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A triumph of preventive medicine
207
NOTES
ON
CURRENT
LITERATURE.
A TRIUMPH OF PREVENTIVE MEDICINE. Colonel CHAMBERLAIN,~ the Chief Health Officer of the Panama Canal and a former student of the old London School of Tropical Medicine, has performed a timely and useful service by compiling a record of the twenty and five fruitful years of American medical activity on the Isthmus of Panama. True, we had heard a great deal about the Canal Zone. The success which has attended the American work in that region has become almost legendary. It is at least historic, but history is apt to be garbled and there has been much loose thinking and reasoning about the marvels achieved in Panama. No good purpose is served by exaggeration, and at times workers in other localities have been criticised by persons not conversant with all the facts for not producing results comparable to those which have followed the famous American occupation of that territory which used, with good reason, to be regarded as a death-trap. Colonel CHAMBERLAINdoes not exaggerate. He deals with facts and he supports his facts by statistics which cannot be gainsaid. There is nothing vain-glorious in his account, it is not in any sense rhetorical, but one can imagine the justifiable pride with which it has been written, for it is a stimulating revelation of what scientific knowledge, properly applied and backed by abundant resources, can accomplish in the way of combating disease and death in the tropics. It is interesting to learn that long before de Lesseps put forward his scheme for the construction of a canal across the Isthmus the idea had been in men's minds. It seems that the conquering Cort6s conceived the notion. In 1529 plans for such a project were actually prepared by a Don with the high-sounding name of Alvara de Saavedra Ceron. In 1534 Charles V of Spain caused surveys to be made with a view to determining the best route f o r an artificial waterway which would connect the Atlantic with the Pacific. Nearly a century later Philip II followed suit, his idea being to build a channel via the Gulf of Darien. That enterprising Scot, William Paterson, promoter of the Darien scheme and founder of the Bank of England, in 1701 gave it as his opinion that a canal was feasible. It was not, however, until the close of the nineteenth century that anything definite was done, and then there came the ill-fated effort of the French. The author agrees with the view commonly held that disease was a potent factor in de Lesseps' tragic failure, but he is fair to the French sanitary authorities who cannot be blamed for a lack of knowledge not attainable during the most active period of their r6gime. Moreover, the French company was handicapped by not having the legal jurisdiction necessary for enforcing sanitation in what, at that time, was Colombian territory. A disease-ridden territory it was, notoriously unhealthy, plagued by malaria, yellow fever, dysentery, typhoid fever, CHAMBERLAIN, WESTON P. (1929). " Twenty-five Years of American Medical Activity on the Isthmus of Panama. 1904--1929." Panama Canal Press.
508
NOTES ON CURRENT LITERATURE.
smallpox, ankylostomiasis, and cutaneous affections. Yellow fever was the special bugbear by reason of its ravages amongst immigrant non-ilnmunes. GORGAS believed that between 1881 and 1889 over 2,000 white employees died from this cause alone, in a Caucasian force which never exceeded 2,500 at any one time and averaged only 1,600 for the period. Yet if yellow fever, by reason of its deadly and spectacular character, excited special terror, it was malaria which proved a far more serious obstacle to construction programmes owing to the great amount of chronic disability it produced among workmen of any race or nativity. It is said that during nine years there died from all causes at least 16,000 employees, this mortality occurring in a total force which did not average over 10,121 for the period. CHAMBERLAIN points out that the United States authorities, when they took over the property of the French Company in 1904, had the inestimable advantage of being armed with what he aptly calls " the magic wand of mosquito control," while they were also possessors of improved knowledge regarding the prevention of intestinal diseases. Furthermore, they had almost unlimited funds at their disposal and were granted absolute sanitary jurisdiction over a wide area. Hence, everything made for succcess, though of course it is true that without the wisdom and driving force of GORGAS, and the loyalty, energy, ability, and keenness of his subordinates, even the above advantages would not have assured success. Let it be noted that these last words are not CHAMBERLAIN'S. He does not sound the clarion or beat the big drum. He allows the facts to speak for themselves, but what he does say is that the American success in Panama has emphasized the truth of the modern precept, that public health is a purchasable commodity; and has also demonstrated that by far the larger part of the morbidity and mortality, formerly attributed to tropical climates, is due not to climate per se, but to isolation, tedium, nostalgia, venereal disease, alcoholic excess, poor municipal conditions and, most important of all, to infection with specific parasites whose invasion is now almost entirely preventable. The record is too long for any detailed consideration here. As a matter of fact, it should be in the hands of all public health officers in the tropics, if only to serve as a stimulant to high endeavour and to provide arguments for hygienic progress. It must be confessed, however, that it may engender sadness in the breast of some eager apostle of Hygieia, hampered by official supineness or indifference and by the lack of funds. Still, it shows what can be done, and, even in such a case, should beckon to better things. A few points only will be noted. Those unacquainted with the Canal Zone may be surprised to read that in a sea-level region, where the sun is nearly vertical, the temperature constantly elevated, and the humidity high, acute destructive effects from heat are not markedly evident. Cases of death from heat exhaustion and sunstroke are very rare. Helmets are not necessities and people may be seen walking, or playing
ANDREW BALFOUR.
