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SANITATION IN PANAMA
[Illustration: Concreted Ditch. Ancon.]
SANITATION
IN PANAMA
BY
WILLIAM CRAWFORD GORGAS
CHIEF SANITARY OFFICER, PANAMA CANAL, SURGEON GENERAL, U. S. A.,
MAJOR GENERAL, U. S. A.
[Illustration: Decoration]
ILLUSTRATED
NEW YORK AND LONDON
D. APPLETON AND COMPANY
1915
COPYRIGHT, 1915, BY
D. APPLETON AND COMPANY
Printed in the United States of America
CONTENTS
CHAPTER PAGE
I. YELLOW FEVER AND THE DISCOVERIES OF ITS TRANSMISSION 1
II. THE EXPERIMENTS OF THE REED BOARD 18
III. THE DISCOVERIES OF THE REED BOARD 32
IV. THE SANITARY BOARD OF HAVANA 40
V. SANITARY WORK AT HAVANA 50
VI. THE RESULTS ACCOMPLISHED IN HAVANA 63
VII. CORRESPONDENCE WITH DR. REED 77
VIII. HISTORY OF YELLOW FEVER 110
IX. GEOGRAPHICAL LIMITS OF YELLOW FEVER 124
X. APPOINTED CHIEF SANITARY OFFICER FOR THE ISTHMUS 138
XI. PRELIMINARY ORGANIZATION AND WORK AT PANAMA 148
XII. YELLOW-FEVER WORK AT THE ISTHMUS 159
XIII. NOMBRE DE DIOS 175
XIV. THE WORK OF THE SANITARY INSPECTORS 182
XV. THE WORK AT THE HOSPITALS 206
XVI. MALARIA WORK AND THE HOSPITAL SYSTEM 219
XVII. MEDICAL AND SURGICAL SERVICE OF ANCON HOSPITAL 241
XVIII. THE SANITARIUM AT TABOGA 248
XIX. THE LEPER COLONY 256
XX. QUARANTINE SYSTEM 260
XXI. MEASURES AGAINST BUBONIC PLAGUE 275
XXII. THE WORK OF THE SANITARY DEPARTMENT OF PANAMA 279
INDEX 293
LIST OF ILLUSTRATIONS
FACING
PAGE
Concreted Ditch. Ancon _Frontispiece_
Map of the Panama Canal Zone, Showing Hospitals
of the Sanitary Department 1
Stegomyia Squad. Havana 52
Screened Water Barrel. Havana 52
Concreted Ditch. Gatun 112
Screened Yellow-fever Ward. Ancon Hospital, Panama 150
St. Charles Ward, Ancon Hospital. Building in
Which Twelve Hundred Frenchmen Died of Yellow Fever 150
Oilers at Work in Marsh 184
Burning Out Ditch with Oil Spray 184
Old French Engine Tender Used as Storage Tank for Oil 194
Mule for Packing Oil to Oilers 194
Distilled Water Cart. Culebra 220
Ward at Ancon Hospital 220
Stoned Ditch near Tivoli Hotel. Ancon, Panama 234
Bad Anopheles Breeding-ground on Artificial Fill. La Boca 234
[Illustration: Map of the Panama Canal Zone, Showing Hospitals of the
Sanitary Department.]
SANITATION IN PANAMA
CHAPTER I
YELLOW FEVER AND THE DISCOVERIES OF ITS TRANSMISSION
Yellow fever for two hundred years before the Spanish-American War
caused great loss of life and much destruction of wealth. Every
few years portions of the United States would become infected with
this disease. In the earlier part of this period the disease was
more or less local. As the Mississippi valley became more thickly
populated, the extent of the disease and the injury caused became
very much augmented. The epidemic of 1878 was probably the deadliest
and most extensive epidemic of yellow fever which ever affected the
United States. In this epidemic over thirteen thousand people in the
Mississippi valley alone lost their lives, and the loss of wealth is
estimated at considerably more than one hundred millions of dollars.
