The degree to which yellow fever had affected his career, his personal life, even his very existence, was quite uncanny. It was because of a yellow-fever epidemic at Mobile in 1853 that his mother and father first met. She was Amelia Gayle, daughter of a former governor of Alabama, who for her safety had been sent to stay with an older brother at Mount Vernon, a small town on high, dry ground to the north of Mobile and the site of a federal arsenal. Her brother, the company surgeon at the arsenal, lived next door to the young ordnance officer who was in command, Josiah Gorgas. The wedding was in December that same year, and William, the first of six children, was born the following year, October 3, 1854. The attending physician, as noted earlier, was Alabama’s pioneer yellow-fever specialist, Josiah Nott.
Gorgas’ own first test as a young officer in the Army Medical Corps was a yellow-fever outbreak in Texas. In 1882 he was assigned to Fort Brown, on the Rio Grande, close to the border settlement of Brownsville where the epidemic raged. “I am sending you the most progressive young surgeon under my command,” the surgeon general informed the post commander, and having set himself to work, Gorgas proved so very persistent, ignoring strict orders to keep away from the infected wards, that he was put temporarily under arrest.
Of particular concern as the epidemic worsened was Miss Marie Doughty, sister-in-law of the post commander, for whom little hope was given. A grave had been dug for her in the yellow-fever burial ground on an island in the Rio Grande and Gorgas had volunteered to go with the body and read the last rites. But then he too fell ill, nearly died, but recovered, as did Miss Doughty, with the result that they were convalescent at the same time and fell in love. She became the doctor’s wife following a visit to Tuscaloosa to meet his widowed mother, and since they were now permanently immune to yellow fever, he would be summoned repeatedly for special duty wherever the disease broke out.
He advanced in rank, to major by the time of the Cuban war, but preferred then, as later, to be called Dr. Gorgas. When the American forces occupied Havana in 1898, he was put in charge of the yellow-fever camp at the village of Siboney. One patient, recalling Gorgas’ efficiency and kindness, wrote that had it not been for him the death rate among the troops might have been twice what it was. But Gorgas was no closer to understanding the cause of yellow fever than he had ever been. When the situation at Siboney became critical, his only solution was to burn the town, along with all the medical supplies.
The great yellow-fever discoveries at Cuba, those later dramatized in Sidney Howard’s play Yellow Jack and in a movie made from the play, were the work of Gorgas’ superior officer, Dr. Walter Reed, who had taken his lead from Carlos Finlay. At the time the Americans moved into Havana, Finlay was still laboring to prove that Stegomyia fasciata –and only Stegomyia fasciata–was the yellow-fever carrier. And for all his persistence he had gotten nowhere. His carefully tended laboratory mosquitoes drew blood from diseased patients and were then permitted to attack the bare arms of willing victims. Yet no yellow-fever cases had ever resulted for Finlay. His notion that the mosquito had to be the transmitting agent was perfectly correct and like Ross in India he had hit upon it alone. What he did not know, what Reed and his staff were to demonstrate, was that Stegomyia fasciata transmits the yellow-fever parasite only according to a very particular time pattern, that the development of the parasite within the insect requires what is known as the period of “extrinsic incubation.”
For the mosquito to become infected it must suck the blood of the yellow-fever patient within the first three days after the patient has contracted the disease. Then once the mosquito has taken the blood, another twelve to twenty days must pass before the mosquito can transmit the infection. Finlay had simply been applying his infected mosquitoes too soon.
Determination of this critical time factor, a phenomenon that evaded not just Finlay but all previous investigators, had been made in Mississippi the year of the Cuban war by an aristocratic Virginian who was with the Public Health Service. Dr. Henry Rose Carter, like Gorgas, had been immunized by a previous attack of yellow fever and consequently made the disease a specialty. He had noted that often when a man developed yellow fever on board ship none of his shipmates became ill. He wondered if somehow there might be a period of delay, or incubation, at the source of the disease. So during an epidemic in Mississippi, he made a statistical study among isolated rural families, meticulously recording how many people–relatives, visitors–came near a yellow-fever patient, when, and with what result. What he found was that a yellow-fever patient could be visited without hazard so long as the visit was made within ten to twelve days after the patient became ill. But beyond that period, even after the patient had died and the body had been removed from the house, family or visitors were in mortal danger. Hence the sick man could not possibly be the source of contamination. Hence there had to be a period of “extrinsic incubation,” as Carter named it.
