A ^-J il Cornell XHnlversiti? OF THE DEPARTMENT OF ENTOMOLOGY IRew l^orft State College of Hariculture .c.n{Am j/dijL.. Z648 RC 248.A83™"""'™"'*^'-"'"^ Uncinariasis (Hool(worm disease) in Porto 3 1924 000 263 784 h Cornell University fj Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000263784 .. ., ^-, yf. _-= , 6 iBT Congress ) cT?\rAT>Tr' I I)6c0ment SdSesnon f SENATE | No. 808 UNCINARIASIS (HOOKWORM DISEASE) IN PORTO RICO A MEDICAL AND ECONOMIC PROBLEM -BY-' ' BAII^EY JL. ASmORD, M. D; Major, Medical Corps, Uls. Army !>■ . ^: V,' AN^t ,-,/ , PEDEO GUTIEEREZ'lGARAVIDEZ, M. D, Director of tjie. Tropical and Transmissible Diseases Service of Porto Rico MEMBERS OF iJ^E FOEMER POKTO JIICO ANEMIA COMMISSION ' SAN JUAN, P»ETO EICO, AUGUST ,S, 1910 :% WASHINGTON GOVERNMENT I'BINTING OFFICE 1911 61st Cokgbess ) QTiTvr A rnji ( Document SdSesdon \ SENATE j j^^_ g^g UNCINARIASIS (HOOKWORM DISEASE) IN PORTO RICO A MEDICAL AND ECONOMIC PROBLEM BY BAILEY K. ASHFOED, M. B. Major, Medical Corps, U. S. Army AND PEDRO GtlTlERREZ IGARAVIDEZ, M. D. Director of the TropicUl and Transmisiible Diseases 8n~eice of Porto Rico MEMBERS OF THE FORMER PORTO RICO ANEMIA COMMISSION SAN JUAN, PORTO RICO, AUGUST 5, 1910 WASHINGTON GOVERNMENT PRINTING OFFICE 1911 ■\ , 3 : IN THE SENATE OF THE UNITED STATES. Febeitaet 6, 1911. \ Resolved, That the report entitled "Uncinariasis (Hookworm Disease) in' Porto Eico ; a Medical and Economic Problem, prepared under the direction of the ^ecfetai'y of War, in the Surgeon General's Office, by Major Bailey K.^ Ashford, Medical Corps, United States Aritiy, and Pedro Gutierrez Igaravldez,; Director ©f Tropical and Transmissible Diseases, Service of Porto Ri'co, mem^ bers of the former Porto Rico American Commission," be printed, with illus- trations, as a Senate document. Chaeles G. Bennett, Secretary, '• By H. M. BoBE, Assistcmt Secretary. OOITTEI^TS. Page. Introduction 1 Conditiona affecting uncinariasis in Porto Eico 3 Comments on the early history of the island — uncinariasis introdiiced into the island by African slaves— social condition of victims of the disease misjudged by foreign visitors. Brief description of the island, its industries, and its working classes in the country districts: physical characters of Porto Rico — population and race — ^raising of coffee, sugar, and tobacco the chief industry — the impoverishment of the island at the time of the last cyclone due to damage to coffee plantations— social, labor, and economic conditions in the country and how these conditions are affected by and affect the endemic — the " jibaro" or peasant — the planter — ^how both are affected economically by the disease — ^the present organization of the health service — the small value of statistics relating to health in Porto Rico. History of a teji years' campaign against uncinariasis in Porto Rico 23 Anemia in the island previous to November 24, 1899 — circumstances attending the identification of the cause of Porto Rican anemia — efforts to secure general recognition of the parasitic nature of the disease — a commission formed to study and report to the insular government upon "anemia" — r6sum6 of this and subsequent work on the island. A clinical study of uncinariasis 36 The clinical types of uncinariasis — reference to notable works on disease — definition of each of types encountered clinically — methods of history taking — cases forming basis of this chapter grouped according to age, color, sex, etc. Prodromes: uncinarial dermatitis — the onset of the disease. The cutaneous system: pallor — cyanosis — petechise — pruritus — ^urticaria — lack of perspiration — dryness and harshness of skin — burning of palms of hands and soles of feet — atrophy of skin — edema. General development — ^muscular system — temperature, —"i^ Digestive system: digestive disturbances not so prominent in advanced cases — ^the dyspeptic form of uncinariasis — the appetite and geophagy — peculiar markings on tongue — catarrhal stomatitis — symptoms of gastric origin — abdominal tenderness — the feces; presence of blood not easily demonstrable — number of ova in a sample of feces — calculation of number of parasites from number of ova found uncertain. Circulatory system: varied signs found on physical examination of heart — vessels — precordial pain — palpitation — dyspnea — pericardial effusion — pulse — dizziaess — tinnitus— syncope — cerebral edema a cause of sudden death. Respiratory system: lack of characteristic symptoms. Urine: albuminuria common. The blood: average hemoglobin percentage in different types of disease — hemoglobin percentage a key to real condition of patient — rise in hemo- globin under treatment — frequent inconsistency between number para- sites harbored and percentage of hemoglobin— reasons for a belief in a poisonous product of parasites causing a toxemia — ^low hemoglobin not a barrier to manual labor — average red cells per cubic millimeter in different clinical types — ^rapid rise under treatment — tendency toward microcytosis in return to normal — changes in red cells — the leucocytes — absence of leucocytosis — eosinophilia common — ^its prognostic value — other leuco- cytes. Nervous system: the mental condition — patients frequently appear as thoflgh "drugged" — hysteria major — uncinarial psycopathies — somno- lence — ^headache — ^neuralgia — tendon reflexes — tactile sensibility — impo- tence — ^amenorrhea — susceptibility to cold — ^paresthesias. The eye: retinal hemorrhages— night blindness— retinitis— premature cataract— interpretation of eye changes. IV CONTENTS. Page. 99 A compilation of the reports of the Porto Rico Anemia Commission The first report, 1904: History of this year's campEiign and finding of the commission — modes of infection — the Porto Rican anemic usually infected through the skin — predisposing causes — the influence of the food of the jibaro upon his anemia — climate — ^humidity and rainfall — occupation a powerful factor — personal habits — earth pollution — age^sex — ^racial and acquired immunity — the "natural cure." Pathogenesis of the disease: anemia not alone caused by loss of blood — reasons for belief in a specific poison — chronic inflammation of intes- tine a contributing factor. Course, prognosis, and lethality: mortality from anemia, 30 per cent of total' mortality in Porto Rico — course of the disease that of a gradually deepening toxemia — intercurrent diseases — a discussion of the animal parasites of the Porto Rican peasant. Diagnosis: descnption of the ova— technique of inicroscopic , exami- nations — suggestive clinical features of uncinariasis — the diseases with which it may be confounded clinically, malaria, tubercu- losis, pernicious anemia, and sprue — pseudo-anemia. Prophylaxis: two main points of attack (1) prevention of soil pollution and (2) treatment of existing cases— personal education of the country people in prevention of their anemia — education in the schools — sanitary laws prohibiting soil pollution — ^forecast of a long and costly campaign. Treatment: thymol — mode of administration — can be taken at homes of patients — refutation of exaggerative accoimts of the dangers from thymol — some of its untoward effects — dosification — ^numbers of days necessary for a cure — ^interval between doses — ^male fern — general description — untoward effects of drug — ^betanaphthol — ^its possible value — the results of anthelmintic treatment in our cases — effect of ferruginous tonics not marked. Summary of four special cases in Bayamon. A synopsis of all deaths. Bibliography. The second report, 1905-6 156 Brief account of the work of the commission this year — the negro not so liable to severe grades of the disease — uncinariasis a disease of young adpJ-ts — low death rate — high percentage of cured — attitude of the peasant toward the new treatment of "anemia" — thymol preferred — betanaphthol too irrigating to the kidney to be an ideal anthelmintic in uncinariasis — patent "olood restorers " — ^iron not necessary, as a rule, for a cure. The prevention of uncinariasis in Porto Rico — ^how and where infection takes place — coffee culture the most dangerous pursuit in the island — methods advised for a continuation of the campaign — actual number of uncinarise expelled in a series of 70 cases treated by thymol and betanaphthol and the comparative value of these drugs^ male fern found to be practically inert for expulsion of Necator americanus — five doses thymol practically cures a case of uncinariasis as a rule. Recommendations to the insular government for the continuance of the campaign. Financial statement. Conaplications and intercurrent diseases encountered at the several stations. Supplementary data on the work of 1905-6 ! 182 Experimental infection of a guinea pig by infected mud poultices ap- plied to the skin — necropsy of pig. The food of Necator amencanus, parasitic in man — description of the lesion in the intestinal mucosa. Thp urine in uncinariasis before and after specific treatment; a series of 24 cases— betanaphthol causes the appearance of the diazo-reac- tion — albuminuria and casts frequently demonstrable in cases before treatment — especially unfavorable effect of betanaphthol in such CONTENTS. V Page. A compilation of the reports of the Porto Rico Anemia Commission — Contd. Supplementary data on the work of 1905-6— Continued. Gross and minute anatomy as revealed by necropsies in uncinariasis — general observations — the heart and lungs — the liver — its tendency to extreme fatty degeneration without connective tissue increase — the kidneys — the stomach — attached uncinarise found in that organ — the intestine — ^its lesion — where the uncinarise are generally found — absence of gross evidences of hemorrhage as a rule — the spleen — pecul- iar paucity of lymphoid elements — ^hemolymph glands — phagocytosis of red cells in theur blood channels — bone marrow — groups of eosino- philous cells. The thu:drei)ort, 1906-7 191 Reorganization of the commission — plans for the year — method of se- curing imiform records of work — inspection service instituted — ^re- sults of the campaign during this year — notes on certain technical studies — ankylostomum duodenale demonstrated in native -bom Porto Rican^ — treatment — experience with eucalyptus oil — ferrugi- nous tonics unnecessary. Education in prophylaxis and laws necessary for the suppression of uncinariasis in Porto Rico. Expenses of the campaign for year 1906-7. Excerpts from reports of directors of 23 stations of the commission re- ferring to the year's work. The fourth report, 1907-8 222 Comments upon the year's work — condensed statement concerning letters and resolutions from mayors and town councils of 37 towns referring to the benefit derived from the year's campaign and rec- ommending its continuance — financial statement. The fifth report, 1908-9 230 Reorganization of the "anemia service" — results of the year's work. Summary of forthcoming report for 1909-10 235 Reorganization of the service. A plan for combating uncinariasis in Porto Rico 239 There should be a special service within an autonomous department of health to combat this disease — the "anemia dispensary" the unit from which all work should proceed — how the work of the commission has rev- olutionized the system of medical aid to the poor — an ambulant service now needed to supplement the work of the stations, as the remainder of untreated anemics are out of reach of the stations. Appendix: Containing case histories of patients who were made the subject of special study — The Ponce series of 1899 — 19 cases. The Ponce series of 1902 — 100 cases. The Utuado series of 1904 — 61 cases. Contain weekly blood records and full details of treatment. The Aibonito series of 1905 — 104 cases. Series of 30 cases treated by betanaphthol in which all worms expelled were counted. Series of 40 cases treated by thymol in which all worms expelled were counted. Series of 24 cases in which urine was examined before and after the administration of each dose of the anthelmintic. Series of 10 cases of peculiar clinical interest. The Rio Piedras series of 1906 — 22 cases. — GRAPHIC MAP — OF — PORTO-RICO — SHOWING BY MUNICiPAUTIES NUMBER OF PE.RSONS TREATED FOR UNCSNARJASiS IN PERiOD FROM I90A- TO !909 A/otB' Arf£/ifA £>/SPEN3/^Ry. ne number of crosses //rd/cat&s fhe rru/TrAer ofL/ears a c/iipensary iv<7-3 m operation SAN JUAN I 1 L, ^"1 / Bayamon / Rio PlEDRAS / 5,82! .^,.-A Vpop.lZ.760^ \ Loi2A I R'o Srance / ^- w pop- 11,965 *^ \ / Trujh.loAlto\^ + \ 728 \ ,' \ pep. 12.365 / 726 Fajaroo 2,604- r ' \ '\ i , — , aoo. 5,683 \ \ ' \ 1,693 1 *" \ ..212 >;-----A. >''V•^-«"\^'^•"■'" Aguas Buenas/ 2.292. ■~.,j^ pop. 19, SSI / S15 \ Naguabo Cacoas \*''t.j:^ Juntos / 384 / \ • / San Lorenzo/ ^^^ / S.^as I 954 /8.6.Z/ ^ / pop. i3,+33 /^^ / HUMACAO/ ■.v^ pAp. 14-, 313 873 o, 13, 90S •'''*, + + + \~^~---.-^ Yabocoa ; ^^ \ 2,229 \ ,,759^^--..^ 25T ,' ,6,2. ''^^^\ ""'^^^ \ "'"""'•• ^ / ^'^'^ / pop- V • \ "-P- / pop. S. 731 / /+e67 \, op. 11. 16b \*'*j/ ^ • SAUNAS / GUAYAMA/^°^°/ pop. 12,749 fopu/atioa taken, from /ast ceftsus Less ('Aon /,ooo Setween. /,ooo cr/id 3,cioo s3,ooo ■■ 6,ooa ff,ooa - e.ooa Over s,aoo Senate Soc. Ho. 808 ; Sist Oong., 3, as could be secured under spreading trees, the P°°/^;^«[f^£?^troyed-was su(^^ ^^^ ^^^ ^^^.^^ ^^ ^^^ where they l^y^^^™^„^^.^;;^^^'j^e^^^^ great extent, were thrown to the ground, country, on Yu/f'^f^^y ^f,f °f^^Ve„ks The misery of people without shelter 24 UNCINARIASIS IN POBTO BICO. This hurricane came at a most unfortunate time, as will be seen from what has gone before. A promising coffee crop valued at $7,500,000 was rapidly reaching maturity when in a trice it was swept out of existence and the farms which produced it were damaged -to one-half their value. Bananas and plantains, which form one-half of the food value of the jibaro's ration, and the very part he does not have to buy, " were practically all destroyed to the roots on August 8." The governor general, writing to the adjutant general of the Army, says, under date of August 17, 1899 : The appearance of the surface of the country now very closely resembles a northern region that has been swept by fire, for everything is brown and lifeless. The Army took brisk hold of this situation and issued rations to the value of $831,480. With marvelous ability and the same thor- oughness which characterized his founding of the superior board of health of the island and the vaccination of 800,000 Porto Eicans, Col. John Van Rensselaer Hoff, of the Army Medical Corps, estab- lished a splendid system of aid to starving people on the principle enunciated by himself: No person shall die of starvation, and no able-bodied man shall eat the bread of idleness. Thus were the lives of untold thousands preserved and the grati- tude of the Porto Rican people honestly earned. In this hurricane 2,780 were known to have died as a direct result of the storm itself, generally by drowning, and 500 more were never heard from. In Jayuya whole coffee plantations slipped down the mountains into the rivers. In the wake of this storm came a period of rain, which was un- usually prolonged and violent; everything was wet and muddy for weeks. Dr. Ashford, who was in Ponce at this time, a city which had suffered severely both from storm and flood, received an order from the general commanding on the 26th of August, 1899, to establish a field provisional hospital for the purpose of accommodating at least some of the thousands of sick jibaros who were thronging the streets of the city. All went well until he attempted to feed up what he considered as- anemics from malnutrition. He very soon found that they did not care for meat and other concentrated foods, but demanded their bulky diet of the hills. Moreover, the diet of a healthy American soldier made them sick with diarrhea, and they began to leave cainp. He states, under date of September 13 : The explanation of this Inaptitude for our cooking is believed to be also due to the fact that many eat little more than dried codfish and a small number of bananas at any time, and that they were in a meat-starved condition when admitted. This is further borne out by the fact that fully three-fourths of the patients are suffering from grave anemia due to this poor diet, and together with this cause bad sanitation, but chiefly from the bad quality of food to which they are accustomed. * * * The cases are many of them chronic. * * * These chronic cases are among those most desperately in need. Pernicious anemia, malarial cachexia diseases of the heart, lungs, and kidneys are the prevalent diseases. From this time on great care was exercised to give these people an abundant diet. He had a ration of 60 cents a day at his disposal and no pains was spent m coaxing and compelling a rational diet' In UNCINARIASIS IN PORTO RICO. 25 this he was successful, for with a Spanish cook the food was made more palatable and the diarrhea subsided, as did the complaints of the barbarous food of the "Americanos," but not one whit more color came into their faces, and the daily death toll was about the same as it had been at first. THE IDENTIFICATION 01" THE CAUSE OF PORTO RICAN ANEMIA. After over two months' examination of many patients and much speculation, it became evident that these chronic sick, the anemics of many years, not of a few months, were all suffering from a common pialady; that they presented a picture identical with that Dr. Ash- ford had observed in the country people in various parts of the island previous to the cyclone ; that gastric dyspepsia, heart lesions, oedema, extreme pallor, and debility did not stand for separate diseases, according to the prominence of one or the other set of phenomena, but were part and parcel of a clinical entity ; that this protean array of symptoms had one definite cause and was not dependent upon a series of predisposing accidents of environment, concomitant disease, or mere poverty and bad hygiene. The suspicion became more fixed when good and abundant food throughout two or three months had utterly failed to influence their condition. At first his attention was directed to the blood in a search for the cause. Malaria was thus excluded, but on a differential count of the leucocytes a decided and rather general eosinophilia was noticed. Remembering that recent investigationsof the blood of sufferers from trichiniasis had unearthed a high eosinophilia, and realizing that the habits of these people would expose them to a general infestation by animal parasites, the feces were searched; ova were found which tallied with those of Ankylostomum duodenale, pictured in Hanson's first edition of Tropical Diseases, and thymol was administered to a typical case. With the recovery of the worms the cause of the anemia of Porto Rico was demonstrated. Thinking that the parasite found was the Old World species, the only one up to that time described, he sent the following telegram: Ponce, 'November 2li, 1899. Chief Surgeon, San Juan: , Have this day proven the cause of many pernicious, progressive anemias of Ihls island to be due to AnkyJostonmm duodenaJe. Asiifobd. This announcement was followed by instructions io Dr. Ashford from the chief surgeon to aid the superior board of health in prepar- ing paniphlet on the subject. This little work, entitled, "Anemia, Sf Causes Treatment, and Prevention," was issued by the board in SoO and distributed among all physicians -'^^gSnTf^SanToS out the island. It contained copies of the illustrations in Manson s work and was PubMied in E^/-h -d^^P^^^^^^ article on 19 spe- cia'Vut SLlnXrwhS- w^^^^^^^^ the Surgeon Gene-l^onhe ciai siuu^ ^u„^ ;t„ re-Dublication was authorized m the JNew lorK MeSaKS ipS ?4, 1900, under the title, "Ankylostomiasis in "^EetSrSfto the United States in December 1899 D- Afford caSedsime of these worms to AVashington, where he called upon 26 UNCINARIASIS IN POETO E.ICO. Dr. Charles Wardell Stiles for the purpose of giving them to him. As Dr. Stiles was not in Washington at the time, they were examined by his assistant, Dr. Albert Hassall, who, after a cursory glance at a female, remarked that the ova were unusually large for Ankylosto- mum, duodenale, and recommended more careful study of them zoologically, but Dr. Ashford, not being a zoologist, left his speci- mens in Washington and made no further study of the worm he had found in Porto Rico. Stiles, in 1902, working with Ashford's specimen of hookworms from Porto Rico, and with others from the United States found sub- sequently, announced that zoologically the parasites beloliged -to a new species, Uncinaria americana, although later he changed the name to that which now obtains, Necator americcmus. The new spe- cies, interesting from a zoologic standpoint, although the mode of infection, symptomatology, morbid anatomy, treatment,^ and pro- phylaxis of the disease caused by the Old- World and the New- World worms are, so far as we know, precisely similar, became of tremendous importance when Dr. Stiles demonstrated that uncinariasis was crippling the South just as Dr. Ashford had shown it to be the in- dustrial curse of Porto Rico. Through the pamphlet issued by the superior board of health in 1900 and the simultaneous appearance of Ashford's article in the New York Medical Journal, physicians in Porto Rico and in the United States were advised of the presence of hookworm in the island and of its tremendous power for evil, but neither here nor on the continent was any especial interest aroused, save in the few who later on have taken an active part in subsequent campaigns against its ravages. Despite the pamphlet of the board of health averring that anemia was the scourge of Porto Rico, " killing at least 1,000 persons each month " and warning the practitioner to be " constantly on the out- look in all cases of anemia for this parasite," etc.; despite the re- publication of Ashford's American article in the report of the supe- rior board of health for the period of military government, with a corroboration of its importance by Lieut. F. F. Russell, of the Army, in 1900, who found the ova in 54 per cent of the inmates of the boys' charity school in San Juan; despite the repetition of the an- nouncement by the succeeding board of health under the new civil government that anemia here was due to an intestinal parasite, Ankylostomum duodenale, no active measures were taken for its study nor for its control. This is not to say, however, that it aroused no mterest among a few medical men in Porto Rico, but there was no general interest manifested, even by the Government at that time. Feelmg sure that a work undertaken to convince the island of the significance of a disease which accounted for over 30 per cent of the total high mortality at that time would have far-reaching conse- quences, and realizing that this death rate would go on until some one would make a sufficiently strong demonstration of the possibility o± Its eradication to awaken both Porto Ricans and Americans in the insular government to action, Dr. Ashford expressed his earnest desire to return to the island. ap;e^a?1orc?'so"^^^e'otrv?l/^up^on.1S'iora;^?.l*Jr ^-'"^'-t^-a duodenale, does ^ot UJNUlJNABiABlS IN PORTO EICO. 27 In January, 1902, after a careful survey of the literature of this disease in the Surgeon General's library, he was again ordered to Porto Rico, and there met Dr. Walter W. King, of the United States Public Health and Marine-Hospital Service, who agreed to take part with Dr. Ashford in a study of such a number of cases as would bring the matter clearly to a head and compel attention not only from the profession, but from the insular government. Throughout 1902 and part of 1903 a series of 100 cases were carefully followed, blood counts made, and treatment detailed. They were ceded for this purpose two wards in the large Tricoche Hospital of Ponce, and every possible opportunity was afforded them by the director and his assistants to complete their labor with success. The report of these 100 cases was published in American Medicine, September 5 and 12, 1903. In this article the following appears: Whatever the attitude of the local practitioner may be, it is a fact that the importance of uncinariasis is not being realized, and that the proper efforts are not being made to cure and stamp out this disease. We appeal for a thoughtful and sensible view of what is now the great scourge of the agricul- tural classes in Porto Rico, and what has come to be a most important economic question in the betterment of the island. The editor. Dr. Gould, was not only good enough to permit this lengthy article to run through two numbers of his periodical, a sig- nal courtesy, as it was contrary to his rule that an article be accepted for publication which could not be terminated in the issue in which it was begun, but he wrote a stirring appeal, which accompanied our thesis, to arouse the medical men of the island and the govern- ment of Porto Eico to a realization of their grave responsibility. One month later Drs. Ashford and King addressed a letter to the president of the superior board of health of Porto Eico, furnishing him with extracts from many European authorities on ankylos- tomiasis and urging: (1) To thoroughly circulate the literature on the subject. (2) To take some part of the island, as Utuado or Adjuntas, where " starva- tion misery," etc., is reported; establish a tent hospital; place two well-in- structed doctors, who are enthusiastic, energetic, and diplomatic in charge ; let them have the nurses, medicines, cots, and food for the running of the station ; and let them go into the highways and byways and seek them out, cure as many outpatients as possible, and take the miserable poor into the tents. After six months publish results, see if the death rate from these centers of uncinariasis does not materially decline, and, above all, let us see how much "starvation, misery " and so forth is the fault of Unomana amencana and how much Is due to real lack of food. * * * , . . Such an experimental station, if conducted by Porto Eican physicians modern voung men men-who will be painstaking, and who will understand that upon fhem iSs a heav7 responsibility ; that they are there to fight down a shock- S hfgh anem^I mortality; such a station, we repeat may cast its helpful U_S. Doc. 808, 61-3- 34 XJNCINABIASIS IN PORTO BIOO. The following table gives a succinct statement of the work to date: Summary of anemia worlc. Patients treated. Age. Years. Under 10 years. Between 10 and 30. Over 30. Not recorded. 1904-5 5,490 18,865 ■ 89,233 81,375 54,725 37,880 566 2,199 8,913 8,964 6,668 4,877 3.138 11,532 61,972 52,608 34,905 24,294 1,764 4,922 28,232 19,152 13,152 8,709 22 1905-6 212 1906-7 116 1907-8 661 1908-9 1909-10 Total 287,668 32,177 11.18 178,449 62.05 75,931 26.40 1,011 Percentage 0.14 CLINICAL TYPE. Years. Very light. Light. Me- dium. In- tense. Very intense. Un- classi- fied. Number of visits. Num- ber of deaths. Amomit spent. 1904-5 1,222 4,483 19,503 14,968 10,720 7,751 1,063 8,706 38,439 40,136 24,248 16,639 2,258 3,601 19,212 19,140 16,409 11,537 '"'446' 4,162 3,465 3,334 2,063 947 367 832 644 4 22,000 76,896 426,131 472,407 305,598 27 67 193 93 46 47 S4,954.84 10, 808. 77 1905-6 1,378 7,085 3,022 1906-7.. . 49,116.31 56,950.57 32,360.91 29,706.98 1907-8 1908-9 1909-10 Total Percentage 11,486 3.99 68, 647 20.39 129,131 44.90 72,057 25.06 13,464 4.68 2,784 0.96 1,302,032 473 183,898.38 Cost of treatment per patient, 63.9 cents. One of the most interesting features of the campaign against uncinariasis has without doubt been the contribution made to the study of the disease by the medical men of the island from the point of view of microscopic diagnosis. No sooner had the commission been formed and its members had proceeded to systematically examine the feces of all who solicited treatment than there awoke in our colleagues who visited the clinics of the first commission in Bayamon, Utuado, and Aibonito, and at those of the second in Kio Piedras, Mayagiiez, and Lares, the desire to scientifically fix their diagnosis of "anemia due to uncinaria " by microscopic examination in all of their own cases. The natural consequence of this was the acquisition of microscopes, of which there were very few when the commission began its labors, for up to this time, with the exception of the Government laboratories and the offices of a very restricted number of men in private practice, the micro- scope had not taken a very prominent place in practical work. The majority of physicians were not familiar with microscopic technique, some because they had not made any special study of it, others be- cause in their daily practice they had forgotten how to use this instrument. Considering all of these things, the labor of the Porto Kican physician who so promptly realized his position in the scientific world and without doubts or vacillation hastened to take his part in the struggle against the disease by first learning to recognize its etiological factor, the ovum of the parasite in the feces, demonstrates UNCINARIASIS IN PORTO RICO. 35 how sincerely interested he was and how eager to press forward in the advance of medical science. From that moment began the demand for microscopes ; many phy- sicians bought them, others received them from the municipalities, and others were loaned them by the commission. Practically there is not a town to-day in Porto Eico that has no microscope, from one source or another. Along with this scientific movement came the dispensaries, which caused a revolution in the health service of the municipality, because the physician from that time on fixed a definite place and hour when he might see the anemics, which practically embraced the entire working population of the municipality. The benefit extended to the sick poor by this organization of the medical service whereby they could be rapidly examined and properly attended was keenly appreciated by those whose difficulties heretofore had been well-nigh insuperable. While the commission was putting into practice in Aibonito its plans, first developed in Bayamon and Utuado, of extending the campaign to a number of towns, Dr. Isaac Gonzalez Martinez con- ceived the idea of forming a league against uncinariasis, but the time was not yet ripe for the realization of his ideals, and unfortunately it had only a short life. This was, however, no obstacle to the sys- tematic campaign carried on by the legislature on the one hand and the practical one begun by the individual efforts of the medical men of the island on the other. To-day, warmly seconded by the approval and personal interest of everyone in Porto Rico, a service has been provided which, although its resources are modest for the enormous responsibility it carries, proposes to carry into the mountain barrios an efficient organization, confiding in the towns to sustain the bur- den of the dispensary work within their immediate limits and hold tight to the territory so far won. The service in charge of this work is denominated the " service of tropical and transmissible diseases," the successor of the " anemia dispensary service " of 1908, which was in turn the successor of the Porto Eico anemia commission. All of these services carried the same idea : The reduction of mortality and morbidity among the laboring classes of Porto Eico, at first attacking anemia merely ; later, after realizing the hold it had begun to get on that formidable enemy of the poor workingman, not only anemia, but all tropical and transmissible diseases. The sum total of persons treated for uncinariasis to June 30, 1910, is 287,568. This represents the work of the commission and its successors, the anemia dispensary service, and the service of tropical and transmissible diseases, since the beginning of the campaign of 1904. We estimate that at least 30,000 more have been treated apart from Government work and of which we have no record. We are entirely safe in saying that over 300,000, or nearly one-third of the population of Porto Eico, have received specific treatment for uncinariasis. A CLINICAL STUDY OF TINCIWARIASIS. The clinical investigation of uncinariasis has always seemed to us to have been less carefully studied than its parasitology and associated problems of prophylaxis. The aim of this chapter is to place before our readers as simply and as concisely as possible (1) the composite picture of the disease uncinariasis; (2) a detailed discussion of the clinical. features; (3) the results of clinical laboratory investigation. Many otherwise excellent treatises on this disease dispose of the clinical features by giving what is little better than a mere list of symptoms from which the patient may suffer, without sufficient refer- ence to the deeper underlying bases upon which these manifestations are founded. This bundling together of symptoms without the con- stant check of the clinical laboratory has led some writers to believe that the symptoms of uncinariasis are solely those of a more or less intense anemia. It is our opinion that this is far too restricted a view of a disease which is a clinical entity, in spite of its protean forms, and even in spite of the prominence of one of its best-known symptoms. We assume and believe that uncinariasis is a toxemia. We assume it from the cumulative evidence that our direct personal observation of about 13,000 cases affords us, and we believe it from the confirmation of our assumption in the experience of those who, under our direction, have treated in a more or less similar manner about 275,000 more. It is proven that the introduction of the malarial parasite into the circulating blood causes the phenomena of " malaria " the moment that endogenous sporulation has produced a number sufficient to overcome the natural resistance of the body to their influence. Do these phenomena take place because the parasites devour red blood cells or because they liberate poisons? Most of us feel that we can venture upon a fairly secure answer to this question, even in the absence of proof that a " toxin " exists. It is equally well proven that uncinariasis is caused by the closely related Ankylostoma duodenale and Necator wmericanus, which for the practical purposes of a physician can be considered as identical. We desire to present enough evidence to permit the entirely reason- able belief in a poisonous product of these parasites, causative in large measure of the clinical picture which we are called upon as physicians to consider. We make this statement to expressly disavow any claim on our part to the discovery of this '' toxin," which is as yet wrapped, as is the product of malarial infection and the virus of typhus, in an im- penetrable mystery. 36 TTNCINAEIASIS IN POETO EICO. 37 Clinical Type or the Disease. Varieties of acute and chronic uncinariasis may be recognized, and to these may be added another in which an acute supervenes upon a chronic form. For convenience, three grades of the disease are distinguished, (1) slight, (2) moderate, (3) marked. But the temptation to reduce uncinariasis to a number of distinct varieties can be fairly said to have failed. The disease is too in- sidious and too complex in its manifestations to harness to any, un- yielding classification of forms. There are forms of the disease really quite distinct the one from the other, but they are the exception. Calmette and Breton mention a large number of clinical forms, such as the acute dyspeptic, the chronic dyspeptic, the anemic, the icteric, etc., but as a matter of fact there are an abundance of cases which present the essential features of all these " forms." Lutz has a cumbersome classification, too long to repeat here. It is carefully worked out, but impracticable, because it is too complex and fails, as do others, for the above-mentioned reason. We believe that the only classification of the manifestations of the disease which is simple is that which divides it into light, moderate, and marked types, a division based upon its intensity. Our decision to so classify was made for a very practical reason : We had a large number of stations throughout the island. To have confided the estimate of the form of uncinariasis to each one of our many assist- ants would have been to have had great confusion in our summing up of the total results of the work. The simpler division was far less exposed to error and we had the security of knowing that every one knew just what was meant by the three types we suggest here. In the rush of a busy clinic it is necessary to reduce to a very few words a fairly faithful picture of the sick man, and this classification gave us the type, while upon the same card was a space for " most promi- nent symptoms." Our subdirectors of stations here entered, first, the system or systems especially involved and all curious or unusual or interesting features of the particular case thereafter. Stiles (Osier's System of Medicine, vol. 1, 1907) desires to estab- lish under symptomatology a classification not based upon the symp- tomatology of the disease, but upon the degree of infection "sug- gested as a compromise between the classification proposed by the writer in 1902 and that used by Ashford, King, and Gutierrez (1904)." We can not accept this classification by the eminent zoologist, as it is contrary to the meaning of " disease " and " symp- tomatology." It is manifestly impossible to speak of the symptoms of his " light infections," for under his classification there are none. And it is certainly not proper to consider such a person as suffering from uncinariasis, in a medical sense, when he is no worse off than the symptomless " carrier " of typhoid bacilli. Let us speak, under the head of symptomatology, of the manifestations of the disease uncinariasis. Later we will treat, in its proper place, of worm car- riers and worm sick. As soon as the stress and strain of the worm carrier's life, perhaps with the incidence of privation or of other diseases, breaks through his relative immunity, he is apt to demon- strate some of the symptoms of uncinariasis and become worm sick, although no more worms, or even less, may be harbored. With the 38 UNCINARIASIS IN PORTO EICO. exception of a few, whose relative immunity is pronounced, these m- dividuals contain comparatively few worms. But when they become hosts of from 300 to 400, symptoms of the disease make themselves manifest unless resistance to the poison is still sufficient to ward them off. While, therefore, uncinariasis is largely a question of intensity of infection, it does not follow that one can base a classification upon the relative number of wonns a host may harbor. In the course of this chapter reference is made to several authors whose observations have been especially interesting to us in prepar- ing this work. The literature upon this subject is now very abun- dant, and, rather than burden this work with a bulky bibliography, we take the liberty of recommending the following treatises, to whose authors we make frequent reference. The difficulty has been that the vast majority of the most eminent students of the parasite have not had the variety of cases, especially the severer grades of the disease, from which to make a complete study of the clinical manifes- tations caused by a number of parasites sufficient to make a man really very ill. 1. " iJber Ankylostomiasis und Ankylostomum duodenale,'' by A. Lutz. Volk- mann's Samml. kliu. Vortr., Nos. 255, 256, and 265. 18S5. This admirable clinical study has been frequently quoted in works treating seriously of the symptomatology. Although written 25 years ago, the observations were made upon patients seriously ill of the disease in a heavily infested region of South America which has already been made famous by writers on uncinariasis. The work can still be considered a classic. 2. " Observations on 400 cases of anchylostomiasis," by F. M. Sandwith. Written for the Eleventh International Medical Congress, held in Rome: 27 pp. 8°. London, 1894. This is a treatise similar to the previous one, valuable for the con- cise and clear exposition of the symptomatology of the disease as observed in heavily infested Egypt. Neither of these two works make special use of laboratory methods for clinical research. 3. "An Outbreak of Ankylostomiasis in England." By A. E. Boycott and J. S. Haldane. Jour. Hygiene, Cambridge, vol. Ill, No. 1, Jan. 1, 1903. "Anemia in Ankylostomiasis," by A. E. Boycott. Brit. Med. Jour., London, Nov. 9, 1907. The study made of the blood in these two treatises is well worth perusal. The observers investigated the disease as it presented itself in the mines of Cornwall. The general type, with the exception of a few cases, seems to have been moderate and light. 4. " Ueber das Wesen und die Verbreitung de Wurmkrankheit." By Loebkei and Hayo Bruns. Imperial Health Office, Berlin, 1906. This work is an excellent one, not only for the symptomatology, of which it treats at length, but for the scientific manner in which the entire subject is discussed and for its thoroughness and at the same time its clearness of exposition. The clinical material was drawn from light cases in the mines of Westphalia and from a general review of the literature. The character of the scientific research at the Gelsenkirchen laboratory by Bruns and his associates is too well known to need further encomium on our part. UNCINABIASIS IN PORTO BICO. 39 5. " Per lo studio dell' anchilostomiasi." " Nuove ricerche ed osservazioni suir anchilostomiasi." " Eosinofili del sangue ed elminti intestinale nell' uomo," by P. D. Siccardi. " Osservazioni cliniclie e sperimentali suH' anclii- lostomiasi," by M. Spargella. " Note sulla diffusione del vermi intestinali e suUa loro Importanza clinica," by L. Messedaglla; All of these theses are published together in "Lavori Dell' Isti- tuto," volume 111, Studi di elmintologia clinica, 1905-1907, Milano, 1907, Istituto di clinica medica generale della R. Universita di Padova. This bulletin of the University of Padua, containing 435 pages, is really a notable one. For remarkably clear and unequivocal language this work, to our mind, surpasses all. It is true that we may be influenced in our opinion of this book by the confirmation of practically all of our own clinical impressions set forth in 1902 and 1904, but, in addition, experimental work of an entirely original character is reported, which has contributed much to the better understanding of some quite obscure points in the disease. The work of Siccardi is especially valuable, as he fearlessly cuts into old and worn-out theories and false deductions with the knife of a surgeon,' brilliantly refuting doctrines no longer tenable in the modern conception of uncinariasis and basing his views largely upon his own personal and laborious work. These theses are essentially those of clinical research in which the laboratory contributes its important part. The histories of the cases recounted in the appendix to our own work are made as brief and concise as possible, and many details are purposely omitted which might be of interest, but whose omission does not alter the conclusions drawn. These cases, plus our direct personal observation of about 13,000 others in clinic and hospital, and our indirect observation of about 275,000 more, serve as the basis for our conclusions with respect to uncinariasis. The " study cases " (see appendix) are those of uncinarial anemics placed under our con- tinuous observation in a field hospital near our headquarters from the day they first consulted us until they were discharged cured, died, or deserted. We believe their histories to be fairly complete, as they were taken with extreme care and all data were collected by us per- sonally. The supplementary data accruing from the enormous daily clinic of out-patients are also taken from a written history made in each case, but parts of these histories are not at all complete, owing to the physical impossibility of handling with a sufficient force the numbers they represent. After these preliminary remarks, we may now describe succinctly what we mean by light, moderate, and marked cases. In previous years we have spoken of "very light" and "very marked" cases. We can not see that such multiplicity of terms adds anything to the better understanding of the classification adopted here, so we have combined " very light " and " light," and " marked " and " very marked" cases, and described them, respectively, as "light" and " marked." LIGHT CASES, Such are those who possess little or no pallor, or, at best, show but an indefinable dirty yellow tinge of the skin in whites, a slight pastiness in mulattoes. In general such patients are " sallow." There is a reduction in the amount of perspiration. 40 UNCINARIASIS IN POUTO RICO. This is the grade of uncinariasis in which we find the patient quite communicative with regard to disturbances of the digestive tract, for the other systems are not yet sufficiently involved, as a rule, to seri- ously attract his attention; The disturbances are manifested by pain in the epigastrium, especially after eating, with heartburn, flatulence, and weight and fullness in the epigastrium. There is some tender- ness in the same region and an unusually large appetite. Excep- tionally the appetite is poor, the pains are intense, and nausea and vomiting are frequent. In the vast majority of cases the feces do not reveal anything out of the ordinary, save ova of uncinarise. In the circulatory system physical examination reveals but little. There is apt to be some degree of overaction of the heart and in- creased frequency of the pulse. There may be slight breathlessness after exertion and some palpitation. A little dizziness may make itself manifest. The most prominent symptoms, next to those of the digestive, are to be found in the nervous system. . There is a distinct reduction in mental activity. Distaste for work, apparent laziness, indifference, abstraction, and a tendency to forget are manifest. The facial expression bears out the conditions mentioned. There may be a tendency to sleep in odd moments. Headache may be complained of from time to time. The hemoglobin of such persons generally lies between 60 per cent and normal, the former sometimes in spite of good color. The ery- throcytes are apt to be normal in number. A frequent sign is'eosino- philia, and a very early one. To sum up the clinical picture of a light case, therefore, we may saj that an individual, previously vigor- ous and energetic, gradually finds himself losing in strength and inclination to work, with symptoms of " dyspepsia " and perhaps with a faint pallor. To his friends and neighbors he is " run down." To unfriendly eyes he is lazy and " good for nothing." MODERATE CASES. These form the usual type seen in Porto Eico, although, naturally, at the beginning of the campaign, in 1904, marked cases predomi- nated among those applying for treatment. Here all symptoms noted under light cases are more pronounced. The pallor is definite and is demonstrable in the mucous membranes. The skin is quite dry and sweating is rare. Patients frequently complain of pruritus. _ In the digestive system we note that the appetite may become vora- cious, even to bulimia and geophagy. Nausea and vomiting are less rare. Meteorism begins to become troublesome, and with it, at odd times, enteralgia and abdominal tenderness. The bowels, while usu- ally normal or constipated, become at irregular intervals' loose with the evacuation of undigested food in vile-smelling stools There is m other words, intestinal indigestion, with the attendant phenomena' a natural sequence of overstuffing plus inactivity of the die'estive organs. s "<= Some cardiac hypertrophy can often be made out with its attendant signs The pulse is more rapid and at times even weak and com- pressible Palpitation of the heart is here a prominent symptom is liable to be severe, and is not always relative to exertion, which latter however, usually brings on breathlessness. Precordial pain, sharp or dull and prolonged, follows great efforts. A hemic murmur is as a A TYPICAL "SEVERE CASE," ARECIBO, 1909, CONTRIBUTED BY DR. ROSES ARTAU, DIRECTOR OF THE STATION OF ARECIBO AND DISTRICT CH I EF. This man was 25 years of age, had many ova of unoinarige in his stools, and was utterly pros- trated. Blood record at time of this photograph was as follows: Hb, 12 per cent; red cells, 876,000 per c. m.; white cells, 9,000 per c. m.; percentage eosinophiles, 4.3. His temperature was 36 degrees C., and the urine revealed one-half per cent albumin and a strong indican reaction. Result of treatment: cured. UNCINARIASIS IN PORTO EICO. 41 rule, readily defined, and pulsation of the vessels of the neck is notice- able. There are much dizziness, especially on sudden changes of posi- tion, noises in the ears and frequent headaches. In general, the circulatory system has taken precedence over the digestive system in the patient's estimate of his own condition. On the other hand, the mental picture is the prominent one to Ihe man's friends. If the symptoms referable to the nervous system are prominent in light cases, they occupy a truly important place in the moderate grades of the disease. The subject is decidedly depressed, quite passive to his surroundings, and appears densely stupid or con- fused, or both. The mental condition is still more strongly reflected in the facial expression and is heightened by th^ pasty complexion in the now frankly " anemic " patient. Sometimes the patellar reflex is exaggerated, but more often it is diminished. There is suscepti- bility to cold and tingling of the feet, which frequently " go to sleep." Partial impotence in men and amenorrhea in women are noted. Blurred vision and other signs of visual troubles make their appearance. The urine may reveal albumin by delicate tests. No emaciation is noticed, but the muscles are flabby, a little painful, and quickly tire. Work is undertaken with a distinct effort. There is much ,pain in the sternum and chest and a feeling of weakness in the knees and legs. The hemoglobin is apt to lie between 30 and 60 per cent, the red cells hover around 3,500,000 to 4,000,000 per cubic centimeter and the eosinophilia is at its height in this class of cases. In a few words, the patient looks and feels definitely sick. There is no longer mere disinclination to work, but partial inability. He is pale, exertion brings on throbbing of arteries and palpitation of the heart ; sudden changes of position, sudden dizziness. He is half narcotized, as it were. The subject can be described as a moderately anemic individual with minus activity of mind and body. MARKED CASES. Here the patient has arrived at that stage where a fatal termination may occur at any time. The yellow pallor is extreme, and it is at times difficult to say where the mucous membrane of the lips begins and the skin ends. Edema of the feet and ankles alone, or this and puffiness of the face, or, not rarely, extreme anasarca, are seen. The patient seldom perspires, the skin being dry, harsh, and wrinkled. The digestive disturbances have changed in character, appetite is often nil, often enormous. Some of the worst forms of geophagy are noted in this grade. Nausea and vomiting are frequent, not rarely aggravated by dilatation of the stomach. Diarrhea may alternate with constipation. The former predominates and is apt to become serious; even enterocolitis may supervene, but, as a rule, without blood. The best description of these diarrheal movements is that they are composed of putrefying, indigested food mixed with mucus. Meteorism and concomitant symptoms mentioned under moderate cases become exaggerated. , . , , It is in this grade of the disease that the hypertrophied heart tends to dilate, with a weak, running, compressible pulse, often becoming 42 UNCINARIASIS IN PORTO RICO, irregular, and tremendous pulsation of the great vessels at the base of the neck. It is not at all infrequent to note venous pulsation with bruit-de-diable of the jugulars and the phenomena of passive conges- tion of all viscera. The murmurs are loud and well defined or ob- scure, muffled and confusing. Diffuse pulsation of the precordium is noted and severe palpitation and precordial pain are the subject of bitter complaint by the sufferer. There is distressing dyspnea on the slightest movement and sometimes when the patient is perfectly quiet. Dizziness and a roaring noise in the head are marked. Effusions into pericardium, pleurae, peritoneum, and cerebral ventricles may be ex- pected. Edema and passive congestion of the lungs are apt to occur. Syncope is not unu^al, and the patient is often afraid to stir out of his house, if, indeed, he can muster the strength to do so. The nervous system suffers very severely. In addition to all of the mental confusional states before noted, manic depressive insanity may supervene. There is much headache and insomnia, the patellar reflexes are abolished and paresthesias become very marked. In men, impotence is an almost invariable symptom; amenorrhea in women. The vision is blurred and the pupil tends to dilate. These patients can not get enough covering; they will shiver in the shade in this tropical country if a breath of air strikes them. The urine has a low specific gravity, is abundant in quantity, and often contains albumin, but usually only a trace, and casts. The muscles are flabby, sore, and painful. Extreme weakness, even to the simulation of paralysis, is observed, and the patient is incapacitated for labor. There may be irregular fever, with inter- vals of subnormal temperature. Marked cases generally have a hemoglobin percentage below 30. As a matter of fact, with regard to blood changes in this grade of the disease, it is better to consider cases that are " marked " and those that can be said to be " very marked." In the flrst we can expect a hemoglobin between 21 and 30 per cent, with often a well-marked eosinophilia, and a red cell count ranging between 2,000,000 and 2,500,000. In these cases the anemia is still a manifestly secondary anemia, with predominance of microcytes and a low color index. In the second or " very marked " cases the hemoglobin falls below 20 per cent, and the lower we get the more apt we are to find that the eosinophilia has disappeared, that the clear picture of a secondary anemia fails us, that macrocytosis, not microcytosis, is dominant, and that myelocytes and megaloblasts are mcreasingly frequent. The color index in these cases at times ex- ceeds 1., and the picture may then be well considered as one of perni- cious anemia. In these very marked cases the red cells tend to fall to very low figures. In general review of all that has preceded, we are enabled- to see why Sandwith divides the clinical phenomena of uncinariasis into (1) digestive, (2) circulatory, and (3) nervous cycles Uncinariasis is a disease, therefore, caused by infection with a sutticient number of these parasites to overcome the natural or racial immunity of man. Its manifestations depend on (1) the number of worms harbored 2) the length of time they have lived in their host (3) the susceptibility of the host to their hypothetic poison ' Ihe effects of such infection are modified by (1) concomitant disease or weakly constitutions; (2) the involvement of organs/sS UNCINARIASIS IN POBTO EICO. 43 as heart, kidneys, brain, blood, etc., to an extent which markedly disturbs their functions and thus establishes a vicious circle for their own further destruction; (3) the ability of the patient, from his position in life, to resist this poison. Good food, a life sheltered from privation and excessive manual labor, and absence of concomi- tant disease make for strong resistance. When, however, we con- sider the obligation of the poor to engage in hard manual labor, to work without shoes, exposed to daily infections in the rain and through long hours, remunerated by half shelter in a poor hovel and the coarsest and most indigestible food, poor in proteids, it is easily seen why the worst victims are to be found among the . country laborers. It has been an unvarying rule of the directors of this work in the island to make a personal history for each patient applying for treat- ment at our dispensaries, and cards for this purpose are on file here with the data called for in the printed headings. Their mere bulk, if nothing else, would require many months for compilation of all the clinical data they contain, but it will perhaps suffice to state thai all give : 1. Current case number. 