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Chapter 10

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Chapter 10


Like their colleagues in Cuba, U.S. medical officers in Puerto Rico and the Isthmus of Panama tackled the public health challenges that confronted them with the confidence and enthusiasm characteristic of those in the forefront of the medical revolution. In Puerto Rico a smallpox epidemic and a mysterious, chronic, and disabling anemia afflicted much of the native population without affecting U.S. soldiers. In the Panama Canal Zone, as in Cuba, yellow fever and malaria threatened newcomers more than long-time residents. The two insect-borne diseases had for years paralyzed efforts to dig a canal from the Atlantic to the Pacific Ocean. Unlike their colleagues in Cuba and Puerto Rico, however, those attempting to improve public health in the Canal Zone worked without the backing of a military government; their chief stumbling block as they attempted to apply the methods that had been so successful in Cuba proved to be the stubborn ignorance of the first members of the Isthmian Canal Commission.

Puerto Rico

In Puerto Rico,1 as in the other newly conquered territories, a military government initially assumed power from the departing Spanish, who officially gave up control over the island on 18 October 1898. Until 1900, when the U.S. Congress granted Puerto Rico an elected civil government with a U.S.-appointed governor, U.S. Army medical officers were responsible for the health of both the handful of small garrisons scattered about the island and the civilians. In June 1899 the Ponce hospital, which had by then been modernized with new plumbing, a refrigeration plant, and other equipment, became a post hospital to serve the city's garrison. The newly established general hospital in San Juan became the island's only general facility, where the supply depot was also located.2

Since the Spanish board of health had been "almost purely ornamental," physicians were confronted from the outset with the island's dirt and stench, its "filthy small huts" and overcrowded "wretched hovels." Like their counterparts in Cuba, Puerto Rican communities were "in a filthy condition." A Marine Hospital Service physician wrote in 1900 that the inhabitants of Ponce, for example, were "a class of people of no great endurance, badly infected with ankylostoma (hookworm), living in unhygienic surroundings, always on the verge of sickness." Because barracks


were located in the midst of Puerto Rican communities, any disease that threatened the civilians was a potential threat to occupying troops as well, and public health on the island became a major concern for medical officers sent to Puerto Rico.3

By September 1898 disease rates were increasing among the soldiers stationed in Puerto Rico. The situation was particularly frustrating to General Brooke, commanding the troops on the island, since he had insisted that high standards of sanitation be maintained for camps. He blamed his soldiers' fondness for the island's fruits-and especially the mango-for the dysentery and diarrhea from which they were suffering, and stated that his medical officers had concluded that cases originally diagnosed as typhoid were actually malaria. A month later, the medical officer sent to inspect camps and hospitals in Puerto Rico concluded that their condition was improving and that sick rates would soon be dropping.4

So great was the perceived danger from disease in Ponce that a U.S. Volunteer surgeon Maj. John McG. Woodbury was named sanitary inspector of the town immediately after its occupation in the summer of 1898. With the assistance of civilian physicians, Woodbury organized a board of health and immediately set to work to have streets and buildings in which troops might be housed cleaned, disinfected, and fumigated. He had silt removed from the pond that provided the city's water supply and a filter applied at the city end of the aqueduct. Since bodies were already being buried in layers in the old city cemetery, he laid plans for a new one. He had the city prison disinfected and repaired, and he ordered vaccine from the United States in order to undertake a compulsory immunization of all citizens against smallpox.5

Smallpox proved to be a threat to the nonimmune not only in Ponce but throughout Puerto Rico. Spanish efforts to vaccinate the population had failed, U.S. Volunteer surgeon Maj. Azel Ames noted,6 because of the Spanish "lack of purpose . . . and vim." The two small vaccine farms that had been established by the Spanish were "nearly moribund." As a result, few Puerto Ricans had been immunized, and when the Department of Puerto Rico was created in October 1898 with John van R. Hoff, now a lieutenant colonel in the volunteers, as the chief surgeon, smallpox was still a great concern. But before Hoff could mount an all-out campaign against this disease, he had to conquer a mass of administrative confusion and disorder, since when he arrived, as he put it, "nothing was and everything had to be." He noted that "the chief surgeon's office [was] without form and void" and there was "not a record, nor a book in which to keep it, not a desk, nothing, indeed, which would furnish any information about the existing organization of the medical department or the number, names, and location of its personnel."7

The chief surgeon had little time to deal with the confusion, however, because by February 1899, smallpox was epidemic. More than 3,000 of the island's 960,000 population had contracted the disease since the occupation began. Any campaign against smallpox would be handicapped because, except for a military road from San Juan to Ponce "and three more short pieces, there [was] not a good road on the island," and thus the many communities scattered about the countryside were virtually inaccessible. Moreover, since Puerto Ricans were generally fatalistic about the disease, they tended to conceal their sick rather than risk having them removed from their homes


and families, rendering the management of the epidemic still more difficult.8

To deal with the rapidly growing number of cases of smallpox, at Hoff's suggestion, orders were issued in January 1899 that all inhabitants of the island who were not already immune be vaccinated under his supervision. The island was divided into five areas of approximately 200,000 population and a medical officer assigned to each to manage the vaccination program. Since guaranteeing that shipments of vaccine from the United States would arrive with the virus still effective was almost impossible, providing sufficient fresh vaccine to immunize the island's population presented a considerable challenge. The responsibility for producing vaccine on the island fell to Major Ames, who was already managing a new vaccine farm, where 1,240 head of healthy young cattle were being tested for tuberculosis so that this disease would not be spread to those being inoculated for smallpox. Medical officers hoped to produce and send out to the vaccinators in the field 15,000 "points" (single dose containers of vaccine) each day. To do so, the farm's manager had to battle the screwworm, a constant threat to the health and vigor of the cattle. In addition, Army doctors had to obtain pack animals, the proper packaging to keep the points sufficiently cool during transportation to prevent the deterioration of the vaccine, and "foot-runners" to take the material into the more isolated communities. Medical Department efforts resulted in the production of a vaccine that proved to be more than 87-percent effective and in the delivery to the vaccinators of quantities sufficient to protect the entire island.9

Hoff, who by this point had returned to his permanent rank of major, described dealing with the epidemic as "an immense task and possible only through military agency." To immunize the entire population of the island, he, like Major Woodbury, worked closely with Puerto Rican authorities. He asked native leaders to appoint local physicians to do most of the vaccinating and to provide the necessary clerical support, the storage, and the runners to carry the vaccine. Those doing the vaccinating had to be impressed with the necessity for washing their hands frequently with soap, water, and a nail brush, and then soaking them in a bichloride solution. They also had to be trained to wash each arm with soap, water, and a bichloride solution before breaking the surface of the skin for the vaccination. U.S. contract surgeons were hired, as necessary, to complete the team, and the Army provided much of the equipment. Since hospital stewards who served as attendants, recorders, and disinfectors at the various vaccination stations assisted the medical officer in charge of each area, the release of many hospital corpsmen from the Army shortly after the end of hostilities made the campaign against smallpox more difficult and more costly; many of these experienced technicians then had to be hired as civilians at twice their Army salaries. Fortunately, frightened by the mortality the disease produced and its rapid spread and possibly inspired by the efficiency with which the Americans were conducting the work, the Puerto Ricans cooperated with the vaccination campaign. By 30 June 1899, 800,000 men, women, and children had been vaccinated. From that time on, all civilians on the island over the age of six months were required to be immunized against smallpox, and local government authorities were ordered to deny access to schools, theaters, and public transportation to all who had not undergone the procedure.10



Major Hoff decided early in 1899 that a board of health for the entire island should be created to oversee public health throughout Puerto Rico and to receive reports from the local boards of health. On 29 June 1899, with the immediate crisis at an end, Hoff was free to serve as president of the new body, which also included a Marine Hospital Service surgeon, a U.S. Navy surgeon, and three civilian physicians. One of the civilians, a public sanitarian with many years of experience in the field, became its permanent secretary. Within six months the board had appointed sanitary inspectors for the Department of Puerto Rico's two districts,11 set up a laboratory to check food supplies, organized vaccine stations, started collecting health statistics, and published bulletins concerning various important diseases. It had also established license examinations for physicians, pharmacists, midwives, and nurses, and created a code of sanitary regulations. The board remained in existence until May 1900, when the territorial governor and executive council appointed by the United States joined an elected assembly to rule the island and the military government in Puerto Rico came to an end.12

The board apparently did not take particular alarm from the presence in Puerto Rico of a mysterious chronic anemia, often referred to as "tropical chlorosis," that subtly undermined the health of the population and had been traditionally and variously blamed on malaria, inadequacies in the diet, the climate, and "unsanitary habits of life." It regarded the problem as "a severe check to the physical and moral development" of the Puerto Rican population, but several years passed before the riddle was solved. The 26-year-old Lt. Bailey K. Ashford, although aware since his days as a student of Dr. Charles W. Stiles at the Army Medical School that the hookworm could cause anemia, nevertheless did not initially suspect this parasite, which apparently was not prevalent in Cuba. He had noticed, however, not long after his arrival on Puerto Rico with General Miles that many natives were abnormally pale and suffered from indigestion, edema, and general debility.13

No serious effort to discover the cause of the mysterious anemia was made until the summer of 1899, when the deteriorating health of the victims of a violent hurricane stimulated Lieutenant Ashford's interest. The storm killed more than 2,200, seriously damaged the hospital at Ponce, and so thoroughly devastated the banana and plantain crops vital to the diet of that island that the United States was at one point feeding as many as 183,000 Puerto Ricans a day. Ordered to establish a field hospital for the victims of the storm, Ashford discovered during the six months it


was in operation that the generally poor condition of his patients frustrated his best efforts to restore them to a state of health and vigor. In the last half of the year 28,700 died because of anemia and dysentery alone. The city of Ponce was "having an epidemic death rate without an epidemic," and Ashford concluded that some common disease or condition must underlie the failure of his patients to thrive.14

