with which to meet the emergency; the Commission, 
 more especially Mr. Grunsky, peremptorily declined to 
 place any sum of money at his disposal, and forced him 
 to rely exclusively upon the established machinery for 
 securing necessary supplies. Colonel Gorgas then asked 
 the privilege of ordering directly from the medical pur- 
 veyor in New York to the amount specifically of 
 $30,000.00, silver, for first month of the yellow fever 
 epidemic, and $15,000.00 for each following month, so 
 long as it might be necessary; the Commission, more 
 especially Mr. Grunsky, again refused, but directed that 
 the Bureau of Material and Supplies be ordered to pur- 
 chase the necessary articles, which it assumed to do, but 
 notwithstanding the lapse of eight months these sup- 
 plies are not yet upon the Isthmus. 
 
 Doors and windows for the hospital at Culebra were 
 asked for in January, but are not yet in place. Flooring 
 for the porch of the hospital at Gorgona, likewise asked 
 for in January, has not yet been furnished, and patients 
 have to be carried up and down stairs and through the 
 open to get them from one ward to another. Colonel 
 Gorgas asked for screens for the hospitals along the line 
 and sent in requisitions for the same in July; the Com- 
 mission, more especially Mr. Grunsky, concluded that 
 they were not necessary; Colonel Gorgas asked that a 
 gang of men for the purpose of making repairs be 
 placed at his disposal, and Chief Engineer Wallace set 
 aside a number of men for this purpose; the Commis- 
 sion, more especially Mr. Grunsky, however, stopped 
 this convenient arrangement and directed that here- 
 after all such things must be done only after estimates 
 had been previously submitted; Colonel Gorgas asked 
 
for pyrethrum, sulphur and other materials for disinfec- 
 tion work — the request having been sent in last Septem- 
 ber; the Commission, more especially Mr. Grunsky, 
 concluded the esimate was large, cut it down to one- 
 fourth and then sent the material only in small lots from 
 time to time; Colonel Gorgas requested that a certain 
 house be constructed at the quarantine station, seriously 
 needed for the benefit of the service; the Commission, 
 more especially Mr. Grunsky, ignored the request, and 
 the service was embarrassed for the want of necessary 
 facilities; Colonel Gorgas asked for the equipment for 
 the research laboratory, and for a small personnel at 
 an aggregate expense of fifteen thousand dollars 
 ($15,000.00), but an annual operating expense of about 
 one hundred and forty dollars ($140.00), the small 
 operating expense for salaries being attributable to the 
 fact that men already connected with Ancon could be 
 detailed for the service; the Commission, more espe- 
 cially Mr. Grunsky, supported in this instance by Gov- 
 ernor Davis, rendered an adverse decision on this appli- 
 cation. Colonel Gorgas asked that an ambulance be 
 kept on the ground at Ancon for prompt service; the 
 Commission, more especially Mr. Grunsky, replied that 
 the ambulance must be kept in the corral outside of the 
 hospital grounds, as a result of which unnecessary time 
 of the Commission was consumed in alleged delibera- 
 tion over this question, and as a further result it is im- 
 possible to get the ambulance on ready call at times of 
 emergency. These are but a few of the many examples 
 that could be cited by which the Commission, more 
 especially Mr. Grunsky, thwarts the honest endeavor of 
 Colonel Gorgas to put the Canal Zone in proper sani- 
 tary condition. There are, however, a number of other 
 questions to which I must hasten to invite attention. 
 
53 
 
 THE UNITED STATES IN CHEAP COMPETITION WITH THE 
 MEDICAL PROFESSION OF PANAMA. 
 