2. Name. 3. Barrio or township in the municipality. 4. Date. 5. Color, age, sex, and social position. 6. Occupation. _ 7. Statement as to presence or absence of a special place for defeca- tion, such as latrine, earth closet, etc. 8. The clinical type of the disease in each case, synthetized from the general appearance, the physical examination, and the personal history. 9. Whether or not the patient had mazamorra or uncinarial der- matitis, and, in case of an affirmative, where same was acquired. 10. AH varieties of parasitic ova in the stools and relative number thereof. 11. Most prominent symptoms. 12. Complications and intercurrent diseases. 13. Treatment. In the eleventh item it was found convenient to make such notes as " circulatory system, marked," " nervous system, slight," " intense pallor," etc., thus accentuating the particular system or systems most notably involved in the classical picture usually presented. Thus, in a few words and without the minutely detailed history, we were able to preserve a fairly clear idea of the state of our patient on ad- mission to clinic. The necessity for these abbreviations will be seen in the large daily clinics we handled (from 200 to 700) and our scanty funds, prohibiting the employment of adequate professional assistance. In the thirteenth item the dose of the specific, the dose of the purge, and the relative number of ova of uncinarise remaining were noted, in addition to any remarks of interest during the course of treatment. The large clinics each day will be better understood when one thinks of our instructions to each patient, i. e., that they should return every week until their feces revealed a complete absence of ova of uncinarise. 44 UNCINAMASIS IN POETO RICO. The following series of cases form the basis in our discussion of the clinical features of uncinariasis for the percentage frequency ot the phenomena which make up the picture of the disease m Porto Kico. These cases, in contradistinction to the "clinic" or out-patients, were hospitalized under our immediate daily observation, llreir histories were taken with great care and are fairly complete. We say " fairly " because in some series predominance is given to one line of clinical investigation over others. Again, in some series cer- tain well-known and practically universal symptoms were not noted, and without the expressly written record we have not presumed to depend on generalities to cover such gaps, preferring to exclude from a percentage estimate, series in which that particular symptom was not uniformly reported upon. With these preliminary remarks we may consider the various series in their order: (1) Ponce series of 1899. — This series comprised 19 cases. ijnder 10 years None. Between 10 and 14 years 1 Between 15 and 24 years * 5 Between 25 and 40 years , 7 Over 40 years i 6 19 Color : White ^ 13 Mulatto 2 Negro 4 19 Sex: Male 18 Female 1 19 Period of illness (very approximate only, in all series) : 1 month 1 6 months 1 9 months 1 18 months 1 2 years .3 3 years 1 6 years 1 19 years 2 " Some time" 1 " Long time " 1 "Do not remember when I was well" 1 " Always " 1 " Don't remember " 4 19 Complications : Elephantiasis arabum 1 Malaria and tuberculosis 1 Pneumonia 1 Abscess of the liver -y XJNCINABIASIS IN PORTO KICO. 45 (2)^ Ponce series of 1902. — These were 19 cases selected for uni- formity of data and completeness from 100 studied that year in the Tricoche Hospital of Ponce, by Ashford and King. Age: Under 10. 1 Between 10 and 14 years 3 Between 15 and 24 years 5 Between 25 and 40 years — 7 Over 4a 3 19 Color : White 13 Mulatto 5 Not stated 1 19 Sex: Male . 19 Female None. 19 Period of illness: 2 months 2 3 months 2 8 months 1 10 months 1 18 months 1 1 year 3 2 years 2 3 years 3 4 years 1 6 years 1 8 years 1 "Don't remember " 1 19 Complications, malaria 3 {3) Utuado series of 1901^. — This entire series is available for a study of the clinical features of the disease and is very complete. There are 61 of these cases. Ase: Under 10 5 Between 10 and 14 years 18 Between 15 and 24 years 18 Between 25 and 40 years 18 Over 40 2 61 Color : White 46 Mulatto 15 Negro 61 46 UNCINABIASIS IN POETO BIGO. Sex: Male 44 Female l^^ 61 Period of illness : 1 montli 2 4 months 1 5 months 1 8 months 1 9 months 2 18 months 1 1 year 10 2 years 7 3 years 4 4 years 5 5 years 4 6 years ,_ 1 8 years 1 12 years 2 18 years 1 " Some months" 1 " Long time" . 1 " Some years" 3 "Many years" 1 " Always " 3 Not defined 9 61 Complications : Bilharziosis recti and bacteremia 1 Bacteremia 5 Bilharziosis recti, distoma hepaticum, and pellagra 1 Tuberculosis pnlmonalis 2 Peruvian wart (?) 1 Malaria 2 12 (4) Rio Piedras series of 1906.— There were 12 of the 22 complete enough to include in this group : Age: Under 10 _1 _ j Between 10 and 14 years "_" ~_ j Between 15 and 24 years '. ~ 1 Between 25 and 40 years ~ k Over 40 IllirH" 4 12 12 Sex: = Male Female J ~'_ ^^ 12 UJSG1NAB.IASIS IN PORTO EICO. 47 Period of illness : 4 months 1 1 year 1 2 years 3 4 years 2 14 years 1 Not defined 4 12 Complications None. Kegarding the clinical type, the first two series were not classified, as were the others, according to the grade of the disease, but from these histories and those of 1904 and 1906 we have the following: Clinical type: Ponce series of 1899 — Very intense 10 Intense 6 Moderate 3 19 Ponce series of 1902 — Very intense 9 Intense 5 Moderate 5 19 TJtuado series of 1904 — Very intense 17 Intense 36 Moderate 7 Light 1 61 Eio Piedras series of 1906 — Very intense 6 Intense 3 Moderate 3 12 Summary of clinical type of the 111 cases — Very intense 42 Intense 50 Moderate 18 Light 1 111 PRODROMES. UNCINARIAL DERMATITIS OR " MAZAMOKRA." Before considering in detail the clinical features of uncinariasis let us preface our remarks by a short description of uncinarial der- matitis, the "mazamorra" of Porto Rico, a phenomenon which pre- cedes by from two to four months nearly every case of uncinariasis, and generally, if not always, heralds the constitutional condition whose description follows. The eruption is generally found between the toes and on the lateral and dorsal surfaces of the feet, Claude Smith's observation, that 48 UNCINARIASIS IN POETO KICO. walking in the mud causes it to be squeezed in between the toes and thus offers a better chance for infection, is borne out by the tacts here. It must not be supposed that the feet, the usual site of i^^^c- tion, is the only one. It may extend even to the buttocks and, indeed, to any part of the body. We have often had histories of it on the hands of washerwomen and others; in one case infection occurred through the skin of the face. "Mazamorra" is a Spanish word whose use is corrupted by the jibaro. It usually means to them a separate and distinct disease of the feet, and they limit it to the phenomena attendant on uncinarial dermatitis. They declare it to be the penetration of the skin by "culebras," or little serpents, to be found in certain pools of stagnant water, decomposing vegetable matter, and mud. The distinction made by the jibaro between maza- morra and other forms of dermatitis of the feet is not made by the better classes. Mazamorra is understood by the latter to signify any dermatitis of the feet, although other and more elegant terms are used as a rule. We are unable to trace the exact application of the Spanish word to this affection, but as one of its correct meanings is "that which is left over at a meal," the "slops" in plain English, it carries with it the idea of putrefaction. This invasion of the skin is especially feared by the coffee planta- tion " peon," not because he recognizes it as a precursor of anemia so much as that he knows that he will spend the night of the day of his exposure scratching, and if the infection has been sufficiently intense, in a few days his feet will be greatly swollen, red, brawny, and full of " water blisters," interfering with, if not entirely prevent- ing, his work. The first evidence of infection is burning or prick- ling in the part which has been in contact with infested soil. Evi- dently the jibaro feels this first of all symptoms of infection, from the assurance that he gives that from certain specified pools and soft spots one may confidently expect to get mazamorra. Should he not feel this prickling a very few minutes after contact, he could never speak so authoritatively of acquiring it from definite puddles and wet spots. While all that has just been said will apply in heavily infested coffee estates, it can not be applied to the great number who suffer from casual, light infections. These, with a distinct recol- lection of having had mazamorra from time to time, can not associate their infection with any one spot. The lesion is first erythematous, with much swelling, often with red lines extending up the leg; then papular; then vesicular. Papulo-vesicular " is the term which should be used to describe typical mazamorra. Only on infection with pyogenic organisms do we find pustules. Some connection, although as yet unproven by us, must exist be- tween the very prevalent leg ulcer of the barefooted laborer exposed to uncinarial dermatitis, and uncinarial infection. These ulcers are extremely stubborn. They are usually situated just above the ankle and are diagnosed by the uninitiated as " anemic " " syphilitic " "varicose " " tropical " and " chronic » ulcers. They are all about alike; not particularly fetid; superficial, with irregular unraised borders ; covered with a sanious, not very purulent liquid, and accom- panied by only moderate infiammatory reaction in the surroundint' tissues. These ulcers last an almost incredibly long time, but are vei-y UNCINARIASIS IN PORTO RICO. 49 easily kept clean. One of us removed one of them by an elliptical incision quite near the borders, and found to our surprise that the ulceration only involved the skin and subcutaneous tissue. It was not at all adherent, and healing of the wound took place by primary intention. A still more peculiar feature is that these ulcers heal readily after a successful anthelmintic treatment. Leg ulcers were noted in 6 of the Ponce series of 1899, in 3 of the Ponce series of 1902, and in 21 of the Utuado series of 1904, an average of 30 per cent of the 99 cases. Loos, 1904, in an address delivered before the Sixth International Congress of Zoology, entitled " Die Wanderung der Ancylostomum- und Strongyloides-Larven von der Haut nach dem Darm," mentions the fact that apart from the route taken through the circulation to the lung larvae may wander about the tissues without gaining the circulation for even as long as five years. He calls this the " creeping eruption." Is there some relation between this and the extremely obstinate leg ulcers above described ? Boycott and Haldane call attention to what they term " New Sump bunches," or " botches," which they state are very emphatically asso- ciated with ankylostomiasis in the mines of Dolcoath. These bunches are a cutaneous eruption resulting from contact with the earth or damp, rotting wood, and appear the same evening or the next morn- ing after exposure, generally on the buttocks, knees, and forearms. As anemia in these mines became less frequent by reason of treat- ment and prophylaxis, the eruptions became correspondingly rarer and less severe. They divide the skin aifections into: (1) Furuncles of various sizes which start from a hair follicle; (2)urticaria which is not so frequent and which they attribute to a circulating poison emitted by the uncinarise; (3) general pruritus without eruption. This is the rarest of the three. These authors did not demonstrate the larvaj in the furuncles above mentioned. The pus was not eosinophilic. BRONCHITIS. Calmette and Breton (" L'Ankylostomiase," Masson et Cie., Editeurs, Paris, 1905), state that the skin lesions are frequently accompanied by an intense catarrhal bronchitis (catarrhe des gourmes) which may cause pulmonary emphysema. We have not yet been able to define this bronchitis in our cases. THE ONSET OF UNCINARIASIS. Very few people who suffer with this disease can clearly relate their first symptoms and the date upon which they were first noted. Uncinariasis is a most insidious disease, and " mal estar," or " feel- ing out of sorts," is about the nearest one can approach to what our patient first experiences. We believe that all who have seen much of the affection 'will agree with us that weariness, listlessness, and dys- pepsia are the most constant symptoms first noted. The more abrupt acute forms, with melena, vomiting, and violent pains, are very rare. Pallor comes on afterwards. In fact, it should be borne in 77759°— S. Doc. 808, 61-3 i 50 UNCINARIASIS IN POKTO EICO. mind that dizziness, edema, palpitations of the heart, pains in the body, and profound nervous symptoms often develop without any anemia whatsoever. In Porto Kico the majority of those who harbor uncinarise in large numbers do not remember when they really did feel well, as their infections are repeated so frequently and regularly as to make only unusually severe infections prominent in the midst of a long period of ill health. One might go further and say that there are many who never really knew what vigorous health meant and state that they were always well previously without analyzing their true condition. There is a diagnosis made by the laity in the interior which elucidates this strange mental attitude. Before the commission's campaigns here it was common, on asking the question, " Of what did your father die ? " to receive the answer, " The natural death " (" la muerte natural ") — that is to say, as closer questioning would reveal, of " anemia." The following were the answers given to us by the 19 cases of the Ponce series of 1902 in response to the question, " What were your first symptoms on falling sick : " Serial No. of case. 1. Pains head and chest, palpitations, and indigestion. 2. Indigestion, wealiness, dizziness, and palpitations. 3. Weariness, palpitation, and indigestion. 4. Ulcer of the foot, pain in abdomen, weariness, and fever. 5. Slight loss of appetite, strength, and endurance. Quantities of blood in the stools. 6. Weariness, headache, bellyache, and palpitations. 8. Tinnitus aurium, edema of feet, pain in chest. 9. Dizziness, palpitation, gastric indigestion, and headache. 10. Palpitation, pain over heart, gastralgia. 11. Chills, fever, pain in head, chest, and abdomen, debility. 12. Pain in knees, weariness in chest, and dizziness. 13. Pains in head, chest, and stomach. 14. Pains in belly, chest, and legs. 15. Debility, fever, pain in body and chest, and uneasiness in stomach. 17. Does not know. 26. Dizziness, pain in chest, legs dead. 23. Debility, indigestion, constipation, palpitation, and headache. 51. Fever, chills, dizziness, and weariness. 52. Weariness in legs, arms, can not work. It is perfectly evident after reading this list of " first symptoms " that the patient has often reached a pretty advanced stage of his disease before he realized that he "had something out of the ordinary." Nevertheless, the salient points come out rather strongly as delin- eated at the outset of our remarks on " first symptoms." CUTANEOUS SYSTEM. PALLOR. The pallor is not usually a mere whitening of the skin. There is almost always an icteric hue which rarely becomes true icterus The color has been described as "lemon-tinted," "waxy white" to a " yellow " or " tan," " tallowy," " yellowish-green," etc. We prefer to describe It as dirty-yellowish or muddy. This is considerably modi- hed by the normal complexion and, in mulattoes, a grayish, pasty UNCINARIASIS IN PORTO RICO. 51 pallor is noted; in negroes a darker, ashen gray. We have seen a dead white skin in blondes. It is very rash to always judge of anemia by pallor. Aside from the remarks made under pseudo- anemia (see " diagnosis," report for 1904) , we desire to call atten- tion to descriptions of the pallor possessed by some of our patients, and found upon their histories, together with the actual hemoglobino- metric readings taken later the same day : "Not very noticeable" Hb. 40 per cent. " Little " Hb. 39, 42, 50, 54 per cent. " Pronounced " Hb. 62, 65 per cent. " Marked" Hb. 58, 86 per cent. '■ Slightly marked " Hb. 24, 44, 47 per cent. " None " Hb. 43, .57 per cent. " Relatively severe " Hb. 58 per cent. " Decided " Hb. 74 per cent. " Very pallid " Hb. 70 per cent. " Moderate " Hb. 22, 32, 33, 34 per cent. " Dirty greenish-yellow " Hb. 62 per cent. In general, however, the pallor is a fair superficial guide to the anemia present. The dirty-yellow complexion of the Porto Rican laborer has been noted by every stranger who has come to the island. The inhabitants of near-by islands have often referred to them in our presence as " the yellow people." The disease is known in Brazil as " the yellows " ( Amarrellao) . Within the last few years, however, due to the intensive campaign carried on in practically all towns on the island, these marked cases of anemia have wonderfully diminished and visitors who ride over the roads communicating town with town no longer complain of the "starving anemics" they passed by the way. While this is true for the environment of towns and for a considerable strip on either side of the highways, we still have an unseen army of pale people hidden away in the mountains where coffee is grown. These are almost never observed by the tourist and casual visitor. The proportion of our patients who presented this symptom with its degree of intensity may be demonstrated by notes on 146 Bayamon cases in the campaign of 1904 : No pallor , 4 Slight pallor 17 Moderate pallor 30 Marked pallor 48 Extreme pallor 47 Total 146 Comparing this with the clinical type of 337 cases in Bayamon the same year, we have : Slight cases 10 Moderate cases 71 Marked cases 193 Kxtreme cases 63 Total 387 Of these, 87 had edema, and 109 presented marked nervous symp- toms. In fact, a profound anemia is not present in many cases with severe clinical symptoms. 52 UNCINARIASIS IN PORTO RICO. The actual hemoglobin of 65 such cases was as follows : Persons. g Between 50 and 54 per cent - ... Between 55 and 59 per cent :J" Between 60 and 64 per cent ^^ Between 65 and 69 per cent *■" Between 70 and 74 per cent ' Between 75 and 79 per cent " Between 80 and 84 per cent j Between 85 and 89 per cent 4 Between 90 and 95 per cent 3 65 Of the Ponce series of 1899, 18 were pallid, 16 markedly so. Of the Ponce series of 1902, 18 were pallid, 1 was not. Of the Utuado series of 1904, all were pallid, 1 slightly, 7 moder- ately, and 53 extremely. Of the total number, 97 per cent were pallid ; of 72 cases in which the degree of pallor was clearly expressed, 69, or 95 per cent, were very pale to extremely pallid. In the Utuado series of 1904 the average hemoglobin reading on admission for each of the four grades of pallor noted is as follows : Grade of, pallo. „.,<:^„, .eTogic Percent- ile o: imog bin. Slight 1 65.00 Moderate 7 41.14 Marked 26 24.70 Very marked to extreme 27 18. 48 Inspection of the mucous membranes affords a better opportunity for making a rough estimate of the anemia present. Especially is this true of the conjunctivae. If there is no inflammation present and care be exercised not to produce a compression of the vessels, practice will accustom one to more closely estimate the real hemo- globin percentage by pulling down the lower lid, than by forming one's judgment from the color of the skin. Sometimes it is difficult to tell at a glance where the mucous mem- brane of the lip ends and the skin begins. The pallor is progressive; first the bulbar conjunctivae become pale, then, little by little, the sac becomes gray, turning milky white or yellowish. Eventually all, or almost all, color disappears "from the skin. The scleras are a bril- liant white or, in brunettes, bluish white (a point of distinction from malarial cachexia), and the patient looks more like a waxen image than a human being. CYANOSIS. In cases where the heart is seriously complicated, cyanosis is prominent, especially in the lips. In two cases of the Utuado series this was extreme. The pallor of sclerotics, nails, and mucous membranes was partic- ularly noted in the Ponce series of 1902 : Mucous membranes of fair color, 3; pale, 15. Color of nails, fair 2; pale, 4: verv Bale 11 Sclerotics, white, 10 ; bluish white, 6 ; yellowish, 2. J f ^ • UNCINARIASIS IN PORTO RICO. 53 PETECHI.E. They are observed at times in the middle-aged and the aged. This lesion was seen only once in our 111 special study cases. GENERAL PRTJKITUS. Pruritus without perceptible skin lesion was observed in 38 of 73 cases, or 52 per cent. It was not noted in the two Ponce series. As a sjmiptom it is not worth much, as can be readily imagined, but, never- theless, it can be considered a common phenomenon in the mild and moderate forms as well as in the severe. URTICARIA. Siccardi demonstrated this condition in his cases of infection by Necator ameriearms, and seems to suspect that it is a manifestation especially marked in infection by this species, in contradistinction to the disease as caused by ankylostoma duodenale, in which he never observed it. We can not remember any case which presented urti- caria as a symptom in uncinariasis here. LACK OF PERSPIRATION. This is really a very prominent and common symptom complained of by patients in all stages of the disease. It is one of the symptoms which the jibaro will select to relate to his physician from among many others of perhaps much more importance. Many hail the re- turn of perspiration after anthelmintic treatment as one of the best proofs of improvement, inasmuch as it had been almost or quite sup- pressed previously, even during hard work in the sun. DRYNESS AND HARSHNESS OF THE SKIN. This follows closely upon the preceding symptom and is, of course, its sequela. Of the Ponce series of 1902, 9 were thus affected. Of the TJtuado series of 1904, 39 presented it. Of the Eio Piedras series of 1906, all were observed to have dry ancl harsh skin. Of 92 cases, therefore, 65.2 per cent were observed to have the skin unnaturally dry and harsh. BtTENING OF PALMS OP HANDS AND SOLES OF FEET. This symptom, so prominent in Thornhill's cases, has been little mentioned. It was only recorded in the Ponce series of 1902, among whom nine stated that it was a clearly defined phenomenon. ATROPHY OF THE SKIN. This is really a very common phenomenon in severe cases, noted by Duprey (J. Trop. Med., Sept. 1, 1902). It still further deforms the natural lines of the face and contributes to the careworn, pitiable expression which has been commented upon by the lay visitor to the 54 UNCINAKIASIS IN POKTO EICO. Porto Rican mountain regions. This condition adds years to the face of a woman, and one of the most remarkable results of treatment was recovery of a texture of skin more in keeping with the age of the patient. It is by no means confined to the aged nor even to those of middle age, but is frequently found in children with a severe grade of the disease. No note was made of this condition in the Ponce series, but in the Utuado series of 1904 it was observed in 29. In 6 it was but slightly marked, in 16 well marked, and in 7 it -was ex- tremely prominent. One of the Rio Piedras series of 1906 also was observed to have it. In all of 73 cases, 41 per cent presented this symptom. EDEMA. To add to the weird appearance of the patient, edema of the face may supervene, distorting and blotting out normal facial expression. Edema, in general, is a late symptom when due to circulatory dis- turbance, but this condition must not be confused with the frequent edema seen quite unexpectedly throughout the earlier stages of the disease. ' The following is a classification of our edematous patients in Bayamon whose hemoglobin was taken. The percentages are ar- ranged in groups of 10 : Hb. Persons. Below 20 per cent 7 Between 20 and 29 per cent 22 Between 30 and 39 per cent 23 Between 40 and 49 per cent 12 Between 50 and 59 per cent 4 Between 60 and 69 per cent 7 Between 70 and 79 per cent 2 Between 80 and 89 per cent 2 Total 79 Edema of the lower extremities is to be found in nearly all extreme cases, first in the feet and ankles, then in the legs, next in frequency in the face, where it appears chiefly in the eyelids and cheeks. It tends, finally, to extend throughout the whole body. It often in- volves the scrotum, which may become enormously swollen. To illustrate what extremes may be reached, we may call attention to a case in which the whole body was water-logged. She could not walk, could not see, the eyelids looking as if dry cups had been applied, and when her pulse was taken the impression of the whole hand was left deeply sunken in the enormously swollen wrist; yet she recovered and became perfectly well, rosy, and fat, running from 20 to 98 per cent hemoglobin. But edema often results from a remote cardiac lesion, due to fatty degeneration or valvular sclerosis, conse- quent upon some previous attack of uncinariasis. We had such a case, an old man with 65 per cent hemoglobin, almost as edematous as the above cited. He lingered 55 days, had no uncinariaj after his second week of treatment, and died of valvular disease of the heart, a sequela of uncinariasis. The urine was examined for albumin in a number of our most edematous cases with negative result, and we were unable to demonstrate that it was due to nephritis. In the Ponce series of 1899, 8 were edematous, 3 intensely so. The lower extremities were affected in 4, both upper and lower extremities in 1, and 1 had general anasarca. TYPICAL FACIAL EXPRESSION OF THE SUFFERERS. UNCINARIASIS IN PORTO RICO. 55 In the Ponce series of 1902, 15 were edematous. Two had edema of the feet alone, 4 of the feet and legs, 4 of the face, feet, and legs, and 5 had general anasarca. In the Utuado series of 1904, 50 were edematous. Twenty-one had edema of the lower extremities, 8 of the face and lower extremities, 4 of the face, upper, and lower extremities, 3 of the face alone, 1 of the face and upper extremities, 1 of the face and trunk, and 12 had general anasarca. Eight of the 50, apart from the cases of anasarca, were noted as having been very extreme. Nine had no edema, and in 2 cases there was no remark made upon this symptom. In the Eio Piedras series of 1906 all had edema, 7 of the lower extremities and 5 of the face and lower extremities. Therefore, of 111 cases (it is true, marked or very marked in over 90 per cent) 76 per cent suffered from edema. As a matter of fact, however, in the out-patient clinic only severe cases were edematous, as a rule, with notable exceptions, as above stated. The edema which we saw in patients who were not very anemic was, as a rule, fleeting. GENERAL DEVELOPMENT. Uncinariasis of childhood is a potent cause of retarded develop- ment and of stunted mental and physical growth thereafter. We have often been deceived in the true age of an individual, persons of 20 years seeming to be of 12 or 15. Puberty is often delayed. In males the genital organs may be undeveloped and the hair of the body lack- ing. In females, menstruation, which occurs here much earlier than in the more temperate climates, may not make its appearance until the age of 18 to 20. We have known cases where children have been born of mothers who have said that they have never menstruated. More than all, many children bom of anemic mothers are rachitic and are little resistant to disease and hardship. Among the 100 cases studied in Ponce, 19 of which form part of the basis for a special study of the symptomatology, there were 4 cases of special mention regarding development : Case 8, 11 years of age, ''^was stunted mentally and physically." Case 18, 16 years of age, " has matured but little and appears to be from 8 to 10 years old." Cases 81 and 83, each 18 years of age and each with the following remark : " Very much stunted mentally and physically. Looked to be about 10 years of age. Genitals infantile type." In the 1904 Utuado series six are noted as having defects in de- velopment. NUTEITION. The nutrition is generally good. In the Ponce series of 1899, 7 were well nourished, 1 fairly so, 3 were not very well nourished, and 8 were emaciated. In this series the average poor nutrition was in part due to lack of food and priva- tion incident to the hurricane. In the Ponce series of 1902, 13 male adults, averaging 66 inches in height, showed an average of 129.2 pounds weight. Two others were not weighed and the rest were children. 56 tTNClNABIASIS IN POKTO BICO. In the Utuado series of 1904, 51 were well nourished and only 9 were emaciated. In 4 of the latter the emaciation should be ex- plained by concomitant diseases. In the Eio Piedras series of 1906, 3 were emaciated. In the moderate grades of the disease, the flesh is flabby, but not doughy. Later in the course of the affection, when anasarca ensues, no correct estimate as to amount of flesh can be naade save in very general terms, and, indeed, some of the cases above cited were subjects of anasarca. Emaciation, however, is not a usual phenomenon in uncinariasis, and when it occurs, it is likely to be due to intercurrent diseases, starvation, or severe digestive disturbances, as above noted. While the weight of an average case does not suffer greatly, it is certainly true that these patients are, as a rule, underweight, for they almost always gain well upon treatment. The average weight of 100 grown men, according to Sandwith, with an average of 65.5 inches in height, on admission was 117.5 pounds. Of those who remained in hospital over two weeks, 70_ per cent gained in weight, 22 per cent lost, and 8 per cent remained stationary. Average loss, 3.2 pounds ; average gain, 5.4. MrSCTJLAR SYSTEM. There is a tendency to ready fatigue of muscles, and patients tire easily. The muscles are flabby and the seat of a dull ache. This weakness may reach an extreme grade with soreness, and, indeed, may roughly simulate paralysis, a condition readily excluded by careful examination. Attention is called to cases 24 and 25 of the Ponce series of 1902. Both of these patients were so very weak as to be utterly prostrated. Case. 25 caused us a great deal of trouble in diagnosis, as it seemed very possible that the man might be afflicted with a complicating peripheral neuritis, given the history. It is interesting to note that he had also a tremendous hemic murmur and profound anemia. This case, however, was merely a severe form of uncinariasis with exaggerated muscular debility, as the prompt result of anthelmintic treatment proved. Every now and then some one reads a paper announcing the presence of beriberi in Porto Eico, but each time these reports have been refuted with great ability by some Porto Rican physicians who know what beriberi is. This lat- ter disease does not exist, we believe, in this island, and such cases are to be generally considered uncinariasis of severe type. Debility is one of the earliest symptoms and is very constant throughout the course of the disease and in all grades. When asked in the clinic why he sought medical advice the jibaro would usually reply, " Because I can not work," an evidence not only of the con- stancy of the condition under consideration, but also a refutation of the sly accusation implied in the name recently applied to uncina- riasis, " the lazy disease." Weakness was a universal complaint among our 111 special cases, but it was especially notable in 17 of the Ponce series of 1902, and in 53 of the Utuado series of 1904, in which latter series debility was extreme in 1 and very marked in 38. No special note was made of the degree of debility in the Ponce series of 1899 and the Rio Piedras series of 1906. SHOWING STATE OF NUTRITION IN SEVERE CASE REPORTED BY DR. ROSES ARTAU. TJNCINAEIASIS IN POETO EICO. 57 In the TJtuado series of 1904, 27 complained that their muscles were sore; 49, that they were painful, either an aching pain or pain on movement ; and 53 had flabby muscles, percentages of 44, 80 and 86, respectively. _ Pains in the body are spontaneously complained of by most uncina- riasis patients. This symptom is at best unsatisfactory. The patient calls it rheumatism, but rheumatism is not nearly so common in Porto Rico as is generally thought. We prefer to look upon these pains as due to overfatigue of muscles. In the Ponce series of 1902, 7 complained of pain in the chest (not " heart pains ") , and 14 of pains in the legs. In the Utuado series of 1904, 26 complained of pain in the chest, which was slight in 5, marked in 16, and very severe in 5. This is often a true bone ache of the sternum. The fact is, however, that some pain in the sternum is made the subject of complaint by nearly every case which is at all well marked and in some where it is one of the very few symptoms present. Indeed, pains in the chest and body is a common complaint from the onset of the disease. Weakness and actual pain in the laiees is a symptom of which many are accustoijaed to complain. TEMPERATURE. Fever at the outset of the disease is probably a fairly constant symptom. In the clinic fever was very rarely obser^^ed in the slight and moderate cases. In fact, the tendency was quite in the other direction, for the patients, when questioned concerning their bodily temperature, generally stated that they felt cold most of the time, and this was easily corroborated by touching their skin. But with astounding frequency a slight to moderate rise in tempera- 'ture is demonstrable at times in the course of severe cases, the " anemic fever" of older authors. This fever disappears on anthelmintic treatment and is replaced by a subnormal temperature. In the Ponce series of 1899, 11 had fever on admission, all save one with but a slight rise. In the Ponce series of 1902, 5 showed a rise in temperature. In the Utuado series of 1904, 29 had a temperature ranging from 37.5 to 39 and 3 above 39. Three of the Ponce series of 1899, 3 of the Ponce series of 1902, and 4 of the Utuado series of 1904 had at the same time intercurrent diseases which commonly cause fever. Deducting, therefore, these 10 cases there were 38 of the 99 cases which presented on admission to hospital a rise of temperature whose cause could not be deter- mined by any discoverable condition. This latter statement should, however be modified in view of certain discussions which have arisen concernino- the pathogenesis of uncinariasis. In the first report of the Porto'^Rico Anemia Commission, December 1, 1904, we find, on 91 under the heading "Pseudo-rheumatic affections," the fol- lowing : . gy prove to be a serious condition in Porto Rico is the invasion of >■ w rifl bv a bacillus. All mention of a bacillus in the blood in our special the oiooa ^^^^j.^^^,^ to this organism. It was first noticed by Dr. Gutierrez on cases '^^ jjjjg examining a specimen of case 41, special Utuado series, and large June 9. j^jg jjacillus were constantly present in additional examinations of numbers "'■ 58 UNCINABIASIS IN PORTO RICO. the blood of the ear and the serum of the feet. She was then suffering with great edema, fever, and rheumatic pains. A pure culture, made under rigid precautions, was subsequently found to be the same as others taken from individuals suffering from a like set of symptoms, irrespective of anemia. In one case there was 91 per cent of hemoglobin and decided edema almost reach- ing anasarca, with fever and joint pains. In all these cases neither albumin in the urine nor heart lesion could be found. We have seen curious instances of localized edema with fever in persons not infected with uncinarise and of good station in life, where the same bacillus (morphologically) was found. Case 44 of the series reported in American Medicine, September 5 and 12, 1903, had a fusiform edema of both legs not extending to the ankles, which greatly puzzled us. It disappeared after a time. The commission is not prepared to give its classification. We are indebted to the laboratories of the Army and the Public Health and Marine-Hospital Service for assistance in studying this microorganism. The organism in question was, according to the late James CarroU, major, Medical Corps, United States Army, on the one hand, and Eosenau, of the Public Health and Marine-Hospital Service, on the other, nothing more or less than one of the colon group. Ferguson, British Medical Journal, 1907, ii, 1320, states that the bites of the parasites in the intestines cause little foci of infection in the mucosa and chronic inflammation. As in 6 of the 28 Utuado cases presenting fever not manifestly due to some intercurrent disease we were able to demonstrate the presence of the bacillus, which later proved to belong to the colon group, in the circulating blood, we offer this as one, at least, of the causes for febrile movement in uncinariasis. DIGESTIVE SYSTEM. The series of symptoms pertaining to the digestive tract are not nearly so prominent in a well-marked case of uncinariasis as are those of the circulatory and nervous systems. For this reason they are apt to be too hastily passed over by patient and physician ; but, although at times indefinite, a fairly clear history may be usually elicited. The period of maxked_digestiy^jymptomS-is_JLQrm ally found at the in - ceptioiroTTEe'diseaser The patient may forget to mention them aiid the physician t6"ask about them when other and more serious devel- opments arise in the involvement of other systems. In this connection it is of the highest importance to emphasize an atypical form of uncinariasis which more frequently than any other puts the physician to confusion in his practice in these tropical coun- tries. This is the dyspeptic form of the disease. There are a great number of persons, and more frequently those accidentally infected whose position in life is good, who for a long time have suffered from what they themselves diagnose " dyap£.psia,; " most unfortunately for them their physician chimes in with their diagnosis. There are a large number of so-called " gastrites," " hyperchlorhydrias," and even " gastric ulcers " that may be permanently cured by thymol after an examination of the feces. Ashford admitted a soldier to hospital with as clear a history of gastric ulcer as one would wish, with pain an hour after eatin'g, vomiting of a considerable amount of blood on several occasions, and a tender spot just to the right of the middle line in the epigastric region. This man had many uncinaria ova in his stools and (whether he really did or did not have a small ulcer or ulcers) promptly became perfectly well after three doses of thymol, UNCINARIASIS IN PORTO RICO. 59 without special diet or other drugging. Another case, that of a child of well-to-do parents, was carried from physician to physician, each one of whom treated him for " dyspepsia," until ova of unci- nariae were discovered in the stools, and one dose of thymol literally cured him. Such masked cases rarely have any other symptom to attract the attention. THE APPETITE. Generally th ere is increased appeti te, often reaching bulimia in the mo^rate andTlharked cases, but in the last stages there is frequently com plete anorexia . Apart from the nature of the food, t he j ibaro wants Jjulk. He does not want meat and concentrated f oo3~s, no "matter what the lay- man may say of his present bill of fare. He does not care for a diet of cream, roast beef, and other concentrated foods nearly so much as for " mar af o," or a poor class of bananas ; " bacalao," or dried cod- fish ; " arroz," or white rice ; and " habichuelas," or beans. While he will eat with avidity almost anything, he must have something that is filling (" algo que le Uena "). It is a modified form of geophagy. Anyone who has been in attendance for any length of time at the municipal hospitals knows that this is true. He needs to fill his stomach fuller than we fill ours. Of course, easily digested concen- trated food would be better for him. His proteid ration is extracted at a greater expense to his gastric and intestinal digestive apparatus from vegetables and grains than it would be from meats. We have heard them plead for a plate of " mafafos," etc., when we had seen the ample and nutritious hospital meal they had just eaten. We explain this phenomenon by the fact that there is a perverted appe- tite; that the stomach craves, perhaps from the irritation of these minute worms or from other consequences of infection, to be stuffed just as is demonstrated in this universally well-known sign of other intestinal worms. Gastric dilatation is often the result and is de- pendent upon the irritating and indigestible nature of the food, upon its enormous bulk, and its characteristic tendency to produce flatu- lence. The intestinal functions are labored and the bowel distended and often partially paretic for short periods. There is no doubt in our minds, however, that this stuiBng of the bowels with enormous quantities of food, with the results of this habit, is a potent factor in sustaining and augmenting any direct inflammation caused by this little nematode. From this it is but a step to true geophagy , at times perhaps a source of infection, but more properly considered a symptom. " Geo- phagia " or " allotriophagia," as the disease has been called, is not a symptom of uncinariasis alone, but occurs in chlorosis, in pregnancy, and in the presence of other intestinal worms. We formerly believed this to be a symptom mainly confined, in Portq Rico, to children, but in one form or another it is found in many adults. Save in children, the eating of mud is not nearly so common as the eating of raw rice, coffee, com, and vegetables. We know of one case where cigar ashes were eaten. It is known as " el vicio," the vice, among the country people. We had one case in hospital, an old negro, who reached camp m a pitiable condition from uncinariasis. He was all doubled up and very weak, crawling from place to place on hands and knees. This 60 XJNCINAEIASIS IN POETO RICO. man, to gratify his inordinate appetite for earth, used to elude all vigilance and painfully crawl away to some distance in a neighbor- ing field, where he would satisfy his craving and howl for the nurse to carry him back to his bed. We expelled most of his uncinariae, and were obliged to send him home on account of this and other filthy habits. To our surprise, we later met him in the streets of Utuado, walking upright and wonderfully improved. Besides earth the patients may consume plaster, feathers, paper, unripe fruit, charcoal, etc. Only 2 of the Utuado series of 1904 confessed to geophagy. In the Ponce series of 1902 the appetite was good in 10, capricious in 8. In the Utuado series of 1904 the appetite was good in 47, capricious in 2, and poor in 8. In addition to these, 3 suffered from absolute anorexia and 1 from bulimia. In the Rio Piedras series of 1906 the appetite was good in 7, poor in 5. Of the total number (92) , 64 had a good appetite, or 69.5 per cent; 10, or 10 per cent, had a capricious appetite; and in 13, or 14.1 per cent, it was poor. TONQTJE. The tongue is pale, often has a whitish coat, is enlarged and tooth- indented. At times it is partially denuded of epithelium, red and raw. A peculiar and often-mentioned symptom is the presence of two purplish smears, one on each side of the central line, making it appear as if a pencil had been sucked. It was first reported by Delamere. (J. Trop. Med., Nov. 1, 1902.) These are engorged veins, and when seen, which is not very common, are circulatory phenomena. Three such cases occurred in our Utuado series of 1904, or 4.9 per cent. This sign should be distinguished from the pigmented spots on tongue and buccal mucous membrane, seen in two of our Utuado series. They are from 2 mm. to 4 cm. in diameter and are apt to be found in patients of a mixed race. We could not establish any clear connection between these spots and the disease. CATARRHAL STOMATITIS. This is sometimes present. It may be very severe, as in one case at Utuado, an old negro woman, where it had denuded tongue, gams, and buccal mucous membranes, extending over the lips to the skin line. It is a very inconstant phenomenon and seems to be associated with severe gastritis, when it does not depend on some local condition. Of the Ponce series of 1902, 6 had it, or 31 per cent, but the condi- tion was not carefully recorded in the other series. SALIVATION. This is a frequent phenomenon, reaching at times a marked grade. It occurred in 9 of the Ponce series of 1902, a percentage of 42. This symptom was not carefully recorded in the other series. FLATULENCE AND HEAETBUEN. These are very common symptoms and are referable to the dys- pepsia present. UNCINABIASIS IN PORTO EICO. 61 Flatulence occuired in 46 of the Utuado series of 1904 and in 3 of the Rio Piedras series of 1906, a total of 49 in 73 cases, or 67.1 per cent. Heartburn occurred in 15 of the Ponce series of 1902, or 78.9 per cent. It was not recorded in the other series. WEIGHT AND FTILLNESS IN THE EPIGASTRIUM. This is an extremely common symptom and is generally brought to the attention of the examining physician by the jibaro, who re- marks that he feels as though his stomach was always " occupied " ("ocupado"). There is apt to be some puffinessover the epigastrium. It was noted in 16 of the Ponce series of 1902, or 84.2 per cent, but not in the others. Of the Ponce series of 1899 nausea was present in 5 and was of moderate intensity. In the Ponce series of 1902 it was present in 11. In the Utuado series of 1904 it was present in 39, of which in 7 it was but slight and in 1 severe. In the Rio Piedras series of 1906 it was present in 6. Thus, in a total of 111 cases nausea existed in 61, or 54.9 per cent. Although these figures show it to be a frequent symptom, as it is in the severe cases of which these are representative, in the clinic nausea is rather an infrequent symptom. It may be due to gastric conditions or it may be an accompaniment of the dizziness, weakness, and tendency to syncope so often observed. VOMITING. This is rarer, but has been present in several cases, with marked dilatation of the stomach. It may occur independently of gastritis, as does nausea, from a tendency to faint. Vomiting of blood should raise a suspicion of gastric ulcer, but this symptom should not be absolutely depended upon, as before demonstrated. Vomiting occurred in 3 of the Ponce series of 1899 ; in 7 of the Ponce series of 1902 ; in 27 of the Utuado series of 1904, among which 2 were severe and 5 slight; and in 4 of the Rio Piedras series of 1906. Of a total of 111 cases, therefore, 41, or 36.9 per cent, suffered from vomiting. This symptom, as in the case of nausea, is a still more infrequent one in the clinic. PAIN IN THE EPIGASTRIUM. This was noted in 8 of the Ponce series of 1902 ; in 51 of the Utuado series of 1904, 7 of which had only slight pain and 2 very severe ; and in 6 of the Rio Piedras series of 1906. Of the 92 cases, 65 suffered from gastralgia, or 70.6 per cent. All authors give prominence to this and the following symptom : TENDERNESS IN THE EPIGASTRIUM. This was noted in 11 of the Ponce series of 1902 ; in 30 of the Utu- ado series of 1904, of which it was slight in 3 and very severe in 16 ; 62 UNCINARIASIS IN POETO BICX). and in 3 of the Eio Piedras series of 1906 ; a total of 44, or 47.8 per cent. Pain and tenderness in the epigastrium is one of the most j)romi- nent symptoms of the earlier stages and lighter grades of the disease, but later becomes so overshadowed by the serious developments of the severer grades as to' lose its importance for the patient. The physicians must therefore inquire of the sufferer in the later stages of uncinariasis for a symptom which in the earlier stages or lighter grades of the disease the patient himself would have undoubtedly mentioned. This statement should be taken also to cover practically all gastro-intestinal phenomena of uncinariasis. There may be only a weight and fullness, or there may be a throb- bing or burning or a sharp lancinating pain, at times relieved by taking food. The pain and tenderness is often located in the right hypochondriac region and seems to be due in some cases to the irri- tation caused by the worms. In others it is merely the expression of a gastric or intestinal fermentation and catarrh. The theory that this pain is due to the change of position of the worms at time of coitus seems to us remarkably far-fetched. Surely the chronic in- flammation of the stomach and upper intestines would explain these sensations without such a fanciful explanation cited by so many authors, notably Lutz. Equallj^ unusual is localized peritonitis due to underlying, deeply fixed uncinarise. We have never seen this peritonitis of which Lutz writes. DILATATION OF THE STOMACH. This is fairly common. There were 3 in the Ponce series of 1902 and 1 in the Utuado series of 1904 suffering from this condition. The latter case was a very severe one, but gastric dilatation is much more common than this, as only the severe cases are noted. METEOEISM. A greater or less degree of tympanites may be generally observed. It IS the result of illy-digested starches, as a rule, and may reach a very severe grade, interfering with breathing or producing a chronic " pot-belly," a not unfrequent sign in children. The peas- ant, we again repeat, has a most bulky food. In order to obtain sufficient nutriment for his bodily needs, he has to consume enormous quantities of protein-weak food within his reach, plantains, tubers, etc., and these set up fermentation in the intestine, the seat of patho- logic changes, giving rise to quantities of gas. Meteorism occurred in 5 of the Ponce series of 1899, in 12 of the series of 1902, in 37 of the Utuado series of 1904, of which 2 were slight and 2 very marked, and in 3 of the Rio Piedras series of 1906. Of 111 cases, 57, or 51.3 per cent, suffered from this symptom. ENTBRALOIA. It was present in 6 of the Ponce series of 1899, in 9 of the Ponce series of 1902, in 30 of the Utuado series of 1904, and in 4 of the Rib Piedras series of 1906, a total of 49 of 111 cases, or 44.1 per cent. Enteralgia was not usually severe. In the general clinic, strange to say, it was rarely a prominent symptoms UNCINARIASIS IN PORTO RICO. 63 ABDOMINAL TENDERNESS. This was observed in 8 of the Ponce series of 1902, in 39 of the Utuado series of 1904, of which 2 were slight and 7 very severe, and in the Eio Piedras series of 1906 in 5, a total of 52 of 92 cases, or 56.5 per cent. In the 8 cases of the Ponce series of 1902 the tenderness was greatest over the umbilicus in 3, above the umbilicus in 1, below the umbilicus in 1, in the inguinal regions in 2, and general in 1. In the Ponce series of 1899, 9 suffered from constipation, 1 from diarrhea, and 1 from alternating diarrhea and constipation. In the Ponce series of 1902, 12i suffered from constipation, 2 from diarrhea, and 2 from alternating diarrhea and constipation. In the Utuado series of 1904, 20 suffered from constipation, 4 from diarrhea, 8 from alternating diarrhea and constipation, and 29 had normal movements. In the Eio Piedras series of 1906 constipation was seen in 4, diar- rhea in 5. Thus there was a total of 46 cases of constipation, or 40.5 per cent ; of 12 cases of diarrhea, or 10.8 per cent; of 11 cases of alternating diarrhea and constipation^ or 9.9 per cent. In the clinic diarrhea is comparatively rare, constipation rather common, but usually the jibaro states that he is "corriente;" in other words, "all right," or normal. In general the bowels are normal or constipated in the early stages of the disease and in all save the severer grades. Exception should be made of the form called by Manouvriez " forme aigue abdomi- nale," in which he states that diarrhea is very marked. "We do not remember to have seen this form suiEciently to permit us to dignify it by a separate designation in our classification of the disease. Diar- rhea is usually a symptom of the severe grades and often presages death. It becomes dysentery in its terminal forms and is a formida- ble complication. FECES. Little may be learned from a macroscopic examination of the feces. Blood, macroscopically, is rarely seen. Of over 22,000 specimens of feces brought us in 1904 for examination only 6 contained blood, and 5 blood and mucus from a naked-eye inspection. Neither is it a prominent feature microscopically, although more frequently seen. It should be remembered that bilharziosis of the rectum was of much more frequent occurrence than appears from this report. Mucus in the stool was not common, but undigested food was frequently observed. Blood in the feces is said to be a common condition when the worms are changing position while young in the intestine. Stiles recommends to those who do not possess a micro- scope, as a " rough test " for uncinariasis, that feces be placed on a piece of white blotting paper. He says : " It leaves upon the paper a reddish-brown stain similar to a bloodstain." This we only mention to condemn as a most dangerous guidepost. It has been on fre- quent occasions a source of surprise to Stiles and others that we do 64 UNCINAMASIS IN PORTO EIOO. not ordinarily find blood in the stools. We can not emphasize too strongly that after hundreds of thousands of examinations of feces by the collective work of physicians in every town in the island, and microscopic examinations at that, blood in the stools was found to be a rarity. There is nothing in all that happens to the average jibaro that will bring him to the physician in abject terror with greater promptness than hemorrhage of any sort, and thousands have testi- fied to us personally that they have never seen blood in their stools. As to occult hemorrhages, we know that blood is consumed along with the cells of the mucous membrane, first demonstrated by Looss and afterwards' corroborated by ourselves, and we never even took the trouble to look for occult blood. This for the very simple reason that we knew that it was there. Had a feasible quantitative test been available it would have been tried. It may be of interest to note, however, that feces of the laborers in Porto Rico are not of the color of digested blood. They are normal or light in appearance and en- tirely consistent with the food of the country — a pretty fairly un- changing bill of fare. We earnestly recommend the abandonment of this "rough test." An apparent positive result would add to a rough test a far rougher, perhaps serious error, in a dysenteric pa- tient, and dysentery is only one of the many much more common causes in the tropics, at least, of blood in the stools, occult or other- wise. Such a patient might be administered to his undoing, from violent purging, one of the three drugs which we have been able to show are, in inflamed states of the bowel, powerful intestinal irritants. Boycott and Haldane state: In no case could any history of melsena be obtained, and in none of the samples of feces examined was the color suggestive of bleeding into the ali- mentary canal. In Siccardi's first four cases hemic crystals were repeatedly and carefully sought but found in only one case. Spargella had the same experience and adds that one would certainly expect to find some occult blood if sufficiently delicate tests were employed. Neither of these authors regard hemorrhage into the intestinal canal as a potent source of anemia m this disease. Spargella was unable to find blood even by spectroscopic examination in three of his four cases. /A^'"l--^^-?