It is very difficult to convey to a reader any idea of the conditions
which exist during an epidemic of yellow fever. All business is
entirely paralyzed, the quarantines not allowing any communication
between the affected districts and those not affected. In an epidemic
of any extent this means hundreds of local quarantines. Some idea
of the condition of affairs can be obtained by picturing what would
occur in any community if all the income of that community should
entirely cease for six months. And this was the condition of business
all over the Mississippi valley every time yellow fever gained
entrance.
The population originally feared yellow fever on account of the
poverty, suffering and business depression always caused by the
quarantines which had to be enforced to prevent its spread, and in
time people came to associate this idea of dread with yellow fever
itself. When this disease was announced in a town, everybody left who
could. The sick were frequently left without care, and often a great
deal of cruelty and cowardice was shown. If a person escaped from
an infected region and became sick with the disease, or sick from
any other cause, he was generally treated as if he were a leper, and
would often be left to starve or die on the roadside.
It requires continuously warm weather for the yellow-fever mosquito
to breed in sufficient numbers to propagate yellow fever; therefore,
this disease never became endemic in the United States. I mean by
endemic, existing all the year round and over a number of years.
The frosts of winter, wherever they occur, either destroy all the
yellow-fever mosquitoes, or reduce their number below the point at
which yellow fever could be propagated.
It was known in the United States that yellow fever was always
brought somewhere from the littoral of either the Gulf of Mexico, or
the Caribbean Sea, and the city of Havana, located on the northern
coast of the island of Cuba, was known to be the center of this
endemic area.
Yellow fever in 1898 was looked upon as the example of a filth
disease, par excellence, and it was thought that if Havana were put
in a proper state of cleanliness, it might cease to be the great
point of infection for the United States. It was known that yellow
fever had existed in the city of Havana continuously for one hundred
and fifty years. It is interesting to note that the endemic infection
of Havana occurred in 1762, when Havana was besieged and captured by
American troops. I say American troops, because the expedition was
largely composed of men from the present United States, then colonies
of Great Britain. It is also interesting to note that this infection
was supposed to have been brought by a vessel from Vera Cruz.
Yellow fever peculiarly affects shipping, and time and again ships
in the harbor of Havana have had every living soul of their crew
die from this disease, and these vessels would have to lie there for
months until another crew could be obtained.
When we went to Havana in 1898 we knew no more of the sanitation of
yellow fever than we had known a century before. The army which went
to Santiago suffered as severely from yellow fever and other tropical
diseases as any military expedition into the tropics had suffered
before that time, and its death rate, had it remained, would have
been just as high as was that of the French army of similar size,
which was exterminated in the island of Haiti just one hundred years
before.
A very deep impression was made upon me by the condition of our army
at the end of two months’ campaigning in this tropical region. It
was utterly used up and of no value whatever as a fighting machine.
Fully four-fifths of the men were having fever. This small army of
sixteen thousand men was as fine a body of soldiers when they landed
at Siboney as could probably be gotten together, but after two
months’ campaigning in this tropical jungle, and after several weeks
of fever from which no one was free, their stamina and morale were
completely gone. After the surrender of the Spanish garrison there
was a complete let-down on our side. Everybody wanted to go home.
No one could see any need of staying in Cuba, and every individual
was perfectly certain that he would die if he remained there a month
longer. Officers and men became nervous and hysterical. I commanded
the base hospital at Siboney, and it was my disagreeable duty to
select from day to day those who would have to remain. Many times
every day the poor fellows, officers and men, would break down and
cry when told that they could not leave on the next ship. I could
form some idea of what it must have been among the French at Haiti
when they knew that they could not get away, but had to stay and die.
Being immune to yellow fever, I made application to go with
the troops that took possession of Havana. We arrived there in
December, 1898. The military authorities concluded that this was the
opportunity which the United States had been awaiting for the past
two hundred years. Thinking that yellow fever was a filth disease,
they believed that if we could get Havana clean enough, we could free
it from yellow fever. It was felt that if we could eliminate Havana
as a focus of infection, the United States would cease to be subject
to epidemics. This meant so much to the United States, financially
and otherwise, that the authorities determined to make all other
efforts secondary to this sanitary effort.
