SANITARY WORK ON THEISTHMUS OF PANAMA

DURING THE LASTTHREE YEARS.

BY

COL. W. C. GORGAS, U. S. A.ANCON, C. Z.

Reprinted from the Medical RecordMay 18, 1907

WILLIAM WOOD & COMPANYNEW YORK

SANITARY WORK ON THE ISTHMUS OFPANAMA DURING THE LAST

THREE YEARS.COL. W. C. GORGAS, U. S A.,"

CHIEF SANITARY OFFICER, ISTHMIAN CANAL ZONE DEPARTMENT OFHEALTH.

My wish in this article is to give a general descrip-tion of the sanitary conditions which existed on theIsthmus at the time the United States assumed con-trol ; to explain the methods which have been takento improve these conditions, and to point out the re-sults attained by these methods.

The Isthmus of Panama at the point where theproposed canal is being constructed extends fromeast to west. The canal course runs nearly northand south. At this point has been located the prin-cipal route of crossing since the discovery of Amer-ica. The Spaniards, however, built a very goodcauseway for pack animals from the old town ofPanama to Porto Bello. This causeway was pavedwith cobblestones and is still in a fair state ofpreservation. The old town of Panama is some sixor seven miles east of the present town of thatname, and Porto Bello is about thirty miles eastof Colon. The advantages of the Chagres as ameans of getting across the Isthmus were soon ap-preciated and travel was gradually transferred tothe Chagres river until about the year 1670, whenMorgan, the famous English buccaneer, captured

Copyright, William Wood & Company

the old city of Panama. After this the old overlandtrail to Porto Bello was abandoned, the city ofPanama changed to its present location, and theChagres almost exclusively used as a route for cross-ing the Isthmus. The Chagres empties into theCaribbean some ten miles west of the present townof Colon. Porto Bello, which has an excellentharbor, remained the port on the north coast. Allvessels crossing the ocean from Europe were un-loaded at Porto Bello, the cargoes transshipped insmaller vessels to the mouth of the Chagres, wherethey were loaded into small dugouts and carriedup the Chagres to the south some forty miles tothe point where the Chagres changes its course.From this point they were carried overland on packanimals to the present city of Panama. A pavedroad was built from this point, Las Cruces, to thepresent city of Panama. This formed the mainroute of crossing up to the time of the building ofthe Panama Railroad. A large portion of the pop-ulation which went from the eastern states and fromall parts of the civilized world to California in 1849and the immediately succeeding years, crossed bythis route. In 1855 the railroad was thrown open totraffic. This road practically followed the formerroutes of crossing, went south up the Chagres tothe point where the Chagres turned. From thispoint it followed up the valley of one of the largetributaries, the Obispo, until it crossed the divide,then followed the valley of the Rio Grande, whichempties into the Pacific near Panama.

Colon is not situated at the mouth of the Chagresriver. The railroad strikes the Chagres at Gatun,some ten miles from its mouth. The canal routepractically follows the line of the railroad fromColon on the north to Panama on the south.

Some thirty years after the completion of the

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railroad a French company under the leadershipof Monsieur De Lesseps commenced building a sea-level canal between Colon and Panama, followingthe route of the railroad. This company, after someseven years’ work, and having done considerable ex-cavation, failed.

The United States has acquired a strip of terri-tory ten miles wide, with the canal as a central line,extending entirely across the Isthmus from Colonon the north to Panama on the south. The countryis low and swampy for the first fifteen miles; therest of the route, some thirty odd miles, is througha mountainous country. The temperature all theyear round in this territory is tropical, varying verylittle between January and July. Conditions as towarmth are thus such that the mosquito will breedprolifically all the year round. Over the mountain-ous part of the route the peaks are from 100 to 1,000feet in height, nowhere being high enough to inany way inhibit from a temperature standpoint thebreeding of mosquitos. Water is abundant every-where, in the mountainous section little streamscoming from every ravine, forming ideal places forthe anopheles, and in the swampy section stagnantpools of fresh water are on every hand. The townsof Panama and Colon were formerly dependent en-tirely for their water supply upon stored rain water.The dry season, when very little rain falls, lasts forsome four months, and rain water had to be storedfor use during this dry season. The large numberof tanks and receptacles containing rain water thusmade ideal • breeding places for the yellow fevermosquito.