Carter’s findings were published two years later, in 1900, just as the Army Yellow Fever Commission under Reed arrived in Havana.* Impressed by Finlay, who volunteered to help in any way he could, and by Carter, who had been sent to Havana as a quarantine officer, Reed decided to concentrate on Stegomyia fasciata, to prove that yellow fever was not a filth disease. Gorgas, who remained positive it was, had been reassigned meanwhile to clean up the city, street by street, house by house.
Associated with Reed were Dr. James Carroll, Dr. Aristides Agramonte, and Dr. Jesse W. Lazear. Late in August, a few days after he had allowed a mosquito to bite him, Dr. Carroll fell ill with yellow fever, and though he recovered, his health was so damaged that he died a few years later. In mid-September, while placing mosquitoes on patients in a fever ward, Lazear saw a free mosquito of undetermined species land on his hand and he also purposefully allowed the insect to take its feed of blood. Five days later Lazear had what Gorgas described as one of the most violent cases of yellow fever he had ever attended. On September 25, the day Lazear died, he was in such wild delirium that it took two men to hold him in bed.
Convinced now of the truth of Finlay’s theory, Reed pressed on with further experiments proving conclusively that Stegomyia fasciata was the carrier, and that neither filth nor “fomites,” the term used for the soiled clothes or bedding of yellow-fever patients, had anything whatever to do with spreading the disease. For twenty nights, as part of one experiment, a doctor and three volunteer soldiers, confined to a one-room shack, slept in the soiled pajamas of yellow-fever patients, on beds reeking of black vomit and other excreta; and for all the discomfort of the experience, none of them suffered the least sign of illness.
Gorgas had been at the bedside of Carroll and Lazear. He had become a close friend of Finlay’s and knew Reed’s work to be of paramount importance. Still, he remained “unconvinced.” He did not believe mosquitoes to be even the principal cause, much less the only cause. There was only one way to determine whether Stegomyia fasciata was the carrier, he insisted, and that was to rid the city of the insect and see if yellow fever disappeared. Reed agreed in theory but is said to have told Gorgas, “It can’t be done.” Gorgas, no less doubtful of success, proceeded because “it was our duty to take precautions in this direction.”
His historic Havana campaign commenced in February 1901. The year before, there had been 1,400 known cases of yellow fever in the city. In 1901 there were 37 cases. But starting in October 1901 there were none. “For the first time since English occupation in 1762,” Gorgas wrote to Ronald Ross, “we have an October free from yellow fever, and malaria decreased more than one half.” In 1902 there was no yellow fever at all and deaths from malaria totaled 77, in contrast to 325 in 1900.
The techniques developed at Havana were what Gorgas intended to use on the Isthmus. However, as he had explained to Surgeon General Sternberg, there were considerable differences between the task at Havana and what had to be faced in a place such as Panama. Sternberg had been one of those in Washington who so badly underestimated the problems of disease when fi
ghting the Cuban war. But he had also been responsible, at the war’s end, for establishing the Yellow Fever Commission. He was one of the very few to appreciate the vast significance of what Gorgas achieved at Havana, and it was he who decided that Gorgas must become the Army’s man on tropical disease. In particular, Gorgas was to prepare himself for a role in building the interoceanic canal, which both men had then assumed would be in Nicaragua. In 1902 Gorgas was sent to attend a world conference on tropical medicine at Cairo and to inspect the work being done on malaria at the Suez Canal according to precepts laid down by Ross. With Sternberg’s blessing, Gorgas also spent several months in Paris going over the medical reports and records on file at the offices of the Compagnie Nouvelle in an effort to determine as nearly as possible what the French experience had been at Panama. But Sternberg had since retired from active duty; it was John G. Walker to whom Gorgas had now to address his explanations and upon whom he became dependent for support.