The city was cleaned as well as it was possible to cleanse it. This
remark applies as well to the private premises as to the public
highways. Energetic and capable Army officers were placed at the
head of various municipal departments, and these departments were
thoroughly organized and made as efficient as possible. By the
middle of the year 1900 all the city governments were perfectly
organized, and were accomplishing all that it was possible for them
to accomplish. I believe that Havana was cleaner than any other city
had ever been up to that time.
The health regulations of the Sanitary Department, such as the
isolation and care of yellow-fever patients, were thoroughly and
carefully carried out. But in spite of all this work and care,
yellow fever had been steadily growing worse ever since we had taken
possession of the city, and in 1900 there were a greater number of
cases than there had been for several years. The Cubans twitted us
with the fact that all our cleaning up and expenditure not only
had not bettered things, but had even made them worse. They called
attention to the fact that the very cleanest and best kept portions
of the city were by far the worst sufferers from yellow fever,
and the evidence was so staringly before our eyes that we had to
acknowledge the truth of what they said.
The health authorities were at their wits’ end. We evidently could
not get rid of Havana as a focus of infection by any method we then
knew.
A few years before this period, an Italian savant had announced in
Brazil that he had discovered the organism which caused yellow fever.
This organism was known as the bacillus icteroides of Sanarelli, and
it was quite generally accepted that Sanarelli had proved this to be
the causative agent in yellow fever.
Drs. Reed and Carroll had proved that the bacillus icteroides of
Sanarelli was identical with the hog-cholera bacillus. They made this
demonstration while comparing the bacillus X of Sternberg with the
bacillus icteroides of Sanarelli. The work was carried on by them
during the years 1897 and 1898, at the laboratory of the Army Medical
Museum in Washington. The investigation was undertaken at the request
of General Sternberg.
In 1899 our Public Health Service published the report of a board
of medical officers who had been sent to Havana to investigate
Sanarelli’s organism. This report made a great impression.
Surgeon-General Wyman, in his letter transmitting the report says:
The findings of this Commission, verifying the discovery made by
Sanarelli, and making still further advances than did Sanarelli
himself by determining the specificity of the bacillus icteroides,
and that the primary infection of yellow fever is received through
the respiratory tract, in other words, verifying one discovery
and making others of almost equal importance, at the same time
eliminating incorrect theories, must be considered a notable
achievement in medical science and one of the greatest practical
value to the people of the United States and other countries
infected, or liable to be infected by yellow fever.
* * * * *
In view of the widespread interest which the report will excite and
the practical deductions to be drawn therefrom, I have respectfully
to request authority to have the same printed.
The findings of this Commission were:
First. That the microörganism discovered by Professor Giuseppi
Sanarelli, of the University of Bologna, Italy, and by him named
“bacillus icteroides” is the cause of yellow fever.
Second. That yellow fever is naturally infectious to certain
animals, the degree varying with the species; that in some of the
rodents local infection is very quickly followed by blood infection,
and that, while in dogs and rabbits there is no evidence of this
subsequent invasion of the blood, monkeys react to the infection the
same as man.
Third. That infection takes place by way of the respiratory tract,
the primary colonization in this tract giving rise to the earlier
manifestations of the disease.
Fourth. That in many cases, probably a majority, the primary
infection, or colonization, in the lungs is followed by a “secondary
infection,” or a secondary colonization in the blood of the patient.
This secondary infection may be complicated by the coinstantaneous
passage of other organisms into the blood, or this complication may
arise during the last hours of life.
Fifth. There is no evidence to support the theory advanced by
Professor Sanarelli that this disease is primarily a septicemia,
inasmuch as cases do occur in which the bacillus icteroides cannot
be found in the blood, or organs in which it might be deposited
therefrom.
Sixth. That there exists no casual relationship between the bacillus
X of Sternberg and this highly infectious disease; and that this
bacillus X is frequently found in the intestinal contents of normal
animals and of man, as well as in the urine and the bronchial
secretion.
Seventh. That, so far as your Commission is aware, the bacillus
icteroides has never been found in any body other than of one
infected with yellow fever; and that whatever may be the cultural
similarities between this and other microörganisms, it is
characterized by a specificity which is distinctive.
Eighth. That the bacillus icteroides is very susceptible to the
influences injurious to bacterial life, and that its ready control
by the processes of disinfection, chemical and mechanical, is assured.
