Panama: history and overview



My visit to Panama in 1913 was the accomplishment of a long-cherished design. At Panama, the American engineers could claim they had carried out “the most formidable engineering feat which had hitherto been attempted,” while the sanitary work had been recognised by the whole world as the greatest achievement it had seen. Before the Americans came to Panama, it had been pre-eminently a land of failure, which the boldest had been unable to turn to success, while death had haunted them at every step. Time and again, Sir Francis Drake had raided the Isthmus and the Spanish Main. His deeds stir the most sluggish imagination. Yet the evil spirit of the place, in one voyage slew half his crew, not sparing even his own brother, and later on it claimed Drake himself; for he died from dysentery in 1595, and was buried at sea off Puerto Bello.

Morgan’s raid across the Isthmus, when he razed the city of Panama to the ground, was a bold exploit. Perhaps it can be called a success, since the city was never rebuilt on the same site; but it can hardly be claimed as a great constructive effort. Even William Paterson, the Scotsman who founded the Bank of England, failed in the Isthmus of Panama. His colony on Darien lasted only two years, when the few who had escaped death from disease and war were only too glad to return to Scotland.

No idea had lured men to destruction more successfully than the spirit of the Isthmus. Intended as it was by Nature to be one of the two great highways of the world, men had fought and struggled for its possession, too often only to find themselves swallowed up by the monster some of whose many mouths are called yellow fever, malaria, and dysentery. The Spaniards made a survey for a canal, but came to the conclusion it could not be constructed, and contented themselves with a cobble road. Over it came all the treasures of Peru. But with the discovery of gold in California in 1849, and the development of the western states of North America, something more was necessary, and in 1855 a railway was completed, at no small cost of both lives and money. Later still, with the discovery of oil in California, an 8-inch pipeline was laid down beside the railway. Through it oil was pumped from Californian oil ships lying at Panama to ships at Colon ready to take it to New York and the Eastern States. This saved the oil-ships from the long and dangerous passage round the Horn.

But the call for a highway that would allow ships themselves to pass through from the one ocean to the other became more urgent, and in 1881 de Lesseps began the Canal he was not to see finished. His failure was, no doubt in part, due to extravagance; but those who know most of how quickly costs mount up when disease dogs an enterprise in the tropics, will, I am confident, be the most lenient in their judgement on the great engineer. But when all excuses have been made, the French attempt was a gigantic failure, for it was the utter collapse of a stupendous work. In thirteen years they had not succeeded in completing even one half of the work on their canal, and that the easier half; while no less than $260,000,000 had been spent, and the cost in lives had been on an equally large scale. Their failure was enough to deter any but the men of a great nation determined to succeed, from resuming the work.


Why the Americans began the Canal

To the commercial men of America the canal had always appealed. By it the ports and states of the East and West would be joined by an easy line of communication. To send goods from East to West, or vice versa, meant either a long and expensive journey by train across the continent, or an even longer, much more dangerous, and no less expensive journey by ship round the Horn. By either route the freights were prohibitive for many articles. A canal would give a short sea route between American ports, and it would also bring many American ports much nearer to European and Asian ports. Nevertheless, although the advantages to American trade were so apparent, it is doubtful if by themselves they would have induced the American Government to take up the work after the French failure.

But in 1900 an incident in the Spanish-American war stirred the nation to its depths, and crystallised in its mind the determination to build the Canal. The war began when the battleship Maine was blown up in Havana harbour. To replace her, the new battleship Oregon, then at San Francisco, was ordered to join the fleet off Cuba. Had there been a canal, she could have done this easily and quickly. As it was, she had to perform the extra 8000 mile voyage round Cape Horn at full speed, with the risk of falling in with the enemy’s fleet on her arrival at the seat of war. For nearly a month, in those days before wireless telegraphy, the nation waited in breathless suspense for news of the ship. Every American was asking himself, Would she escape? Would she fall into the hands of the enemy and share the fate of the Maine? That month of suspense decided the question of the Canal. There must be a canal. It was necessary for safety. Without it two fleets must be kept, one in each ocean. And that is why the Canal is being built by the War Department of the United States of America.


