MALARIA WORK AND THE HOSPITAL SYSTEM
In the early years of our construction malaria was very common and
gave a great deal of trouble. As I have explained before, malaria is
caused by a small animal parasite which lives in the blood of man
and feeds upon the red globules. The excretions of this parasite
poison man and cause the fever and other symptoms which we know as
malarial fever. This parasite is transferred from the sick man to
the well man by the bite of the mosquito. Now it is quite evident
that if in any way we can kill the parasites as they exist in man,
we not only cure the individual man of malarial fever, but at the
same time prevent his being a means of infection for other men who
have not yet acquired the disease. In a purely empirical manner,
some one hundred and fifty years ago a drug was discovered which man
could take without injury to himself, and which, when absorbed into
the circulating blood was deadly to the malarial parasite there
swimming about. It is somewhat singular that this drug should have
been discovered not very far from Panama. A Peruvian Catholic priest
found that the Indians in certain parts of Peru cured themselves of
the fevers native to that country by the use of the bark of a certain
forest tree common to that region. Its benefits were so evident that
the wife of the Captain-General of Peru became interested in the
matter, and spread about a knowledge of the virtue of this wonderful
bark, and introduced it into the mother country and other parts of
Europe. This lady was the Marchioness of Cinchona. No drug ever
discovered has been as useful to mankind as quinin, and it remains
up to the present time one of the few specifics known to the medical
profession.
Besides curing the malarial patient after he had gotten the parasite
into his blood, it was the desire of the Sanitary Department to have
the blood of all persons on the Isthmus in such condition that it
would not harbor the parasite. We believed that if everybody would
take five grains of quinin a day, this quinin would be absorbed into
the blood and render the blood so poisonous to the malarial parasite
that when the parasite was injected into the blood by the mosquito it
could not thrive and develop, but would die.
[Illustration: Distilled Water Cart. Culebra.]
[Illustration: Ward at Ancon Hospital.]
With the object of getting as many people as possible to take
quinin every day, each district physician had attached to his staff
one or more quinin dispensers. This quinin dispenser was a man
furnished with quinin in various forms, who spent the day going about
among the laborers offering them quinin. It was the endeavor of the
district physician to have each laborer once a day offered quinin.
The dispenser carried with him what was known on the Isthmus as
quinin tonic. This was a quinin solution made up so that each ounce
should contain five grains of quinin. Other ingredients were added so
as to make it attractive in smell, taste and appearance. The quinin
dispenser also carried with him quinin pills, capsules and tablets,
and the patient was allowed his choice.
The Commission ran a large number of hotels and eating-houses, where
all classes of employees were fed. Quinin tonic and quinin tablets
were placed on the tables of all these eating-houses and messes, and
an educational campaign was vigorously pushed among the employees,
with the idea of teaching them what was aimed at by taking quinin
in this way. No attempt was ever made to force anyone to take this
prophylactic quinin, but explanation and persuasion were used to
their fullest extent.
By these methods we succeeded, when the use of quinin was at its
maximum, in getting our force to take about forty thousand doses per
day. The men responded very heartily and loyally to this system
of education. I was very much gratified at the results, and feel
confident that no system of compulsion could have been as successful.
I am satisfied that during the early years of construction, before
our other anti-malarial work had produced results, this giving of
prophylactic quinin on so large a scale was of the very greatest use
to us.
Under some circumstances we required our employees to take quinin.
At Taboga, down in Panama Bay, we had a convalescent hospital where
the men were sent to spend a week or two when convalescing from the
severer forms of malarial fever. A man with malarial parasites in his
blood was a source of infection and of danger to his well companions.
With the idea of being certain to kill all the parasites in his
blood, he was required to continue large doses of quinin for a week
or ten days after the stoppage of his fever. But such is the nature
of man that as soon as you begin to force him to do a thing, from
that moment he begins to seek ways by which he can avoid doing the
thing you are trying to force upon him.