^o^,'.i^^^^\°^ physician, Aburi, Gold Coast, Africa (Archiv. fur Schiffsund Tropen-Hygiene, No. XII, 1908, Leipzig), Veranderte Beschaffenheit der gtiihle, makroskopische oder mikroskopische ^^JT^Z^f r^ ^^""i ,^''^^,'^^ P*« beobachtet, wo reine Uncinariasis vorlag beweisend ^'^ Nachwels von Blut im Stuhl hier fiir * ^Jl^ofJ^his does not mean that blood does not occur in the feces, but tor the benefit of those who consider direct loss of blood from the small bites of the worm in the intestine the chief, or at least an im- portant cause of the anemia, we affirm it to be the experience of the physicians_ who have been working under our direction at the manv uncinariasis stations throughout the island that blood in the stools as a result of uncmarial infection is really rare, as a macroscopic phenomenon; still unusual microscopically, in quantity sufficient to constitute hemorrhage; and not presumably abundant transformed chemically, owing to the usual normal color of the feces. tTNCINABIASIS IN POETO BICO. 65 In two of our Utuado series of 1904 blood was found in the feces, but this only once in each case after the course of repeated weekly exaniinations. In 47 the feces were normal in appearance, micro- scopically; 7 contained a good deal of mucus, 2 had entirely undi- gested food, and 2 were unnaturally dark in color. Mosler and Peiper give us interesting information. They say that blood in the stools was not a common event in the St. Gothard tunnel epidemic. It is perfectly safe to consider loss of blood one of the contributing factors to the anemia. Any parasite whose hold on the mucous mem- brane is such as that represented in the micro-photograph (pis. 23 and 24, p. 189) of the worm in situ, must draw some blood into his intestinal canal at times, even though his normal food be the covering cells of the intestinal wall. That from time to time a small vessel is opened and hemorrhage results is also evident from the testimony of good observers. But that the worm should be termed " a blood sucker of the worst type" and the anemia considered to result from direct loss of blood is certainly open to question. When Necator americanus is thus described we imply that its nourishment is chiefly or entirely derived from the blood of its host, and once this is accepted the anemia has a plausible explanation. But, as a matter of fact, our findings at autopsy, performed generally a considerable time after death it is true, but in some cases as early as two or three hours, usually revealed white or gray worms, not filled with blood. We quote in this connection a paragraph from Observations on the Campaign against Uncinariasis in Porto Rico (Boston Medical and Surgical Journal, Vol. CLVI, No. 14, Apr. 4, 1907, p. 417) : In our 12 autopsies of this year (1905) and those of the last, we have only once seen the rose-red ecchymoses described In the older works as occurring in the jejunum. In all save this one it would have been very difBcult indeed to have found the point of attachment of a worm after it had become detached. In the case we were able to see the little red points, which were very small and only noticeable by holding the cleaned intestine against a good light and looking through it, the patient had not received any specific treatment. This case was the only one in this year's series in which no anthelmintic had been administered. Had we not held the intestine up to the light we probably would not have noticed these spots. A number of them were removed and were found to present very minute and superficial erosions with no invasion of the submucous tissue. We are fully aware of the discordant note we are sounding in stating our position regarding the pathogenesis of uncinarial anemia. Future investigations, perhaps autopsies performed sooner after death, may modify these views. We have not had many autopsies as yet, but we have been unable to accept hemorrhage as the chief cause for this anemia from evidence we have so far collected. In view of the conflicting testimony so far presented we hope to make this the object of a special study in the future. CHAECOT-LEYDEN CRYSTALS. These are very frequent in the feces of a patient infected with uncinariae. Sometimes they are found in enormous numbers. They 77759°— S. Doc. 808, 61-3 5 66 UNCINARIASIS IN POETO BICO. are a valuable sign when ova of uncinarise are not readily found, although they are observed in the presence of other intestinal para- sites. We have not been able to establish any clear relation between their abundance and eosinophilia. An inspection of our Utuado cases will reveal this fact. Of the Ponce series of 1902, 11 had Charcot-Leyden crystals; in the Utuado series of 1904, 35 had them ; in a total of 80 cases, 46^ or 67.5 per cent, had these crystals in the feces. OVA or UNCINAEI^". We have evidently been dealing with very heavy infections here. One reading the reports of the disease' in other countries is struck with this fact. Especially to be noted in this regard is the tend- ency to diagnose " uncinariasis " because ova of the parasite are found in small number in the feces. Maj. W. P. Chamberlain, of the Armj, reports 60 cases of a hundred southern soldiers examined, under the title of " The prevalence and importance of uncinariasis among ap- parently healthy southern-bred white men in the United States Army." Few, if any, of these cases would be considered any- thing but very light infections in Porto Rico, if, indeed, such light infections could be often found. The total number of uncinarise ex- pelled by anthelmintic treatment in these 60 cases was 1,041, less than many of our individual cases contained. He thoroughly under- stands the fact that no consequent symptoms could be expected in such light cases and writes from a prophylactic point of view, but we wish to emphasize to all who might gather the idea that unci- narise do not constitute. a particularly great menace to health, that we can not look upon these cases as cases of uncinariasis but as in- stances of infection by uncinarise; in other words, they are worm carriers, not worm sick. These light infections are the ones that have undoubtedly prompted some medical officers in India and physicians elsewhere to deprecate the idea that uncinarise are a source of general invaliding of labor. As a matter of fact many very light infections do (subtlely, it is true) influence the quality of labor, as a careful perusal of Cham- berlin's cases will demonstrate. Twenty ova to a field (one-third objective, 4 ocular, Leitz), was common in our experience, and we have often seen more than this, even to a hundred. Rare is it that the first field does not disclose one. Compare this with Chamberlin's conclusion, " In manv light infections the ova are difficult to find, requiring the complete ex- amination of five or six cover-glass preparations." _ Leichtenstem's method of estimating the number of femate para- sites from the number of eggs is to divide the number found in a gram of feces by 47. Lutz made a 25 per cent suspension of the feces in water and counted tlie eggs in a square centimeter into which the slide was divided. This square centimeter held 4 milligrams of the liquid, or an equivalent of 1 milligram of feces. This amount is multiplied by the weight m grams of the daily amount of feces expelled. It is said that 6,000 ova are the normal output of each female in a day 4. STAGES OF DEVELOPMENT OF OVUM OF NEGATOR AMERICANUS. Photocraohed bv Dr. Wm. Grav. Army Medical Museum, and contributed by him to this worlc. UNCINARIASIS IN PORTO RICO. 67 Grassi and Parona state that 150 to 200 ova per centigram of feces indicate 1,000 uncinarise — 750 females and 250 males. These calculations are, however, easily upset. We soon found that it was impossible to commit to figures a calculation of the number of uncinarise harbored by the host from the number of eggs found in the stools. In a very broad sense we could say, saving accidents, of which we will speak later, that a person had a few, a moderate num- ber, or many parasites; and thus our examinations of the feces are recorded, as a rule, not by niimbers per field, but in a general sense, after observation of several fields, as " few," " moderate," " many," " great many." And this is as close, we believe, as -one can come to guess the number of worms from the number of eggs in the feces. Even this is extremely fallacious. We very soon found that it was much more difficult to find ova in a diarrheal stool. Dieminger states that not only does diarrhea greatly reduce the number of ova, but that a drinking bout will cause them to well-nigh disappear from the stools in which before they had been abundant. This same result, he adds, may be produced by the eating of herring. A sus- pended ovulation is suggested. In the severe cases here, however, neither alcohol nor dried codfish, or apparently anything else, seems to entirely suspend ovulation. Siccardi completely discredits any attempt at an estimate of the number of uncinarise from the number of eggs in the feces. We cordially unite in supporting his statement, demonstrated by our Aibonito cases in 1906. No more shifting ground can be assumed than that one can judge of the number of uncinarise inhabiting an intestine, save in a general way. And why should we " mortify the spirit " in a work which should be practical and yet as scientific as we can make it, by adopting standards which can not in truth be sustained. All that has been said for the numerical valuation of uncinarise by a " scientific guess " from the ova in feces will apply to any pro- portion fixed for the relative number of males and females. Our own ■ observation is that such estimates, save in a most general way, are valueless and further invalidate results of attempts to calculate the number of uncinarise harbored. . As Siccardi says, the diverse propor- tions fixed by well-known authors demonstrate this statement. CIRCULATORY SYSTEM. The disturbances caused in the circulatory system are among the chief sources of suffering and invaliding of the patient. THE HEABI. The protean nature of the symptoms and the physical signs in this organ impressed itself upon everyone who has had an opportunity to investigate the disease here. " Mai de coeur," as a popular name for uncinariasis, is not inappropriate. PHYSICAL DIAGNOSIS. Inspection. — The apex beat is pronounced in the light grades of the disease, due to overaction of the heart muscle. In the moderate 68 UNCINARIASIS IN PORTO RICO. grades it is often found to be displaced downward and to the left. In the marked grades, a notable phenomenon is the great reduction of the force of the apex beat, which is replaced by a wavy, indefinite pulsation in the epigastrium. At times there is a tumultuous heav- ing of the whole precordium. Cyanosis is liable to be noticed in such cases, chiefly in the lips, and contributes to the muddy gray element in forming the color of so many anemics here. Two very severe cases of cyanosis due to heart dilatation were noticed in our special cases. Palpation. — This corroborates the signs described above. _ A presystolic thrill is not infrequently noted in moderate, and especially in severe cases. In the Ponce series of 1902 one such case was noted ; in the Utuado series of 1904 two were seen. Percussion.— In the slight grades hypertrophy is generally not made out. In the moderate grades, hypertrophy, especially of the left ventricle, is the cause of the enlargement of the heart area which may reach to and even beyond the nipple line. In the severe grades a general increase is noted, often due to dilatation and sometimes to pericardial effusion. Auscultation. — The point at which murmurs are best heard in this disease is the third left intercostal space. In light cases an impure first sound and snappy aortic valves may be the only sign present. In moderate cases hemic murmurs are almost always present and may take on a seemingly organic character. Indeed, they may be- come organic. Heart lesions are not rare in apparently healthy per- sons who give a clear history of having passed through a period of uncinariasis in early life. In dilatation the usual confusion of mur- murs may be heard. In the Ponce series of 1899 there were 8 with hypertrophy of the heart. In the Ponce series of 1902 there were 7. In the Utuado series of 1904 there were 18. In the Rio Piedras series of 1906 there were 4. In 111 cases there were 37, or 33 per cent. Many of these cases had proceeded to dilatation, and in some this dilatation was extreme, with pulsation of jugulars and brachial veins, enlarged liver, etc. As a matter of fact, slight hypertrophy is exceedingly common in moderate cases at the clinic. We have only included in the 37 cases above cited such as were frankly hyper- trophic. The typical heart murmur of anemia, the " hemic murmur," is the most constant and is very frequent in all moderate cases. In the severe cases this murmur is often replaced by a series of murmurs embracing nearly all of the cardiac sounds to be distinguished in diseases of the heart, and this is natural when we come to consider the organic changes that supervene. Of these the most common modifications are a harsh, systolic, apical murmur, at times very loud indeed, and the diverse murmurs of cardiac dilatation. In the re- capitulation of these murmurs in our cases we wiH understand by "usual hemic murmur" a sound of a blowing character, generally loud and obscuring the first sound, best heard at the third intercostal space on the left side. UNCINABIASIS IN POBTO RICO. 69 In the Ponce series of 1899 there were 13 cases presenting cardiac murmurs — 3 harsh, systolic, apical; 10 the usual hemic murmurs. In the Ponce series of 1902 there were 16 cases with murmurs — 5 harsh, systolic, apical; 11 usual hemic murmurs. In the Utuado series of 1904, 52 presented cardiac murmurs — 7 harsh, systolic, apical; 41 usual hemic murmurs; 1 purring aortic murmur after the second sound ; 3 of extreme cardiac dilatation. Thus of 99 cases, 81.9 per cent had cardiac murmurs; 18.5 per cent of whom had a harsh, systolic, apical murmur which seemed to be organic. That it was not organic, or that at least the valvular defect was remedied by nature, we were able to prove in some of these cases at a later date. We have not attempted to mention all cases giving evidence of cardiac dilatation, as these were so inextricably confused with the hemic murmurs as to prohibit an exactness which would be necessary for these statistics. Lutz distinguishes four groups of cardiac phenomena which we can recommend as a most acceptable classification : 1. Phenomena in seemingly normal hearts, with acceleration of the beat. 2. Hypertrophy and dilatation, chiefly manifested in the left heart. There are increased area of dullness, exaggerated force of the beat, displacement of the apex, and cardiac murmurs. They may even be protrusion and pulsation of the precordium. 3. Signs of imperfect closure or the auriculo-ventricular valves of one or both sides; continuous murmur, even to obscurity of the second sound, or a systolic murmur over mitral valve, and accentua- tion of second pulmonary sound. 4. Group showing degeneration of cardiac parenchyma, with inter- mittent, irregular, and feeble pulse, and indistinct, at times almost imperceptible, heart murmur. At first the heart's overaction is but slightly noted, chiefly in the vessels of the neck. As the disease becomes more severe the tremen- dous pulsation in the supraclavicular spaces may be seen at some distance. Pulsation and bruit-de-diable are not infrequent. We have seen pulsation of the brachial vein and its ramifications, with every one marked by little knots, corresponding to the sites of valves. One of the most common errors in diagnosis may be aneurism of the vessels at the base of the neck and the aorta. "\Vhere harsh murmurs are transmitted to the arteries the pulsation and pain in the sternum are excessive, and where a thrill is perceptible it is really difficult to exclude aneurism on a simple examination of the circulatory system, and this may indeed become a complication. Distension of superficial abdominal veins has been not infrequently seen. In the Ponce series of 1899j 11 had noticeable throbbing of vessels of the neck ; in the Ponce series of 1902 it was present in 15 ; in the Utuado series of 1904 it was present in 33. In the latter series 4 had a most tremendous heaving of these vessels. Of the 99 cases, there- fore, 59, or 59.5 per cent, presented this symptom. These cases were accompanied, generally, by a well-marked bruit-de-diable. 70 UNCINARIASIS IN PORTO RICO. In the Ponce series of 1899, 6 had visible undulation of the brachial veins ; in the Ponce series of 1902, 5 presented this phenomenon. As these were exaggerated cases of uncinarial anemia, they must be, of course, placed in the category of severe cases. For a good example of the general condition of such a patient see case 47 of the Utuado series of 1904 (Appendix). A thrill at the root of the neck, systolic and very like aneurism, was found in 1 case of the Ponce series of 1902. PBECOEDIAL PAIN. Excluding sternal pain, there is a cardiac pain, prolonged and diffuse. Some describe it as dull, others as sharp and burning. There is no irradiation wherein it differs from angina pectoris and aneur- ism. Lutz concludes that it is due to fatigue of the heart muscle, as it generally manifests itself after sudden, severe exertion. It was noted in 8 of the Ponce series of 1902 ; in 46 of the Utuado series of 1904, of whom 4 complained of severe pain ; and in 9 of the Eio Piedras series of 1906 — a total of 63, or 68.4 per cent. PALPITATION. This is one of the very first symptoms of the disease and one of the most prominent and constant. Light work may induce it, but later it may develop in repose and even as a result of passing emotions. It often becomes a very distressing symptom. In the Ponce series of 1902 palpitation occurred in 16 cases ; in the Utuado series of 1904 in 58 cases, in 6 of whom it was extreme ; in 6 in the Eio Piedras series of 1906 ; in all, a total of 86 cases of 92, or 93.4 per cent. DYSPNEA. This is not so common as palpitation in the light cases, but it is certainly frequent and becomes universal in the later stages, where it may occcasion great suffering. This symptom occurred in 50 of the Utuado series of 1904; it was slight m 8 and very severe in 6. In the Rio Piedras series of 1906 It was present in 11. In the Ponce series of 1899 and 1902 this symptom was not noted. Thus of 73 cases 61 or 83.5 per cent were affected with dyspnea. PEEICAKDIAL EFFUSION. This is common in the later stages with edema and constitutes a further obstacle to heart action. Accurate data in all of our cases IS not obtainable, but in some we demonstrated it. PTJISE. In the first stages the pulse is strong and full, later it becomes dicrotic, then weak and compressible, until in the last stages it is rapid, thready, irregular, and intermittent. The artery, however, is almost never sclerotic and the pulse is soft. Increased frequency is a very common condition and is noted at the very inception of the disease without necessary relation to fever. UlfCINABIASIS IN PORTO BICO. 71 In the Ponce series of 1899 the pulse was weak and compressible in 8, weak and intermittent in 2, weak and thready in 2 ; a total of 12 cases with a weak pulse. In the Ponce series of 1902 there were 6 cases in which the pulse was noted as weak, 2 with dicrotism, and 1 which was irregular and intermittent. In the Utuado series of 1904 the pulse was weak and compressible in 29, weak in 7, weak, dicrotic, and compressible in 4, dicrotic and compressible in 4, and strong and full in 17; a total of 40 with a weak pulse and 8 with dicrotism. In the Rio Piedras series of 1906 the pulse was weak and com- pressible in 9 and full and strong in 3, a total of 9 in whom a weak pulse was noted. A weak pulse was noted therefore in 60.3 per cent and dicrotism in 9 per cent of the total 111 cases. Only in the Utuado series of 1904 was the pulse rate systematically recorded under conditions proper for a true appreciation of the usual rapidity of a pulse; that is to say, when the patient was sitting down or in bed and free from mental excitement. The average rate in these cases was exactly 100. DIZZINESS. This is very annoying and very common, and is to be found in all grades of the disease, reaching its greatest intensity in the latter stages. Its severity is often all out of proportion to the anemia present. It was not made a matter of record in the Ponce series of 1899. In the Ponce series of 1902, 18 suffered from this symptom. In the Utuado series of 1904, 59 had it, 18 suffering very severely from it. In the Rio Piedras series of 1906, 11 complained of it. Thus a total of 88 or 95.6 per cent suffered from dizziness. TINNITUS AUBIUM. This symptom is almost as frequent. Apart from mere ringing in the ears the patient complains bitterly at times of what he de- scribes as " pooh-pooh " in the head, which seems closely related to cardiac and vascular murmurs, frequently preventing sleep by night and stupefying the patient by day. Tinnitus aurium existed in 16 of the Ponce series of 1902 ; in the Utuado series of 1904 in 59, in 18 of whom it was very severe ; and in the Rio Piedras series of 1906 in 11. Thus there was a total of 86, or 93.4 per cent, who suffered from this symptom. SYNCOPE. Many who state that they swoon really mean that the weakness becomes so extreme, with nausea, dizziness, and roaring in the ears, that they are obliged to sit down wherever they happen to be. Real fainting does, however, occur. Syncope was reported by 10 of the Ponce series of 1902, and 29 of the Utuado series of 1904, a total of 39, or 48.7 per cent. 72 UNCINAEIASIS IN PORTO EICO. CEREBEAL EDEMA. This fortunately not common accident may cut off a patient in a few hours when all indications point to a betterment. This appar- ently occurred in Leichtenstern's famous case with 72 per cent eosin- ophilia. The blood had reacted splendidly, but sudden cerebral symptoms supervened. Edema of the brain is not a very unusual occurrence, however, although it can not be called frequent. We lost several cases in this way, notably case 33, Utuado series of 1904 (appendix). It should be counted upon as one possible explanation of sudden death during treatment. We will mention later the tend- ency for thymol to cause, in severe cases, a sudden increase in serous effusion. Care, however, should be taken to eliminate cerebral edema before blaming thymol for a direct poisonous action. We feel sure that this error has been made by some authors. EESPIEATOBY SYSTEM. There are no characteristic symptoms. Pain in the chest is due to other causes. Edema of the lungs may occur in severe cases. Hydrothorax is common in the last stages. A short dry " heart cough " is common. THE TJRINE. In April, 1907, we published (Drs. Ashford and King) in the Boston Medical and Surgical Journal (Vol. CLVI, No. M) in an article entitled, " Observations on the campaign against uncinariasis in Porto Rico," a brief resume of animal experimentation with regard to skin infection and study of the urine before and after the adminis- tration of the anthelmintics we had been employing. The paper was the result of the second year's campaign in Aibonito and in it we rectify our error of 1904 in considering the urine to be usually free from albumin.^ The study was made by all three members of the commission. Sic- cardi, about the same time, published his work in which he states that in all of his cases he was able to find more or less well-defined traces of albumin in the urine. As the major part of this study treats of the influence upon the urine of the anthelmintics employed, we will reserve the full quota- tion for inclusion in the report of 1906-7, but for the present let it suffice to say that of the 23 cases of uncinariasis in the series of special cases for the study of the urine, 20, or 87 per cent, are seen to have had albumin in the urine before the administration of the anthel- mintics. In 18 of these 20 cases, or 90 per cent, casts were also demonstrated. Generally the casts were few in number; in only 6 of the 18 were they at all abundant. The average hemoglobin per- centage in those persons showing albumin before the administration ' In the first report of the Porto Rico Anemia Commission it is stated that albumin is rarely found, although note is made that the kidneys may be very pale and slightly fatty, sometimes being the seat of parenchymatous inflammation, sometimes of amyloid degeneration, but generally speaking, without marked involvement of these organs. We would like to considerably modify our former opinion. It was based on the examination of a series of cases but was not made, as was the blood, a matter of special study, inasmuch as Heller's nitric-acid test and the absence of clinical evidence gare us no clue to the real condition. It is significant that writers on uncinariasis make practically the same statement with exception, among a few others, of Siccardi. UNCINARIASIS IN PORTO RICO. 73 of the anthelmintic was 46.1. Sixteen of the 20 cases showing albumin before taking the specific drugs had but a slight trace, 1 a trace, 3 a fairly abundant amount. Of the 23 who expelled uncinarlse, in 1 case the worms were not counted. In the rest, 9 expelled less than 300, and of these 2 had no albumin in their urine before the administration of the anthelmintic ; 5 had a slight trace ; 1 a trace ; 1 a considerable amount. Eight expelled between 300 and 1,000 uhcinarise, and of these 1 showed no albumin before treatment ; 6 a slight trace ; 1 a consider- able amount. Three expelled between 1,000 and 2,000, and of these 2 showed a slight trace and 1 a trace of albumin before the drug. Those who expelled more than 2,000 uncinariae (one 2,749, the other 4,397) gave only slight traces of albumin before treatment, demonstrable solely by boiling.' The varieties of casts found is of interest : Hyaline, few 4 Hyaline and granular, few 6 Hyaline, granular and fatty, few 1 Epithelial, few 1 Hyaline, many 2 Hyaline and granular, ma'ny 3 Hyaline, granular and fatty, many 1 18 Urobilin was almost always present, fluorescence by the zinc chloride test being elicited, but it was often remarkably slight, even with a profound anemia and heavy infection. Peptones in traces were found to be inconstant, but often demonstrable. Indican in abundance was a very constant and persistent phenomenon. Bile pigment was relatively rare. The specific gravity tended to be low. Of 19 of the series of special cases for the study of the urine, the average specific gravity was 1.013. Sugar was not present in any examination made by us.' ' Of the Ponce series of 1902, 16 in which the specific gravity was taken gave an average of 1.009; in 15 of the 16 the reaction of the urine was acid ; and in 3 there was much albumin with hyaline and epithelial casts. Eighty-seven per cent seemed to us very high for albumin in the urine of the average case of uncinariasis. These special cases have the com- mon defect that they reflect faithfully the picture in intense cases, but do not usually portray the average case. So we determined to take any number of cases in the daily clinic just as they happened to come, and in a series of 127 out-patients we found 34 who contained albu- min in their urine, a percentage of 26.7. These examinations were made in persons who had never taken the anthelmintics, and from this it can be affirmed that about one-fourth of all cases of all grades have albumin in their urine. Six of the 34 had a heavy precipitate of albumin by the boiling test, and 5 had casts, generally hyaline and granular, with now and then a fatty or epithelial cast. Siccardi confirms these investigations of 1905 by stating as follows: Nei miei casi le orine, sempre acide, contengono tutte, in traccei piu o meno sensibili, I'albumlna." He failed, however, to find casts in his four cases. Jle attributes the albuminuria, as do we, to a toxin. 'Ashford and King, Boston Med. and Surg. Journal, Vol. CLVI, No. 14. "In my cases the urine, always acid, never failed to contain alhumin in more or less appreciable traces. 74 UNCINARIASIS IN POETO RICO. THE BLOOD. The blood gradually loses color and consistency lantil in severe cases it is pale, thin, and watery, resembline " beef washings." In- stead of exuding in a globular drop it spreads out and runs down the lobe of the ear so that it is often difficult to secure one of sufficient size for examination. Coagulation was observed to take place slowly, but it was not timed exactly ; neither did we attempt to study reaction, specific .gravity, volume of corpuscles, and volume of blood, owing to lack of time and instruments. HEMOGLOBIN. We used the v. Fleischl hemoglobinometer as a standard until 1905 ; thereafter the Dare, as the latter is, after sufficient practice, just as accurate and much more of a time saver. Kegarding the hemoglobin percentage as the best index to the grade of the anemia, it was estimated in a certain number of cases in each year's campaign up to 1907, when the variations to which it was subject were sufficiently plain to us, and it seemed unnecessary in view of far more practical work to continue our readings. The following table will serve as a basis for a study of the changes in the hemoglobin in this disease: !B Fl g « 9 J. g . P, M ?.o a i!.P a P. M a S ^W ^S 1 ^w s 5« CD 1 1 a i ' 3| 1 '^S S sS Is V 1 •a| %-^' P. SJH P4 Ife ft P. fe a .|| "•a ■R" uM 'is s is 0+3 s I s S - Is ss |§ ^ 3 n S.H B " « |s OJ Bm M 3 - ment. Number otun- ■ cinariae. expelled. Per cent. 35 28 35 20 10 27 59 40 39 25 37 64 39 89 88 73 40 19 83 50 47 40 44 21 Per cent, 100 120 82 110 120 99 93 100 95 70 94 61 68 109 120 112 50 47 91 92 94 42 76 39 32 32 32 31 43 46 22 28 24 49 38 29 15 12 15 24 17 44 10 22 53 53 22 16 1,007 2,015 1.871 465 544 490 908 881 J)q 1,352 1,446 424 J)0 J)0 847 1,148 236 Po Do 326 X)o 716 Do 623 Do 249 1,160 1,110 96 2,316 1,348 39.3 86.5 33.8 870 If there is one thing more than another which attracts the atten- tion it is that the number of parasites harbored and the hemoglobip do not seem to follow any hard and fast rule in their relation, the one with the other. To further emphasize this point, which is an im- portant one, let us refer also to the following table, in which the worm-count cases are divided, according to the percentage of their hemoglobin, into four classes which may be considered as representing the very intense, intense, medium, and benign grades of the anemia. Here one would expect to find, if intestinal hemorrhage were the chief cause, a greater consonance between the number of worms expelled and the intensity of the anemia, but compare cases having almost identical initial hemoglobin percentage and see the widely differing number of uncinarise they expelled. If it were at all doubtful that all worms were not expelled in the series or that all which were ex- pelled were not counted, the position taken would be a weak one, but knowing as we do that these counts, which we alone made, are cor- rect, and that the patients' evacuations were carefully checked by ourselves and perfectly trustworthy assistants the table has an un- usual significance. We do not pretend to say what poisonous prod- uct of uncinarise does this, but we can not understand how uncinarial anemia can be produced principally by the direct loss of blood, judg- ing from our own experience elsewhere described, even conceding the additional fact that there is a substance secreted at the site of the " bite " which prevents the coagulation of blood and permits con- tinued capillary hemorrhage and that frequent change in the feeding ground of the worms multiplies these wounds. It is begging the question to say that at times blood is found in the feces occult or formed, when not only ourselves but others (notably Siccardi and Spargella) have found this to be the exception rather than the rule. UNCINABIASIS IN PORTO RICO. 79 We have not sought occult blood for reasons given, although we now wish that we had done so in view of the fact that certain Italian authors have often failed to find it, but the color of feces means some- thing as does this tabular data which we do not offer as proof that the anemia is not the result of the direct loss of blood from hemorrhage but only as a piece of strong circumstantial evidence that there may be another factor in the pathogenesis of this anemia. Numhet of unomariw etcpelled in persons with very intense, intense, medium, and, light grades of anemia. AIBONITO SEEIES; BETANAPHTHOL AND THYMOL GROUPS. Very intense. Intense. Medium. Light. Hemo- globin. Number of unci- narise. Hemo- globin. Number of unci- narise. Hemo- globin. Number of unci- nariae. Hemo- globin. Number of unci- nariae. Thymol Per cent. 12 14 16 18 18 20 16 20 10 19 1,125 1,979 1,361 1,167 651 2,073 1,021 465 544 623 Per cent. 22 25 28 27 ■26 21 327 4,397 2,016 490 1,446 1,348 Per cent. 40 58 32 35 35 35 69 40 39 37 39 40 50 47 40 44 776 1,367 3,493 959 1,007 1,871 908 881 1,352 424 1,148 716 1,160 1,110 96 2,316 Per cent. 120 64 89 88 73 83 574 Do 847 Do 236 Do 336 Do 326 Do 249 Do Do Do Do Do Do Do . Do Do . Do Average 16.3 1,090 24.6 1,670 41.8 1,224 86.1 428 Betanaphthol Do IS 20 18 18 8 16 1,316 1,778 650 1,108 2,234 152 21 29 25 24 23 22 27 1,122 1,727 73 2,724 995 946 725 35 34 53 35 35 33 68 67 37 44 35 333 864 406 497 664 235 1,566 1,387 362 1,195 932 65 81 65 118 97 247 680 Do. 642 Do 118 Do 159 Do Do Do. Do... . DO' Do Average 16.3 1,206 24.4 1,187 41.4 765 86.2 349 Incomplete worin^count eases. Drug; Hemo- globin on admis- sion. Hemo- globin on discharge. Days un- der treat- ment. Number otun- cinariae expelled. Betanaphthol Per cent. 12 20 52 22 9 i 65 Per cent. 65 40 64 38 556 Do 543 178 47 37 47 60 1,446 Betananhthol 1,020 Do 639 30 44.7 49.7 730 80 UNCINABIASIS IN PORTO RICO. Rio Piedras cases. FIRST GROUP. Drag. Hemo- globin on admis- sion. Hemo- Jlobinon ischarge. Days un- der treat- ment. Number of un- cinariae expelled. Eucalyptol Thymol Do Eucalyptol Do Do Do Thymol Do Average SECOND GROUP. Per cent. 18 8 21 19 30 20 30 8 19 Per cent. SO 22 30 447 950 874 276 271 1,492 12 1,644 304 19.2 32.2 Eucalyptol 76 33 14 70 46 45 14 31 561 Do 21 Do 220 Do 45 Do 458 Do 276 Do 18 Do 420 Average. . .-. 41.1 252 These cases were not followed sufficiently long to ascertain whether all uncinariae were expelled or not as the patients ran away from hospital or felt so much improved as to be able to return to work and could not be persuaded to stay. With regard to the average of the out-patient clinic and the changes in the hemoglobin in such patients, we will refer again to the^ 579 Bayamon cases. In that series subsequent hemoglobin readings were made on 423 with the following results : Three hundred and seventv- one gained from 1 to 71 per cent, average gain 21.34; 45 lost from"l to 16 per cent, average loss, 5.04; 7 neither gained nor lost. It must be understood that they were under treatment and observation vary- ing lengths of time and few over six weeks. The rise in hemoglobin is not a regular ascent, but subject to marked variations in the same individual. It may fall just after the beginning of treatment or fall after rising considerably, then con- tinue to rise. In the above 423 cases at some time during their course, 45 rose after falling more than 3 and 38 fell more than 3 after hav- ing risen. Had those of the latter group and the 45 which lost been taken later, they might have shown a net increase. This irregular course was also manifested by the special cases in the Utuado series of 1904. In 42 of them the hemoglobin reached 85 per cent or above, averaging 100.38 per cent. A weekly rise of 20 to 30 -per cent was not uncommon and in case 58 of that series it rose 42 per cent. The patients looked and felt correspondingly improved. We believe that two factors may be here engaged. (1) That the blood regenerating organs, working overtime to offset the deleterious effect of the parasites and being relieved of much opposition by the removal of a large number, produce a rapid actual increase. UNCINAKIASIS IN POK.TO BIOO. 81 (2) W-Tiile not agreeing with Boycott and Haldane that it is all a simple hydremia, yet it would seem from their experiments that there is more or less increase in the volume of the blood, and that during progress of cure this condition is more or less rapidly remedied, producing a relative increase. A very noticeable peculiarity of these low hemoglobin percentages is that persons with as low as 16 to 20 per cent can and do keep at their accustomed labor. It is painful to witness but it is a fact. Boycott and Haldane note this also, but attribute it to what they conceive to be a hydremia. They state that, were the blood reduced in fact as it is apparently demonstrated by the hemoglobin percent- age, work would be suspended long before such low percentages were reached. These observers give a series pf experiments to demonstrate that the total oxygen capacity of the blood was only slightly, if at all, decreased. They were obliged to use almost as large a quantity of CO to saturate the hemoglobin in anemics from uncinariasis as in a normal person. In other words, the total oxygen capacity was re- duced by only 11 per cent and the volume of the blood was increased by 94 per cent. They deduced that in place of anemia there is really a hydremic plethora and that hemorrhage can not be the cause of the blood condition, as by hemorrhage there would be a reduction in hemoglobin and the CO necessary to saturate it would be much less than is actually the fact. They class uncinarial anemia in this regard with chlorosis. BED CELLS. The following table shows the average red-cell count in each of the series in which the red cells were counted. They are grouped according to the percentage of hemoglobin into very intense, intense, moderate, and light grades of anemia. Average red-cell count. Series, Ponce, Series, Ponce, 1902. Series, Utuado, 1904. Series, Hio Pie- dras, 1906. Number cases with 20 per cent Hb. and less. . . Average red cells per c. mm Number cases witn from 21 to 30 per cent Hb. . Average red cells per c. mm Number cases witn from 31 to 60 per cent Hb. Average red cells per c. mm Number cases with more than 60 per cent Hb. Average red cells Total number oases Average Hb. per cent these cases Average red-cell count, all cases Average color index 11 1,593,947 7 2,062,537 17 1, 632, 441 12 2,832,755 14 3,427,048 18 20.4 1, 776, 188 0.57 43 25.1 2,661,703 0.49 26 1,716,627 20 2, 608, 664 14 3, 259, 600 1 4,362,000 61 24. 3 2,406.427 0.50 2,372,044 3 3,148,266 7 4,382,880 3 6,080,933 22 33 3,487,098 0.47 A much more profitable way of studying the influence of the dis- ease upon the red-cell count is seen in the following table. Here only the 61 Utuado cases are considered, as they are the only ones with a consistent weekly blood record. The count on admission with corresponding hemoglobinometric reading is compared with the same data on the occasion of the first count not falling below the normal of 5,000,000 per c. mm. and with the highest red-cell count noted in the course of the disease during its treatment. In addition, the number of days of treatment required to bring the red cells to normal is shown. 77759°— S. Doc. 808, 61-3 6 82 UNCINARIASIS IN POKTO EICO. Series, Utuado, 1904. Case. On admission. First count not showing a re- duction in red cells, witli hemoglobin of that date. Highest red cell count noted, with hemo- globin on that date. Hemo- globin. Red cells. Hemo- globin. Bed cells. Days. Hemo- globin. Bed cells. 1 33 38 25 28 45 22 10 34 20 20 32 27 14 16 11 20 9 16 28 22 13 12 14 26 22 52 27 11 24 24 29 19 9 24 23 12 15 10 13 21 9 31 20 40 16 36 32 26 26 27 20 25 25 40 39 33 56 65 18 19 2,968,000 3,968,800 2,640,000 2,656,000 4, 432, 000 2,288,000 2,266,640 2,292,800 2,600,000 3,195,520 2,666,000 2,306,640 1,226,408 1,561,200 1,608,800 1,656,000 1,062,160 1,584,000 3,480,000 2,976,000 1,240,000 984,000 2,372,800 2,195,200 1,946,640 2,420,000 2,288,000 1,616,000 2,492,800 2,581,600 2,216,000 1,897,600 754,400 3,137,600 2,572,800 1,160,000 2,468,000 880,000 1,820,800 2,264,000 1,624,000 2,844,000 1,360,000 3,981,600 1,776,000 2,732,800 2,195,200 2,517,600 2,284,000 2,080,000 2,160,000 3,741,600 4,128,000 4,336,000 2,660,000 3,221,600 6,025,600 4,352,000 1,212,800 2,360,000 67 37 103 41 70 66 25 47 58 41 60 5,261,600 5,400,000 6,048,800 6,066,400 5,506,400 5,020,100 5,000,000 5,048,800 5,372,800 6,901,600 5,600,000 51 16 71 29 22 66 22 38 50 39 88 83 66 103 82 90 66 76 56 68 104 80 7,635,200 6,632,000 5,048,800 6,720,000 6,836,200 5,020,100 6,755,200 6,724,000 5,372,800 6,724,000 6,400,000 2 3 4 5 6 7 8 9 10 11 12 13. » 95 69 50 90 5,092,800 5,238,400 5,382,160 5,320,000 ' 87 43 36 91 109 90 87 90 5,190,400^ 6,688,000 7,400,000 5,320,000 14 15 16 17 18 80 64 70 102 75 60 75 51 61 62 54 6,492,800 5,786,400 5,284,000 6,040,000 5,064,000 6,244,000 5,088,000 5,017,600 5,280,000 5,224,000 5,124,000 92 29 26 70 36 36 90 29 22 29 22 82 103 70 102 71 60 90 100 85 70 73 5,796,200 7,088,000 6,284,000 5,040,000 5, 624, 000 6,244,000 6,440,000 5,184,1)00 5,636,000 6,390,400 6,430,400 19 20 21 22 23 24 25 26 27 28 29 30 103 83 86 6,106,600 5,024,000 5,184,000 35 64 76 103 83 86 6,106,600 5,024,000 5,184,000 31 32 33 34 46 5,075,200 43 60 35 36 86 82 85 66 69 89 5,096,000 6,044,000 5,364,400 5,709,600 6,312,000 5,016,000 63 49 70 57 58 60 101 87 85 92 84 101 37 38 39 40 41 42 43 44 45 60" "S," 684," 666" 22" ioo" ""7," 724," 666 47 85 93 45 6,866,000 5,000,000 5,492,800 29 29 15 85 102 102 6,856,000 48 6,261,600 49 7,008,800 61 102 80 76 85 104 63 97 66 107 5,832,800 5,261,600 5,386,400 6,337,600 5,506,000 5,248,000 6,061,600 5,025,600 5,346,400 36 43 29 22 36 29 43 54 8 102 83 76 109 104 100 97 83 107 5,832,800 52 5,624,000 53 5,386,400 54 6,097,600 55 5,506,000 56 5,368,800 57 6,061,600 58 6,200,000 59 60 5,346,400 Average 24 2,406,422 57 5,364,597 44.6 87.3 6,988,030 Taking all grades of the disease as encountered in Porto Rico, the average on admission is too low, as our experience has been that the reds are relatively less decreased in the milder cases. Under treatment, the production of red corpuscles proceeds rapidly, reaching and exceeding normal some time before the hemoglobin. \Yhile tor 80 per cent of these cases an average of 62 days were re- quired to bnng the hemoglobin to 80 per cent or over, the remaining 20 per cent of the cases not even attaining that percentage, only 44.6 UNCINARIASIS IN PORTO RICO. 83 days were needed for the red cells to reach and to pass 5,000,000 per cmm. An interesting feature of this table is the tendency under treatment for the red cells to rise to a surprising number in excess of 5,000,000 per cmm., and this often while the hemoglobin lags well be- hind below normal. This rise is only seen a brief time, as a rule, as a fall to normal usually occurs very rapidly. The rise is probably due to the microcytosis which occurs as a result of specific treatment. In this connection we wish to state that blood platelets increased in num- ber, at times enormously, as the condition of the blood improved. No counts of these cells were made, but unusually high numbers are to be found in our clinical histories of these cases. As the anemia progresses, the cells become polychromatophilic %nd show poikylocytosis. We have never seen these conditions absent in severe cases. Macrocytes and microcytes are constantly seen in such cases, and while, as a rule, the latter are more numerous, the former often predominate, especially in severe cases before treatment, and, with oval forms and megaloblasts, present a picture very suggestive of pernicious anemia if -only the stained smear be depended upon for diagnosis. The assertion has been made that this secondary anemia may become pernicious, but while uncinarial anemia is often per- nicious in the sense that it is frequently fatal, and sometimes even when all parasites are expelled, owing to a more or less complete exhaustion of the hemopoetic organs, this is not pernicious anemia. We do not believe that true pernicious anemia can be the result of uncinarial anemia ; were this so, the severe -cases we relate in this work would have, at least some of them, failed to respond to specific treatment. One who makes a diagnosis of pernicious anemia in a case which faiis to respond in several months to specific treatment that has re- lieved the patient of all uncinarise should see that same patient after 9 months or a year. Normoblasts are fairly common and in many instances increase, while megaloblasts show a tendency to diminish under treatment. There is little doubt in our minds that at irregular intervals in prac- tically all cases there are showers of normoblasts. The megaloblasts are seldom very large. Macrocytosis also gives way to microcytosis as improvement is noted. The extremes in size of both classes were often seen in bad cases. In 61 of the 61 Utuado cases our notes on the blood refer with great care to the degree of poikilocytosis, polychromasia, macrocytosis, microcytosis, and to the number of normoblasts, megaloblasts, mye- locytes, and stimulation cells. Omitting the last two, which will be considered under the caption of leucocytes, the following summary will establish the frequency of departures from the normal in this regard for grades of the anemia which these cases represent : Summary of notes on changes in red Mood cells in 51 cases of the Utuado series. Change. None Slight Few Moderate. Marked . . . Many Extreme . . Poiky- locytosis. Poly- chromasia. Ma- crocytes. Mi- crocytes. 4 20 23 84 UNCINABIASIS IN POE.TO RICO. In 32 cases of the 61 the predominance of macrocytes over micro- cytes and vice versa was distinctly expressed. The microcytes pre- dominated in 19, the macrocytes in 13. Normoblasts were found in 30 of the 51 cases ; the average number per cmm was 67.9. It should be explained in this connection that in each case where normoblasts were noted the highest number appear- ing throughout the case was taken in calculating this average. The same should be applied to our remarks on the megaloblasts. High normoblast counts were 173.6; 102.4; 268.8; 153.6; 217.6 per cmm. Megaloblasts were found in 11 of 51 cases with an average of 54.6 per cmm per case. The megaloblasts exceeded the normoblasts in nu^nber in four of these cases. The 10 cases of the Utuado series which are not included had the simple remark, " usual blood changes," so that, although they could not be included in the statistical data, they were all similar to the above. Cases in this series of especial interest are the following : Unusually low red cell count. — Case 22 (984,000 per cmm) ; case 33 (754,400 per cmm) ; case 38 (880,000) ; case 69 (964,000 per cmm). Stained smear reserrobles pernicious anemia. — Cases 12, 50, and 59 are perfect pictures of blood of pernicious anemia. Case 15 had one enormous macrocyte, 20 microns in diameter, among many others not quite so large. In this case macrocytosis was found. Later the picture changed to that found in chlorosis with a predominance of smaller red blood cells. Case 17 ; one-third of the red cells were oval and abnormally large. Case 18 ; macrocytes very large. Irregularity in size of tocZs.