 The course of the Commission in its endeavor to 
 establish a cheap medical service, naturally enough 
 made up of cheap doctors, v^hich they hope in the 
 future to send to the Zone, is not limited in its influence 
 and in its pernicious results to the Zone itself. To 
 make this clear, however, it is important to remember 
 that under the truly remarkable plan of organization of 
 the Sanitary Department devised by Mr. Grunsky, 
 adopted by the Commission and duly engrossed in the 
 laws of the Canal Zone, it is provided that all persons 
 not employes of the Commission, but who may be 
 "sick in the Canal Zone and in Colon and Panama, 
 should be admitted to the hospitals, but such persons 
 shall pay according to their means." This practically 
 opens the hospitals of the Zone as private pay hospitals 
 to all the world, for it would be difficult for any sick 
 persons to come from anywhere and to enter the Zone 
 at either end without being sick in Colon and Panama. 
 As a matter of fact it happens with increased frequency 
 that patients, not only from Panama, but from various 
 points along the coast and in the interior, are received 
 and treated in the hospitals at Ancon. I have no 
 knowledge touching this point at Colon, but can see no 
 reason why it should not be equally true. The thing, 
 however, would not seem so bad if the provision that 
 these patients should pay according to their means had 
 been permitted to stand without qualification. Unfor- 
 tunately, however, the Commission, more especially 
 Mr. Grunsky, with his fondness for prescribed details, 
 proceeded to lay down a per diem charge for room and 
 for nursing at Ancon; the rates being about the same 
 
54 
 
 as those charged for similar service in the better hos- 
 pitals of the United States. He, however, did not stop 
 at this point, but made it a part of the laws of the 
 Canal Zone that ''surgical operations shall be charged 
 for according to their importance and the financial 
 ability of the patient to pay, but no charge in excess 
 of fifty dollars ($50.00) shall be made without the ap- 
 proval of the Director of Hospitals." As the office of 
 Director of Hospitals has been abolished, the maximum 
 rate to be charged for surgical operations, without ref- 
 erence to their gravity, stands at fifty dollars. It is 
 furthermore provided by Mr. Grunsky, and made part 
 of the laws of the Canal Zone, that physicians con- 
 nected with the hospitals must visit the residences of 
 persons ''entitled to treatment at the hospital, at a fixed 
 daily rate of pay," which visits "shall be charged for at 
 the rate of one-half dollar ($.50) for each visit, but no 
 such charge is to be made for emergency calls nor in 
 the cases of persons entitled to free hospital treatment 
 until after the person has been ordered into the hos- 
 pital." These rates, which in the instance of surgical 
 operations vary from one-fourth to one-tenth of the 
 average charge in the United States and in the Republic 
 of Panama; and in the instance of visits, less than one- 
 fourth of the ordinary rates charged in the two coun- 
 tries, cannot but be disgusting to the medical profession 
 in the States who are not in the least influenced by the 
 belittling competition. It is important, however, to 
 bear in mind that the physicians at Ancon are in no 
 sense the beneficiaries of the extra revenue that is thus 
 derived by extra service that is imposed upon them. 
 On the contrary, it is provided by the Commission, 
 more especially by Mr. Grunsky, and duly engrossed in 
 the laws of the Canal Zone that "the money realized 
 
in the hospitals from charges for board, medical attend- 
 ance, surgical operations and the like, and from visits 
 at residences as set forth, shall be considered public 
 funds and turned over to the Government of the Canal 
 Zone." It follov^s, therefore, that it is not the medical 
 men sent to the Canal Zone, but the United States, our 
 own great nation itself, that is engaged in this belittling 
 business which must be recognized as a personal insult 
 to any decent practitioner of medicine in any country 
 of the world. In the Republic of Panama it amounts 
 to more than an insult; it is an actual damage. 
 
 This was brought to my attention by one of the most 
 distinguished members of the medical profession of that 
 country, who has made me aware of the situation, and 
 who did so in terms of bitter complaint. He explained 
 that under the operation of this order of things, and in 
 spite of the existence of other hospitals in Panama, pri- 
 vate patients, attracted by the cheap rates and the pres- 
 tige of the medical staff at Ancon, are flocking to that 
 institution, to the present serious embarrassment and 
 prospective ruin of medical practitioners. 
 
 I took the liberty to mention the matter in the course 
 of a personal interview with President Amador, himself 
 the most distinguished medical practitioner of the Re- 
 public. As he is a friend of long standing, I had no 
 hesitancy in securing from him a very frank expression 
 of fact that the subject had become so serious that he 
 had been waited upon by his colleagues of the medical 
 profession, his constituents and fellow-citizens, by 
 whom he had been requested to make formal represent- 
 ations of the subject to the American Minister, but that 
 he had desisted out of his great desire to avoid even the 
 semblance of friction with the United States and in the 
 belief that a question so flagrant of injustice would 
 
56 
 
 sooner or later reach executive circles in Washington 
 and be corrected. 
 