Preparation for the Labour Force

There were political difficulties to be overcome before the work could be begun; but the revolution whereby the State of Panama broke away from the Columbian federation, proclaimed itself a separate republic, and placed itself under the protection of the United States, smoothed the way for the work. Even then, however, the Americans did not rush a large labour force on to the Canal at once. They realized how much disease had contributed to the French failure, and they sent Colonel Gorgas, who had won his spurs in ridding Havana of yellow fever, to make the Canal zone habitable. It was well they did so, for when after eighteen months sanitary work, the staff and labourers began to arrive in numbers, a fierce outburst of disease occurred. Yellow fever spared neither high nor low, and, for a time, work on the Canal had partly to be abandoned. The Canal Commission could not work in harmony; and, as I heard Colonel Gorgas tell a Washington audience, the executive asked for his (Colonel Gorgas’) removal. They wanted a “practical man,” not one who wasted time and money in fighting mosquitoes.

This really was the critical moment in the history of the Canal when in American hands. I wonder how many countries would at that time have given the right decision. The wrong decision would have meant failure. Had a “practical man” been sent to replace Colonel Gorgas and his unpractical methods, one need have no hesitation in saying that the Canal could never have been completed. There was, however, a strong man then as President of the United States; one who had seen Colonel Gorgas sweep yellow fever out of Havana for the first time in the history of 250 years. President Roosevelt not only supported Colonel Gorgas, but raised him to a seat on the Canal Commission. It was the obstructing engineer who was removed. Colonel Gorgas was given a free hand, and from that moment the health of those on the zone has steadily improved, and the work has been uninterrupted.

When President Roosevelt charged the first Commission with the great work, he called it, and rightly called it, “the most important and also the most formidable engineering feat which has been hitherto attempted.” Not only have the Americans practically completed this great task, but they have given the world the finest example of sanitary work ever seen, and converted one of the most pestilential spots in the world into one which compares favourably with most places even in temperate zones. And to me it seems the real triumph of the Americans lies in the perfection of the whole Canal administration. It has been the high state of perfection of each branch of the administration which has given the success. And while competition both in work and play has been strongly encouraged between the component parts of this great organization, the triumph has been in subordinating that competition to the welfare of the whole, and in the creation of an admirable esprit de corps on the zone. The Canal builders have indeed built morally as well as physically a superstructure perfect in all its parts, and honourable to the builders.


My Failure to understand the Sanitary Work

It was now to be my privilege to see these great works. Of the engineering work I am not qualified to judge; but it was of paramount importance for me to understand the sanitary work. It is true that in the low coastal land of the Federated Malay States the health is as good as in Panama. Indeed, there is even less malaria in the Federated Malay States; but for our hill land, and certainly one-sixth of the peninsula is hill land, we could afford to neglect no method which promised success. I had studied a number of reports on the work in Panama. I had read how they destroyed the Stegomyia and the Anopheles; how they had provided water and sewage systems; how they had cleaned the towns, and screened the houses; how they had fed the people, and treated the sick. If we were to copy those methods a knowledge of the details was necessary. Success or failure in such things lies in the details. We have seen how the subsoil drainage failed at first in Kuala Lumpur through the neglect of detail.

After careful study of reports I was not satisfied I understood the full value of the different measures employed in Panama, and how much each had contributed to the successful result. As success was so manifest, and its importance so far-reaching, I had come to learn the details for myself. There were a thousand and one questions I wished to ask; but the most important related to malaria. It had been stated that in Panama Anopheles flew only 100 yards across open land, and so anti-larvae measures were carried out only for this distance. My experience in Malaya showed such a distance would have been of little use against our Anopheles; and I concluded the results in Panama must therefore depend to no small degree on the screening of houses. I was prepared to employ screening, oiling, or any other measure which would give a good result; but in practice I had been more and more drawn towards drainage.

