CHAPTER XX. Quarantine System

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.