 WHY IS THERE YELLOW FEVER IN PANAMA? 
 
 Yellow fever is demonstrably a preventable disease, 
 and, as a consequence, all deaths resulting from yellow 
 fever must at once raise the question of responsibility. 
 Panama has long and justly been recognized as a seat 
 of yellow fever infection, just as was Havana before the 
 brilliant sanitary achievements of Colonel Gorgas in 
 that city — achievements which resulted in his call to the 
 Isthmus. The real campaign against the disease in 
 Havana, more particularly against the disease-bearing 
 mosquitoes, lasted from January to September, 1901. 
 As Panama is but a village in comparison with the Cu- 
 ban metropolis, it was naturally expected that similarly 
 satisfactory results would be realized there in the same, 
 if not less, time, but yellow fever is still endemic in 
 Panama. Why is this true? 
 
 The dangers of the situation were thoroughly appre- 
 ciated by Colonel Gorgas even before he went to the 
 Isthmus, and he laid a plan of campaign before the Com- 
 mission which embraced several distinct features, 
 namely: 
 
 1. The installation of a sewer system in the cities of 
 Colon and Panama. 
 
 2. The installation of water supply in those cities. 
 
 3. The cleaning of the streets, including the disposal 
 of garbage and night soil. 
 
 4. General sanitation of houses, including their fumi- 
 gation, and the drainage of neighboring pools, the abo- 
 lition of water barrels and cisterns and other places for 
 the propagation of the yellow fever mosquito. 
 
 5. The prompt isolation of all cases of yellow fever. 
 
57 
 
 These various steps bore such a logical relation to 
 each other that one would become practically inopera- 
 tive vi^ithout the other. 
 
 This viev^ v^as apparently accepted by the Commis- 
 sion, even including Mr. Grunsky, before the first visit 
 of that body to the Isthmus, and it was likewise the view 
 still of Colonel Gorgas and the entire personnel of the 
 Sanitary Department, as well as of Mr. Wallace, the 
 head of the Engineering Department, when on June 
 28th full sanitary government was established in the 
 Canal Zone. Panama was then apparently free from 
 yellow fever, and Colonel Gorgas, with his Cuban ex- 
 perience, and knowing the danger that was lurking in 
 the immediate future, set about promoting complete 
 measures of prevention, while Mr. Wallace addressed 
 himself to plans and specifications for water works and 
 a sewer system for Panama. The plans of both of 
 these men went promptly before the Commission, but 
 it was not until that body had returned to the Isthmus 
 in August following that they were given serious con- 
 sideration; meanwhile the danger of which Colonel 
 Gorgas had forewarned them had developed, for on 
 July 12 Charles Cunningham was stricken with yellow 
 fever, from which he died two days later. Fourteen 
 days after this death another case developed, which, 
 however, went on to recovery. When the Commission 
 arrived at Ancon on the occasion of its second visit — 
 that is, on August 3rd — Colonel Gorgas again urged 
 the prompt assumption of control over Colon and Pan- 
 ama, and cited the case still in the hospital and the fatal 
 one that had preceded it as danger signals of sufficient 
 gravity to justify action. But the Commission, more 
 especially Mr. Grunsky, had not yet determined the 
 degree of humiliating subordination to which the Sani- 
 
S8 
 
 tary Department was to be subjected, under pretext 
 of perfecting a plan of organization, deferred action for 
 another three and one-half weeks — valuable weeks — 
 that is, until August 28th. On this date the Commis- 
 sion, on the report of Mr. Grunsky, adopted Mr. Grun- 
 sky's plan of organization, by which, as I have already 
 shown. Colonel Gorgas was subordinated to the seventh 
 degree below the original source of authority, and even 
 then, with cases of yellow fever staring them in the face, 
 the Commission, at the instance of Mr. Grunsky, di- 
 rected Colonel Gorgas, acting through Governor Davis, 
 to refrain from any attempt to secure sanitary control 
 over the cities of Colon and Panama, citing certain more 
 or less diplomatic frivolities as a pretext for deferred 
 action. It was only after four more months had elapsed, 
 only after the progressive development of yellow fever 
 had reached the sensational point, and only after the 
 personnel in the Canal Zone had become thoroughly 
 alarmed over the situation, that Colonel Gorgas was 
 permitted by those in authority over him to assume the 
 sanitary control of the two cities, one of which, Panama, 
 being already very generally infected. 
 