Lieutenant Ashford's attempts to solve the riddle first led him to examine the blood of the victims of the mysterious disease. The abnormal proportion of one type of white cell that he found triggered vague memories of having heard of a similar condition caused by internal parasites. While following up on this idea, he discovered on a fecal slide "four fluffy gray balls" resembling the eggs of a parasite that had been found in anemic Italian workers some time before. A patient heavily dosed with thymol expelled what Ashford later described as "a family of tiny worms" that differed from the European hookworm principally in having "no front teeth." Since both types of hookworm caused the same symptoms and responded to the same treatment, Ashford, working with Dr. Stiles, then on the staff of the Marine Hospital Service, determined that the new parasite was closely related to the European variety.15

Discovering the cause and cure of hookworm disease (uncinariasis) proved easier than launching a successful campaign to eradicate it from the island. The hookworm larva penetrates the skin and migrates to the small intestine. Since many inhabitants of the island worked barefoot in soil that was infected and reinfected by victims who relieved themselves in the fields where they were harvesting coffee, uncinariasis afflicted many inhabitants of the rural areas. Lieutenant Ashford's research suggested that perhaps as many as 80-90 percent of those whose work brought them into contact with the soil fell victim to the disease and that in the fiscal year 1901 more than 11,000 died as a direct or indirect result. Hookworm disease severely undermined the health and stamina of as many as 70 percent of those who survived, leaving many victims mere "ghost-like invalids," weakened by anemia and often suffering from diarrhea, headaches, listlessness, depression, and, sometimes, such complications as an enlarged heart. Although this problem adversely affected the island's economy as well as its population, Ashford was initially unable to gain the wholehearted support of Puerto Rican authorities for his work and, as a result, progress in dealing with hookworm disease was very slow.16

Sanitation in the island remained extremely poor, raising the question of whether the Puerto Ricans should be left to manage the problem by themselves when the civilian government took control. Although Lieutenant Ashford returned to the United States in 1900, the Army reassigned him to the island in 1902, when he was promoted to captain, to care for troops stationed there, and thus he could resume his efforts to inspire Puerto Ricans to fight the disease that was devastating the population. Ashford, who had married a native Puerto Rican in 1899, addressed local medical associations in Spanish. His reputation as a Spanish scholar enhanced his influence. The Puerto Rican Board of Health created by the new government made his report on hookworm disease into a circular and sent it out to local physicians and pharmacists. His growing affection and respect for the Puerto Rican people no doubt made it easier for him to work with them. In 1904 the


governor appointed Ashford, Public Health and Marine Hospital Service physician Walter W. King, and Pedro Gutierrez Igaravidez, a Puerto Rican physician whom Ashford came to regard highly, to a commission to undertake a campaign against hookworm.17

Ashford became convinced that the best approach to the hookworm problem would involve the treatment of all affected, a campaign to educate all Puerto Ricans on the nature of the disease and the way in which it was spread, and the careful, tactful application of laws against what he politely called "surface pollution." He also pointed out that eliminating the disease from the island would contribute significantly to its economy by making its workers more efficient. Ashford and those who worked with him cured approximately 22,000 in the first eighteen months, but he believed that Puerto Ricans should run their own affairs and was confident that many native physicians were capable of serving on the commission. In 1906, at Captain Ashford's urging, Gutierrez became head of what now became the Permanent Commission for the Suppression of Uncinariasis in Porto Rico. Commission members were all Puerto Ricans, but the Army detailed Ashford to assist in the anti-hookworm effort, which continued despite the administrative changes. As many as 89,000 patients were treated in a year at the height of the campaign, but many more were yet to be reached. Dispensaries for the victims of this parasite were scattered over the island, numbering thirty-five by mid-1908 and eventually reaching fifty-nine.18

When, after some confusion, the U.S. Congress established a health service for Puerto Rico in 1911, the governor wished to have Ashford, now a major, serve as its head, but the judge advocate general ruled that Ashford could function only in an advisory capacity. Although the new Board of Health appeared at times less than eager to take Ashford's advice, he apparently felt committed to the island and its welfare in spite of his frustration. The Army relieved him of his military duties so that he could assist the Puerto Ricans, and since he obviously expected to remain for a long period on the island, he opened a private practice to help support his family. To his delight, the Puerto Rican legislature rewarded his efforts in 1912 by creating the Institute of Tropical Medicine and Hygiene that he had long sought. Through it, he was able to establish a teaching program for sanitary inspectors and to undertake research expeditions to study the island's diseases.19

Major Ashford's work had a significance that went well beyond the bounds of one island. The exact extent of his influence upon subsequent hookworm campaigns is debatable, but Ashford's "initiative" was responsible to a significant degree for the campaign against this disease in the southern United States and for that of the Rockefeller Institute. Research undertaken by medical officers in the United States now began to suggest that hookworm was also present in many recruits from southern states. In the Deep South as in Puerto Rico, the soil rarely froze far enough down to kill the hookworm's eggs. When the Army began checking recruits from the South for hookworm, medical officers discovered that 16 of the first 19 they examined at Fort Slocum, New York, were harboring the parasite. Further studies confirmed the finding that as many as 85 percent of recruits from the South had hookworm. Ashford's research concerning uncinariasis encouraged many other scientists, including those whose work to eradicate the parasite



on a worldwide basis was financed with Rockefeller funds.20

Still other diseases endangered the health of the island. With the hookworm problem under control, Ashford turned his attention to the problem of sprue, a tropical disease whose cause is still unknown. Sprue affected the digestion, causing diarrhea and leading to debilitation. He proved to his own satisfaction that the disease was not, as another researcher had suggested, caused by the fungus then known as Monilia albicans (Candida albicans). He noted that he had found a new species of Monilia in bread eaten in the area of Puerto Rico where the disease appeared to be endemic and speculated that this organism might be the cause of tropical sprue. Although by 1915 he had concluded that the increase in the number of cases had placed this disease "in the very front rank of the serious and fatal affections of our islands, especially dreaded by American residents," he was, like the scientists of the 1990s, unable to determine the exact cause.21

Among other diseases in Puerto Rico, yellow fever was not a significant problem, although a few cases might be seen in the course of a year. Brucellosis, or Malta fever, may have been endemic, and Ashford estimated that as many as 10 percent of the Puerto Ricans were suffering from filariasis, caused by a tiny internal parasite that could not be eradicated without the elimination of the mosquitoes that carried it. These ailments did not cause any great alarm, but when cases of bubonic plague were reported in San Juan in 1912, the Army created a special duty team to fight the disease. Lt. Col. Jefferson R. Kean and two other medical officers hastened to the island, accompanied by three hospital corpsmen and a field laboratory. By the time they arrived, 22 cases had been reported on the island. Although examination of dead rats picked up in the area revealed that only a small percentage was infected, the sampling could not indicate specifically how widespread the problem was. After less than two weeks, the effort against the dreaded disease was well under way, and the Army turned the laboratory over to Public Health Service physicians, who completed the campaign.22

Panama Canal Zone

Health problems in the Panama Canal Zone on the western shores of the Caribbean resembled those in Cuba more than those in Puerto Rico. Its primitive environment, where, as one physician put it, "eternal summer reigns and the diabolical mosquito goes on propagating descendants," made insect-borne disease a diffi-



cult enemy to conquer. Although interest in enabling ships to sail from the Atlantic to the Pacific without facing the dangers and delays of Cape Horn had taken root in both the United States and Europe decades before the Spanish-American War, yellow fever and malaria had been a major frustration to those trying to construct such a passage. During the eight years the French spent on the canal until they abandoned it in 1889, diseases endemic to the jungles of Central America had killed more than 20,000 men, representing as many as one-third of the workers brought in to handle the construction. Moreover, these deaths had come with terrifying promptness. Reportedly, 75 percent of the newcomers died within three months of their arrival, most often from malaria, regarded by some as "the commonest and most fatal disease"; yellow fever; or the several forms of dysentery prevalent in the area. The anonymous author of an article in the Medical Record for 1903, well aware of the role played by mosquitoes, raised the question of whether Asian workers on the canal might carry yellow fever from Panama back to Asia, where it had never been found.23

Having defeated yellow fever in Havana, Major Gorgas hoped for a new challenge. Still in Cuba in April 1902, he unhappily wrote a colleague: "My canal scheme does not seem to be materializing and [it] looks now as if I would have to settle down to post life again." Eager for a chance to apply the techniques the Army had developed in Cuba to Panama's "damp, tropical jungle, intensely hot, swarming with mosquitoes, snakes, alligators, scorpions, and centipedes; the home, even as Nature made it, of yellow fever . . . ," he urged that he be named to any commission chosen to oversee such a project. Encouraged by, among others, General Wood and Surgeon General Sternberg, who recommended that Gorgas be put in charge of sanitation when canal work began, he familiarized himself with the antimalarial efforts of the French at Suez while in Egypt attending a professional meeting and later studied the few records relating to their canal work that were available in Paris.24

Only in the spring of 1904, however, did Gorgas, now a colonel,25 at last find himself on the brink of the challenge he had sought. The treaty granting the right to build the canal required the United States to assume responsibility for sanitation in both Panama City and Colon, communities outside the ten- by forty-five-mile Canal Zone and under the control of the Panamanian government, as well as in the Canal Zone itself. But, in spite of pressure from the American medical community, Gorgas was not appointed to the new Isthmian Canal Commission that President


Theodore Roosevelt named on 3 March, which would serve under War Department control. Named to the commission early that year were five civilians and two military officers, none of them physicians. Colonel Gorgas, Navy surgeon John W. Ross,26 and Army surgeon Maj. Louis A. LaGarde were asked to accompany the commission on its first tour of inspection.27

