Chapter 9
PUBLIC HEALTH IN CUBA
The diseases that defeated V Corps troops in Cuba would also threaten those serving under the occupation. Victory on the island ultimately came from the efforts of Army physicians to improve sanitation and from the discovery of how yellow fever was spread. Unimpeded by the need to obtain popular approval for their work that frustrated reformers in the United States, medical officers in the conquered territories waged a vigorous public health campaign, combining the new medical knowledge with the old rules of sanitation to create practical weapons for the fight against disease.
The period from 1875 to 1900 was a "golden era of communicable disease control." As early as 1870 urban death rates in the United States had started to fall. In Memphis, Tennessee, which, according to the noted historian of the public health movement, John Duffy, was "one of the filthiest places in the United States" in 1872, one of the nation's highest annual death rates (46.6 per 1,000) was halved in seventeen years by an energetic campaign to install city sewers and a safe water supply. In other municipalities in the South, improvements came more slowly, and rural areas were yet to be affected by the public health movement. But by the time American troops occupied the former Spanish territories, "improved sanitation and a higher standard of living" had produced a drop in the death rate in New York City from 30 per 1,000 in 1873 to 26 in 1886. Although the population of Louisville, Kentucky, increased significantly from 1871 to 1874, the death rate fell from 23 per 1,000 to 16.5 per 1,000. From 1873 through 1886 in Cleveland, Ohio, the average death rate was 18-19 per 1,000. By fiscal year 1887-1888 the average death rate in San Francisco was 18.27 per 1,000; by 1891 in Seattle, Washington, it was 11.5 per 1,000.1
Physicians now knew that specific bacteria found in body wastes were responsible for the spread of such epidemic diseases as typhoid and cholera. The mosquito had just been identified as the carrier of the organism that caused malaria, and almost all those knowledgeable about yellow fever agreed that it, too, was caused by a microbe, although neither the responsible virus nor the way in which it spread had yet been discovered. Scientists still tended to look on yellow fever as a disease linked in some way with poor sanitation. Fortified by the benefits that had followed improvements in sanitation and public health in the United States, by confidence in what would be learned in the future, and by the strong backing of their surgeon general, Army medical officers faced their assignments in the tropics with enthusiasm as well as determination.2
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Health of the Troops
Because of the widespread fear that followed the defeat of the victorious V Corps by disease, President McKinley wished to limit the number of U.S. troops sent into Cuba to replace the V Corps until the months of the highest disease rates had passed. As a result, the initial occupation force of seven new infantry regiments from the United States, four of them composed of men believed to be immune to tropical diseases, was sent only to the area around Santiago and Guantanamo. Most so-called immunes proved to be susceptible to tropical diseases once they arrived in the Caribbean, and thus even after the last of the V Corps left for Camp Wikoff on 26 August 1898, the Medical Department had to keep open the 150-bed yellow fever hospital in Santiago. An "observation station," apparently established to isolate suspicious cases after the closing of the yellow fever detention camp outside Santiago, also continued in use, while in late August a few patients remained at the Siboney yellow fever facility.3
To prepare for the occupation of the entire island during the late fall and winter months, the Military Evacuation Commission, named to plan the U.S. takeover of the rest of the island, worked with the Spanish to arrange the timing of the replacement of their troops by American forces. The formal turnover of power was to take place 1 January 1899, regardless of whether the Spanish had completed the removal of their troops. In anticipation of possible disorders following the departure of Spanish troops, as many as 43,000 U.S. troops arrived on the island in the winter months of 1899. But the transition went so smoothly that within a few weeks almost half of this number had departed the isand, leaving only the volunteers of the VII Corps in Cuba. Most of these troops served in the Havana area, with the remainder scattered at key points about the island. On 31 March 1,207 officers and 25,197 men formed the occupation force, and the total dwindled still further when the volunteers began to leave Cuba in March-all volunteer troops were mustered out in May. By October the small force of regulars that assumed responsibility for the occupation upon the departure of the volunteers numbered less than 15,000 officers and men.4
From the outset, the occupation troops arriving in Cuba benefited from the growing awareness of the role played by the mosquito in malaria. Ronald Ross, the British scientist responsible for the discovery of the malaria vector, had written Surgeon General Sternberg in late August 1898 from India about the results of his latest work, hoping that they would be helpful to him in developing "a rational prophylaxis against malaria."5 U.S. Volunteer surgeon Maj. Jefferson R. Kean, who came to Cuba in December with the VII Corps, recommended that the troops use mosquito netting, a step that, when followed, led to a marked decrease in the number of malaria cases. During the early months of the occupation, line officers failed to take the use of netting seriously, however, and detachments tended to leave nets behind when they moved, causing sharp increases in the number of men who fell victim to malaria. Finally, on 21 December 1900 general orders requiring the use of mosquito netting were issued from the headquarters of the Department of Cuba.6
While the Spanish were still being evacuated from Cuba in late 1898, Surgeon General Sternberg sent Colonel O'Reilly, the chief surgeon on the staff of the Military Evacuation Commission, to study the
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problems encountered by the British on Jamaica and to consult with the departing Spanish on the difficulties that they had confronted while occupying Cuba. Impressed by the death rates from yellow fever, dysentery, and malaria, diseases that could devastate new arrivals in the tropics, O'Reilly recommended that the occupation troops be at least "thoroughly protected against smallpox" before leaving the United States and, once in Cuba, that they be kept from contact with the civilian population to the extent possible. Convinced that sanitation was the key to maintaining the health of the occupiers, he also emphasized that strict regulations should be enforced among the men.7
With the benefit of O'Reilly's advice, the information garnered by medical officers sent to inspect the various Cuban towns where U.S. troops would be quartered, and the ample funding that Congress had made available for wartime needs, Surgeon General Sternberg could make preparations for the occupation that were "of the most generous character." The regimental facility was welcomed back into the Army; each regiment arriving in Cuba brought a hospital with it. Division hospitals were ready to care for 1,000 patients each. Every camp on the island, no matter how small, was provided with its own carefully equipped hospital, and in each of the military departments into which occupied Cuba was divided, an additional facility was established to handle any overflow from the camp hospitals. Hospital ships and the general hospitals in the United States formed a further backup. By restricting the area within the United States that the New York supply depot-"our cheapest purchasing market," as Sternberg put it-was expected to serve, the Medical Department could rely upon it to meet easily all the needs of troops in the Caribbean. Supplies of all kinds, including microscopes, were thus available in quantity on the island, and Sternberg stood by to fill promptly the orders sent to his office. In the spring of 1899 U.S. Volunteer surgeon Major Ives reported that "never before in that respect was an army more completely equipped." Regular troops replaced the volunteers in April, and the number of U.S. troops on the islands became so few that the comprehensive system designed by Sternberg to serve the occupation force was no longer necessary. By June 1900 all general hospitals supporting these men had been closed.8
Sanitation on the somewhat modest scale required by military posts was a familiar challenge to medical officers, but the physicians given this assignment in Cuba had little knowledge of the island and its geography and geology. Attempts to prepare campsites before the arrival of the men who would replace both the V Corps and departing Spanish troops were not always satisfactory. When the first men of the VII Corps arrived in the Havana area in December 1898, water was scarce at their camp, tents lacked floors, and latrines were in poor condition. Although the surgeons advised commanding officers on such matters, supervised the disinfection of buildings taken over for barracks, and encouraged the maintenance of strict standards of camp sanitation, including protection of food supplies from flies, their arguments were apparently not always entirely convincing. Dysentery rates were higher than in the United States. Since some regiments coming to Cuba had been infected with typhoid before they arrived, occasional cases continued to appear, although this disease had not previously been a serious problem on the island. In
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the Department of Matanzas and Santa Clara, soldiers were required "to avoid touching their lips before washing their hands" if they had touched anything that might be infected, to remain indoors after dark, and to disinfect their living quarters every week and their privies daily. These regulations, when strictly obeyed, did limit the spread of disease.9
A rash of typhoid fever cases appeared on one occasion in the spring of 1899, when latrines were not expanded to accommodate 1,000 Cuban laborers who arrived to construct new barracks near Havana. The outbreak occurred because the Cubans, permitted to ignore regulations, "defiled the surface at will." When the latrines were enlarged, the improvement in sanitation was followed by a drop in the number of cases. A flare-up of typhoid in the Puerto Principe area in February and March was not so easily managed. Major Reed, ordered to investigate, concluded that once again the misdiagnosis of early cases had permitted the disease to make considerable headway before the problem was identified as typhoid and that inept attempts to stem the spread of the disease had further contributed to the epidemic.10
The sanitary revolution had not reached the towns and cities of the former Spanish empire. The "environment [was] reminiscent of America in the early nineteenth century, if not Europe in the Middle Ages," according to historian Gaines M. Foster in his study of the Army Medical Department's role in disaster relief. After years of guerrilla warfare, Cuba's cities were, as military historian Graham A. Cosmas described them in his definitive work on the Spanish-American War, "filthy and war-ravaged," with some parts of Havana resembling "an outdoor cesspool." The shortage of food had brought hunger to the city's population. One eyewitness recorded that "dead animals abounded, garbage was encountered everywhere, gutters were foul, and open mouths of sewers running into the ocean or into the harbor were reeking." Another commented that the city was "practically untouched by real progress and . . . years behind in everything except natural and man-made beauty." In Santiago, where water mains had been seriously damaged during the siege, disease was already rampant. Much of the rural population had been gathered by the Spanish into villages, where they could be more effectively controlled. By devastating the countryside between these communities and killing off the livestock, the Spanish had reduced the inhabitants to a state of semi-starvation, while the guerrillas resisting them destroyed the improvements that the occupiers had initiated. The first U.S. troops sent to Cuba had to be stationed near towns and cities, especially seaports and rail junctions, to be able to respond promptly to the first signs of trouble, but conditions in Havana led authorities to caution against locating troops in the city.11
Improving Sanitation
The proximity of troops to Cuban communities made the problems involved in preventing disease among troops and in the civilian population interdependent. Because local authorities in the impoverished nation did not have the resources needed to conduct a thorough cleanup and disinfection of Cuban towns, "reclaiming towns from their present unsanitary condition" became the responsibility of the military government of the island, established in December 1898 and headed by General Brooke. On the recommendation of
