of special symptoms is not a hopeless problem. The old-fashioned remedies do relieve cough, and even nightsweats and hemorrhage may often be benefited by simple vinegar sponge-baths or an attempt to repair demineralization by calcium salts. . . . Finally, since in this malady pyschotherapy plays so important a part, above all, confidence must be established between the patient and the physician, and the patient's own interest in curative measures must be awakened. . . . The patients must be made to feel that something is being done for them, or we will fail entirely in holding their interest and attendance."

Tuberculin: Tuberculin therapy in order to attain any degree of efficiency must be controlled by the temperature reaction and the clinical manifestations of the patient. As it is applicable only in selected cases and should only be given by an experien ed practitioner who is able to maintain the closest supervision over his cases, its value in dispensary work is questionable.

This in brief is what we should be prepared to do for the "at home" case. Those cases who refuse to observe sanitary precautions should be complained of and their commitment to a hospital obtained. Children who are exposed should, if possible, be sent to a Preventorium, or an attempt made to have them cared for outside of the home.

TROPICAL SANITATION IN ITS RELATION TO GENERAL SANITATION*

W. C. GORGAS, M. D.

Surgeon General, U. S. Army

For the last three or four hundred years it has been known by Europeans that military expeditions involving any large bodies of white troops could not be undertaken in the tropics on account of the great loss from disease. In the many cases in which such campaigns had been undertaken, they had failed on ac ount of the loss of life caused by, and the disability due to, tropical diseases. These tropical diseases in the western hemisphere, were chiefly yellow fever and malarial fever. It is astounding to the military sanitarian of the present day to read of the losses caused by yellow fever to military expeditions in the West Indies. One can hardly believe the loss reported as possible. The English army in the Windward Island in 1794 under Sir Charles Grey, out of a total strength of 12,000 men lost 6,000. The French army in San Domingo in 1798, out of a total strength of 25,000 lost over 22,000

Address delivered at the fifteenth Annual Conference of Health Officers of New York State at Rochester, September 6, 1915

from yellow fever. Again in 1802 the French army in San Domingo, out of a total strength of 40,000 lost 20,000.

During the nineteenth century the United States was so frequently ravaged by epidemics of yellow fever, and such great loss of life and loss of wealth was thereby brought about, that the people were willing to go to great expense or submit to drastic measures for the purpose of getting protection therefrom. It was very evident to sanitarians who had given any study to the matter, that the epidemics which affected the United States were imported from the endemic focus, which had existed at Havana, Cuba, for the preceding one hundred and fifty years. The United States was, therefore, very anxious to get rid of Havana as an endemic focus.

When we came into possession of this city in 1898, as a result of the Spanish-American war, every endeavor was made by the authorities to eradicate yellow fever. The whole attention and force of the government was centered upon the effort to clean up the city. Yellow fever was then believed to be the best example of a disease caused by filth. In 1900, two years after our occupation, Havana was one of the cleanest cities in the world. But yellow fever was worse than it had been for several years. At this time I was the health officer of the city under the Military Governor. The authorities were at their wits' ends and knew not what to try. The Cubans were very much inclined to poke fun at us and at our extraordinary ideas on the subject of sanitation.

A distinguished physician of Havana, Dr. Carlos Finlay, had been maintaining for the previous twenty years, that yellow fever was conveyed from man to man by a certain species of mosquito, the Aedes. From the known facts with regard to yellow fever and from the life history of this species of mosquito, Dr. Finlay had reached this conclusion by a most logical and interesting argument. Dr. Finlay has died in Havana within the last month at the ripe old age of 82. He is one of the greatest men in medicine who lived long enough to see his work recognized.

They

The army board, consisting of Reed, Lazear, Carroll and Agramonte, took up in 1900 the investigation of the question of the transmission of yellow fever by the mosquito. They carried to conclusion one of the most mathematical demonstrations ever accomplished in medicine. placed men out in the country near Havana, so guarded that it was impossible for them to contract yellow fever from their surroundings. They then took the female Aedes mosquito, allowed her to sting men sick with yellow fever, and then bite the men in this camp. The men bitten developed yellow fever. The investigators then took material soiled by yellow fever patients in every possible manner and had men sleep

in rooms filled with this material for weeks at a time. No one contracted yellow fever in this way. This board, as the result of their labors, published the following very important conclusions:

That yellow fever is conveyed from man to man by the bite of the female Aedes mosquito, and, in nature, is probably conveyed in no other way, and that the disease is not conveyed by fomites of any kind.

The sanitary department of Havana took these important announcements of this board, and worked out the measures whereby they might be made of practicable effect in our fight against yellow fever. We established a quarantine whereby all infected ships or persons coming into the harbor of Havana were cared for; and a system of inspection whereby all such persons coming in by land were looked after. A yellow fever patient was so screened and cared for that the Aedes could not bite him. The attempt was made to kill by fumigating all mosquitoes that might have become infected from each case. And, finally, the attempt was made to destroy all mosquito larvae breeding anywhere within the city limits.

In the long run we found the destruction of the larvae to be of more importance than all the other measures put together.