A certain number of men, when they were given their daily dose
of quinin in the dispensary, would manage to throw their tablets
out of the dispensary window. The old turkey-gobbler that was the
pet of the hospital seemed to like the stimulating effect of the
quinin and gobbled up all the tablets he could find. He became so
dissipated in this way that he finally developed quinin amblyopia.
This amblyopia is a species of blindness that is sometimes caused by
too much quinin. The doctor finally had to confine his old gobbler
and keep him away from quinin tablets until he recovered his sight.
I cannot vouch for this story, but I was often twitted with it as an
illustration of how the men were treating prophylactic quinin. Even
if this story were true, it could not be used as an argument against
prophylactic quinin on the Isthmus. In general, no attempt was made
at compulsion, and there would therefore be no object in a man taking
quinin and throwing it away.
I have noted before that our hospital system was planned upon the
scheme of some forty sub-district hospitals, or rest camps, which fed
about twenty district hospitals. These twenty district hospitals,
by means of hospital trains, fed two base hospitals, situated
respectively at the northern and southern end of the Canal, Colon and
Panama. The one at the southern end was much our largest hospital,
containing at its maximum about fifteen hundred beds.
The city of Panama is situated on a peninsula, stretching into the
bay of Panama. Just north of the city rises Ancon mountain, some six
hundred and fifty feet in height. This mountain is only accessible
to a pedestrian; the trail is too rough and precipitous for horse or
mule. The northern suburb of the city of Panama is known as Ancon,
and this village nestles about the southern foot of Ancon mountain.
The line dividing United States territory from Panama passes
between Ancon and the city of Panama. Ancon is therefore under the
jurisdiction of the United States.
Ancon Hospital is beautifully located along the southern and eastern
front of Ancon mountain. The French early in their construction
period, about 1882, commenced building their main hospital there.
The side of the mountain was graded for roads and laid off in the
most beautiful and picturesque manner. Every variety of tropical
shrub and plant was introduced from other parts of the tropical world
and planted around the grounds. Every opportunity for picturesque
location of buildings was seized, and over thirty hospital buildings
of various kinds were located over a large area, extending along the
northern and eastern sides of Ancon mountain.
The maximum bed capacity under the French was about seven hundred
beds. The hospital built by them was well manned and equipped, and
was a very much better institution than any hospital in America that
I know of at the same period carried on by a firm or corporation.
The French did most of their work by contract so that almost all
of their patients were employees of the various contractors. Each
contractor was made responsible for sick employees whom he sent to
the hospital, and was charged one dollar a day for each sick employee
as long as he remained in the hospital. A dollar a day was a very
moderate charge for the care and attention given a sick man in Ancon
Hospital, and I know that the charge did not cover the cost to the
old company.
It is the general belief among the people on the Isthmus, who were
there during the general construction work of the old French Company,
that a very small portion of the employees of the contractors came
into the hospital. Notable among these is Sir Claude Mallet, who
was the English representative in the city of Panama during the
period referred to, and who is at present the British minister to
the Panaman Government. From my knowledge of human nature I feel
sure that the French contractors did not send a large proportion
of their sick to Ancon Hospital. I am surprised that under these
circumstances the hospital ever contained seven hundred patients. If
we had been doing the work and had twenty-five or thirty American
contractors employing sixteen or seventeen thousand men, I should be
very much surprised if we at any time had seven hundred patients in
the hospital, if the contractors were required to pay one dollar per
day for each of the seven hundred patients.
Attached to the hospital the French had a dairy with a very complete
set of dairy buildings. In connection with this dairy was a farm of
some three or four hundred acres. The water supply for the hospital
during the French occupation came from three or four beautiful
springs which issued from the side of Ancon mountain. Night soil was
taken care of by a bucket system of closets.
The hospital system, on account of the topography, was necessarily
the pavilion system. This system was probably the best that could be
adopted for both the local and climatic conditions. The cooking was
done at one central kitchen, and the cooked food distributed to the
wards, where it was consumed.
