QUARANTINE SYSTEM
Panama, from its situation and location, was peculiarly liable to
infection from other places in both North and South America. It was
the gateway through which a large traffic passed, and through which
a continuous stream of travelers had been entering and departing for
the previous four hundred years. After we had once freed it from
yellow fever, it was very important that we should keep it free, and
to do this we had to take such measures as would prevent a person in
the early stages of yellow fever coming into Panama, and infecting
the mosquitoes there, and thus starting an epidemic.
It was possible, also, for a ship to come into a port with infected
mosquitoes aboard. These infected mosquitoes might escape to the
shore and in this way start the disease, or they might bite some
non-immune visiting the ship, and cause this non-immune to develop
yellow fever at his house in from three to six days after he had
visited the ship.
To protect ourselves against the introduction of yellow fever in the
above ways, quarantine regulations were established. Any ship that
had developed a case of yellow fever aboard was considered infected.
We knew that if the case were developed aboard, she must have had
infected mosquitoes there which had bitten the patient and caused
the disease. The ship was, therefore, fumigated in such a way as to
kill all mosquitoes. After she had been fumigated, we considered her
safe. But though the ship could be rendered safe by the fumigation,
some of the passengers or crew might have been bitten by the infected
mosquitoes just before the fumigation of the ship, and such person
might develop yellow fever during the succeeding six days. We
therefore took all the non-immunes to our quarantine station, and
kept them for six days. At the end of six days we allowed them to
return to the ship. The vessel itself, with all the immunes aboard,
was released from quarantine as soon as the fumigation had been
completed.
As I have said before, a person who has once had yellow fever is not
liable to a second attack. Such person is known as an immune. To
prove immunity, a passenger or member of the crew was required to
present a written statement from some recognized authority stating
that the writer knew that the person under consideration had suffered
from an attack of yellow fever.
Wherever yellow fever is endemic, it is a well-recognized fact that
the native of the endemic area is not subject to this disease. This
is explained on the theory that he had a mild attack in childhood,
which, though not recognized, gives him protection in after life.
This statement may strike one with surprise at first. We have,
however, an exactly similar state of affairs among cattle. The beef
native to a Texas fever region does not suffer from the disease, but
an animal brought from anywhere outside this region always contracts
the disease, and generally dies. The calf of the native cow is
believed to have a mild attack which does not make it seriously sick,
but protects it from Texas fever all through life. If the calf of the
foreign cow is born in the endemic area, it seems to survive just as
does the native calf, though the mother may have died of Texas fever.
An adult human being frequently has yellow fever in so mild a form
that it is not recognized as yellow fever. Many Europeans are found
in a yellow-fever endemic center such as Havana, who have lived there
for years and not had yellow fever, as far as they themselves were
aware. If, therefore, an individual could prove that he had lived
for ten years continuously in a yellow-fever center, his immunity was
accepted by the quarantine authorities.
If a ship had touched at a port where yellow fever prevailed, before
coming to Panama, there was a possibility of infected stegomyia
having gotten aboard, even though no cases of yellow fever had
developed on the ship. For by chance the infected mosquitoes may not
have bitten anyone, or if they had bitten persons on the ship, the
biting may not have taken place a sufficient length of time for the
development of the disease, before the arrival of the ship at Panama.
Such a ship was considered as possibly infected, and was treated at
quarantine exactly in the same way as above described in case of a
ship known to be infected.
The fumigation of a ship was generally accomplished by burning
sulphur, as above described in the case of fumigating a house. In the
parts of a ship, such as the engine-room, where there was valuable
machinery which would be injured by sulphur fumes, pyrethrum was
used, just as in similar circumstances it was used in fumigating
dwelling-houses. We had more elaborate machinery than the pots and
pans described in the fumigation of houses, with which sulphur fumes
could be developed much more rapidly and in much larger volume. This
was used by us on special occasions where its use seemed desirable.
In the history of yellow fever, many curious cases of ship infection
from this disease have occurred. During the fall of 1904, one of our
warships, the _Boston_, spent several months in Panama Bay. While
down the coast on gun practice, in January, 1905, she developed seven
cases of yellow fever. She had been away from Panama such a length
of time that the doctor knew that the cases must have received their
infection aboard, and that therefore the ship was infected. The cases
were well marked and most of them were severe, the doctor and one
of the men dying of the disease. Nothing could be found in the sick
records of the ship which would indicate that anyone belonging to the
ship had contracted yellow fever ashore and developed a mild case,
and thus infected the ship. All the cases were connected, directly
or indirectly, with the wardroom, three of them being commissioned
officers. As we were having at the time some yellow fever in Panama,
the crew had not been allowed ashore. One or two of the officers,
only, had been permitted to come into Panama for the transaction of
necessary business.
A short time before the ship had left the harbor, New Year’s
Eve, 1904, they had given a ball aboard, which had been attended
by a large number of the citizens of Panama. After a careful
investigation of the matter, we concluded that some one of these
persons was in the initial stages of a mild case of yellow fever.
