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WISH to take this opportunity to express on behalf of the medical profession of the District of Columbia the gratification which we feel that you have honored us by choosing the capital city of your nation for the place of meeting for 1925. We hope each one of our guests has found upon the program something of sufficient interest to repay him for coming to us at this time.

I am happy to make acknowledgment of the loyal, whole-hearted support which I have received from all of the medical men, both in the three branches of the public services, as well as those in civil practice. I would fall far short of just tribute did I not say but for the untiring devotion to the work in hand of the chairmen of the various committees, we could not have been able to have carried this undertaking to whatever measure of success it may achieve.

The aid and encouragement which we have received at all times from the Secretary-General, the Treasurer, and several of the past presidents has materially lightened our burden.

Originally, I intended to discuss with you at this time, some of the vital problems which confront each and all

Presidential address, American Congress on Internal Medicine, Washington, D. C., March 9, 1925.

of us just now. However, after passing many days in the Panama Canal Zone recently, and at the timely suggestion of Colonel Chamberlain, the Chief officer of the health activities there, I am instead, going to briefly describe to you the impressions which I gained of the medical work of that remarkably administered territory.

At the outset I wish to correct the widespread erroneous belief that the health work of the Canal Zone is under the control of, and carried on by the United States Public Health Service, or the United States Army Medical Corps, for such is not the case.

Colonel Chamberlain, like his predecessors in office, is in supreme command of all health activities and sanitation within the Zone and the Republic of Panama, and is directly responsible to the Governor-General alone. It is true that the United States Public Health Service and the United States Army Medical Corps detail officers for duty in the Zone, but when they so act they, to all intents and purposes, become civilian medical men, and cease to be under the immediate direction of their superiors in the States.

The entire administration of the Canal Zone is that of an independent principality with the Governor General in supreme command.

This clear understanding of the con

trol of affairs in the Canal Zone is necessary in order to evaluate properly the work which has been accomplished in the past, and that which is being carried on at the present time.

The three diseases which largely caused the defeat of the attempt to construct the canal by the French engineers were malaria, yellow fever, and bubonic plague. Of these, malaria alone remains as the chief active menace to the health of the inhabitants of the Zone, and will always remain so. This is so because of the prohibitive cost of extending the anti-malaria fight, through ditching and other permanent sanitary measures, any considerable distance beyond the principal towns, villages, and hamlets of the region.

Up to recent years the fight against malaria has been through screening the dwellings; by the use of oil and other larvicides principally, but somewhat also, by drainage, both by subsoil rock covered tiling, and by open ditches, which more recently are often lined with concrete and kept free from vegetation by periodically dragging through them oil soaked mops made from old rope ends; and finally, by spraying hot crude oil wherever the larvae of the anopheles albimanus tasimaculata are found to breed.

During the past few years the health department of the Zone has endeavored to extend progressively the ditching and permanent draining operations, and are thereby reducing the areas requiring constantly repeated treatment by oil. In this way the cost of fighting malaria is gradually being lessened.

It is known that minnows are "voracious devourers of mosquito larvae,

and but for the protection afforded the larvae by certain aquatic plants they would prove a dependable aid in destroying the larvae."

Already the permanent defense against the anopheles albimanus is so complete in and to within a mile of all of the cities, towns, and villages of the Zone, Panama City and Colon, that were their inhabitants to remain strictly within these sanitated areas probably few, if any cases of malaria would develop therein. However, it is quite impossible to restrict the free movement of the people in any direction, especially after nightfall. And, furthermore, the Canal Zone government is encouraging the resettlement of the evacuated zone areas, and is aiding the settlers in developing banana plantations and truck gardens. These plantations are widely scattered, making it impossible to carry the sanitation to these isolated dwellings. And, furthermore, these farmers do most of their farm work during the early morning and evening hours, when the anopheles are the most active. For the foregoing reasons, acute and chronic malaria will always have to be dealt with in this region. The health department of the Zone is fully alive to this situation, and is accomplishing most amazing results in the protection of these isolated dwellers by teaching them how to protect themselves against malarial infection, typhoid fever, and hookworm.