The nursing force was composed of Catholic Sisters, assisted by negro
maids and orderlies. These orderlies and maids did the manual work
and rough nursing, under the supervision of the Sisters.
The medical staff consisted of a sufficient number of French
physicians. The superintendent during most of the period of
construction of the old company and up to the time that we took
charge in 1904 was Dr. La Crosade. He remained with us for several
years, and did for us most valuable and useful work.
The hospital was not popular among the French employees. The
mortality there was very high, and it was soon recognized that
men contracted yellow fever there; for instance, a man, otherwise
well, would break his leg, be sent to the hospital, in the course
of four or five days develop yellow fever, and within ten days
be dead. This fear of the hospital was another reason why French
employees did not go there. Most of the whites and the better class
of French employees, when they were taken sick, remained in their
boarding-houses and homes in the city of Panama.
In making these remarks I do not intend to reflect in any way
upon the management of Ancon Hospital by the French. If we had
had this hospital in 1884 we should probably have obtained no
better results than they did. At that time they did not know that
the mosquito transmitted yellow fever from man to man, nor did we
know it then. Still, the hospital records show that in the nine
years of construction under the old French Company, twelve hundred
patients died in Ancon Hospital from yellow fever. These were mostly
Frenchmen, and they died in the building used for white employees,
the Saint Charles. This building was occupied for the first few years
of our construction of the Canal by Dr. Carter and myself, with our
families. The fact that we were willing to place our families in such
a building, located in one of the worst yellow-fever centers, shows
how thoroughly we believed that yellow fever was not infectious in
the ordinary sense of the term.
This building was about the center of the hospital grounds, and
occupied a most attractive site. It was situated about two hundred
feet up the side of the mountain looking to the northeast. A
macadam road skirted the building on the down side, and the masonry
retaining-wall supported this road on the lower side. Between the
border of the road and the retaining-wall was a superb row of stately
royal palms. Behind the building rose the mountain for four hundred
feet, covered by a perfectly impenetrable tropical forest, giving to
the picture the deepest possible dark green background. The view to
the north and east extended for miles and miles. To the east, over
the bay of Panama, dotted with its forest-clad islands, I have many
times watched from the gallery of this building that anomaly, so
generally remarked at Panama, the sun rising out of the Pacific.
To the north and east were in view the various ranges of Andean
Mountains which make up the backbone of the Isthmus. From this point,
four or five ranges of mountains could be seen, and in the evening,
when the sun was setting behind the Ancon mountain at one’s back,
the play of colors was superb: light green upon the nearer ranges,
changing into deep azure upon the farther ranges, with the mountain
tops and higher valleys covered here and there with a robe of white
mist.
For the fourteen years after the failure of the old French Company in
1889, Ancon Hospital had financially a most straightened time, and
the Sisters who were in charge had to reach out in all directions
to make both ends meet. They deserve a great deal of credit for the
brave and successful struggle which they made in supplying the wants
of the sick intrusted to them.
Major La Garde, of the United States Army, was appointed
Superintendent of Ancon Hospital, and took charge in June, 1904. He
rapidly and successfully proceeded to organize the hospital on such a
basis that it was always able to care properly for all patients who
presented themselves.
For the first year there were almost insuperable difficulties in the
way of getting supplies of all kinds, but gradually these troubles
were corrected. We used all the old French buildings in much the
same manner as had the French. As the number of patients increased,
the old French buildings were enlarged, generally by adding a second
story, and a few new buildings were added, until finally the capacity
of the hospital had risen to fifteen hundred beds.
Into all these buildings a piped water supply was introduced, and
the bucket system for night soil was everywhere replaced by modern
flush closets. Bathing facilities were also supplied wherever needed.
A good sewage system connected all these buildings with the sewers
of the city of Panama. The old lighting system of candles and lamps
were replaced by electric lights. All the buildings were thoroughly
screened with wire netting. This precaution was almost essential in
the early years before we got mosquito-breeding as thoroughly under
control as it later became.