Ninth. That the bacillus icteroides produces in vitro as well as in
vita a train of the most marked potency; and that, from our present
knowledge, there exists a reasonable possibility of the ultimate
production of an antiserum more potent than that of Professor
Sanarelli.
About the same time an officer of the Public Health Service, Dr. H.
R. Carter, was making in Mississippi his epoch-marking observations
upon the extrinsic incubation of yellow fever. Measured by the
results produced, this was one of the most important papers ever
written. Yet as high an authority as the Surgeon-General of the
Public Health Service expected the greatest results to flow from the
conclusions reached by this Board, and did not notice the report from
his subordinate concerning the extrinsic incubation of yellow fever.
The conclusions of his Board turned out to be all wrong and useless
as to results. The report of Carter turned out to be pure gold, and
was one of the great steps in establishing the true method of the
transmission of yellow fever. I do not say this in criticism. It
is almost impossible for contemporaries to judge the true value of
discoveries, or to give the proper position to the men of their own
time who make these discoveries.
General George M. Sternberg, the then Surgeon-General of the Army,
was one of the leading bacteriologists of the profession, and was
also one of the best known authorities on yellow fever. He doubted
the findings of this Board, and obtained authority from the Secretary
of War to appoint a board of Army medical officers to investigate
this same subject. He appointed on this now famous and immortal board
Reed, Lazear, Carroll and Agramonte. They came to Havana, and spent
several months in investigating Sanarelli’s organism. They proved
beyond peradventure that it had no causative relation to yellow
fever, and identified it as a well-recognized organism.
It is an interesting historical fact that one of the yellow-fever
patients in whom the Board of Public Health Service found Sanarelli’s
organism was a patient of mine. He was a soldier, Private Patrick
Smith, Eighth Infantry, a non-immune living in an infected part of
Havana, so that I thought that he ought to be reported as a suspect.
The case continued nine days, long enough to convince me clinically
that the disease was not yellow fever. The symptoms in a case of
yellow fever dying on the ninth day are always so well marked that
the diagnosis should not be in doubt. But the Board found Sanarelli’s
organism, and being themselves convinced that this was the organism
of yellow fever, they believed the case to be that disease. It shows
the necessity in scientific matters of being on one’s guard, and of
approaching investigation with an open mind.
The Army Board having satisfied themselves that Sanarelli’s organism
bore no relation to yellow fever, but was simply the ordinary
hog-cholera bacillus, turned their attention to other matters, though
they were always working in relation to yellow fever. They spent a
great deal of time in examining the intestinal flora in cases of
recognized yellow fever, but could find nothing that seemed to have
any relation to this disease in a causative sense.
Being at that time the health officer of the city of Havana, and
in that capacity having charge of all cases of yellow fever which
occurred in the city. I necessarily came in contact with this Board
a great deal, and with its various members. I was naturally much
interested in the work, and kept in very close touch with it. The
Sanitary Department of Havana had a commission of medical men to
whom all cases of yellow fever were referred for diagnosis. I was
a member of this Commission, and Dr. Carlos Finlay, Dr. Antonio
Albertini and Dr. John Guiteras were the other members. Each of us
had had a very large practical experience with yellow fever. It
is likely, therefore, that our Commission was as accurate in its
diagnosis of this disease as it was possible for fallible doctors
to be. Most of Dr. Reed’s experimental cases were seen and passed
upon by this Commission. Dr. Reed requested us to do so, in order
that the diagnosis of his cases might be upon the same footing as the
diagnosis of the other cases occurring in the city of Havana.
Dr. Carlos Finlay, of Havana, the physician just mentioned as being
a member of our Commission, had ever since the year 1881 been
investigating, thinking of and writing about the relation of the
mosquito to yellow fever. He had convinced himself that this insect
was the means whereby the disease was conveyed from person to person.
Others before Dr. Finlay’s time had referred to the possibility of
this being the case, notably Dr. J. C. Nott, of Mobile, Alabama.