Gorgas and the Opposition

Colonel Gorgas and his team soon found that they were working under a significant handicap. The commissioners lacked all respect for the research of Walter Reed and the Yellow Fever Board, an attitude that some members of the medical profession still shared. In spite of Gorgas' achievements in Havana, they rejected the notion that mosquitoes spread yellow fever and malaria. In an area where even the largest communities had neither sewers nor safe water supplies, they believed that cleanliness was the obvious answer to the problem of disease. Brig. Gen. Robert M. O'Reilly, who replaced Surgeon General Forwood on 7 September 1902 and who greatly admired Gorgas and his work in Havana, warned the commission that "a knowledge of Sanitary Engineering [was] not sufficient" for dealing with the problem of preventing disease among those working on the canal, but his admonition failed to impress them. The order that formally assigned Gorgas to the position of chief sanitary officer of the Canal Zone in June 1904 made him subordinate not only to his military superiors but to the commissioners as well. His insistence upon delaying the traditional cleanup to concentrate upon ridding the area of mosquitoes made his relationship to his immediate superiors awkward from the outset.28

Gorgas' medical team, like Hoff's Puerto Rican health board, came from the Army, the Navy, the Public Health and Marine Hospital Service and, most often, from civilian life. Many had worked with Gorgas in Havana. Ross became director of hospitals in the Canal Zone and Major LaGarde superintendent of the area's major hospital, a facility at Ancon originally built by the French. Henry Carter of the Public Health and Marine Hospital Service, whose research about the incubation period of yellow fever had been so valuable to the Yellow Fever Board, became chief quarantine officer. The Medical Department played a major role in "the sanitary regeneration of the Isthmus of Panama," since a total of six Army medical officers were detailed to public health work there. In recognition of the importance of their work, their salaries were markedly higher than those they drew in their regular assignments. Gorgas, who normally earned only $4,950 from the Army and would have received a 20-percent increase for tropical service, was paid $7,500 a year, a sum later increased to $10,000.29

Colonel Gorgas, Ross, and Major LaGarde organized the Department of Health for the Canal Zone.30 Together with Joseph Le Prince, the chief sanitary inspector, who had been responsible for the destruction of mosquitoes in Havana and who arrived in Panama with them in June 1904, they formed the board that ran the new department. Many of those who served under them were contract physicians brought in from the United States, although a few additional Army, Navy, and Public Health and Marine Hospital Service officers held responsible positions in the Canal Zone as well. Among the U.S. physicians were hos-


pital interns, who received $50 a month for a year's service, in addition to transportation to and from one of the principal ports in the United States. Should they wish to remain longer, they were given contracts that paid them salaries smaller than those given Army contract surgeons. Trained female nurses were also brought in under three-year contracts and paid $50 a month for their services.31

Colonel Gorgas' problems began the moment he took up his duties as chief sanitary officer, bearing the ultimate responsibility for the care of the sick, street cleaning, and garbage collection, as well as for campaigns against mosquitoes. Supply caused him "insuperable difficulties," since little of what he needed was available in Panama and those in the United States responsible for supplying him were "slow in getting organized." The commissioners rarely left the United States to visit the Canal Zone, but they monitored its expenses from afar. Although they promptly authorized the creation of a research laboratory to be staffed by experts provided by Dr. Welch of Johns Hopkins and also allowed that facility to spend freely, Gorgas found it difficult to obtain even such basic items as screens and disinfectants. Economy was uppermost in the commissioners' minds, and many of his requisitions were for items they did not regard as necessary.32

The preoccupation with minor expenses was endlessly frustrating. Colonel Gorgas' attempts to have more men sent out to help him were also thwarted. Even after he returned briefly to Washington to plead his cause, he was ordered to hire his inspectors locally. The relationship between the commission and the medical team was so poor that, during a rare visit by some of the commissioners to the Canal Zone, Major LaGarde reportedly took his revenge on one, who was known to be particularly terrified of yellow fever. While this particular commissioner was inspecting a wharf, LaGarde made sure that six elaborate coffins were on prominent display. When asked why the six were so obviously more expensive than others being unloaded, LaGarde reminded him that one of the seven commissioners had not made the trip to Panama on this occasion.33

Ghoulish humor did not help to convince the commissioners that an anti-mosquito campaign would reduce the threat of disease faster than the removal of filth. They undoubtedly felt vindicated, when, months after Colonel Gorgas initiated his effort against disease but before serious work to clean the towns had started, an epidemic of yellow fever erupted. Gorgas was using the same approach to eradicate yellow fever in the isthmus as had been applied in Cuba. Since Panama City was less than one-tenth the size of Havana, it seemed obvious that if his solution to the problem were valid, he should have been able to prevent a reappearance of the disease. But 90 percent of the mosquitoes in Panama City were Aedes aegypti, while only 5 percent of those in Havana were capable of spreading yellow fever. Moreover, although Havana was much larger than either Panama City or Colon, the area involved in Havana was small, U.S. authorities completely controlled the government, and few restrictions were placed on expenditures. Gorgas' failure to duplicate his earlier success promptly was taken by those who did not understand the problem as proof that mosquito-hunting was a waste of time and that he had erred in delaying the Canal Zone cleanup.34

Only scattered cases of yellow fever developed among the foreigners in the Canal Zone before November 1904, but as the number slowly but inexorably increased in


spite of Colonel Gorgas' efforts, the lack of confidence in the chief sanitary officer grew. After a personal visit to Panama late in November, Secretary of War Taft joined the opposition. Shortly thereafter, however, Dr. Charles A. L. Reed, an outspoken former president of the American Medical Association and a close friend of Tafts, also visited the Canal Zone. His purpose in coming was concealed from the public, but he had been sent by Taft to investigate the situation there. His impressions of the management of sanitation and health there led him to mount an attack on the commission so vigorous that even Gorgas wished it had been "written more temperately " After examining the situation in the Canal Zone for fifteen days, Reed concluded that "very much has been accomplished in the way of sanitation under exceedingly adverse circumstances; that much remains to be done which can not be done unless better facilities are afforded; and that very much more ought to be done and would have been done if the facilities had been properly furnished." Reed maintained that the earliest plans for the Canal Zone had called for the chief sanitary officer to operate with considerable independence but that Gorgas had been made subordinate to layer upon layer of others, "subordinated in fact in the seventh degree from the original source of authority."35

Many of those through whom Colonel Gorgas had to work were ignorant of the problems that he had been asked to solve and upon which he was an authority. The commission, Dr. Reed reported, ignored or pushed aside Gorgas' suggestions and requests, one commissioner responding to a request for more latrines to improve sanitation with comments extolling the efficiency with which hogs and buzzards disposed of night soil. Since the commission insisted upon taking direct responsibility for the most minute matters and since many questions were "taken under advisement," decisions of any kind were extraordinarily slow in coming. Reed also noted that Gorgas' people were not even permitted to determine the suitability of the items available to fill their requisitions, which were handled by a tortuous and time-consuming process under the supervision of a purchasing agent "notoriously ignorant" of their needs.36

While Colonel Gorgas was enduring the turmoil of politics and personalities and the blame for the growing epidemic, he was also profoundly worried about his wife, whose health had been of concern for many months before their arrival in the Canal Zone. With her husband facing the greatest challenge of his career, on 17 January 1905 Marie Gorgas was forced to leave the Canal Zone for the United States to undergo a series of major operations that would eventually include two radical mastectomies, the removal of both ovaries, and "an X ray course in New York." Apparently at Marie's urging and despite his instinct to "throw up the whole job" to be with her during her ordeal, Gorgas remained at his post, telling himself that "in two or three weeks" he would "have yellow fever here under control" and be able to join her in Philadelphia for the second round of surgery. Time proved that while Gorgas' appraisal of the epidemic was tragically overoptimistic, Marie's "good hope of ultimate recovery" was justified. She lived to play the widow's tragic role in Gorgas' magnificent funeral in the summer of 1920.37

Leaders in Washington realized that the Canal Zone was not being well managed, but no solution to the difficulties encountered there was immediately forthcoming. Dr. Reed's obvious "personal animus" and


his "often extreme and somewhat flippant remarks" diminished the impact of his message. Although Colonel Gorgas concluded that the concept of rule by commission was inherently flawed, "seven men [being] too many to do executive work," Surgeon General O'Reilly believed that while "the Commission are going to have trouble," Gorgas might "go down with them." When changes were finally made in the management of Canal Zone affairs, Gorgas retained his position, but the commission concept was not abandoned. To achieve greater efficiency, President Roosevelt named three of the members to an executive commission, relegating the remaining four to a figurehead position. The administrative departments involved in managing the Canal Zone were divided up among the three members of the executive committee. The "high-minded and honorable men" who replaced the first commission in March 1905 proved to be almost as skeptical about the role of mosquitoes in the sqread of disease as their predecessors. They did move to alleviate delays in obtaining medical supplies by arranging for the Medical Department to provide essential items and to be responsible for meeting Canal Zone requirements in the future. Thus, according to O'Reilly, the process of handling the area's needs was "rescued from confusion and delay"38

The epidemic's continued spread throughout the spring of 1905 did not improve the relationship of Gorgas and the new officials. By April several high canal officials had died of yellow fever. Piles of coffins appeared at railroad stations. Panic grew, spread in the United States by the tales of those fleeing the Canal Zone. Many deaths resulting from other causes were blamed on yellow fever. From April through June 500 fearful Americans working on the isthmus fled home, and when the canal's chief engineer joined them at the height of the epidemic, rumors became yet more desperate. Fortunately, by summer Gorgas' efforts to eradicate yellow fever in the Canal Zone were beginning to show results. June's 112 cases were followed by only 42 in July, and at last fears began to subside.39