209
tennis, bare-headed in the bright sunlight at midday. White men carry on outdoor labour, the working hours being from seven to eleven, and from twelve to four. The author refrains from discussing the vexed question of the effects of heat and humidity during prolonged residence in a place like Panama. In the light of what he tells us it would be interesting to have had his considered opinion. A considerable portion of the report deals with the control of mosquitoborne diseases and traverses well-trod ground. There is not much that is new, but the author notes that the custom of screening houses, so prevalent in the Canal Zone, in addition to lessening the risk of acquiring yellow fever and malaria, affords many collateral comforts such as the exclusion of flies, moths, beetles, winged ants, scorpions, tarantulas, reptiles, etc. He says nothing about any possible disadvantages of mosquito-proofed dwellings. In the case of the antimalaria campaign, routine killing of adult mosquitoes was at one time extensively employed and was considered of much value, especially in the case of temporary camps. Now that drainage and oiling have become so extensive, adult mosquitoes are rarely seen in screened houses, but occasional catching is still practised as a guide to the prevalence of anophelines. In the Isthmus, as elsewhere, i.e., Malaya and Mauritius, it has been found that the destruction of vegetation which provides shade over pools and streams will often permit dangerous anopheline development where previously it did not occur. Natural enemies, such as fish, play no great part in the malaria control, while oil has been found more economical and suitable than Paris green. Latterly a great deal of permanent drainage has been installed, and mention is made of a new or " double-decker " type of drain, which has proved i t s value in places where there is some water flowing all the year and where the storm flow in the wet season is so rapid that the rock commonly used as a covering for tile drains would be washed away. The " double-decker " consists of the ordinary pre-cast concrete hemi-cylindrical section with a 6-in. or 8-in. tile immediately beneath it. The cost of ditching and of various kinds of drains is given and will be useful for comparison with such costs in other parts of the world. The sums spent for anti-mosquito sanitation (house-screening excepted) are listed. In 1928, there were expended 116,000 dollars ; but that this expenditure was worth while is shown by a striking graph which demonstrates the reduction in admission rates from malaria among employees of the Canal and Railroad from 1906 to 1928. In 1906 it was 821 per 1,000, in 1928 it was 14 per 1,000, and in 1927 it was as low as 11 per 1,000--the best record in the series of years. The death-rate graph for Canal employees is even more remarkable. During the last eight years there have been only two deaths among employees, one white and one coloured. The control of other communicable diseases forms Part III of the record and makes interesting and encouraging reading. It should be noted that in
910
NOTES ON CURRENT LTERATURE.