Now for four hundred years we have had a con-stant stream of unacclimated persons of the whiterace crossing this Isthmus. This constant streaminfected the territory with both malaria and yellow

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fever and kept up the infection to a very muchhigher degree than in the neighboring tropical coun-tries which did not have this stream of whites con-stantly in their territory. The travelers in a greatmany cases were dignitaries of importance, mer-chants, and people of wealth. Everybody who trav-eled from the west coasts of North and South Amer-ica, in general, crossed at Panama, so that manyimportant personages sickened or died at Panama.For this reason it has acquired a reputation for badhealth which is second to that of no other localityin the world.

The French began the construction of a canalin this same territory in the year 1881 and kepton the Isthmus some 19,000 laborers, 2,200 of whomwere whites. This large body of men remainedhere some seven years working on the canal. Theinfection of both yellow fever and malaria beingalready present and other conditions being favor-able, this large access of unacclimated people greatlyincreased the ordinary mortality, and as the projectinterested all the world the health conditions be-came widely known and gave to the Isthmus thevery bad reputation it had when we came down here.The locality, however, is not naturally unhealthful.On the whole, it is a pretty and attractive country,with pleasant climatic conditions. Conditions as totemperature, rainfall, and local water supply hap-pen to be favorable to the development of the stego-myia and anopheles mosquito, and then for fourhundred years unacclimated whites were introducedin a steady stream,' sometimes in very large num-bers, such as during the construction of the rail-road, and of the canal under the French, but I aminclined to think that such a thing would occuranywhere else in the world where the altitude wasless than 2,000 feet, the minimum temperature not

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less than 6o° Fahrenheit, and the rainfall morethan thirty inches, provided the unacclimated whiteshad been brought there in the same way.

This, in general, had been the history of the Isth-mus when the United States acquired possession in1904. In April of 1904, just before the propertywas transferred to the United States, I was one ofa party of American officials who spent a monthon the Isthmus looking carefully into the then ex-isting conditions. At this time there were some40,000 people in the territory at present under oursanitary control, about 6,000 in Colon, about 24,000in the city of Panama, and some 10,000 scatteredin twenty-two villages along the line of the railroad.The principal business of the community was thatconnected with the railroad. The French were em-ploying about a thousand men in digging on thecanal, but they apparently were doin~ this only tohold their franchise. Business of all kinds waspractically dead and the whole community was verypoor and financially much depressed. The healthconditions were about those common to the neigh-boring tropical countries. A case of yellow feveroccurred now and then and malaria was pretty gen-eral. Two years before Panama had suffered ratherseverely from yellow fever on account of the intro-duction of a considerable body of troops from theinterior of Colombia, but by the time we arrivedthis had quieted down to a few scattered cases.Colon had no water supply or sewage system, wasbuilt in a swamp, and every house had several waterbarrels for the collection and storing of rain water.Panama, though built on high, well-drained ground,was the same as Colon with regard to collecting ofrain water. The French had some 2,000 buildingsfor the accommodation of their working force, scat-tered at various points along the line of the canal

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between Colon and Panama. The jungle everywherehad grown up to the railroad track, and on thewhole the country presented a desolate scene ofdilapidation, business depression, and financial fail-ure. After considering the matter, it was clear thatyellow fever was the disease that would' interfereparticularly with our success, and to which mostattention would have to be given, and that the canalwould probably not be completed unless we couldprotect our force from this disease. Yellow feverinfection was evidently in Panama, and as our un-acclimated force of whites was introduced from theUnited States I knew it would affect them just as itdid the whites among the French force, unless wetook measures to prevent it. The stegomyia mos-quitos were everywhere in abundance, their breed-ing places were to be found on every hand, and thetemperature was such all the year round that theycould breed uninterruptedly. Malaria I also foundeverywhere. If this were not checked it wouldcause considerable mortality and a still larger rateof inefficiency among our forces, but even if un-checked would not have the moral effect that yel-low fever would have. I know of no disease thatcauses the panic among the whites that yellow feverdoes. I found there was some dysentery, but nota great deal, considerable beriberi, principally lo-cated in the cities of Panama and Colon, and a greatdeal of Asiatic plague in the cities of Peru to thesouth of us. I also found considerable ankylosto-miasis among the population, and these diseasesmight have to be considered in bringing a largeforce to the Isthmus. With the assistance of Dr.John W. Ross, U.S.N., and Dr. Eouis A. LaGarde,U.S.A., I drew up plans for meeting these con-ditions. Major C. E. Gillette of the EngineeringCorps of the Army drew up plans for water supplies