Although the worst of the epidemic was behind him and he could hope that yellow fever would no longer threaten the Canal Zone, its history continued to haunt his thoughts. "The moonlight & the royal palms & the great Pacific are outside as quiet as the grave," he wrote one October evening in 1905, "& in the shadows of my room I can hear the rustle of the ghosts, along the edges of the light cast by my lamp, of the dozens of gallant French engineers who gave up their lives in their gallant fights down here. . . . I suppose more gentlemen have died of yellow fever in this building than in any other building now standing in the world." What would be the last case of yellow fever to originate in Panama City occurred not long after he penned this letter, but from 1 July 1904 through 31 January 1906, 64 of the 246 who were stricken joined the spirits in the dark corners of Gorgas' office. Only when he was sure that a case contracted in Colon in May 1906 was the last for the Canal Zone could Gorgas hope that the arrival of hordes of canal workers would not increase the volume of the rustle in the shadows and that his ghosts could rest in peace at last.40

New cases of yellow fever were still appearing when the newly appointed Canal Commission concluded that Gorgas and his supporters would have to go. After consulting Dr. Welch and Alexander Lambert, a personal friend and a physician, both of whom gave Gorgas their unqualified support, President Roosevelt ordered the com-



mission to cease its opposition and cooperate fully with Gorgas. The chairman of the Canal Commission accepted this decision so wholeheartedly that he made Gorgas' organization into an independent bureau reporting directly to him. When yellow fever had been defeated in the Canal Zone, the president officially visited Panama in November of 1906 and, upon his return to the United States, made a speech in which he devoted much of his message to the praise of Gorgas and his accomplishments.41

Fighting Disease

In his campaign against disease in Panama, Colonel Gorgas relied on the same approach that he had found so successful in Havana. His first effort was directed against Aedes aegypti, the carrier of yellow fever. He divided the affected communities up into districts, placing in charge of each a Panamanian sanitary inspector familiar with the life cycles of the various types of mosquito. Every inspector had 20 to 100 workers under him and was responsible not only for inspections but also for the "actual direction and supervision of work for the extermination of mosquitoes and a general cleaning of premises and places and the disposal of night-soil and waste." Gorgas knew from the outset that because early diagnosis of yellow fever was difficult, it would be impossible to keep mosquitoes from biting victims during the first days of


their disease, when they were infective. He had some hope that the screens would keep mosquitoes from infecting the healthy and recommended for each house the construction of a screened veranda in which there was only one entrance. Very limited success greeted this aspect of his campaign, however, although many frame buildings were U.S. government property.42

The campaign against the sociable Aedes aegypti was concentrated in the larger communities, especially Panama City and Colon. Since Panama City was so much smaller than Havana, Colonel Gorgas decided that a house-to-house fumigation campaign to kill adult mosquitoes would be feasible. When yellow fever appeared in spite of a month of effort, he had his men repeat the process twice more. In a year Gorgas' teams consumed 300 tons of sulfur, 120 tons of insecticide, and the entire supply of newspaper they had acquired to seal openings in houses undergoing fumigation. To deal with the larval form of the insect, Gorgas launched another massive campaign. Teams drained standing water and, where this was not feasible, poured oil over the water to smother the larvae and covered containers, such as cisterns, with a screen. They even emptied pitchers and jars. As the more obvious breeding places of the Aedes were eliminated, inspectors filled and set out containers of the kind Aedes preferred to tempt the frustrated insect to lay her eggs in locations where they could be easily found and destroyed.43

A particularly severe yellow fever problem surfaced at the large hospital at Ancon in the suburbs of Panama City. Colonel Gorgas' investigation revealed that this facility, known for its "picturesque and delightful location," its gardens, its cleanliness, and its high yellow fever rate, had become a breeding place for the Aedes partly because of the care of its staff, rather than in spite of it. Nurses desiring to spare their patients the torment of ants that invaded the hospital placed the legs of each bed in small saucers of water, and even gardeners hoping to spare their plants damage from insects placed "hollow earthenware rings of semi-spherical section around each plant." These containers had become breeding places for the Aedes, a situation akin to one encountered by Major Reed in Cuba, where he had found mosquito larvae in cans placed under table legs to thwart invasions of ants. As a result, many patients hospitalized at Ancon with other health problems contracted yellow fever. Gorgas and Major LaGarde, who was directly in charge of this facility, had the saucers removed, the buildings screened, and the gardens cut down, to be replanted only when the mosquitoes of the area had been eliminated. Thereafter, any troublesome ants were followed to their nests, which were then poisoned, and the dishes of water were never again needed. Mosquito netting over the vehicles taking patients to Ancon prevented the infection of more mosquitoes and thus the further spread of yellow fever. At Ancon as elsewhere, Gorgas' campaign against the Aedes was, in time, successful.44

In spite of the vigor with which he fought yellow fever, Colonel Gorgas personally regarded malaria as an even greater threat to the health of canal workers, a belief others shared. Malaria, and particularly the more severe falciparum form of the disease, was so common in the Canal Zone that many older members of the population had gained a partial immunity to it. Since they carried the disease even though they had no symptoms, they became, in the words of one physician, "walking laboratories for the propagation of the plasmodia." When


at the end of 1905 Gorgas extended the anti-mosquito campaign to include the malaria-carrying Anopheles, he had to use a somewhat different approach. Although these insects were plentiful at night, even within the hospital where research was taking place, unlike the Aedes, they were "peculiarly a country mosquito." They favored wet grassy areas or fresh water well supplied with algae, both of which were plentiful in the Canal Zone, where an estimated 14,000 people lived between Colon and Panama City.45

Nevertheless, to some degree Colonel Gorgas' campaign against the Anopheles resembled that against the Aedes. He urged the screening of the boxcars in which some workers lived. Wherever possible, he had accumulations of water drained and water that could not be drained treated with a larvacide or covered with oil. Brush and grass and, when necessary, gardens were cut down. Because even wagon tracks and hoof prints could hold water long enough for a brood of Anopheles to mature, the eradication of this insect throughout the Canal Zone would obviously be an enormous undertaking. Since Anopheles mosquitoes did not usually fly far during their life cycle, Gorgas concluded that it would be feasible to concentrate his efforts within a radius of 200 yards around human habitation.46

Colonel Gorgas placed Le Prince, his chief sanitary inspector, in charge of the new campaign and provided him with three assistants and a clerical staff. He then divided the countryside into seventeen sanitary districts and assigned an inspector to each district to supervise the work of the forty to fifty laborers who dug drainage ditches and carpenters who installed screens. A district physician was also appointed to keep both the central office and the district inspector informed about the number of cases of malaria he encountered each day. Gorgas required that all anti-mosquito work be done in an inspector's presence and under his control, since the "ordinary engineer has no special knowledge of the life history of the mosquito," and therefore might not understand how to design and place drainage ditches to achieve a maximum beneficial effect. The drainage system eventually included 5 million feet of open, 1.5 million feet of concrete-lined, and 1 million feet of rock-filled ditches, plus 1 million feet of drain tile, all to drain 100 square miles of land. After discovering that grass tended to clog open ditches and that debris could dam concrete-lined ditches, Gorgas decided to rely more heavily on subsurface drainage tile. Because the Anopheles favored slow-moving water, he had vegetation removed from an entire mouth of a river to increase its flow. Gorgas also had the channel deepened and narrowed and the banks lined with stone. Leaving little to chance, when he learned that small fish, lizards, and even spiders could take a high toll in mosquito larvae, he had these natural predators bred and introduced into streams and areas of lush plant growth to increase still further the devastation among the mosquito populations.47

Because destroying all infected mosquitoes in the entire Canal Zone was impossible, the fight to reduce malaria rates required eternal vigilance and considerable ingenuity. Any time a district physician reported a significant rise in the number of malaria cases, Le Prince was required to send experts to assess the situation and pinpoint the cause of the increase. Sometimes it was determined that the mosquitoes were breeding in a swamp too large to be dealt with by ordinary methods. In one instance, investigation revealed that silt


was being dumped into a swamp from the canal construction and that the Anopheles were apparently very fond of the resultant brackish water. Colonel Gorgas had large quantities of salt water pumped from the canal into the swamp, producing a mixture that was too salty to suit these insects. A particularly severe problem developed despite precautions around a quarry from which stone for a set of locks was being taken. The malaria rate at nearby Porto Bello was high, but the town was outside the Canal Zone and beyond the Medical Department's authority. After consultation, the Panamanian government gave Gorgas the authority to manage sanitation in Porto Bello and to introduce whatever control measures he deemed necessary.48

Occasionally when inspectors were unsure about the origin of mosquitoes causing high malaria rates, they had a large number of Anopheles sprayed with aniline blue dye and then, since these insects seemed to "find a strong light repulsive," released at night from the area suspected of harboring the guilty mosquitoes. At the affected campsite, a man willing to serve as bait was set up for the night in an open tent near where workers were camped. In the morning the tent was closed, thus trapping the insects so that they could be examined. Should blue mosquitoes be found among them, the inspectors knew where they should concentrate their efforts against larvae. Jamaican workers were apparently often used to tempt the insects, Colonel Gorgas having concluded that they regarded being paid to sleep in the tent "as near complete bliss as was to be found in this world." In instances where no other means of prevention was available, Gorgas resorted to having the men take three-grain doses of quinine, although this precaution was not always effective. To guarantee as much success as possible in this endeavor, one or two men in each district were sent among the workers to offer pills, capsules, and a liquid quinine solution to all who would take it. Quinine was even placed on the table in all messes. An average of 45,000 employees took 20,000 doses a day.49

