Sanitation in Panama

by William Crawford Gorgas

There are very many beliefs as to the locality at which yellow fever developed; that it originated among the earliest nations of the world inhabiting Asia Minor; that it originated in Africa in connection with the slave trade; that it originated in America, and was not known to Europeans until the discoveries of Columbus.

A recent writer on yellow fever, Augustin, suggests that its origin can be traced back to the siege of Troy, and that the Greeks and Trojans suffered severely from this disease during the prosecution of the war. Mr. Augustin argues quite forcibly in favor of the idea that many of the great epidemics of Europe and Asia, before and since the Christian era, were yellow fever. He thinks that the population became immune from the fact that all at some time suffered from the disease, and thus, in the course of time, it died out from want of material on which to feed. I consider Mr. Augustin one of the most competent authorities that we have on the history of yellow fever, and anyone writing on that disease in any of its phases would do well to consult his monumental work.

It seems to me, however, that the evidence is against yellow fever having occurred in Europe before the fifteenth century. If it had been general in southern Europe, semi-tropical Asia Minor and semi-tropical Africa, it would be there now, just as it is in similar localities in tropical and semi-tropical America. If the Phœnicians had suffered from yellow fever during the time of Abraham, and the great epidemics of Smyrna, Thebes, Athens, Rome and Carthage had been yellow fever, this disease would be in those countries now. History does not show that yellow fever can immunize a whole country, but merely the locality in which it prevails endemically. While the old inhabitant of Havana was immune to yellow fever, the man from the interior of Cuba where yellow fever had not been endemic knew that he was just as liable to contract yellow fever when he visited Havana as was the man who came from the United States, and he feared the disease just as much.

The native of the city of Panama was immune to yellow fever, but the soldier coming from the mountains of the interior knew that he would catch the disease, and this actually occurred many times whenever a fresh regiment was brought to Panama. At present, Guayaquil in Ecuador is the seaport of Quito, the capital of the country. Quito is situated some three hundred miles up in the mountains, and is connected by rail with Guayaquil. Yellow fever is at present endemic in Guayaquil and has been so for many years. The old resident of Guayaquil is immune to yellow fever, but the natives of Quito dread Quayaquil as they do death. They never go there when they can avoid it, and when they have to visit the outside world, they remain in Quayaquil just as few hours as will enable them to catch their ship. And the fear is well founded. Very many Ecuadorians of high position have lost their lives from yellow fever contracted in passing through Quayaquil. But all these years of endemicity of yellow fever in these cities, the inhabitants of the respective countries in which they are situated have never become immune.

The same is true of Europe, Asia and Africa. If Memphis, in Egypt, had been an endemic center of yellow fever in the dim dawn of man’s civilization, the disease would be endemic there at present. While the native of Memphis who labored on the pyramids of Cheops would have been immune to yellow fever, enough fresh material from up the Nile would have continued coming into Memphis to have kept the disease going. And the hundred thousand men whom old Cheops kept at work on his pyramids for twenty years would have died in such numbers that he would either have had to give up this work, or would have exhausted the population of his kingdom; but the interior of Egypt would never have become immune any more than has the interior of Cuba, or Panama, or Brazil in our own time.

Had Athens been subject to yellow fever in the time of Alcibiades, yellow fever would certainly be there to-day. All the citizens of the city of Athens would have become immune, but a sufficient number of Greeks would have been constantly coming into the city from the interior to have kept the disease endemic, exactly as has occurred in our own time at Havana. I think, then, that we can throw aside Europe and Asia as the original source of yellow fever.

Another theory of the origin of yellow fever is that it originated in Africa and was carried to America in connection with the slave trade. Next to that of the origin in America, this is the most generally accepted explanation. But the arguments against this belief are unanswerable.

According to Lind, the first yellow fever that appeared in Africa was in Senegal, in 1759. If yellow fever had existed along the coast, it would certainly have spread in the two hundred and fifty years during which this coast had been occupied by Europeans since its settlement by the Portuguese in the year 1415. As a matter of fact, it was recognized many times in America before it appeared in Africa. The American origin of yellow fever impresses me as being the most reasonable and the one most in accord with the recorded facts. But it seems to me that the bulk of evidence points toward its having originated in America at some period prior to its discovery by Columbus.

Dr. Carlos Finlay, in a paper published in The Climatologist, of Philadelphia, in July, 1892, gives very clear proof that the disease existed in America before the discovery by Columbus. It seems to have been endemic in the neighborhood of Vera Cruz, Mexico, and to have been very well known to the Aztec authorities. The Government, before the arrival of the Spaniards, had many times caused a forced emigration from the interior to the neighborhood of Vera Cruz, to repopulate a country that had been depopulated by an epidemic disease known to the Aztecs as “cocolitzle.” To induce them to stay, these people were given many privileges, such as exemption from taxation, etc. This cocolitzle was known among the Mayos of Yucatan as “black vomit.” The Spanish historian, Father Lapey, gives a very clear account of cocolitzle as it occurred in Yucatan in 1648. It is such a clear description of yellow fever that I think it instructive to quote from his report as given in Dr. Finlay’s paper:

With such violence and rapidity were the people attacked, big and small, rich and poor, that in less than eight days the whole population of the city (Campeche) were sick at the same time, and many citizens of the highest rank and authority died. In most of the cases the patients were taken with a most severe and intense headache, and pains in all the bones of their bodies, so violent that their limbs felt as if torn asunder, or squeezed in a press. A few moments after the pains, there came on a very intense fever, which in most instances produced delirium, though not in all. This was followed by vomiting of blood, as if putrified, and of such cases very few survived—and many suffered the fever and pain in the bones without any other symptoms. In the majority the fever seemed to remit completely on the third day; they would say that they felt no pains whatever, the delirium would cease, the patients conversing in their full senses, but they were unable to eat or drink anything; they would continue thus for several days, and while still talking and saying that they were quite well, they expired. A great number did not pass the third day, the majority died on the fifth, and very few reached the seventh. The most healthy and robust of the young men were most violently attacked and died soonest. When the laity began to improve, the disease broke out among the priests. Of the eight members of the Jesuit College, six died; of our own order (Franciscan) twenty died in the city. Almost all the heads of institutions and persons of highest rank, both ecclesiastics and seculars, were carried away by the epidemic. The disease continued over the whole country during the space of two years. Few that then lived in this land, or visited it, in the course of those two years, escaped being sick, and it rarely happened that anyone died of a second attack after having recovered from the first. I then reflected that of the young children who were attacked by the peste in Yucatan, only few had died, as compared with the adults.