In March, 1848, he published in the _New Orleans Medical Journal_
an article in which he maintained that the spread of yellow fever
could not be explained by the assumption of a diffusible miasm in
the atmosphere. But Dr. Finlay had given more attention to this
subject than anyone who had gone before him. He had written upon it
constantly from the year 1881. His argument from the then known facts
with regard to yellow fever, showing from these facts that it was
probably the mosquito that conveyed this disease, was most beautiful
and logical. But a still more beautiful piece of reasoning was the
induction that it was the stegomyia mosquito, out of the six or
seven hundred species of mosquitoes, that conveyed yellow fever.
Dr. Finlay, in the twenty years before we went to Havana, had done
a great deal of experimenting on the human subject with regard to
yellow fever. But he had not been successful in transmitting the
disease. He had no means of knowing that it took the mosquito twelve
days from the time when she swallowed the blood of a yellow-fever
patient to become herself infectious. Not knowing this fact, it was
perfectly natural for Dr. Finlay to use his mosquitoes upon his
experimental cases within the first four or five days after they had
bitten a yellow-fever patient. At any rate, in a large number of
experimental bitings of the human subject he did not have a single
case in which the evidence was conclusive that yellow fever had been
conveyed by the mosquito. Reed says of Finlay: “To Dr. Carlos Finlay,
of Havana, must be given, however, full credit for the theory of
the propagation of yellow fever by means of the mosquito, which he
proposed in a paper read before the Royal Academy in that city at its
session on the 14th day of August, 1881.”
The Reed Board, after many months of inconclusive work in other
directions, turned their attention to Dr. Finlay’s mosquito theory.
Dr. Reed discussed the matter with Dr. Finlay a good deal before he
commenced his mosquito work, and was thoroughly familiar with Dr.
Finlay’s arguments and ideas on the subject. Indeed, we all knew Dr.
Finlay well, but were rather inclined to make light of his ideas,
and none more so than I. He and I met every day on the yellow-fever
Commission above referred to, and it is probable that every day for
more than a year we had more or less discussion on this subject.
Dr. Finlay is a most lovable man in character and personality, and no
one could be constantly thrown with him as I was daily for several
years without becoming warmly attached to him and forming the highest
estimate of his scientific honesty and straightforwardness. Being
very familiar with yellow fever, both historically and clinically,
I was constantly bringing to his notice instances in the past which
could not be accounted for on the mosquito theory. He, with the
greatest ingenuity, was equally ready to explain how the mosquito
theory could be turned so as to meet just this condition.
Dr. Finlay is still living in retirement and comfortable old age in
the city of Havana. When the American forces were withdrawn from
Cuba in 1902, Dr. Finlay succeeded me as health officer under the
Cuban Government. He has since been retired on a pension by that
Government. I called on him in Havana several years ago, and found
him enjoying his more than eighty years of age, and the honors that
were being heaped upon him. He is one of the few great men who has
had his work recognized during his lifetime.
Dr. Reed got from Dr. Finlay the eggs from which he raised the
mosquitoes used in his experimental work. Dr. Finlay says on page
1 of his “Agreement between the History of Yellow Fever and Its
Transmission by the Culex Mosquito”: “The experiments made by Drs.
Reed, Carroll, Agramonte and Lazear were started in June, 1900,
with a brood hatched from eggs of the identical insect which at Dr.
Lazear’s request I had handed to him. All the successful experiments
have hitherto been made with that particular mosquito.”
Dr. Reed says in his paper, “The Etiology of Yellow Fever,
Preliminary Note”: “We here desire to express our sincere thanks
to Dr. Finlay who accorded us a most courteous interview and has
gladly placed at our disposal his several publications relating to
yellow fever, during the past nineteen years; and also for ova of the
species of mosquito with which he had made his several inoculations.
An important observation to be here recorded is that according to
Finlay’s statement, thirty days prior to our visit, these ova had
been deposited by a female just at the edge of the water in a small
basin, whose contents had been allowed to slightly evaporate; so that
these ova were at the time of our visit, entirely above contact with
the water. Notwithstanding this long interval after deposition, they
were promptly converted into the larval stage, after a short period,
by raising the level of the water in the basin. With the mosquitoes
thus obtained we had been able to conduct our experiments. Specimens
of this mosquito forwarded to Mr. L. O. Howard, Entomologist,
Department of Agriculture, Washington, D. C., were kindly identified
as culex fasciatus—Fabr.”