 But even then his hands were tied. Sometimes, and 
 in important particulars, by the arbitrary exercise of 
 super-imposed authority, but all the time, and in still 
 more important particulars, by the fact that the water 
 supply and the sewage system were not installed. Mr. 
 Wallace had drawn the plans and specifications in July 
 previous, and had taken care to specify only such pipe 
 as manufacturers keep in stock, and that could, there- 
 fore, be procured without a moment's delay. But the 
 Commission, more especially Mr. Grunsky, in total 
 disregard of the emergency that was present, saw fit to 
 indulge in some views about pipe, and as Mr. Grunsky 
 is a civil engineer, and needed to impress that fact upon 
 
59 
 
 somebody, he summoned Mr. Wallace, now his sub- 
 ordinate, before the Commission to explain why he had 
 specified both Eastern and Western standards of pipes. 
 The explanation given by Mr. Wallace that either one 
 or both these standards would answer the purpose, and 
 that it had been simply his desire to get the pipe 
 promptly upon the Isthmus, seemed to make no appeal 
 to either the Commission or Mr. Grunsky, and pipe of 
 the Western pattern alone was ordered. The delay 
 upon this particular point consumed another precious 
 two weeks, when Mr. Wallace was authorized to pro- 
 ceed with the work. This he undertook with his char- 
 acteristic energy, and, allowing for all reasonable delay 
 in procuring the pipe and in sending it to the Isthmus, 
 promised the people of Panama that they should have 
 water by December. He finished the work at the Rio 
 Grande reservoir; the trenches for the pipe were dug, 
 washed full of dirt and re-dug, but still there was no 
 pipe. Mr. Wallace then cabled to Washington urging 
 that the pipe be sent, only, however, to receive a repri- 
 mand from Admiral Walker, Chairman of the Com- 
 mission, admonishing him that cablegrams from the 
 Isthmus were expensive. It is now nearly the ist of 
 March, and the schooner which brought the first con- 
 signment of pipe, not enough to complete the work at 
 Panama, was discharging the cargo at Colon as I left. 
 It is further understood that before the work can go on 
 this same schooner must sail back to Mobile, await the 
 arrival there of enough pipe to make a full cargo, then 
 sail back to Colon and again unload, a proceeding that, 
 at a conservative estimate, will consume at least from 
 two to three more months. And all this by a Commis- 
 sion that controls a line of steamers plying weekly be- 
 tween New York and the Isthmus! 
 
 In the light of all these facts, in contrast with the 
 
6o 
 
 brilliant results achieved by Colonel Gorgas in Havana, 
 the responsibilty for the present existence of yellow 
 fever on the Isthmus can be placed nowhere else than 
 upon the Isthmian Canal Commission, more especially 
 upon Mr. Grunsky. 
 
 THE CAMPAIGN AGAINST MALARIA THWARTED BY THE 
 COMMISSION. 
 
 But sensational as is yellow fever, now apparently 
 on the increase at the Isthmus, the fact remains that 
 malaria is the more serious pest. The discovery that 
 malaria is disseminated by the anopheles has, however, 
 made it possible to minimize the disease by proper pre- 
 ventive methods. These embrace (a) drainage, (b) the 
 isolation of malarial patients, (c) prophylactic cinchon- 
 ism. That these three things might be done, and done 
 before the onset of the dry season, Colonel Gorgas 
 asked the Commission last August to furnish men to dig 
 ditches and drain pools about the houses of natives. 
 He asked also for wire screening with which to isolate 
 all patients afiflicted with malaria, and quinine with 
 which mildly to cinchonize laborers and others exposed 
 to the malaria-bearing mosquitoes. The Commission, 
 more especially Mr. Grunsky, however, thought that 
 the number of ditches asked for — something like twen- 
 ty — was too many, and allowed only half those esti- 
 mated; but as the dry season has arrived and is almost 
 past, and as the small squad of ditchers is still digging, 
 it would seem that the original estimate was justified 
 by the necessities of the situation. The wire screening 
 was likewise cut down from 2,500 yards to 500 yards, 
 and even that has not yet arrived upon the Isthmus. 
 The use of quinine as a preventive of infection did not 
 commend itself either to the great therapeutic skill or 
 