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Colonel O'Reilly, the chief surgeon of the Division of Cuba from January to November 1899,12 Brooke initiated an island-wide campaign to improve sanitation. The effort was continued by Brooke's successor in December 1899, former medical officer Leonard Wood, newly promoted to major general in the volunteers, whose assignment as physician to the White House during the presidencies of Cleveland and McKinley had given him powerful supporters in his career as an officer of the line. General Wood was advised by O'Reilly's successors, Lt. Col. Calvin De Witt and, subsequently, Major Havard.13 Throughout his rise to increasingly responsible positions in the military government,14 Wood gave his unswerving support to efforts that he assumed would render the island a healthy place in which to live for Cubans, visitors, and occupying troops alike. Under him, medical officers strove to improve sanitation and educate the Cuban public, both medical and lay, about public health. By mid-1900 six Army surgeons were assigned as municipal sanitary officers, supervising civilian government workers. The management of Cuban charities, including city hospitals, being in a state of confusion, the military government created a department of charities under the supervision of a medical officer to restore order to this aspect of the island's life.15
The cleanup of some smaller Cuban communities was accomplished with considerable success. As early as September 1899 the commander of the Department of Matanzas and Santa Clara could proclaim that "the cities and towns, from a condition of filth and unhealthiness, have been perfectly cleaned and put in first class condition. Cesspools have been emptied; yards and foul places have been cleansed; holes and badly-drained localities have been filled and ditches and drains opened, until the sanitary condition of the towns and cities is as good as it is in cities of like size and situation in the United States or elsewhere." Nevertheless, the surgeon general still considered the disease rate in Matanzas to be too high.16
The greatest challenge for medical officers, however, was the responsibility for the sanitation of large civilian communities, whose inhabitants had been accustomed for generations to wholesale filth but not to taking orders. Large numbers of half-starving men, women, and children were crowded together in "dark and damp houses" under conditions of incredibly poor sanitation, where the threat of disease remained serious even after the prompt restoration of food supplies to the once-be-sieged Santiago and the provision of medicines for the sick in the cities. The formation of Anti-tuberculosis League chapters in Cuba was encouraged, and attempts were made to end the prevalent custom of spitting on the floor. Even though the death rate dropped, U.S. authorities became increasingly convinced that most public buildings were infected by yellow fever.17
In Santiago the siege had led to a serious deterioration in the health of the population, and "the very air seemed laden with death." Thus a public health campaign became necessary even before the V Corps left Cuba. General Wood ordered that cleanup of the city start as soon as its defenders capitulated, at a time when 2,000 Spanish soldiers lay sick within Santiago and another 2,000 were ill in their camps outside it.18
As military governor of Santiago, General Wood moved quickly in his effort to sanitize the city. He divided it into five sections, placing a medical officer in charge of each and assigning him a team of in-
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spectors and street cleaners. This "paramilitary force attacked filth with . . . vigor," removing from the streets and burning 1,100 bodies of both humans and animals in barely more than two months and for a time handling as many as 200 loads of trash a day. Wood had the overflow from cesspools that had flooded the streets eliminated and ordered work on a modern sewage system to begin. Accompanied by a committee of surgeons, he personally visited each house to ensure that it was properly cleaned up, "almost working miracles with the dirty old town." He also reorganized both military and civilian hospitals in Santiago, hired Cuban physicians to staff them where necessary, and inspected these facilities personally. He had the former Spanish military hospital cleaned up and disinfected so that it could be used for U.S. military patients. Total deaths in the city dropped from 103 a day on 17 July 1898, the day the siege ended, to 37 a day only three weeks later, just as the V Corps began leaving Cuba. After the departure of the disease-ridden V Corps, several facilities were closed, among them two military hospitals that were shut down in September. The yellow fever hospital, which took in 35 patients in September, 22 in October, and 2 in November, all from supposedly immune troops, was optimistically closed in November. More than 1,100 patients remained ill within the city, half with fevers of one kind or another.19
Fighting Yellow Fever
When yellow fever struck the island again in mid-1899, most of the sick were U.S. soldiers, since they formed the bulk of the nonimmune population on the island. Many other victims were civilians, presumably either employees of the Army or, since immigration was increasing after falling to near zero in 1896, newly arrived Spaniards. In spite of General Wood's energetic cleanup campaign, the disease took its heaviest toll in Santiago. The first soldier fell ill on 21 June, and by mid-July 158 cases had been reported. Military authorities were criticized for not acting more promptly, but they responded to the epidemic on 30 June by removing as many soldiers as possible from the immediate vicinity of buildings where yellow fever had appeared and by disinfecting barracks, clothing, and the men themselves. Two companies and the band were ordered to set up tents outside the parade ground while their barracks were fumigated. The clothing of the remaining two companies was sent to the Marine Hospital Service ship in the harbor to be disinfected, and a contract surgeon and several hospital corpsmen escorted the men through a disinfection process that apparently involved a "sublimate bath" ("sublimate" presumably meaning corrosive sublimate or mercury chloride) before they marched two miles into the countryside. Although 5 cases appeared shortly after their departure from Santiago, no more fell ill once the incubation period had passed. Of the 23 men stricken, 8 died. Yellow fever also struck patients in the general hospital, triggering an evacuation of the facility under the assumption that it was infected. More than 80 patients and almost 40 attendants were moved to the grounds. Cases continued to appear for several days after the move began, but no more occurred after 7 July, when the last patients were removed. On the twelfth the hospital was moved to a new site.20
Assuming that when yellow fever struck a private home the building became in-
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fected, General Wood ordered that its inhabitants be removed while it was fumigated with sulphur fumes or formaldehyde. If the building could not be well sealed, he had it washed down with a disinfectant. He ordered corrosive sublimate to be spread around the ground outside. Each supposedly contaminated home was guarded by sanitary police to prevent entry for a week before immunes were allowed to return. Until 4 September, no one was allowed to remove furniture or bedding from an infected house, and even after this date such items had to be disinfected before being taken into a noninfected house. This routine was complicated in mid-September by the unexpected refusal of the Marine Hospital Service to handle any more disinfection.21 After this point, therefore, civilian property was taken either to the steam room at the old Spanish military hospital or to a formaldehyde pressure room built earlier for the Army. After conferring with civilian doctors and some of the city's merchants, U.S. Volunteer surgeon Maj. Lawrence C. Carr, who had been placed in charge of all yellow fever patients, closed bars and hotels where yellow fever had appeared. The city's physicians agreed to report all suspicious cases to the Medical Department, a measure to which all but one adhered faithfully.22
Astounded by the magnitude of the outbreak, which eventually produced more than 200 cases and a 22.8-percent death rate, General Wood imposed a quarantine upon the entire city. Americans were forbidden to enter Santiago without the authorization of the city's military commander. Ships were denied permission to unload or take on passengers, or even to touch at a wharf. Pack trains were ordered out of Santiago to campsites at least five miles from the city and at some distance both from infantry camps and from the stream that constituted the municipal water supply. Those who were authorized to leave the city had to be disinfected before departing. Members of the staff of the yellow fever hospital in Santiago harbor were ordered to wear distinctive yellow armbands and not to leave that facility without both receiving permission and undergoing disinfection. Carr's experience with the epidemic led him to conclude that a health officer should be assigned by the city to guarantee that doctors reported possible cases of yellow fever within twelve hours and to supervise disinfection routines and quarantines. Since he regarded "the non-immune tramp element [as] a source of grave danger," he urged that each May, before the start of the yellow fever season, all in that category be deported from Santiago.23
More important than all other measures, however, was the isolation of yellow fever patients, whether military or civilian. Ambulances marked with a yellow flag and devoted exclusively to the transportation of yellow fever victims were kept at Carr's headquarters at the officers hospital. A detention camp with a staff of four surgeons was set up nearby, where all nonimmune inhabitants of infected houses were sent for five days of isolation. Since early diagnosis had assumed a critical importance, patients even suspected of having contracted yellow fever were taken to an observation facility guarded by a policeman who denied entrance to unauthorized personnel. If the diagnosis was confirmed, they were usually then moved by launch to the yellow fever hospital, but since yellow fever victims might become ill before their cases were diagnosed, some were apparently left at home until they had recovered sufficiently to be moved. Convalescents from yellow fever were sent to a
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detention ship in the harbor, where they remained for eight days, by which point most military patients were capable of performing light duty and could be sent ashore to become part of a guard of immunes for the city. By 13 August so few men were still convalescent that the detention ship was returned to its original owner. Following the imposition of these measures and the quarantine, the epidemic began to taper off, with only 74 additional cases recorded from 13 July to 15 October 1899. Carr noted with apparent surprise in October that none of the staff members at the observation and detention facilities, at the yellow fever headquarters, or among the patients in the detention camp ever contracted yellow fever.24
Although under the personal direction of the relentless Wood the public health campaign in Santiago may have been more effectively conducted than in any other community in Cuba, the Santiago experience was not unique. In other communities markedly increased municipal cleanliness might also result in a lower incidence of typhoid, but it failed to eliminate yellow fever. As far as sanitation was concerned, a miracle was performed in Havana, where 250,000 people lived in 26,000 buildings, a "great number of neglected male infants [were] often allowed, even in winter, to go naked or scantily clad," and decades of political upheaval had undermined sanitation. Havana's 30 hospitals, 6 of them military, were all inspected. Because of their poor sanitation and their widespread failure to thoroughly isolate their yellow fever and smallpox patients, these facilities were placed under the supervision of Major Gorgas, who had been appointed chief surgeon of the Department of Havana when it was created in January 1899. Major Reed was sent to Havana to test disinfectants in an attempt to learn how best to prevent the spread of disease by disinfecting water supplies, sewers, streets, and households. Diligent efforts transformed the foul-smelling city, whose soil was saturated by cesspool effluent and whose disease rate was comparable to that of a seventeenth-century European city, into a community that for health and cleanliness rivaled any in the United States. Dysentery, malaria, and typhoid rates dropped markedly.25
In spite of both improvements in sanitation and attempts to prevent the importation of the disease from other ports, yellow fever also struck Havana in 1899. As in Santiago, removal of potential victims from infected sites and disinfection of clothing and quarters failed to prevent the spread of the disease. In the course of the year 28 soldiers and 32 civilians in the Havana area contracted yellow fever. Of the total, 14 died, a death rate that was regarded as low.26
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General Wood and the Department of Havana commander, Brig. Gen. William Ludlow,27 eventually became involved in a quarrel over yellow fever statistics. Wood publicly implied that Ludlow had suppressed these figures, especially those for 1899-1900. Ludlow appealed to his chief surgeon, who was thereby placed in a very awkward position, since he felt that Ludlow did not "appreciate the importance of the work." Gorgas diplomatically replied that he believed that the physician in charge of reporting all cases of yellow fever tended to avoid classifying possible cases as actual yellow fever, thus producing lower figures than might otherwise have been expected. He added that by the fall of 1900 the figures on yellow fever were also being more widely reported than they had been earlier.28