the case of refuse disposal, a method of burial (using crude oil to prevent flybreeding) has superseded incineration. It is more efficient and cheaper. There can be little doubt that much of the benefit to health which has accrued from the American occupation is due to the fact that an efficient water carriage system of sewage has been introduced in the case of all the Canal Zone towns and in the cities of Panama and Colon. Cesspools and pit privies are not allowed except in rare instances. Short sections deal with plague, respiratory diseases and smallpox, and there follows an illustrated account of the hospitals and other health institutions, Ancon Hospital having now, be it noted, been renamed Gorgas Hospital. And so we come to Part V, and not the least interesting and suggestive portion of the record, for it deals with the Organization of the Health Department and its Costs. It seems well worth while quoting part of the section headed " Financial Operations of the Health Department," even if it should make some of the Fellows of this Society gnash their teeth with envy. " The annual appropriations made by Congress for the Panama Canal include three items: (a) Maintenance and Operation, (b) Civil Government, and (c) Sanitation, the sums appropriated for the fiscal year 1929 being respectively $6,832,000, $ 1 , 1 5 8 , 0 0 0 , and $670,000. T h e amount for sanitation, $670,000, has been the same for several years back ; this amount issupplemented by the entire earnings of the Health Department, which have materially increased of late years and are as follows : Earnings, fiscal year 1 9 2 3 . . . . . . $687,836.77 . . . . 1924 . . . . . . 688,669.47 . . . . 1925 . . . . . . 708,399.54 . . . . 1926 . . . . . . 723,425.74 . . . . 1927 . . . . . . 812,525.10 . . . . 1928 . . . . . . 901,014.51 . . . . 1929, estimated from nine months' operation 974,378.00 " Consequently, the amount available for sanitation for the fiscal year 1928 was $670,000 plus $901,014, or a total of $1,571,014. The t e r m ' sanitation ' as used in our Health Department expenditures includes all the items referred to in this article, the most important being sanitation proper, street cleaning, garbage collection and disposal, maritime quarantine, dispensary treatment, hospital treatment including care of lepers and insane, charities, board of health laboratory operation, undertaking, and cemeteries." This must conclude our brief survey of an excellent synopsis of remarkably effective work. Its sub-heading is "A Triumph of Preventive Medicine," and very fittingly it is dedicated to those who gave their lives that a canal might be built. ANDREW BALFOUR.
NOTES
ON
CURRENT
LITERATURE.
A TRIUMPH OF PREVENTIVE MEDICINE. Colonel CHAMBERLAIN,~ the Chief Health Officer of the Panama Canal and a former student of the old London School of Tropical Medicine, has performed a timely and useful service by compiling a record of the twenty and five fruitful years of American medical activity on the Isthmus of Panama. True, we had heard a great deal about the Canal Zone. The success which has attended the American work in that region has become almost legendary. It is at least historic, but history is apt to be garbled and there has been much loose thinking and reasoning about the marvels achieved in Panama. No good purpose is served by exaggeration, and at times workers in other localities have been criticised by persons not conversant with all the facts for not producing results comparable to those which have followed the famous American occupation of that territory which used, with good reason, to be regarded as a death-trap. Colonel CHAMBERLAINdoes not exaggerate. He deals with facts and he supports his facts by statistics which cannot be gainsaid. There is nothing vain-glorious in his account, it is not in any sense rhetorical, but one can imagine the justifiable pride with which it has been written, for it is a stimulating revelation of what scientific knowledge, properly applied and backed by abundant resources, can accomplish in the way of combating disease and death in the tropics. It is interesting to learn that long before de Lesseps put forward his scheme for the construction of a canal across the Isthmus the idea had been in men's minds. It seems that the conquering Cort6s conceived the notion. In 1529 plans for such a project were actually prepared by a Don with the high-sounding name of Alvara de Saavedra Ceron. In 1534 Charles V of Spain caused surveys to be made with a view to determining the best route f o r an artificial waterway which would connect the Atlantic with the Pacific. Nearly a century later Philip II followed suit, his idea being to build a channel via the Gulf of Darien. That enterprising Scot, William Paterson, promoter of the Darien scheme and founder of the Bank of England, in 1701 gave it as his opinion that a canal was feasible. It was not, however, until the close of the nineteenth century that anything definite was done, and then there came the ill-fated effort of the French. The author agrees with the view commonly held that disease was a potent factor in de Lesseps' tragic failure, but he is fair to the French sanitary authorities who cannot be blamed for a lack of knowledge not attainable during the most active period of their r6gime. Moreover, the French company was handicapped by not having the legal jurisdiction necessary for enforcing sanitation in what, at that time, was Colombian territory. A disease-ridden territory it was, notoriously unhealthy, plagued by malaria, yellow fever, dysentery, typhoid fever, CHAMBERLAIN, WESTON P. (1929). " Twenty-five Years of American Medical Activity on the Isthmus of Panama. 1904--1929." Panama Canal Press.