Despite the handicaps under which Colonel Gorgas worked, his campaigns against mosquito-borne disease were eventually successful. The yellow fever epidemic was over by the end of 1905 and never recurred in spite of an occasional isolated case that appeared thereafter. The rate at which men were hospitalized with malaria dropped as the population of the Canal Zone increased. The cases per 1,000 men, which reached a high of 821 in 1906, when Gorgas was just beginning his campaign against the Anopheles, dropped to 424 in 1907 and to 282 in 1908, and by 1913 was below 100. By 1913 the overall yearly death rate in the Canal Zone was 8 per 1,000, as compared to the French yearly average of 240 per 1,000.50

Insect-borne diseases were not the only ones with which Colonel Gorgas, as chief sanitary officer, had to deal, and his problems, though similar to those his colleagues faced in other tropical areas, were not identical with theirs. He had reason to believe, for example, that hookworm infestation was common, but since anemia was not, he saw no need to become involved in attempts to eradicate this disease. Beriberi, too, was frequently encountered, but apparently caused no great concern. Because of the understanding reached by the Canal Commission with the government of Panama, Gorgas' Department of Health was responsible for the care and housing both of the Canal Zone's lepers, who were placed in a colony under


Carter's supervision, and of the mentally ill of the entire nation of Panama.51

Like malaria and yellow fever, respiratory diseases were one of Colonel Gorgas' major concerns. For the canal workers, and especially for the black laborers from the Barbados who formed a large part of the work force, one of the most serious threats was pneumonia, sometimes complicated by tuberculosis. Physical examinations excluded many unhealthy men from the work force, and all new hires were vaccinated against smallpox when they were put on the rolls. Many were from the West Indies and immune to yellow fever, and since they often lived with their families outside the Canal Zone, they were found in its network of hospitals much less frequently than whites. The blacks were badly housed, and most had no resistance to pneumonia. Their death rate was initially two to three times that of white laborers. Wet for the eight months of the rainy season, too poor to own a change of clothing, crowded into cabins that were chill and damp, they were very vulnerable to respiratory ills, which spread rapidly among them, reportedly killing more than all other causes combined. Believing that crowding contributed to the problem, Gorgas had dwellings, each well separated from the others, built for the workers and their families. The incidence of pneumonia dropped markedly thereafter.52

Colonel Gorgas made a strenuous effort to avoid having infectious ills imported to the Canal Zone from the outside. He had a quarantine established at Porto Bello in an attempt to keep the local Indians from introducing disease when they entered the city to sell coconuts. The Public Health and Marine Hospital Service, which had been inspecting ships bound from Panama to the United States since 1893, set up a quarantine to protect the isthmus from imported disease. Ships arriving with yellow fever victims on board were fumigated and all nonimmune passengers isolated at a quarantine station for six days. The vessel and those on board who could prove their immunity to yellow fever were released from quarantine when the fumigation process had been completed. Quarantine officers also kept a particularly sharp watch for signs of plague, endemic in some areas of South America, after a worker on a wharf at La Boca died of this disease. A campaign against rats and the fumigation of ships and quarters in the wharf area prevented the appearance of any more cases. The quarantine stations established and run by the Public Health and Marine Hospital Service at either end of the canal were equipped with fumigating equipment, and hospital facilities were divided so as to be able to isolate patients with several different contagious diseases, one from the other.53

Gorgas did not deny the need for greatly improved sanitation in the Canal Zone, and the cleanup of local communities was not long delayed once the yellow fever threat had been removed. The treaty with the Panamanian government obligated U.S. authorities to install sewage and water systems in the Zone. Both were duly established in Panama City and in Colon, where cisterns had been collecting water that drained from roofs swarming with "vultures [that] cover the roofs with fecal matter." Eventually smaller communities, where even "the most rudimentary ideas of cleanliness [were] unknown," acquired sewers and water systems, to which increasing numbers of homes were hooked up. The elimination of cisterns and standing water containers was then possible, further reducing the number of places where mosquitoes could breed. Gorgas had homes whose occupants were


STREET IN COLON, PANAMA, before and after paving


suffering from dysentery, pneumonia, or typhoid disinfected. To reduce the typhoid threat, he had latrines made "fly proof," foods screened in mess tents, and ditches and drains disinfected. Other measures included paving streets in Colon and Panama City and the start of garbage collection; in Panama City in 1907 this responsibility was turned over to the Panamanian government. Where no sewers existed, night soil by the bucket was also collected daily. Overflowing privies were cleaned up or closed down, and public facilities opened where needed. As sewer connections were completed, the size of the staff devoted to garbage collection and similar duties began to diminish, and Gorgas' empire began to shrink.54

The Hospital System

In time, Colonel Gorgas' success in reducing the incidence of disease also reduced the need for hospital beds in the Canal Zone. In setting up the hospital system in Panama, he had originally estimated that the sick rate might run 50 per 1,000 or more at any one time-about half that of U.S. soldiers in the Spanish-American War. Thus he initially concluded that he would need a minimum of 2,500 beds and possibly considerably more. Starting with three and expanding the network as construction of the canal progressed, he established in each sanitary district one or more 20- to 100-bed hospitals, sometimes referred to as "sick camps."55 Many such facilities held dispensaries for outpatients, and at least one in each sanitary district could handle emergency surgery. Patients whose condition made moving unwise could also receive care in these small facilities. Since each district physician was responsible for the health of all who lived in his district, whether or not they worked on the canal, he knew about prevailing diseases and could act promptly at the first sign of an impending epidemic. Gorgas also had "rest camps," or hospitals with 5 to 15 beds, set up in each worker village, where those with minor ills could rest for a day or two until able to return to work. Regardless of the size of the facility they served, all physicians had to be medical school graduates and eventually were also required to pass a civil service examination. Because they were paid a salary, they received no fee from the sick, and the medicines they dispensed were also free of charge to workers who could not pay for them.56

Colonel Gorgas preferred to have patients treated, when possible, at the Ancon and Colon facilities, which he was determined to make "first-class in every respect." In June 1905 he had a hospital car put into daily service on the railroad that ran from one end of the Canal Zone to the other, retrieving patients to be deposited at one of these hospitals. He brought in more than 100 of what he regarded as the best young physicians from the United States to care for the sick and injured and, by using the buildings that had housed French facilities, could devote most of his hospital budget to bedding and supplies. The largest hospital, the 700-bed Ancon facility, achieved a fine reputation once yellow fever had been routed from its premises, flush toilets had been installed, and connections had been made to the new sewer system of Panama City. Its staff numbered more than 400 and increased in size even when Gorgas' Department of Health was otherwise growing smaller. Because private patients used this hospital instead of going to the United States or Europe, it became a profit-making organization; Gorgas esti-



mated private patients produced $50,000 in revenues for every $30,000 the hospital spent for their care. Nonemployees paid $2 a day to stay at Ancon, with extra charges being made for private rooms and private nurses. The charge the hospital made for families of employees (employees themselves received free care) varied according to income, from $1 a day for the families of employees earning $50 or more a month to 30 cents a day for those with an income of less than $50 a month. Most of the insane of Panama, who had previously been jailed, were now sheltered at Ancon for 75 cents a day. The sums collected from private patients did not go to help finance Gorgas' work, but were rather fed into the general funds of the Canal Zone government.57

Colonel Gorgas could take pride in the staff at Ancon, among whom was Maj. Theodore C. Lyster, Marie Gorgas' nephew. Lyster set up an eye, ear, nose, and throat department, whose fine reputation drew patients in from a great distance. The hospital laboratory was well enough equipped to enable hospital physicians to conduct original research. After discovering that the French Sisters of Charity "did not possess the technical knowledge necessary for this work," Gorgas replaced them with American nurses. The care at Ancon was so highly regarded that, in spite of the drop in the number of workers in the Canal Zone and in the incidence of disease among them, by 1909 the hospital was required to expand, adding two new buildings and 150 beds to its capacity. By the end of 1907, when Gorgas' campaign against mosquitoes was beginning to show results, the need for hospital beds was already lower than had been originally anticipated, and by 31 December fewer than 1,200 remained in the institutions serving the Canal Zone.58

A Worthy Rivalry

As a reward for his successes, Colonel Gorgas also finally became a member of a new commission, consisting entirely of military officers, that was appointed in 1907. Ironically, by this point the Canal Commission's power was rapidly disappearing as the determined Col. George W. Goethals, the new chairman, consolidated his authority over the construction of the canal and all that pertained to it.59

The rivalry between Colonel Gorgas and Colonel Goethals was intense almost from the outset. Even though Goethals had no quarrel with Gorgas over the need to eliminate mosquitoes, he would not grant Gorgas full credit for eliminating yellow fever in both Havana and the Canal Zone and for reducing the incidence of malaria. Goethals insisted that Gorgas had merely been fol-


lowing a program that had been worked out in full by Walter Reed, who had made specific suggestions about the use of screens, fumigating houses, and similar matters in 1901, and, before Reed, by the English military surgeon Ronald Ross, who proved that mosquitoes spread malaria. Aristides Agramonte, one of Reed's colleagues on the Yellow Fever Board, quickly pointed out that the board had never been concerned with the practical application of the results of its research and that Gorgas had personally devised the methods that he had used to defeat mosquito-borne disease in both Havana and the Canal Zone. Indeed, before his death in 1902 Major Reed himself had recommended the procedures that Gorgas had developed. Apparently unmoved, Goethals further irritated Gorgas by removing from the surgeon's authority the responsibility for such anti-mosquito activities as grass cutting and ditch digging, placing them under the Quartermaster's Department, though subject to Gorgas' instructions. This logical move reduced the number of men in Gorgas' organization assigned to "Zone Sanitation" and thus appeared threatening to him. Neither the praise Gorgas was receiving nor his election as president of the American Medical Association in 1908 seemed to impress Goethals, who continued until Gorgas left the Canal Zone in 1913 to belittle the chief sanitary officer and his department.60