We commenced our anti-mosquito work at Havana in February, 1901. The last case of yellow fever in the city occurred in September of the same year. Havana had been the great endemic focus of yellow fever for all the northern hemisphere during the preceding one hundred and fifty years. Since the extinction of yellow fever in Havana fourteen years ago, this disease has practically disappeared from the northern hemisphere.

In 1898 Sir Ronald Ross of the English army had demonstrated that malaria was conveyed from man to man by another species of mosquito, the Anopheles. He, and other workers, had established much the same condition as to the transfer of malaria that I have just described with regard to yellow fever. It was evident to the sanitary authorities, therefore, that a very slight extension of the work against yellow fever ought to cover work against malaria. This has turned out to be the case. Malaria rapidly decreased with the inauguration of the anti-mosquito work and has since become practically extinct.

In 1904 our government undertook the construction of the Panama canal. On account of the success of the work at Havana, I was placed in charge of sanitation at Panama. For a period in 1905, when yellow fever was at its height, we found ourselves working among a panicstricken population who believed that we were cranks and fools. Our superiors on the Isthmus at this time had become affected by the prevailing panic and were reporting to the authorities at Washington that

our work had failed and were asking that we be relieved, and that men more practical and sane replace us.

This report would have ended sanitary work at Panama along the lines of modern tropical sanitation had it been acted upon.

For the two years succeeding this time we were given the loyal support of our superiors and by the middle of 1907 the work was accomplished. The request for our dismissal was made by the Commission in June, 1905. In September, 1905, the last case of yellow fever occurred in the city of Panama, and only one case has occurred in the Republic of Panama since that time. All health conditions rapidly improved; and soon the Isthmus, as to health, compared favorably with many parts of the United States.

The eradication of yellow fever and the control of certain other maladies was undoubtedly due to the special sanitary measures taken against these diseases. But these special measures could have had no effect upon general health conditions. For the last fifteen years I have given a great deal of thought to this matter. What did we do at Havana and Panama to cause the great general improvement in health conditions which took place shortly after our arrival at both places, and has since continued?

At Panama shortly after our arrival we increased the wages of the common laborers from eleven cents an hour to twenty cents an hour. This was nearly four times the wages of the laborer in the surrounding countries. The laborer knew that every fourth man would die each year of diseases prevalent on the Isthmus and it took strong inducements to get him to come at all.

This large increase in wages caused a great general improvement in all living conditions,― more room to live in, better food, and better clothing. I am satisfied that to this improvement in social conditions, caused by our high wages, we principally owe our extraordinary improvement in general health conditions. It is a health officer's duty to urge forward in his community those measures which will control individual diseases, but my long experience has taught me that it is still more his duty to take that broader view of life which goes to the root of bad hygiene, and do what he can to elevate the general social conditions of his community. This, my experience has taught me, can best be accomplished by increasing wages. Such measures tend at the same time to alleviate the poverty, misery and suffering that is occurring among the poorest classes everywhere in modern communities. At Panama we increased wages by the edict of the government. But our government got this money by taxing the people of the United States. It would have been of little benefit to our laborers if we had increased their wages

by ten cents an hour and then taxed them by ten cents an hour in order to raise this money.

Such would be the result in the United States if we attempted to increase wages here by edict of the government as we did at Panama; and such an increase would be of no benefit to the laborer.

Natural, just and proper wages are what each man produces, not a cent more or a cent less. We can look back in the history of our own country and see that this condition of affairs was approximated in the early settlement of the country. A man coming to this country would take up land for which he paid nothing, and his wages were all he produced on that land. After a while all the land is taken up and the next man who comes has to work for someone else. Later a great many more men come, and these men bid against each other for work, and thus force down wages. This has gone on in the United States, and in all other civilized countries, till at the present time all producers get much less than natural wages, that is, less than what they produce. Can this unfortunate and undesirable condition of wages be rectified?

Suppose an area of land as great in extent, and as fertile in production as the present Mississippi valley, should to-morrow rise from the bottom of the Atlantic ocean off the coast of Long Island. Suppose the United States should own this island and offer it to its citizens under our present homestead laws. Thousands of the citizens of New York would flock there and take up this land. Their wages would be natural wages. Each man would get all that he produced; this would be very much in excess of the wages now given in New York. All the poverty, sickness and degradation caused at present by low wages would be rapidly ameliorated. The man who was so fortunate as to be appointed health officer for this island would in a few years be able to publish the most astounding health reports.

It is entirely possible for us to raise from the bottom of the sea just such an island as I have described. In every town and county of New York a large part of the lands are unused or only partially used. If this large body of unused land could be brought into use, the effect upon the health conditions of New York would be exactly the same as would be produced by raising the island I have described.

Can these unused lands be brought into use? If these unused lands were taxed to such an extent that the owners would have to use them to the fullest extent in order that they might pay the taxes, is there any doubt as to what the result would be? All unused lands would soon be utilized to their fullest extent. The only way of making any profit from them would be to so use them.

I have been fortunate enough to labor as health officer in a field