The successful efforts of smaller communities on the island to improve sanitation also failed to result in freedom from the onslaught of yellow fever, which struck 81 more victims and caused 22 deaths outside the major cities. Surgeon General Sternberg was obviously relieved that the toll had been no higher and attributed what he considered the minor nature of the outbreak in 1899 to prompt action by Army surgeons in diagnosing the disease, isolating its victims, and encouraging the prompt removal of garrisons from infected posts. None of the cases that developed among troops there could be traced to outside sources, and since removal from the post apparently brought the epidemic in its garrison to an end, medical officers concluded that the disease resulted from the infection of buildings. Apparently more strongly convinced than ever of the role played by poor sanitation, General Brooke concluded that installing complete sewer systems in various communities, despite the enormous expense that would be involved, would be necessary if yellow fever were to be finally defeated.29
Major Gorgas' success in dealing with the disease problems of Havana was so great that his appointment in 1900 to the position of chief surgeon for the Department of Santiago and Puerto Principe was greeted by protests. General Ludlow, whose opinion of Gorgas was obviously higher than Gorgas' opinion of him, pointed out to the adjutant general of the Division of Cuba that no one could replace Gorgas because he offered an unmatched combination of skill with a profound familiarity with conditions in Havana. Ludlow believed that the sanitation of Havana was "in a general sense, more important than all the rest of the Island put together." To the apparent satisfaction of all concerned, the transfer was promptly canceled, and on 4 April Gorgas "finally settled down as Chief Sanitary Officer of the City of Havana."30
Although the main concern of medical officers in Cuba was yellow fever, from the outset they also had to deal with a disease that, unlike yellow fever, was far more of a threat to the civilian population than to the military. Cuban law requiring all citizens to be vaccinated against smallpox was apparently often ignored, and when an epidemic broke out in a small area of the Department of Santiago in the fall of 1898, General Wood deemed it wise to launch an anti-smallpox campaign. He sent 100 sanitary workers out to disinfect buildings that had sheltered smallpox victims and had as many people as possible vaccinated. He assigned a few medical officers to supervise Cuban physicians in setting up an isolation hospital; cases were so numerous that from November 1898 to January 1899 it handled 1,185 cases. Doctors discovered that only 2 percent of those who contracted the disease had ever been vaccinated. None of the
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10 percent who died had ever been immunized. Thanks to the warnings of medical officers like O'Reilly, none of the medical officers or soldiers who guarded the hospitals contracted smallpox. The success of the campaign was attributed to a large extent to the local doctors, who were able to overcome the distrust of the Cubans both for vaccination and for the hospitals where patients with potentially fatal contagious diseases were isolated. Although the U.S. military government managed to enforce the earlier legislation in some areas, it was not until 1901 that the law was revised to require that all children be immunized before their first birthdays.31
The occupying authorities, firmly convinced of the benefits to be derived from the great improvements achieved by their public health campaign in Cuba, apparently faced 1900 with some confidence as far as disease was concerned. Even so, faith in sanitation as the answer to the yellow fever problem was waning. The number of those not immune to yellow fever coming to the island was great. On the advice of Major Carr, now the chief surgeon of the Department of Santiago and Puerto Principe, a circular was issued in March 1900 outlining the usual precautionary steps, among them isolating or removing nonimmunes among the destitute, to be taken in the attempt to avoid a recurrence of the 1899 epidemic. Whether in spite of the precautions or because of them, yellow fever did not reappear in Santiago in 1900.32
Other communities were not so fortunate. One isolated patient with yellow fever was reported in January 1900, and in the spring a growing number of cases appeared scattered about the island. On 10 May a soldier at Santa Clara and another at Pinar del Rio Barracks contracted the disease, although the latter, who died six days later, was initially believed to have had malaria. A second case at the barracks was diagnosed as yellow fever on 14 June, and it was followed by four more cases that month, all but one of which ended fatally. In July twenty-seven cases were diagnosed, four among civilians, with eight fatal. At this point, the command at Pinar del Rio was ordered to leave the barracks. Since only two more cases occurred after the move, authorities concluded that this step should have been undertaken much earlier. At Santa Clara the disease eventually afflicted thirty-six officers and men, killing ten of them. The first case at Quemados, near Havana and the headquarters of the Department of Havana and Pinar del Rio, appeared on 19 May, and eleven officers and men eventually fell ill, but the nearby Columbia Barracks was spared. By 1900 yellow fever and the fear of its spread had led to the establishment of seven hospitals where yellow fever victims could be isolated-at Santa Clara, at Havana, at Quemados, and four in the Department of Santiago and Puerto Principe. Havana's Los Animas hospital, well staffed and equipped with ambulances to transport patients, handled the victims of all contagious diseases.33
Removal from the affected area seemed to bring epidemics at the various posts to an end, but the fear that the health of soldiers stationed near towns might be endangered if yellow fever erupted there led medical officers to continue their attempts to limit the spread of yellow fever among civilians. While discouraged at the failure of high standards of sanitation to eliminate yellow fever as a threat in towns and cities, military authorities continued the struggle. When the chief surgeon of the Department of Havana and Pinar del Rio, Major Kean, fell ill with yellow fever, the post surgeon at Columbia Barracks super-
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ARISTIDES AGRAMONTE, wearing the uniform of an acting assistant surgeon that was authorized for contract surgeons
vised the removal of the nonimmunes of the population of Quemados to a camp two miles away. Houses of prostitution, bars, and other public places of entertainment frequented by soldiers were then closed. On 1 July a circular was issued for the Department of Matanzas and Santa Clara similar to that issued in March for the Department of Santiago and Puerto Principe. Despite the most strenuous efforts, yellow fever caused more than 300 deaths in the civilian and military population of Cuba in 1900, the highest toll, according to Major Gorgas' wife, in the history of the island. Gorgas blamed this record in part on the growth of the nonimmune population of Spanish immigrants.34
The Yellow Fever Board
Not surprisingly, given the failure of cleanup efforts to prevent the epidemic of 1899, yellow fever became the focus of intensive study in the spring of 1900. Apparently at the instigation of Commanding General of the Army Miles, Surgeon General Sternberg appointed a board to study infectious diseases in Cuba. From the outset this body concentrated on yellow fever and thus became known as the Yellow Fever Board or the Yellow Fever Commission.35 Sternberg named Major Reed as chairman and assigned three contract surgeons-Aristides Agramonte, James Carroll, and Jesse W. Lazear-to work with him. Agramonte had been born in Cuba and was the only member of the board immune to yellow fever. He had been educated in the United States and was serving as a bacteriologist in the New York Health Department when the Spanish-American War began. Carroll, who had been one of the bacteriologists investigating the diseases of Army camps in the United States in 1898, had studied medicine while serving in the Hospital Corps and had taken laboratory courses at Johns Hopkins. According to Agramonte, he was "industrious and of a retiring disposition," while Lazear was "a thorough university man, . . . the type of old southern gentleman, kind, affectionate, dignified, with a high sense of humor."36
Discovering how yellow fever was transmitted would be important for the civilian population of the United States as well as for troops in Cuba, since the disease periodically afflicted U.S. communities, causing more than 100,000 deaths from 1793 to 1901. It had inspired the fear that had earlier precipitated the formation of the commission upon which Surgeon General Sternberg himself had served before the Spanish-American War. Although
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his research had led him to speculate that the responsible organism might be too small to be seen under the microscope, his chief accomplishment had been to prove current theories concerning yellow fever to be false.37
One theory retained credibility in 1900, however. A highly respected Italian bacteriologist, Guiseppe Sanarelli, maintained that yellow fever was caused by an organism he had dubbed Bacillus icteroides. Many highly respected authorities regarded his theory with favor, all the more so since he had followed Koch's postulates in assembling his evidence. Some maintained that they had found Sanarelli's bacteria in many yellow fever victims they had examined. By 1899 this scientist had become so sure of his theory that he mocked Surgeon General Sternberg for "not readily" conceding "success to another when he had himself failed." Everyone who was a true "man of science," Sanarelli announced, would rejoice with him that the riddle had been solved. Commenting that the surgeon general's work had been completed before the most recent progress made in bacteriology, he crowed that Sternberg's "primitive and defective technique" had resulted in "very serious lacunae" in his research.38
When Surgeon General Sternberg ordered the new board to concentrate on the various theories concerning yellow fever, Sanarelli's Bacillus icteroides seemed a good starting point for its research. Major Reed, Agramonte, and Carroll had all worked with the organism in the late 1890s, and when they arrived in Cuba and began their work in facilities at Columbia Barracks, near Quemados and several miles from Havana, they continued this work. The epidemic under way in the summer of 1900, both at Quemados and within Havana it-
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self, provided plentiful material with which to work. They examined the blood of twenty-four patients with yellow fever and the internal organs of eleven who had died of it without finding any trace of Bacillus icteroides or of anything else upon which they could fasten blame, a result that surprised Agramonte, who had personally identified the bacillus in 33 percent of the autopsies he had performed in Santiago in the 1898 epidemic. Further research led the board to conclude that Bacillus icteroides was the cause of hog cholera.39
After disposing of Sanarelli's theory to its own satisfaction, the Yellow Fever Board looked to the work of other scientists for ideas about further research. Major Reed accepted the conclusions of Marine Hospital Service scientist Henry Rose Carter, who had demonstrated that twelve to fifteen days usually elapsed between the appearance of the first case of yellow fever in a community and the development of subsequent cases. Reed then turned to a much disputed theory put forward by Carlos Juan Finlay, a U.S.-trained physician practicing in Havana who had long maintained that a specific mosquito, Aedes aegypti,40 was the yellow fever vector-in actual fact, of course, only the female could serve as the vector because only the female mosquito bites. Unwilling to abandon his theory yet unable to prove it to anyone's satisfaction but his own, Finlay had become an object of ridicule. Among the nonbelievers in Finlay's theory, apparently, was Surgeon General Sternberg himself; when the surgeon general later maintained that he had known yellow fever to be mosquito-borne all along, he earned Reed's scorn and distrust. By 1900 Carter was sufficiently impressed by Finlay's theory to write Lazear that it was "more than plausible, although his arguments as I read them are not convincing."41
After familiarizing himself with the work of both men, Major Reed concluded that in light of recent revelations about insects as disease vectors and of the data produced by Carter's research, Finlay's theory deserved further investigation. The pattern of the spread of yellow fever was quite different from those classified as filth diseases, and the cleanup campaign in Havana had had no effect upon yellow fever rates. The disease sometimes spread from one home to another without any contact between the families involved. Unlike the victims of typhoid, moreover, yellow fever patients did not usually give their disease to their nonimmune nurses. Reed's decision in the summer of 1900 to turn from the puzzling question of the causative organism to the more promising one of the vector led to the research that would make his name famous.42