From quinine I expected no permanent benefit. Against oiling I was prejudiced, partly because in running water a very concentrated poison, in combination with the oil, seemed to be necessary; but chiefly because I was not satisfied it would be applied with proper care. Writing in Grenier’s Rubber Annual in 1911, I said:

Theoretically this method, if used over an area of half a mile from a house, should abolish malaria. In practice, however, the result would depend entirely on the minute care with which the work was done and the nature of the poison used.

When I recall the difficulty there has often been in obtaining a satisfactory administration of quinine, I have little confidence that a really efficient application of either oil or poison would take place. My experience with quinine has been that the efficiency of its administration depends entirely on the manager or assistant in charge. The disbelief of a new manager in the value of quinine is soon reflected in inefficient administration; or, while the manager may be convinced of its value, and imagines it is being given, the assistant who takes the muster either may neglect to give it at all, or give it in a perfunctory manner. These things I have seen time and again, although perhaps not so much in later years.

And if such occurs with so simple an affair as the giving of a pill to each coolie at muster, I confess I regard with serious misgivings, the prospect of the periodical application of oil or poison to the almost innumerable tiny breeding places which occur in a ravine. For these reasons I have never been able to place a high value on oiling or poisoning as a practical measure on estates.

To screening I was more attracted, because, from an experiment at Jeram in 1902, it appeared to give excellent results. But it was in drainage alone, and for hill land in subsoil drainage, that I placed my faith, rather than in the combination of every known method as used in Panama. I thus wrote:

It will be readily realized that, should it be possible to abolish malaria as completely from the hill land as from the flat by drainage alone, this will be an enormous advance on an elaborate system and organization which necessitates the screening of houses by mosquito-proof gauze, the oiling of pools, the administration of quinine, the catching of adult mosquitoes, etc. Men will then go about as in other parts of the world, doing nothing and taking nothing which they would not do or take elsewhere. To look for such a change in the conditions of life in hill land today is to make no greater demand on one’s faith in science than to prophesy a similar improvement in flat land eight years ago. … For the system I am advocating it may at least be claimed that it offers at a reasonable cost a complete solution of the problem of keeping coolies on estates which have so far been intensely unhealthy. The only alternative system I know of is that put into practice at Panama. And while all must admire the Panama system as the finest sanitary organization ever seen, I trust it may never be required on estates.

It is an open secret that at one time the success of the engineering works at Panama was imperiled by the subordinate position of the Chief Sanitary Officer. President Roosevelt, however, grasped the situation, and Colonel Gorgas is now practically dictator, having full executive powers over all sanitary works. Everything is subordinate to the health of the Canal zone, because the American Government realizes that without healthy labour the Canal will never be completed.

And while the system has been a success in Panama, it is more than doubtful if it would be a success elsewhere. There is not an unlimited supply of either Roosevelts or Gorgases.

Few directors of Rubber Companies would care for the estate medical officer having the power of a Gorgas. And few medical officers (I certainly am not one) would care to be responsible for a Panama organization on an estate, even if armed with the sufficient authority, while without it the necessary organization and discipline would be impossible.

In a memorandum to the Malaria Advisory Board of the Federated Malay States on “The Prevention of Malaria in Rural Districts, and the need for further Experimental Work,” I wrote:

Experiment No. 3

As it is very undesirable to neglect any measure which may be of value, I suggest that an experiment with mosquito-proof lines be tried. Mosquito-proofing, although expensive and requiring considerable supervision, has undoubted merits. This was proved at Jeram Hospital in the year 1902, and in 1907 Government granted $2000 to carry out a mosquito-proof experiment with coolie lines. I spent about $1000, but went on leave just as the experiment began. Unfortunately the experiment was neglected during my absence. On my return I could get no information, and the lines had been abandoned. I am still of the opinion such an experiment should be carried out, and from what I can learn the improved health in Panama must depend more on the mosquito-proofing than on any of the other measures carried out.


For while in Panama no expense or trouble has been spared to keep the labour healthy, and all the various anti-malarial methods are employed, drainage is done only for from 100 to 200 yards from buildings. Now we have abundant experience here to show that intense malaria will prevail at 200 yards from breeding places, even when quinine is given, and it appears to me that the mosquito-proofing must be the important measure.