— Case 10 had hardly a single normal sized cell. Cases 34 and 52 ; changed from macrocytosis to microcytosis under treatment. Cases 38 and 48 ; macrocytes and microcytes about equal in number on first examination ; later, in course of treatment, microcytosis made itself evident. Especially interesting cases in the Ponce series are : Series of 1899. — Case 2 had a color index of 1.43 and the lowest count of red cells ever made by us, with the exception of one recount in case 10, same series. This case could have been well confounded with pernicious anemia as there were many macrocytes, poikylocy- tosis, polychromasia, and 46 megaloblasts per cmm. It is true that there were at the same time 144 normoblasts per cmm, but variation in this regard is not so unusual in essential anemia. Series of 190%, first group.-— Q,^^ 13 gave a red cell count of 960,640 per cmm; case 15 gave 904,370. THE LEUCOCYTES. We are unable to demonstrate a characteristic leucocytosis in uncinariasis. In the majority of cases the number of these cells lies somewhere between 5,000 and 10,000 per cmm, and often m chronic cases of long standing there is leucopenia. There is gen- erally some other reason for leucocytosis, save in certain cases toward the end of their convalescence. It may be seen where mazamorra has UNCINABIASIS IN POBTO RICO. 85 produced extensive eruption, or an increased volume of the blood may influence the count as in the case of red cells. The differential counts of leucocytes were made in the usual manner. In 1899 the Ehrlich triacid stain was used; in 1902 and 1904 the Jenner stain was employed as a standard although Wright's, Leisch- man's and Goldhorn's were frequently used in especially interesting cases ; in 1906 the Teideman stain was the standard. Of the stains we have used, the Jenner was found to be the most stable in this country where the light is strong and the humidity great, and it gave most excellent results as prepared by ourselves. The more modern stains are better for fine nuclear changes and for this purpose they were used, but they last only an incredibly short time in Porto Rico and we were obliged to have frequent supplies forwarded us from the United States to replace those already deteriorating. Only 250 leucocytes were counted for a differential, but it is believed that this number gives an exceedingly close estimate of the actual percentage. In marked cases, there is a decided degeneration of leucocytes. This was most marked in eosinophiles, but very common in polymorpho- nuclear neutrophiles and in large lymphocytes. Pale, shredded cells were found; nuclei without protoplasm and others with only a few granules to distinguish their neutrophilic character; vacuolation of nuclei; fragmentation of nuclei, etc. Not only this, but frequent instances of mitosis (or apparent mitosis) in both eosinophiles and polymorphonuclears were noted. Neutrophiles were sometimes under- sized and almost bereft of granules or oversized with large granules. EOSINOPHILES. The chief interest centered around the eosinophiles in all of these differential counts. It will be profitable to quote our remarks in the report made of our 100 cases in Ponce in 1902 : Before drawing conclusions, let us classify, in so far as possible, the cases in whieli the differential counts were made: 1. Cases showing eosinophile count of less than 15 per cent, but more than 10 per cent. These may be subdivided into : (a) Those with but one count on admission and before treatment, viz, cases 1, 14, 20, 32, 33, 74, 81, 88, 93, 95. (b) Those with two counts, one before treatment and the other after treat- ment had expelled a great number of uncinarlse, showing a rise in the second eosinophile count over that recorded on admission, viz, cases 2, 71, 86. (c) Same as b, but that a fall or no change is noted in the second count, viz, cases 65, 70, 89. 2. Cases showing an eosinophile count of less than 10 per cent : (a) Those with but one count on admission and before treatment, viz, cases 5, 24, 28, -36, 49, 62, 64, 75, 76, 87, 91, 92. (b) Those with two counts, one before treatment and the other after treat- ment had expelled a large number of uneinariae, showing a rise in the second eosinophile count over that recorded on admission, viz, cases 3, 13, 68, 84, 85. (c) Same as b, but that a fall in the second count is seen, viz, case 69. 3. Cases showing a high eosinophilia (above 15 per cent) before treatment, viz, cases 22, 23, 60, 61, 66, 67, 90, 98. 4. Cases showing a high eosinophilia (above 15 per cent) some time after beginning treatment, but without a count before treatment, viz, cases 4, 15, 19, 40, 41, 42, 43, 57, 77. 5. Cases showing low eosinophilia (below 15 per cent) under the same con- ditions, viz, cases 8, 12, 44, 78, 82, 83. 6. Unclassified cases, viz, cases 9, 17, 18, 29. 86 UNCINABIASIS IN POBTO EIOO. From this data we may, with caution, make the following deductions : (A) Uncinariasis is a disease marked at some period of its course at least, by eosinophilia. In all cases a proper interval, generally a week, was left after administration of thymol to insure its thorough elimination that the differential count might not be influenced by the drug, other well-known causes of eosinophilia being absent. (B) In those who have suffered but a short time from the disease, or whose blood regeneration is still active, a high eosinophilia is to be expected. Such cases are 23, 61, 66, 67, 90. Case 22, with 16.8 per cent, and case 98, with 17.3 per cent, are exceptions to this statement, yet they can hardly be said to negative the rule, as they are but little above the arbitrary limit of 15 per cent. (C) In chronic uncinariasis or in those who have been for a long time subject to profound anemia, the eosinophile count is more apt to be low than high. An exhausted or malnourished condition of the bone marrow may explain this condition. Such cases are those cited under headings 1 and 2, and possibly others. Apparent exceptions to this rule are cases 5, 18, 62, and 74, but the state- ments of patients are often inexact concerning the beginning of the disease; in fact such data are most dlflicult to determine on account of the insidious onset. (D) After treatment in chronic cases and in those in the later stages of the disease, a rise in eosinophiles may be expected and is of good prognostic import It may be due to a more active regeneration in the bone marrow. Cases illus- trating this are 2, 3, 13, 68, 71, 84, 86, and probably others in which the data are lacking which would enable us to include them. (e) When, however, there is a fall of eosinophiles, accompanied by lack of improvement in physical signs, death may often be the result. Care must be taken to distinguish this from the final fall in eosinophiles which marks the establishment of the blood equilibrium and the return to health. In general, also, a slow rise of eosinophiles marks a long convalescence, as is frequently seen in the old, whose recuperative powers are limited. Illustrative cases are 12, 44, 69, 78, 82, and 89. Cases 12, 69, and 82 are Improving v€ry slowly; case 44 is almost sure to terminate fatally. In case 78 the patient nearly died during a period corresponding to an eosinophile count of 1 per cent ; case 89 remains unimproved. Cases 22; 24, 49, and 76 all terminated fatally, and, with the exception of case 22, all the patients had a very low eosinophile count. While this was a careful study, it had the disadvantage of having to depend on irregular blood data. The weekly differential counts of the 61 Utuado series do away with this source of error and give us ideal data upon which to base a corroboration of the conclusions of 1902. Of these cases, 34 had a rise in eosinophiles under treatment and upon their recovery were discharged with a higher eosinophile per- centage than that with which they were admitted to the hospital. Seventeen showed a rise under treatment, with a subsequent fall to a percentage below that which they possessed when admitted. They were generally cases whose fall in eosinophilia corresponded to the final fall to the normal blood count on recovery. This gives a percentage of 87.9 of 58 cases who did not die in wnom a rise in eosinophile percentage occurred under treatment. In gen- eral these rises were remarkably high. Seven cases showed a fall in eosinophiles under treatment; 2 of these were cases of concomitant tuberculosis pulmonalis and 1 was a light case of uncinariasis. Of the 3 that died, cases lY, 33, and 42, none had eosinophilia. on admission and in 2 the eosinophile percentage they had on ad- mission went down under treatment. Case 33 is an example of a favorable blood reaction cut short by death from an accident, viz, a sudden and immediately fatal edema of the brain. UNCINARIASIS IN POBTO EICO. 87 The following cases never had an eosinophile percentage reaching 10 during the entire period of their stay in hospital : Cases 12, 13, 17, 18, 23, 25, 35, 38, 42, 46, 53, 58, and 59. Of these cases, 12 and 23 were tuberculous, 17 and 42 died, 18 was extremely stubborn in his recovery and was expected to die on several occasions, and case 58 was a slight case which can not be considered in the light of what has been said. Therefore we feel ourselves justified in reiterating our conclusions of 1902 succinctly as follows: 1. Very severe chronic cases with poor resisting power and ex- hausted blood-making organs have little or no eosinophilia. 2. A rise in eosinophiles is generally found in cases which progress favorably and should influence the prognosis. 3. If very severe cases, presenting little or no eosinophilia, fall in their eosinophile percentage without improving in their general con- dition the prognosis for such a case is less favorable. In general good resistance to the poison of uncinaria is expressed by eosinophilia. The cases found in the Utuado series of 1904, being nearly all severe, gave an average of 10.8 per cent eosinophiles before treatment was begun and an ultimate percentage, after all treatment was concluded, of 13.7. But the most interesting feature of these differential counts is revealed in the average of the highest eosinophile percentages during the course of the treatment ; this was 21.24 per cent. As 42 of the 61 Utuado cases were completely cured at the time of the last count, and 15 were nearly so, it is clearly seen that the num- ber of uncinarisB has nothing to do with eosinophilia directly. As to the oft-cited remark that eosinophilia and Charcot-Leyden crystals increase and fall together, there are cases which fail to show such relation. The eosinophiles behave in the most extraordinary way in the course of cure. There seems to be a general rise to a certain percent- age, varying according to the individual, after which a fall to normal takes place. This fall to normal may occur before the patient reaches a normal hemoglobin percentage or may be delayed until some time after cure. In this course of rise and fall, great undula- tions may take place in the curve, which as yet seem to be difficult to explain. The eosinophiles which we have seen in this study of the leucocytes are almost always larger than normal. Sometimes they are very large and tend to degeneration, apart from their evident fragility seen in preparation. The granules are also veiy large. Myelocytes are more frequently eosinophilic than neutrophilic. The following table gives a detailed account of the number of leuco- cytes per cmm, the corresponding hemoglobin and the eosinophile percentage before treatment, the same data on the occasion of the highest eosinophile percentage registered during the course of the case and after all treatment was concluded. 88 trNOlNAMASlS IN PORTO MOO. On admission. On occasion of highest eosino- phile count. Hemo- globin. Leuco- cytes per Eoslno- phUe. Hemo- globin. Leuco- cytes. Eoslno- phlle. On discharge. Hemo- globin. Leuco- cytes per cmm. 13,200 6,000 7,400 9,000 7,600 9,000 7,000 9,200 6,200 6,400 6,800 6,200 4,200 7,800 19,200 6,700 9,200 5,400 7,400 9,800 6,300 5,200 9,000 9,800 3,200 9,400 3,400 3,200 7,400 7,800 7,800 6,400 14,600 6,000 4,600 12,600 8,600 6,600 5,000 5,800 17,600 11,000 7,400 ,7,400 8,200 5,000 4,800 5,800 15,200 6,000 13,400 6,200 4,200 5,400 6,000 12,600 7,200 11,200 10,800 8,200 16.8 13.6 9.8 19.6 9.6 20.4 18.4 4.0 27.6 .8 22.0 2.0 8.4 18.3 20.8 12.8 1.6 .4 10.0 15.6 6.4 8.0 .4 4.4 6.8 20.8 8.8 14.0 15.2 10.4 8.4 16.4 6.8 20.4 6.4 5.2 10.0 .8 1.2 15.2 4.8 2.0 8.6 20.8 4.8 4.0 10.8 26.0 11.2 2.4 6.0 20.4 7.6 17.0 26.4 13.6 14.4 9.5 4.8 6.8 2.0 36 50 41 44 90 68 23 37 57 55 32 25 14 59 110 26 11 80 90 39 89 52 20 75 22 52 54 73 40 55 83 32 15 31 23 66 75 41 92 55 89 41 101 46 62 70 32 SO 77 91 70 100 85 104 43 64 S3 05 16 66 87 5,000 18,400 6,200 9,200 9,400 7,600 6,600 8,800 6,800 6,400 6,800 3,800 4,200 11,200 7,800 5,000 11,000 9,000 6,400 7,800 6,800 7,200 4,800 9,400 3,200 9,400 6,000 5,200 6,000 6,200 8,000 6,800 11,600 7,600 6,000 6,200 13,600 7,600 7,000 13,000 12,000 18,400 8,200 5,000 7,600 9,200 5,000 9,000 9,400 6,400 5,600 8,000 11,200 5,800 11,800 4,800 12,200 7,200 5,600 7,200 11,200 22.4 23.5 23.2 25.6 20.0 21.2 30.0 23.2 43.6 21.2 22.0 4.1 8.4 46.0 35.6 21.4 2.8 6.8 12.0 16.0 28.0 16.0 6.0 16.0 6.8 20.8 20.0 42.8 24.0 10.8 28.0 46.8 20.8 31.6 6.4 20.8 16.4 9.2 12.8 44.0 44.0 3.2 14.4 23.2 19.2 6.0 10.8 33.6 17.2 24.8 18.0 22.0 9.6 35.2 28.8 28.0 31.6 9.5 8.4 24.8 26.8 101 100 103 100 105 70 103 78 103 104 80 30 109 101 110 90 15 82 103 70 102 104 80 90 100 100 100 101 61 103 83 86 15 62 77 101 100 85 92 84 101 34 101 100 62 104 102 102 77 102 83 100 109 104 100 103 83 107 75 87 1,000 10.86 8,013 21.24 7,800 22,600 6,800 10,200 9,200 8,600 16,400 5,600 9,800 7,800 8,800 8,600 10,800 10,200 7,800 7,400 19,400 6,400 17,800 9,600 6,400 4,200 7,000 7,000 6,800 6,800 9,000 10,600 5,000 8,000 8,000 7,400 11,600 10,000 4,000 7,400 11,400 5,200 7,000 7,000 9,400 11,400 8,200 9,000 7,600 5,800 7,800 7,200 9,400 7,600 4,200 8,000 8,000 5,800 15,600 9,400 12,200 9,000 7,400 8,600 11,200 8,921 1 Died. LYMPHOCYTES, LAEGE AND SMALL. In our counts we have preferred Cabot's classification to Swing's, from motives of convenience, there being apparently no essential question nivolved as to increase or diminution of the percentage of ■ ' large mononuclear leucocytes." All leucocytes were called small if UNOIKABIASIS IN l>OMO MCO. 8d below 10 microns in diameter, and all large above that size. There seems to be a decided tendency to increase in the proportion of large lymphocytes in soine cases. ^ " STIMULATION CELLS " OF TURCK. These cells were looked for at first, but were counted as lymphocytes. In two or three weeks, however, after beginning our special cases in Utuado we began to note them separately and many fine specimens were seen. Their great irregularity in appearing does not lead us to think that any deductions can be made concerning them in this dis- ease. They were present in 49 of 51 of the Utuado series and their average percentage was 4.8. MYELOCYTES. In 43 of 51 cases in the Utuado series myelocytes appeared. The average percentage of these cells was 1. They were generally eosino- philic, as above stated. BASOPHILES. These cells appeared to be increased at times. Basophilic granules appeared rather frequently in lymphocytes. In general conclusion, we cite the average percentage of the four chief classes of leucocytes in 29 cases before treatment was begun, and in which 10 per cent of eosinophiles or over was observed : Eosinophiles 17. 1 Polymorphonuclears 54. 5 Small lymphocytes 16. 3 Large lymphocytes 8.6 96.5 Other leucocytes 3. 5 100.0 According to Ewing the total leucocyte count may vary, in nor- mal blood, between 24 and 29 ; according to Cabot, between 24 and 38. Our total is 24.9, which rather approximates the lower than the higher limit, but is still within the normal. Our percentage of small lym- phocytes is lower than normal according to both authorities, and our percentage of large lymphocytes is decidedly above the maximum of normal, according to Ewing. Therefore it would seem as though the large lymphocytes had gained at the expense of the small. The polymorphonuclear neutrophiles seemed to have lost decidedly (normal, 62 to 70 per cent — Cabot; 70 to 72 per cent — Ewing), and the eosinopfhiles to have gained about what the first named have lost. As will be observed, there is generally no eosinophilic leucocytosis. NERVOUS SYSTEM. THE MENTAL CONDITION. Over all the varied symptoms with which the unfortunate jibaro, infected by uncinaria, is plagued, hangs the pall of a drowsy intellect, of a mind that has received a stunning blow. There is, to us, no one symptom at once so characteristic and so pitiable. A benumbing in- 90 UNCINARIASIS IN PORTO RICO. fluence seems to be exerted on the mental faculties even before anemia and heart changes are noted. There is a hypochondriacal, melan- choly, hopeless expression, which in severe cases deepens to apparent dense stupidity, with indifference to surroundings and lack of all am- bition. We believe the expression of countenance in a well-marked case, together with puffiness of the face and the peculiar color, to be very suggestive and not common to all anemias. Many of our patients stated that they came to our hospital expecting to die. There is but one way of portraying the facies of an uncinarial anemic and that is to recount case by case the actual words used by us in describing their facial expression when they first came under our notice. This has an especial value because the terms used were employed under the most varied conditions and the observations are separated by long periods of time. The Ponce series of 1899. Heavy, leonine. Very dull ; lie can not understand the simplest question. Very poorly developed mentally with a passive expression. Intellect limited. The Ponce series of 1902. Hypochondriacal. Passive, characteristic, stupid. Passive, quiet, pleasant. Apathetic. Stupid. Most decided apathy. Placid. Listless. Very dovs^ncast and passive ; takes interest in nothing. Exceedingly dull of comprehension. Passive. The JJtuado series of 190^. Cast down. Very typical facies. Miserable and cast down. Hypochondriacal. Very peculiar, half sullen, half melancholic expression. Melancholy and dispirited, with a hopeless, staring expression. Sad and dispirited expression. Dull and torpid, always lamenting his poverty and sickness. Dispirited and lifeless. Staring. Beyond description ; very hypochondriacal ; completely hopeless and querulous. Neurasthenia of the worst sort, with a worn, dissatisfied, excited expression. Depressed, anxious, and hypochondriacal. Sad and dispirited. Extremely despondent. Hypochondriacal ; very peevish. Depressed and quiet. • Almost melancholic. Downcast and apathetic. Stupid and depressed. Good. Usual hopeless expression. Depressed and hysterical. Melancholy and lifeless. Downcast and hypochondriacal, with a bewildered air. Great mental depression ; seems stupefied. Weazened. Weazened and woeful. Very melancholic. Bewildered and downcast. TYPICAL FACIES. UNCINAKIASIS IN PORTO BICO, 91 Cast down and lifeless. Obtunded Intellect ; apathetic and timid. Bewildered. Pleasant. Stupefied; dazed. Very depressed and nervous. Deeply suspicious of the doctor and prepared for the worst ; hopeless. Depressed and lifeless. Old; drawn; pinched; appearing to be about 50 years of age (is 30). Passive. Very dull ; frightened. Indifferent and lifeless. Dull, morose, and apathetic. Very nervous. Picture of misery. Sad and lifeless. Very dispirited. With this data as a basis we can certainly describe the victim of uncinariasis as a man who has the appearance of being " drugged." To further emphasize this description, the following dialogue be- tween the patient first applying for treatment and his physician may be of interest because it is so typical : What is your name? TJmph? I say, what is your name? What is my name? Yes; what is your name? Juana. Juana what? Juana Maldonada. What Is the matter with you? What is the matter with me? Yes ; what is the matter with you ? I get tired. Where do you live? Who— I? Yes; you; where do you live? Over there (pointing toward the mountains). In what barrio? In what barrio? Yes; in what barrio? El Asomante. (Etc., etc.) Let it be understood that this is a typical case, rather severe. That the stupidity is merely apparent is seen from the almost uni- versal fact that on being cured these questions are promptly and intelligently answered. The jibaro is not at all stupid; he is astute but unschooled, and the vast majority are not as slow to understand as the example given ; but for the very reason that this is a frequent example of what we mean by apparent stupidity we have cited it. In addition it will be noted that the question is repeated in the same words as those used by the examiner. This echolalia is a very notice- able symptom indeed. While this examination is going on the distinct effort made by the patient to concentrate his attention on what is being said to him is really painful, as it is clear that if the question were not repeated with an emphatic, decisive air it might never be answered. Here, again, we note another bit of evidence: In the severest forms true dream states occur, and they have to be veritably awakened to answer. Another mental condition is amnesia. Patients who have been stolidly staring at us while we were explaining how the medi- 92 TTNClNAElASlg US' PORTO MCO. cine should be taken will beg us to write it down, " as I can't remeni- ber the simplest thing," with a silly laugh. In bad cases there is real paralysis of thought. Their undecided timid mien bears out their mental condition ; when they are given their instructions as to how the medicine should be taken, etc., they have to be told to go away and get it, signaling several times the place. Hypochondria in the midst of this narcotic state is a curious interpolation, but it is nevertheless a very palpable fact; their expression frequently shows , it, and their remarks prove it. Melancholia, or, as a Porto Eican alienist puts it, " pseudomelancholia," is extremely common, and tinctures the mental state of nearly every one of those whom we are authorized to consider as suffering mentally from the effects of infection. This is the mental state of the man whom many an unjust foreigner labels lazy, lacking in initiative, stupid, degenerate, etc. From this deplorable state of mind it is but a step to more pro- nounced neuroses. First and most common is the well-known " ataque " or " nervous attack." All " ataques " are not caused by uncinariasis. There are the usual quota of highly nervous people in the island common to all southern countries, but the majority of such cases in the otherwise stolid jibaro are due to uncinariasis. When a woman of the mountains gets an ataque everyone turns in to help, and between all talking at once and trying to do things for her she reaches a state, if not cataleptic, at least one very similar. Preceded by a period of melancholia, suddenly a loud, long cry or a series of cries is emitted, and the patient falls (carefully) , stiffens out, becomes purple, rigid, quiet, immovable, only to follow with a series of clonic convulsions thereafter. This latter stage is prolonged way beyond the usual time of an epileptic attack, which it roughly simulates, and all neighbors and friends pile on the unfortunate patient to hold her down. Now succeeds a period of logorrhea, in which the patient tells the most remarkable stories, displaying a loquacity entirely at variance with her normal character, uses the most vile and abusive language, and upon being addressed by any of the observers catches upon a word or expression and with this as a basis enters abruptly into the most elaborate texture of words bearing upon this expres- sion. At such times the appearance of the patient is one of a truly insane subject. The attack passes away in a trance-like condition. They arouse with enough remembrance of what has happened to recount events that seemingly were acts of insanity. This ataque can be often called " hystero-epilepsy " and is all too frequent in Porto Rico. From this point on we enter into the realm of the alienist, but before submitting their evidence we wish to affirm that uncinariasis does not cause true insanity as often as might be believed, but in reality a series of the most varied and remarkable neuroses, which are often diagnosed insanity, but are not. The director of the insular insane asylum stated to us in a personal conversation that a large percentage of the insane patients sent him from different parts of the island were simply cases of uncinariasis. And' now, to consider the cases which are admitted as insane, and who are, in fact, although perhaps but temporarily, insane- In a paper written by Dr. Eliseo Font y GuiUot, assistant director ol: the insular insane asylum, entitled " The role played by uncin- UNOINAIIIASIS IN POETO BICO. 93 ariasis in the causation of some psychopathias and the syndrome per- taining thereto," we find the following: As the nature of Infectious diseases and those affecting nutrition become more patent, we see more clearly that the accumulation in the organism of cer- tain poisons, resulting from disorders of assimilation and from the absorption of certain toxic substances engender, among other causes, nervous and mental affections which up to a very recent date were clinically interpreted, at times arbitrarily and whimsically, as diathetic or sympathetic insanities, or reflex gastric or intestinal neuroses. To-day we know that these affections are clothed in the habit of a mental confusion in which intoxication of the cerebral cells Is proven, and to these belong pseudo-hysterics and pseudo-choreics with the family of tics so common in the victims of uncinariasis. This I have observed In almost 100 cases in the insane asylum of San Juan. He compares the confused state of the anemic from uncinariasis to the typhoid state, and speaks of a true cerebral " impotence " with disassociation of ideas, with at times, visual and acoustic hallucina- tions, and a mania which is generally religious. He calls attention to the fact that these psychic states are only pseudo-manic and pseudo- melancholic diifering from the real affections in that the latter are continuous and the former are only temporary. True melancholia is due to a moral trauma, while the pseudo-melancholia of the victims of uncinariasis is only a sort of mental confusion combined with catatenic phenomena. He states that from the many varieties of uncinarial insanity we can define two types : One in women, or hysteria ; the other in men of choreic quality allied to the tics, and both interrupted by alternat- ing delirium and hallucinations. The hysteria mentioned may be summed up in the expression " dream state." The form in which choreic states are manifest is demonstrated by borborygmus, hiccough, uncontrollable laughter or sobs, logospasms, eructation of feces, etc. To conclude, and in conformity with the fact that there exists clearly, defi- nitely, and concretely an uncinarial mental confusion, I assert that it is enough to give the usual anthelmintics employed for the expulsion of the worms and we see our patient restored to complete mental health. The most notable case of Dr. Francisco Goenaga, ex-superintendent of the insane asylum, the details of which he has kindly furnished us, should receive special attention: C. P., female; accused of murder; placed in the insane asylum November 19, 1902. She was then suf- fering from mania with hallucinations and from the most profound grade of anemia. Little by little ferruginous, arsenical, and other tonics, aided by needle baths, exercises in the open air, and proper food bettered her mental condition a good deal. But she remained a victim of anemia until, aided by my dis- tinguished colleague. Dr. Don Pedro Del Valle Atlles, the uncinaria duodenalis was discovered by microscopic examination. I proceeded to their expulsion. In a surprisinglv short period (three months) a complete regeneration of her blood was obtained, which effected at the same time a cure of her mental con- dition The 27th of June, of this year, it was possible to hold the trial which had heretofore been in suspense. She was declared innocent by the district court and returned to her home in Kio Grande. We close our remarks on the mental condition of the Porto Eican anemic by citing a personal case of Dr. Pedro Gutierrez. Ramon S., H to 26 years of age, white, single, peon and ox-cart driver m a sugar plantation near Bayamon, was suddenly attacked by acute mania which turned out to be persecutory, and which obliged his employer to 94 UNCINARIASIS IN POBTO RICO. deliver him over to the municipal authorities for confinement. His treatment there consisted of the administration of a purge and a cold douche. He quieted down, but was later seized with another wave of mania and broke his arrest, escaping to the plantation where he was employed. At this time Dr. Gutierrez saw him. He appeared to be then suffering from melancholia; expression stupid, gaze fixed on space, extreme pallor, tongue heavily coated, and breath stinking, and all the severe circulatory phenomena, with bruit-de-diable in the veins of the neck. On inquiring of the family the history of the case he was told that previous to the outbreak of mania the man had suf- fered from extreme melancholia, gradually developing the idea that he was to be supplanted by another farm hand, and that he was to be thrown out on the world. This ended ia his walking about at night in the plantation with an umbrella over his head muttering to himself and at times shouting commands at an imaginary team of oxen. Without waiting for an examination of the feces, for the case was clear and the necessity pressing, thymol was given after the preceding purge and from the next day the man began to improve. In two weeks all mental symptoms had disappeared and in six weeks from the time thymol was first administered the man was an enormous, powerful, ruddy, and perfectly sane man. He married and is known now in the barrio, where the cure made a great impres- sion, as " Ramon el loco," " Kamon, the crazy," in commemoration of his sensational visit to the town jail and because the night he was confined the authorities had made out commitment papers for his transfer to the Insular Insane Asylum. SOMNOLENCE. This is at times marked. In one instance, two children, brother and sister, patients in the hospital, passed their entire time sleeping. Their blood was examined for Trypanosoma, but the result was negative. Although we had several other cases of somnolence, in general, insomnia was the usual complaint. Somnolence occurred in 2 of the Ponce series of 1902, 2 of the Utuado series of 1904, and 2 of the Rio Piedras series of 1906 ; a total of 6 in 92 cases, or 6.5 per cent. Insomnia occurred in 9 of the Ponce series of 1899, in 4 of the Ponce series of 1902, in 21 of the Utuado series of 1904, and in 5 of the Eio Piedras series of 1906 ; a total of 39, or 35.1 per cent. HEADACHE. This is very frequent. It is generally temporal and frontal, but pain in the vertex and cerebellar region is not rare. The prevalence of this symptom is seen in the tightly wound cloth about the fore- head, so often encountered in this country. In the Ponce series of 1899, 9 suffered from headache; in the Ponce series of 1902, 9. In the Utuado series of 1904, 56 complained of headache. In 23 of these it was general, frontal in 16, temporal in 8, fronto-cerebellar in 1, temporo-frontal in 6 and temporo-cerebellar in 2. In the Rio Piedras series of 1906 there were 11. Two had general headache, 3 temporo-frontal, temporal 2, temporo- occipital 1, frontal 2, and parietal 1. This makes a total of 85, or 76.5 per cent of 111 cases. UNCINAMASIS IN POETO KICO. 95 NETJEALGIA. Neuralgia occurs but it is not common. It is usually confused with headache, joint pains, muscle pains, etc. In the Ponce series of 1902 there were 4 cases of neuralgia, and in the Utuado series of 1904 there were 9. These cases are irrespective of headache, some cases of which may well be considered neuralgic. THE PATELLAE REFLEX. This is very often diminished or entirely abolished, a frequent condition. In the Ponce series of 1902 the patellar reflexes were exaggerated in 4 and diminished in 6 cases. In the Utuado series of 1904 they were slightly dulled in 2, much dulled in 7, abolished in 31, and ex- aggerated in 5. In 80 cases, therefore, they were exaggerated in 11.2 per cent, dulled in 18.7 per cent, and abolished in 38.7 per cent. TACTILE SENSIBILITY. This is often impaired, but was not carefully investigated in most of our cases. It was found to be decidedly blunted in 3. IMPOTENCE. This is exceedingly frequent and in bad cases is almost always complete. In the Ponce series of 1902 there were 15 men of an age in which this symptom can be considered; 4 were partially and 7 completely impotent. In the Utuado series of 1904 there were 26 men with the above con- ditions, of whom 17 were completely impotent. This gives a total of 41 males, of whom 58.5 per cent were com- pletely impotent and 9.7 per cent were partially so, a total of 68.2 per cent partially or completely impotent. AMENORRHEA. This is fully as frequent. Of the 8 women of age consistent with menstruation in the Utuado series of 1904, 7 had amenorrhea. This is borne out in the clinic, where even in the moderate cases this is a most frequent symptom. Of the 9 women who had reached the childbearing period, 3 had had abortions and 1 of these had aborted three times. Stillbirths cause havoc among women in Porto Eico. SUSCEPTIBILITY TO COLD. This is a common symptom. The nights in the mountains are often quite cool (even as low as 53° F. has been registered m the year 1903) , and the complaint of being " frozen " is very common. Susceptibihty to heat is much less noticeable. ^ .,„.-, j. xi Susceptibility to cold was the subject of complaint of 11 ot the Ponce series of 1902, and of 36 of the Utuado series of 1904 ; a total of 47 of 80 cases, or 58.7 per cent, and to both heat and cold by 5, or 6.2 per cent. 96 UNCINARIASIS IN POE.TO BICO. PARASTHESIAS. Parasthesias are almost general. Tingling and formication are the most notable. Such expressions as " se me mueren las piernas " (my legs feel dead), and " tengo un hormigueo en los pies " (I feel as though ants were crawling on my feet) , are often heard. These sensations may extend to the arms or may even become general. Twelve of the Ponce series of 1902 stated that they suffered from parasthesias. This was a symptom in 32 of the Utuado series of 1904, a total percentage of 55. Among the 32 Utuado cases there were 9 who said that they generally had these sensations in the feet and legs, 3 in the feet alone, 2 in the legs alone, 1 in the hands, and 20 who stated that the sensations were generalized throughout the body. THE EYE. Unfortunately, we did not make a careful study of the eye grounds. Every year our time was entirely taken up with the collection of the data herein set forth, and we had to content ourselves with noting subjective symptoms and scattered objective ones. In the Ponce series of 1902, 15 complained of " colored images before the eyes," 11 of blurred vision. Of this series 16 gave symp- toms referable to the eye. In the Utuado series of 1904, 43 had visual disturbances, 34 blurred vision, 7 blurred vision with excessive dilatation of the pupil, 1 of excessively dilated pupil, blurred vision, and night blindness, and 1 of blurred vision and night blindness. In the Eio Piedras series of 1906, 5 had blurred vision. Thus, of 92 cases, 64, or 69.5 per cent, had more or less serious dis- turbances of the eyes. We can not doubts that much of this was due simply to the degree of anemia, but there remains a considerable per- centage both of these cases and among a large number seen in the clinic who had more or less marked visual affections with very little anemia. Maj. W. F. Lippitt, United States Army, examined the eye grounds of 10 of our cases in 1904 and found evidence of old retinal hemor- rhages in 2, which he very kindly demonstrated to us. The fundus is generally very pale and the retinal arteries small. Fischer and v. Meden state that T to 8 per cent show eye-ground changes. Loebker and Bruns remark on the pallor of the eye grounds and state that there may be pulsation of veins, lowered intraocular pressure, pronounced convolution of veins, and, commonly, retinal hemorrhages. According to v. Nieden, a much cited observer, these signs of hemorrhage appear in long streaks or in spots corresponding to the course of the ocular vessels, with more or less signs of fatty degeneration. They add that it is rare to observe changes corre- sponding to those found in a;lbuminuric retinitis. Many authors speak of edema of the optic papilla. Siccardi notes nystagmus, diplopia, amblyopia, muscular and ac- commodative asthenopia and restriction of the field of vision. He states that Kampoldi, who first called attention to the changes in the eye grounds, found exudative retinitis of the same variety as that described by Liebreich in leucemia. Rampoldi observed a case of XJNCINABIASIS IN POETO RIOO. 97 sudden blindness in a young subject (19 years of age) with the usual signs of atrophy of the papilla. (See case 1330, Aibonito series, 1905 ; circumstances prevented a study of the eye grounds. We considered this to have been a hysterical state and to this we attributed the blindness. We may have been mistaken.) Lutz mentions, as a rare sign, chemosis of the bulbo-palpebral fold. He had 3 such in 25 cases. Fuchs found small, whitish spots, due probably to old retinal hemorrhages. Siccardi, from an observation of his cases, comes to the conclusion that the changes he saw speak loudly for a nephritis. He admits the possibility of a simple anemia being the cause of pallor of the retina, edema, and hemorrhages, and likewise acknowledges the reason for attributing functional disturbances of vision to the reflex action on the eye from the irritation caused by the attached worm in the intes- tinal canal, but there are, he thinks, other changes that can not be explained by reflex stimulation or by simple anemia, and such are those demonstrated by a retinitis. Where retinitis is found with atrophy of the optic papilla a general affection is to be considered ; in other words, a circulating poison. He avers that it is his belief that the changes of this nature are produced by a toxin, just as alcohol, leadj iodoform, etc., cause such lesions. Night blindness is not a symptom to be ignored. Thornhill reports that he found it in 9.5 per cent of his cases, and Swan and Nell in 24 per cent of theirs ( !) . Only our special cases were questioned on this point, but three of our general series volunteered the information that they suffered from it. Case 15 of the Ponce series of 1902 suffered from night blindness and partial amaurosis, and 6 and 8 from night blindness alone, a total of 3 in 80 eases, or a percentage of 3.7 in 80 cases. Nystagmus is a rarer symptom which we have several times observed. Case 15, cited above, is a good example. Cataract.— K most interesting observation is its great prevalence in Porto Eico, not only in the old, but sometimes in the young. Maj. Lippitt, whose experience is large, states that fully three-fourths of his cases in Porto Rico were anemic. A. W. Calhoun (Ophthalmo- logic Record, new series. Vol. XII, No. 7, Apr., 1904) calls attention to the occurrence in several of his cases of a double, chalky-white cataract, beginning a short while (one year) after the establishment of uncinariasis. One was a boy 14 years of age, where the condition began eight months after the disease, and another a boy 16 years old. Corneal ulcers are also reported. One such case was observed in the Ponce series of 1899. We made a special effort to corroborate Stiles's observations on the pupil, and found, indeed, a decided tendency to its dilatation. But the patient is weak, dizzy, and sick, andalthough we have not seen that writer demonstrate how he obtains the phenomenon described, we can not believe it to be diagnostic. The fact is, in trying to demonstrate this symptom, we nearly hypnotized some of our patients. Stiles says : " If the patient is directed to stare intently into the observer's eyes, there will be noticed a symptom which it is difficult to describe, but which I have found more constant than almost any other noticed, namely: After a moment, the length of time apparently varying 77759°— S, Ppc 808, 61-3 7 98 TJNCINARIASIS IN POE.TO BICO. slightly, according to the degree of the disease, the pupils dilate and the patient's eyes assume a dull, blank, almost fish-like or cadaveric stare very similar to that noticed in cases of extreme alcoholic intoxi- cation." He states that he does not go to the extent of considering the stare diagnostic of uncinariasis. We certainly do not consider this a prominent symptom per se, but the dilatability of the pupil is noticeable and goes to make up the tout ensemble of a facies which is very suggestive of uncinariasis. The expression in moderate and marked cases, as will be noticed by the cuts in this report, is habitual and need not be elicited in this manner. Not only this, but w4 may consider ready dilatability of the pupil a symptom of infestation by many varieties of intestinal parasites. THE REPORTS OF THE PORTO RICO ANEMIA COMMISSION. 00 AN ACT To provide for the study and suppression of the disease known as anemia In Porto Eico. Be it enacted liy the Legislative Assembly of Porto Rico: Section 1. Tbe governor Is liereby authorized, to take such measures as in his judgment may be most expedient to encourage the study and cure of the disease known as tropical anemia iu Porto Kico. Sec. 2. For the prosecution of the work, the construction of field hospitals, the employment of temporary help, purchase of medicines, instruments, la^bora- tory supi)lie&, and other incidental expenses, the sum of $5,000 is hereby appro- priated out of any moneys in the treasury not otherwise api propriated, the said sum to be disbursed in such manner and for such purposes as the governor may direct. Sec. 3. This act shall take effect form and after its passage. Approved : Wm. H. Hunt, Governor. Executive Mansion, Fehruary 16, 1904. 100 LETTER OE TRANSMITTAL. San Juan, P. R., Decernber 1, 190^. Sir : We have the honor to submit the folloTving report of the com- mission named by the governor of Porto Rico, by authority of " An act to provide for the study and suppression of the disease known as anemia in Porto Rico." Owing to limitations of time and space, it was not found possible to produce it complete in both English and Spanish, but it has been so arranged as to give the substance in each language, though parts of particular interest to readers of one language are more in detail in that language. Respectfully, Bailey K. Ashford, M. D., Georgetown University, Gaptam, Assistant Surgeon, United States Army. W. W. King, M. D., University of Louisville, Passed Assistant Surgeon, United States Public Health and Marine-Hospital Service. Pedko Gutierrez Igaravidez, M. D., University of Seville, Health, Officer of Bayamon, and Director of Municipal Hospital. Hon. Beekman Winthrop, Governor of Porto Rico, '1 San Juan, P. E. 101 THE FIRST REPORT OF THE PORTO RICO ANEMIA COMMISSION. * The method to be pursued was left entirely to the discretion of the commission, and it was decided that a formal organization would be unnecessary but that all matters would be informally discussed as occasion should arise. It was determined that no member should devote himself exclusively to one or several phases of the work, but that they should participate equally in all details, so that the con- clusions finally drawn would represent the consensus of opinion of three individuals working along the same lines. Thus every observa- tion would be confirmed by two others. By approval of the War Department, the Surgeon General of the Army lent to the insular government the hospital tents, cots, bed- ding, and practically all of the camp equipage and utensils. Each member provided his own instruments and laboratory outfit. Had the commission been obliged to purchase these articles out of the appropriation, there would not have been left sufficient money to carry on its operations. Even with this assistance, it was necessary to practice the strictest economy in all expenditures. Needed techni- cal assistants, clerks, etc., could not be employed. The commission "recognized that it was undertaking a delicate and arduous task, not only on account of its limited resources, but in the management of a class of people naturally suspicious of innovation and apprehensive of being made subjects of experimentation. We were advised that they were too ignorant to properly take the medi- cine in their homes; that they would not sleep in tents for fear of dampness and exposure to night air ; that they were too irresponsible to be depended upon to return regularly for treatment. All of the members of the commission speak Spanish and have considerable knowledge of the peculiar dialect and idioms of the " jibaro." By the exercise of tact, patience, and kindness, we gained their confidence and faith, so that they would talk to us freely. We found them easily managed, respectful, obedient, deeply grateful, and much more intel- ligent than is generally believed, even in Porto Rico. Many considerations led to the location of the hospital first at Bayamon. It was accessible to San Juan, our base of supplies.' Rooms and beds for some patients in the Bayamon Municipal Hos- pital were placed at our service. It was desired to give the physicians of San Juan an opportunity to observe the practical work and the results of treatment. We regret that many were unable to visit the camp. The site selected was in the rear of the Municipal Hospital, and was located in a field sloping toward a small stream beyond. In spite of heavy rains the interior of the tents remained dry and comfortable. In fact, the tent hospital proved a complete success. 103 104 tJNCINAIlIASIS IN PORTO RIOO. Authority for the use of the tents, etc., was received by cable March 7. They were transported from San Juan to Bayamon, pitched, and ready for use by the 14th. Each tent had a portable floor designed for us by Mr. Scott Truxtun. Two lar^e sills supported in notches smaller cross pieces, on which the flooring was laid. No nailing was necessary, yet it was always steady, easily laid, or taken up. Each tent contained six folding hospital cots, except the dining and the administration tents. Along the bank of the stream a row of eight tents was placed facing the one used for the dining room, and between the latter and the Municipal Hospital building was placed the admin- istration tent. At a convenient distance, in one coAier of the field, privies were placed. ' The pail system was used, and each night the cans were carried to a distant field, the contents buried, the cans washed, limed, and dried before re-use. The privies, made of palm bark, were burned after removal of the hospital. Food for the patients and employees was cooked at the kitchen of the Municipal Hospital, and in the same building were located the office, dispensary, and laboratory of the commission. The personnel at Bayamon was : Per month. Apothecary $50 Housekeeper 20 Nurse, male 6 Nurse, female 6 Cook 4 General helpers (2 at $4 each) 8 Scavenger r 12 Treatment of patients at Bayamon began on March 6 in the Municipal Hospital and continued until April 30. During this period 961 cases of anemia were treated. Persons applying for medicine were required to bring, for microscopic examination, a small speci- men of their feces. This fact soon became general knowledge, and they usually came provided. Patients were first examined for the uncinaria. In 947 of the 951 cases it was present and was the sole cause of anemia in nearly all cases, a few having some contributing cause, as advanced tuberculosis, chronic dysentery, etc. The presence of the parasites having been determined, the patient was sent to another room where the hemoglobin was estimated and the percentage recorded. A full clinical history was attempted in each case until increasing numbers at the daily clinic made it a physical impossibility, and we were compelled to limit ourselves to a record of hemoglobin and certain other information to be used in this report. Even after it was decided to move the camp to Utuado we continued to admit new patients in order to give them the benefit of even short and incomplete treatment, but we did not estimate their hemoglobin as the short time rendered such record of no particular value. There were 304 such cases and 19 others in which the hemoglobin was not recorded. Patients were given a prescription which they presented to the apothecary who delivered the medicine with directions as to how it should be taken, the patients, or those accorapanying them, being required to repeat these instructions until they were thoroughly under- stood. They were directed to return in one week for reexamination trNClNAMASlS llT I>ORTO EICO. 105 and more medicine, most of them doing so with more or less regu- larity. This fact alone is an eloquent testimonial of the efficacy of the treatment. Had they not felt better, they would not have continued to come long distances on foot, as many did. The hospital was used for patients who were unable to return to their homes, or who were so ill that we wished to have them under our personal observation while taking thymol. The latter class, as a rule, remained only three or four days m hospital, when they were discharged to give room to others. The majority of cases, both in Bayamon and Utuado, never were in the hospital and never received any food from us. Patients in the hospital were subsisted by the commission, but no attempt was made to forward their recovery by extra diet. They received a sufficient quantity of good food and were satisfied. At the request of the alcaldes of Naranjito and Toa Alta, visits were made to these towns on March 19 and April 9, respectively, and a large number of anemics were examined at each place. They were invited to come to the hospital at Bayamon, and many did so. It was our intention to establish substations at these near-by towns, but the members of the commission were too busy to visit them regularly and the plan was abandoned. Our operations at Bayamon closed April 30. The vast majority of patients then ceased to come, but some desired further treatment. Dr. A. Stahl, of Bayamon, who had been working with the commis- sion, was left in charge and supplied with medicines to treat such patients who continued their visits. His services continued until June 15, and the results in these cases have been included in the Bayamon statistics. From May 1 to 9, we were occupied in moving the camp to Utuado, one of the most " anemic " districts of the island. Consider- able delay was caused by the difficulties of oxcart transportation from Arecibo to Utuado, but on the 9th the hospital was ready for occupancy, and the treatment of patients begun. The commission had previously visited Utuado and selected the hospital site, which was located in a field of high rolling ground across the Vivi River from the town. The soil was sandy loam and so well drained that it never became muddy. The tents were ar- ranged in the form of a rectangle, four on the long sides, with one at each end between the lines. One was used for a dining room. The former administration tent, being no longer needed as such, was converted into a bed tent, thus increasing the capacity from 48 to 54 beds. The same privy system was used. Some 200 yards from the hospital was a large country house rented by the commission and used for quarters of employees, clinic rooms, dispensary,, laboratory, and storerooms. Food for the camp patients and employees was cooked at the kitchen of the house. The personnel at Utuado was : Per month. Apothecary $25 Housekeeper 20 Nurse, male 8 Nurse, female , 4 Cook 4 Scavenger 9 General helper , 4 106 UNCINARIASIS IN PORTO EICO. In the organization of the work in Utuado, profiting by our expe- rience in Bayamon, we were able to improve and better systemize our methods. Each patient was given an identification card giving case number, name, and residence. This card impressed upon the patient that he was under obligation to return at the time specified and possi- bly explains, in large measure, why the Utuado cases returned with greater regularity than those at Bayamon. The record books were numbered to correspond to these cards, so that, when a patient re- turned, his previous record was easily found. Notes on condition, microscopic examination, treatment, etc., were entered at each visit, and in this way the information regarding the Utuado cases was made more complete than at Bayamon. Anticipating that a large number of patients would be treated, it was decided not to attempt to take the percentage of hemoglobin on entrance and at each visit, except in special cases. On some days between 500 and 600 patients were examined and treated, and to have estimated the hemoglobin of each would have left no time for other things. At Bayamon the hemoglobin was recorded on entrance to show the grade of anemia, and the Utuado cases averaged about the same, or worse, if there was any difference. The weekly records of a series of special cases at Utuado (see appendix) were illustrative of the changes occurring in the other cases at Utuado and Bayamon. These special cases were a series of typical ones, in which a weekly record of hemoglobin percentage, counts of red and white cells, and differential leucocyte count was made. The general procedure at Utuado was the same as at Bayamon with the exceptions noted. Patients began to arrive early in the morning, in many cases hav- ing traveled since the day before, generally on foot, resting from time to time according to their strength, and it was no uncommon occurrence for them to have been several days on the road. Very bad cases were carried in hammocks to the camp, 12 such being received in a single day, of whom 1 died the same night. The patients, arriving singly and in groups, congregated in the large " patio," or yard, adjoining the house. They were admitted by small groups according to their turn, and frequently had to wait several hours, yet little or no complaint was made. The very ill and those from a long distance were given a preference whenever possible. On light days, we were able to finish the clinic by noon or 1 o'clock, but others required until 4 or 5 in the afternoon. The remainder of the day was occupied with the blood studies, patients in hospitals, etc., and most of the clerical work was done at night. In the latter part of June, Dr. Tulio Lopez Gaztambide, of Arecibo, came to study and work with the commission. By this time, the work was becoming so heavy that we prevailed upon him. to continue his valuable services until the end of our stay in Utuado. There seemed to be no end of applicants for treatment. Beginning with 10 to 20, by the latter part of July, we were receiving from 125 to 150 new patients daily. The rate continued to increase, and these, with the old patients returning, made our clinic from 300 to 600 per day. Not to speak of the physical strain upon ourselves, it was too great a tax upon our time and funds. Considering that the old patients should be given the preference, and desiring to continue as long as we could, in order to cure as many as possible, announce- A "HAMMOCK CASE" AT THE UTUADO STATION, 1904. ^^^^^^^-^R^^mii^^^^^^^^^^H '-' "^s i" - - 'l^^l THE THATCHED SHED— OUR WAITING ROOM, DISPENSARY AT UTUADO, 1904. UNCINAE.IASIS IN POETO BICO. lOY Tff ^ ^^s made that no new patients would be treated after July 23. Alter that date, only a few were received, generally very bad cases that we did not have the heart to turn away. 1 he same class of patients was admitted to the hospital in Utuado as m Bayamon. There were more of desperately ill ones, but not so many transient cases, as our experience in Bayamon proved to us that it was reasonably safe to allow thymol to be taken at home, even in severe cases. The patients on whom the weekly blood examinations were made were kept in the hospital or about the caihp, if possible, m order to have them present at the proper time. The demand for beds soon became a serious question, as every day applicants came to whom it was impossible to refuse admission. To provide beds, the improved and least ill of the special cases were taken out of the hospital and given bedding, which at night they spread on the floors of the house. It was not ideal hospital management but a concession to urgent necessity, and even then many had better accommodations than they would have had at home. At one time there were more sleeping in the house and outbuildings than in the hospital. The hemoglobin was taken when patients had expelled all their uncinarisB and appeared to have regained their normal color. If it registered 85 per cent or over they were considered cured of their uncinariasis and were discharged. The first case thus discharged was on June 11. The hemoglobin examinations were equivalent to handling that many additional patients, and as they became numer- ous, we were efficiently assisted in this labor by Mr. Octavio Jordan, of tjtuado, a student at the Jefferson Medical College, Philadelphia. During the last few days patients were told not to return, as our dispensary would be closed. On August 15 treatment of patients ceased, 4,543 cases of uncinariasis and 6 of anemia from other causes having been treated. From August 15 to 19 the camp effects were packed for storage or shipment to San Juan. On leaving Utuado, we were much grati- fied to observe among the people of that city that the former skepti- cism as to the curability of the disease by medicine had given place to belief. Through the kindness of Maj. W. F. Lippitt, surgeon in charge, the commission was provided with cool and commodious quarters in the Military Hospital in San Juan, and by September 1 had begun the task of classifying and tabulating the immense mass of data, prelimi- nary to writing the report. Two months were spent before this was accomplished, and the remainder of the time was occupied in the formation of the report. The commission, basing its opinions upon the result of its investi- gations which form the body of this report, has drawn the foUowmg conclusions: -r,- ■ i The disease known as anemia, in Porto Kico, is only a symptom of some definite pathologic entity, or a consequence of some aberration of physiologic processes, caused by improper diet, unhygienic sur- roundings, etc. The finding of a specific disease one of whose chief symptoms is anemia and the disappearance of this symptom under treatment directed to the disease alone, while the general causes remain unmodi- fied lead us to believe that the anemia in Porto Eico is due, in the 108 UNClNAIlIAglS IN POrTO felCO. great majority of instances, to this specific disease, i. e., uncinariasis or ankylostomiasis. As is well known, this affection is caused by the presence of a small worm (uncinaria) in the intestines of the patient. This parasitic worm gains entrance to the subject generally by penetration of the larva through the skin. The disease iS marked by profound anemia and degeneration of vital organs, leading to chronic invalidism, and often results in death. About 90 pA" cent of the rural population in all parts of the island are affected. The large number of sufferers must affect the social and economic status of the country. The affection is curable in the great majority of cases, and is sus- ceptible to restriction or elimination in proportion to the observance of elementary hygienic laws and the treatment and cure of those already afflicted. The few cases in which anemia is symptomatic of other disease or condition are the same as in other countries and are produced by the same causes. As exceptions to the rule, they tend to strengthen our conclusion that the prevalent anemia in Porto Eico is a consequence of uncinarial infection. ******* [We omit the chapter on the history of uncinariasis. It is preceded by a definition of the disease and a resume of the terminology applied to it since the earliest times.] 