Finlay was happy to provide the eggs and larva of the insect he suspected of
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spreading yellow fever, but the small animals usually used in laboratory experiments did not contract yellow fever. To find the necessary human guinea pigs, Major Reed turned to U.S. citizens in Cuba, both soldiers and civilians, and to Spanish immigrants who had arrived so recently in Cuba that they had not yet contracted yellow fever. History would suggest that if these men remained long in the island they would, sooner or later, contract yellow fever. All those who came forward for the experiment were offered $100 after being warned of the potential consequences of taking part, and those who contracted yellow fever were offered another $100. Although Havana newspapers vigorously deplored the use of human guinea pigs, the Spanish consul gave his approval after receiving assurances that no minors would be used and that the unusual step (at the time) of obtaining written consent would be made in every instance.43
The Spanish immigrants rounded up by Agramonte were initially most enthusiastic, believing the notion that mosquitoes could spread yellow fever was ridiculous. When they learned that those bitten were falling ill, some, according to Major Reed, "suddenly appeared to lose all interest in the progress of science" and "incontinently severed their connection" with the experiments. Although no U.S. soldiers were asked to participate in this aspect of the board's work, fourteen, of whom eleven were hospital corpsmen, requested permission to do so, and one joined a U.S. civilian employee of the Army in refusing to accept payment. Thoroughly aware of the implications of what he was doing, Reed found the burden he had assumed a great one. In January 1901, when one of his subjects was very ill, he commented that "the responsibility for the life of a human being weighs very heavily, . . . and I am dreadfully melancholic."44
Because of his previous training in handling mosquitoes in Italy, Lazear was asked to take charge of the "rather striking-looking and handsome" insects, each with a "broad, semilunar silvery stripe" on the middle of her body, that would be vital participants in the work of the following months. He bred them, dissecting some of them and taking others to the nearby yellow fever hospital to feed on its patients to become infected. His charges failed at first to infect the nonimmunes they were subsequently encouraged to bite. Since Finlay had also been unable to transmit yellow fever in this way, the faith of Reed's team in his theory weakened. Like Finlay, these physicians had not realized that the mosquito did not become infective immediately upon biting a yellow fever patient and that the length of time the patient had been suffering from that disease at the moment the bite was inflicted was also critically important.45
The first experiments with mosquitoes were initiated on 11 August, after Major Reed had returned to the United States to work on the Typhoid Board report. When Carroll volunteered on the twenty-seventh to be bitten by a mosquito that had fed upon the blood of a patient in his second day of illness, no one had yet acquired yellow fever in this manner. Carroll did not anticipate dire consequences, and although he began to feel unusually tired two days later, he did not realize he was ill until the thirty-first. After an examination of his blood for signs of malaria parasites proved negative, on 1 September the official diagnosis of yellow fever was rendered. Nevertheless, because Carroll had been directly exposed to patients with yellow fever, his contracting the disease did not
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prove conclusively that the mosquito was the vector. The insect that bit him was one of several that also feasted at the expense of a man who had not been exposed to yellow fever patients, and he also came down with yellow fever.46
In spite of the illness of his colleague, Lazear remained casual about the danger posed to him personally by his mosquitoes. Having already been bitten several times without ill effect and knowing that it was possible to have an attack of this disease so mild that it might not be recognized for what it was, he may have assumed that he had somehow acquired an immunity. (Finlay himself had suggested that the bite of a mosquito that had recently feasted upon a yellow fever patient could, as Surgeon General Sternberg put it, "confer an abortive attack of yellow fever.") Carroll and Agramonte agreed that when an insect that was flying about a yellow fever ward during one of his visits bit Lazear on 13 September, he made no attempt to interrupt her meal. Some concluded that Lazear had deliberately intended to infect himself. In any event, five days later, he, too, was ill. On 25 September, when Carroll was on his way to recovery, Lazear died.47
When Major Reed returned to Cuba shortly after Lazear's death, Agramonte was apparently on leave in the United States. Carroll, embittered by his conviction that Reed would deny him credit for the Yellow Fever Board discoveries and by what he insisted was Reed's flight to avoid contracting yellow fever, soon returned to the United States to complete his recuperation. The truth of the former charge was clearly a matter of definition, but evidence exists that the latter charge was unfair. Reed maintained that initially he and his colleagues had all agreed to experiment on themselves and that he personally would have done so had he not left Cuba. He evidently promised Surgeon General Sternberg as a condition of his return to the island that he would not allow himself to be bitten by an infected insect. Agramonte, on the other hand, maintained that after Reed returned to Cuba, he did not submit himself to a mosquito's bite because of the insistence of his colleagues there that the work they were doing was too important to "justify our taking risks which then seemed really unnecessary. . . . For this reason he was never bitten by infected mosquitoes."48
While Agramonte and Carroll were in the United States, Major Reed examined Lazear's carefully maintained notebooks and concluded that a mosquito could be infected only by biting a yellow fever patient in the first three days of the disease and that the insect could transmit the infection only after twelve more days had passed. Although Reed was now personally convinced that yellow fever was indeed mosquito-borne, only one of the three yellow fever victims in his study had acquired the disease under controlled circumstances. The theory was yet to be proved, and the scientific community in the United States remained unenthusiastic about the board's line of research.49
Using funds provided by General Wood, now military governor of Cuba, Major Reed undertook to prove that the mosquito spread yellow fever. At a site where no cases of yellow fever had ever been reported Reed established a camp named after Lazear. He had two frame huts built eighty yards apart in a well-drained and uncultivated open field, where he could control all access to the camp and thus eliminate outside sources of infection. The "Infected Mosquito Building," as Reed called it, was well ventilated and divided by a screen down the middle of the inte-
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rior. The "Infected Clothing Building," on the other hand, was not divided. Its ventilation was strictly limited so that the resultant heat and humidity would foster the spread of infection and the occupants would be, as Reed's biographer William B. Bean described it, "thoroughly saturated with an agent known to be effectively malevolent." Both huts were designed to prevent penetration by uninvited insects. Among those running the camp were two contract surgeons, one of whom was immune; an acting hospital steward, also an immune; nine Hospital Corps privates, one of whom was immune; and an immune ambulance driver. These men were quartered in seven hospital tents, each set twenty feet apart from every other.50
Major Reed proceeded with great care to see that no cases of yellow fever appeared at Camp Lazear other than those that were deliberately transmitted. Two men who developed fevers before the initiation of attempts to infect them with yellow fever were removed from the camp. All those suspected of having contracted the disease were at once put to bed at the camp, in the belief that absolute rest was necessary to the care of the yellow fever patient, and then carried, still in those beds, to the isolation of the yellow fever hospital. Several physicians in Havana were available to examine them and to confirm a diagnosis of yellow fever.51
The experiments at Camp Lazear in the autumn of 1900 eventually involved a total of sixteen cases of yellow fever, twelve from mosquito bites. To keep their supply of insects alive and lively to make these experiments possible, the team at Camp Lazear had to become familiar with the life of Aedes aegypti. Major Reed undertook the study of entomology and maintained his contact with an authority on insects. Since even with devoted care, the scientists at Camp Lazear were unable to keep the average mosquito of this type alive more than five weeks in captivity, and since few survived even that long, they had to undertake a breeding program. Because Reed wanted to establish whether yellow fever, like malaria, could be acquired by the "injection of blood taken from the general circulation of a patient suffering from this disease," he injected another four with infected blood. He succeeded in giving the disease to all but one, whose failure to react to subsequent bites by infected mosquitoes proved that he had actually been immune. Reed's attempts to produce a case of yellow fever by the injection of the blood of a diseased patient were apparently not the first, since Surgeon General Sternberg said he had seen the experiment made, albeit unsuccessfully, several times at Vera Cruz, Mexico, in 1887. Further work by Carroll in the fall of 1901 resulted in six more cases. After Lazear's death, none of the cases produced by the Yellow Fever Board's experiments proved fatal.52
The first phase of the research at Camp Lazear called for mosquitoes known to be infected to bite men believed to be nonimmunes who had been isolated from all other possible contacts with yellow fever. Some insects used in this test had bitten several yellow fever victims at various stages of the disease, and some men were bitten by more than one mosquito. The first volunteer began to sicken on 8 December, less than four days after he had been bitten by five mosquitoes. The next day his case was diagnosed as yellow fever. All but one of the men involved in this phase of Major Reed's research eventually contracted yellow fever, thereby substantiating the theory that Aedes aegypti carried the dread disease. The test also provided more information on the re-
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lationship of the time factor to the transmittal of the disease and demonstrated that the mosquito's role was merely that of the carrier and the injector of the blood.53
The next step required that two sets of subjects be placed in the Infected Mosquito Building. On one side of the screen a volunteer shared his quarters with infected mosquitoes, and on the other side two more volunteers breathed the same air but shared neither the insects nor the yellow fever he contracted. The fact that the bite of Aedes aegypti could spread yellow fever was again confirmed by this test, but the question of whether fomites (items exposed to vomit, urine, or feces) were a factor remained to be determined. To answer this question, volunteers slept in the Infected Clothing Building, in close contact with clothing and bedding that had been thoroughly saturated with the vomit, urine, and feces of yellow fever patients. Although at times their stomachs churned while so intimately exposed to such unappealing items, the supplies of which were several times renewed, the men did not become ill, nor did those participating in two repetitions of the experiment. When subsequently exposed to bites by infected mosquitoes, the first three men who had been involved in the fomite test, an acting assistant surgeon and two hospital corpsmen, fell ill, thus demonstrating that their failure to contract yellow fever from the infected items had not resulted from any immunity to yellow fever.54
Other questions remained to be answered. The fact that the mosquito spread yellow fever specifically by means of the infected blood she had drawn was established by further experiments involving the injection of blood from yellow fever patients into nonimmunes. To demonstrate that the symptoms of yellow fever were not caused by a toxin, Major Reed and Carroll heated blood from an infected patient to 55 degrees Centigrade for ten minutes, a procedure likely to kill bacteria but not to destroy toxin. Nonimmunes injected with this blood did not develop symptoms. Dr. Welch of Johns Hopkins called Reed's and Carroll's attention to work done by other scientists that had demonstrated that the organism responsible for foot-and-mouth disease in cattle would pass through a porcelain filter, and they decided to conduct the same experiment with the blood of a victim of yellow fever. Infected whole blood transmitted the disease even after going through the finest of filters, thereby demonstrating, as Reed and Carroll put it in a paper read before the Society of American Bacteriologists on 31 December 1901, that "yellow fever, like the foot-and-mouth disease of cattle, is caused by a micro-organism so minute in size that it might be designated as ultramicroscopic." Its minute size established that it was certainly not Bacillus icteroides.55