508
NOTES ON CURRENT LITERATURE.
smallpox, ankylostomiasis, and cutaneous affections. Yellow fever was the special bugbear by reason of its ravages amongst immigrant non-ilnmunes. GORGAS believed that between 1881 and 1889 over 2,000 white employees died from this cause alone, in a Caucasian force which never exceeded 2,500 at any one time and averaged only 1,600 for the period. Yet if yellow fever, by reason of its deadly and spectacular character, excited special terror, it was malaria which proved a far more serious obstacle to construction programmes owing to the great amount of chronic disability it produced among workmen of any race or nativity. It is said that during nine years there died from all causes at least 16,000 employees, this mortality occurring in a total force which did not average over 10,121 for the period. CHAMBERLAIN points out that the United States authorities, when they took over the property of the French Company in 1904, had the inestimable advantage of being armed with what he aptly calls " the magic wand of mosquito control," while they were also possessors of improved knowledge regarding the prevention of intestinal diseases. Furthermore, they had almost unlimited funds at their disposal and were granted absolute sanitary jurisdiction over a wide area. Hence, everything made for succcess, though of course it is true that without the wisdom and driving force of GORGAS, and the loyalty, energy, ability, and keenness of his subordinates, even the above advantages would not have assured success. Let it be noted that these last words are not CHAMBERLAIN'S. He does not sound the clarion or beat the big drum. He allows the facts to speak for themselves, but what he does say is that the American success in Panama has emphasized the truth of the modern precept, that public health is a purchasable commodity; and has also demonstrated that by far the larger part of the morbidity and mortality, formerly attributed to tropical climates, is due not to climate per se, but to isolation, tedium, nostalgia, venereal disease, alcoholic excess, poor municipal conditions and, most important of all, to infection with specific parasites whose invasion is now almost entirely preventable. The record is too long for any detailed consideration here. As a matter of fact, it should be in the hands of all public health officers in the tropics, if only to serve as a stimulant to high endeavour and to provide arguments for hygienic progress. It must be confessed, however, that it may engender sadness in the breast of some eager apostle of Hygieia, hampered by official supineness or indifference and by the lack of funds. Still, it shows what can be done, and, even in such a case, should beckon to better things. A few points only will be noted. Those unacquainted with the Canal Zone may be surprised to read that in a sea-level region, where the sun is nearly vertical, the temperature constantly elevated, and the humidity high, acute destructive effects from heat are not markedly evident. Cases of death from heat exhaustion and sunstroke are very rare. Helmets are not necessities and people may be seen walking, or playing
ANDREW BALFOUR.