In 1904 and 1905 we treated a good deal of yellow fever in this
hospital, and in the wards where we treated yellow fever we had to
be particularly careful. Most of the patients in these wards were
non-immunes, that is, were patients who had not had yellow fever. The
nurses and doctors were also generally non-immunes, who were liable
to yellow fever. We had, therefore, to be absolutely certain that no
mosquito which could carry yellow fever from patient to patient, or
to the doctors and nurses, got into these wards.
The screening was very carefully done under the supervision of Mr.
Le Prince, who formerly had charge of similar work at Havana. Only
one entrance was used for each ward, and this entrance was closed by
a screened vestibule, with double doors. A watchman was always on
duty in this vestibule, whose business it was to see that any person
entering the vestibule from the outer door, closed the outer door
before opening the inner. Notwithstanding the large number of cases
of yellow fever treated in the yellow-fever wards of Ancon Hospital
in the years 1904 and 1905, and in spite of the fact that in these
wards were a considerable number of non-immune patients who did not
have yellow fever, and the further fact that most of the doctors and
nurses were non-immunes, not a single case of yellow fever developed
in Ancon Hospital during American control of that institution. I wish
to except from this statement one of the female nurses. This nurse
did have a very severe case, and came very near dying. The evidence
seemed very strong that she had not contracted the disease in the
hospital. She was in the habit of going down frequently into the
city of Panama in the evening after sunset where infection was very
rife. Soon after her recovery she married one of the young doctors
connected with the hospital upon whom public opinion settled the
blame for her contracting the disease, because he had so frequently
inveigled her into taking trips into town.
That no case of yellow-fever infection occurred in the hospital is
the greatest possible compliment to the efficiency of the system
established by the authorities for its prevention. It made a very
strong impression both upon the Americans and Panamanians. All could
see that we had done something that had radically changed conditions
as they had existed before in Ancon Hospital. Formerly, nearly every
white non-immune who was taken to the hospital developed yellow
fever. Now, they could see that the yellow-fever wards of Ancon
Hospital were safer for a non-immune than was any part of the city of
Panama. When it was explained to them that there was no mystery about
this; that it had been discovered that yellow fever could not be
conveyed from man to man except by the stegomyia mosquito, they were
prepared to accept this as the proper explanation.
Probably, if the French had been trying to propagate yellow fever,
they could not have provided conditions better adapted for this
purpose than the conditions which they did establish with an entirely
different object. The stegomyia were bred everywhere about the
Ancon Hospital grounds in the usual numbers found in almost every
tropical community, due to old cans, bottles, rain-water barrels,
roof gutters, etc. As I have mentioned before, the grounds were
most beautifully laid off and every kind of tropical bush and shrub
carefully fostered in the various plots about the grounds. There
is down there a large ant, known as the umbrella ant, that is very
destructive to most shrubs and plants. A colony of these ants will,
in the course of a single night, cut every leaf from a good-sized
orange tree. The leaf is cut into a piece about half an inch in
diameter and carried off by the ant in his nippers, and when you see
a column of these ants crossing the path, hundreds and thousands of
them, with these circular pieces of leaves in their nippers, it looks
very much as if they were carrying them for protection against the
sun. Hence their name, “umbrella ant.”
Now, in order to raise any vegetation at Ancon, the plant has to be
protected from these ants. The French used for this purpose a pottery
ring. The ring was filled with water and the plant was placed in
the large hole in the center. This thoroughly protected the plant,
as the ant was unable to cross the water. But the water in the ring
was an ideal breeding-place for the stegomyia mosquito, and as there
were several thousand of these earthenware rings about the grounds,
close to the wards, a more perfect arrangement for the propagation of
yellow fever could not have been adopted, if the authorities had this
object in view.