I would like to point out here, in what respect the problem in Panama differs from that here, as I understand it. On this point I may shortly be able to place more information before the Board.

In Panama the object of the Government was to keep at its maximum of efficiency, for a few years, a body of men who numbered at the most 80,000. At the end of that period the labour force would be reduced to about 5000. There was everything then to be gained by keeping the labour at the maximum efficiency, for in this way the period of construction would be shortened, the wages bill greatly reduced. The time would arrive when the Canal would be earning revenue, and the population would be brought down to a few thousands. Temporary measures, therefore, like oiling and mosquito catching, and semi-temporary measures like mosquito-proofing, were thus of much value; while permanent and expensive drainage, except in what would be the ultimate settlements, would be less necessary.

Even apart from this the total cost of all the medical charges was so trivial, when compared with the total cost of the Canal, and the importance of finishing the Canal, that they could well be neglected.

Further, as the whole area has been under a very strict discipline, it has been possible to exclude from the Canal zone any but those in good health, and generally to insist on the employees carrying out sanitary orders which with an ordinary native population would be very difficult, even if not impossible.

While, then, we all recognise the very high place in sanitary organization, if indeed the highest place must not be given to it, which the work at Panama takes, we also recognise that the organization was specially suited to a special occasion and to special work. We must also realise that the methods adopted are less suitable for an ordinary tropical population, and that the problem here differs materially from that in Panama.

Here, the population so far from diminishing after a short period of years, as it is doing in Panama, is increasing, and every year will still further increase it.

Here, again, it would be quite impossible to employ men to visit all houses daily to catch mosquitoes; and here, too, it is impossible, except in a very general way, to control the arrivals.

What we want to attain on the hill land is the power over malaria which we have on the flat land, the results of malaria prevention on which cannot be excelled—for the simple reason that abolition of the disease is complete—and are not equaled by Panama, either in efficiency or simplicity. And I hope to attain this perfect result on hill land by ascertaining as soon as possible the minimum area that must be drained to give it. And on this hill land I aim at placing the population in the same position as those on the flat land—namely, that they live in ordinary houses, and do and take nothing which other people do not do or take.


Criticism of Sanitary Work in Panama

The position had been still further obscured by criticisms from American and other sources. One critic, an American, whose name I do not give, for he is dead, was a man whose high scientific attainments were coupled with a singularly sincere and attractive nature. Of the honesty of his conviction there could be no question, and the impression he gave was that the labour force in Panama was under an iron discipline. He also stated deportation of the sick was carried out on an extensive scale; while entrance to the zone, except for men in robust health, was impossible.

There were, too, all sorts of other critics less qualified to speak than the foregoing. A few, and I am glad to say only a few, were evidently of the meaner sort, who cannot see others successful without suffering from spleen. They damned with faint praise. Other criticisms were obviously made in an honest spirit, but were no less incorrect and unjust to the Sanitary Staff of Panama. Such is Mr Foster Fraser’s remark, that “if you picked your men, you could prove the most fever-soaked swamp in the world was the healthiest spot on earth.”

There is much less excuse for Mr Logan Marshall, when he writes:29

The fact that medical services are entirely free, and that removal to a hospital is compulsory on the part of the attending physician, has much to do with the excellent conditions of health maintained there. It must be confessed, however, that in spite of all these precautions malaria still exists upon the Isthmus, and must be regarded as a serious problem, the only solution of which is the entire extermination of the Anopheles mosquito. The Canal operating forces must continue to live in screened houses, take quinine in large quantities, remain indoors at night, and continue the various precautions which have been adopted.

Mr Marshall, if he has really been to the Canal zone, ought to have seen for himself that most of these statements are incorrect. How he comes to say the Canal operating forces must continue to “remain indoors at night,” is utterly beyond my comprehension, and absolutely incorrect. The fact is that on the Canal zone people go out of and into their houses as they do in other countries, and with exactly the same freedom; that practically no one takes quinine unless he is ill, and that only a small percentage of the people live in screened houses.