1. The great lurking places of the uncinaria of man are not fully exploited. In spite of an abundant literature, physicians are not yet acquainted with it, and many excellent practitioners are ignorant of all save one of the popular names of the disease and possibly a few clinical facts to identify it. In certain civilized tropical and sub- tropical countries, the same may be said with far less excuse. 2. There are countries where the disease is endemic among classes following certain pursuits, and where there is little danger of exten- sive spread. Such, for example, are Germany, Belgium, and France. As countries said to be infected, they can not be placed in the same category with Porto Rico and other parts where uncinariasis is the scourge of scourges, and is as fatal, if not more so, than yellow fever in its palmiest days. 3. There are regions said to be infected because a few straggling cases have been reported, but such cases are really imported into cli- mates where neither occupation nor temperature will ever' favor a spread of the disease. 4. Finally, there are places presenting favorable conditions for the development of this parasite, and which, by analogy, medical geog- raphers have considered infected, but the parasite has not yet been demonstrated, and the clinical data are merely suggestive. [We also omit the chapter on the parasitology, believing that by this time the publicity given to Dr. Stiles's painstaking work needs no repetition by us, apart from the fact that this is his field of research and we do not wish to encroach upon it. Leaving, therefore, the purely zoologic discussion for men who have made this branch of science their lifework, we will consider the question of how man is infected.] GROUP OF PATIENTS AT BAYAMON. CHARACTERISTIC DWELLING OF THE POORER CLASSES OF THE COUNTRY. FIELD HOSPITAL AT BAYAMON. 4 . i^^ii>4 jLa A A/^ ,} !, 1 r .... 1 1 1 FIELD HOSPITAL AT BAYAMON. UNCINABIASIS IN PORTO EICO. 109 MODES OF INFECTION. There are two modes of infection ; one, and until recently the only- one known, by the ingestion of larvae; the other, still doubted by many, through penetration of the skin by the larva3 and their subse- quent migration to their point of election, the small intestine. Infection ly ingestion of larvoe. — Leichtenstem first clearly showed that infection per os is possible but, we think, erroneously considered this to be the usual mode. He found that in from five to six weeks the parasite became sexually mature, but fails to explain clearly how the little worm maintains its usual position in the jejunum until develop- ment is complete. Grassi believed that they encysted themselves on reaching their destination, a belief strengthened by Leuckhart, reason- ing) by analogy, from the encystation of strongylus equinum in its host during its developmental stage. As most authorities are agreed that this is at least a possible avenue of infection, let us call attention to some of the means by which our laboring classes might thus become infected. It should be noted that all traces of human ordure have usually disappeared by the time infection takes place; thus man's natural disinclination to touch feces does not cause him to avoid infective material. More than this, the larvae are motile, and rains scatter them about, so that large nests of infection, as we may say, are dispersed over considerable area. We believe that we should emphasize the fact that it is usually in the immediate vicinity of his home, and even some- times when the floor is of earth, inside the hut, that the jibaro is infected. He defecates " en el montecito," or, as we say, " in the bushes," and this montecito has become a synonym for privy. Owing to weakness due to the disease itself or to indolence, his excursions to the montecito become shorter and shorter and result in a general pollution, by himself and his family, of a considerable area around his home. A jibaro hut is usually well shaded by banana plants, so we have shade, humidity, which is practically never lacking in such spots, and an ideal temperature. Another heavily infected locality is beneath the coffee plant ; coffee picking is at times interrupted by a call to stool, which is obeyed in the immediate vicinity. The coffee bush itself produces shade, being always shaded in turn by some tree or variety of plantain. Thus we have in every coffee plantation in Porto Eico a mass of liberated larvse. The shade of a coffee estate admits no superior for an ideal culture medium. The quintessence of perfection is, however, only attained when a mass of decomposing banana leaves and stalks fall into a little depression in the dense shade. In a few days a ram comes on and a " charco," or little pool of water, forms. Certain " charcos " are popularly known and feared by the peons for reasons to which we will afterwards refer. Sugar fields are not nearly so heavily infected as coffee estates be- cause of two circumstances. The earth is plowed up every year and the sun acts powerfully upon it after the crop is harvested. One suffocates many larvse by turning them under a heavy layer of earth, the other kills them by direct light, heat, and drying. We have been entirely convinced that the observation of Stiles, that s?ind areas were practically the only ones infected, can not be sub- 110 UNCINAKIASIS IN POBTO EIOO. stantiated here in Porto Eico. Sandy regions were not those which contributed the majority of our cases in Bayamon. On the contrary, the foothills were apparently the heavily infected parts." Bayamon, although near the sea, is not sandy. Cataiio, a large settlement only an hour away, where every condition is afforded for a heavy infection of the inhabitants, only furnished 11 cases. On the other hand, very distant interior barrios contributed most of our patients. In order to determine the facts, we made a trip to Naranjito and other towns well elevated in the foothills, and were able to confirm our suspicions. Cataiio, a purely sandy locality, is generally infected, but in the foothills, noted for a rich alluvial soil, the number of ex- treme cases of anemia is something beyond description and not to be compared with the cases seen in sandy barrios of the coast. Utuado is a sandy town, but we received the majority of our patients from barrios which could not really be so described. We therefore con- clude that sand is not proven to be any better culture medium than alluvial deposits and clay, soils common in districts where it is diffi- cult to find one single person not infected with the uncinaria. This should not be taken to mean that sandy districts can not be heavily scourged. All varieties of soil in Porto Rico can provide a good culture of larvae if the infected feces are deposited under proper shade. If we believe that infection takes place generally by ingestion of encapsuled larvae, we only have to call to mind the manifold habits of life possessed by every people on earth who deal directly with the soil. Some of these may be specified as follows : Soiling the mouth with muddy hands at meal time ; eating muddy vegetables and fruits ; drinking muddy water; drinking from muddy receptacles; inad- vertently swallowing muddy water while bathing in streams; earth eating ; carrying muddy clothing home to soil the hands of wife and children; cleaning of muddy feet and transferring the infection to the finger nails ; crawling of children in earth which they frequently eat; handling of mud-bedraggled dresses before meals; eating of sweets made in dirty, muddy houses; drinking of guarapo, the ex- pressed juice of sugar cane. This list comprises by no means all of the possible modes of infection by the mouth. The important point is, that, if infection by the mouth. takes place, the mud ingested must be wet at the time. We have positive evi- dence from almost every observer who has cultivated the larvae, and from our own culture experiments, that they die rapidly on drying. If infection takes place by drinking muddy water, that water must be exceedingly repulsive to contain more than one part of solid mat- ter to the thousand, a proportion shown by Bruns to be fatal to the larvae. In our opinion, infection by the mouth is so restricted by the lat- ter facts as to be a rarity indeed. We Imow of many instances of infection in well-to-do persons where it is not probable to conclude an infection through the ingestion of either mud or water, and in which an explanation can only be made by the fact of skin infection. What, then, is the common route chosen by these small larvae ? Infection hy penetration of the sM?i..— [Under this heading the origmal report contained a description of the Looss demonstration in 1898 . of the passage of the larvae of ankylostoma duodenale through the healthy skin and the subsequent appearance in the stools of the ova of that parasite in individuals previously known not to METHOD OF BRINGING IN VERY ILL PATIENTS. HAMMOCK CASE. INTERIOR OF A HOSPITAL TENT. UNCINARIASIS IN PORTO RICO. Ill have been infected. Following this was a resume of Bentley's and Boycott and Haldane's clinical observation on the dermatitis coinci- dent upon ankylostome infection and Claude Smith's human and Looss animal experiments. All of this is omitted, as it is now well known, and we take up the thread of the report again in its applica- tion to what was then but a theoiy to many and at best a scientific fact unsubstantiated by any great number of cases such as our work, for the first time, was able to bring forward.] ******* It is believed that it will always be impossible to rigidly exclude other routes of infection, but we are also verv positive of the fact, which further remarks will render all but certain, that infection by uncinaria of man, in this island, is generally contracted through penetration of the skin by the larvae, and that, once having thus effected an entrance, they pursue a more or less direct course to the intestines, the point of election. This may seem strange to some, but it is no more so than accepted phenomena of similar nature, sucji as the migration of the embryo of trichina from the intestines to the muscles. It is certainly not as odd as the unexplained and weird pilgrimage of millions of embryos of filaria nocturna into the pe- ripheral blood during certain hours of the night. In fact, we are accustomed to such behavior in the life history of many animal parasites of man and animals. As to the chances offered the larva for effecting a lodgment in his human host, the skin is by far the most exposed. We are really unable to account in any other way for some infections we have seen. The conditions under which the jibaro lives will be again referred to, but suffice to say that uncinariasis in Porto Eico is a chronic dis- ease, with acute exacerbations occurring in the rainy season; that at this time most deaths occur from " anemia ; " that the great sufferers from " anemia " are the unshod poor ; that they themselves lay great stress upon the fact that " anemia " comes from the dampness of the soil which, they say, ascends through the soles of the bare feet and " chills the blood," causing " enfriamiento." We wish to specially emphasize this general observation of instinctive jibaro pathology, because, for all that they may say of improper and insufficient food, this word of explanation is almost always appended. The sharper ones accuse their annual dermatitis of being the cause of their in- firmity. We wish to observe, further, that the coffee sections and damp shady localities in general are the most anemia-plagued spots in Porto Eico, and that, in such localities, mazamorra hardly spares anyone at any rainy season; that for every one who will give a history of probable mouth infection a thousand will attest to attacks of maza- morra. We realize that many persons dislike to acknowledge the possibility of having introduced, even inadvertently, wet mud into their mouths, but many also do not care to recount an eruption of any kind, because it is considered a taint and, on the feet, an evidence of 'filth. We believe that of the few who stated to us that they never had a skin eruption many had had mazamorra and had forgotten it, which is unlikely, or would not confess to it, which is much more probable. In fact, among such of our patients whose station in life was far better than that of the poor jibaro and who never vrork with the soil mazamorra was almost always elicited in their previous 112 UNCINARIASIS IN PORTO RIOO. history and ascribed to the paddling about on the edges of streams incident to a country bath. In such cases, to attribute their infection to swallowing mud or muddy water would be in the face of strenuous denials by the patient that such a thing could have been possible. We have frequently had cases of chronic uncinariasis in persons who always normally wear shoes, but who date their illness back to the " exposure " incident to the cyclone of August, 1899, and its subse- quent heavy rains. This means that for perhaps the first time in their lives these persons, always accustomed to live well, were ex- posed to the grumous mud and water following the hurricane^ and in- undation, and thus became infected. We have no way of determining that, among the well-to-do classes, this was a common time of infec- tion, but we are almost positive of it in some cases and have good reason to suspect it in others. What, then, shall we say of the huge army of country poor who frequently date their anemia from that period which gave, in the year following, the largest number of deaths yet known here from anemia, 12,000 and more f Here poverty and suffering joined hands with disease to bring about a calamity. That the deepening anemia in these country people at that time could not have resulted from poverty and distress alone we know, although we have had ocular demonstration of the profound distress, general at that time. At the field hospital for the indigent poor of the Ponce district, the cases of anemia applying" for admission, seen three weeks after the cyclone, were not anemics of three weeks nor of three months. We have no doubt that many were the subjects of an acute exacerbation of their chronic disease through reinfection at that time, for, in the days that followed, all the best food that could be bought was unsuccessful in reclaiming many cases. Let us turn our attention to a very few examples culled from many similar in- stances, and first invite special attention to cases 14, 19, 20, etc., of the 61 special cases at Utuado, and to cases 1 and 16 of the Bayamon series. A perusal of these will illustrate the point in question. One of our most interesting cases is found in case 4,431 : R. M. ; 29 years of age; full-blooded negro. He was hired by us to cart the large ash cans, used for the reception of feces in the camp privies, to the ground selected for burying their contents. His duties were to dig a hole, empty the cans, rinse them with milk of lime, and replace them He worked for 16 days, and at the end of that time reported to us lor lyeatment, saymg that although he badly needed the money he was too ill to work any longer, for he was very weak, had severe lanci- nating pains m his stomach, and was "eaten up" by mazamorra. He stated that the gastralgia supervened on the eighth day after his dermatitis began, and explained that his disease had risen from his leet to his stomach, and that that " hole in the ground " was responsi- ble for the entire matter. We found that he had had mazamorra some years before, but had never before been sick. He had manv ova of uncmaria; in his stools, and his hemoglobin registered 15 per "cent We conclude that his relative racial immunity was overcome hv nn' enormous infection. ^ The last case to be cited is that of a soldier in the Porto Rican regiment stationed in San Juan. He was admitted to hospital with severe mazamorra which he acquired cleaning some pits near Morro Castle, barefooted. We were given permission by the surgeon Mai Lippitt, to study the case, and the man w^ sent for §ome of th^ mud ,^,:i|^,Jy.; IF M :^;|f>:'^-^ V^; ^-'-i'-W I ■ 'FH B --- .'^■- •;■*.' "■«• =^-. ..*•..■"■ ■•'.■-..■..■ 'Mill • " 'm ' ' Wr''^^''''^-^' ■-»:^ ^Sl i j. • ■^{t;:.;^ if 1 ^^ pf JB yLi j IX: ' 1 _pp __^^_l_l_ iiii' ^||r. / 1; ^^^^^^^BMHHH^b F r i^^^^^KciJ^HHHHH ^^lalll ^^^^^^^^^^^^IH^^R^ n-VKjOfA^in*; ^"iCiMM^H^^^i^^^^^^ gBE^^?S9N^^^^^^Ks» ^SKj^i^v^Ka^K^^^^^^^^ HHHHn^i^^^ r^'^vVfli^^^^l^^^k ^ 1^ THE LARVA OF NEGATOR AMERICANUS. By late Dr. Wm. Gray. THE ACTIVITY OF THE LARVA OF NEGATOR AMERICANUS. By late Dr. Wm. Gray. UNCINAKIASIS IN PORTO EICO. 113 which, he said was that from which he had contracted his dermatitis. Larvae of uncinaria were found in abundance. Of the 947 cases at Bayamon, 284 were asked about mazamorra ; 263 said that they had had it and 21 gave no history_ of attacks. Most of the cases at Utuado were questioned on this point. Of the 61 special cases, 1 gave a doubtful history of the affection, the rest positive. Of the 4,482 cases belongingto the general series, there were 86 who were not questioned on this point and 65 who stated that they had not had it. Most of these who gave a history of mazamorra stated that they were victims of it " at every coffee crop," and some of them were com- pletely incapacitated for work. In all of 5,490 cases of uncinariasis, 749 were not questioned con- cerning mazamorra. Of the 4,741 who were, 4,654 stated that they had had it, a percentage of 98-|- PEEDISPOSING CAUSES. There has been a long list of conditions which have been cited in the past as causes of " anemia " in the Tropics. While their influence upon the blood is not lost sight of, it is well known that they have heretofore been considered, not only in Porto Eico, but in all tropical and subtropical countries, as the determining cause of the profound anemia which is but a symptom of the disease under consideration. An entire population, not only anemic, but suffering from a series of other symptoms which form a distinct clinical picture, and which, for this reasoUj have led medical observers, before Ankylostomum duode- nale was discovered, to dignify by a separate and distinct name, can hardly be considered, in these days,_to be the subjects of one infirmity caused by a thousand and one etiologic factors. No one to-day would venture to prove that tuberculosis could exist without the tubercle bacillus, and yet no one denies that bad food, hardship, and. an unpro- pitious climate work destruction in the presence of this terrible infec- tion. The days of " miasms " have- gone, yet we know that a cabin in a swamp is generally malarious because it is a breeding place for ano- pheles mosquitoes. It is unfortunate that such explanations are needful, but, as so many are still inclined to lay the blame for a wide- spread endemic on a motley collection _ of predisposing causes and debilitating influences, winch act in uncinariasis as they do in every other disease, we think it proper to give to the prominent ones their places in a tragedy which without Uncinaria would be Hamlet with- out Hamlet. Food. — The question of insufficient and improper food as a cause, and to the majority, the chief cause, of anemia on the island has pre- viously so dwarfed all other considerations that, until recently, little thought was given to any other. The essential point is, does the pro- tein element in the food of the Porto Eican jibaro suffice to keep him in physical well-being? Of course, protein alone is entirely insufficient and carbohydrates and fats must be supplied. This is practically seen, as Oilman Thompson remarks in his " Food and Dietetics," by the Eskimo, who eats enormous quantities of fat with his meat to enable him to resist the cold and fatigue of long sledge journeys. He is, however, no stronger than the Central-African negro whose proteid is chiefly of vegetable origin, assisted occasionally by fish and game. Both, 77759°— S. Doc. 808, 61-3 8- 114 UNCINARIASIS IN PORTO RICO. however, hare a proteid and carbohydrate constituent in their foods, although one derives it from animal, the other from vegetable sources. The Polynesian warrior is more ferocious on a diet of plantains than the Eskimo who eats nothing but fish, meat, and fats. The Japanese are essentially a rice-eating people with a small but potent amount of nitroo-enous food. " The Mexican, whose supply of meat is scanty and of poor quality uses the native bean or frijole at almost every meal, made into a stew with vegetables and, perhaps, shreds of sun- dried beef" (M. A. Abel). The same might be said of many parts of South America, Hutehinson says: But vegetable foods possess not merely abundance of carbohydrates, they con- tain proteids and fats as well. Some members of the class, such as the pulses, are particularly rich in the former ; nuts in the latter ; but of vegetable foods as a whole it may be said that they tend more than the animal foods to con- tain representatives of all the three groups of nutritive substances. In con- sideration of this fact, the vegetable kingdom must be pronounced a better source of human food supply than the animal, and, if one were confined in his selection of a dietary exclusively to one kingdom or the other, it would be wiser to patronize the miller and green grocer than the butcher and fish- monger, for it is undoubtedly possible to live on vegetable diet alone, whereas it is difficult to live for any length of time on nothing but meat. The way for most people, however, is to avail themselves of the resources of both kingdoms. The food of the Porto Eican jibaro embraces bananas, plantains, various tubers whose food value approaches that of the potato, " gan- dules," of the value of the pulses, rice, and beans. He can almost al- ways cultivate corn but knows very little of preparing it for use as a food; codfish, though cheap, is an article which must be purchased, and many of these poor people can not do so. Still, many more have it than is generally supposed. For example, in Utuado, the poorest district on the island, we noted the presence or absence of meat fibers in the first 200 specimens of feces examined. In 83 they were found. Of these 83 persons, 60 were profoundly anemic, 15 were moderately so, and 8 had slight or no anemia. It is not understood why fresh fish can not contribute to the protein element lacking in the food of the poor in Porto Rico as it does in Japan, also a thickly populated country. While not unmindful that many believe that even vegetable food is lacking in the interior, it is believed that this is an error. Veg- etable food can be secured in amount necessary to sustain life. With few exceptions it is only when a whole family is too sick from un- cinariasis to work that all food becomes scarce and starvation threat- ens. We know of innumerable cases where half -sick jibaros are sup- porting invalids too ill to do more than lie in one position all day. We do not intend to write a thesis on the food value of the vegetables of the island, but we desire to call attention to several articles some- what despised for a supposed low nutritive value. Varieties of bananas and plantains. Banana flour. Wheat flour. Moisture Per cent. 13.0 4.0 .5 80.0 2.5 Per cent. 13.8 7.9 1.4 76.4 .5 Proteirl Fat Carbohydrates Mineral matter XTNCINABIASIS IN POBTO EICO. 115 Knight quotes M. Humboldt who states that 33 pounds of wheat and 99 pounds of potatoes require the same space as that in which 4,000 pounds of bananas are grown, and remarks on the smallness of the spots under cultivation around a cabin which contains a numerous family of Indians. Hutchinson says : It is evident from this that we possess in the banana a potential source of cheap nourishment which may one day be of great importance. Surg. Parke ("My Personal Experience in Equatorial Africa," p. 416), in an account of the Emin Pasha relief expedition refers to Mr. Stanley, who was at the time suffering from acute gastritis, as follows : He eats porridge made with banana flour and milk. It Is very light and digestible * * * a.nd is also very nutritious. We whites have very good reason to know this fact now, as we have mostly lived on banana flour for the past two years. Long marches and frequent attacks of malarial fever, from which they suffered, were severe tests of the nutritive qualities of any dietary. Banana flour can be easily prepared and is vastly superior to any other preparation of the fruit. We have had our attention called to the variability in the nutritive value of different members of the banana family, but we possess no data to prove that it would ma- terially alter our general conclusions. We have already spoken of the high . proteid value of the pulses, of which the bean and " gandul " are excellent illustrations. To mention the famous " iron ration " of the Germans in the Franco-Prussian war, is to evidence the esteem in which this vegetable proteid is held. " Erbswurst," as it is called, is a mixture of pea meal, salt, and fat, and its modifications generally form part of every military emergency ration. Corn. — In the south of the United States this much prized food forms the staple diet of many poor people. It contains about 9 per cent fat, a component which the jibaro lacks. It is best eaten as corn meal, but here, the " hoe cake " seems not to be generalized. It contains as much proteid as wheaten flour, if not more, and should be more consumed in this island than it is, foy it is a wholesome fattening food. Alligator pears, or " aguacates," deserve special mention, as they furnish an enormous amount of fat. Sugar in certain sections is always at hand. It is a powerful pro- ducer of energy. Our conclusions are that the diet of the jibaro is generally poorly balanced and that many times this results in a condition of malnutri- tion. Between an illy-balanced dietary and actual starvation there is a great difference. One is an insufficiency of one or more of the food elements, proteids, carbohydrates, fats, or salts ; the other is lack of food. Starvation came in 1899 after the hurricane and, but for the superhuman efforts of our Army, would have been more terrible than it was. Starvation may come to some who are too sick to raise crops or to work, if work be found, and to some others, from one cause or another. But starvation has one general symptom, emaciation, and such sights as we see portrayed at the time of famine in India are rare here. Before death from starvation takes place, 90 per cent of the IIQ UNCINARIASIS IN PORTO RICO. body fat is consumed. Moreover, nearly all authors are agreed in stating, whatever be the actual condition of the blood, that the red cell counts and hemoglobin percentages are above normal. This is emphatically not to be found here as a general thing Hayem gives us two exaniples of blood counts in cases of genuine starvation which illustrate this point. One gave 12,000,000 red cells per c. mm. and 120 per cent hemoglobin, the other, 8,780,000 red cells. The objections to a vegetable diet are: 1. Bulk.— In order to get the sufficient amount of proteid one has to consume 3,500 grams daily. This means that the stonaach, which holds but 1,200 grams normally, has to be stuffed three times a day, often causing putrefaction of food and dilatation of the stomach and intestines with their well-known effects. _ ... 2. Insufficient assimilation.— l^ot only do the gastric and intestinal juices penetrate the food mass with difficulty, but it is an established fact that vegetable proteids are from 20 to 40 per cent less assimilable ; in other words, that proportion is not utilized as food. 3. Cellulose. — This is an entirely indigestible material prominent as the exterior covering of most grains and pulses. Poorly cooked beans will pass through the intestinal canal entire on account of this jacket which, unless broken, locks up all nutritive material. In addi- tion, by its mechanical irritation, food is hurried out of the canal before chance to absorb is given. 4. Vegetable diet is not as good a source of nervous energy wMch shoidd he distinguished from muscular strength as evidenced hy the actual force produced in a day''s work. — ^Not only is it lacking m power to produce such energy, but it lowers the power of one to resist disease. This is apparent from the facility with which many vegetable-eating races fall an easy prey to epidemics. All this may be modified by the fact that carbohydrates are the sources of force, and that the laborer of the tropics can generally get from his diet enough protein to build up his tissues if enough carbo- hydrate or " force food " is supplied. Herein he differs vastly from the sedentary individual who fails to perspire enough to carry off the excess of water in such a diet. In treating of this subject, we know of no saying so wise as that of Gilman Thompson: There are many facts in nature, in addition to those already discussed, which, indicate without doubt that man from his earliest prehistoric days has been omnivorous, adapting himself to his surroundings and eating in his primitive condition whatever his environment afforded, with least expenditure of labor to obtain it, now vegetable, now animal food. * * * ^ brief glance at the dietetic habits of the more primitive tribes of mankind at present living, shows no arguments can be drawn from them as to the advantages of any particular class of food. Taking the dietetic habits of these people into account, we may conclude that they are not materially different from what they always were. By this, it is not meant that such food is not a menace to their periect physical well-being, nor is it intended that any one shall think that we do not share the desire of everyone to see a poorly bal- anced diet improved. It is also known that in certain sections great poverty has supervened from depression of certain industrial interests and that the protein element in the diet of the jibaro has suffered. We also realize that a certain degree of anemia may result from ex- treme poverty of protein. UNCINARIASIS IN PORTO RICO. 117 We therefore believe, in spite of the quotations of authorities cited (whose opinion expressed later is not different from our own on food in general), and from Thompson's remarks, that the food eaten by the jibaro in Porto Rico can not fail to produce an effect upon the prognosis of a blood-impoverishing disease. Lest we generalize too much, let us review some clinical observa- tions, the results of our work : Of 947 cases treated at Bayamon, a statement concerning the nature of the food eaten was secured from 355. Of these, 225 said that they ate the usual food of the country people ; i. e., rice, beans, vegetables, and codfish (now and then) and that, such as it was, they suffered no lack in quantity. Ninety who were of the better classes or their servants, stated clearly that they had a daily mixed diet. Forty said that their food was deficient in quality and quantity. Of the 225 with the usual food of the country, 217 had their hemoglobin per- centages taken with the following results : Persons. Below 20 per cent 14 Between 20 and 29 per cent 37 Between 30 and 39 per cent 50 ^tween 40 and 49 per cent 47 Between 50 and 59 per cent 30 Between 60 and 69 per cent 21 Between 70 and 79 per cent 11 Between 80 and 89 per cent 5 Between 90 and 100 per cent 2 Total . 217^ Average hemoglobin percentage in this class, 43+- Of the 90 persons with a full mixed diet, 86 had hemoglobin per- centages of blood taken as follows : Persons. Below 20 per cent 2 Between 20 and 29 per cent 17 Between 30 and 39 per cent 21 Between 40 and 49 per cent 20 Between 50 and 59 per cent 11 Between 60 and 69 per cent 8 Between 70 and 79 per cent 5 Between 80 and 89 per cent . 1 Between 90 and 100 per cent 1 Total 86 Average hemoglobin percentage in this class, 43.5. The remark " best class of food " is found in two cases, one with 93 per cent Hb. and the other with 24 per cent. All the 40 persons on a diet, which they said was purely vegetable, and restricted at that, gave hemoglobin percentages as follows : Persons. Below 20 per cent 1 Between 20 and 29 per cent 10 Between 30 and 39 per cent 7 Between 40 and 49 per cent __ 8 Between 50 and 59 per cent 5 Between 60 and 69 per cent 3 Between 70 and 79 per cent___ 4 Between 80 and 90 per cent 2 Total 40 Average hemoglobin percentage in this class, 44+. 118 UNCINARIASIS IN PORTO BICO. We find the following remarks in our notes on these 40 cases : " In two Toa Alta cases who ate the poorest of poor food, one had 95 per cent Hb., the other 28 per cent." The first had extremely few ova o± uncinarise, the second many. We have repeatedly_ noted instances where one with severe anemia was accompanied to clinic by markedly rosy and healthy individuals of the same family who ate exactly the same food. In some of these families the poorest kind of food was eaten; in others the best, depending on their station m life. Gen- erally, the healthy looking ones had little or no infection ; the pallid were always heavily infected. For notable illustrations of how little food may influence the "anemia" of the island, see Case 2 in IJtuado series, where ex- pulsion of uncinarise was followed by a rise in Hb. from 38 to 100 per cent in about six weeks, although the man never received a bite to eat at the hospital at any time, and was continually complaining of poor food at home. Case 7, same series, left the hospital after requir- ing six weeks to rise from 10 to 64 per cent Hb. In two weeks more he rose from 64 to 103 per cent Hb., living at home and eating what his father described as the poorest of food. Cases 8, 11, 15, and 47 are similar. Case 19 shows severe anemia developing, once in Ponce with good food, and once in Utuado with poor food. Cases 20 and 68 of the IJtuado series, and Cases 1, and especially 16, of the Bayamon series, illustrate how the best of food does not prevent anemia of uncinariasis. Climate. — As a cause of marked anemia, per se, there is no reason- arble ground for fear in Porto Eico on account of climate. We will not attempt to defend what on its very face is evident : that, with a bright, sunshiny little island out in the Atlantic, fanned constantly by breezes, with a mean monthly temperature of 75° in January to 82° in August, and a mean annual temperature of 72° in the moun- tains, excessive heat can not be cited as a cause of anemia. If diseases run riot, the hand of man has sown them, and, until measures are taken to prevent it, he will continue to sow them and reap the fruit of his own negligence ; for the climate of Porto Rico is propitious, not only for the perfect development of human kind, but for that of the manifold varieties of parasitic life. In this sense, climate is a factor in the epidemic under consideration, in that it affords to the parasite a proper temperature for its development in the open air. So does it provide a home for Stegomyia fasdata^ " the yellow fever mos- quito," but efficient quarantine has prevented its infection. ^ Ewrmdity and rainfall. — The average humidity is 80 per cent, which is, of course, high. The annual rainfall varies considerably. In San Juan it is 60 inches, but in the northeast corner of the island it is 100 inches and over. Thus Porto Rico has an abundance of rain. It is rare, however, that the sun does not shine the major part of the day. Seasons of drought do occur, especially in certain parts of the island, but Porto Rico is noted for its heavy green mantle and rich, fertile soil. There is a rather indefinite division made of a wet sea- son and a dry season, the former corresponding to the time of har- vesting the coffee crop. This is known everywhere as the sickly sea- son, as will be noted by the inspection of annual mortality tables here. The mud formed is slippery, grumous, and pervades everything, and it is no wonder that at this time of the year the mortality rises, UNCINARIASIS IN POETO EICO. 119 for here again is added another of the necessary elements in the development of the uncinaria ovum. We realize that humidity is the general condition which aids in bringing about many diseases, but the fear of a damp locality in Porto Eico is all out of proportion to that felt in other regions. Towns are popularly divided into " damp towns " and " dry towns." Although the temperature is lower, the wet season is the deadly sea- son, chiefly because it is the hatching time par excellence of uncinaria ova. We do not mean that in the dry season, often visited by rains, development does not also occur, for Porto Rico is seamed at short intervals by brooks, streams, and rivers which furnish abundant moisture. There is one more source of humidity in the island — ^the heavy dews, which, falling in shady spots, keep them damp all day in spite of the sun. Uncinariasis is a disease of the poor, and the poorer the man tRe more exposed is he to heavy infection. Here again poverty alone is considered a cause of " anemia," whereas it is really a predisposing element. It is unnecessary to mention more than a few of the occu- pations which bring people into conditions which favor infection. 1. Cojfee culture. — Coffee pickers and laborers on coffee estates are the most exposed of all laborers in the island. They are doubly exposed in that the environment of their dwellings is loaded with uncinaria larvae and that a similar condition exists at their place of work. This is, to the barefooted man, the most dangerous pursuit in Porto Rico, and this danger is enhanced by the fact that the most of their Avork is done at the very time when conditions are most pro- pitious for infection. So tnie is this that practically all of our Utuado cases stated that at the time of coffee harvesting their feet were literally " eaten up with mazamorra." 2. Sugar plantations. — Infection in sugar plantations is not so common at the place of work, but nevertheless is frequent, especially in the irrigating ditches. 3. Washing on the edges of streams sometimes produce maza- morra. Such spots are often heavily infected. 4. Banana groves. — A most intense infection may be acquired in such localities. Habits. — Uncinariasis is preeminently a filth disease. The only means of infesting the soil is by evacuation of the bowels where the ova in the feces will later develop. If sanitary privies were gen- erally used, uncinariasis would forever disappear. This is the key to the whole situation, as outside the human body the larvae never pass beyond the encysted stage. Even the last census report gives no conception of the absolute disregard for sanitation in this respect in the country districts. Practically all of our Utuado cases stated that they deposited their feces in the open country and had no privy nor even a hole in the ground for this purpose. Our special cases there are fair examples of the average — of 61 persons 55 had no privies and 6 generally used them, but only two of the latter lived in the country, the rest in the town. In Bayamon a much larger percentage of our patients were more comfortably situated in life-^342' were questioned on this particular, and 53 stated that they used privies; the rest, 289, never used one. Thus the average individual living in the country, barefooted and devoted to agricultural pursuits, from time to time acquires more and more uncinariaj from infections sown 120 UNCINARIASIS IN PORTO RICO. by himself and his neighbors. This is a constant inflow. The time naturally comes when the parasites in his intestines die of old age or of some accident which cuts off their existence, and, as Boycott and Haldane remark, the dead larvae are at least partially digested by the intestinal juices. Thus they are passed out of the canal with no mark by which they can be recognized. This is one of the reasons why, when a jibaro comes to town where infection is not possible, or at least rare, he often gradually gets better of his anemia, i. e., his multiple reinfections are cut off and the parasites he brings with him die as they reach the limit of their natural existence. Such improvement is often explained here by the statement that "the most anemic jibaro, on reaching San Juan and finding proper food and lodging, immediately begins to improve." The fact of improvement is often seen, but not immediately. The refkson for improvement is not correctly expounded. This is the so-called "natural cure." A study of the following data, obtained from a systematic exami- nation of the inmates of the Girls Christian Orphanage is illustrative of this point. These girls reached the school in all grades of anemia, undoubtedly due to uncinariasis. The superintendent stated that 31 of them were pale, some extremely so, and that after a few months their general condition began to improve, until at the end of two or three years " all anemia " had disappeared. Four were in the institu- ' tion less than two years, 5 between two and three years, 35 over three years, and 1 a period unknown to us. As will be seen from the table, their average hemoglobin now is 82+ per cent, the average of those without ova in the stools being 82.8-(- per cent, and with ova 82 per cent. A few of them are still pale. Thirty-eight of them have ova in their feces, and 7 have none. There was considerable difficulty in finding ova in the majority, and some had to offer a second speci- men before they could be found. In general, therefore, few were encountered. They are all well shod, neat, tidy girls, and the chance of reinfection is small as good latrines are provided. A noteworthy bit of mformation is obtained from the column headed "geophagy," where 16 are found to be "earth eaters." It would seem as though this was an almost certain mode of infection, but the "earth" eaten was almost always plaster or similar incon- gruous material, not wet earth. Sixteen of the 45 had this habit, which throws a flood of light on the habits of the jibaro, practices which he will never acknowledge and which are only known by just such accurate data as this obtained from observing teachers. Let us assume that practically all were infected on admission : 1. Many uncinaria gradually died off and none took their place, or, if any, very few. 2. Under good care and hygiene an individual relative immunity was established to those that remained. Aside from the nonuse of latrines, the various local habits, some not pecuharly affecting the disease, others offering other means of in- fection, need not be detailed. For example, the abuse of alcohol can hardly affect uncinariasis and its attendant anemia more than it affects other diseases ; the general habit of going barefooted is a real source of danger and a means of direct infection, etc. The playing of children in muddy places should not be lost sight of, UNCINAEIASIS IN PORTO RICO. 121 Some curious infections occur : One prominent American, a man of most scrupulous personal habits and one in whom infection by the mouth seems impossible, contracted slight mazamorra by taking off his boots and wading in a small pool. Several months afterwards ova of uncmaria were found in his stools. He informed us that an- other American, similarly affected, was sent home very ill with anemia, and that he is supposed to have malaria cachexia. The pic- ture drawn of his symptoms makes it more than probable that he is at least suffering from uncinariasis, whatever else he may have. In broad general terms, it may be stated that the conditions found in cities and large towns of the island do not conduce to so heavy an infection as in the country and that many pallid individuals seen on the streets of San Juan have been infected in the interior. The un- sanitary_ habits of the laboring classes in some towns and hamlets render it likely that infection does take place in certain of the worst sections, given shade and moisture. ^ffe._ — The ages of all our patients, arranged in groups of five years, is as follows : Age. Baya^ mon. Utuado. Special cases. Total. Under 6 U 99 122 114 131 142 67 72 44 43 31 30 7 13 2 2 17 24 427 887 636 601 564 424 326 219 145 164 65 61 17 8 5 3 1 5 5 18 9 9 5 6 7 1 1 Between: 5 and 9 531 10 and 14 1,027 759 15 and 19. . 20 and 24 641 25 and 29. . 711 30 and 34 497 35 and 39 405 40 and 44. . 264 45 and 49 189 50 and 54 195 ^r, a.nr} 59 95 60 and 64 68 65 and 69 30 70 and 74 10 75 and 79 7 80 and 84. 3 85 and 89 1 Age not given 22 Total 947 4, 482 61 5,490 Thus the fiirst decade furnished 566; the second, 1,786; the third, 1,352; the fourth, 902; the fifth, 453; the sixth, 290; the seventh, 98; the eighth, 17 ; the ninth, 4. 92+per cent were below 50 years of age and 62+per cent of these were between 10 and 30. In interpreting these figures, we desire to call attention to a sen- tence in a previous report on this disease in the island (A Study of Uncinariasis in Porto Rico, Am. Med., Vol. 6, Nos. 10 and 11) : It is a startling fact that while Porto Eico has a larger proportion of children to adults than any other State except South Carolina, yet in 1890 the percent- age of persons over 60 was but 40 per 1,000, compared with 62 per 1,000 in the United States.' j^ We believe, that apart from this, the disease is most destructive in the young, not only of life, but that it is between 10 and 30 that the great amount of sickness occurs, as seen from the table. A relative immunity may, and probably does, come to those who have suffered 122 UNCINARIASIS IN POETO RICO. the consequences of infection and who have survived its baneful effects. Persons of all ages are liable to become infected, given exposure to the parasite. Sex.—Oi 5,490 patients, 3,259 were males and 2,231 were females or 40.6+per cent. This is largely due to chances offered for infec- tion, males naturally being more exposed from the nature of their occupation. Not only is this so, but the degree of anemia is less in females than in males, obeying to a certain extent, at least, the num- ber of parasites with which each sex is infected. In Bayamon, of 577 persons in which the hemoglobin percentage was estimated, ex- cluding the Girls Christian Orphanage cases, 165 females gave an average of 48+ per cent Hb. and 412 males, 41+ per cent. Sex compared with hemoglobin. Between; 10 and 19 per cent hemoglobin. 20 and 29 per cent hemoglobin. 30 and 39 per cent hemoglobin. 40 and 49 per cent hemoglobin. 