Knowing that shrubbery protected and harbored mosquitoes, we cleared
off, as was our rule, everything within two hundred yards of any of
the buildings. It looked very much like vandalism on our part to see
all the beautiful plants, rose bushes, flowers, etc., which had been
for so many years carefully nurtured and cared for by our French
predecessors, ruthlessly destroyed.
But our work was successful, and in the course of time we got rid of
mosquitoes entirely in the grounds of Ancon Hospital. We continued to
keep the buildings well screened, however, though I feel sure that we
could now treat cases of yellow fever in Ancon Hospital in unscreened
wards and still not have the disease transmitted to the non-immunes
in the ward, for the reason that there are no stegomyia there to
transmit the disease. This statement is not altogether theory on my
part.
On the next hill, about a quarter of a mile from the old yellow-fever
wards of Ancon Hospital, is the Tivoli Hotel. This hotel is owned and
operated by the Canal Commission, and for the last few years has been
filled with visitors from abroad, principally from the United States,
who were of course entirely unacclimated. During the months of the
dry season the hotel is crowded, and for the last two years it has
been kept full nearly all the year round. During these last two years
about thirty thousand sight-seers have visited the Isthmus.
[Illustration: Stoned Ditch near Tivoli Hotel. Ancon, Panama.]
[Illustration: Bad Anopheles Breeding-ground on Artificial Fill. La
Boca.]
This hotel is practically unscreened. While the doors and windows
are provided with screens, such screening, where there are many
doors and windows, is so imperfect that in the tropics it gives
little protection against yellow fever and malaria. No attempt
at all was made to screen the galleries of this hotel. Hundreds of
visitors spent the whole evening on these galleries until twelve
and one o’clock at night, yet we had no cases of yellow fever or
malaria developing from such exposure. If this had occurred ten
years before and three hundred of these unacclimated visitors from
the United States had sat for an hour or two after sunset on this
gallery, exposed to the deadly night air, it would probably have
meant that every single one of them would have contracted fever, and
a considerable number of them would have died. The only difference
between now and then is that we have drained and cleaned the country
around this hotel, so that now there are no pools or puddles, or
places of any kind within two hundred yards of the hotel where
mosquitoes can breed, and consequently there are no mosquitoes.
The fact that unacclimated non-immunes can live in the Tivoli Hotel
without contracting fever is evidence that we could do without
screening in our wards at the hospital, but we thought it unwise to
do away with the wire netting there. We thought it equally unwise
not to screen the Tivoli Hotel, but the expense was large, and the
architect thought it would mar the appearance of the building,
so it was left off by the authorities, in spite of my advice on
the subject. The first guests in the Tivoli Hotel were President
Roosevelt and his party, who were there in November, 1906. I
succeeded in getting the authorities to screen thoroughly the portion
of the building occupied by the President.
As time went on and we found that we had freed the hospital grounds
from mosquitoes, we began to replace the flowers and shrubbery which
we had swept away in the early sanitary work. But we realized that
we had to protect all vegetation from the ants; if we did not, it
would be at once destroyed. While the methods used by the French for
this purpose had been entirely successful and efficient as far as
protection from ants was concerned, we could not use it on account of
its mosquito-breeding qualities.
The umbrella ant, in leaving its nest on its foraging expeditions,
makes a very distinct trail some four or five inches wide between
its nest and the tree to be attacked. Next morning, by following
the trail, you can easily find the nest. Colonel Phillips, the
superintendent of the hospital, found that by pouring a little
bisulphid of carbon into the ant-hole, allowing it to vaporize for a
few minutes and then exploding it, the gas would penetrate into every
part of the nest and kill all the ants. In this way, all the umbrella
ants around Ancon Hospital were killed off. At first it was very
laborious, and took the entire time of one man, but in the course of
time all the nests in the neighborhood were destroyed, and it is
now only at long intervals that a new colony comes in and has to be
killed off.