Despite his adversarial relationship with Goethals, Colonel Gorgas never developed the single-minded intensity of the dedicated feuder. Obviously aware of the humor in the situation, Gorgas reported to his family just when his rival was at the peak of his power, that "Goethals & I are getting along most lovingly. We seldom meet but write daily. And are just as polite as two dancing masters." Woodrow Wilson's election as president in 1912 brought a delightful change in Goethals' attitude, Gorgas concluded in September 1913. He reported: "Everything is running along here smoothly. Goethals is as mild as a lamb. He does not feel quite as certain of this good Democratic administration as he did of the former." In October Goethals asked Gorgas to tell Mrs. Gorgas "that he would gladly do anything he could for her and that she had no better friend than he was." He even unexpectedly and "warmly" approved several requests that Gorgas made, including one that he be permitted "to go to South Africa for a sanitary inspection" in November 1913, all of which led Gorgas to conclude that "the old villain is up to something."61

Colonel Gorgas' appointment as surgeon general on 16 January 1914 brought an end to his confrontations with Goethals in Panama. In the spring of 1914, when the death rate was less than half that in the United States, the Isthmian Canal Commission was abolished, and Goethals was appointed governor of the Canal Zone.62

The work of medical officers in both Puerto Rico and the Panama Canal Zone in the years immediately following the Spanish-American War had significance well beyond those two small portions of the globe. Captain Ashford's work in reducing the toll taken by hookworm disease in Puerto Rico ultimately led to successful campaigns against that disease in many other parts of the world. Gorgas' achievements as chief sanitary officer in the Panama Canal Zone went beyond his claims of saving more than 70,000 lives, of preserving the health of three times that number, and of saving the Canal Commission a total of $80 million, half in hospitalization costs alone. Gorgas had proved to his own satisfaction that those of European extraction could live and


thrive in the tropics. In doing so, he likened himself to Columbus because he had thrown "just as large an area of the earth's surface open to man's settlement" as had that explorer when he discovered America. This part of the world no longer need be a green hell. In the future, all who knew the land that Gorgas regarded as "my Panama" could remember it as he did, "a beautiful mountainous country. . . , the hills covered with deep green verdure & the valleys filled with clear & sparkling streams."63



1. Although the name of the island was spelled Porto Rico in contemporary documents, the modern spelling has been used throughout this volume.

2. War Department, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1898, p. 147, and 1899, pp. 174, 178-79, 181, 184-85 (hereafter cited as WD, ARofSG, date); idem, [Annual] Report of the Secretary of War, 1899, 1(pt.3):320-21; Ltr, John R. Brooke to Alger, 18 Oct 1898, file 155700, Record Group (RG) 94, National Archives and Records Administration (NARA), Washington, D.C.

3. First quotation from William F. Smith, "Sanitation in Puerto Rico," p. 171; second and third quotations from United States, Congress, Senate, Report of the (Dodge) Commission To Investigate the Conduct of the War Department in the War With Spain, 1:628 (hereafter cited as Dodge Commission Report); fourth quotation from WD, ARofSG, 1898, p. 146 (see also 1899, p. 188); fifth quotation from Walter W. King, "Report on the High Mortality on the Island of Porto Rico," p. 2723.

4. Ltrs, John R. Brooke to AG, 8 Sep 1898, file 128803, and Rush S. Huidekoper to AG, 7 Oct 1898, file 221633, RG 94, NARA.

5. Dodge Commission Report, 1:628; WD, ARofSG, 1898, pp. 146, 152-53, and 1899, pp. 188, 191.

6. Ames was initially a contract surgeon and was "appointed brigade surgeon . . . while the work [of vaccination] was in progress." See WD, ARofSG, 1899, pp. 191-92.

7. Azel Ames, "The Vaccination of Porto Rico," pp. 301 (first quotation), 302, 305-07, 310; WD, ARofSG, 1899, pp. 173, 177 (remaining quotations); Charles H. Alden, "Porto Rico," p. 19.

8. Alden, "Porto Rico," p. 19 (quotation); Ames, "Vaccination," pp. 300-301, 313; WD, ARofSG, 1899, p.176.

9. Ames, "The Vaccination," pp. 301-02, 305 (first quotation), 306-07, 310; WD, ARofSG, 1899, pp-191, 246.

10. Alden, "Porto Rico," p. 21 (quotation); WD, ARofSG, 1899, pp. 191-92, 246-48; Ames, "Vaccination," pp. 302-04, 306-07, 310, 313; John van R. Hoff, Military Government of Porto Rico From October 18, 1898, to April 30, 1900, p. 131.

11. The Department of Puerto Rico was divided into the District of San Juan and the District of Ponce. See WD, ARofSG, 1899, p. 177.

12. Ibid., p. 189; Alden, "Porto Rico," p. 22; John van R. Hoff, "The Share of the 'White Man's Burden' That Has Fallen to the Medical Departments of the Public Services of Porto Rico," p. 798; idem, Military Government, p. 134.

13. Alden, "Porto Rico," p. 20 (first quotation); Bailey K. Ashford and Pedro Gutierrez Igaravidez, Uncinariasis (Hookworm Disease) in Porto Rico, p. 23 (second quotation); Bailey K. Ashford and Walter W. King, "A Study of Uncinariasis in Porto Rico," p. 391; "Uncinariasis: An Economic Question for Porto Rico," p. 422 (third quotation); Edgar Erskine Hume, Victories of Army Medicine, p. 158; Dictionary of American Biography, supp. 1, s. v. "Ashford, Bailey Kelly"; Martha L. Sternberg, George Miller Sternberg, p. 212; William G. Morgan, "Contributions of the Medical Department of the United States Army to the Advancement of Knowledge," pp. 784-85; Rpt, John van R. Hoff, FY ending 30 June 1900, Ms 4890, Entry 52, RG 112, NARA; Stanhope Bayne-Jones, The Evolution of Preventive Medicine, p. 136; J. Hamilton Stone, "Remarks Suggested by Three Years' Service in Cuba," p. 330; Charles W. Stiles, Report Upon the Prevalence and Geographic Distribution of Hookworm Disease (Uncinariasis or Anchylostomiasis) in the United States, Hygienic Laboratory Bulletin no. 10 (Washington, D.C.: Government Printing Office, 1903), p. 33.

14. King, "Report," pp. 2724, 2726 (quotation); Gaines M. Foster, The Demands of Humanity, pp. 48-49; Ashford and King, "Study," p. 391; "Uncinariasis," p. 422; "Editor's Table," p. 281; Alden, "Porto Rico," p. 22; Hoff, "Share," p. 796; idem, Military Government, p. 140.

15. Quotations from Bailey K. Ashford, A Soldier in Science, pp. 3, 45. Ashford maintained that vague memories of having encountered an article on "pork measles" led him to consider the possibility of an intestinal parasite (ibid., pp. 42-43). John Ettling, however, suggests that the article recalled by Ashford was probably on trichinosis (idem, The Germ of Laziness, pp. 29-30). See also Ashford and King, "Study," p. 392.


16. Bailey K. Ashford, "Where Treatment of All Infected Is the Surest Prophylactic Measure," p. 42 (quotation); Ashford and King, "Study," p. 391; WD, ARofSG, 1903, p. 49, and 1906, p. 131; Rpt, B. H. Dutcher, 13 Oct 1915, Ms 5367, Entry 52, RG 112, NARA; Ashford and Gutierrez, Uncinariasis, pp. 8, 11, 16-17, 25, 27-28, 40-43, 109-10.

17. WD, ARofSG, 1900, p. 274, 1905, p. 159, and 1913, pp. 177-78; Ltrs, Bailey K. Ashford to Gorgas, 15 Nov 1903 and 13 Mar 1906, William C. Gorgas Papers, Manuscript Division, Library of Congress (LC), Washington, D.C.; Ashford and Gutierrez, Uncinariasis, p. 28; Ltrs, Ashford to Albert K. Smiley, 26 Sep 1905 and 12 Oct 1908, and to Henry Haskins, 6 May 1913, Albert K. Smiley Papers, Quaker Collection, Haverford College (HC), Haverford, Pa.; Ralph C. Williams, The United States Public Health Service, 1798-1950, pp. 261-62. In RG 112, NARA, see Ltr, W. A. Jones to Jefferson R. Kean, 31 May 1910, Entry 231, and Rpt, B. H. Dutcher, 13 Oct 1915, Ms 5367, Entry 52. See also in Bailey K. Ashford Papers, Entry 561, RG 94, NARA: Individual Svc Rpts, 1 Jul 1903 and 29 Sep 1906; Ltrs, William P. Craighill to SG, 14 Mar 1904, and Ashford to Merritte W. Ireland, 12 Mar 1906.

18. Bailey K. Ashford, "Notes on Medical Progress in Porto Rico," p. 727; idem, "Where Treatment of All Infected," p. 47 (quotation); Ashford and Gutierrez, Uncinariasis, pp. 1-2, 230; WD, ARofSG, 1906, p. 131, and 1908, p. 127; Individual Svc Rpt, 29 Sep 1906, Ashford Papers, Entry 561, RG 94, NARA; Rpt, Dir, Anemia Dispensary Svc, p. 329, and Summary of Anemia Work, Entry 231, RG 112, NARA.

19. WD, ARofSG, 1914, p. 129; Ashford, Soldier in Science, p. 131; Ltr, Ashford to Henry Haskins, 3 Sep 1911, Smiley Papers, HC; Ltr, O. W. Underwood to Ashford, 25 Jul 1911, Gorgas Papers, LC. In Ashford Papers, Entry 561, RG 112, NARA, see Telg, George R. Colton to SW, 11 Mar 1911; Memo, C. R. Edwards to AG, 13 Mar 1911; Memo, Arthur Murray to AG, 7 Jul 1911; Memo, General Staff to Capt Graves, 17 Mar 1911; and Ltr, AG to CG, Eastern Dept, 15 Sep 1915. See also in Entry 231, RG 112, NARA: Ltrs, Ashford to Jefferson R. Kean, 29 Mar 1911 and 7 Feb 1912, and W. Lippitt to Kean, 5 Feb 1912.