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and sewage systems for the cities of Colon and Pan-ama. We introduced systems based, so far as theyapplied locally, on the plan we followed in Havana.We established health departments in each town,with functions in general similar to those of ourhealth departments at home, such as sweeping thestreets, disposing of garbage, and such general sani-tary work as is done in a city of the same size inthe United States, but our energies were principallyconcentrated upon the question of yellow fever. Forthis purpose the towns were divided into small dis-tricts, such that an inspector could get around toeach house twice a week. This inspector looked afterthe premises, principally with regard to breedingof stegomyia. On his report a force would be sentto the house to make all water barrels and cisternsmosquito proof. This was done at public expense,and all other collections of water were either gottenrid of or oiled. All unacclimated persons sick withfever were treated as if they were suspected ofhaving yellow fever. Physicians were recmired toreport all such, and in case they had yellow feverthey were either removed to a screened ward at thehospital or the houses in which they were sick werecarefully screened. After the case was disposed of,the houses occupied, and all contiguous houses, werefumigated for the purpose of killing all infectedmosquitos. A record was kept of all the nnac-climated people in the city, and houses occupied bysuch people were visited daily by an inspector, andwhen he found any such persons sick he reportedthem at once to the Health Office. In addition tothis, in both cities anopheles work was done, ditch-ing, draining, and oiling in the suburbs. TheCanal Zone, between Colon and Panama, was dividedinto some twenty odd districts and a sanitary in-spector was placed in charge of each district. His

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duties were to attend to the general sanitary workof his district, look out for the proper care oj night-soil, disposal of garbage, ditching, and draining foranopheles work, the stegomyia work around houses,isolating and screening for yellow fever, etc.

In order to prevent the introduction of yellowfever and other contagious diseases from the outsidea strict quarantine was established at the two endsof the zone, Colon and Panama.

For the care of the sick employees a hospital sys-tem was established, but as it was of great import-ance from a sanitary point of view to get hold ofcontagious diseases early these hospitals were thrownopen to the whole Isthmian copulation. This schemehas been elaborated for the past three years, untilat present we have the Sanitary Department organ-ized into the following divisions; The HospitalDivision, the Quarantine Division, the Health Di-vision of Panama, the Health Division of Colon,the Health Division of Bocas del Toro, and theDivision of the Chief Sanitary Inspector, which hassupervision of health matters along the line of thecanal between Panama and Colon.

The Quarantine Division maintains a maritimequarantine at the ports of Ancon, Panama, Colonand Cristobal. This division has been most ef-ficiently organized under the supervision, first, ofDr. Henry R. Carter, and afterwards under Dr.J. C. Perry, both of the Public Health and MarineHospital Service.

The Hospital Division was organized first by Dr.John W. Ross of the U. S. Navy, who, when he lefton account of ill health, was succeeded by Dr. HenrirR. Carter. It consists of two principal hospitals ateach end of the line, Colon Hospital in the city ofColon, and Ancon Hospital at Panama. ColonHospital is built on a coral reef, over which the

sea washes freely, and is beautifully located as faras exposure to the breeze is concerned. Ancon Hos-pital is situated on the side of a mountain just backof Panama, and is most favorably located both as tobeauty of view and accessibility to the breeze. Wealso have a convalescent hospital of some seventybeds, which is located at Taboga Island, twelvemiles .distant from Panama in Panama Bay. Be-tween Colon and Panama, on the line of the rail-road, we have some twenf--five hospitals, having- acapacity of from ten to forty beds each. Colon Hos-pital has 500 beds, and Ancon 700. On account ofthe expected increase in force, we are at present ex-tending Ancon Hospital with the expectation that bythe end of the present year we shall have some 1,200beds, the idea being to have the two base hospitalsequipped with all modern appliances, with a com-petent nursing force and men more or less special-ists in their various branches, so that any classof cases could be well cared for. The twenty-fiveline hospitals are only intended to care for thepatients until they can be moved to the base hos-pitals, and for such of the seriously sick and in-jured whom it is thought not advisable to move.Last summer when our sick rate was at its max-imum we were able to accommodate in these hos-pitals some 1,700 patients.