II
Before leaving for Panama, Gorgas made an ardent appeal for proper supplies and sufficient experienced personnel to carry out his program. The commission deliberated and decided that for the time being considerably fewer personnel would suffice than what he had in mind and that the question of supplies required further study. So the advance party that landed at Colón in June 1904 consisted of a mere seven men, including Dr. Carter and one woman, an English nurse named Eugenie Hibbard, and they were forced to begin their campaign without benefit of even such essential supplies as wire screening and disinfectants. “It is hardly an exaggeration to say . . . when they landed at Panama to engage in the mighty task of ridding this jungle of disease, [they] had little more than their own hands and their own determined spirit to work with,” Marie Gorgas would recall.
The whole of the Isthmus, they found, was a “mosquito paradise.” The temperature, scarcely changing the year around, allowed constant breeding of the insects. A first inspection of Panama City revealed an abundance of Stegomyia in practically every building. Anopheles were still more numerous. By local custom, household drinking water was kept indoors in red earthenware jars, tinajas, within which Stegomyia larvae abounded. Mosquito larvae, or “wrigglers,” swarmed in the open cisterns and rain barrels beside nearly every building. It was the rainy season and innumerable pockets of water, perfect for mosquito breeding, collected everywhere–in large quantities along the old French diggings, in small quantities in the impressions left where railroad ties had been pulled up or in the hoofprints of cattle that grazed in an open field on Ancon Hill.
At Ancon Hospital, where Gorgas established his headquarters, there were no screens in the windows; plants in the surrounding gardens created by the French were still protected from umbrella ants by crockery rings filled with water. In the wards it was still the practice to set the legs of the beds in shallow pans of water. There was no yellow fever among the few patients in the wards, only malaria; but most of the hospital’s small staff–French Sisters of Charity, two French doctors, one priest–were also infected with malaria. After dark the mosquitoes were so thick in the wards that work had to be done in relays, one set of doctors or nurses using fans to protect those working. A nurse named Jessie Murdock, who arrived in July with a small contingent of American nurses, would tell how during night duty they wrapped themselves in bandages soaked in citronella.
At Havana the task had been confined to a comparatively small area and the success with malaria had been largely a side effect of the main campaign: the assault on Stegomyia had simply resulted in the destruction of most Anopheles as well. But Stegomyia and Anopheles are quite different creatures, just as yellow fever and malaria are quite different diseases, and here, at Panama, there was not one city but two, and fifty miles of jungle between. It was by considering the mosquitoes as predators more deadly than the most savage beasts of the jungle that Gorgas intended to solve the problem. Only by understanding the exact nature of the particular mosquitoes in question–their reproductive processes, feeding habits, flight range, and so forth–could he hope to destroy them.
Until the Cuban war comparatively little had been known about mosquitoes. It was not until 1895, for example, that a full account was published of even the common North American variety. The general impression was that all mosquitoes were more or less alike. At the time Reed and his co-workers identified Stegomyia as data as the yellow-fever mosquito, no studies had ever been made of the insect’s natural life history. So this too had been part of Gorgas’ task at Havana and consequently he and his associates had discovered astonishing peculiarities that were of enormous value.
Seen under the microscope, Stegomyia is a creature of striking beauty. Its general color is dark gray, but the thorax is marked with a silvery-white lyre-shaped pattern; the abdomen is banded with silvery-white stripes and the six-jointed legs are striped alternately with black and pure white. Among mosquitoes Stegomyia is the height of elegance.
Stegomyia is also, like the rat, a creature of human society. It survives by maintaining a close proximity to human beings. As among all mosquitoes it is only the female that bites–that is, only the female feeds on blood, while the male gets by on other liquids such as fruit juices and is quite harmless. For the female, blood is essential to mature her eggs. Though the female Stegomyia can feed on any warm-blooded animal, her decided preference is for human blood, and thus the whole life cycle of the insect must be maintained in close association with human society.