The work of the Yellow Fever Board in the fall and winter of 1900-1901 solved the mystery of how yellow fever was spread and laid many misconceptions to rest. It clearly established that eighteen days were required, if the weather was cool, for the virus to mature within the mosquito's body before she became capable of infecting, although the period was appreciably shorter in warm weather. It also demonstrated that to become infective a mosquito had to bite a patient within the first three days of his illness. Once infected, the mosquito remained capable of spreading the disease indefinitely. The incubation period from the time of the bite to the time the disease first appeared varied from forty-one hours to five days, seventeen hours.56
Perhaps the most significant finding of the board was the proof that while mosqui-
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toes did spread yellow fever, fomites did not. The implications of this discovery were far reaching. A house or a ship became infected only by the presence of infected insects, and their elimination removed the infection. Yellow fever was not a so-called filth disease, and improper sanitation played no role in its spread. The expensive and time-consuming disinfection of clothing, bedding, merchandise, and cargos served no useful purpose in preventing the spread of this particular disease because a ship could carry yellow fever to a foreign port only if a yellow fever patient or a living and infected mosquito were on board. Aedes aegypti, as the Reed team had learned, could live no more than five days without food and water. Thus, under normal circumstances, the insects in a ship's hold would all be dead by the completion of any but the shortest voyage. Medical historian James D. Goodyear suggested in 1978, however, that mosquitoes may be able to survive long voyages by feeding on molasses seeping from containers of raw sugar being exported from areas where yellow fever is endemic. Since Aedes aegypti never flew far from where it was hatched, a ship loaded in midstream was in no danger of infection from the shore. Only the passage of 16-21 days without the development of a case of yellow fever could prove that a ship loaded at an infected port carried neither infected mosquitoes nor infected passengers. The board recommended that if a passenger developed yellow fever during a voyage, nonimmunes on board be quarantined for five days. Only if another case of the disease appeared in this time, according to Reed, would it be advisable to fumigate the ship's quarters, where mosquitoes might have remained alive by feeding on passengers.57
The members of the Yellow Fever Board, satisfied about the way in which yellow fever was spread even though unable to find the organism responsible for it, dispersed in February 1901 to concentrate on what would be an unsuccessful search for the elusive virus in the laboratories of Havana. A somewhat embittered Reed predicted that, recognizing the importance of the board's discoveries, Surgeon General Sternberg would "of course, . . . at once, write an article and say that for 20 years he had considered the mosquito as the most probable cause of yellow fever. That would be just in order for him to do so." Those who were unable to accept all of the board's conclusions, on the other hand, began to publish their objections. One maintained that the board's research consisted of "very imperfect observations" and that the spread of yellow fever by mosquito was possible only when it occurred by accident or by "artificial inoculation." Another, while accepting the notion that mosquitoes spread yellow fever, noted that he knew of epidemics that had appeared in areas without mosquitoes or without any "precursory case of yellow fever" and concluded that the role assigned the mosquito by Major Reed left much still to be explained. The modern evaluation of the Yellow Fever Board's work is unequivocal. "This simple initial report," wrote a medical historian in 1978, "is a model in scientific literature."58
A Time of Trial and Triumph
The prevalence of yellow fever and other diseases in the Caribbean had inspired the work of Major Reed and his colleagues, but even after their discovery that a mosquito was the yellow fever vector, disease rates could not be significantly lowered until practical means of acting on what they had discovered had been devised. Major Reed,
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however, was apparently confident as a result of his contacts with an expert entomologist in the United States that a successful approach to reducing the population of mosquitoes already existed and need only be applied. The Yellow Fever Board played no role in the translation of the board's research into practical measures, but the entire nature of the anti-yellow fever campaign was transformed because of its work. A directive issued by General Wood in December 1900 detailed the approach to be taken throughout Cuba and authorized Major Gorgas to mount both an anti-Anopheles campaign and an anti-Aedes aegypti effort. Gorgas, discouraged by the failure of sanitation to prevent yellow fever epidemics, found the facts revealed by Reed most welcome. Even though he was not yet convinced that the mosquito alone was responsible for the spread of yellow fever and was still more reluctant to rule out some role for fomites, the isolation of yellow fever victims from mosquitoes to prevent the spread of the disease and the destruction of Aedes aegypti now became the focus of Gorgas' efforts.59
The campaign initially centered on Havana, although Major Reed believed that because of the city's size and the ignorance of its physicians, the chances of success there were minimal. Major Gorgas was not optimistic about the possibility of killing a significant number of mosquitoes, but he encouraged the use of all approaches that would prevent breeding, kill the adult insects, or prevent the mosquito from biting patients. He set up three units, two to deal with the prevention of the breeding of Aedes aegypti and the third to destroy the adults. He also divided Havana into twenty sanitary districts, each with its own inspector, who was required to examine every house in his area each month, looking for conditions that might favor the breeding of Aedes aegypti. Any work required to cover cisterns, to pour oil over puddles, or in other ways to eliminate breeding places was done at public expense. The five men who accompanied each inspector on his rounds even unplugged blocked gutters and retrieved old bottles that might hold water. Possible breeding sites were common in Cuban homes, where a container full of drinking water was often kept in the house, to be replenished as needed without ever being emptied and cleaned out. The courts fined those who permitted water to stand uncovered, but the sum could be remitted by the inspector if the problem was eliminated. Cubans, accustomed to graft, assumed that the inspectors kept the fines for themselves and therefore were particularly impressed when the money was returned to them, since it seemed to be a personal gift from the U.S. official.60
The homes of yellow fever victims and houses near them were fumigated, usually with burning sulfur or pyrethrum, to kill adult mosquitoes that might have become infected. The patient's room was disinfected and his clothing sent to the Los Animas disinfecting plant, but these steps were soon abandoned as unnecessary. Carpenters were sent to the dwellings of patients who had remained in their homes to screen windows and construct double doors separated by a vestibule at the entrance, thus making it unlikely that any insect could enter. A sanitary officer was stationed near the doors to guarantee that the first door was closed before the second was opened. Adult mosquitoes were also sought out in tobacco warehouses, where burning tobacco stems were used to destroy this minute enemy. When it became apparent that yellow fever was being brought into Havana from a nearby com-
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munity, a team began fumigating homes there in areas where cases of yellow fever had originated. The problem of the importation of yellow fever into Havana by sea was managed by a quarantine placed on all arriving ships. Any vessel carrying yellow fever victims was fumigated, and all nonimmune passengers were isolated for six days. The tedious disinfection of baggage that had been part of what Gorgas called "the mediaeval quarantines heretofore used" was no longer required.61
The promulgation on 27 April 1901 of a new circular based on the board's discoveries simplified the management of the hospitals where yellow fever patients were isolated. Major Gorgas' initial skepticism about Major Reed's determination that yellow fever could be spread only by the mosquito was apparently soon dispelled. Although the fumigation of rooms and clothing exposed to yellow fever victims was still required to be sure that all infected mosquitoes were killed, on 21 August he finally issued an order ending the required and tedious disinfection of clothing and other material that had come into contact with yellow fever sufferers. Medical officers were now allowed to move freely from yellow fever victims to their other patients and from one institution to another without fear of infecting the community. The movement of attendants caring for yellow fever patients was still limited because of the possibility that they might take infected insects with them. Because of Gorgas' campaign, within three months yellow fever had disappeared from Havana, although it was reintroduced from time to time thereafter from the outside. The ponderous routines used without success to combat this disease had been proved unnecessary. For most scientists, Gorgas' success may have provided proof of Reed's theory about how yellow fever was spread, but a few skeptics still insisted that while the mosquito obviously could spread yellow fever, other means must also be possible.62
Major Gorgas' only failure in his battle against yellow fever occurred at the very time that he was winning his campaign against the mosquito that spread the disease. In the summer of 1901 Gorgas and contract surgeon Guiteras, who had served as an adviser on tropical diseases to the unlucky V Corps in 1898, were conducting research to discover whether they could safely immunize volunteers against this disease by deliberately infecting them, as had been done with smallpox in the days before vaccination. They theorized that men inoculated with matter from mild cases of yellow fever could be given a mild case that would result in permanent immunity. Using principally Spanish volunteers, they gave yellow fever to ten. Unfortunately, three of their subjects, including Clara L. Maass, a nurse from the United States, died because of the attempts to immunize them, and the experiment was abandoned, partially because of the opposition of Major Reed, who was horrified by the fatalities. His own work with yellow fever had produced no deaths but that of Lazear, who had personally made the decision that resulted in his own demise. The deaths also made it more difficult to find volunteers for further experimentation.63
The campaign against yellow fever and Aedes was already well along when the less-publicized campaign against Anopheles began in Cuba. The use of mosquito netting had never been particularly successful, largely because line officers, presumably unconvinced that malaria was carried by mosquitoes, failed to realize its importance. The scientists working under Major Gorgas studied the habits of Anopheles,
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learning, among other things, that it was extremely successful in locating holes in screens and that it was very selective in its choice of victims. The Anopheles, unlike the yellow fever mosquito, preferred fields and open places to human habitation, and thus the campaign against insects in the city was not as effective against malaria as it was against yellow fever. Gorgas assigned fifty men to trim banks and remove vegetation from slow-moving streams so that fish and tadpoles could feast on mosquito larvae as part of the campaign against Anopheles.64
Between the two campaigns, the incidence of both malaria and yellow fever in the Havana area dropped dramatically. Malaria deaths in Cuba as a whole numbered 325 in 1900 but fell to 151 in 1901 and to 77 in 1902. In Havana itself the malaria rate was reduced by 75 percent. Since, in addition, Havana had had no cases of smallpox since 1900, the death rate in that city reached its lowest in more than ten years. For the year 1901 the annual death rate of 22.1 per 1,000 compared favorably with that of such southern U.S. cities as New Orleans and Charleston, whose populations were also exposed to malaria and periodically to yellow fever as well. A jubilant but somewhat surprised Gorgas concluded that he had established that both malaria and yellow fever could be eliminated in the tropics and that U.S. troops could, as a result, serve as easily in the tropics as in temperate zones. Messages of congratulations were soon pouring in to the man who had made Havana as safe to live in as any of the cities of Europe.65