The Health Division of the zone is under the ablemanagement of Mr. J. A. LePrince, a sanitary en-gineer who did similar work in Havana, Cuba. Hehas under him some twenty-five sanitary inspectorsand about one thousand laborers to attend to theditchm?- . draining', and sanitary work generally ofthe 40,000 people scattered along the line of thecanal between Panama and Colon.

The Health Office of the city of Panama is underDr. John H. Purnell, who employs some 200 men

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in street cleaning, ditching, draining, garbage col-lecting, and sanitary work in general of the city ofPanama.

The Health Office of Colon is under the charge ofDr. E. H. Wheeler, who employs about 200 men indraining, ditching, and brush cutting in the swampsin which Colon is built, and attending to any othermatters pertaining to the health work of the city.

As there was some yellow fever last year at Bocasdel Toro, the President of the Panaman Republicappointed one of the officials of the Sanitary De-partment as Health Officer of Bocas. We employsome twenty men at this small port doing generalsanitary work there.

This work has so far accomplished very satisfac-tory results. Yellow fever has apparently been en-tirely eliminated. We have had only one case onthe Isthmus durinp- the last fifteen months. A re-cent critic of Isthmian sanitary affairs has statedthat this is merely accidental; that there have beentimes in the past when Panama was free from yel-low fever for several years in succession, and thatwe would certainly have an epidemic of yellow feversome time in the near future which would stop theconstruction of the canal. It is true that Panamahas been free from yellow fever for several yearsin succession at various periods in the past. Thisis the case in all small tropical cities subject toyellow fever, and it occurs for this reason: Forone cause or another the native population, whereveryellow fever exists continuously, becomes immuneto yellow fever. This is a well-recognized facteverywhere. Such being the case, it is the non-immunes, or strangers, who keep up the disease.Take a place of 25,000 or 30,000 inhabitants such asPanama, and in ordinary times the strangers whosettle in the community are comparatively few. They

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soon all have yellow fever and then the disease diesout; but a few strangers continue to come in andin the course of a few years quite a number accumu-late. Then when yellow fever is introduced fromthe outside enough nonimmune material is present tokeep the disease going for a time, but if for anyreason a large number of strangers come in everyyear then the epidemic of yellow fever becomes con-tinuous and keeps up as long as the strangers con-tinue to come in. This has been exemplified atpretty much every town where yellow fever hasprevailed in the tropics. At Rio de Janeiro yellowfever has prevailed continuously for the last fiftyyears, due to the large foreign immigration con-stantly coming into the city. At Havana it was pres-ent for considerably over one hundred years contin-uously from the same cause. At Panama the inter-mittent condition was well exemplified. In ordinarytimes they would have yellow fever for two or threeyears and then be free of it for two or three years,but whenever they had a considerable foreign immi-gration yellow fever was continuous. Thus yellowfever was continuous all during the construction ofthe railroad and again to a greater extent duringthe work on the canal by the old French company.The French, of course, brought over a large num-ber of European employees. During the construc-tion by the old company, from 1881 to 1889, con-siderable numbers of these European employeescame over every year. This continuous influx keptyellow fever goinp- during the whole time of con-struction by the old French company. In AnconHospital alone the old hospital records show that1.200 deaths occurred from yellow fever duringthis period, and when it is remembered that thesecame from a force which at no time exceeded 3,000men, one can appreciate what a heavy tax it was

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upon this force. The French during all these years,from 1881 to 1889, with a white nonimmune forcewhich had as its maximum 3,000 men, did not passa month in which one or more deaths from yellowfever did not occur in this force. With a non-immune force four times as large, for we now haveover 10,000 whites, if we include women and chil-dren, we have passed fifteen months with not a sin-gle case of yellow fever. The case which occurredin May, 1906, was in a man not an employee of theCommission. There never has been a time in thewhole history of the Isthmus, from the time it wasdiscovered by Columbus up to the present time,when there have been anywhere near as many mensubject to yellow fever present on the Isthmus asthere are now. The disease was on the Isthmuswhen we came in April, 1904, and remained withus up to December, 1905. During this time we wereconstantly increasing our nonimmune population.I therefore feel confident that the same methodswhich eliminated yellow fever from Havana haveaccomplished the same results at Panama. Ido notbelieve that our present freedom from yellow feveris in any way accidental. Our work here, I think,is another evidence of the great obligation mankindis under to the Army Board, of which Major WalterReed was chairman and Lazear and Carroll weremembers, for establishing the fact that the stego-myia mosquito was the transmitter of yellow fever.Without this knowledge I do not believe we couldhave done any better than did the French, and, judg-ing from the alarm- that was caused by the compara-tively mild epidemic which we had among our em-ployees in 1905, I doubt, in case we were havingthe same amount of yellow fever that the Frenchhad, whether we could keep a sufficient force ofwhite employees here to carry on the work. And

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even if we could keep white employees here undersuch circumstances, I doubt whether public senti-ment in the United States would allow the canal tobe built at such a sacrifice of human life.