As I have already pointed out, it will never be possible to extend protection through drainage ditches and other permanent protective measures much beyond a mile or two outside the environs of the cities, towns, and

ANNALS OF CLINICAL MEDICINE, VOL. III, NO. 12

villages of the Zone and Panamanian cities on account of the excessive cost of this type of sanitation.

The reasons for encouraging the resettling of the zone areas which were originally evacuated under compulsion are:

1. In order to care for the large numbers of laborers who had been employed during canal construction, but who, at the present time are no longer needed, and who are thus left without means of support, and therefore likely to become a public charge.

2. To increase the production of food stuffs in the Zone; and finally, to keep in reserve a large number of laborers in case of emergency.

I have dwelt somewhat at length upon the malarial problem as it now remains the chief concern of the health department of the Canal Zone.

The next important fight which the health department of the Zone has continually upon its hands is rat extermination. This becomes of the greatest importance because of the ever present menace from bubonic plague, which exists in many of the coast cities of South America. There is, perhaps, no problem which is causing the health department of the Zone so much constant concern as the campaign against the introduction of bubonic plague into the Zone, as well as into Panama City and Colon. Should even a very small number of cases of bubonic plague appear in Colon, Cristobal, Balboa, Ancon, or Panama City, it would prove immensely costly to the United States, for the reason that a strict quarantine of the Isthmus would have to be abruptly established. Inasmuch as the daily receipts from ship tolls alone amount to $45,000,

which is by no means all the revenue from the zone activities, the monetary loss would be heavy.

The usual preventive measures are vigorously and unceasingly employed against the introduction of the plague. In addition to these measures, there is a relentless war carried on against rats, and will always have to be continued to be waged, because there is a constant supply of rodents coming in from Panamanian territory. Rat breeding and hiding places in the Zone are already under control. Panama City and Colon the merchants and market men are being gradually taught it is to their pecuniary advantage to rid their cities of this form of pest, and are beginning to coöperate in this campaign.

In

Yellow fever has been so far completely stamped out in the tropics generally as to render it no longer a serious quarantine problem. No case of yellow fever has developed in the Zone since 1905, and none has been discovered among incoming passengers since 1919. Even if sporadic cases were introduced into the Zone or the cities of Panama, it would present no practical danger because the sanitary conditions are such that there are no house mosquitoes in the dwellings to carry the contagion.

Typhoid fever in the Zone is so far under control that of the few cases reported as occurring each year in the Zone, Panama City, and Colon, all are believed to have been contracted from carriers rather than from polluted water or food.

The water supply for domestic uses is taken from the Chagres river. It first goes into sedementation reservoirs where it receives chemical precipi

tants. It then goes through slow sand filtration. And, as an extra precautionary measure, a minute quantity of chlorine is added. Therefore, the claim that the Canal Zone and Panamanian cities have one of the purest water supplies, is justified.

Infant mortality is being progressively reduced by free prenatal and child welfare clinics in Panama City and Colon, and by an educational campaign constantly carried on in both English and Spanish in the daily press, and through the employment of visiting nurses wherever money is available for that purpose.

The control of the housefly is so complete that they are rarely seen in or about dwellings, shops, or eating places. This has been accomplished by rigid enforcement of laws controlling the disposal of garbage and

manure.

Garbage is collected twice daily and carted into the suburbs wherever a swamp is to be filled, and there dumped. It is then immediately sprayed with hot crude oil, and then covered with earth, which in turn is oil-sprayed. The result is that there are no flies even at or about these dumps.

The care of manure receives the same prompt, energetic, intelligent treatment. Fertilizer, like most commodities in the Canal Zone is scarce, and therefore, valuable, and must be preserved for use on truck gardens. It also is collected twice a day and carted to government reservations where it is dumped into cement pits and thoroughly treated with effective larvicides, then covered with canvas. and allowed to decompose for some days. At the end of this time, this

manure is sold to truck farmers by the load, and must be completely used up by nightfall of the day on which it is received.

