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1. The installation of a sewer system in the cities of Colon and Panama.

2. The installation of water supply in those cities.

3. The cleaning of the streets including the disposal of garbage and night soil.

4. General sanitation of houses including their fumigation and the drainage of neighboring pools, the abolition of water barrels and cisterns and other places for the propagation of the yellow fever mosquito.

5. The prompt isolation of all cases of yellow fever.

These various steps bore such a logical relation to each other that one would become practically inoperative without the other. Thus, without drainage, a water supply would only augment the evil; without both it would be impossible to abolish the cisterns and water barrels that are breeding places of the yellow-fever mosquitoes; without abolishing the breeding places of these mosquitoes, it would be useless to attempt the formation of more than demonstrably infected houses.

This view was apparently accepted by the commission, even including Mr. Grunsky, before the first visit of that body to the Isthmus, and it was likewise the view still held by Colonel Gorgas and by the entire personnel of the sanitary department, as well as by Mr. Wallace, the head of the engineering department, when, on June 28, the sanitary government was established in the canal zone. Panama was then apparently free from yellow fever, but Colonel Gorgas, with his Cuban experience, and knowing the danger that was lurking in the immediate future, set about promoting these complete measures of prevention, while Mr. Wallace addressed himself to plans and specifications for water-works and sewer system for Panama. The plans of both of these men went promptly before the commission, but it was not until that body had returned to the Isthmus, in August following, that they were given serious consideration; meanwhile, the danger of which Colonel Gorgas had forewarned them had developed; for, on July 12, Charles Cunningham was stricken with yellow fever, from which he died two days later. Fourteen days after this death another case developed, which, however, went on to recovery. When the commission arrived at Ancon on the occasion of its second visit, that is, on August 3, Colonel Gorgas again urged the prompt assumption of sanitary control over Colon and Panama, and cited the case still in the hospital, and the fatal one that had preceded it, as danger signals of sufficient gravity to justify action. But the commission, more especially Mr. Grunsky, had not yet determined the degree of humiliating subordination to which the sanitary department was to be subjected, and, under pretext of perfecting a plan of organisation, deferred action for another three and one-half weeks,—valuable weeks,—that is, until August 28. On this date the commission, on the report of Mr. Grunsky, adopted Mr. Grunsky's plan of organisation, by which, as I have already shown, Colonel Gorgas was subordinated to the seventh degree below the original source of authority. Even then, with the cases of yellow fever staring them in the face, the commission, at the instance of Mr. Grunsky, directed Colonel Gorgas, acting through Governor Davis, to refrain from any attempt to secure sanitary control over the cities of Colon and Panama, citing certain more or less diplomatic frivolities as a pretext for deferred action. It was only after four or five months had elapsed, only after the progressive development of yellow fever had reached the sensational point, and only after the personnel in the canal zone had become thoroughly alarmed over the situation, that Colonel Gorgas was permitted by those in authority over him to assume the sanitary control of the two cities, one of which, Panama, having by this time become very generally infected.

But even then his hands were tied, sometimes, and in important particulars, by the arbitrary exercise of superimposed authority, but all the time, and in still more important particulars, by the fact that the water supply and the sewage system were not installed. Mr. Wallace had drawn the plans and specifications in July previous, and had taken care to specify only such pipe as manufacturers keep in stock, and that could therefore be procured without a moment's delay. But the commission, more especially Mr. Grunsky, in total disregard of the emergency that was present, saw fit to indulge in some views about pipe, and as Mr. Grunsky is a civil engineer and needed to impress the fact on somebody, he summoned Mr. Wallace, confessedly one of the ablest engineers but now his subordinate, before the commission to explain why he had specified both eastern and western standards of pipes. The explanation given by Mr. Wallace that either one or both of these standards would answer the purpose, and that it had been simply his desire to purchase the pipe promptly, if necessary in small lots, and to get the pipe promptly on the Isthmus, seemed to make no appeal to either the commission or Mr. Grunsky, and pipe of the western pattern alone was ordered. The delay in the consideration, of this particular point consumed another precious two weeks, after which Mr. Wallace was authorised to proceed with the work. This, he undertook with his characteristic energy, and allowing for all reasonable delay in procuring the pipe and in sending it to the Isthmus, promised the people of Panama that they should have water by December. He finished the work at the Rio Grande reservoir in a short time; the trenches for the pipe were dug, washed full of dirt and redug, but still there was no pipe. Mr. Wallace then cabled to Washington, urging that pipe be sent, only, however, to receive a reprimand from Admiral Walker, chairman of the commission, admonishing him that cablegrams from the Isthmus were expensive. It is now nearly the first of March, and the schooner which brought the first consignment of pipe, not enough to complete the work at Panama, was discharging the cargo at Colon as I left. It is further understood that before the work can go on this same schooner must sail back to Mobile, await the arrival there of enough pipe to make a full cargo, then sail back to Colon and again unload-a proceeding that, at a conservative estimate, will consume at least from two to three months. And all this by a commission that controls a line of steamers plying weekly between New York and the Isthmus!

In the light of all these facts, in contrast with the brilliant results achieved by Colonel Gorgas in Havana, where he was given not only a free hand, but his own purchasing and distributing agents, the responsibility for the present existence of yellow fever on the Isthmus can be placed nowhere else than on the Isthmian Canal Commission, more especially on Mr. Grunsky.

THE CAMPAIGN AGAINST MALARIA THWARTED BY THE COMMISSION.