The success of the campaign against yellow fever inspired much enthusiasm for what preventive medicine could do. An Army engineer wrote Gorgas that he could think of "several communities" in the United States where public health would be improved "if military supervision could be exercised over them as has been done in Havana." The death rate in Havana from those diseases found in all large cities had also been high, that from tuberculosis averaging more than 7 per 1,000 per year from 1890 to 1899. After a cleanup campaign that saw all houses regularly inspected and more than half "overhauled by the cleaning brigades of the sanitary department," mortality from tuberculosis fell to barely more than 3 per 1,000 in 1900, a rate lower than that in Vienna or Paris. After Major Gorgas became chief surgeon of the Department of Cuba in December 1901, he undertook a campaign to eliminate this disease from Havana entirely, although he concluded that a longer time might be required to reach this goal than had been needed to eliminate yellow fever.66
In 1902, as U.S. forces prepared to end officially the occupation of Cuba, Major
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Gorgas was left behind to serve as "District Surgeon for troops in Cuba." His principal assignment was apparently to be the continuation of his experimental work with yellow fever and mosquitoes. When Brig. Gen. William H. Forwood succeeded Sternberg as surgeon general in early June, official support of this aspect of Gorgas' work began to wane. Concerned about the possibility of fatalities resulting from Gorgas' attempts to find out more positively exactly when yellow fever patients became infective, Surgeon General Forwood consulted Major Reed, who advised him against "assuming such risks with human life" when the basic questions about yellow fever had already been resolved. Forwood forbade Gorgas to use mosquitoes longer than eleven days after they had become infected with yellow fever because he believed that after that point the risk of "fatal infection" was great. He did permit the use of mosquitoes whose infection was more recent, but even in granting this permission, the surgeon general added that such experiments were acceptable "at least so long as no accident occurs." Gorgas interpreted Forwood's orders as forbidding all experimentation.67
Before leaving Cuba in 1902, Wood, who as military governor appointed Cuban civilians to run the government, named a five-man board of health to oversee the administration of public health measures in the island. Finlay, "a most lovable man," Major Gorgas believed, a physician respected for his "scientific honesty and straightforwardness," was a member. His authority was apparently limited, and in the four years before disorders in Cuba resulted in the return of U.S. military government, yellow fever reappeared and sanitation in many communities, except Havana itself, deteriorated.68
The incidence of yellow fever grew with the influx of nonimmunes after a new occupation force of 4,000 U.S. soldiers-the Army of Cuban Pacification-arrived late in 1906. In Cienfuegos 12 soldiers contracted the disease in the summer of 1907 and 3 died. All 12 had been working in the hospital, which took in both military and civilian patients. Charles E. Magoon, appointed as provisional governor of Cuba in October 1906, theorized in a report to Secretary of War William H. Taft that a patient in the hospital with a mild and therefore undiagnosed case must have been bitten by a mosquito that in time transmitted the disease to the nonimmunes in that facility. After noting that sanitation outside Havana had been left to local authorities who did not cooperate with efforts to maintain appropriate standards, presumably including those calling for the elimination of sites where mosquitoes could breed, Magoon concluded that the sanitation service must be managed on a nationwide basis. Although Magoon and Major Kean, his chief adviser on sanitation, were in conflict over the desirability and even the possibility of moving the drive for improved sanitation out of the political arena, Magoon turned the administrative control of sanitation on the island over to Kean and four other medical officers detailed from the Army of Pacification. A sixth medical officer was assigned to work with the provisional government on the administration of hospitals and similar institutions.69
Many diseases still plagued the population, among them smallpox, malaria, dysentery, and typhoid, but Magoon's primary interest was apparently yellow fever, always a greater problem for strangers to the island than for Cubans. He sent Finlay, Guiteras, and Agramonte to Cienfuegos to take control of the situation there, which they
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promptly succeeded in doing, and later sent Kean and a second medical officer to join them to enforce sanitary regulations. In fiscal year 1908 a total of eighteen soldiers, thirteen of them stationed in Cienfuegos, contracted yellow fever, of whom five died. The following year, however, only one case was diagnosed in the Army. When the troops again left Cuba in April 1910, no further cases had appeared. When the provisional government was dissolved in January 1909, the management of public health on the island had been reorganized and centralized. The responsibility for sanitation in all the island's towns and cities had been taken from local bureaucracies and given to the national government, thus making the administration and financing of public health uniform throughout the island. The result was a marked drop in the rate of those diseases considered preventable, among them infantile diarrhea and tetanus resulting from unsanitary care of the umbilical cord. The Army had restored Havana to such a high level of sanitation that an American visitor to that city hardly a year after the second occupation professed himself astounded by what medical officers had achieved in ridding the city entirely of filth and insects.70
The good health record of the men of the second occupation force was credited largely to the fact that only Regular Army physicians accompanied them to Cuba. Medical officers had been taken from several important posts within the United States to accompany the new army of occupation, and except for the brief epidemic of yellow fever, the health of the garrisons, though still linked with that of the civilian population, was generally maintained at a high level. Malaria rates were initially higher than those in the United States, but lower than that in the Philippines, a situation that in the early months was also true of dysentery. The rates of other digestive ailments was high, although no deaths occurred as a result. An outbreak of dengue, which is carried by Aedes aegypti, that accompanied the yellow fever epidemic, caused no deaths and was easily distinguished from the more fatal disease. The most serious health threat throughout the period of the new occupation was typhoid fever, which appeared in localized epidemics that caused occasional fatalities.71
The V Corps had been defeated by malaria and the fear of yellow fever, sent into headlong flight back to the United States by the inability of the Medical Department in 1898 to prevent either disease. But even as Surgeon General Sternberg devoted considerable energy to preparing the department to deal with potential epidemics in Cuba, he ordered the department's best scientists into the battle to reduce the likelihood that U.S. troops would ever again have to face such dangers. The Army's success in ridding Cuba of yellow fever would bring fame to Majors Reed and Gorgas and the Medical Department they served. The dramatic reduction of morbidity and mortality from both yellow fever and other diseases would have far-reaching consequences for other tropical lands. The return of yellow fever to Cuba when the campaign against mosquitoes was allowed to lapse after the departure of U.S. troops only provided additional proof of the value of this approach. For U.S. medical officers, this example of what the new, scientific medicine could do would be a continuing reminder that they were no longer helpless in the face of disease.
NOTES
1. First quotation from Wilson G. Smillie and Edwin D. Kilbourne, Preventive Medicine and Public Health, p. 9; see also pp. 5-6, 10-13, 241. Remaining quotations from John Duffy, The Sanitarians, pp. 145, 190; see also pp. 80, 126, 128, 139-44, 146-54, 175.
2. Margaret Warner, "Hunting the Yellow Fever Germ," pp. 361-63; Wesley W. Spink, Infectious Diseases, pp. 162, 165, 241-42, 368-69.
3. Quotation from War Department, [Annual] Report of the Surgeon General, U.S. Army, to the Secretary of War, 1899, p. 170 (hereafter cited as WD, ARofSG, date); Ltr, AG to Shafter, 13 Jul 1898, Microfilm (Mf) Reel 3, and Telg, Shafter to AG, 16 Aug 1898, Mf Reel 5, William R. Shafter Papers, Stanford University (SU), Palo Alto, Calif.; Marvin Fletcher, "The Black Volunteers in the Spanish-American War," p. 51; Graham A. Cosmas, "Securing the Fruits of Victory," pp. 85-86.
4. Cosmas, "Securing," pp. 85-87; War Department, Correspondence Relating to the War With Spain, 1:138, 179, 225, 381, 548; idem, [Annual] Report of the Secretary of War, 1899, 1(pt. 1):12 and 1(pt.3):4, 124 (hereafter cited as WD, ARofSW, date); idem, ARofSG, 1899, pp. 163-64.
5. R. A. Ward, "The Influence of Ronald Ross Upon the Early Development of Malaria Vector Control Procedures in the United States Army," p. 208. See also pp. 207, 209.
6. The geographical units into which Cuba was divided by the occupation forces government varied with time. On 10 August 1898 the Department of Santiago was created to include all of Cuba then under U.S. control. On 13 December the Division of Cuba was created. On 17 January 1899 the limits of the Department of Santiago were redefined to include only the Province of Santiago. On the twenty-fourth the Division of Cuba was divided into seven departments: the Department of Pinar del Rio, the Department of the Province of Havana, the Department of Havana, the Department of Matanzas, the Department of Santa Clara, the Department of Puerto Principe, and the Department of Santiago. On 19 April the Departments of Matanzas and of Santa Clara were merged into the Department of Matanzas and Santa Clara and the Departments of the Province of Havana and of Pinar del Rio into the Department of the Province of Havana and Pinar del Rio. On 1 July the Departments of Santiago and Puerto Principe were merged, leaving the Division of Cuba with four departments: the Department of Havana, the Department of Matanzas and Santa Clara, the Department of Province of Havana and Pinar del Rio (often referred to merely as the Department of Havana and Pinar del Rio), and the Department of Santiago and Puerto Principe. Both the Department of Havana and Pinar del Rio and the Department of Santiago and Puerto Principe were discontinued on 23 July 1900, when the Department of Western Cuba and the Department of Eastern Cuba were established. The Departments of Eastern Cuba and of Western Cuba were discontinued on 15 November, at which point the Division of Cuba became the Department of Cuba. See WD, ARofSW, 1899, l(pt.3):122-24, 300, and 1901, l(pt.3):282.
7. WD, ARofSG, 1899, pp. 145-50 (quotation), 151, 169; Ltr, AG to Shafter, 5 Aug 1898, Mf Reel 4, Shafter Papers, SU; R. S. Woodson, "Smallpox in Cuba," p. 1466; Duffy, Sanitarians, pp. 193-203.
8. WD, ARofSG, 1899, pp. 5-7, 150-54, 156, 162-63 (first quotation), 164, 168, 171, and 1900, pp. 7-8, 25 (second quotation), 168; idem, ARofSW, 1899, l(pt.2):363-64, 498, 505 (third quotation); Cosmas, "Securing," p. 87.
9. WD, ARofSG, 1899, pp. 98, 146, 151, 168-69 (quotation), and 1900, p. 174; idem, ARofSW, l(pt.2):450; Valery Havard, "Sanitation and Yellow Fever in Havana," p. 18; John H. Stone, "Remarks Suggested by Three Years' Service in Cuba," pp. 330-31.
10. WD, ARofSG, 1899, pp. 152, 163 (quotation), 164, 173, 275-80, and 1900, p. 174; idem, ARofSW, 1898, l(pt.2):376-77.
11. First quotation from Gaines M. Foster, The Demands of Humanity, p. 27 (see also pp. 26, 28); fourth quotation from Franklin Matthews, The New-Born Cuba (New York: Harper and Bros., 1899), pp. 95-96, cited in ibid.; second and third quotations from Cosmas, "Securing," p. 87 (see also p. 86); fifth quotation from Wilfrid Turnbull, "Reminiscences of an Army Surgeon in Cuba and the Philippines," p. 31. See also WD, ARofSG, 1899, pp. 162-65; idem, ARofSW, 1899, l(pt.3):132-33, 217-18, 301, 312, and 1(pt. 6):7-8; Ltr, SW to John R. Brooke, 5 Jan
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1899, file 243526, Record Group (RG) 94, National Archives and Records Administration (NARA), Washington, D.C.
12. O'Reilly was honorably discharged from the volunteers on 12 May 1899, at which time he reverted back to his permanent rank of major. He was promoted to lieutenant colonel on 21 February 1900, to colonel on 14 February 1902, and to brigadier general on 7 September 1902, when he became surgeon general.
13. The position was apparently vacant in December 1899, but O'Reilly was replaced by De Witt from January to April 1900 and then by Havard, who served through most of 1901. See WD, ARofSG, 1900, p.172.
14. Wood took over as military governor of the city of Santiago immediately after the city's surrender. He was commander of the Department of Santiago and its successor agency, the Department of Santiago and Puerto Principe, from October 1898 to December 1899, when he became military governor of Cuba. He remained in this position until May 1902. Wood held various ranks in the volunteers: brigadier general from 8 July to 7 December 1898 and again from 13 April to 5 December 1899; major general from 7 December 1898 to 13 April 1899 and again from 5 December 1899 to 4 February 1901, when he reverted back to the permanent rank of brigadier general. On 3 August 1903 he was promoted to major general. See WD, ARofSW, 1899, l(pt.3):300, 1901, l(pt.3):282, and 1902, 1:9.