60 and 69 per cent hemoglobin. 60 and 69 per cent hemoglobin. 70 and 79 per cent hemoglobin. 80 and 89 per cent hemoglobin. 90 and 99 per cent hemoglobin. Over 100 per cent hemoglobin Total 165 Females. Males. 7 24 26 86 30 97 21 97 29 43 24 34 20 17 6 9 1 5 1 412 Only three of Sandwith's 400 cases were females, due, he says, to the oriental custom of immuring women. Eace and immunity. — It seems difficult to separate the two, so we have proceeded to discuss them together. Sixty per cent of the population of the island is said to be white. The negro race possesses a higher degree of immunity than the white, but this is not absolute in the Americas. Jacoby and Zinn state their belief in the immunity of the negro. The dangerous nature of the parasite was first practically demonstrated in Egypt, and has since been fully proven there. Literature on uncinariasis is not com- plete without reference to the terrible ravages of this disease in that country, yet the aboriginal tribes of the Congo, and, indeed, all through Africa, are infected but show no signs of disease. Here, in one continent, we have a sharp contrast between the negro and the white race. We are fortunate in having direct information of the section least explored. Mr. T. Stevenson, a missionary for some years in Central Africa, was living in Utuado during our stay there. He had had occasion to use medicine in his work in Africa, and was attracted to our camp. He told us that the food of the tribes where he served is almost exclusively vegetable; that they are men of gigantic stature and perfect physical development, yet were subject to a severe derma- titis of the feet in wet weather, which they ascribed to poison laid on the ground by their enemies. He states that the resulting ulcers were very severe at times, but that he had not noticed the disease in A.frica, although the dermatitis was familiar to him. As to racial differences in the grade of anemia, we are able to compare 540 per- sons in whom race and hemoglobin were noted. UNCINARIASIS IN POETO RICO. 123 Race compared with Hb. Whites. Mulattoes. Negroes. Below 20 per cent Hb 20 83 88 82 43 39 10 6 8 23 31 26 26 16 11 5 1 Between: 20 and 29 per cent Hb 1 30 and 39 per cent Hb 4 40 and 49 per cent Hb g 60 and 59 per cent Hb 2 60 and 69 per cent Hb 2 70 and 79 per cent Hb 2 80 and 89 per cent Hb 1 90 and 99 per cent Hb 100 and llOpercentHb 1 Total 371 146 23 This gives an average of 45+per cent Hb. for the white race, 44+ per cent for the mulatto, and 49+per cent for the negro. A much more important observation was that very few negroes sought our clinic. The people who did, came not because they were pale, but because they were ill, and had the negro felt ill he would have come just as readily as the mulatto. Now, Bayamon, from which came these 540 cases, is a municipality in which many negroes live. We must conclude that immunity to the toxin exists in them, at least to a certain extent. In other words, absence of several generations from its haunts reduces the immunity of the negro race. That it is not absolute is seen by case 4,431, cited before, and we conclude that in this country racial immunity is no longer a protec- tion from an unusually large infection. Leichtenstem, in 1899, stated that the old races of Asia are relatively immune to the toxin, but are wprm carriers. Such are notably the Hindus, where Dobson shows an infection of 75.68 per cent of "healthy" coolies. That even there there is no absolute immunity is amply attested by the storm over this assertion, in which Thornhill and Giles proved its death-dealing qualities in that same country. But not only this, Thornhill adds that, in Ceylon, uncinariasis is more fatal than cholera, and McDqnald, in that island, reports 1,760 cases treated m hospital, with 395 deaths from the disease. One of the writers had a case of a soldier with uncinariasis who was infected in the Phil- ippines, and who said that about 20 men in the company had the same symptoms, causing them to fall out on the march. He further added that the natives are very healthy. _ Thus negroes, and possibly Malays and Mongolians, are relatively immune to the disease while harboring the parasite, remembering that we have no knowledge of the number of worms these people usually carry, an important point. There is nothing at all strange in this, as it is well known that relative immunity exists in yellow fever, especially in negroes. No one to-day denies that individuals exist in whose blood the plasmodium of malaria can be found, but who show no symptoms of malaria, nor that the famous French phy- sician, who found that 60 per cent of the many cadavers he autop- sied presented lesions caused by the tubercle bacillus, was correct in his statement that a relative immunity holds the bacillus m abeyance until a long life is run, the individual dying of other causes, _ This brings us to the question of individual resistance to the toxm. Literature and the personal experience of many here attest the frequency of infection by uncinaria without objective symptoms ot 124 UNCINARIASIS IN POBTO RICO. disease. Many of them have no anemia,, yet are clearly suffering from other manifestations of uncinariasis. Frequently our light cases in Utuado had little anemia, yet were far from well, seeking our camp on that account, and while some were lightly others were heavily infected. . , . , Individual resistance to the disease is natural, inherited, or ac- quired. In all these, one prominent factor is ever present. We refer to the conditions of life under which a person lives. As we send a case of incipient tuberculosis to parts where climatic and other influences build up the resistance; as we feed up a convalescent, with the intention of supplying to the body a force which will better enable him to cope with disease, so it is perfectly clear that good food in uncinariasis is not only an aid to recovery, but an aid to the body in fighting a poison, and to good food might be added a host of other factors. We have cited, however, an instance (case 16, Bayamon series, p. 148), where all that care and money could bestow resulted in a complete failure until specific treatment removed the cause of his infirmity. Yet it is a valuable weapon to turn against uncinaria when we are able to command a good pantry and a good bed for our sick. Thus were our desperately ill cases tided over a critical period in Bayamon and Utuado, and for this reason hospitals are needed. Boycott and Haldane say with regard to infection in the mines of Cornwall : Fresh infections must, however, be occurring and the facts are most easily explained on the theory that in the majority of individuals some form of im- munity is gradually established to the presence of the worms. Nearly all the men worliing in the mines appear to be infected. A great many of these suf- fered at first from anemia, but gradually recovered completely without giving up their employment and without treatment. On the other hand, there are some individuals who continued to be ill for long periods even after giving up work underground and in whom therefore the immunity did not become estab- lished, though they recovered when treated with thymol. We are immediately impelled to cite the fact that after a sharp at- tack of diphtheria has been overcome the bacilli remain, propagate, and excrete their poisons in an otherwise perfectly healthy throat. We are not, however, in accord with Boycott and Haldane that this is all a question of acquired immunity. From their descriptions we are inclined to believe that they were not dealing with such heavy reinfections as we have here. All of the data concerning predisposing causes is insignificant as compared with the following facts elicited from a study of the disease. Of 4,482 persons treated in Utuado (excluding our special cases) , not more than 300 of whom were ever rationed even for a short time by the commission, living, in their homes as they had always lived, extremely poor, and generally with an illy balanced, often an insuf- ficient, dietary, 2,151 were radically cured, expelling their uncinariee and leaving the clinic with normal blood, tested by instruments ; 273 were practically cured; and 1,495 were improved. We may now understand why Stengel writes of secondiary anemia as follows : The effect of diet is diflScult to determine, as the experimental evidence and some of the investigations made upon persons undergoing prolonged fasts have been quite at variance in their results. Senator and Luciani found that the blood of the Italian fasters, Oetti and Lucci, did not undergo the deterioration UJNUiJNAKlASia IN POBTO KICO. 125 that might be expected, apd experiments on animals have sometimes shown con- siderable increase in the number of corpuscles instead of decrease. When the blood IS decidedly affected, this is probably due to secondary or associated con- ditions, such as fever, organic disturbances, etc. Continuous bad food, however, is usually associated with other debilitating influences and undoubtedly leads to anemia, as is seen by the inhabitants of besieged cities or in times of famine. * Residents of tropical climates frequently present a strikingly anemic appearance, particularly when they have recently arrived in such climates, but to a large extent this appearance is deceptive, being probably due to vaso-motor conditions rather than to a condition of the blood itself. The actual anoBmias of the tropics are dependent upon definite and specific causes. (Alfred Stengel, M. D., " Twentieth Century Practice of Medicine," v. 7., pp. 312-313, Wm. Wood & Co.) The italics are ours. _ After reviewing all the evidence, we find it clear that heavy infec- tions generally produce the disease in practically all save those who are racially immune, and often in them ; that slight infections often do and, according to the facts of immunity, may not; that moderate infections oftener do produce the disease in the people of Porto Kico than not ; that every circumstance which tends to devitalize a human organism will decrease this immunity and give fuller play to a dangerous and, many times, fatal toxin. Hence to trust alone to building up the resistance of the Porto Eican jibaro and not to treating him for his disease would be as ridiculous and costly as to order a fire brigade to turn its entire attention to soaking with water houses a block away in the hope that this would prevent a general conflagration, leaving the fire to burn at its own sweet will. From a clear knowledge of these truths, Germany is attacking a disease for the possibilities it represents. This is all the greater tribute to their grand foresight and sane judg- ment, when we realize that but 6.8 per cent of the infected workmen present signs of anemia. For the same reason the United States and Europe are beginning to view uncinariasis with alarm and to seek to stamp it out before a general sacrifice of health, happiness, and human life is made. Porto Rico has taken the initiative in the Tropics in inquiring into the cause of the profound anemia of her laboring classes and in test- ing feasible means of treatment and prophylaxis. We have seen that the major portion of this " anemia " is uncinariasis and we earnestly recommend to our professional brethren, some of whom need no such recommendation, that no further reliance be placed on iron, quinine, and tonics in general, which after a trial of years have proved them- selves utterly incapable of controlling a disease which is every day threatening more and more the existence of the unfortunate jibaro. PATHOLOGY. i [In the original report both pathogenesis and morbid anatomy were combined, but as it is unnecessary to rehearse this entire chapter, the gist of which is covered in a more acceptable manner elsewhere, we will merely cite the part devoted to the pathogenesis.] PATHOGENESIS. The worm has always been considered a bloodsucker, sustaining itself by assimilation of the plasma, not the corpuscles. It is found 126 UNCINARIASIS IN PORTO RICO. with its head buried in the mucous membrane and the buccal capsule so well fastened to the intestinal wall as to require some force to dis- lodge it. Many writers have declared the amount of blood thus lost to be utterly insufficient to produce anemia of such grade, a belief with which we have been in accord. Loeb and Smith (Proc. Path. Soc. Phila., June, 1904) state that the worm excretes a substance at the point of its attachment to the intestine, which prevents coagula- tion of the blood, as do leeches, and that on changmg their feeding ground they leave a wound which bleeds for some time. Calculating the loss of blood occasioned by each worm to be one drop daily, 500 would cause a loss of 20 grams. There are, however, some facts which throw doubt on hemorrhage as a cause of the anemia: (1) Blgod in the stools is not a common symptom in our experience. (2) The worms are rarely seen to contain blood in many examinations we have inade. (3) In some individuals a few worms, too few to cause an appreciable loss of blood, will keep up a severe anemia which is cured by their expulsion. Leichtenstern believes that the male is not a bloodsucker, and also states that a general change of feeding ground is apt to occur every three to six months. During pairing time colicky pain and all diges- tive symptoms are prominent, and blood sometimes appears in the stools, but in the intervals neither one nor the other is marked. Our own observations lead us to consider the latter discussions of little moment here. The worm undoubtedly changes feeding ground, but as the infected in Porto Rico are constantly receiving fresh infec- tions, they can not well be free from pairing of their uncinarias at any stated time. Pains in the epigastrium are common in all stages of the disease here, perhaps due to frequent reinfections. The late observations of Looss are of the greatest interest. He states that all authors until now, save Sangalli, have agreed that the nematode is' a bloodsucker. The latter believed that the uncinaria feeds on the intestinal mucosa, a view which Looss declares is correct, and adds that if blood is found in the intestinal canal of the worm, it means that by accident it has opened up some vessel which, if small, causes slight and imperceptible bleeding; if large, hemorrhage, which will be perceptible in the stools. Considering loss of blood by hemorrhage a partial source of anemia, let us turn to what is undoubtedly the chief cause of this and, per- haps, many other pathologic conditions found during life and at autopsy — the toxin. The reasons for our belief in a specific poison are: 1. There is a remarkable eosinophilia in this disease, to be dis- cussed later. 2. There are nervous symptoms, out of all proportion to the anemia actually present. 3. There is a rapid improvement in the mental condition of the patient while yet the treatment has failed to affect the other symp- toms, especially the anemia. 4. There is a relative immunity to the disease enjoyed by some who harbor the parasites. All equally infected should lose a like amount of blood, and, if hemorrhage alone were the cause of anemia, we would not see such disparity in the reaction to the infection as daily experience demonstrates. UNCINARIASIS IN PORTO RICO. 127 5. By some cases of anemia in hmnan beings supervening on infec- tion when time was not given for the ultimate ecdysis and formation ot a suctorial apparatus (special case 19 and others). 6. The repeated observation that red cells may be normal, or nearly so, with a very low hemoglobin, and this at the onset of the disease. ^ -E^etmal conditions frequently found in the eye in uncinariasis. The third great cause of anemia is the mechanical wounding of the intestine, setting up chronic inflammation and perhaps affording en- trance to micro-organisms. As the disease progresses, overstuffing of the stomach, chronic disease of vital organs like the liver and heart. and a host of concomitant causes aid in protracting and aggravating the deterioration of the blood. CouKSE, Prognosis, and Lethality. In cases where a moderately heavy infection takes place, and thp patient is young, resistant, and has the benefit of wholesome food and good care, a certain degree of anemia results, which, as a rule, gradu- ally wears off as time goes by, provided that no new infections are engrafted upon the first. Such cases are rare here, for in Porto Rico the country people, who form the mass of anemias, are very poor. They are limited to the confines of a narrow valley, a coffee planta- tion on_ a mountain side, or a sugar field. They are constantly open to reinfection and lead a life of chronic invalidism. In their half sick condition they become dispirited, indolent, and thoughtless of the future. Before long food gets scarce for lack of strength to procure or produce it. The family is large, and the man, the breadwinner, falls ill. He becomes edematous and dies, leaving his wife and chil- dren to work out their own precarious salvation. Many times this varies ; the children go first, or the wife dies of the disease itself or of childbirth, its dangerous complication. They live far from town and to reach them the municipal physician has to risk life and limb over rocks, mud, steep mountain trails, and swollen streams. Many times they are never reached in time of illness, and the disease has become such a curse that it is known by the jibaro as " la muerte natural " (the natural death) . It has been said that but a small per cent of the deaths recorded as due to " anemia " are really due to any such thing. We are emphati- cally of another opinion. The jibaro knows his disease better than his educated countrymen who rarely have it. He dies of " hinch'a- zon " (general edema), is " descolorio " (pallid), and the picture he draws is so faithful that we have come to rely upon it. Such deaths are recorded as " anemia " by the " comisario," the chief of the barrio, and are so entered in the register. Apart from this, how many are able to trace deaths from cerebral edema, generally re- ported as " perniciosas " (pernicious malarial fever), or the final diarrhea or dysentery, etc., often the closing scene in uncinariasis? It would be startling to one not familiar with the disease here to listen to the story of destruction that " anemia " has made in the families of these unfortunate people. No one denies that it is the most fatal affection in Porto Eico. In the United States and Europe the number of deaths from uncinariasis is exceedingly small, but here the mortality is something terrible. Our own estimate of it is that it 128 UNCINARIASIS IN POETO RICO. causes about 30 per cent of all deaths, and the superior board of health has recorded from 20 to 30 per cent in times past. Many authors who have only the morbidity resulting from infection to deal with would be shocked to see to what extent its lethality may come. We see by published reports from both continents that what we have regarded here as light infections have been considered heavy there. The essential feature is the number of worms contained in an indi- vidual more than all other modifying factors put together. For this reason it is natural that one should not be surprised that there are but few cases beyond hope of cure, even in the absence of the comforts of life. A return to health is liable, however, to be followed by reinfection and a subsequent descent to the same condition. We realize that some immunity is conferred by one attack, but this is powerless be- fore the tremendous infections these people incur. This has already occurred in some of our cured cases in Bayamon and will continue to occur. So, until a determined effort to educate, direct, coax, or com- pel the use of some form of sanitary privy, and a general intelligent crusade is begun, in which the infected are treated, uncinariasis, or " anemia," is it is popularly known, will continue to reduce the white and mixed inhabitants forming the country class of the island to a lower and lower grade mentally, morally, and physically, until the very existence of the class will be threatened. We have purposely detailed our views and the facts on predispos- ing causes in order to show how it is that the majority are lulling themselves into a fatal security in citing "causes" which are not such and which merely aggravate the disease. In order to get better food people have to work for it, and these people are not usually capable of such labor in their present condi- tion. So much for the general course of the disease in Porto Rico, which is seen to result in an increasing enfeeblement of the laboring classes. In considering the course of typical individual cases, we refer to symptomatology and our recorded cases in the appendix. It is a gradually deepening toxemia, until the last-stages arrive in which the patient, unable to get about from debility, edema, etc., lies down in his hammock or wherever he may be, exhausted, swollen, with a dilated and failing heart, and succumbs. Such cases were brought to the hospital in hammocks swung on a pole carried by two men, and a '" hammock case " became a synonym for a patient in the very grave stages of the disease. In such cases anasarca was usually manifest and extreme, often with edema of the lungSj enormous ascites, dilated heart, and peri- cardial and cerebral effusions. Obstinate diarrhea frequently marks a fatal termination. Some- times the heart symptoms, with emaciation and diarrhea, are the prominent features, and such cases are of bad prognosis. The patient as a rule dies of pure exhaustion. On the other hand, the subject's surroundings, his resistance to the toxin, and his relatively moderate degree of infection may prevent him from any further inconvenience than the effects of a moderate anemia, indigestion, and certain nervous symptoms, with periods of improvement and of advance of the disease. He may thus lead a life of semihealth, working a few days and resting a week. UJMCiJSTARIASIS IN PORTO EICO. 129 The prognosis is dependent, at least to a considerable extent, on the presence or absence of eosinophilia, as disousse^ elsewhere. Espe- cially dangerous is pregnancy, and abortion,' premature labor, and nuscarriages are many times observed. Childbirth is often the cause of death of anemic women, although not so frequently as might be supposed, and if stillbirth does not result, the offspring is apt to be poorly developed and liable to marasmus. Barring intercurrent dis- eases, the prognosis is good in the light, moderate, and even severe grades of the disease,, provided no additional infectirais occur, but in the extreme grades, even under treatment, the outcome is dubious. INTERCURRENT DISEASES. Only the more common ones will be mentioned in detail. A list of such others as came under our notice in our clinic will be given with the number of times observed, MALARIAL FEVER. This is a serious complication and, when it occurs, the combination is apt to be fatal if continued any length of time. Case 6 (Utuado series, appendix) was an instance of the intercurrfenc'e of this disease. Here> in Porto Rico, tertian benign fever is the usual form en- countered, but we have found several cases with the typical ring forms, crescents, etc., of the estivo-autumnal variety. In Ponce one of our cases, nearly cured of uncinariasis, was suddenly seized with pernicious malarial fever, which was rapidly fatal. Other physi- cians here cite pernicious forms, especially in Ponce. While malaria is not rare, it is not as common as in many tropical sections not con- sidered to be especially malarious. We have seen two cases of " ague cake " previous to our present investigation, but of the entire number since that time (5,500), only 16 cases of malaria have been observed, some of these due to the estivo-autumnal variety. It seems to be com- paratively infrequent in the mountains, where anemia is most seen. It may be of interest to note the results of treatment by thymol of five cases of uncinariasis complicated by malaria, in which the hemoglobin was estimated before and after the administration of the drug: (1) Hb. 30 per cent Marcli 8; 55 per cent April 25. (2) Hb. 74 per cent Marcli 9 ; 84 per cent April 27. (3) Hb. 42 per cent Mnrch 16; 46 per cent April 27. (4) Hb. 32 per cent March 21 ; 70 per cent April 28. (5) Hb. 47 per cent Marcli 14; 80 per cent April 24. SYPHILIS. Syphilis is a relatively rkre disease among the people of the moun- tains, and care should be taken not- to confound ulcers resulting from mazamorra with a tertiary lesion. TUBERCULOSIS. While this is found to be the scourge of the towns and hamlets, it is very fortunately not so frequent among the country class. If one in a family acquires it, the whole family is apt to become in- 77759°— S. Doc. 808, 61-3 9 130 UHrCINAMASIS IN PORTO BIOO. fected. We noted 20 cases in all, but the incipient form might have escaped us. Uncinariasis creates a strong predisposition to the dis- ease, and to sow it on such soil is to insure a rapid and fatal termina- tion. In spite of the few cases seen, this disease was our greatest enemy in treatment, as will be seen from the deaths chronicled in the appendix. ANIMAL PARASITES. The following list embraces all animal parasites encountered in our cases at Utuado. The majority were determined from the char- acteristic ova in the feces, but the number of persons so infected under each species is low compared with the actual facts. Especially is this true of Ascaris lumhricoides and Schistosoma mansoni, the first not having been always noted, the second frequently not sought for, as when a sufficient estimate of the number of ova of uncinaria was made, search was concluded. They are believed to be a far more common cause of disease in Porto Eico than the figures indicate. Bilharziosis recti is particularly common and is frequently un- accompanied by blood in the feces. There is often, however, a large amount of mucus seen in the stools. In many cases known to be heavily infected with Schistosoma manso7ii, there are periods in which no ova can be found, and on account of this fact, amply dem- onstrated in several of our cases of bilharziosis, we conclude that we have passed over many such in our daily clinic. In one of the cases (case 42, appendix), Fasciola hepaticum, was unsuspected, but one adult parasite was found at post-mortem by Dr. Gonzalez Martinez: Special cases are not included. Parasite. In combi- In combi- nation witb uncinaria alone. and other parasites. 1,199 209 155 171 25 11 8 6 16 6 1 2 1 1 1 2 2 2 3 1 Total. Ascaris lumbricoides Tricocephalus dJspar , Strongyloides intestinalis Balantidium coli Bilharzia hematobium (Schistosoma mansoni) Oxyuris vepnicularis Diplogonoporus grandis ' Ascaris canis Ameba coli Fasciola hepaticmn Tyroglyphus longior Tenia saginata Tenia; solium 1,408 326 36 14 21 3 1 1 3 2 2 3 2 1 Probably an error. The following numbers of cases of various intercurrent affections were seen: Pellagra- 1 Pneumonia - 1 Laryngitis- 1 Paresis - 1 Varicella - 1 Elephantiasis - 2 Jaundice - 4 Tonsillitis - 1 Filariasis - s Conjunctivitis - i Hemiplegia - i Kenal calculus i Scabies'- 2 Ulcer stomach i Marked trachoma 2 UNCINARIASIS IN POE.TO KICO. 131 In one case of jaundice the stools contained ova of Faseiola hepati- cum and the urine was chylous, the latter probably due to a concomi- tant filariasis. Diagnosis. This should usually rest upon the careful microscopic examination of the feces. There was a time in our work in Utuado when for about six weeks the three of us (later four) made from 300 to 600 of these examinations a day. This is excessive and beyond endurance if continued for any considerable length of time, especially when other duties are imposed. Number of persons. Number of times. Examined once 339 668 1,011 862 837 392 201 110 44 13 3 1 1 339 Examined twice 1,336 3,033 3,448 4,185 2,352 1,407 Examined four times Examined six times Examined seven times 880 Examined nine times . . . . 396 130 33 Examined twelve times 12 13 4,482 17,564 To these should be added about 4,500 examinations more for our special cases and our cases in Bayamon, a total of over 22,000. THE OVA. These are characteristic, and the only thing liable to be confounded with them are the ova of ascans lumbj'ic aides, stripped of their heavy bile-stained outer shell, but these latter have double contour and "contain a shapeless mass of granular matter, not differentiated into clear segments. The ova of Necator americanus are " ellipsoid, 64 to 76 microns long by 36 to 40 microns broad, in some cases par- tially segmented in utero, in other (rare) cases containing a fully developed embryo when deposited." (Stiles.) The ova of ankylostomum duodenale are "ellipsoid, 52 to 60 microns by 82 microns, laid in segmentation " (Stiles) . In one case in Baya- mon an ovum was encountered, in every respect typical of Necator americanus, except that it was double the size, with segments pro- portionately large. The two varieties are practically the same in appearance, excepting size. They are clear and chitinous-shelled, with grayish, finely granular vitellum balls, generally from four to eight in number. If segmentation has progressed further, the speci- men is apt to be old. In such cases, the embrj^o, moving about m the shell, has often been observed but this is a change which usually occurs outside the human host, as we know of no instance where the ovum has hatched in the intestinal canal. When free embryos are seen they are generally those of strongyloides intestinalis. For a more exact differentiation of the ovum some work on zoology should 132 UNCINARIASIS IN PORTO RICO. be consulted. Suffice to say, that ova of uncinaria are not generally bile-stained but clear, whereas those of the commonly associated intes- tinal parasites are of a yellow to a deep amber or brown color. TECHNIC or MICEOSOOPIC EXAMINATIONS. A bit of feces the size of a match head is removed with a toothpick and placed on a glass slide. Upon this is placed a thick cover glaps and compressed so as to give a clear center to the specimen. In manipulating the cover glass, rubber fingercots are desirable in case of accident. The addition of water is to be deprecated and should be used only when absolutely needful to secure a spread, as it obscures the field by a fine precipitate, and delays results. This specimen is best examined under a one-third or two-thirds objective, and a No. 4 ocular. Some prefer the one-sixth, but here again valuable time is lost and the field is not so clear nor so large. Too much light must not be employed as the delicate ovum will be passed over. The thin- ner parts of the spread should be first examined. Generally here in Porto Eico, from one to two minutes sufficed for the entire proceed- ing at the first examination, but in cases where more than one speci- men must be prepared, the use of the mechanical stage is invaluable. When this procedure gives negative results in a suspicious case, the feces should be sedimented, when a still greater surety may be secured. We have used the centrifuge with good results. Finally, failing in all else, the patient should be given a dose of the anthelmintic. If the feces are washed and placed in a flat dish with water, the characteristic worms may be found. All feces passed within 12 hours of the last purge should be examined. This is really the best procedure in absence of ova and, in most cases, is entirely justifiable. It is important to remember that if a purge is not given after the anthelmintic, no evacuation of the bowels may occur in time to find the worms, for in 12 hours they may be digested in the intes- tinal canal, and as a consequence not found in the feces. Thus the lack of a microscope will not excuse the withholding of appropriate treatment, for treatment is harmless and the worms are visible to the naked eye. Quinine is administered on flimsier evidence than that presented by the anemic jibaro of Porto Eico. The opportunity is here seized to emphatically recommend that such treatment should never proceed from anyone but a doctor of medicine. Among those anemics not liable to have been infected by uncmarise microscopic examinations should always be made. We con- sider the clinical picture as seen here very suggestive, but we do not forget that cases of profound anemia from other causes will make such a diagnosis as uncinariasis precarious. Moreover, there are con- comitant diseases which may keep up severe anemia. Still further, we may expel all parasites and leave organic diseases of heart, liver^ and blood-making organs (the result of previous infections) to work out a fatal effect. The suggestive clinical features of uncinariasis are: History of one or more attacks of mazamorra, remembering that the mazamorra of the better classes is not always the mazamorra of the jibaro- pallor, using the conjunctiva as the best guide; hemic murmur' pain in the epigastrium with large appetite and still with decided digestive disturbance ; meteorism ; lack of pronounced diarrhea ; pal- UNCINARIASIS IN PORTO RICO. 133 pitation of the heart ; dizziness ; pain in the chest without cough ; and a passive, indifferent, stupefied, or preoccupied condition of mind. For those who have the instruments but who for some reason have not examined the feces, low hemoglobin percentage, low color index, and, in certain cases, presence of eosinophilia, make, with the clinical symptoms, a still more suggestive picture. In brief, uncinariasis has been defined as a profound anemia without apparent cause. We should be inclined to add that, in so far as Porto Eico is concerned, all anemias in which sufficient cause can not be found, should be sub- jected to some test to determine the presence or absence of uncinaria. As to diseases with which uncinariasis is confounded, we will only refer to the more prominent ones with which a physician in this island will have to deal. MALARIA. Malaria can be most accurately diagnosed by the microscopic ex- amination of the blood. The absence of the parasites from the circu- lating blood in one examination does not preclude the possibility of the presence of this micro-organism in the internal organs, but once found, the evidence is conclusive. Generally speaking, malaria is not a very common disease in Porto Eico, but in certain localities in the island, as Salinas, it certainly is. There are few persons who will not say that they have at some time had " malaria," but it is a popu- lar diagnosis for fever in any form. Indigestion, autointoxication, enteritis, " colds," typhoid fever, filiariasis, etc., are often embraced in this all-sufficient word. Malarial cachexia is really rare. This is a condition which in the south of the United States used to be almost universally confused with uncinariasis and other diseases. TDBEKCTJLOSIS. In its incipient stage, where diagnosis is most important, the microscope is almost indispensable, unless we are peculiarly gifted in physical diagnosis. But anemia in incipient phthisis is oftener absent than present, although pallor is frequent. Only when a cavity exists is it that marked anemia from tuberculosis may be expected, and this does not always occur. Syphilis very frequently produces extreme anemia in the second- ary stage and should be carefully looked out for. Diarrheal diseases and dysentery, when chronic, often produce considerable anemia, sometimes severe. PERNICIOUS ANEMIA. This is a very rare disease ; none of us has ever seen a case in Porto Eico. The high color index, with preponderance of megaloblasts over normoblasts, should be sufficient to exclude it. PSEUDO-ANEMIA. We were visited by large numbers of persons in the better walks of life who desired treatment for " anemia " because they were pale. In many it was nothing more than the normal complexion of persons lining in the south of the continent; in others the lips were pallid 134 UNCINARIASIS IN POBTO RICO. and symptoms of neurasthenia were present. In none of these was anemia found if 85 per cent is to be considered the lower limit of normal hemoglobin, according to the Von Fleischl apparatus. Most of them had over 100 per cent. On the ground of this complexion and occasional pallor of lips, which is usually transitory, we often hear that " everybody " in Porto Rico is anemic. Persons from tem- perate zones frequently note a. loss of ruddy color, to a certain extent, after a few years' residence here (or much less) but many never lose their color. Those who do become pallid say they are " nervous and run down," and we are inclined to view this phenomenon as more nervous than organic. / Stengel says: It is very well known that certain individuals of the same family present marked pallor without exhibiting evidence of anemia in a clinical way or upon the most careful examination of the blood. * * * The explanation of such cases is found in the study of the general circulation. Sahli found among the causes of such "apparent anemia" reduction in the blood pressure with, conse- quent deficiency of circulation in the skin. In other cases disturbances of the vasomotor system doubtless play a part. * * * In these instances there is a sudden or gradual accumulation of blood in the interior with reduction of the amount customarily present in the skin. The consequence of this is an anemic appearance without actual anemia. In general, diseases which have been cited as productive of anemia do not so frequently produce profound anemia as is thought. Ke- ferring again to Stengel : Taking blood examinations of 100 consecutive cases of gastric, intestinal, cardiac, nervous, and pulmonary diseases in which a certain degree of pallor led to examination of the blood, I found the average percentage of hemoglobin to be 74 per cent. This is 30 per cent higher than the average hemoglobin percentage of anemics here. It is notable, also, that he considers 40 to 50 per cent a severe anemia and 50 to 75 per cent moderate. [Note. — An important addition should be made here in sprue which we have found not at all rare among the well-to-do classes. Sore mouth, the bright mental condition, and characteristic stools should lead us to consider it ; and negative examinations of the stools for uucinaria, and the fact that mazamorra is absent from the personal history should exclude uncinariasis.] Peophtlaxis. Many suggestions have been made to us, and we have reviewed a large amount of literature on this phase of our labors. Some of the plans have been already proven worthless, some of doubtful value, others not applicable to peculiar conditions existing in Porto Rico, or they have too limited an application. The experiments referred to under etiology show how useless or impracticable are all attempts at chemical disinfection. Boiling or filtering the water is not neces- sary, as the chances for infection by this agent are negligible. The coffee plantations are, in Porto Rico, the most heavily infected places, yet the ground can not be plowed or burned off. We are therefore left two points of attack, i. e., (1) prevention of soil pollution, (2) treatment of existing cases. PREVENTION OF SOIL POLLUTION. _ Instead of the infection being confined to mines, brickyards etc It IS here spread over the entire island, an area of 3,606 square miles^ trNCINABIASIS IN PORTO EICO. 135 populated by about 1,000,000 people, scattered throughout the hilly interior, often isolated many miles from town. Here they eke out a miserable existence, victims of their insidious illness which they neither know how to avoid nor cure. Remarkable, indeed, are some of the precautions they take to avoid certain diseases; for example, it is no uncommon sight to see people carrying an umbrella on a clear night to keep the dew from an injured finger. If the danger of soil pollution could be so en- grafted upon their minds, half the battle would be won. Every possible means should be used to disseminate the facts among these people. A small pamphlet written in simple, plain language should be published, and so generously and repeatedly dis- tributed throughout the island that no house should be without it. Illiterate as most of them are, they would find some one to read and discuss it, for it is to them a matter of life and death, and they know it. This pamphlet should explain the cause of their affliction ; how, by defecation upon the ground, the ova of the parasite are spread about ; how they develop under the proper conditions of tem- perature, dampness, and shade ; and how the larvae gain entrance to the human body and produce the disease. The necessity of sanitary privies should be made very clear. A suggestion of Dr. A. Stahl affords another excellent means of reaching them. It is that the teachers in the schools, especially in the country and smaller towns, should assist in the promulgation of this sanitary doctrine, not only among their pupils but wherever they can. The insular police stationed m the country districts could exert a powerful influence by authoritative counsel. We know of one, a former patient, who announced his intention of doing what he could. Indeed, it is not surprising that those who have been cured should become enthusiastic in this work. If the above propaganda be thoroughly carried out, there would be no necessity for a law requiring the construction of privies for every house. The effect, however, would be less felt in some circum- stances, and compulsion should be used if necessary to have privies, either portable or fixed, on coffee plantations, sugar plantations, pub- lic works, etc., wherever large or small bodies of workmen are con- gregated. In connection with this idea, and for the benefit of those who believe that the country peon will pay no attention to such advice, we were told that as a result of our labors in Utuado the workmen employed in road building annoyed the foremen by de- manding privies near their work. Privies may be of the simplest form, practically without cost except for a little labor. A hole in the ground surrounded by a thatch or bark lean-to is sufficient. When nearly full, it can be covered with earth, and another dug. When working in the field, the laborer is scarcely ever without his hoe or machete, which could be used for covering the excreta voided there of necessity. TREATMENT OF EXISTING CASES. Each person who harbors this parasite, whether suffering from anemia or not, is a focus of infection to others ; hence the reduction of these foci becomes a most important prophylactic measure, and it 136 UNCINARIASIS IN POETO RICO. should be emphasized that the slight cases are the most dangerous, because they often do not present themselves for tre'atment, but must be sought out. The present system of municipal aid is entirely in- adequate to accomplish the results desired, as the municipalities lack sufficient resources; some have no physician, nor even medicines. Thus, of necessity, it becomes the ihiperative duty of the insular Gov- ernment to take hold of this work with decision and enei'gy. The demand for assistance and treatment for sufferers from, this disease is already being felt in those districts where the commission has worked, and' proves the efficacy of the plan instituted. But these municipalities can not pay for necessary professional attendance, sup- ply medicines, nor even house in their small hospitals the nurnerous grave cases that exist within their boundaries. Moreover, this de- mand will soon spread through all the island, as it is already notice- able in those parts where the efforts of enthusiastic physicians are combating the disease with brilliant success, although having but limited resources. For these reasons, the commission believes that a methodic and scientific organization sustained by the Government and cooperating with the municipalities in their charitable institutions will be the most feasible plan of operation and give practical results. This organization could be confided to a commission that would establish a central station with a small portable hospital annexed, remaining a specified length of time in each district, and locating branches in suitable places, until there would be formed a complete system of dispensaries and hospitals for the exclusive treatment of this plague. Having indicated the lines along which the commission believes preventive measures should be taken, it is not within our province to discuss the question of expense nor where shall be found the necessary funds for this work. While not losing sight of the economic condition of the country, the sanitarian a!nd physician, face to face with the evil which they have to prevent and cure, should not, indeed can not, compromise to financial conditions their prophylactic ideas, founded- upon scientific facts. It remains for others to harmonize the exi- gencies of " Salux populi suprema lex," with the precarious state of the contingent of affected who constitute, in Porto Eico, 90 per cent of the rural population. As Eome was not built in a day, neither can success be rapidly attained in the elimination of this disease from Porto Kico. The measure of results will depend upon systematic and continued hard work, begun gradually and extended as rapidly as consistent with efficiency. It will require years to accomplish the perfect result, but the inter- est on the labor and money expended will not be so long delayed, as each year will return multiplied benefits in the form of lowered death rate, increased efficiency of the laborer, reduced demands upon public charities, etc. Treatment. The object of treatment is, of course, to remove the cause by expul- sion of the parasites. In many light and moderate cases this will suffice, but in old chronic cases, and in those where the disease has UNCINARIASIS IN PORTO RICO. 137 reached a severe grade, some regenerative treatment should follow the specific. There are only three drugs worthy of serious mention: thymol, male fern, and beta-naphthol. THYMOL. This was first used by Bozzolo in 1880. It is preferred to male fern in the United States and England. Sandwith says he " went through a weary apprenticeship of failing to get rid of the parasite with other drugs."' In our work the mode usually adopted in its administration was the following: In the evening, a dose of either magnesium or sodium sulphate was exhibited.. In the case of the latter, a less nauseous draft, 30 grams seemed sufficient, for to give more would be to often precipitate a too exhausting diarrhea. The object to be attained is the emptying of the bowels so that the anthelmintic will act upon an exposed intes- tinal mucous membrane. On the next day, the patient is kept in bed without food until 1 p. m., and is given 2 grams of finely powdered thymol in capsules at 8 a. m. ; at 10 a. m. this dose is repeated, and at 12 m. another purge of the salts. This was the method employed in •our outpatients, but in our hospital we have occasionally deviated from it in order to compare the efficacy of thymol with that of other drugs. We believe that the second purge is needful, because it is not desired that thymol be absorbed, and sodium or magnesium sulphate is an antidote. When a soluble sulphate arrives upon the scene, all the damage that the anthelmintic is going to do to the worm, has been done, and from that time it is proper to hurry the drug out of the intestines. For the same reason we warn against all solvents of the drug while it remains in the digestive canal. Such are alcohol, ether, glycerine, turpentine, chloroform, and oils. Nearly all our patients took their medicine in their own homes. Some undoubtedly failed to take it properly, but generally they obeyed to the letter the directions given. There were exceedingly few instances when the medicine was carried home and not taken at all. This we know from subsequent examinations of their feces and from general results of treatment. In this respect we were agreeably sur- prised, as we had been warned that our plans would be frustrated by the throwing away of the medicine. Those who constantly attended the clinic until cured or until we left often dreaded the adminis- tration of thymol on account of its accompanying purge, and some- times from the dizziness and burning of the stomach produced. This is undoubtedly one of the various reasons why 607 of the Utuado cases failed to repeat their visits until cured, apart from the long distances to be covered over mountain trails, and the time lost from their daily -occupations. Many ceased to return because they felt well after several doses. In general, however, they will take any- thine that will rid them of their anemia, no matter at what sacriface, no matter what the distance to be traversed We have frequently seen them come from barrios where they had been obliged to start out for the hospital at midnight to reach there m time for examina- tion and treatment, and many times it happened, where the crowd was too large to be handled in the morning hours, that 200 persons 138 TTNCINARIASIS IN POBTO RICO. have patiently waited from daybreak to late afternoon before receiv- ing attention. It may be asked, why was thymol preferred to other drugs said to be less dangerous? We have not shared the opinion of many as to the danger of administering thymol under a certain amount of pre- caution. The experiences of two of us in some hundreds of cases in Ponce demonstrated that its danger was greatly exaggerated and generally resulted from a solution in alcohol or oil. We came to know that thymol was an exceedingly inoffensive drug, as a result of our further acquaintance with it, for we have had no death that we can attribute to it unless it was the indirect cause of death in cases 18, 25, and 76 (p. 149) by acting unfavorably in a chronic enterocolitis. This tendency to irritate the mucous membrane is the only serious objection we have found with it, although it is perfectly well known that when absorbed it has produced death. Our practical observation is that it is not absorbed to any great ex- tent. Patients frequently volunteered the information that they had iio effect from the purge and some remained even two and three days before a movement of the bowels resulted. Absolutely no symptoms of intoxication were seen in such persons, and now and then they failed to show ova thereafter in the stools. In spite of solemn warn- ings given each and every one, at times they confessed to having taken " a swallow " of rum on feeling dizzy from the drug, yet no cases of poisoning occurred, although we had one with quite severe symptoms of collapse. It was sometimes given to pregnant women to save life. Of the 11 cases of pregnancy in which it was so admin- istered, one was probably in the second month, one in the third, six in the fifth, three in the sixth. Two women in the fifth month aborted, but one did so six days after thymol was given, and her con- dition was so serious from uncinariasis and the time so long after its administration that it is not believed that she aborted as a result of the drug. In view,, however, of the other abortion, possibly due to thymol, it should not be used unless it is seen that more risk is con- tracted by withholding than by giving it. Several women were re- fused treatment on this account. On several occasions nursing mothers were given thymol without bad effect to either mother or child and without serious diminution in the secretion of milk. One case, in particular, is worthy of remark: The woman was ghastly pale and struggling to nurse a puny baby a month old, with a daily decreasmg secretion of milk. The child was crying with hunger and was given a little modified milk the day on which the mother was given a full dose of thymol. It was placed at breast on the night of the same day. After a series of such doses of thymol both mother and baby became fat, of good color, and perfectly well. The effect on the milk was remarkably prompt, causing it to become very abundant. One patient repeatedly vomited thymol when given with salts but held It down on changing the purge to podophyllin. In several instances the thymol was taken in water without effecting emesis according to the patients' statements. Manson states that at times thymol gives rise to a very unpleasant form of intoxication with ver- tigo, excitement, etc., and the urine may become dark as in carbolic acid poisoning, reporting Thomhill's case of fatal collapse due to UNCINARIASIS IN PORTO RICO. 139 administering liquor at the time of the second dose of thymol. Scheube adds to Hanson's list fall of temperature, retardation of the pulse and respiration, burning in the stomach and esophagus, and, finally, delirium and collapse. A tendency to vomit is seen at times. Avhich may bring the drug in contact with the laryngeal mucous membrane and cause strangling. Boycott and Haldane, who used, in the Cornwall endemic, three successive doses of thymol, in capsule or emulsion, at intervals of two hours, state, in regard to the effects of thymol, " no unpleasant effects were observed. Patients were all treated at home so results could not be so well observed as at the hospital." The same remark could be made of the work here although some did have dizziness, burning of the stomach, and a temporary increase in debility. The majority, however, had no symptoms from the drug. Excitement, burning in the urethra, and olive green or smoky urine were not observed.