In this connection I would like to call atten-tion to the little credit the French white employeesget for the heroism which they exhibited in comingto Panama. Every Frenchman who came to Pan-ama knew that he was going to have yellow fever,and he also knew that every second man would diewith it. To face such chances took no little cour-age.

The most useful result of our work, I think, how-ever, as far as the canal work is concerned, is theextent to which malaria is held in check. Whileyellow fever was the fatal disease to the French, itdid not affect their sick rate to a very great ex-tent; that is, if you take their sick report day byday you would find thirty to forty men sick fromyellow fever and 400 or 500 sick from malarialfever, so that malaria was causing eight or ten timesthe financial loss that yellow fever did. Malaria isstill with us the principal cause of sickness; I meanwe have a good many more men every day sickfrom malaria than from any other one cause, butour whole sick rate is very small. Last month(March) 1907 our sick in hospitals amounted to lessthan 20 per 1,000, and our total excused on accountof sickness from all causes to about 23 per 1,000;that is, out of every thousand men we had absent onaccount of sickness in hospitals, their homes, andeverywhere, an average every day during the monthof twenty-three men. This is as small a rate as wewould probably have if we were working in theUnited States, and I doubt if we are ever able toobtain a smaller rate than this. I am inclined tothink that our sanitary work, as far as the sick rate

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is concerned, has reached its maximum efficiency,and that all we can expect to do for the futureis to hold it up to that rate, though to keep this ratea great deal of work will have to be done.

The good water srmnly furnished all our em-ployees has kept dysentery from being troublesome,so that I think we can claim that our sanitary workhas directly controlled malaria, yellow fever, anddysentery, the three tropical diseases to which weare liable. Bubonic plague is pretty firmly estab-lished in some of the Peruvian ports to the south ofus, and we have been very anxious on this subjectduring our occupancy of Panama. In the summerof 1905 two cases of plague occurred at La Boca,the Pacific terminal of the railroad and canal. Bothmen had been living there for some time and evi-dently contracted the disease there, but a very care-ful isolation and disinfection of the town of LaBoca, under the supervision of Dr. J. C. Perry,Chief Quarantine Officer, eradicated the disease atthis point, and we have had no cases since. Beriberiwas ouite prevalent on the Isthmus during our firstyear, but it is now entirely confined to the city ofPanama, and much reduced in numbers.

I think, therefore, that the United States authori-ties can fairly make the following claim for theirsanitary work: That when they got control of theIsthmus in May, 1904, the territory along the routeof the canal was in its normal condition as to health.It was overgrown by a dense tropical jungle; thenatural conditions were everywhere ideal for breed-ing stegomyia a'nd anopheles mosquitos. The re-gion was inhabited by a considerable population,which was very poor, as the result of the failure ofthe French canal company and the recent bloody anddestructive war which had involved the whole coun-try for some three years. Malaria, dysentery, and

smallpox were prevailing among these people aboutas they would anywhere in the tropics under similarconditions. Yellow fever infection was present inboth Panama and Colon. In fact, the conditionswere more favorable for producing a high mortal-ity upon the introduction of a large force than theyhad been at any time in the past. Into this regionthe Canal Commission has introduced the largestforce ever before present on the Isthmus, some fortythousand persons, ten thousand of whom are whitenonimmunes. Yet the sanitary measures taken bythe United States during the period of the introduc-tion of this unprecedented force have been such thatyellow fever has disappeared, malaria been heldin check, and the total sick rate in this force dur-ing the month of March, 1907, was only 23 per1,000.

I think that there can be no reasonable doubt thatthere is a direct relation of cause and effect betweenthe sanitary measures taken by our Government andthe present health conditions on the Isthmus.

Ancon, C. Z.