20. Quotation from Dictionary of American Biography, supp. 1, s. v. "Ashford, Bailey Kelly"; Bayne-Jones, Preventive Medicine, p. 136; Ashford and Gutierrez, Uncinariasis, p. 26; Ltrs, J. F. Siler to SG, 7 and 26 Dec 1908, Ms 5345, Entry 52, RG 112, NARA; WD, ARofSG, 1904, p. 89, 1909, p. 123, and 1910, pp. 122-23; Sternberg, Sternberg, p. 212; Ashford, "Notes on Medical Progress," p. 727; Wilson G. Smillie, Preventive Medicine and Public Health, p. 167; Weston P. Chamberlain, "Is the Poor Physical Development of Southern Recruits due to Uncinariasis?," pp. 49-50; Marie D. Gorgas and Burton J. Hendrick, William Crawford Gorgas, p. 296; Victor C. Vaughan, Epidemiology and Public Health, 2:508, 513; Stiles, Report, p. 33. For a discussion of the Ashford/Stiles rivalry, see Ettling, Germ of Laziness, pp. 29-32, 124, 127.

21. Bailey K. Ashford, "Studies in Moniliasis of the Digestive Tract in Porto Rico," pp. 681 (quotation), 690.

22. Alden, "Porto Rico," p. 20; WD, ARofSG 1904, p. 92, 1912, p. 103, and 1913, pp. 177-78; Foster, Demands of Humanity, p. 51; Richard H. Creel, Outbreak and Suppression of Plague in Porto Rico, pp. 3, 9.

23. Ltr, John W. Ross to Ed., The Independent, 23 Jul 1904 (first quotation), box 3-13, John W. Ross Papers, Tennessee State Library and Archives (TSLA), Nashville, Tenn.; H. Goldthwaite, "Matters of Sanitary Interest on the Isthmus," p. 56 (second quotation); "Yellow Fever and the Panama Canal," p. 580; Miles P. DuVal, Jr., And the Mountains Will Move, p. 126; Hume, Victories, p. 97; Richard F. Nyrop, ed., Panama, pp. 3, 22; Hugh G. Miller, The Isthmian Highway, pp. 26-27; Richard L. Sutton, "The Diseases of the Isthmian Canal Zone," p. 43; P. Desfosses, "Canal de Panama et fievre jaune," pp. 731-32, 732n.

24. Bayne-Jones, Preventive Medicine, p. 139; Sternberg, Sternberg, pp. 266-67; Gorgas and Hendrick, Gorgas, pp. 140 (second quotation), 146-47; William C. Gorgas, Sanitation in Panama, pp. 138-42, 149; David McCullough, The Path Between the Seas, pp. 159, 415; Hermann Hagedorn, Leonard Wood, 1:104. In Gorgas Family Papers, W. S. Hoole Special Collections Library, University of Alabama (UA), Tuscaloosa, Ala., see Ltrs, Gorgas to Dick [brother], 9 Jan 1903, and to mother, 7 Mar 1903 (copy). In Gorgas Papers, LC, see Resolution, Assoc Mil Surgs, 20 May 1903; Ltrs, Gorgas to Valery Havard, 14 Apr 1902 (first quotation), to SG and AG, both 28 Jun 1902, to Harry F. Hodges, 14 Jul 1902, to Harper & Bros., 17 Jul 1902, and to Philippe Bunau Varilla, 19 Aug 1902; and Ltr, Charles A. L. Reed to Theodore Roosevelt, 24 Feb 1904.

25. Gorgas was promoted from major to colonel by an act of Congress. As Gorgas put it, "It is the first time an Army Medical Officer has been directly recognized by Congress. It places me in a rank that would have taken me about fifteen years to reach in the ordinary course of promotion." See Ltr, Gorgas to mother, 7 Mar 1903, Gorgas Family Papers, UA.


26. According to the inventory for the Ross Papers, TSLA, Ross received the rank of medical director in 1903 by a "special act of Congress" (p. 3), and in 1904 he signed himself in that fashion. Ross is also inexplicably referred to as "Major Ross" for a time period when he was serving in Cuba but apparently was still in the Navy (pp. 2, 5). See also Ltr, Ross to Ed., The Independent, 23 Jul 1904, box 3-13.

27. McCullough, Path, p. 407; John W. Ross, "Outline of the Organization of the Department of Health of the Isthmian Canal Commission, Isthmus of Panama," p. 419; Gorgas, Sanitation, pp. 142-43; Congressional Research Service, Library of Congress, Background Documents Relating to the Panama Canal . . . (Washington, D.C.: Government Printing Office, 1977), p. 504; in Gorgas Papers, LC: Resolution, Assoc Mil Surgs, 20 May 1903, and Ltr, C. Reed to T. Roosevelt, 24 Feb 1904, and Memo for Col Gorgas' Efficiency Rpt, 18 Jul 1904.

28. Quotation from Memo, SG to SW, 24 Feb 1904, William C. Gorgas Papers, Entry 561, RG 94, NARA. In loc. cit., see SO 125, 27 May 1904, and Ltr, John C. Walker to SW, 16 May 1904. See also Ross, "Outline," pp. 418-19; H. W. Austin, "Retrospect of Co-Operative Work of the Medical Services of the Government," p. 455; WD, ARofSG, 1903, pp. 48-49; Gorgas, Sanitation, pp. 142-43, 146-47, 152-53, 156-57; Gorgas and Hendrick, Gorgas, pp. 150, 161-65, 188; DuVal, And the Mountains Will Move, p. 311; McCullough, Path, pp. 421-22; Draft Article, Oct 1908, Gorgas Papers, LC; Ltr, Gorgas to Dick, 9 Jan 1903, Gorgas Family Papers, UA.

29. WD, ARofSG, 1903, pp. 48-49, and 1908, p. 127 (quotation); Rpt, "Organization of the Department of Health for the Isthmus of Panama," p. 1, box 5-8, Ross Papers, TSLA; "News of the Service," p. 141; Ross, "Outline," pp. 418-19, 426; Ltr, Gorgas to [Kia?], 15 Aug 1904, Gorgas Family Papers, UA; Weston Chamberlain, Twenty-five Years of American Medical Activity in Panama, 1904-1929, p. 65.

30. The organization headed by Colonel Gorgas is variously referred to as the Department of Health, the Department of Sanitation, and the Sanitary Department. An examination of the letterheads of Gorgas' letters in the Gorgas Family Papers at the University of Alabama suggests that the term Department of Health was used in the early period and that it was replaced by Department of Sanitation sometime after 1906. The term Sanitary Department is used in Marie Gorgas' biography of her husband.

31. Rpt, "Organization of the Department of Health," pp. 2, 9-10, box 5-8, and Ltr, John W. Ross to Edward R. Marshall, 21 Oct 1904, box 3-13, Ross Papers, TSLA; Ross, "Outline," pp. 419-20, 423-24; William C. Gorgas, "Sanitary Conditions as Encountered in Cuba and Panama and What Is Being Done To Render the Canal Zone Healthy," p. 163; Charles A. L. Reed, "Isthmian Sanitation," pp. 815, 818; Chamberlain, Twenty-five Years, p. 66; McCullough, Path, pp. 416, 419.

32. Gorgas, Sanitation, p. 148 (quotations); DuVal, And the Mountains Will Move, p. 150; Ltr, Gorgas to Valery Havard, 7 Feb 1908, Gorgas Papers, LC; Gorgas and Hendrick, Gorgas, pp. 150-52, 162, 164-65.

33. Gorgas and Hendrick, Gorgas, pp. 166-67; Draft Article, Oct 1908, Gorgas Papers, LC.

34. Miller, Isthmian Highway, pp. 23-24; Goldthwaite, "Matters of Sanitary Interest," pp. 59-60; Roland G. Curtin, "Medical Conditions of the Isthmus of Panama, With Other Notes," p. 345; William C. Gorgas, "Mosquito Work in Relation to Yellow Fever on the Isthmus of Panama," pp. 322-24.

35. First quotation from Ltr, Gorgas to mother, 3 Apr 1905, Gorgas Family Papers, UA; remaining quotations from Reed, "Isthmian Sanitation," pp. 812-13; ibid., pp. 814, 817; Gorgas and Hendrick, Gorgas, pp. 190-92; Jefferson R. Kean, "Editorial," p. 368.

36. Reed, "Isthmian Sanitation," pp. 812-13 (quotations), 814-18; Gorgas and Hendrick, Gorgas, pp. 162-63, 189-92, 194-97; Gorgas, Sanitation, pp. 152-53; Ltr, SW to Roosevelt, 17 Mar 1905, Entry 231, RG 112, NARA; DuVal, And the Mountains Will Move, pp. 151, 190.

37. First quotation from Ltr, Gorgas to mother, 3 Apr 1905, and remaining quotations from Ltr, Gorgas to Dick [brother], 16 Jan 1905, Gorgas Family Papers, UA. In loc. cit., see also Ltrs, Gorgas to [Kia?], 15 Aug 1904; Richie to Jessie, 18 Aug 1920; and Aileen Gorgas to Marie Gorgas, 25 Jan 1905.

38. First two quotations from John G. Leigh, "Sanitation and the Panama Canal," p. 1531; following three quotations from Ltr, Gorgas to Dick, 16 Jan 1905, and sixth quotation from Ltr, Gorgas to mother, 3 Apr 1905, Gorgas Family Papers, UA; final quotation from WD, ARofSG, 1908, p. 127. See also ibid., 1905, p. 148; McCullough, Path, pp. 449-50.