6i 
 
 to the economic judgment of the Commission, more 
 especially Mr. Grunsky, so the observation of medical 
 men on the Isthmus, the conclusions of authorities in 
 tropical medicine, such as Munson and Giles, the inves- 
 tigations of the Italian authorities, and the unequivocal 
 verdict of Koch, were pushed aside, and quinine for 
 this purpose was stricken from the list. The result is 
 that while much has been accomplished by drainage, 
 and by the admission of small fish into the runnels made 
 by the small force of workmen, and while much has 
 been accomplished by the prophylactic use of quinine 
 by the personnel and employes of the higher grades, 
 and taken by them in spite of the action of the Com- 
 mission, the fact remains that in the absence of the wire 
 screening ordered last August, each case of malaria be- 
 comes a focus for the further dissemination of the dis- 
 ease. This is shown even at the Ancon Hospital, where 
 in the absence of wire screening for the malarial wards 
 and the consequent impossibility of excluding the ma- 
 laria-bearing mosquitoes, non-malarious patients are 
 becoming malarious, while white nurses and attendants 
 are being made frequent victims of the disease. Two 
 members of the medical staff likewise were suffering 
 from malarial infection during the time of my stay at 
 Ancon, yet in spite of these facts the Isthmian Canal 
 Commission, in its report under date of December, 1904, 
 page 88, states that "All cases of employes sick with 
 malaria are taken into the Colon and Ancon hospitals 
 and so screened that mosquitoes cannot reach them" — a 
 statement that is an absolute and an unqualified false- 
 hood. 
 
 CHEAP NURSING SERVICE. 
 
 This report might be indefinitely amplified, but time 
 will not permit. I feel it important, however, to allude 
 
62 
 
 to the fact that the policy that the Commission, more 
 especially Mr. Grunsky, has adopted with reference to 
 furnishing cheap medical service to those who risk their 
 lives in the Zone has been adopted for the purpose of 
 furnishing nurses for service in the Sanitary Depart- 
 ment. The effort has been made under the subterfuge 
 of the training school to be conducted at Ancon, to get 
 nurses to go to the Zone at about the same rate that is 
 paid for pupil nurses in the training schools of the 
 United States. The same conditions practically are im- 
 posed upon the nurses with reference to time service 
 as is imposed upon the internes, with the difference, 
 however, that the period of enforced detention upon 
 the Isthmus under contract is placed at three years. 
 This is not a place to take untrained nurses under any 
 pretext, for nothing but fully developed talent in the 
 various departments of activity should be sent to the 
 Isthmus. 
 
 CONCLUSION. 
 
 In view of the foregoing facts, and disregarding 
 equally serious facts relating to the Department of En- 
 gineering and Construction upon which I do not feel 
 qualified or authorized to report, I beg leave to call 
 attention to the further observations of the President 
 when he inducted the Commission into office, as fol- 
 lows: i . . 
 
 "I believe that each one of you will serve not merely 
 with entire fidelity, but with the utmost efficiency. If 
 at any time I feel that any one of you is not rendering 
 the best service which it is possible to procure, I shall 
 feel called upon to disregard alike my feelings for the 
 man and the man's own feelings, and forthwith to sub- 
 stitute for him on the Commission some other man 
 whom I deem capable of rendering better service." 
 
63 
 
 I have the honor not only to submit the suggestion, 
 but really to urge the view that the time has arrived 
 when the President ought to* redeem his word and ask 
 for the resignation of the Commission. 
 I have the honor to be 
 
 Very respectfully, 
 
 Charles A. L. Reed. 
 President, Committee on Medical Legislation, American 
 Medical Association. 
 
 OF THE 
 
 :VERS1TY ) 
 
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