It is quite possible for such a person to be up and around without
appreciating that he has the disease. This person, we concluded, was
bitten by some of the stegomyia aboard. At the end of two weeks these
stegomyia became infectious and gave the disease to the crew.
Dr. G. A. Perry, of the Public Health Service, who had immediate
charge of the work, found a small flat tub under the steps going down
from the wardroom, in which stegomyia were breeding freely. This
was the only place on the ship where larvæ were found, and this one
piece of carelessness was responsible for the epidemic on the ship.
All the mosquitoes aboard ship undoubtedly bred here. We could never
find out why this tub was kept here, as the wardroom steward who was
responsible, contracted the fever and died. The surgeon of the ship
also died.
The ship was carefully fumigated, under the supervision of Dr. Henry
R. Carter, and no more cases occurred, though the ship immediately
went to sea with all of her crew aboard, with the exception of the
sick, who were brought to Ancon Hospital.
As an instance of what a man sick with yellow fever may do in the way
of going about, I will narrate here the case of one of our patients
which will well illustrate this point.
An American machinist, coming from San Francisco to Panama, got off
the steamer at Corinto, Nicaragua, got on a spree and was locked
up in the Corinto jail. He was left there by the steamer, but was
released from jail in time to catch the next steamer going to Panama.
He reached Panama at the end of five days, went to work for the
Commission, and worked one day, but being taken sick, he quit work,
though he did not report to the doctor. Instead, he again commenced
drinking. On the second day of his disease, he was arrested by the
Panaman police, and placed in jail as being drunk and disorderly.
He was released on the third day of his disease and continued his
debauch. He was again arrested on the fourth day, put in jail, and
was then discovered by one of our inspectors who recognized that he
was sick as well as drunk. He had him brought to Ancon Hospital,
where he died on the sixth day from the beginning of his attack.
The symptoms of the disease were well-marked, black vomit being
profuse. An autopsy confirmed the diagnosis. Here was a man suffering
from a case of yellow fever, of which he finally died on the sixth
day, who, for the first five days of the disease, was about town,
going from saloon to saloon, drinking immoderately, eating what came
to hand, and sleeping where convenient. Twenty-four hours before he
died, he rode up to the hospital in a cab and walked into the ward.
He was having black vomit before he left the jail.
It is often extremely difficult to trace a case of yellow fever and
discover the source of infection. In 1909 we were very much startled
by what appeared to be a case of this disease, which had apparently
been contracted in the city of Panama, and developed there.
A young Englishman had boarded the Royal Mail steamship at
Southampton, bound for Colon. While the ship had touched at several
points en route, the Captain certified that no one had left the ship
at Cartagena, the only infected port at which she had touched. He
arrived in Panama January 6, and after being in Panama six days, he
developed yellow fever, of which he died on January 24. The symptoms
were well marked, and an autopsy confirmed the diagnosis.
As far as we knew, there had not been a case of this disease in
Panama for four years, and the stegomyia were so scarce that we did
not believe that yellow fever could be transmitted. The poor fellow,
just before he died, told Dr. William Deeks, his attending physician,
that on the night during which they were anchored in the Bay of
Cartagena, the first mate and himself had slipped off unobserved
in one of the ship’s boats, spent the night in Cartagena, and had
gotten back to the ship before daylight. This confession at once
cleared up the case. He had evidently been bitten by a stegomyia
mosquito while in Cartagena. Had it not been for his confession, the
evidence would have been very strong that in some way the disease had
been contracted in Panama.
During 1899 we had the most curious case in Havana of infection in
the person of a nun, Sister Maria de los Angeles, a Dominican nun,
and a native of France. She had come direct to New York from Europe,
on the steamship _Celtic_, remained there two days, and then took the
Ward Line steamer _Vigilancia_ for Havana. The trip from New York to
Havana by this steamer occupies four days.
The nun reached Havana September 8. She was feeling badly, though she
did not give up her duties on that account. On September 11 she was
taken sick with a chill, and died with well-marked yellow fever on
the sixteenth.
The circumstances were such that the Board was convinced that she had
contracted the disease on board ship, and not in Havana. She must
have gotten it in some way between New York and Havana. She could not
have been infected in New York, as there had been no yellow fever
there during the preceding twenty years. The steamer under discussion
plied between Vera Cruz, Mexico and New York City, touching at
Havana both going and coming.
We found that the records of the ship showed that the last case of
yellow fever aboard had occurred on the second trip before the one
under consideration, antedating the time the nun was aboard by about
a month. This was in the person of a passenger from Vera Cruz, who
was taken off at the quarantine station at New York. He occupied the
stateroom that afterwards was occupied by the nun on her trip to
Havana. Such an instance twenty years before would very readily have
been explained as an instance of infection from the room, but we now
know that yellow fever can be contracted only through the bite of
an infected female stegomyia mosquito. No other case had occurred
on the ship during the month following this case, in the passengers
from Vera Cruz. It is probable, therefore, that a stegomyia mosquito
in this room must have bitten the passenger sick with yellow fever
during the trip up to New York; that this mosquito remained in this
room for nearly a month, biting the unfortunate nun soon after she
got aboard.