39. DuVal, And the Mountains Will Move, pp. 176-77, 179-80; Gorgas, Sanitation, p. 154.

40. Ltrs, W. W. Keen to Gorgas, 12 Oct 1904, 2 Feb 1905, and 6 and 17 Mar 1905, Gorgas Papers, LC; Ltrs, Gorgas to mother, 17 Oct 1905 (quotations) and 19 Jun 1906, Gorgas Family Papers, UA; DuVal, And the Mountains Will Move, pp. 164-65; Gorgas, Sanitation, pp. 275-76.


41. Gorgas, Sanitation, pp. 136, 142-43, 148, 154-55, 172-73, 183, 197-98; Gorgas and Hendrick, Gorgas, pp. 196-97, 204; Percy M. Ashburn, The History of the Medical Department of the United States Army, p. 266; DuVal, And the Mountains Will Move, pp. 175, 190, 240; McCullough, Path, pp. 447-48, 468, 500; Miller, Isthmian Highway, pp. 23-24.

42. Rpt, "Organization of the Department of Health," p. 19 (quotation), box 5-8, Ross Papers, TSLA; Gorgas and Hendrick, Gorgas, pp. 172, 175-76, 180; Gorgas, Sanitation, pp. 182, 192-93, 195-97; McCullough, Path, p. 448.

43. Gorgas, Sanitation, pp. 150-51; Gorgas and Hendrick, Gorgas, pp. 176-81.

44. Goldthwaite, "Matters of Sanitary Interest," p. 58 (first quotation); Joseph A. LePrince, A. J. Orenstein, and L. O. Howard, Mosquito Control in Panama, pp. 18-19 (second quotation); Gorgas and Hendrick, Gorgas, pp. 183-85; Gorgas, Sanitation, pp. 224, 230-32, 236-37; Walter Reed and James Carroll, "The Prevention of Yellow Fever," p. 119; Curtin, "Medical Conditions," p. 346.

45. Sutton, "The Diseases of the Isthmian Canal Zone," p. 41 (first quotation); Gorgas, Sanitation, p. 159 (second quotation); McCullough, Path, p. 419; Goldthwaite, "Matters of Sanitary Interest," p. 56.

46. LePrince et al., Mosquito Control, pp. 17-18, 22; Goldthwaite, "Matters of Sanitary Interest," pp. 56-57; Gorgas, Sanitation, pp. 159-60; idem, "Sanitary Conditions," p. 162; Gorgas and Hendrick, Gorgas, pp. 225-32; Miller, Isthmian Highway, pp. 25-26; Draft Article, Oct 1908, Gorgas Papers, LC; Monthly Rpts, Sanitary Dept, May 1907 and Feb 1908, RG 185, NARA.

47. William C. Gorgas, "The Sanitary Organization of the Isthmian Canal as It Bears Upon Anti-malarial Work," pp. 263-64; idem, Sanitation, pp. 183-90, 192-93, 195 (quotation); Gorgas and Hendrick, Gorgas, pp. 180, 230-31; McCullough, Path, p. 448; Draft Article, Oct 1908, Gorgas Papers, LC; Monthly Rpts, Sanitary Dept, May 1907, RG 185, NARA.

48. Gorgas, Sanitation, pp. 160, 166-67, 202-05; Monthly Rpts, Sanitary Dept, May 1907, RG 185, NARA; Draft Article, Oct 1908, Gorgas Papers, LC.

49. LePrince et al., Mosquito Control, p. 94 (first quotation); Gorgas, Sanitation, pp. 199-200, 203-04 (second quotation), 205; idem, "Sanitary Organization," pp. 263-64; Draft Article, Oct 1908, Gorgas Papers, LC.

50. Gorgas, Sanitation, pp. 156, 205, 275; DuVal, And the Mountains Will Move, pp. 199-200; Annual Rpts, Sanitary Dept, 1905-1914, esp. 1907, 1:6-7, RG 185, NARA; Fullerton L. Waldo, "Panama," p. 773; Louis A. LaGarde, "Relation of the Civilian Physician to National Preparedness," p. 238.

51. Gorgas, Sanitation, pp. 256-57; Ltr, Gorgas to Bailey K. Ashford, 8 Jun 1905, Gorgas Papers, LC; LePrince et al., Mosquito Control, pp. 24-25.

52. McCullough, Path, pp. 405-06, 501, 577, 585; Gorgas and Hendrick, Gorgas, pp. 266-68; Michael L. Conniff, Black Labor on a White Canal, pp. 3, 27, 30; Annual Rpt, Sanitary Dept, 1904, 1:13, and Monthly Rpts, Sanitary Dept, 1905-1914, RG 185, NARA.

53. Rpt, "Organization of the Department of Health," pp. 16-19, box 5-8, Ross Papers, TSLA; Gorgas, Sanitation, pp. 166-67, 261-62 (quotation), 263, 271-73, 276; DuVal, And the Mountains Will Move, pp. 135-36; McCullough, Path, p. 454; Annual Rpt, Sanitary Dept, 1908, 1:6-7, RG 185, NARA.

54. Curtin, "Medical Conditions," p. 343 (first quotation); Goldthwaite, "Matters of Sanitary Interest," p. 57 (second quotation); Monthly Rpts, Sanitary Dept, 1906-1914, esp. May 1907 (third quotation), and Annual Rpts, Sanitary Dept, 1907-1909, RG 185, NARA; William C. Gorgas, "Sanitation on the Isthmus of Panama," pp. 37-38; Chamberlain, Twenty-five Years, p. 13; DuVal, And the Mountains Will Move, p. 247.

55. There is some confusion in the records of this period about the nomenclature used to classify the various hospital facilities. The term sick camp is frequently used to describe many of the smaller district units, but in some reports individual facilities are called sick camps and in others hospitals.

56. Gorgas, Sanitation, pp. 206-07, 209 (quotation), 210-11, 213-14, 223; Rpt, "Organization of the Department of Health," p. 14, box 5-8, Ross Papers, TSLA; Miller, Isthmian Highway, p. 23; Gorgas and Hendrick, Gorgas, p. 247; Monthly Rpts, Sanitary Dept, 1905-1914, and Annual Rpts, Sanitary Dept, 1906, 1:26-27, 32-33, 1907, 1:28, 30, and 1908, 1:28-29, RG 185, NARA; Ross, "Outline," pp. 421-22.

57. Gorgas, Sanitation, pp. 209 (quotation), 210-12, 223-24, 229-30, 241-43, 247; DuVal, And the Mountains Will Move, p. 179; Rpt, "Organization of the Department of Health," p. 7, box 5-8, Ross Papers, TSLA; McCullough, Path, p. 501; Monthly Rpts, Sanitary Dept, 1906-1914, esp. May 1907, and Annual Rpts, Sanitary Dept, 1907, 1:77, and 1909, 1:31, 71, RG 185, NARA; Reed, "Isthmian Sanitation," p. 816.

58. Gorgas and Hendrick, Gorgas, p. 185 (quotation); Gorgas, Sanitation, pp. 213-14, 226, 242, 245; The Canal Record, 15 Sep 1909, p. 19, Entry 231, RG 112, NARA; J. F. Siler, "Major-General


William Crawford Gorgas," p. 162; Annual Rpt, Sanitary Dept, 1906, 1:26-27, and Monthly Rpts, Sanitary Dept, 1905-1907 and Feb 1908, plus Rpt, Caldwell, Jan 1912, RG 185, NARA; Ltr, Stephen C. Craig to Author, 5 Apr 1990, Historian's file, U.S. Army Center of Military History, Washington, D.C.

59. Draft Biography, Gorgas, n.d., Gorgas Papers, LC; Ltrs, Gorgas to mother, 11 Oct 1912, to Mamie, 27 Oct 1912, and to Jessie, 2 Jul 1913, Gorgas Family Papers, UA; Gorgas and Hendrick, Gorgas, pp. 213-14.

60. Annual Rpts, Sanitary Dept, 1907, 1:77 (quotation), and 1909, 1:71, RG 185, NARA; Gorgas, Sanitation, p. 155; Gorgas and Hendrick, Gorgas, pp. 184, 220-21, 232-38; DuVal, And the Mountains Will Move, pp. 240, 260-61, 270, 309-11, 330; McCullough, Path, p. 572; Draft Biography, Gorgas, and Ltr, E. Striver to Gorgas, 2 Dec 1904, Gorgas Papers, LC; Ltr, Gorgas to mother, 5 Jun 1908, Gorgas Family Papers, UA; Reed and Carroll, "Prevention," p. 123; George W. Goethals, "The Building of the Panama Canal," p. 721; Henry S. Wellcome, "Observations on the Medical and Sanitary Department of the Panama Canal Commission. . . . ," pp. 3, 10.

61. Ltrs, Gorgas to Mamie, 27 Oct 1912 (first quotation), 20 Sep 1913 (second quotation), 16 Oct 1913 (third, fourth, and sixth quotations), and 27 Aug 1913 (fifth quotation), Gorgas Family Papers, UA; Siler, "Gorgas," p. 167; Chamberlain, Twenty-five Years, pp. 65-66; Robert E. Mitchell, Jr., "Notes on the Medical History of the Panama Canal," p. 89.

62. LaGarde, "Relation," p. 238; Ltr, Gorgas to Mamie, 1 Jan 1914, Gorgas Family Papers, UA; Siler, "Gorgas," p. 167; Chamberlain, Twenty-five Years, pp. 65-66; Mitchell, "Notes," p. 89.

63. Gorgas, Sanitation, pp. 280, 282-83, 291-92 (first quotation); Speech, Gorgas to American Med Eds., 5 Jun 1907 (remaining quotations), Gorgas Papers, LC; Gorgas and Hendrick, Gorgas, p. 259; Ltr, Gorgas to [Kia?], 15 Aug 1904, Gorgas Family Papers, UA.