15. WD, ARofSG,1899, pp.145-46, 162, 165-67 (quotation), 168-69, 1900, pp. 172-74, 176, and 1908, p. 127; idem, ARofSW, 1(pt.6):5-6, 10, 129, 362, 367-68; Hermann Hagedorn, Leonard Wood, 1:260; "Public Health-Good Sanitary Results at Santiago de Cuba," p. 869; Carlos J. Finlay, Sanitary Conditions in Cuba, p. 4; Cosmas, "Securing," p. 87; "To Select Camps in Cuba for the Army of Occupation," p. 524; J. Hamilton Stone, "Our Troops in the Tropics," p. 364; Jefferson R. Kean, "Hospitals and Charities in Cuba," pp. 141-42; Woodson, "Smallpox," pp. 1466-68; Edward S. Petersen, "The Military Surgeon in the West," p. 2.
16. WD, ARofSG, 1899, p. 168; idem, ARofSW, 1899, l(pt.6):340 (quotation), and 1900, 1(pt.1,vol.1-pt.1): 7-8.
17. J. Hamilton Stone, "Remarks Suggested by Three Years' Service in Cuba," p. 329 (quotation); Duffy, Sanitarians, pp. 175, 205; WD, ARofSG, 1899, 1(pt. 6):8-9, 128-29, 360-61.
18. Leonard Wood, "Santiago Since the Surrender," p. 517 (quotation); WD, ARofSG, 1899, p. 171; Hagedorn, Wood, pp. 186, 188-89.
19. Foster, Demands of Humanity, p. 28 (first quotation); "Public Health-Good Sanitary Results," pp. 868 (second quotation), 869; Wood, "Santiago Since the Surrender," pp. 515-17, 524; "Yellow Fever Hospital at Santiago Closed," pp. 628-29; Stone, "Our Troops," p. 364; Hagedorn, Wood, 1:190, 192, 202; WD, ARofSG, 1899, pp. 60, 170-71; idem, ARofSW, 1899, l(pt.6):8-9, 366, 827-28.
20. Dept of Santiago and Puerto Principe Cir 22, 21 Dec 1899, p. 4 (quotation), William C. Gorgas Papers, Manuscript Division, Library of Congress, Washington, D.C. (hereafter cited as Gorgas Papers, LC); Rpt, P. S. Rossiter to SG, 1 Oct 1899, box 5-5, John W. Ross Papers, Tennessee State Library and Archives, Nashville, Tenn. (hereafter cited as Ross Papers, TSLA); Hagedorn, Wood, 1:188-89, 192, 242; Ltr, Shafter to QMG, 22 Jul 1898, Mf Reel 4, Shafter Papers, SU; United States (U.S.), Congress, Senate, 61st Congress, 3d Session, Yellow Fever..., pp. 224, 235; WD, ARofSG, 1899, pp. 98, 145, 171, 240, 251-55, and 1900, p. 175; idem, ARofSW, 1899, l(pt.6):15.
21. The Marine Hospital Service was the ancestor of today's Public Health Service. Its progenitor was a series of government-owned hospitals for sick and injured merchant mariners, which were organized into the Marine Hospital Service in 1798. The name of the organization was officially changed to Public Health and Marine Hospital Service in 1902. The Marine Hospital Service part of the name was dropped in 1912. See Ralph C. Williams, The United States Public Health Service, 1798-1950, pp. 25-32, 166-67 (hereafter cited as USPHS).
22. WD, ARofSG, 1899, pp. 257-58; Hagedorn, Wood, 1:243.
23. WD, ARofSG, 1899, pp. 254-55, 260 (quotation); Hagedorn, Wood, 1:242.
24. WD, ARofSG, 1899, pp. 254-58; Ltr, Gorgas to "My Dearest" [presumably Mrs. Gorgas], 21 Nov 1899, and Dept of Santiago and Puerto Principe Cir 22, 21 Dec 1899, Gorgas Papers, LC.
25. Havard, "Sanitation," p. 17 (quotation); William N. Bispham, "Sanitary Work in the City of Havana," p. 1094; U.S., Congress, Senate, Yellow Fever, pp. 237, 244; Louis A. Perez, Jr., "Vagrants, Beggars, and Bandits," p. 1103; WD, ARofSG, 1899, pp. 155-63, and 1900, pp. 171, 177-78; idem, ARofSW, 1899, l(pt.6):361, 366; William C. Gorgas, Sanitation in Panama, p. 73; Ltr, AG to C. S. Walton, 10 Jun 1899, Gorgas Papers, LC.
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26. WD, ARofSG, 1899, pp. 261-62; William C. Gorgas, "Sanitation of the Tropics With Special Reference to Malaria and Yellow Fever," p. 1075; Ltr, Gorgas to "My Dearest," 15 Nov 1899, Gorgas Papers, LC.
27. Ludlow received his second volunteer commission of brigadier general on 13 April 1899 and his regular commission for the same rank on 21 January 1900.
28. Quotation from Ltr, Gorgas to John W. Ross, 30 Dec 1899, box 3-6, Ross Papers, TSLA; Ltrs, William Ludlow to Gorgas, 31 Oct 1900, and Gorgas to Ludlow, 7 Nov 1900, Gorgas Papers, LC; WD, ARofSW, 1899, 1(pt.l):59.
29. U.S., Congress, Senate, Yellow Fever, pp. 235, 237, 244; Hagedorn, Wood, 1:281; Perez, "Vagrants," pp. l096, 1103; WD, ARofSG, 1899, pp. 155-62; idem, ARofSW, 1899, l(pt.6):15; Stone, "Remarks," p. 329.
30. First quotation from Ltr, William Ludlow to AG, Div of Cuba, 4 Apr 1900, and second quotation from Ltr, Gorgas to Ludlow, 16 May 1900, Gorgas Papers, LC. In loc. cit., see also Telg, Henry Carter to Leonard Wood, 4 Apr 1900; Div of Cuba SO 44, 3 Apr 1900; and Ltr, Gorgas to Valery Havard, 11 Apr 1900.
31. WD, ARofSG, 1899, pp. 245-46; Hagedorn, Wood, 1:213; Foster, Demands of Humanity, pp. 32-33.
32. WD, ARofSG, 1900, pp. 168-69, 176, and 1901, p.147.
33. Ibid., 1899, pp. 162-63, 1900, pp. 170-71, 173, 176, and 1901, p. 177; Ltr, Gorgas to Ed., NY Med Journal, 19 Oct 1901, Gorgas Papers, LC.
34. WD, ARofSG, 1900, pp. 168, 170-71, 177-86; Marie D. Gorgas and Burton J. Hendrick, William Crawford Gorgas, pp. 87-88; Edgar Erskine Hume, Victories of Army Medicine, p. 96; Robert S. Henry, The Armed Forces Institute of Pathology, p. 129 (hereafter cited as AFIP); U.S., Congress, Senate, Yellow Fever, p. 235; Ltr, Gorgas to William Ludlow, 16 Jun 1900, Gorgas Papers, LC. Jefferson R. Kean's March 1925 editorial in Military Surgeon (pp. 366-70) was highly critical of the autobiography of her husband that Mrs. Gorgas co-authored. He maintained that this volume gives Gorgas credit for accomplishments that Gorgas personally never claimed and that were not his.
35. Although the official name was Yellow Fever Commission, it was popularly known as the Yellow Fever Board, a term that is especially useful because it differentiates this organization from the earlier Havana Yellow Fever Commission and emphasizes the similarity with the tropical disease boards of the Philippines.
36. Aristides Agramonte, "The Inside Story of a Great Medical Discovery," pp. 214-15 (quotations); Henry, AFIP, pp. 113-31; WD, ARofSG, 1900, p. 22.
37. Hume, Victories, pp. 93-94; Henry, AFIP, p. 109; Walter Reed and James Carroll, "The Prevention of Yellow Fever," p. 641; U.S., Congress, Senate, Yellow Fever, pp. 131-32, 136, 161.
38. Guiseppe Sanarelli, "Some Observations and Controversial Remarks on the Specific Cause of Yellow Fever," pp. 193-94 (quotations), 201; U.S., Congress, Senate, Yellow Fever, pp. 25, 162, 208; Walter Reed, "The Propagation of Yellow Fever," pp. 201-02; George M. Sternberg, "Yellow Fever Etiology," p. 1040; "Tropical Diseases," p. 377; Warner, "Yellow Fever Germ," p. 375.
39. Warner, "Yellow Fever Germ," pp. 374, 376-78, 381; Ms, Carlos J. Finlay, n.d., Gorgas Papers, LC; Ltr (copy), W. Reed to W. Gorgas, 27 Jun 1901, Ms C48, Walter Reed and William C. Gorgas Papers, National Library of Medicine (NLM), Bethesda, Md.; U.S., Congress, Senate, Yellow Fever, pp. 161-63, 208; Walter Reed, James Carroll, Aristides Agramonte, and Jesse Lazear, "The Etiology of Yellow Fever," p. 790; George M. Sternberg, "The Bacillus Icteroides as the Cause of Yellow Fever," pp. 225-28; WD, ARofSG, 1901, p. 181; Walter Reed and James Carroll, "A Comparative Study of the Biological Characters and Pathogenesis of Bacillus X (Sternberg), Bacillus Icteroides (Sanarelli), and the Hog-Cholera Bacillus (Salmon and Smith)," p. 216.
40. Aedes aegypti was then known as Stegomyia.
41. Williams, USPHS, pp. 259-60 (quotation), 261; H. R. Carter, "A Note on the Interval Between Infecting and Secondary Cases of Yellow Fever From the Records of the Yellow Fever at Orwood and Taylor, Miss., in 1898," pp. 617-36; Esmond R. Long, A History of American Pathology, pp. 165-66; Ltr, Reed to Gorgas, 27 Jun 1901, Ms C48, NLM; WD, ARofSG, 1901, p. 182; U.S., Congress, Senate, Yellow Fever, p. 196; Carlos J. Finlay, "Mosquitoes Considered as Transmitters of Yellow Fever and Malaria," pp. 737-39, and other articles on this topic by Finlay listed in the Bibliography. Finlay was by no means the first physician to theorize that a mosquito might be behind the transmission of yellow fever (see Sigismund Peller, "Walter Reed, C. Finlay, and Their Predecessors Around 1800," pp. 195-200), but debates about what credit belongs to whom seem to be unending and sometimes far-fetched (see, for example, Francois Delaporte, The History of Yellow Fever).