^ Nevertheless, as much care as possible was exer- cised and very ill patients were admitted to hospital and given pre- paratory treatment. Had it not been for this, our experiences in the use of this drug might have been much less fortunate. Unfavorable to the administration of thymol are, great debility, very old age, pregnancy, advanced cardiac or other organic disease, a tendency to vomit, anasarca, chronic diarrheas, and dysentery. Sandwith says : " Warned by the death of at least one of my patients I have always administered to feeble men 25 grams of brandy with each 2 grams of thymol." We are not in accord with this, as we believe that whisky or brandy hypodermically, or nitroglycerin, strychnine, and digi- talin are preferable for reasons stated above, though we feel sure that many of our patients neglected to observe our warning in regard to rum with thymol. In fact, our principle has been to stimulate and support all very advanced cases before the exhibition of thymol. The effect of a full dose on edematous persons is generally marked. Usually the next day the edema is very much increased and may prove fatal from edema of the brain or lungs, not to speak of the dangerous increase of an already extreme ascites. We have referred to the tendency to aggravate a case of dysentery or diarrhea. A most important detail in the treatment is the purge. It is believed that too powerful purges will kill a debilitated subject more quickly than thymol. ■,. , , ^ The dose of thvmol was graduated accordmg to age. but more especially according to the degree of debility, etc ,_ of the patient Thus it happened that many times a very weak subject took 1 or 2 erams the first visit and the full dose thereafter, when his condition had been improved from the number of worms expelled. We do not agree with some English writers, who state that large doses are always needed. They are preferable, but small doses by expelling a goodly number of parasites, will often tide over a patient who might not resist a full dose. We have practically proven this by inspection of feces after small doses of thymol and observing the happy results obtained therefrom. One thing seems certain, as the total amount must reach the intestine within the space of two hours (for we are to Eu parasites, not merely sicken them), the blow must f all heavily. 1 Olive green urine was later observed in Aibonito, 1905. 140 TTNCIK-AMASIS IN PORTO BIOO. Three decigrams' every three or four hours is not a proper use of thymol. We have given 0.5 gram to little children under 5 years with excellent results. In general, between 5 and 10 years, 1 gram is sufficient; between 10 and 15, 2 grams; between 15 and 20, 3 grams; between 20 and 60, 4 grams ; above 60, 2 or 3 grams is generally all that we should give. . . .o« A tabulated chart showing the doses employed by us m 4,482 cases, arra;nged accordiiig to the age of the patient and the number of times a specific do§6 was given, is here seen. It should be remembered that the total number of persons is more than 4,482, for it often happened that one received different amounts at different times. ONE-SALr GRAM THYMOL. Times. Total persons. Total Age. 1 2 3 4 times. 20, 3 2 1 26 36 ONE GRAM THYMOL. Age. Times. Total persons. Total 1 2 3 4 5 6 7 S times. Under 5 ,4 83 69 4 2 109 31 1 1 70 31 2 40 19 9 332 157 5 19 5 to 9.... 16 7 8 6 1 844 10 to 14 336 15 to 59 6 Total. 160 143 102 61 22 8 6 1 503 1,204 TWO GRAMS THYMOL. Age. Times. Total per- sons. Total 1 2 3 , 4 5 6 7 8 9 10 11 12 times. 6to9 33 132 40 36 216 16 27 139 8 9 69 9 4 31 3 11 1 ■"e" 3 3 116 607 74 284 10 to 14 1,544 OverU 138 Total. 205 2S8> 174 87 35 is 6 6 796 1,966 THREE GRAMS THYMOL. Age. Times. Total persons. Total 1 2 3 4 5 6 7 8 9 10 11 12 times. Uridferlo 2' 75 203 14 2 244 561 62 10tol4 -84 171 19 42 107 10 8 13 16 6 8 1 3 6 1 581 1,242 16toS9 1 1 * Over 60 Total fe94 274 159 77 29 15 8 1 1 1 859 1,945 XJNCINABIASIS IN POETO BICO. 4'OUR GRAMS THYMOL. 141 Age. Times. Total persons. Total times. 1 2 3 4 5 6 7 8 9 10 u 12 1 7 ' 69 391 73 11 2 Under'lO. . . . 10 to 14 ".••■■ 15 to 19 1 16 338 2,012 205 30 5 6 113 560 53 7 1 3 77 479 39 4 2 28 898 20 to 49 ! 48 344 21 4 18 136 12 2 7 65 3 4 21 2 1 1 16 1 1 50to69 1 1 5,673 Over 60 Age not given '..'.'.'.'.'.'. 1 80 10 Total 554 740 604 417 167 75 28 18 2 1 1 2,607 7,179 Of 185 of Sandwith's cases, 954-per cent were cured in five or less closes, about the same result as we have secured There IS no complete record of the number of doses given in Bava- ™^^ ^*,7® ^^^® calculated that about 2,000 doses were given. ^ ■ r I -.VcH^ *^^^^^ ^^^^ ^^^ number of times thymol was admin- istered in 4,482 cases, general series, Utuado. A details the number o± times It was used; B the number of times it was needed to expel all uncinanse; C the number of times it was given without effecting dislodgment of all uncinarise : ^ Number ol doses. A. B. C. Per- sons. Times- Per- sons. Times. Per- sons. Tim«s. 1 935 1,334 1,011 667 288 143 67 29 6 2 1 1 8 936 2,668 3,033 2,668 1,440 858 399 232 64 20 11 12 1,518 1,166 518 247 104 47 19 6 3 1 1 1,518 2,332 1,554 988 520 282 133 48 27 10 11 363 190 133 88 44 22 7 6 2 2 353 3 i 4 352 220 132 49 40 18 5 6 7 8 9 10 11 12 Thymol not given Total 4,482 12,330 3,630 7,423 844 1 943 Following is a table showing the days needful to cure, arranged in groups of 10, and the number of persons classified according to the severity of the disease. Days. SUght. Moderate. Marked. Total. 1 to 9 367 428 168 52 28 12 10 3 1 2 2 217 239 110 60 41 23 21 3 2 54 75 88 68 34 26 16 2 369 10 to 19 647 20 to 29 461 30 to 39 237 40 to 49 176 SO to 59 121 67 49 80 to 8Q 20 90 to 99 4- 1,071 716 364 2,161 142 UNCINARIASIS IN POBTO E.IOO. As to the number of days necessary to cure, it is needful to classify our cases according to degree of severity of the disease. In general, the time to cure depends upon the latter factor. Leichtenstern and German writers of later date believe that the recently infected are the most difficult to cure from the small size of the worm and the readiness with which it is covered by mucus and folds of mucous membrane. We hardly believe that such a generality obtained. Old infections were to us very difficult to eradicate, but we quite agree that very early infections are still more so. We know of many cases where thymol given previous to maturity of worms failed to expel them. This may be due to encystation of the larvae in the submucosa. It was discovered late in our work that, whether from suspended ovulation, the result of sickening of the worm, or from whatever cause, ova disappeared from the feces to appear again in two or three weeks, or even longer. In some cases this was certainly due to subse- quent infections. In view of these facts, we came to give thymol, even in absence of ova, when there was persistently low hemoglobin and continuance of symptoms. Many cases of failure to cure are thus due to a suspension of anthelmintic treatment in absence of ova from the stools, for the resumption of it caused the hemoglobin to rise with extraordinary rapidity. From this it may be deduced that about 10 per cent of our cases might have reached a higher hemoglobin percent- age. With this end in view 3,964 doses of thymol were administered after all ova had disappeared. With the exceptions noted, thymol was given once a week as long as ova remained in the feces ; 97.8+ per cent of those who expelled all their uncinarise received thymol five times or less ; 41.8+ per cent expelled all in one dose; 32.1-4- per cent in two doses; 14.2+ per cent in three doses; 6.8+ per cent in four doses; and 2.8+ per cent in five doses. Of 4,474 cases (excluding special cases) which received thy-- mol, 81.1+ per cent expelled all uncinarise, but, subtracting 507 who never returned or ceased to return after two or more doses, this per- centage rises to 91.5+. This is to say that 68.6+ per cent were cured in less than 30 days ; but about two-thirds of these were light cases; 93.4+ per cent of the moderate cases averaged two months to cure, but 68.4+ per cent of these only one month ; 15+ per cent of the marked cases required less than 30 days; 63+ per cent from 30 to 59 days, and 21+ per cent from 60 to 100 days. We do not believe it necessary nor justifiable to administer more than 4 grams of thymol at a time nor to repeat this oftener than once a week, on account of the tendency of thymol in some persons to irri- tate the mucous membrane of the bowel. MALE FERN. The official " oleoresina aspidii " (United States Pharmacopoeia) is a violent poison in overdose, according to H. C. Wood (Therapeutics Its Principles and Practice, 11th ed., 1900), "producing excessive vomitmg and purging, with general weakness, tremors, and cramps in the extremities, increased reflexes, amaurosis, and, finally, in some cases, violent tetanic convulsions, with opisthotonos, stupor deepening into coma, and collapse. Icterus is sometimes apparent * * * g drachms (22.2 grams) has several times proved fatal in the adult. Disturbances of the special senses is a not infrequent symptom in UNCINARIASIS IN PORTO RICO I43 tation nTfV> ^"'^^^'.*^,'^ !^tal result is partly due to the violent irri- tation ot the gastrointestinal tract and is partly the result nfnn influence upon the nervous system. ^ ^ ^ °^ ^"^ Ihese symptoms are rarely observed. It is a remedv nf ar-^.t antiquity as one of the best anthelmintics known forTapewormTd late y, foundto be very efficacious in uncinariasis; k is Smost^xch, sively used m the continent of Europe Dreferrerl wl^l u bought less dangerous and more effectJ^e' tC th;!? It s a vlrv frequently adulterated drug, is variable in stre^n^lh, much more costly than thymol and liable to deteriorate, especially Tn this cli mate. We can not believe it less dangerous than ?hymal, and it i^ SpSce^tirir^'^^ ^ *^^^^' '' '^^^ --^ -' f'om'oufsh^oit ol'of Tollln'i.'^'T^^''7ir" -"^ ^^j^ "^"^ ^y 0-13 «f <^^i°^«l -d u.Urf ot podophylhn. The following day 8 grams of the ethereal extract was exhibited, and at noon a small dSse^f salts, if needed m some cases where parasites were resistant to thymol this gave good results, and in others it did not. It seems to cause more dizzi- ness and nausea, and patients generally complained that they felt sicker and weaker after it than after thymol. These effects were certainly corroborated by their appearance. Undoubtedly both dru<^s are very efficacious, and a choice between them will always depend upon the physician's personal preference. It is evident, however, to us that the extract of male fern is inferior to thymol here in Porto Kico tor reasons given, and we further consider that its use should be restricted to those cases in which thymol fails to have a satisfac- torj^ ettect. A change from thymol to male fern, or vice versa, seems at times very effective.^ BETANAPHTHOL. We have expelled over a thousand uncinarise by a single dose, and have obtained several cures from its use, but we have not had extended experience with it, owing to the fact that we had concluded our field work when Bentley's important article fell into our hands. He states (Indian Medical Gazette, Calcutta, Apr., 1904, vol. 29, No. 4) that he abandoned thymol two years ago to use betanaphthol, and has used it in several thousand cases with excellent results. It is administered just as is thymol, save that 2 grams are employed instead of 4. RESULT or TREATMENT. The following is a classification of the results obtained in Bayamon : Persons. Cured 52 Practically cured 91 Improved 22S Unimproved 52 Kesult not recorded .522 Died 2 Total 047 iThe real nhorteomings of male fern were not observed until the work of counting the worms expelled by each dose was taken up. See second report. 144 UNCINARIASIS IN POETO RICO. In Utuado 4,482 persons composed a general series, in which only cardinal points were noted. The following table gives the result^ according to the clinical type: Result. Slight. Moderate. Marked. Total. 1,071 13 61 1 2 35 38 716 51 170 8 2 55 59 364 209 1,264 25 18 134 186 2,151 273 1,495 34 Died 22 224 Ceased to return . .... 283 Total 1,221 1,061 2,200 4,482 From the 61 special cases we have extracted the following sum- mary : Result. Slight. Moderate. Marked. Total. Cured 1 1 1 40 12 3 3 42 Practically cured 13 3 Died v.. .. 3 Total 1 2 68 61 Grand total of 5,490 cases : Cured 2,244 Practically cured 377 Improved 1, 727 Result not recorded 522 Never returned 224 Ceased to return 283 Unimproved 86 Died 27 5,490 One death has been excluded from this list because it does not belong to the commission's field work. " Cured " should be taken to mean disappearance of all symptoms of the disease, with absence of ova from the stools, and a hemoglobin percentage of 85 (v. Fleischl apparatus). This class forms 40.8+ per cent of the whole number. The percentage of cured in Utuado alone was 48+. " Practically cured " has the same meaning, with the exception that the percentage of hemoglobin lies between 70 and 86. These form 6.8+ per cent of the total. Added to the number of cured, the percentage would be 47.6+ of the entire number and 54+ for the Utuado cases. " Im- proved " form 31.4+ per cent of the total; in Utuado they formed 32+ per cent of those cases. Thus the percentage of cured, practi- cally cured, and improved to the whole number is 79. In Utuado these form 87+ per cent of all cases treated there. " Unimproved " form 1.5+ per cent of the total, and the " Deaths " 0.5— per cent. Those who never returned after the first dose, or who ceased to return after attendmg a short while, form 18+ per cent of the total in such persons we had no opportunity to complete the treatment. ihe majority of cases were from two weeks to two months under treatment, excluding the last-named class. The difference between the results obtamed m Baya^^on and those of the Utuado series lies UiNLilJNAJilAISIS IN POKTO RICO. 145 mPn?^ T^'n^J^* ^^^f^ the former exceeded three weeks of treat- ment. In other words, all but 53 of these cases were incomiDlete cured "ni 5^ i^«^«. "«t«,4 as "Improved" and "Practically nnri Itf ^7 ^^^^' discounting those who have become reinfected, and taking into account the 622 of whom there is no record. Thus the diiference lies chiefly in the length of our stay at each place-in Bayamon but 7 weeks against 14 in Utuado. ^ We have accurate data concerning the number of visits paid us bv our patients only in the Utuado cafes : ^ ^ One visit Two visits Tliree visits... Four visits Five visits Six visits , Seven visits Eight visits Nine visits Ten visits Eleven visits . . Twelve visits.. Thirteen visits. Fourteen visits Total Number or persons. 331 664 965 861 667 446 265 166 84 29 11 1 2 4,482 Number of times. 331 1,328 2,865 3,444 3.335 2,676 1,855 1,328 756 290 121 12 28 18, 369 The percentages of hemoglobin of the cured, practically cured, and 578 of the improved in the Utuado general series may be detailed as follows (special cases are excluded as they appear elsewhere) : Cured : Persons. Between 85 and 89 726 Between 90 and 94 411 Between 95 and 99 258 Between 100 and 109 426 Over 110 330 Total 2,151 Practically cured : 53 per cent' 1 70 per cent 57 71 per cent 8 72 per cent 20 73 per cent 21 74 per cent 13 75 per cent 41 76 per cent IT 77 per cent 7 78 per cent 17 79 per cent 6 80 per cent 28 81 per cent ^ 82 per cent 10 83 per cent ^ Not given 1° Total 273 1 This patient, though only possessing 53 per cent Hb., had good color and said he felt completely cured. 77759°— S, Poc. 808, 61-^ 10 146 UNCINARIASIS IN PORTO RIOO. Improved (578 cases) : Persons. Between 20 and 29 per cent 3 Between 30 and 39 per cent 38 Between 40 and 44 per cent 36 Between 45 and 49 per cent 55 Between 50 and 54 per cent ^__ 92 Between 55 and 59 per cent 106 Between 60 and 64 per cent 141 Between 65 and 69 per cent 107 Total -, 578 Classification of the other cases in this series according to the clinical type is as follows : Never returned : Persons. Slight cases 35 Moderate cases 55 Marked cases 134 Total 224 Ceased to return : Slight cases 38 Moderate cases 59 Marlied cases 186 Total 283 Died: Slight cases 2 Moderate cases 2 Marked cases: 18 Total 22 The unimproved and 917 of the improved are not classified. Although the actual results are here chronicled, no accurate con- ception can be formed of the effect of expulsion of all uncinarise upon the patient sick of uncinariasis unless the progress of conva- lescence be followed in person. Children in the extreme grades of the disease, without life enough to take interest in things that belong to childhood, often rapidly gain in color and spirits to such an extent as to change them entirely in physique and character. This is, of course, by no means confined to children. A curious effect of the first dose of thymol is frequently seen in that, although the anemia usually remains as profound as ever, the patient looks and feels better. This is the chief reason why our large clinic was so regular in its attend- ance, notwithstanding the inconvenience entailed. In older persons, who for a long time have been anemic and debili- tated by many other concomitant conditions, a slow convalescence is frequently seen, due to a loss of power of regeneration of the blood ; but as frequently we see an apparently hopeless case, turned away after six or seven doses of an anthelmintic in the belief that a return to health is impossible, appear six months later, healthy and with normal blood. There is a very decided tendency to slow recovery when food is especially poor, and a small percentage of our cases who were not cured fall in this group. Another element to be considered IS the presence of even a few worms, so few, perhaps, that ova in the feces are not found. UNCINARIASIS IN PORTO EICO. 147 One of the most surprising results appeared when a division of the cured cases was made into those who took iron and those who did not, viz: Iron in relation to days to cure (groups of 10), and grade. Days. Slight. Moderate. Marked. Total. 1-9 15 74 30 26 11 10 3 1 2 8 106 83 SO 35 22 20 2 2 24 66 73 50 33 24 16 2 25 204 169 10-19 20-29 30-39 40-49 50-59 96 60-69 70-79 47 80-89 90-99 Total 172 326 280 778 No iron in relation to days to cure (groups of 10), and grade Days. Slight. Moderate. Marked. Total. 1-9 367 413 94 22 2 1 2 209 133 27 10 6 1 1 1 30 19 15 18 1 1 369 10-19 622 20-29 . . 257 30-39 68 40-49 27 60-59 . 25 60-69 2 70-79 2 gO-89 1 90-99 Total 899 390 84 1,373 These results should be considered in the light of the following explanation. Iron was not given to patients at their first visits, except in very severe cases, and if they progressed well it was often- times never given. When progress was slow iron was given m the form of Blaud's, Vallet's, or Blancard's pills, 3 to 6 daily. It will be noticed that slight cases readily recover without iron, and here the difference in the tables is more marked, while there is less difference among the marked cases in proportion to their number In other words, the more resistant cases of all grades received iron but even then did not generally recover as rapidly as those less rebellious without, for while ferruginous preparations seem to act readily m some instances, still, in the majority its effect was not very marked. The rapidity of cure is due, apparently, more to the personal equa- tion ome patient and the Rapidity with which the Parasites are ex- pelled than to the amount of reconstructive treatment. J^us it is quite difficult to accurately judge the comparative ^^j^^^ of differen iron preparations, yet it was noticed, even by some patients, that Blaud's pills gave more rapid results. . In a series of 22 cases selected to represent approximately the varfous ^ades of the disease and all ages of Pf ;-^' XX'^bl" e five treatment of any kind was given, so as to Pai;ti^7^3^f;";^^^ the effect of expulsion of the uncmari^ alone Th«„5!^^"%^^\"f ! Cured 7 (31.81+ per cent) ; practically cured, 2 (9.09+ per cent; , 148 UNCINABIASIS IN PORTO EIGO. improved, 10 (45.45+ per cent) ; unimproved, 3 (13.63+ per cent). Their average of hemoglobin percentage on entrance was 44.59+; final average, 64.67+. These percentages compare very favorably with the general results. It is the testimony of many patients and physicians here that iron without expulsion of uncinarise, is of little benefit and oftentimes of positive harm, inciting diarrhea. This may depend somewhat upon the form given. Iron, therefore, while generally advantageous, especially in severe cases, has a much less important role in the therapeutics of this dis- ease than anthelmintics. BAYAMON. Case 1. — J. M. Admitted, March 6 ; ex-soldier in Spanish Army. Native of Province of Galicia, Spain. Has lived in Porto Kico 17 years. First fell ill while working on a sugar plantation near Bayamon, and his first trouble was a sharp attack of mazamorra. His employer paid him well, and his food was always excellent, with plenty of meat, etc. Typical severe case of chronic uncinariasis, with general edema, atrophy of skin, and advanced nervous and circulatory symptoms. A curious symptom was night blindness, which disappeared under treatment. March 6 : Hb., 27 per cent ; reds, 3,728,000 ; whites, 8,400 ; eosinophiles, 7 per cent. On April 20 he had Hb. 81 per cent and eosinophiles 28.8 per cent. He became our most trusted and efficient nurse and left us, a powerful ruddy man, with 98 per cent Hb. Case 4. — A. S. Municipal hospital. Age, 73 ; about moribund, with tremen- dous edema of whole body; pulse, 150; dilated heart; all but unconscious. Hemoglobin, 16 per cent; eosinophiles, 2.5 per cent. We were told that the man had been for some time under stimulative treatment, and concluded that the only chance he had was to administer thymol. One gram was given with hypodermic stimulation. He died on the 12th, five days afterwards, but with- out having shown the slightest symptom of intoxication from thymol. Case 8. — J. O. Admitted, March 8. Age, 60; female. Was a celebrity in town as the "swollen woman." Usual symptoms. Hb., 65 per cent- eosino- philes, 43.5 per cent. On the 21st of March Hb. was 103 per cent. Perfectly well. Case 16.— J. T. Admitted, March 11. Age, 30 ; bookkeeper of a well-known company in San Juan; a man of education and refinement; lives well- used to be very ruddy and well. In October, 1902, went hunting, and in kneeling bare-kneed in the mud to take aim at a bird contracted mazamorra The peon who accompanied him also contracted the Infection. He said the itching began very soon after infection and went through all the typical changes from papule to pustule. He began to get pallid in January, 1903. Tried many iron tonics ■ ate great quantities of roast beef; took patented beef juices, and all failing utterly his physician advised a European trip, which he made. He returned to the island practically no better and came to us, presenting a picture of severe and what promised to be a fatal chronic uncinariasis. There was no compli- cation of any sort, and his case was thoroughly studied. An enormous number ot ova of uncmana was found in his stools. On March 11 his Hb was 24 per cent, eosinophiles 8 per cent; March 18, Hb. 28 per cent, . eosinophiles 10 per cent; April 1, PIb. 54 per cent. On April 30 he was in apparent good health and color. On October 7 he came to our office, ruddy, strong, and without a sign of his previous disease. Hb., 115 per cent ; eosinophiles, 17 per cent. Synopsis of all Deaths. r.J^^? r'^i^'''^^ °^ *^®'^*^^ occurred in our hospital, but to get a complete list ^nttip rt1«tHn<.''S>°?Tf °T Pft^'^.^ts, the official copies of death certificates for the entire district of Utuado, kept m the registrar's office in that city and covering the period of our sojourn there, was compared with an indexed list of our patients, and a few more were found. This was not done for the Bayamon cases, but their lesser number made it possible to keep track of them Of 5,500 cases of anemia, 5,490 of which were due to uncinariasis wp in^t 97 patients. Thirteen of these died of uncinariasis, pure and Smple! and of them trNCllTAIllASlS IN PORTO RICO. 149 5 never received an anthelmintic. Nine died of other diseases or of complica- tions, with uncinariasis as a more or less potent contributing factor. Two of these died of direct sequelae of uncinariasis. Five died of diseases In which uncinariasis was not, even remotely, a contributing cause. Thus our total mortality from all diseases was 0.49 per cent. Our mortality for uncinariasis alone was 0.23 per cent, and including all those who died from uncinariasis alone or as a concurrent cause, 0.41 per cent. BAYAMON. Case li- — A. S. In municipal hospital for some time previous to March, 1904. Arrived In last stages of chronic uncinariasis with tremendous anasarca. Had received stimulants, etc., in hope of building up his strength preparatory to taking anthelmintic, but without success. Hemoglobin 16 per cent, E. 2.5 per cent, P. 91 per cent, S. L. 5 per cent, L. L. 1.5 per cent. In view of the fact that the patient's only chance for recovery was specific treatment, 1 gram of thymol was administered, preceded and followed by magnesium sulphate. No bad efCects of the drug were observed, but the patient steadily sank, and, on March 12, succumbed from exhaustion. Cause of death : Chronic uncinariasis, extreme grade. Case 307.-^J. C. Aged 10, extremely emaciated but not very anemic (Hb. 65 per cent). He stated that he walked from Ciales with some people who aban- doned him on the way. Was very weak. Deglutition very difficult owmg to stricture of the esophagus. Infection by uncinariasis recent and severe. One day of concentrated food and stimulation. Two grams of thymol with mag- nesium sulphate was administered on second day in hope of riddmg him ot at least some of his uncinaria;, but he died of exhaustion on the third day. Cause of death : Stricture of the esophagus. Contributing cause : Privation and acute uncinariasis. UTTJADO. Cases 17, 33, and 42 are given in full under the account of special cases, ^^I^eis'-G. C. Admitted to hospital May 11; male; age, 40 Stools were verv liauid and contained much mucus but no blood. History of severe mter- nTtLnt'torrSea."Many ova of uncinaria and ascaris. Was P-Joundly anemic nnd emaciated but had no edema. Was extremely weak. Hb., 19 per cent. GivenT40 on May 13. He seemed much better in the next two days, but on niJTfith he was attacked by a furious diarrhea, with much weakness Given SLm*and%Tsmum'afd\/podermic stimulation by strychnine and digitalm. '''^^T^^f^^'^^^^^^^^^ --«■ — ''-- -j?r iniridmitted to ^-ital^-y ll; male; a^..^a5, mark^ca^^^ colitis. „ TH 1^ qf; -„mi-« of aire- many ova of uncinaria. Was Case 55.— J. S. Female, ^5 yeais of age, many extreme brought to hospital in a l^ammo^^^f ^^^^^^^.tere^^^ but she rcumbel SnlTou? s t^T^lr^Z. ^Te.^^ not reSve an anthelmintic. Ta^eff "death: Chronic ^amsise.^^^^^^^^^ ^^^^ ^^^^^^ ^^ Case 76.— L. M. Admitted to Ho^P'^^i. ^^^^ j^^' but was anemic and had ova be suffering more from old age than anything else but was ^^^ ^^^^^^ ^^ of uncinaria in his stools, which ^^^re dysentenc w irrigations of the was given 2-30. From that time on he recened opm ^^^^ ^^ ^Ta1r]^«P.-N.M..AdrnittedtocHnicasoi^^^^^^ rce^^^mo^r^?ub\fcu^osTs^%W^2To U never returned; dymg the 150 tTNCINAEIASIS IK POBTO EICO. Gase 182. — G. O. Admitted May 13 to hospital. Age, 58; male. Almost moribund with dilated heart and marked anasarca. Had some anemia and many ova of uncinaria in stools. For two days he received hypodermic injec- tions of strychnine and digitalis, and, on May 15, 2-15. From this time until the 19th the injections were continued. On the latter date, the hypodermic medication was supplanted by tincture of nux vomica and digitalis. Opium was administered to control a short attack of diarrhea. Adrenalin was added to the other cardiac remedies, but in spite of all we were obliged to perform para- centesis to relieve him of the pressure caused by the extreme ascites. May 29 he felt much better and 4-20 was administered. June 6 the ascites was worse than ever. No albumin in urine. Paracentesis repeated and 10 liters of fluid removed. June 15 the anemia was much improved. He had 65 per cent of hemoglobin, but the heart signs were worse. Died July 16, despite all effort to establish compensation of the heart. Cause of death : Dilatation of the heart due to organic lesions secondary to chronic uncinariasis, marked grade. Case 183. — P. A. Admitted to hospital, May 13. Age, 70; female. Was brought in hammock. Was in last stages of chronic valvular disease of heart, a probable sequela of chronic uncinariasis judging from her previous history. Ova of uncinaria found in stools. Hb. 69 per cent. Treatment: Hypodermic stimulation by means of strychnine and digitalin. No anthelmintic adminis- tered. Died May 20. Cause of death : Mitral insufficiency and dilatation of heart. Case ifOS. — I. H. Admitted to hospital, May 21. Age, 55 ; male. Marked case. May 23 given 3-25. He was sent home May 25, at his own request. June 24 his card was brought by his daughter who stated that her father was very sick ; that he was very constipated and vomited all he ate. On July 9 his daugher brought her father's card, saying that he was very weak and had profuse diar- rhea. He was sent opium and astringents, but died about the middle of the month. Cause of death : Chronic uncinarias, severe grade. Case JtOT.—B. C. Admitted to hospital. May 23. Age 25; female. Light case of uncinariasis but had extreme grade of pulmonary tuberculosis with cavities in both lungs. Ova of uncinaria found in stools. May 24, 2-20. June 4, few ova of uncinaria. Given 4U25. Died at home in latter part of June. Cause of death : Pulmonary tuberculosis. Case 536. — M. A. Admitted to clinic as out-patient. May 29. Age, 15 ; female. Had marked anemia ; many ova of uncinaria ; given 2-25. June 14, some ova uncinaria; given 2-25. June 26, no ova uncinaria; given Blaud's pills. July 4, brought in hammock to the hospital. Was very edematous. Given 3-10 with 0.02 podophyllin, as ova of uncinaria were found. Returned home several days later. July 24, specimen of feces brought by father who said that she was very ill with edema, great weakness, and some diarrhea. Blaud's pills were repeated. August 13, father brought card saying that she died on the 26th of July. Cause of death : Chronic uncinariasis, extreme grade. Case 606.— -M. J. Admitted to hospital. May 22. Age, 13, male. Was brought ni a hammock, moribund, semiconscious, and tremendously swollen He pre- sented symptoms of effus'ion of serum into the ventricles of the brain Became unconscious, passing feces and urine involuntarily. A great many ova of uncinaria were found but no anthelmintic was given. Stimulants freely administered hypodermically. Died May 25, in a comatose state Cause of death : Edema of ventricles of brain, due to chronic uncinariasis extreme grade. ' Case 791.— P. R. Admitted to hospital. May 23. Age, 42; male. Marked case. Constant pain in stomach with vomiting of blood. Many ova of uncinaria Uiven 6-60. June 1 still ova uncinaria ; given 3-30. Died June 6 Cause of death : Chronic uncinariasis, severe grade, and ulcer of stomach ca.se 895.— J. R. Admitted to clinic as out-patient, June 8. Age 14- female Moderate anemia but was a severe case of acute phthisis, with sputum loaded with tubercle bacilli. Given 2-15. Never returned. Died about the middle of July. Cause of death : Pulmonary tuberculosis. Case 1329.— J. S. Admitted to clinic as out-patient, June 19. Age 19- male- negro. Had a moderate grade of anemia but many ova of uncinaria ' fSiv^n ^30. Coming for his second visit, he fell into a stream! got very w"?.' a^d r^ UNCINAE.IASIS IN PORTO RICO. 151 turned home. As a resuU of this, contracted pneumonia, and was brought to hospital, June 27. Examination revealed consolidation of the greater part of the right lung. This extended to the other lung, and he died, July 1, in spite of appropriate treatment. Cause of death: Double lobar pneumonia. Case 1358.— F. R. Admitted to hospital, July 22. Age, 25; male. Many ova of uncinaria. Great anasarca ; profound anemia ; signs of compression of brain by efeusion of fluid into ventricles. Died, July 24. Ko anthelmintic admin- istered. Cause of death: Edema of ventricles of brain due to chronic uncinariasis, extreme grade. Case IJfOO. — J. R. C. Admitted to clinic as outpatient, June 20. Age, 25; male. Marked case. Many ova of uncinaria; given 4-30. Anemia became more profound, and he died, July 10. Cause of death : Chronic uncinariasis, extreme grade. Case 1443. — J. M. M. Admitted to clinic as outpatient, June 21. Age, 40; female. Very marked case ; great many ova of uncinaria. Died, July 3. Cause of death : Chronic uncinariasis, extreme grade. Case 2231. — R. M. Admitted to clinic as outpatient, July 2. Very extreme case ; many ova uncinaria. Given 2-10. Died, July 9. Cause of death : Chronic uncinariasis, severe grade. Case 2551. — F. P. Admitted to clinic as outpatient, July 6. Age, 20 ; male. A moderate case. Many ova uncinaria ; given 3-20. July 13, still ova unci- naria ; given 3-20, in hospital as boy said he had no home. He worked around the hospital grounds, seemingly improving steadily, but on July 20 he went to town and got hold of some spoiled .lerked beef. That afternoon he was taken ill with ptomaine poisoning, and in spite of all measures taken, died the follow- ing day. Cause of death : Ptomaine poisoning. Case 3095. — M. R. Admitted, July 11. Very marked case with great an- asarca. Given 4-25. Died at home, middle of July. Cause of death: Chronic uncinariasis. Case S4IS. — M. S. A. Admitted, July 10. Age, 30; female. Very marked case. Hb. 15 per cent. Heart dilated. Tubercular cavities in both lungs. Strychnine and digitalin given hypodermically every 3 hours. July 12, 2-10 was given. On the 16th diarrhea supervened. On the 19th many ova of unci- naria were found. 2-20 was given with .02 podophyllin. She died, July 21. Cause of death : Pulmonary tuberculosis. Contributing cause : Chronic unci- nariasis, severe grade. Case U38.—y. R. Admitted, July 23. Very severe case. Great anasarca; great debility ; profuse diarrhea. No anthelmintic administered, but stimulants and astringents given. Died, August 5. ' Cause of death : Chronic uncinariasis, extreme grade. Bibliography. We here cite only the more important works which we have read. '^'"'igOS^C^nsideraciones sobre dos cases de anemia por ankylostoma duodenal & & As soon as the central station at Aibonito could be thoroughly organized and put m good running order we turned our attention to the establishment of substations at several towns which had requested our aid. The first was opened July 15, at Lares, under the charge of UNCINARIASIS IN PORTO EICO. J 59 Dr. Francisco Sein, of that town, and from timp ta fin., ^fi opened as fast as arrangements cou?d be made to do n F M'' we had placed in operation the six substSions alt that ^JZv^^'a possible to maintain with our limited resources vnrL/fi, ^ vJ^^ requited similar on^, but unfortuLtX wTcouTd^rr^e'tS £p flf ''^'"''^'';- ^H''"^^ S"^ Sebastian asked for Ldicres alone Under these conditions four additional substations, at San Sebastian Barros, Moca, and Patillas, were established. The lattTr however' was opened so late m November that practically no work was done' m the time embraced by this report. j x" woik was aone • The physicians who were to take charge of the substations were mvited to visit he central station at the expense of the approS tion to observe the methods of working, manner of keepinfrecSrds etc thus insuring uniformity m the data obtained at^th! varTous' stations. This system of substations was somewhat of an experiment and Its success has been one of the most gratifying results of the year's work. It proves the feasibility of establishing a number of stations in various parts of the island which will wo?k in harmonv under a central direction. We acknowledge with pleasure that the credit belongs more to the directors of these stations than to the com- mission, which exercised only an administrative function toward them. Their statistics have been tabulated with those of the central station for the purpose of showing the combined results of all stations. The disease is one to which the white and mixed races are predis- posed, having always in mind, however, the possibility of encountering serious symptoms in the infected negro. We were working in parts of the island where the negro is relatively rare, with exception of two substations. Color of all patients in relation to the clinical type of uncinariasis. Type of uncinariasis. Very light... Lighit Medium Intense Very intense Unclassified. Total.. White. 946 3,061 7,135 3,034 384 101 14, 661 Mulatto. 349 1,111 1,343 427 48 02 3,340 Negro. 311 228 40 682 Not recorded. 182 Total. 1,378 4,483 8,706 3,501 440 357 18,865 Relation between the color of all patients treated and the relative number of uncinaria ova found in their stools on microscopic examination. Relative number ova uncinaria. White. Mulatto. Negro. Not recorded. Total. Great many 330 4,330 5,665 2,696 198 60 958 1,355 873 43 13 142 360 153 5 403 5,430 7,380 Few 3,722 Very few 246 173 173 Total 13,219 3,289 673 173 17,354 1,425 86 18,865 1 1 160 UNCINARIASIS IN POB.TO BICO. From the summary of Table 4 we see that 78+ per cent of 18,865 patients were white, 18+ per cent were mulattoes, and only 3+ per cent were negroes. -, -,■ j.-, Of the total number of 14,560 whites treated, excluding those m which the type of the disease was not stated, Y2+ per cent were medium, intense, or very intense cases, while only 41+ per cent of the 670 negro patients fall in this classification. On the other hand, from the summary of Table 5 we find that the white patients in whom a moderate, large, or very large number of eggs of uncinaria were observed in the stools, form 78+ per cent of the 13,219 whites treated, and that 76+ per cent of the 673 negro patients fall in this classification. In other words, the negro is just as heavily infected, just as. dan- gerous to the community in which he lives, as the white man, but he possesses a relative immunity to the effects of the parasite. The ages of our patients are graphically portrayed in the follow- ing summaries: Relation 'between the ages of all patients treated and the clinical type of uncinariasis they presented. Years of age. Type of uncinariasis. Less than 5. 5 to 9. 10 to 14. 15 to 29. 30 to 49. 50 to 59. Over 60. Not re- corded. Total. Very light 28 77 82 43 4 6 216 628 830 235 30 20 371 1,049 1,906 650 63 26 489 1,682 3,687 1,468 179 74 220 822 1,844 859 112 34 39 153 311 179 30 9 13 60 142 68 21 6 2 12 5 9 1 183 1,378 Light 4,483 8,706 TTlt,fiTl.',A 3,501 440 Unclassified 357 Total 240 1,969 4,063 7,469 3,891 721 310 212 18,865 Relation between the ages of all patients treated and the relative nvmier of uncinaria ova found in their stools on microscopic examination. Relative number ova unci- naria. Years of age. Less than 5. 5 to 9. 10 to 14. 15 to 29. 30 to 49. 60 to 69. Over 60. Not re- corded. Total. Very few 7 61 126 33 1 41 487 811 425 20 62 762 1,691 1,104 93 87 1,516 2,916 2,222 146 37 715 1,378 1,336 111 7 124 289 239 22 5 49 157 65 9 8 14 7 1 173 246 3,722 7,380 6,430 403 173 Few Moderate flrfint Tna.ny Unclassified Total 227 1,784 3,712 6,886 3,576 681 286 203 17,354 1,425 86 Plus substation Barranqul- tas (no microscope) Plus substation Moca (no mi- croscope) Grand total 18,865 From this we see that 72+ per cent of all our patients were under 30 years of age. Two facts should be borne in mind in the consideration of these last four tables: UN-CINABIASIS IN PORTO RICO. 161 1. The degree of the disease was estimated by the clinical sioiis and symptoms. Here in Aibonito, at least, cases classed as "me- dium " would be considered as severe in the United States and in Europe. 2. The same observation may be made with regard to the estimate made of the number of eggs of uncinaria per field of the microscope (No. 4 eyepiece and 3 objective, Leitz). '* Moderate " signifies from two to five eggs per field. The results of treatment are summarized from Tables 8 and 9 as follows : Results of treatment of patients, classified according to the clmical type of uncinariasis presented. Type. Cured. Under treat- ment. Died. Total. Very light 618 1,449 2,747 1,091 110 82 860 3,033 5,949 2,382 304 100 1,378 4 483 Light U 10 28 26 2 8,706 3,501 440 Intense Very intense 184 Not recorded 173 Total 6,997 12,628 67 18,865 1 Case 5,128 had a light grade ol uncinariasis, but came to our clinic with advanced tuberculosis, from which he died. At the close of the chapter devoted to the prevention of uncinariasis an explanation of the expression " under treatment " is made. Suffice it to say that fully 10,000 (estimated) of the 12,628 persons classed as under treatment are practically cured, which, with the 5,997, gives an estimate of 84+ per cent cured. Our death rate has been extremely low, only i-\- per cent of the total number. Most of these deaths were due to other causes. A fair estimate of what has occurred at the various substations may be seen in the following table of deaths occurring among the 6,162 patients treated at the central station, Aibonito : Deaths, central station, Aiionito. Case. 18 296 966 1182 1315 1990 2504 2606 2668 3325 4194 4661 5128 5177 Date of admis- sion. June 2 Tune 8 June 18 June 22 June 24 July 9 July 27 July 28 July 29 Aug. 18 Sept. 9 Sept. 20 Oct. 3 Oct. 1 Date of death. July 14 June 15 July 15 Oct. 18 July 7 Oct. 19 Aug. 4 Oct. 19 Aug. 16 Oct. 29 Oct. 20 Nov. 4 Oct. 30 ...do.-.. Municipality. Morovis Aibonito Barranquitas. Aibonito Barranquitas. Aibonito Barranquitas. Aibonito Barranquitas. Coamo Cidra ..do Aibonito Cayey Cause. Chronic parenchimatous nephritis. Chronic uncinariasis. Chronic enteritis. ^ ^ „j „„ „f Gangrene lower extremities, due to extreme oedema of uncinariasis. . . Dilatation of heart due to uncmanasis. Chronic nephritis. Pulmonary tuberculosis. Chronic amoebic dysentery. . . Dilatation of heart due to uncinariasis. Clironic dysentery. Tuberculosis of the larynx. Uncinariasis. Pulmonarjf tuberculosis. Uncinariasis. 77759°— S. Doc. 808, 61-3 11 162 UNCINARIASIS IN PORTO RIOO. All deaths whose cause is noted as due to diseases other than unci- nariasis, save case 5128, were complicated by an intense or very intense grade of uncinariasis. The following is a summary of the number of doses of anthelmintic administered and the number of times each case received the drug : Results of treatment of patients, classified according to the nurnber of doses of the anthelmintic administered. Doses anthelmintic. Cured. Under treat- ment. Died. Total. One . . . . 17 195 981 1,085 882 661 509 459 352 271 191 145 94 61 34 35 17 7 6 ~4 2,182 2,554 1,741 1,701 974 1,102 601 549 334 329 186 153 63 60 31 20 17 11 8 2 2 1 2 1 2 21 20 14 7 4 2,220 2,769 2,736 2,793 1,860 1,763 1,110 1,008 686 601 377 298 Two Three Five Six Seven Eight Nine Ten 1 Eleven Twelve Thirteen Fourteen 121 Fifteen 65 Sixteen Seventeen 34 18 Eighteen Nineteen Twenty Twenty-one 2 Twenty-two Twenty-three 1 Twenty-five 1 Not stated 2 Unclassified Total 5,997 12, 626 67 18,865 Grand total doses of anthelmintic, 89,908. Total numher of patients from each of the rmmicipalities reached hy the combined work of all stations. Municipality of — Aibonito 3, 774 Barranquitas 1, 868 Barros 1, 550 Comerio 1, 644 Coamo 1, 531 Utuado 2, 058 Guayama 623 San Sebastian 746 Moca 86 Lares 3, 457 694 190 81 5 122 26 13 17 Cidra. Cayey. . More via . Naranjito Aguas Buenas. Salinas Corozal Municipality of — Fajardo Ciales San Juan. . . . Arecibo Juana Diaz... Santa Isabel . . Bayamon. . . . Ponce San Lorenzo. . Patillas Arroyo Hatillo Adjuntas Las Marias . . . Camuy 1 19 2 67 7 8 18 3 2 104 8 27 94 14 6 Total 18,865 A consideration of this summary permits the following deductions to be drawn: '^ /^^■/?^*'^?®^ municipalities possessing a station of the commission (farst 10 ot the summary) the work of treating infected persons has UNCINAEIASIS IN PORTO RICO. 163 been actively prosecuted. In most of them the prophylactic value of this work is enormous, as ^en from the large numbers treated ,• • ."i ot^fi"%such as Cidra, the campaign has reached such propor- tions that it offers every assurance of a like result 3 In all others, generally far from the stations, the value of the work IS being made the subject of general conversation amono- the laboring classes, due to the cures effected in individuals from^such municipalities who sought treatment. It may be confidentlv ex- pected, when a number of persons from them has been cured that all these municipalities will begin to demand a station of their own 'so overwhelming is the propaganda made by those who have the evi- dence of their personal experience to lead them to speak. Number of visits made by patients to the central station at Aibonito arranged according to the municipality from which they proceeded. Municipality. Aibonito Barranquitas.. Barros Comerio Coamo Cayey Cidra Morovis Caguas Naranjito Aguas Btienas Number of visits. 16,095 2,207 879 603 1,935 522 2,271 2 6 25 16 Municipality. Salinas Corozal Utuado San Juan Arecibo Juana Diaz.. Fajardo Ciales Santa Isabel Total . Number of visits. 26 11 S 6 1 9 2 1 6 24,628 This summary shows how relatively little the distance operates to deter the jibaro from pursuing a treatment once begun. Total number of visits made by patients to the various stations. Stations. Patients beginning treatment. Patients returning for treatment. Total visits. Aibonito 6,152 1,425 1,255 1,048 1,676 746 663 86 1,813 4,001 18,476 6,113 6,536 4,730 7,830 1,223 1,419 105 3,841 8,272 24, 628 7,538 Barros 6,791 6,778 9,506 1,969 2,082 Moca 191 5,654 Lares 12,273 Total 18, 865 57, 545 76,410 Persons in whose feces no eggs of uncinaria were found. This 486 76, 896 This enormous number of visits, in each of which personal cogni- zance of the patient's condition and progress was taken, a micro- scopic examination of his feces made, and an appropriate prescription written and dispatched, record being made on the history card kept on file, as before described, demonstrates what an immense work it is possible to accomplish, proceeding along the lines laid down by the commission for the present year and recommended on a larger scale for the future. 164 UNCINAEIASIS IN PORTO BIOO.- It has been said that the jibaro seeks novelty and the air of mystery pervading a clinical laboratory, in which many strange instruments are grouped about the patient, and many examinations of his blood, feces, etc., are made. While not discounting the human trait that may be attributed to all people under such circumstances, the com- mission is persuaded that the jibaro is not actuated to any great extent by such motive in his long tramp from some distant mountain barrio. It is his health he seeks. When we began to receive patients at the station in Aibonito, and for at least two months thereafter, no other station existed within reach of the people of Barranquitas, Barros, Comerio,, Cidra, and Cayey. An ever increasing number from these municipalities swelled our clinic. In August we established substations in Barranquitas, Comerio, and Barros. At these stations no laboratory, properly speaking, existed— only the excellent doctors who took up the work at those places, and the neat little offices fitted up by their own personal efforts, forwarded by the enthusiastic municipal authorities. At once our patients from those municipalities began to fall away from the cen- tral station. They knew that the same treatment was being employed at these points ; they were kindly received there, and their chief ob- ject—to get cured — was satisfied. In the meantime the number from Cayey, and especially from Cidra, where no stations could be estab- lished, kept steadily increasing, although, both are far distant and consume at least an entire day in the trip to Aibonito. So we see that it is the opportunity to regain their health that attracts them — not novelty. The effects produced by the drugs thymol and beta-naphthol have been carefully studied by the commission. Their relative value is discussed in the chapter on prophylaxis. Both are excellent in their results, and each has special uses, which, together with the compila- tion of our data on this subject, will be fully discussed in a future report. Suffice it to say that the repeated use of these anthelmintics weekly for two or three months in cases which have suffered from intense anemia is not advised. Beta-naphthol in such cases may, by adding the element of irritation to a kidney already profoundly dis- eased, aggravate the existing process. This is by no means believed to be a contraindication to its general use, but it should be considered in a small proportion of cases. Thymol is far less irritating, aiid our belief is that five consecutive doses of either is sufficient, usually, to bring the patient, if not to a technical cure, at least to the assurance of a practical cure. After this he can be instructed to return for further treatment at the end of a month, when, if need be, the vermi- fuge may be repeated. Thus we see that the specific treatment of " Porto Eican anemia " is a fact established beyond all quibble or question. The long list of " sure-cure " patent iron pills, powders, and blood and nerve restorers, so csarly paid for by the unfortunate and credulous " jibaro," paid for, it should be remembered, from the earnings of a class said to be starving in poverty, is a list too long and too disgusting to contem- plate without anger and a sense of shame. Its length is sufficient guaranty of the utter inefficacy of any one of such preparations to cure, for had any particular one of the marvelous fabrications been true all others would have sunk into oblivion. As it is, all have prospered, enriched by the sweat of thousands who spend an immense UNCmARIASlS IN POETO EICO. 165 quota of their savings to reap a bitter disappointment in broken promises of health and vigor. We believe that no more startling instance of the pernicious custom of trusting to patent medicines exists than in the exceedingly interesting history of the recovery in Porto Rico by scientific medicine — ^by the doctor — of a territory ex- ploited by commercialism, the innocent faith of the poor " jibaro." In regard to iron and all iron preparations, let it be said that the commission has well-nigh abandoned its use, even in the presence of 8 per cent Hb. Many of our directors are coming to adopt the same position, and, as the work goes on, as they become familiar with the relatively small value of iron, they are gradually dropping its use, where previously it was, as it was with us, a sine qua non in the treatment of uncinarial anemia following specific medication. The subject is referred to and emphasized because the eager throng of vendors of patent ferruginous tonics is pressing in to recommend their preparations, basing their supposed value upon a previous report of this commission, on which no very different construction can be placed from that just expressed. We do know the relative value of iron in uncinariasis. It is of some value, but its value is the same in the aftertreatment of this disease as in the treatment of malaria or syphilis. Lack of space forbids us to acknowledge individually the services and moral support of the thousands of friends of this work. Besides those whose active part has contributed so much to its success, we desire to express our deep appreciation of valuable services rendered the commission by the pharmacist of Aibonito, Licenciado Seiior Don Teodoro Moscoso. Fully one-half of this pharmacist's income came from patented blood restorers. When he saw the results of anthe- mintic treatment he refused to sell them to anemics until they had sought our clinic. THE PREVENTION OF UNCINARIASIS IN PORTO RICO. HOW DOES INFECTION TAKE PLACE. The commission, as a result of its two years of investigation, has come to the conclusion that, if not in all, at least in 99 per cent ot all those who harbor uncinaria in their intestinal canal, the parasite effected its entrance into the body through penetration ot the skm in contact with soil or water loaded with the young larvae. In other words, we now know that the barefooted laborer m infected soil who contracts the. characteristic "ground i^h " or " mazamorra so fa- miliar to every shoeless individual on the island, is invaded by """l^bSef the sequence of events is as follows: The parasite lives in the intesdneyman. An ordinary case .of. --n-iasis, su^h as we see so frequently here, produces over a mil ion ^ff J^ ^f f^^^ ^e are laid by the female worms m the "PP^^ P^^* ";^^*^''. JSef S? 166 UNCIN-AUIASIS m PORTO RICO. not reproduce their species outside of the human body, nor do they live indefinitely in the earth, although we have not yet been able to define their limit of natural existence. When one harbors but few worms, the symptoms of infection are usually few or absent entirely and the individual is much less dangerous to the community in which he lives than he who is sick or ailing from a large number. Mazamorra is the first sign of infection by uncinarla, and if severe or repeated attacks take place uncinariasis will follow. Uncinariasis is that condition resulting from infection by un- cinaria in sufficiently large numbers to overcome a man's resistance to the poison elaborated by the parasite resident in the intestinal canal, a poison whose effect is manifested by certain notable dis- turbances in the functions of vital organs. While frequently the symptoms are confined to a general reduction in strength, dizziness, and vague pains in chest and stomach, without noticeable pallor, it is only too common to observe a more or less grave alteration of the blood, resulting in that symptom of advanced uncinariasis which the layman has so much reason to fear and respect from years of dread experience, anemia. This is the lamentable condition which some continental news- papers have been pleased to call " the lazy disease." Thus we know that the long-time curse of Porto Eico, its anemia, is a disease, not an expression of an insufficient or improper diet, no matter how evident the poverty and wretchedness of thousands of poor on this island. With regard to the latter, we as medical men may deplore but can not help such conditions wherever they may exist. With the former only physicians and sanitarians can success- fully deal. Therefore, whether very ill or apparently well, everyone infected by uncinarise is a menace to the public health, for, if he defecates upon the earth where others must tread he stocks it with a numerous progeny, which, maturing, will seek another human host, perhaps one of his own family. As evidence in part for our decided views with regard to skin infec- tion, we refer to the fact that only 4+per cent of all whom we found infected denied having had mazamorra. Even among this small number of persons many will be found who either forgot that they had had it or who did not care to mention it for fear of humiliation. The correctness of both of these suppositions we have had ample opportunity to prove. Moreover, in 486 -persons who presented themselves for treatment in Aibonito and in whom neither eo-o-s of uncmaria were found nor anemia present, only 234 stated that'they had had mazamorra and generally such persons had suffered from it at a period so remote that all worms had long ago come to the end of their natural existence, or, in other wwds, had died of old age. All other routes of infection are rarities, at least in Porto Eico, and do not merit the space necessary to discuss them. WHERE DOES INFECTION TAKE PLACE. The conclusions of the commission are based upon two facts : iu'^Y'^Y*^ soiling is commonest in Porto Rico around the house, in the bushes, or m the dense shade of banana plants which shelter so many huts. Exposed places are not sought for the accomplishment ot this act but rather a secluded spot. The jibaro goes to " el moiite " UNClNARlASlg IN PORTO KlCO. 16Y "the bushes." As these huts in the interior are very frequently on S^^l^^^T/'' ^^^ "^'^^^ °^ ^ ^°^®^ plantation, it thus comes about that the latter contains many true foci of infection. Not only this but apart from earth soiling near the house, we must consider the general pollution of the plantation by the laborer who is interrupted while at work by a desire to evacuate his bowels. 