At the present time the grounds are even more filled with shrubbery
and flowers and tropical plants generally, than they were under the
French, and they present as beautiful and attractive an appearance as
can be found anywhere in the tropics. Entomologists tell us that this
ant does not collect the leaf for food, but chews it up into a pasty
mass, places it in the storehouses of its nest, and grows upon it a
fungus which he uses for food.
The food for this large hospital of over two thousand people was
cooked in a large and airy kitchen, situated about the center of the
grounds. This kitchen was equipped with every modern convenience both
for good and economical cooking. Cooking by steam was used in part,
and cooking on the range, for such things as were best prepared in
that way. The food when prepared was sent to the various wards, the
receptacles being carried in hand carts.
The wards were so arranged that every two of them had a dining-room
and diet kitchen in common. In each diet kitchen the heating
apparatus was so arranged that the food brought from the center
kitchen could be re-heated before being used.
On a spur of the mountain near the center of the grounds was located
the operating-room, with seven or eight surgical wards grouped
around. This operating-room was erected by the French about the year
1882. We repaired the building and enlarged it somewhat. Dr. A.
Herrick, the chief surgeon, equipped this building with every modern
surgical appliance, such as x-ray machine, etc., etc. The results
of the surgery at Ancon compare favorably with the results obtained
anywhere else.
A medical clinic was built up under the supervision of Dr. W. W.
Decks, where every variety of tropical disease could be seen in all
its phases.
A laboratory for original research was also attached to the hospital.
This laboratory was developed by Dr. Samuel Darling, and in it a
great deal of useful original work has been done. The pathological
work of the hospital was done in this laboratory.
From the peculiarity and isolation of our position on the Isthmus,
many things were done by the Sanitary Department which in the
United States are done by other branches of the Government, or by
individuals. In the early days, when there was a great deal of
fear and alarm on the Isthmus among the Americans with regard to
health conditions, the Commission promised their American employees
that all who died on the Isthmus should have their bodies returned
to their friends in the United States, at the expense of the
Commission. The fulfilling of this promise was turned over to the
Sanitary Department, and to carry it out, an undertaking department
was established and attached to the laboratory. The expense of this
department is one of the very many items that bear no relation to
sanitation, merely because the officers of the Sanitary Department
supervised the work, and the employees were carried on the rolls of
this Department.
There being nothing else of this kind on the Isthmus, it gradually
came about that whenever anyone died and his friends wished to have
the body embalmed, we were called upon to do it, and in later years,
as the non-employee population increased, there was a great deal of
this outside work. Strange to say, in our rather complicated and
involved accounts on the Isthmus, when the President of the Republic
of Panama died, the Sanitary Department was called upon to embalm
the body. The considerable cost of this operation, $100 or more, is
charged to sanitation on the Isthmus, and while the Commission was a
good deal more than reimbursed by the family from this expenditure,
the reimbursement was not credited to sanitation, but went, under the
law, to engineering and construction.
It seems all through as though the laws were framed with the idea of
making sanitation appear to have cost as much as possible, and the
construction of the Canal as little as possible.
In a former chapter I stated that when we came down, in June, 1904,
we purchased in New York and took with us $50,000 worth of supplies.
Among these supplies were a certain number of coffins. When they were
unloaded on the dock at Colon, the fact was considerably commented
on. Among these coffins were six metallic cases, of a quality
much superior to the others. These metallic cases were piled by
themselves. The Commission, the governing body at that time on the
Isthmus, was composed of seven men, of whom six on that date were
present on the Isthmus.
Major La Garde was superintending the unloading of the ship. One of
these six commissioners happened to be passing at this particular
time, and he was very much impressed by what he saw. Stepping up to
Major La Garde, he said: “Doctor, why do you bring six caskets of
so much better kind and quality than the ordinary coffin?” Major La
Garde promptly replied: “Mr. Commissioner, you know that Commissioner
Blank is not on the Isthmus, and that only six commissioners are down
here.” The inference was so obvious that the Commissioner is said to
have returned home and to have taken to his bed at once. I am glad to
say, however, that none of the Commission ever had any use for those
caskets.