42. The yellow fever virus was not discovered for another twenty years. See Wilbur G. Downs, "The
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Story of Yellow Fever Since Walter Reed," p. 723; William B. Bean, "Walter Reed and Yellow Fever," pp. 661-62; U.S., Congress, Senate, Yellow Fever, pp. 9, 17, 93, 201-03; Williams, USPHS, Reed to Carter, 26 Feb 1901, following p. 260; Hagedorn, Wood, 1:326; Juan A. del Regato, "Carlos Finlay and the Nobel Prize in Physiology or Medicine," pp. 2-3.
43. U.S., Congress, Senate, Yellow Fever, pp. 88-89; "The Etiology of Yellow Fever," p. 461; Hagedorn, Wood, 1:327; William B. Bean, "Walter Reed and the Ordeal of Human Experiments," pp. 75-92; idem, Walter Reed, pp. 146-48.
44. First and second quotations from U.S., Congress, Senate, Yellow Fever, p. 99 (see also pp. 21-22, 27-29); third quotation from Martha L. Sternberg, George Miller Sternberg, p. 227.
45. U.S., Congress, Senate, Yellow Fever, pp. 25-26, 135 (quotations), 176.
46. Ibid., pp. 18, 21, 26, 210; Agramonte, "Inside Story," pp. 210, 219; WD, ARofSG, 1901, pp. 183-84.
47. WD, ARofSG, 1900, p. 22, and 1901, pp. 187, 195 (quotation); U.S., Congress, Senate, Yellow Fever, pp. 16, 18, 26; Agramonte, "Inside Story," pp, 221-22; Bean, Reed, pp. 134, 137.
48. Bean, Reed, pp. 126, 134 (quotation), 136-38, 141-42; Henry, AFIP, pp. 120-21.
49. Bean, Reed, pp. 126, 136-38, 141-42; U.S., Congress, Senate, Yellow Fever, pp. 11, 26; Regato, "Carlos Finlay," p. 4.
50. U.S., Congress, Senate, Yellow Fever, pp. 71, 97 (first two quotations), 210-11; Bean, Reed, p. 151 (final quotation); idem, "Walter Reed and Yellow Fever," p. 660; WD, ARofSG, 1901, pp. 187-88.
51. WD, ARofSG, 1901, pp. 188, 195; Sternberg, Sternberg, p. 223; Henry, AFIP, pp. 122-24; Bean, Reed, p. 150; U.S., Congress, Senate, Yellow Fever, pp.10, 26, 70-71, 80.
52. U.S., Congress, Senate, Yellow Fever, pp. 10, 19, 82 (quotation), 135, 140, 163, 196, 229; Bean, Reed, p. 144.
53. WD, ARofSG, 1901, pp. 178, 188-89; U.S., Congress, Senate, Yellow Fever, pp. 18-19.
54. Bean, Reed, pp. 150-53; WD, ARofSG, 1901, pp. 177-78, 199-200; U.S., Congress, Senate, Yellow Fever, pp. 19, 22-23, 82-84, 103.
55. U.S., Congress, Senate, Yellow Fever, pp. 149, 158, 164-65 (quotation); Bean, Reed, p. 154.
56. U.S., Congress, Senate, Yellow Fever, pp. 81, 100-101, 181; Walter Reed, James Carroll, Aristides Agramonte, "The Etiology of Yellow Fever," pp. 431, 439-40; WD, ARofSG, 1901, pp. 178, 195, 200-202; Henry, AFIP, p. 121.
57. WD, ARofSG, 1901, pp. 146, 198-99, 200-202; Reed, "Propagation," pp. 203, 209; U.S., Congress, Senate, Yellow Fever, pp. 83, 86-87; Reed and Carroll, "Prevention," pp. 648-49; Michael D. Malison and Stephen H. Waterman, "Dengue Fever in the United States," p. 498; James D. Goodyear, "The Sugar Connection," pp. 5-21.
58. Bean, Reed, p. 153 (first quotation); Eugene Wasdin, "The Etiology of Yellow Fever," pp. 951-52 (second and third quotations); A. N. Bell, "Fomites and Yellow Fever," p. 303 (fourth quotation); Spink, Infectious Diseases, p. 156 (fifth quotation); WD, ARofSG, 1901, p. 179, and 1902, p. 56. Shortly before his death, Brig. Gen. Jefferson R. Kean, who worked with Reed in Cuba and who reportedly was the first case of this disease that Reed had ever seen, reported that Reed's papers disappeared from his desk after his death. He stated that one of Carroll's sons was suspected of having taken them. Although proof of this fact was never found, the son refused to deny any involvement in the theft. See folders Interview, 1950, p. 13, and Biographical Data, Curriculum Vitae, Ainsworth, Ireland, Ms C14, Jefferson R. Kean Papers, NLM.
59. Hume, Victories, p. 96; U.S., Congress, Senate, Yellow Fever, pp. 235-36; Ltr, AG to C. S. Walton, 10 Jun 1899, Gorgas Papers, LC; Stanhope Bayne-Jones, The Evolution of Preventive Medicine in the United States Army, 1607-1939, pp. 137-38; Kean, "Editorial," pp. 366-68.
60. Joseph A. LePrince, A. J. Orenstein, and L. O. Howard, Mosquito Control in Panama, pp. 236, 240, 243; Ltr, Reed to Gorgas, 27 Jun 1901, Ms C48, NLM; Rpt, William C. Gorgas and John W. Ross, "Methods of Destroying Adult Mosquitoes by the Sanitary Department of Havana," box 5-6, Ross Papers, TSLA; Gorgas, Sanitation, pp. 40-43, 56-59, 63; Bean, "Walter Reed and Yellow Fever," p. 661; idem, Reed, p. 169; U.S., Congress, Senate, Yellow Fever, p. 11; Ltrs, Joseph A. LePrince to Gorgas, 28 Jun 1901, and Gorgas to Los Sres. Inquilinos y Duenos de Casa, 25 May 1901, Gorgas Papers, LC; Bayne-Jones, Preventive Medicine, p. 139.
61. Quotation from Ltr, Gorgas to W. A. McLaughlin, 12 Nov 1901, Gorgas Papers, LC. In loc. cit., see Ltrs, J. A. Lopez to Gorgas, 2 Jul 1901, and LePrince to Gorgas, 2 Jul 1901. See also LePrince et al., Mosquito Control, pp. 252-53; Gorgas, Sanitation, pp. 51-57, 63-64, 93, 102-03; U.S., Congress, Senate, Yellow Fever, pp. 223, 235-36, 247.
62. WD, ARofSG, 1901, pp. 145-46; Rpt, 31 May 1899, William C. Gorgas Papers, Entry 561, RG 94, NARA; U.S., Congress, Senate, Yellow Fever, pp.
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225-26; in Gorgas Papers, LC: Treas Dept Cir, SG, Marine Hospital Service (MHS) to Med Offs, MHS, 20 Jun 1901, and Ltrs, Gorgas to Manuel Cuevas, 19 Feb 1901, and Stanford E. Chaille to Gorgas, 27 Jan 1902.
63. Bean, Reed, pp. 146, 160, 168; idem, "Walter Reed and Yellow Fever," p. 662; U.S., Congress, Senate, Yellow Fever, pp. 19, 29-30, 150, 169; Ltr, Gorgas to AG, Dept of Cuba, 1 April 1902, Gorgas Papers, Entry 561, RG 94, NARA; Helen Tigertt and W. D. Tigertt, "Clara Louise Maass," pp. 252-53; Ltr (copy), W. Reed to W. Gorgas, 4 Sep 1902, Ms C48, NLM.
64. Ltrs, Gorgas to AG, Dept of Cuba, 6 Apr 1901, and to L. O. Howard, 29 Jul 1901, and William Binckley to Gorgas, 29 Jun 1901, Gorgas Papers, LC; U.S., Congress, Senate, Yellow Fever, pp. 144, 237, 247-48; WD, ARofSG, 1899, p. 288.
65. See many letters of congratulations in boxes 3 and 4, Gorgas Papers, LC; Bayne-Jones, Preventive Medicine, p. 137; Henry, AFIP, p. 128; Hume, Victories, p. 161; LePrince et al., Mosquito Control, pp. 4-7, 90-92; United States, Bureau of the Census, Census of the Philippine Islands . . . , 3:74.
66. First and second quotations from Ltr, Lansing H. Beach to Gorgas, 14 Mar 1901, Gorgas Papers, LC. In loc. cit., see Dept of Cuba GO 32, 23 Dec 1901, and Ltr, Gorgas to Henry C. Baker, 21 Mar 1902. Third quotation from Havard, "Sanitation," p. 15; see also pp. 14, 20-21.
67. First quotation from Ltr, Gorgas to "Theo," 16 Apr 1902, and third and fourth quotations from Ltrs, SG to Gorgas, 15 and 20 Aug 1902, Gorgas Papers, LC. In loc. cit., see also Ltr, Gorgas to SG, 25 Sep 1902. Second quotation from Ltr, W. Reed to W. Gorgas, 4 Sep 1902, Ms C48, NLM. In loc. cit., see also Telg, SG to Gorgas, 15 Aug 1902, and Ltr, SG to Gorgas, 20 Aug 1902.
68. Gorgas, Sanitation, p. 15 (quotations); WD, ARofSG, 1909, p. 135; idem, ARofSW, 1900, 1(pt. 11,vol.1-pt.1):6; Order 159, Mil Gov, Cuba, 17 May 1902, Gorgas Papers, LC.
69. WD, ARofSG, 1907, p. 80, 1909, pp. 86, 135-36, and 1910, p. 85; Ltr, Charles E. Magoon to SW, 19 Aug 1907, Ms 5324, Entry 52, RG 112, NARA; Allan R. Millett, The Politics of Intervention, pp. 208-10. Kean was promoted to the permanent rank of major on 2 February 1901.
70. WD, ARofSG, 1908, pp. 66, 68, 1909, p. 81, and 1910, p. 85; Ltr, Magoon to SW, 19 Aug 1907, Ms 5324, Entry 52, RG 112, NARA; Gorgas, Sanitation, p. 15; Charles F. Craig, "The Army Medical Service," p. 425; "The Army as a Sanitary Corps," p. 425; Foster, Demands of Humanity, pp. 45-46; Jose Antonio Lopez del Valle, The Development of Sanitation and Charities in Cuba During the Last Sixteen Years, pp. 4, 20; Millett, Politics, pp. 208-10; Charles E. Magoon, Republic of Cuba, 2:440-41; in Gorgas Papers, LC: Ltr, Gorgas to "Theo," 16 Apr 1902, and Hq Army SO 91, 17 Apr 1902, and Order 159, Mil Gov, Cuba, 17 May 1902.
71. WD, ARofSG, 1907, pp. 80-82, 1908, pp. 66-68, 1909, pp. 80-88, and 1910, p. 85; idem, ARofSW, 1906, p. 33.