209
tennis, bare-headed in the bright sunlight at midday. White men carry on outdoor labour, the working hours being from seven to eleven, and from twelve to four. The author refrains from discussing the vexed question of the effects of heat and humidity during prolonged residence in a place like Panama. In the light of what he tells us it would be interesting to have had his considered opinion. A considerable portion of the report deals with the control of mosquitoborne diseases and traverses well-trod ground. There is not much that is new, but the author notes that the custom of screening houses, so prevalent in the Canal Zone, in addition to lessening the risk of acquiring yellow fever and malaria, affords many collateral comforts such as the exclusion of flies, moths, beetles, winged ants, scorpions, tarantulas, reptiles, etc. He says nothing about any possible disadvantages of mosquito-proofed dwellings. In the case of the antimalaria campaign, routine killing of adult mosquitoes was at one time extensively employed and was considered of much value, especially in the case of temporary camps. Now that drainage and oiling have become so extensive, adult mosquitoes are rarely seen in screened houses, but occasional catching is still practised as a guide to the prevalence of anophelines. In the Isthmus, as elsewhere, i.e., Malaya and Mauritius, it has been found that the destruction of vegetation which provides shade over pools and streams will often permit dangerous anopheline development where previously it did not occur. Natural enemies, such as fish, play no great part in the malaria control, while oil has been found more economical and suitable than Paris green. Latterly a great deal of permanent drainage has been installed, and mention is made of a new or " double-decker " type of drain, which has proved i t s value in places where there is some water flowing all the year and where the storm flow in the wet season is so rapid that the rock commonly used as a covering for tile drains would be washed away. The " double-decker " consists of the ordinary pre-cast concrete hemi-cylindrical section with a 6-in. or 8-in. tile immediately beneath it. The cost of ditching and of various kinds of drains is given and will be useful for comparison with such costs in other parts of the world. The sums spent for anti-mosquito sanitation (house-screening excepted) are listed. In 1928, there were expended 116,000 dollars ; but that this expenditure was worth while is shown by a striking graph which demonstrates the reduction in admission rates from malaria among employees of the Canal and Railroad from 1906 to 1928. In 1906 it was 821 per 1,000, in 1928 it was 14 per 1,000, and in 1927 it was as low as 11 per 1,000--the best record in the series of years. The death-rate graph for Canal employees is even more remarkable. During the last eight years there have been only two deaths among employees, one white and one coloured. The control of other communicable diseases forms Part III of the record and makes interesting and encouraging reading. It should be noted that in
910
NOTES ON CURRENT LTERATURE.
the case of refuse disposal, a method of burial (using crude oil to prevent flybreeding) has superseded incineration. It is more efficient and cheaper. There can be little doubt that much of the benefit to health which has accrued from the American occupation is due to the fact that an efficient water carriage system of sewage has been introduced in the case of all the Canal Zone towns and in the cities of Panama and Colon. Cesspools and pit privies are not allowed except in rare instances. Short sections deal with plague, respiratory diseases and smallpox, and there follows an illustrated account of the hospitals and other health institutions, Ancon Hospital having now, be it noted, been renamed Gorgas Hospital. And so we come to Part V, and not the least interesting and suggestive portion of the record, for it deals with the Organization of the Health Department and its Costs. It seems well worth while quoting part of the section headed " Financial Operations of the Health Department," even if it should make some of the Fellows of this Society gnash their teeth with envy. " The annual appropriations made by Congress for the Panama Canal include three items: (a) Maintenance and Operation, (b) Civil Government, and (c) Sanitation, the sums appropriated for the fiscal year 1929 being respectively $6,832,000, $ 1 , 1 5 8 , 0 0 0 , and $670,000. T h e amount for sanitation, $670,000, has been the same for several years back ; this amount issupplemented by the entire earnings of the Health Department, which have materially increased of late years and are as follows : Earnings, fiscal year 1 9 2 3 . . . . . . $687,836.77 . . . . 1924 . . . . . . 688,669.47 . . . . 1925 . . . . . . 708,399.54 . . . . 1926 . . . . . . 723,425.74 . . . . 1927 . . . . . . 812,525.10 . . . . 1928 . . . . . . 901,014.51 . . . . 1929, estimated from nine months' operation 974,378.00 " Consequently, the amount available for sanitation for the fiscal year 1928 was $670,000 plus $901,014, or a total of $1,571,014. The t e r m ' sanitation ' as used in our Health Department expenditures includes all the items referred to in this article, the most important being sanitation proper, street cleaning, garbage collection and disposal, maritime quarantine, dispensary treatment, hospital treatment including care of lepers and insane, charities, board of health laboratory operation, undertaking, and cemeteries." This must conclude our brief survey of an excellent synopsis of remarkably effective work. Its sub-heading is "A Triumph of Preventive Medicine," and very fittingly it is dedicated to those who gave their lives that a canal might be built. ANDREW BALFOUR.