First Impressions

Landing at Colon, I took a quick walk round the town. It certainly was not much above the sea level, and had evidently been reclaimed. There were practically no mosquito-proof houses. No obvious Anopheles breeding places could be seen.

The town seemed a very ordinary place, not one in which I should have expected malaria. My first impression was, in fact, one of great disappointment. There seemed nothing of interest in Colon, and if the whole zone was like this my journey was a waste of time and money. Then I took train across to Panama City. At Gatun I could still see nothing of special interest. The swamps were all carefully drained. But when I reached Gorgona, and the series of settlements from there to Panama, I was completely puzzled. I saw crowds of houses with jungle and swamp within 100 yards and often less. They were not screened. Of oil barrels I saw a few. And the question pressed in on me: how could these people possibly keep healthy? They lived practically in jungle, with swamp oiled or drained, as I then believed, for only 100 yards round them. This was something quite beyond my experience and understanding, and when I reached Ancon I was still in complete darkness.


“Esprit de Corps”

In due course I presented my letters of introduction to Colonel Goethals, chairman and chief engineer, and to Colonel Phillips, who was acting for Colonel Gorgas. From these gentlemen and the staff of the Sanitary Department I received every kindness and assistance. Major Noble, the acting chief sanitary inspector, was kind enough to arrange for me to see everything that I expressed the slightest desire to see. Dr S. T. Darling, the chief of the Board of Health Laboratory, placed a room in his laboratory at my disposal, and gave me every assistance possible.

The sanitary inspectors at each of the stations were equally kind, and took me to all the places of special interest. In addition they were of the greatest help to me in getting to places which, from the lie of the land, would, I thought, present special difficulties to the sanitarian. And as I got to know the staff, what I appreciated most was their kindness in discussing the whole question so freely, pointing out what was good and what they thought could be done better. The tone of the Department was admirable. A false modesty which would have belittled the work, or made them pretend they were unconscious of its merits, would have been no less offensive than bragging of its greatness.

There was a singularly happy spirit in the Department, too, which made men strive to do their best and improve their methods, yet which never for a moment made them forget their esprit de corps and the welfare of the zone. And this spirit was there, not because the greatness of the work operated on the workers and raised them to its high level. The source was in the chief, whose spirit pervaded the Department and made it great.


Historical significance of the work

The greatness of the work was derived from the builders; they were its inspiration. As from day to day I saw more and more of this vast undertaking, learned to appreciate what it was, to understand the difficulties, to feel something of the spirit which had overcome them; and as I thought how on the completion of the Canal this organization of builders would soon melt away, would cease to be a living demonstration, would become only a lesson in history, and one perhaps only imperfectly understood, I determined to spare no effort to master its details, that I might explain them to others. That I can do it justice, I cannot pretend to hope. I do hope that on the completion of the Canal a full history of the sanitary work will be written by Surgeon-General Gorgas and his staff on the zone, that every figure and record which has been accumulated will be published. Some have already been published. Others, as yet unpublished, I have seen, and allude to in this narrative. I believe that in these records we have observations and truths of infinite value to all tropical countries, and that their publication in full would be a lasting benefit to mankind. Until this has been done, perhaps, this and the other accounts of the work which have been published will help to give some idea of its nature and magnitude. For this account I can claim no merit except that it is written with a desire solely to tell the truth as I saw it. If the picture I draw conveys something of value to other fellow workers, it will have served its purpose. While if I succeed in doing even scant justice to the subject, I have no fear that to see themselves as others see them will be other than a pleasure to those who afforded me so much pleasure and profit in Panama. For I shall always regard it as one of the greatest privileges of my life that I saw the Panama Sanitary Department at work, and had the pleasure of meeting the men who composed it.