As no other cases occurred afterwards, it is quite probable that
the nun killed the mosquito at the time of the biting. It is also
probable that some immune occupied this room on the trip up from Vera
Cruz to New York City, who would not be injured even if the mosquito
bit him. On the preceding trip down from New York to Vera Cruz the
person occupying the room would not have been injured by the biting
of the mosquito, even if the person had been a non-immune, as the
mosquito requires two weeks from the time she bites a yellow-fever
patient before she herself becomes infectious. The preceding trip
down was within this two weeks period of non-infectiousness in
the mosquito. At first blush, the case certainly appeared very
mysterious. How was it possible for a person coming from France via
New York to Havana, to have yellow fever when she reached Havana!
In 1904, when we first reached Panama, yellow fever surrounded us
in all directions. Guayaquil, Ecuador, on the west coast of South
America, three days’ sail from Panama, was badly infected. On the
west coast to the north, Corinto in Nicaragua and other ports, we
knew to be infected. On the Caribbean Sea, within from one to three
days’ sail, Cartagena, Colombia, Porto Caballo, La Guira, Venezuela,
the port of Caracas, and other ports were having yellow fever. On the
Gulf of Mexico, Vera Cruz, Mexico, was an endemic center. Progreso,
the capital of Yucatan, was also having this disease. In 1905, New
Orleans, Louisiana, had a sharp epidemic of yellow fever. With all
these places we had frequent and close commercial relations. In
1906, Cuba had some yellow fever at many points. All these places had
to be carefully guarded against by our quarantines.
Bubonic plague existed endemically at Guayaquil, and several other
ports on the west coast of South America, and this disease occurred
sporadically at ports on the Caribbean Sea and the Gulf of Mexico.
Quite a number of cases of plague developed in New Orleans during
1914. Our quarantines had to look after this disease in the same
manner that yellow fever was guarded against.
I have already mentioned that in 1905 plague established itself
at La Boca and Ancon, in spite of our quarantines. This is no
reflection upon our quarantine system. I am glad to say that under
the administration of Dr. Henry R. Carter and Dr. James A. Perry, our
quarantines were as efficient as could be found anywhere, but the
very best quarantine will at some time allow a case of infectious
disease to pass. Such accidents cannot be entirely prevented, except
by the entire abolition of commerce.
For the care of passengers and ships under quarantine, we built
two quarantine stations, one at the north end of the Canal on the
Caribbean Sea, the other at the south end on an island in the bay of
Panama.
Culebra Island, on which was located the Panama quarantine station,
is an island of four or five acres in extent, the center of the group
of islands on which are now located the fortifications protecting
the southern mouth of the Canal. These islands are mountain tops
projecting from fifty to three hundred and fifty feet above the
surface of the waters of the bay of Panama. They are heavily wooded,
and are very picturesque in appearance. They are now connected with
each other and with the mainland by an artificial causeway, built
during the period of Canal construction by dumping here the spoil
from Culebra Cut.
On Culebra Island, nine or ten comfortable and substantial frame
buildings were erected, capable of caring for some three or four
hundred persons. They consisted of two small hospitals, divided
so that five or six different kinds of contagious diseases could
be cared for, if necessary, at the same time; a large barrack
building with a capacity of two hundred beds for the care of
steerage passengers, divided into a male and female side; a large
building of a capacity of seventy-two beds, for the care of first
and second-class passengers, divided into small wards and rooms for
the separate care of the two classes of passengers; another large
building for the housing of the employees of the station; a smaller
building for the dispensary, doctor’s office and administration, and
a comfortable residence for the doctor and his family.
The station was well equipped for making the different classes of
passengers comfortable, and for the care of the sick. In connection
with the station we kept equipped a self-propelling barge of about
one hundred tons capacity. This vessel was named the _Walter Reed_,
and was supplied with modern machinery for generating sulphur fumes
and pumping these fumes aboard the ship to be fumigated.
These islands are about three miles from the mainland. There was
no more desirable place about Panama in which to spend a week than
the quarantine station. The site was as picturesque and attractive
as could be desired, and its location, three miles out in the bay,
made the temperature cool and agreeable. I have to confess that,
as a general thing, the passengers quarantined at Culebra did not
appreciate its beauties and comforts sufficiently to stay an hour
after their quarantine period. One of our ministers, however, coming
up the west coast with his family, was held at the quarantine station
for several days, in order that his quarantine period might be
completed. When the time had expired, he came to the city of Panama,
took a look around, remembered the beauty and comfort of Culebra
Island and the quarantine station, and concluded that he would like
to take his family, return to the island, and stay there until his
ship sailed. This we gave him permission to do, and he and his family
remained at Culebra about a week after his quarantine period had
expired. This established the reputation of the Panama quarantine as
being a salubrious, delightful and desirable place in which to be
detained.