CHAPTER XVI. Malaria Work and the Hospital System

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.

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.

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.