Yellow Fever and Malaria in the Past


Yellow Fever among the French

If we would understand what has been done for Panama by sanitation, a glance at its past medical history is essential, but it is not necessary to go very far back into its records; for at no time was the health worse than in the days of the French company. At that time there were large bodies of men, both Europeans and others, who were susceptible to both yellow fever and malaria; and such susceptible material is the very fuel for outbursts of disease. The Frenchmen working before Ross’ discovery in 1897 of the transmission of malaria by the Anopheles mosquito, and of the discovery by Reed, Carrol, Lazear, and Agramonte—the American Yellow Fever Commission—in 1900 that the Stegomyia mosquito carried yellow fever, were therefore unaware of the danger oi these insects, and took no steps to destroy them. So both yellow fever and malaria had full play among the French labour force.


Highest officials not exempt

Neither Anopheles nor Stegomyia is the consequence of the presence of filth in the ordinary sense; indeed sewage pollution is unfavourable to both, so neither yellow fever nor malaria were confined to the less cleanly. Those who were best housed and best fed were quite as liable to contract the disease as those who lived in hovels. In a very striking passage Colonel Gorgas tells how, in order to eradicate yellow fever the ordinary sanitary measures were vigorously pushed in Havana in 1899 and 1900. They brought the general death rate down from 91.03 in 1898 to 33.67 and 24.40 in the two following years. Gorgas writes:30

Smallpox had been entirely eradicated. But the great result at which we aimed seemed to be as far away as ever. Our sanitary measures, if they had any effect upon yellow fever, seemed to increase it. The cleanest and best built part of the city seemed to suffer most from the disease, and the best fed and best cared for part of the population was that which had the largest rate of deaths from yellow fever. It was the well-to-do class of Americans, and the highest officials on the staff of the governor general, who suffered out of all proportion to the rest of the population. In 1900, on the staff of the governor general, the chief quartermaster, the chief commissary, one of the aides, and one of the inspectors general, all died of yellow fever, and the preceding year the chief quartermaster and the chief ordnance officer had died.

I mention this to show that the class of population whose surroundings were the best and as good as it was possible to make them, were suffering most from yellow fever. And the same can be said of the disease generally throughout the city. In 1898 there were 136 deaths; in 1899, 103; in 1900, 310. It looked very much as if the cleaner and better hygienically we got the city, the worse we were making yellow fever.

As Gorgas states elsewhere,31 the French had had the same experience in Panama:

We hear of many individual instances of heavy loss. The first French director, Mr Dingier, came to the Isthmus with his wife and three children. At the end of the first six months all had died of yellow fever except himself.

One of the French engineers, who was still on the Isthmus when we arrived, stated that he came over with a party of seventeen young Frenchmen. In a month they had all died of yellow fever except himself. The superintendent of the railroad brought to the Isthmus his three sisters; within a month they had all died of yellow fever. The Mother Superior of the sisters nursing in Ancon Hospital told me that she had come out with twenty-four sisters. Within a few years twenty-one had died, the most of yellow fever. Many other instances of this kind could be cited.


Doctors and Nurses Attacked

Doctors and nurses, although much more exposed to infection than the majority of the population, are notably exempt from attack of epidemic disease. But in Panama it was not so with yellow fever, as the foregoing shows.


Death rate of French Labourers

The death rate among the whole French labor force was also terrible. Colonel Gorgas says of it:32 “From the best information which I can get, and which I consider accurate, I believe the French lost 22,189 labourers by death from 1881 to 1889. This would give a rate of something over 240 per thousand per year.” And he generously adds: “I think it due to the French to say that we could not have done a bit better than they, if we had known no more of the cause of their tropical diseases than they did.”

Indeed the experience of the Americans who came down to the Isthmus in the first few years of their occupation was by no means exhilarating.