The Panamanian open markets are interesting places to visit. For cleanliness, freedom from flies, and attractiveness they surpass most of those in the States. Two or more sanitary inspectors are constantly patrolling these markets.

Perhaps the most interesting experience which I had while in the Zone, was the visit I paid to the Leper colony at Palo Seco. The first request which I made of Colonel Chamberlain, when I met him in Balboa, was to be permitted to visit the leper colony, and to see the actual methods of housing, feeding, and treating those unfortunate outcasts of society. Colonel Chamberlain not only granted my request, but volunteered to accompany me, which he did on the following morning.

I wish I had a facile pen that I might do full justice to one of the most remarkable spots of the world. Remarkable for its exquisite beauty of exterior; remarkable for the sanitary cleanliness; remarkable for the type of men that make up its personnel, both those who actively care for the colony as a whole, and those who conduct the medical side of the work, as well as those who are responsible for the colony as a unit.

For many years I have had a growing desire to visit a leper colony, and yet, coupled with it was an instinctive dread of what I fully anticipated would be a loathsome, depressing, harrowing spectacle.

As we were crossing the bay in the leper colony motor launch, I pointed

to a charming little hamlet, clinging to the side of the mountain, the bungalows of which were almost hidden among royal, and cocoanut palms, and asked what delightful little suburban village it was. Colonel Chamberlain replied: "That's where we're goingthat's the leper colony." From that moment the fear of what I was to see vanished, and nothing during my several hours stay renewed it.

It is well nigh impossible to pay too high a tribute to Mr. F. B. Tucker, the resident superintendent, for the housing, feeding, care, and recreational diversion of those under his supervision; nor to Dr. Philip Horwitz, the attending physician who conducts the active treatment of those in the colony; nor to Dr. D. P. Curry, Assistant Chief Health Officer of the Canal Zone, under whose immediate supervision this work falls. They each in turn exert a definite influence in maintaining what is considered one of the model leper colonies of the world.

One of the outstanding accomplishments of Mr. Tucker is the abiding peace and contentment which I saw shining from the eyes and faces of those sufferers. There was no atmosphere or hint of prison or detention camp, but merely that of a happy little village tucked away among the tropical hills in the Zone. It is indeed a rare occurrence for any patient to attempt to leave the colony without permission, and that, too, in spite of nothing physical to restrain them from going.

Their chief amusement outside of reading, card playing, etc., is the "movies." Mr. Tucker, several years ago, got hold of a moving picture machine, which he has worked so as

siduously that it is now well nigh completely worn out, and should be replaced by a new, up-to-date machine, but for which there seem to be no funds available. I wish we here tonight might raise the amount necessary to purchase a suitable machine both for "movies" and still pictures to help those unfortunates to bear their all-too-heavy burden; and as a tribute to the unselfish devotion to duty of Mr. Tucker and Dr. Horwitz.

Dr. Horwitz is doing a wonderful work. He combines the kindly, tactful physician with the keen, alert observer and skilled, enthusiastic research worker; a rare character complex, I grant you.

The method of treatment used by Dr. Horwitz at Palo Seco is quite simple. His medicaments are confined, for the most part, to chaulmoogra oil acid esters, castor oil acid esters, DakinCarrel solution, and iodine externally and internally.

The specific treatments are given each patient every alternate day. These treatments consist of intravenous or intramuscular injections and local applications of the chaulmoogra oil or castor oil preparations. In addition, the ulcers are cleaned and painted either with tincture of iodine, or treated with the oil preparations, and finally dressed with the above-named solution.

On the days for the treatments Dr. Horwitz and a trained orderly take up their station in the dispensary at the colony. The patients file by, each with sleeve of right arm rolled up. The orderly quickly applies a tourniquet, and Dr. Horwitz deftly inserts the needle and gives the injection. Almost instantaneously, the patient