While all mosquitoes lay their eggs in water, the yellow-fever mos-quito is extremely particular about where the water is located and its condition. The female Stegomyia will deposit her eggs only in or near a building occupied by human beings and only in water held in some sort of artificial container such as an earthenware jar or a rain barrel. In addition, it is essential that the water be clean.
With such information available, all acquired during the work at Havana, the problem of destroying the yellow-fever carrier became infinitely more manageable. “Men who achieve greatness,” the brothers Mayo were to write in an essay about Gorgas, “do not work more complexly than the average man, but more simply. . . . In dealing with complex problems, with the simplicity natural to him he went directly to the point, unaffected by the confusion of details in which a smaller man would have lost himself.” At Havana the hopeless task of destroying all mosquitoes was reduced to destroying a particular mos-quito; then, once the natural peculiarities of that species were recognized, it was possible to reduce the task further still. The campaign would center on the insect’s method of propagation. The task, very simply, was to eliminate every possible opportunity for the female Stegomyia to deposit her eggs. Yellow fever was eradicated chiefly by ridding the city of all standing fresh water, or by sealing it off with wire screening or wooden lids, or with a skim of oil or kerosene, an idea first suggested for mosquito control in 1892 by the entomologist Leland O. Howard. (The oil not only discouraged the mosquito from depositing her eggs, but killed any larvae already in the water, since the larvae require air to survive.)
Thousands of adult mosquitoes had been destroyed in Havana by systematic fumigation of houses wherein yellow-fever cases had been found. Doors and windows had been sealed off with newspaper, room by room, and pans full of sulphur or powdered pyrethrum (a dried flower used as an insecticide) had been burned for an hour or more. But the main attack had been on water jars, barrels, cisterns, any stray bucket, tin can, or broken dish in which rainwater might collect. A card file had been made on every house and building within city limits; the city had been divided into sections and inspectors had been sent out daily to report on the Stegomyia-producing status of households within their districts. Water kept indoors for household use had to be covered. It had been a laborious, often thankless task, yet extremely simple in concept, and the results had been amazingly rapid.
The female Stegomyia lays anywhere from 35 to 120 minute black eggs and the maturation cycle from egg to larva to pupa to mosquito takes less than ten
days. So with the campaign fully organized and in effect, Havana’s Stegomyia population diminished quite suddenly. Adult mosquitoes died off, of fumigation or of old age, after three or four weeks, and because Stegomyia has an extremely limited flight range (another crucial characteristic discovered by Gorgas and his people), few replacements migrated into the city from outlying villages. It was thus that victory over yellow fever had come so quickly and decisively.
Anopheles, the malaria mosquitoes, were quite different creatures and thus a wholly different kind of problem. Anopheles, to begin with, are not purely house-bred insects. The female, unlike her Stegomyia counterpart, will deposit her eggs in still water of any kind–any stagnant swamp, marsh, any clogged drain or ditch or mud puddle. Anopheles, therefore, are as much creatures of field or jungle as of the backyard. So while Stegomyia mosquitoes were always readily within range, their breeding grounds closely, neatly defined, Anopheles were literally everywhere, and in fantastic numbers, since the female deposits as many as two hundred eggs every ten days.
The sanitary measures taken at Havana–the clearing away of garbage and refuse, the installation of proper drainage systems plus the campaign on Stegomyia’s breeding grounds had had the effect of giving no mosquito, Anopheles included, much chance to propagate within the city limits. But what chance would there be at Colón with its swamps or along the canal line?
Malaria, not yellow fever, Gorgas stressed to his associates, was the problem upon which their success would ride or fall. Malaria, he emphasized, had accounted for the greatest loss of life during the French years. “If we can control malaria, I feel very little anxiety about other diseases. If we do not control malaria our mortality is going to be heavy.” Knowledge of the kind gathered at Havana on Stegomyia would now have to be gathered on Anopheles.
David McCullough Library E-book Box Set Page 377