The Americans begin in 1904

In July 1904, the first labour arrived to work at making the place fit for the larger force to follow. By 4th July 1905, a pipe water supply for Panama City was completed. The department then devoted its energies to the abolition of rainwater tanks, now no longer necessary, but formerly the only water supply of the city, and the chief breeding place of the Stegomyia mosquito. Yet despite this year’s work a sharp outbreak of yellow fever occurred. From six [cases] in December 1904, it jumped to nineteen, fourteen, and eleven in the succeeding three months. Again, it seemed to show a predilection for high places, for of nine cases which occurred in April 1905, no less than seven “were among employees in the French Administration Building, which had become the headquarters of the Commission in Panama, where about three hundred Americans were engaged. When three of them died, a panic arose among Americans on the Isthmus, and all steamers outward bound were laden to the full capacity with frightened employees.”

Further increases of the disease to thirty-three cases in May and sixty-two in June, particularly affecting the employees, “added to the panic, and nothing except lack of sailing accommodation prevented the scattering of the whole force.” So writes Mr Bishop, the secretary of the Isthmian Canal Commission, who was on the zone at the time.33

Some may be inclined to point the finger of scorn at this panic. If there be such, they will not, I think, be those who have passed through the grave ordeal of a great epidemic disease. It is only veterans in any warfare who can stand unmoved as each day opens to show more and more blank files in the ranks. Nor should it be forgotten that the Americans were under fire for the first time. But whatever is said of the 1905 panic, the subsequent brilliant record is sufficient to close the lips of the thoughtless scoffer.


The Last Yellow Fever Epidemic

It was an uphill fight.

From March to September 1905, the commonest sight on the streets of Panama was some detachment of the fumigation brigade.

The city was fumigated in sections once, then again, yet again, and in the fourth and supreme effort there was a general fumigation over the entire city at the same time. Tons upon tons of paper went to plaster up the crevices in the walls of houses, and some of the crevices in some of the houses would easily have admitted the historic barn door. The fumes of sulphur and pyrethrum were in constant ascent to the upper air, while all around a Pelee-like aspect prevailed. Those were trying days to the householder. He’d barely recovered from his last dose before men with ladders, buckets, and rolls of paper were again besieging his premises.

It was a nip and tuck battle for three or four months in 1905. At one time the outlook might be said to have looked dubious, but the leader of the sanitary forces never wavered in his belief in his theory, and the contest went steadily on.

At last, towards the end of 1905, results began to be apparent. Sources of infection were destroyed, and on 11th November of that year occurred the last case of yellow fever in Panama. The last case in Colon was reported on 17th May 1906.34



With malaria, too, the fight was a tough one. It lasted much longer; but as the rate of mortality was not so high, and death did not as a rule occur so suddenly, it had a less demoralising effect on the population than yellow fever. The maximum malaria admission rate was 821 per 1000 in 1906.

But this entirely fails to give an idea of what the rate would have been had nothing been done to reduce the number of Anopheles in the thirty months previous to the end of 1906. For before the end of that year, 1,758,953 lineal feet35 of ditches had been cleared out, 231,365 feet36 of new ditches cut, and 14,468,968 square yards37 of brush cleared. This must have affected the malaria rate very materially, quite apart from the screening of the houses and distribution of quinine and the oiling, which had also been carried out very thoroughly.

A truer idea of what malaria would have been can be got from the fact that among the 253 U.S. troops stationed at Camp Eliot in 1906, there were 796 cases of malaria, giving an admission rate for malaria of 3315 per 1000. And of 450 men stationed at Mount Hope “taking ten grains of quinine daily,” nearly 100 percent developed malaria either while on the Isthmus or within a month after leaving. As we have seen similarly high rates in the Federated Malay States, we can easily understand this.

With the sharpshooters picking off the officers, with the fatalities among the men higher than occur in ordinary warfare, while every reinforcement of the army aggravated the mortality by introducing more susceptible material, we can understand why it was necessary to abandon operations on the Canal for a time in 1906 until the sanitary conditions could be still further improved. That temporary abandonment was necessary in 1906, even after the eighteen months’ preliminary sanitation from July 1904 to December 1905, during which an enormous amount of sanitary work was done, including the provision of water supplies for the two chief towns and most of the subsidiary stations, demonstrates beyond question that it would have been impossible ever to establish the large labour force necessary to construct the Canal without the strenuous work of the Sanitary Department.