But sensational as is yellow fever, now apparently on the increase at the Isthmus, the fact remains that malaria is the more serious pest. The discovery that malaria is disseminated by the anopheles has, however, made it possible to minimise the disease by proper preventive methods. These embrace (a) drainage, (b) the isolation of malarial patients, (c) the prophylactic synchronism. That these three things might be done, and done before the onset of the dry season, Colonel Gorgas asked the commission last August to furnish men to dig ditches and drain pools about the houses of natives; he asked also for wire screening with which to isolate all patients afflicted with malaria, and quinin with which mildly to cinchonise laborers and others exposed to the malaria bearing mosquitoes. The commission, more especially Mr. Grunsky, however, thought that the number of ditches asked for, something like twenty, was too many, and allowed only half those estimated, but as the dry season has arrived and is almost past, and as the small squad of ditchers is still digging, it would seem that the original estimate was justified by the necessities of the situation. The wire screening was likewise cut down from 2,500 yards to 500 yards, and even that has not yet arrived on the Isthmus. The use of quinin as a preventive of infection did not commend itself either to the great therapeutic skill or to the economic judgment of the commission, more especially Mr. Grunsky, so the observation of medical men with previous experience on the Isthmus, the conclusions of authorities in tropical medicine, such as Munson and Giles, the investigations of the Italian authorities, and the unequivocal verdict of Koch, were pushed aside and quinin for this purpose was stricken from the

list.

The result is that while much has been accomplished by drainage, and by the admission of small fish into the runnels made by the small force of workmen, and while much has been accomplished by the prophylactic use of quinin by the personnel and employes of the higher grades, and taken by them in spite of the action of the commission, the fact remains that in the absence of the wire screening ordered last August, each case of malaria becomes a focus for the further dissemination of the disease. This is shown even at the Ancon Hospital, where in the complete absence of wire screening for the malarial wards and the consequent impossibility of excluding the malarial-bearing mosquitoes, non-malarious patients are becoming malarious, while both nurses and attendants are being made, frequent victims of the disease. Two members of the medical staff likewise were suffering from malarial infection during the time of my stay at Ancon. Yet in spite of these facts the Isthmian Canal Commission, in its report under date of December 1, 1904, page 88, states that “all cases of employes sick with malaria are taken into the Colon and Ancon hospitals and so screened that mosquitoes cannot reach them”— a statement that is an absolute and an unqualified falsehood.

CHEAP NURSING SERVICE. This report might be indefinitely amplified, but time will not permit. I feel it important, however, to allude to the fact that the policy which the commission, more especially Mr. Grunsky, has adopted with reference to furnishing cheap medical service to those who risk their lives in the zone has been adopted for the purpose of furnishing nurses for service in the sanitary department. The effort has been made under the subterfuge of establishing a training school to be conducted at Ancon, to get nurses to go to the zone at about the same rate that is paid for pupil nurses in the training schools of the United States. The same conditions, practically, are imposed on the nurses with reference to time service that is imposed on the internes, with the difference, however, that the period of enforced detention on the Isthmus under contract is placed at three years instead of one. This is not a place to take untrained nurses under any pretext, for nothing but fully developed talent in the various departments of activity should be sent to the Isthmus.

CONCLUSION. In view of the foregoing facts and disregarding equally serious facts relating to the department of engineering and construction, facts which the really valuable services of such individual commissioners as Messrs. Parsons and Burr could not entirely neutralise, but on which I do not feel qualified or authorised to report, I beg leave to call attention to the further observations of the President when he inducted the commission into office, as follows:

I believe that each one of you will serve not merely with entire fidelity, but with the utmost efficiency. If at any time I feel that any one of you is not rendering the best service which it is possible to procure, I shall feel called on to disregard alike my feelings, and forthwith to substitute for him on the commission some other man whom I deem capable of rendering better service.

In view of the facts which I have presented, in view of many more facts of similar purport which might be presented, in view of the President's manifest and expressed wishes and their complete disregard by the commission, but more particularly in view of the vital interests at stake, I have the honor not only to submit the suggestion, but really to urge that the time has arrived when the President ought to redeem his word and ask for the resignation of the commission. I have the honor to be, very respectfully,

CHARLES A. L. REED,
Chairman of the Legislative Committee of the

American Medical Association.

United States Civil Service Examination.

PHYSICIAN (FEMALE)-GOVERNMENT HOSPITAL FOR THE INSANE. The United States Civil Service Commission announces an, examination on April 26-27, 1905, at: Buffalo, N. Y., to secure eligibles from which to make certification to fill a vacancy in the position of physician (female) in the Government Hospital for the Insane, Washington, D. C., at $1,500 per annum and quarters, and vacancies as they may occur in any branch of the service requiring similar qualifications. Only unmarried women will be admitted to this examination.

Applications will be received from graduates of recognised medical schools. Credit will be given for experience obtained in a professional capacity in institutions for the care of mental diseases, in general hospitals, and in the actual performance of surgical operations and the care of operative cases. Two days will be required for this examination. Age limit, 25 to 40 years on the date of the examination. This examination is open to all citizens of the United States who comply with the requirements.

Applicants should at once apply either to the United States Civil Service Commission, Washington, D. C., or to the secretary of the board of examiners at Buffalo, for application form 1312. No application will be accepted unless properly executed and filed with the commission at Washington. In applying for this examination the exact title as given at the head of this announcement should be used in the application.

As examination papers are shipped direct from the commission to the places of examination, it is necessary that applications be received in ample time to arrange for the examination desired at the place indicated by the applicant. The commission will, therefore, arrange to examine any applicant whose application is received in time to permit the shipment of the necessary papers.

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