2. (a) In order to ripen to the larval stage the egg must be de- posited under proper conditions of shade and moisture. In order that the life of the larva be preserved, drying must be avoided. The egg is far less resistant to this influence than the fully developed larva. (6) All decomposing vegetation, especially the detritus from the banana plant, forms a perfect medium for the protection of the youno- parasite. ^ Our conclusion is that the coffee plantation of Porto Rico offers the most perfect conditions for the development of the larva from the egg and for its preservation thereafter. Total number patients classified according to the usual localities where their mazamorra was contracted. Coffee plantations 11, qqq Coffee plantations and surroundings of the home 1, 090 Surroundings of the home only 401 Open country 977 Roads and paths 2.201 Rivers, streams, and pools of water 165 Town streets 161 Stables and corrals 703 Tobacco plantations 19 Banana patches 161 Sweet potato patches 2 Surroundings of public schools 17 Sugar plantations 28 Not classified 420 Persons with ova of uncinarla in their stools who deny having suffered from mazamorra 791 Total 18,865 The question, " Where do you generally get mazamorra ? " was answered by 67+per cent, " In the finca." As we were working in the interior, this generally meant, " finca de cafe " (coffee plantation). When one stated that he had received his infection from the sur- roundings of his home, he generally meant its immediate proximity ; not from the shade of near-by bushes, but from the patio, or yard, shaded by the house or trees. All other localities mentioned always refer to damp places infected by human feces ; spots which the sun fails to thoroughly dry. Mere sunlight does not usually kill the larvse ; however, it may retard their . growth. Drying must be effected to destroy them. Infection in rivers and streams occurs from mud at the edges ot such streams, not from the flowing water. Many washerwomen and water carriers thus contract uncinariasis. Tobacco plantations and sugar plantations are not such dangerous sources of infection, save in certain spots not open to the influeiice ot continuous sunlight or localities containing at all times a sufficient amount of water, such as ditches for irrigating Purposes, simply because such spots are few and far between, although they form ideal culture grounds for the larvae. 168 UNCINARIASIS IN PORTO UICO. Thus, in all parts of the island where coffee is not the chief prod- uct, as on the coast, infection is generally derived from the bushes in the vicinity of the home. The foregoing reflections are merely very general. While it is a fact that the commission plainly sees that coffee plan- tations will always be the chief sources of mazamorra for the people of the interior, and we include the surroundings of the home as part of such plantation in the vast majority of instances, as Table 10 shows, almost no place is exempt from contamination, because when night falls to screen his act, the countrymen soils anywhere it may be convenient for him to do so. In the period of the annual rains, not only are the infective larvae widely scattered, but this is precisely the season when work goes on in the coffee plantation. Coffee picking usually begins and ends at the time of torrential rains. This is not generally a continuous rain, but an almost daily soaking of the earth. At such a time the planta- tions in the shade of a heavy vegetation never dry. Barefooted workmen, men, women, and children, swarm to secure the benefits of about the only regular employment they can count upon during the whole year. The little nicknacks and innocent pleasures of the elaborate Spanish Christmas festival, not to speak of the supply of clothing necessary for the ensuing year, all depend upon reaping the small annual stipend allotted the pickers for this two or three months work. Thus the time of coffee picking is for tens of thousands the only fixed revenue of the entire year, and with all the eagerness with which they have flocked to our station for the cure of their terrible disease, they have temporarily, to a great extent at least, abandoned their cure to seek this pittance that they may be enabled to spend a "Merry Christmas." Pitiful as it may be, it is a stern truth that thousands have thus gone to their death. Many times have we heard, .in answer to the question, "Where did you get your mazamorra"? "During last year's coffee picking." Here in a pouring rain they work, picking coffee and sowing disease and misery for the annual harvest of lives, as portrayed by the island health reports in the usual 5,000 to 7,000 deaths a year from anemia. As generally the laboring man and his family in the country go barefooted, in the rainy season mazamorra may be contracted almost anywhere, so that multiple infections generally bring about uncinari- asis, and any large increment of parasites may carry off the already half-sick "jibaro." The anemia of Porto Rico is a disease, it is an infectious disease, not an inherent condition, not an exhaustion of vital forces, not the natural end of man's existence here in Porto Eico. It cuts down man, woman, and child of every age. It cripples industrial effort, limits mental expansion, weakens the body, and depresses the spirit, until many laborers in a country where apiculture is the chief source of revenue are enervated, despondent, without hope of betterment, and without the power to save themselves. Sometimes a man can not earn enough to feed his family, and he is driven to eat the crudest gifts of a bountiful nature in the wild fruits of Porto Rico. UNCINAEIASIS IN PORTO EICO. Igg We are now speaking of the great mass of the people, numerically considered, the very heart's blood of the country, a blood which on an average, is below 50 per cent of what it should and can be. Methods to le employed in a campaign against the anemia of Porto mco.--A.±t%T many and serious discussions the commission has taken a hnal and determined position in regard to all future eflForts to with- stand this epidemic. We believe that in the universal treatment of persons affected lies the secret of successful opposition to uncinariasis. _ In this belief we are supported by the best medical opinion of the island, and by the principles adopted by England, Germany, France, and Belgium in combating the same disease in their mines. 'What- ever other measures may be taken, and many more are both advisable and necessary, the unit of prophylaxis should be the dispensary and hospital. Here we not only cure our sick, but we render innocuous the feces of thousands who will continue to pollute the soil in spite of prayers, lectures, advice, coaxing, and even the prohibition imposed by the law. At the station for treatment and prevention, which will be the place of places to teach the voluntary seeker after health why he is sick and how to avoid a repetition of his illness, a triple purpose is served — the man is cured and warned at the same time that he is rendered at least relatively incapable of spreading his diesase. That all these ends can be attained is evident from our practical experi- ence in Aibonito and that of the directors of substations elsewhere. Every person who seeks treatment at this station first receives a microscopic examination of his feces. If eggs of uncinaria are pres- ent he receives one of the specific vermifuges to take at home. Then he is well talked to, kindly advised, shown the parasites which cause his illness, how they bring about the condition of which he complains, and how he may protect himself from future attacks. He is told to return weekly with a small specimen of his feces until all eggs of the parasite disappear and he is pronounced cured. The results of the six months' work ending December 1, 1905, have already been referred to. This vast number of persons who in that brief space of time applied for treatment is more eloquent than words. It is the mute appeal of the " jibaro " for aid, and it is directed to his more fortunate countrymen who run very little risk of contracting his disease and who receive, at least indirectly, the benefit of his labors. We can not believe that in the face of these facts, with a total of 18,798 persons cured or under treatment, and all this in so short a period, there can be any doubt as to the necessity for continuance of the work. In Aibonito, where about one-half of the entire popula- tion of the municipality have been under treatment, it is said that this year mazamorra is less than it was last year. Coffee pickers make this assertion. We have not been able to prove it, but it is cer- tainly true of some plantations. . i • . We have already spoken of the result of our direct preaching to the " jibaro " at the central station. „ , ^ Not only does he fear to be without a privy for the fane or im- prisonment imposed, but he fears, more than all besides, the disease from which he has just been liberated. It is only ]ust to say that the character of the man we wish to help is such that when once convinced he is very tolerant of reform in his behalf. But he needs lYO tTNClNAHlASlS IN PORTO RICO. the moral effect of inspection and law. He is accustomed to be told what to do and he awaits the order. In spite of this nothing will secure obedience to a sanitary law in which he can see no reason. And knowledge comes from seeing results, from practical demon- strations such as a station for the general treatment of infected and sick has given and will give. It is futile to think of reaching him by pamphlets. This should be reserved for the plantation owners. He must be reached by word of mouth and the demonstration of the truth. To this end we would advocate inspectors, chosen from among those in whom these country people have confidence, some person of superior knowledge, but who is one of them, who speaks their tongue, lives their life, and whose processes of thought are theirs. Such a person going about from house to house will preach the gospel of sanitary reform in a manner such as could never be ac- complished by a prohibitory measure. He will accentuate to each one the truth of what may have been taught at the station. He will convey the very sick to where they can be properly treated, and he will discover recalcitrants of whom the law should make an example. In order to complement the efforts of the physician and the ad- rnonishments of the law, we believe that all proprietors of planta- tions, especially those of coffee, should require their laborers to defe- cate in sanitary trenches, or even pits near the place of work, the digging and care of which should be under the surveillance of some special person. The wearing of shoes should be universally counseled in the schools and wherever the vast opportunities offered by conversation between employee and employer can be seized. In our last report this was not mentioned, not because we were unaware of the importance of so self-evident a preventive measure, but because we believed it premature to advise. At the dawn of a general attack on the disease, with the execution of the plan within recommended, all measures of value should be pushed to their fullest extent. Such a campaign will make the law something more than a dead letter and gives ample opportunity 'to all to comply with and under- stand the spirit of that law. At the close of our remarks on the prevention of uncinariasis, the commission desires to make clear what we believe is a completely new phase of the fight against the disease. Early in our labors we saw the necessity for ascertaining the rela- tive value of the drugs heretofore advised for the expulsion of un- cmariiB. In brief, for determining the actual number expelled by each successive dose of the anthelmmtic employed. The following table shows the result of this investigation : UNCINARIASIS IN PORTO RICO. 171 "Number of uncinariw expelled, by successive doses of the anthelmmtic, THYMOL. Case number. First. Second. Third. Fourth. Fifth. Sixth. Sev- enth. Eighth. Ninth. Total. 3934 - - 670 660 1,149 1,307 286 93 818 309 182 481 541 1,070 368 1,273 1,237 3,101 287 1,223 49 674 77 887 1,404 884 1,610 489 704 1,068 281 236 215 1,215 234 918 1.321 919 3,686 719 2,264 114 372 169 10 19 36 205 17 25 51 216 57 61 90 83 77 203 36 492 775 46 47 ■■■■-■ 1 85 12 2 3 12 23 4i' 11 26 183 4 230 119 15 5 1 2 4 31 7 1,110 3784 881 4286 1,160 3622 1,352 3291 326 3526 10 424 5022 . . 847 6032 336 6049 236 7 2 2 . 716 5124 623 3 1 1,136 3203 490 3722 1,367- 13 6 3 4 1 1,361 5188 3,493 327 5287 11 99 20 13 3 2 1,979 5158 17 3 1,077 574 6067 19 21 517 58 252 111 286 866 142 107 212 150 15 174 108 185 480 83 39 245 96 908 96 17 8 287 8 40 25 105 62 19 36 18 2 2,073 959 1 216 7 36 7 72 41 1,871 18 2 2 6 22 21 2 1,122 1,007 3 5 2 2,015 465 544 551 1,384 44 17 15 218 346 13 156 12 1,446 428T 5991 3 11 1,122 4,395 1,167 4505 6257 6077 29' ■■"isg 43 2,316 776 Total 34,912 7,064 2,345 687 334 66 18 3 45,429 Average percentage expelled after- One dose Two doses Three doses Four doses Five doses 70.84+ 92.39+ 97.56+ 99.07+ 99.80+ 172 UNCINARIASIS IN PORTO E.1C0. lHumber of vncinarice expelled 'by successive doses of the anthelmintic — Contd. BETA-NAPHTHOL. Case No. First. Second Third. Fourth. Fifth. Sixth. Seventh Eighth Ninth. Total. 3476 591 305 1,669 242 675 469 788 387 326 312 626 804 978 96 386 693 63 603 2,372 2,007 708 339 94 662 178 97 1,687 432 725 115 7 414 106 3 5 32 273 19 128 9 9 379 258 9 54 108 10 235 307 201 233 2 68 62 372 9 141 496 166 103 3 130 36 1 49 15 8 1 650 5434 S64 3204 8 1,727 247 4243 4241 680 4933 18 67 11 29 80' 12 5 542 5655 1,242 406 5676 5807 1 12 19 279 26 7 89 182 14 17 12 497 6089 333 5944 654 3475 66 56 3 11 37- 38 65 1,566 3605 4 1,387 115 5808 4647 2 68 542 5537 22 25 60 1,195 73 3783. -■ 3190 92 28 16 5 8 113 17 2 43 5 4 995 3356 2,724 2,234 946 3206 8 1 5533 4934 2 1 352 5826 152 5626 2 100 2 22 233 76 17 726 5609 185 18 18 76 12 186 4 10 70 12 15 1,032 5809 14 159 4197 1,778 1,316 5802 10 117 5237 12 1,108 5848 Total , 19,128 4,207 1,470 743 599 216 56 60 26,477 Average percentage expelled after — Oi^dose 72.24+ ^„,„ .,„„„. ^ jg^ : 93.68+ 96,49+ 98,75+ Two doses Three doses. Four doses. . Five doses . . These tables only contain data obtained from the use of thymol and beta-naphthol, and in explanation of the reason why male fern was not the subject of a like investigation, it should be said that the attempt was made. An ethereal extract of male fern from one of the most reputable German pharmaceutical laboratories was purchased in 1 orto Eico. Practically no uncinaria were expelled by it and we were compelled to abandon its use, believing that it had possibly deteriorated from climatic influences, to which it is said to be very susceptible. A fresh solid extract was then obtained from one of the best American pharmaceutical houses. It gave no better results, although such effects as dizziness, etc., followed its administration. Ihe highest number of uncinarise expelled by either of these prepa- rations was 8, while a subsequent administration of onlv three- fourths of the usual dose of thymol brought away 3,686, and this in the veiy same case ( !). So much time had been wasted in these unfruitful trials that had we again ordered other preparations of the drug we could not have completed a series of cases with it. Thymol was administered to 40 hospital cases at intervals of one week. All feces evacuated during 24 hours from the time of receiving the anthelmintic were saved, washed on filters of gauze by specially trained employees of the commission, and the residue placed in a 10 per cent formalin solution. From this residue the uncinarise were recovered by steel forceps and counted by us. UNCINARIASIS IN PORTO RICO. 173 Beta-naphthol was administered to 30 hospital cases under like conditions. The finding of the commission is that after 1 dose of thymol, 76.85 per cent of all uncinaria in the intestinal canal of the patient are expelled; after 1 dose of beta-naphthol, 72.24 per cent; after 2 doses of thymol, 92.39-(- per cent of the total number were expelled ; after 2 doses of beta-naphthol, 88.13 per cent ; after 3 doses of thymol, 97.56+ per cent of the total number were expelled ; after 3 doses of beta-naphthol, 93.68 per cent; after 4 doses of thymol, 99.07-|- per cent of the total number were expelled ; after 4 doses of beta-naphthol, 96.49 per cent. The remarkable results of the first doses, entirely unknown to the commission until we made these very important and disagreeable investigations, have come to modify not only our treatment but our prophylaxis. For a long time the commission has been seeing cases clinically cured of the anemia after one or two doses of medicine. Especially is thus true of very light, light, and medium cases. Nevertheless, it was found that they still had some eggs of uncinaria in their stools. We now understand well, for the first time, the significance of this phenomenon and why such cases often fail to return. It is because they feel well and do not see the necessity for further medication. When a patient has been relieved of three-fourths to nineteen- twentieths of the parasites which caused his illness and the few remaining can not reproduce in the intestinal canal (a well-known fact), he either loses all of his symptoms or the major part of them. Therefore, what we have considered a " cure " has been a techincal, a scientific cure. The 5,997 cases counted as cured fall under this category, but fully 10,000 of the 12,628, classed as under treatment are really freed of their anemia and other symptoms and are follow- ing the ordinary avocations of their life without the disease, which previously was more or less an obstacle to their work. They are classed as " under treatment," either because they still carried m their intestinal canal a few uncinaria or because they have tailed to return that we may verify by the absence of eggs of the parasite from their stools their technical cure. In other words, they are cured, as far as evidence of disease, is concerned. . Looking at the matter from another point of view, namely, the infectiousness of such persons not completely and technically cured, as defined above, we find by calculation that we have been able to reduce about 94.5 per cent the power of spreading the disease the power of infecting the earth, in the 18,865 cases treated, and that the 12,628 cases reported as still under treatment are only about 8 5 per ceAt so dangerous as carriers of the worm and sources of infection as they were before. Tbpsp facts lead to most valuable conclusions. 1 In general terms, five doses of thymol are sufficient o practically cure ^pftienTlulnng from uncinariasis. ExceptionaUy more than five may be needed, and less than five "^^^ ^^^i^^ ?,V^™^ 2. This number of doses general y reduces the danger ot a patient to the community, in regard to his power to infect the soil, about "if l7the'tfatment of outpatients, beta-naphthol is decidedly infer&r to thymol In the hospital all cases who receive any anthel- 174 tJWCINAKIASIS IN PORTO BICO. mintic are prepared for 24 hours before by a strict milk diet. Thus the vermifuge falls upon the parasites, unprotected by the mechanical covering offered by a full or partially filled intestine, and the results are not very different in one or the other drug; .but in prescribing anthelmintics to patients who are to take their medicine at home, in spite of our directions, these dietary instructions are not always obeyed. Under such circumstances thymol is far more efficient than beta-naphthol, in that, by the use of the former, the eggs disappear from the stools with fewer doses and the patient recovers more rapidly. RECOMMENDATIONS. Keasoning from what has been accomplished, we recommend that the present system of central station and substation be continued and further amplified, so that the opportunity to receive specific treatment will be placed within reach of practically every anemic in Porto Rico. We advise that this work be directed by a commission appointed by and responsible to the governor of Porto Eico for its faithful and economic administration. This commission should at all times be in touch with the governor, rendering regular reports of its opera- tions and consulting him before making any extraordinary or unusual expense or change of plans. The commission would formulate the necessary regulations for the proper organization and administration of stations and substations, and should see that such regulations were carried out. It would in- vestigate the conditions in regard to this disease in Porto Eico, select the locations for stations, substations, and dispensaries, make agree- ments with the various municipal authorities for their assistance, and establish the stations when these agreements are fulfilled. It would also continue the medical investigation and study of the disease. We advise the establishment of seven central stations located at convenient points so that each will dominate a large district and form for it the administrative center and distributing depot for medi- cines and other supplies; each central station to be in charge of a physician, who would have direction of all work in his district, re- sponsible to the commission for all operations throughout all terri- tory that may be confided to him, making monthly reports to the commission. Tributary to the central station, there should be one or more sub- stations and two or more dispensaries located in the smaller towns, as the necessities of the district may require. The physicians in charge of these would be responsible to the director of their central station, making weekly reports of their operations. We estimate that 10 substations and 20 dispensaries will be needed throughout the entire island. A central station should have a dispensary of at least four rooms, viz, examining room, dispensing room, storeroom, and office. It should be equipped with two microscopes with necessary accessories for examining patients, utensils for preparing and dispensing medi- cines, and such furniture as may be desired. In connection with this dispensary, there should be a hospital of at least 20 beds with equip- ment complete for the treatment of very grave or special cases. It UNCINABIASIS IN PORTO EICO, 175 should be incumbent upon the city in which this station may be located to provide the building and ordinary furniture, as chairs, tables, etc., for the dispensary, and building and equipment, as beds, bed clothing, cooking utensils, furniture, etc., for the hospital. The commission should supply medicines, instruments, special equipment, and bear the expenses of personnel and maintenance of dispensary and hospital. The personnel of a central station should be : Annually. Director $1,800 Assistant 1,000 Practicante 360 Scavenger 150 2 nurses 120 Cook 72 Peon 60 Total ' 3, 562 The other expenses, exclusive of medicines, transportation, etc., are estimated as follows : Annually. Installation and preservation $120 Subsistence, witli the ration at 15 cents 1, 000 Microscopes and clinical accessories 200 Miscellaneous supplies 150 Total 1. 470 Each substation should have a dispensary on somewhat smaller scale than that of a central station and hospital accommodations for 10 beds, the town in which it may be located providing assistance m the same manner as in the case of a central station. The personnel of a substation should be : ^ Annually. Physician «!• ?2 Practicante ^2 Nurse ri2 Scavenger and peon g^ Cook go Female nurse and laundress 1,564 Total Estimating the other expenses at one-half of those of the same class at cehtral stStions, the annual cost would be $735 f^ substation The dispensarieL would be on a still smal er scale than the substa- tions, without hospital accommodations. The town should assist m the same proportion as at the larger stations. The personnel of a dispensary should be: Annually. $600 Physician 180 Practicante 60 Peon 840 Total physician serving as health officer at the same time. 176 UNCINABIASIS IN POBTO E.ICO. Other expenses are estimated for a dispensary : Annually. Installation, etc $25 Microscope and supplies 60 Miscellaneous 25 Total 110 The general expenses may be classified and estimated as follows: -Annually. Personnel of commission $8,200 Medicines 10, 000 Transportation 2,000 Printing, stationery, and office supplies 1, 000 Travel 750 Laboratory 1,000 Postage and telegraphing 1 200 Miscellaneous 616 Total 23,766 We recommend that a sanitary inspector be attached to each cen- tral station, who would make periodical trips through the district to advise, persuade, and explain to the people the necessity for the con- struction of privies and the prevention of earth soiling. He would inform the director to what extent patients carried out the advice given them at the clinics, and report any cases of persistent and will- ful neglect of these simple sanitary rules. He would also look up, patients who failed to return, and assist very ill patients to go to the* station when they could not do so of their own resources. For the seven inspectors the cost is estimated to be : Annually. Salaries _. $2,520 Horses 350 Care of horses 420 Total 3,290 At one central station, the commission would have its headquar- ters, general depot of supplies, and a small clinical laboratory. At that station the commission would take direct charge of the work of that district in place of the director and assistant. A clerk should be employed to keep records and accounts, attend to correspondence and many small administrative details. To recapitulate, we estimate the cos't for a full year's work as out- lined to be as follows: Annually. One central station, substituting the commission and clerli for director and assistant eg 952 Six central stations 30* 192 Ten substations ~ 22' 990 Twenty dispensaries I9' qqq Medicines jo' qqq Transportation 2' 000 Printing, stationery, and office supplies 1, OOO Sanitary inspectors 3' 290 Laboratory " ~ j' qqq Travel _ ' -^^q Postage and telegraphing I_I__I 200 Miscellaneous gig Total ._,-„„„ 100,000 UNCINARIASIS IN PORTO EICO. 177 As already stated, this amount is estimated as if each station were organized and working during the entire year. As a matter of fact, only the 11 stations now in operation would draw upon these funds from the beginning. First these would have to be reorganized in ac- cordance with the plan outlined, then new stations organized and put into operation as rapidly as possible. Some delay would inevitably occur before all arrangements could be made with the municipalities where stations may be located, and they be able to fulfill their part. Allowing that this delay would cause a reduction of 20 per cent in the entire year's expenses, the annual estimate is thus reduced to $80,000. We recognize that this sum is a large advance over the present appropriation of $15,000, of which nearly $11,000 was expended dur- ing six months' work. Here it must be taken into consideration that two of the members of the present commission are oiBcers of the United States and received no monetary recompense whatever from the insular government. Also that they were supplied with the greater portion of the laboratory equipment by their services with- out expense to the appropriation. This assistance will be lacking in the future. Again attention is called to the fact that the substations at Barros, San Sebastian, and Moca have cost the commission only the expense of the medicines and transportation of the same. The physicians at these places so desired to take part in this labor, and, dissatisfied with the results obtained in the treatment of this ." anemia " by iron, tonics, etc., so desired to extend the benefits of scientific treatnient to the anemics of their localities, that they volunteered their services to take charge of these stations without recompense from the commission. Even to those physicians who were remunerated, the amounts paid were miserably inadequate for the services rendered. This is a sacrifice of time and labor which Porto Rico has no right nor need to demand, but should reasonably recompense such valuable services. " The laborer is worthy of his hire." While the operations of the present commission have been carried out on a really large scale, yet in proportion to the conditions con- fronting us it has been comparatively small. By reference to the financial statement, it may be seen how economically it has been done. In 1903 a systematic examination of the miners of Westphalia showed that 17,161 of 188,730 miners were infected by the parasite causing this disease. _ , ^, • j: .• In certain mines, during nine months' work, the infection was re- duced 73 per cent. In addition to the large sums contributed by the miners and mine owners, the German Government spent 3 000,000 marks {$720,000). We have treated 18,865 cases m six months, at a cost of $10,908.77, and have reduced the infection 94 per cent among * The Access attending our efforts convinces us that what this com- mission and its coworkers have accomplished on a comparatively Si scale can be done on a sufficiently large scale to meet the urgent need of Porto Eico. It is simply a question of funds, and proper administration by those who have knowledge and experience in this Scilar field. Ve do not believe that $80,000 ^lUmeet fully the condTtion that it is proposed to attack, but it is probably sufficient to 77759°_S. Doc. 808, 61-3 12 178 UNCINARIASIS IN POETO K.IOO. cover what can be done during the coming year. In following years new stations should be established in places that may be but remotely touched by the present estimated work, or in case some stations should have accomplished their end, they could be moved to another place yet heavily infected, leaving only a dispensary to care for those few who may not have applied for treatment, and those tew who become reinfected. .,-,■, j j u* j-t. During 1904 this commission demonstrated beyond a doubt the character and curability of this " anemia," and during 1905, proved the feasibility, from both curative and preventive points of view, of , the measures advocated. With this conviction of certain success, did we recommend any less, we would fail in the most important phase of our duty. „ „ ... , Slower yet more deadly than yellow fever, uncinariasis caused more deaths in 1905 in Porto Eico than yellow fever did throughout the entire world, notwithstanding the unusual prevalence of the latter disease during the year, yet cost is not considered in the presence of yellow fever. t . i. No doubt the sum herein advised may seem startling to some, be- cause they have not been accustomed to regard this work as a regular gbvernmental expenditure. Large amounts for asylums, police, jails, quarantine, and the vast machinery of the law are expenses to which everyone is familiar, and thev are expected as a matter of course. During the fiscal year 1904-5 $457,320.54 was expended for police and jails, the administration of justice requiring $262,250.36; the insane asylum $34,420.73 to care for such unfortunates; for the leper asylum, $7,079.95 to care for and protect others from its inmates; for the boys' charity school, $32,317.47; the girls' charity school, $18,064.63. We do not wish to belittle the necessity for such expenditures nor to criticize them, as we recognize that such are necessary if a gov- ernment fulfill its primary duty — the preservation of the lives and health of its citizens. We do wish to emphasize by comparison with accepted expenditures that the amount that we advise is small in the face of such vast need and in relation to the great benefits to be received, not only in saving of life and suffering, but a financial economy of thousands of doflars to laborer, employer, and the island generally. We most earnestly advise and urge that the campaign against uncinariasis in Porto Eico be pushed with utmost energy. It would be economy of life, time, and money to expend from the first the greatest amount possible to obtain from every resource. The greater the amount expended now means the sooner and cheaper the results will be accomplished. The greater number treated the less number to spread infection, and a resulting less number reinfected each year. In all discussions about this disease much attention has been paid to the prevention of it. We have shown that the wholesale treat- ment of the infected, thus removing numerous foci of infection, is the most thorough and practical method of prevention. Our expe- rience coincides with that of the German workers in this same ques- tion. It is a simple arithmetical computation to show that small appropriations will simply prolong, almost indefinitely, the condi- tions now existing, and the money expended would be a constant drain on the insular treasury^ amounting to much more in the end. e UNCINABIASIS IN PORTO RICO. I79 The stations once established, the per canita cn^ nf t™o+^ + u comes proporti^onately less as the nuUerTf Vat entf ncreTsTs t cause the actual cost of medicines (including trLsnortat^n ?/ ' ^ IS but a few cents, and, while this ^cost wSKrea^^^^^^^^ other expenses would not be materially affected. Thus a la?ee num ' number^'"'"' ''" ^' '"'^''^ ^^"^^* ^^ "^^^^Ply - a muchfmalE; We estimate that about 800,000 of Porto Eico's 1,000 000 inhabit ants are infected with the parasite causing this disease and thX. infection is increasing i, e those yet ulaffected are beconS in fected and those already infected are becoming more heavTrso^ .n^Li^^ expenditure of the amount advised we estimate tLtovPv 100,000 persons can be treated. Until large Tumb^s L t/eate^^^ thus destroying dimerous sources of infection, the dT^asew^?! con- tinue to increase or hold its own. Sooner or ater large sums must be spent, and until then the loss of life, time, and money wrch could have been saved will have been sacrificed for nothing ihe problem of attacking uncinariasis is now confronting almost every country of tropical and subtropical climes, not to Ipeak of the many infected mines of more northern countries. Porto Eico has taken front rank in the solution of this problem by the vigorous campaign which has been inaugurated. Its work has become known and watched by the entire world. To allow it to end at this point or even to fail m fulfilling, to the limit of its resources, its plain im- perative duty m the matter would be to lose a great part of what has been accomplished at the cost of much labor and money. FINANCIAL STATEMENT. Salaries $4 426. 90 Medicines — — . 2, 086. 24 Actual cost of medicines $2, 086. 24 Transportation of same '397.96 2, 484. 20 Average cost per patient, 13.11-1- cents. Subsistence, 9,994 rations of patients and employees at 14.31-1- cents. 1, 430. 51 Travel, members of the commission, directors of substations, etc__ 067.06 Transportation fj46. 00 Medicines .$397.96 Hospital from Utuado to Aibonito, and materials 193.57 Laboratory supplies 4. 85 Clinic supplies 3. 66 Miscellaneous 45. 96 646. 00 Installation, repairs, bouse for employees, etc 520. 23 Printing, stationery, and olEce supplies ,307. 14 Hire of carriage (^^including driver, etc.) for service between Aibo- nito and hospital 267.00 Laboratory 234. 41 Installation, etc $30.68 Supplies and apparatus 203.73 Transportation 4. 85 239. 26 Instruments for clinic 141.52 Microscopes 91.00 Slides, covers, and miscellaneous 50. 52 Transportation 3. 66 145. 18 180 UNCIWABIASIS IN PORTO RICO. Postage and telegrapliiug $44. 84 Miscellaneous 36. 92 10, 808. 77 Appropriated by municipality of Aibonito, expended for labor of installation 100. 00 Total cost of six months' work^ 10, 908. 77 Average cost per patient, 57.82+ cents. Complications and intercurrent diseases. CENTRAL STATION, AIBONITO. Tropical diseases: Filariasis ; 7 Clinically diagnosed. Elephantiasis , 2 Chronic ulcer of the leg 31 Loosely termed " anemic ulcer," " tropical ulcer," etc. Often due to severe secondary in- fection following mazamorra. Dysentery 22 Confirmed as amebic dysentery by microscopic examination in several cases. The type was usually chronic and the clinical picture was the same. All were probably due to ameba coli. Bilharziosis recti 5 Diagnosed by microscopic ex- amination. Malaria ,__ 29 Included here because tropical forms predominated. Almost always diagnosed by micro- scopic examination. Unknown ] This disease, to which reference was made in the last report of this commission, is termed " La H e r m o s u r a " ( " The Beauty " ) by the country folk and is characterized by ana- sarca, fever, and tendency to fatal termination. There may be no albumin in the urine and even no anemia. It is re- garded by some as a form of acute uncinariasis. Affections which may be in some man- ner related to uncinariasis: Icterus 4 Stomatitis 2 Cataract 11 One of these cases was a boy of only 12 years of age. The cataract was complete and not congenital. Night blindness 2 Probably many more existed, but the question was put to but few patients. We have no- ticed that it is not an infre- quent condition. Affections which may be in some man- ner related to uncinariasis — Cont'd. Nystagmus •. 4 Retinal hemorrhage 1 Partial amaurosis 7 Pathological condition not known. Vicarious menstruation 1 Gangrene of legs 1 Due to failing circulation and extreme oedema. General infectious diseases : Pulmonary tuberculosis 32 Not a very frequent disease in the country. A large propor- tion came from the town. Tuberculosis of the larynx 2 Tuberculosis of hip joint 1 Scrofula 1 Lupus 2 Cervical adenitis, tubercular.. 3 Tuberculosis, elbow joint 1 Gastric cancer 1 Epithelioma nose 1 Syphilis, acquired 3 Not as infrequent as these fig- ures would seem to indicate, as only well-defined cases were noted. It is not, however, by any means common in the country and is even very rare in certain localities. It is rather common in the towns. Syphilis, congenital 1 Gonorrhea 6 Trachoma 1 1 Said to be very common in some schools in other parts of the island. Echinococcus of liver 2 Diagnosed by microscopic ex- amination. Typhoid fever 3 Other diseases and conditions: Nephritis 5 Pyelitis 1 Renal calculus 1 Hypertrophy of prostate 2 Vesical calculus 1 Metrorrhagia, cause unknown- 1 Hematuria, cause unknown— 1 Not due to fllaria nor to bil- harzia. UNCINAllIASIS IN PORTO EICO. Complications and intercurrent diseases— Continued. CENTRAL STATION, AiBONiTO— Continued. 181 other diseases and conditions— Cont'd. Hemorrhoids 3 Rhinitis, chronic I 1 Cystitis, chronic I 1 Diarrhea 144 Many of these cases were un- doubtedly dysenteric in char- acter, but as nearly all of these complicating diseases were brought out in the visits made by out-patients, we have been unable to do more in these instances than take the patient's statement as to the symptoms and character of the stools as observed by him in his home. The source of these gastro-in- testinal affections, in the vast majority of instances, is the use of impotable water from one of the sources of water supply in Aibonito. The citizens of this town have promptly subscribed the money for an aqueduct which will contribute largely to make the town one of the healthiest on the island. Note. — This aqueduct has been in operation since 1906, since Other diseases and conditions— Cont'd, which time epidemic diarrhea, dysentery, and typhoid fever have not existed. Cirrhosis of the liver 1 Tonsillitis 3 Hematemesis, cause unknown. 1 Pneumonia ] Asthma 4 Epilepsy 7 Hysteria major 7 Chronic rheumatism 4 Exophthalmic goitre 2 Otitis media 4 Corneal ulcer 1 Conjunctivitis 1 Bronchitis 2 Syringomyelia 1 Chorea 2 Insanity 1 Neuralgia 4 Spastic paraplegia 2 Psoriasis 2 Eczema 2 Vitiligo 2 Hernia , 1 Harelip 3 Polydactilia 3 Deaf mute 2 Microcephalus 1 Dwarf 1 SUBSTATION., TJTUADO. Syphilis , 2 Malaria Nephritis 7 Idiot Epilepsy 1 Asthma Chronic rheumatism 13 The director of this station has made a special study with regard to the num- ber of women suffering from uncinariasis in whom the symptom amenorrhea was present. This number was 159. 3 1 1 SUBSTATION, LARES. Influenza 4 Malaria 7 Puerperal fever 1 Bronchitis Impetigo contagiosa Chronic articular rheumatism- SUBSTATION, BARROS. Chronic articular rheumatism 3 Valvular lesion of the heart 3 Asthma . 3 Pulmonary tuberculosis 1 Dysentery 1 Scrofula 2 Malaria 2 Hysteria major 2 Stomatitis (aphthous) — _ 1 SUBSTATION, COMERIO. Dysentery 1 2 Malaria 23 Hemorrhoids — ' 1 Aathma 2 Ulcer of leg 1 Chronic rheumatism 2 Scrofula 1 Metrorrhagia 1 1^2 ITNCINARIAStS IN PORTO McJO. Complications and intercurrent diseases — Continued. SUBSTATION, GTTAYAMA. Filariasls 2 Gangrene of penis and scrotum 1 Blepharitis ^ 1 Hysteria major 1 Ulcer of leg 9 Pulmonary tuberculosis 4 Typhoid fever • 1 Syphilis 1 Einterocoliitis 1 Measles 2 Epilepsy 1 Renal calculus 1 Impetigo 1 Nephritis, chronic 1 Osteoperiosteitis 1 Gonorrhea 1 SUBSTATION, COAMO. Malaria 20 Enterocolitis 18 Laryngeal tuberculosis 1 Valvular (aortic) lesion heart 1 Cirrhosis of the liver 5 Asthma , 2 Nephritis, subacute . 1 SUBSTATION, SAN SEBASTIAN. Malaria 32 Enteritis 13 Dysentery . 8 Influenza 15 The following is quoted from an article written by Drs. Ashford and King, and read by Dr. Ashford at the Boston Medical Library meeting February 6, 1907, entitled " Observations on the Campaign against Uncinariasis in Porto Eico." It was published in the Bos- ton Medical and Surgical Journal, Volume CLVI, No. 14, April 4, 1907, but we cite it here as it was part of the work of the Porto Rico Anemia Commission of 1905-6, and deals with some very im- portant scientific points not brought out in previous reports for lack of time in which to prepare this material for publication : ******* Not only have we been able to experimentally corroborate skin infection, but we feel justified in saying that this Is practically the only way the worm enters the body. We have never found a case which was clearly due to ingestion of the larvae. The inhalation of infected dust does not merit consideration, as drying almost Instantly kills them. On the other hand, we have seen that 96 per cent of 18,865 patients have acknowledged to having had an afCectlon known the length and breadth of Porto Rico as a special and peculiar condition, not confounded with any other by those exposed to it, always acquired from con- tact of the bare but healthy skin with mud or muddy water, " mazamorra " or "ground itch." This mazamorra and the anemia of Porto Rico are always found together, and both are seen in exaggerated degree where the most perfect conditions for the development of the larva from the egg and Its subsequent desiderata, constant moisture and shade, are found— the coffee plantation. On the other hand, both mazamorra and anemia are generally conspicuously absent among those who wear shoes. The following experiment brings out in this connection a very interesting point and also demonstrates that we have In the guinea pig an animal capable of being infected by Necator americanus, a fact likely to be of value in future experimental work. On the 1st of March, 1906, the feces of a newly acquired servant of the com- mission, heavily laden with eggs of uncinaria, was mixed in a Petri dish with such quantity of sterile sandy earth as to remove much of the offensive odor, a proportion of about 1 part of feces to 2 of earth. Water in sufficient quantity to give the consistency of mud was added, the dish covered and set away in the shade. On the 4th of March larvse were very plentiful to every field of a No. 3 Leitz objective. Some were moving lazily but the majority were apparently dead and lying fully straightened out. The immersion in excess of water of those which were before active brought all movement to a standstill. This effect was noted in about 15 to 30 minutes. UNCINABIASIS IN PORTO EICO. 183 On the 5th of March the dish having been slightly tilted overnight and about two tablespoonfuls of virater added, all larvse in the water which had collected at the lowest level of the dish were motionless and straight, while those in the damp mud above this level were exceedingly active and encapsuled. March 8 we found changes in the larvre in the water which showed us that they were. dead. Those in the damp earth were just as lively as before. We took a 4-day-old guinea pig, reared under conditions where infection by uncinaria was practically impossible, clipped the hair from its back without subsequently shaving the area, made a mud poultice in cheese cloth about the size of a silver dollar from the upper part of the contents of the Petri dish in which the larvffi were found so active, and bound it gently on the animal's back, the pig being held for a half hour by the feet and head to avoid contact of its mouth with the mud. At the end of that time the spot was appropriately cleansed, rubbed well with absolute alcohol, and the animal returned to its cage. The behavior of the pig after the first 5 or 10 minutes was remarkably sug- giestive, as he squealed and squirmed with unmistakable desire to scratch. March 9 the same procedure was repeated, the gentleman who had stocked the culture officiating as guard over the animal's feet. The same struggling took place in about the same time, and the man remarked, with an appreciative grin, that the pig was suffering with mazamorra. On March 10 the same application was made. The pig seemed well. Abso- lutely no uncinarial dermatitis had developed in these three days. That night the pig died ; the jibaro said that he had noticed him about six hours before, and that he had a very blue nose and seemed triste (sad). Necropsy. — No edema ; skin at site of infection, stomach, intestines, peri- toneum normal. The kidneys and the liver were violently congested, but showed no larvse. On opening the chest the cause of death was seen; the lungs were hemorrhagic. One lung was solid with blood and the other filled with dark-red, almost black, spots. One of these spots was excised, crushed between two slides, and examined with a No. 3 Leitz objective. Ten encap- suled larvae were found, all very active, wriggling with an exceedingly violent movement. They seemed to overcome by their enormous strength all obstacles, breaking up lung tissue wherever it opposed them. The larvee seemed to be in the alveoli and are prone to seek little pools of blood. . , J! J The heart's blood was examined without result. Nothmg else was found to be abnormal. . ^ ^ ^ •<- k A very interesting deduction, among others more important and quite ob- vious, without any special attention being drawn to them in this paper, is that the so-called "natural cure," to us a rather trying process with so sure and rapid a remedy as thymol, is possible in a heavily infected country. Provided that stout shoes are worn and further uncmarial dermatitis avoided. The fact that the ova of uncinaria never develop into larv^ m the intestme of the hog, coupled with the fact that we have not seen infection to occur save by the skin not onTy explains why patients sick of anemia in the fo^^tams gradually get well on taklne UD their abode in the cities of the island, where the niud of . rtrL^evertlouy subject to occasional eontamination is subject«l to fatal to the life of the larvffi. It explams why the ^oWiws of the Poito R.can regiment, almost universally infected on Presenting themselves foi their fir^ enlistment, but not to an extent to be noticeable, ^.^ thus to incapacitate them from acceptance in the physical examination for t^^^ service are sucbpeitect specimens of manhood after a few years, f ?^J° l«f /fo^d fnd solicitous care were compelled to wear shoes ^^^drfeived the ample food «ff' ^^^^^ou^ ,„^. can be done by the redemption of the Porto liican j^ibaio. ^ ^ The* food of uncinaria i^* ^^o^^.^^^Z'^'Ts^ ^^T^t^fs 'a^hoTograS almost diagrammatic, photograph of tHe woim m sita x ^ ^^^^ tUe of one of a number of ™cinari^ which we remojed from the ca^^ ^^ ^^.^^ ^^^^ parasite was still alive and feeding with a P0™°'^ "/ alcohol These specimens were attached. They were d/opped immediately ^^to^l^^^f ^^3^ ^t the Army were imbedded and sectioned very sk;llfully by Dr w^^^- ^jj^^^^^ „ j,lni_ Medical Museum, and the accompanying P^ot^f f P"^„!^" „u as were all others we take pleasure in bemg able to show you. 184 UlfCINAMASIS IN POBTO RICO. There are, at least, two valuable lessons to be learned from a careful inspec- tion of these photographs of the worm in situ : (1) The lesion is practically confined to the mucosa. (2) Although the ani- mal had drawn Into his mouth the submucosa, which has become completely denuded of epithelium, among the contents of the intestine of the parasite the conspicuous objects are epithelial cells — ^not red blood cellB. The picture here shown corresponds in every ijarticular with a 'previous description and photograph published by Loos in " The Anatomy and Life His- tory of Ankylostoma duodenale," Records of the Egyptian Government School of Medicine, volume 3, Cairo, 1905. We feel obliged to conclude that the epithelium lining the intestinal canal of the host furnishes the normal food supply of Necator americanus, Just as he previously describes it to be that of anlcylostoma duodenale. In conclusion we wish to note that in the immense majority of about 80,000 unclnarise counted personally by us in the stools of our patients after the admin- istration of the anthelmintic, as well as in those attached worms foitnd in the Intestines at necropsy, the worms did not appear to contain blood, but were generally grayish white. In fact, this peculiarity was made use of in the device adopted for their recovery ■ from the stools, which were washed slowly down a trough painted black, the stool having first been filtered through gauze. In a report on ankylostomiasis by Lobker and Bruns, 1906, we find the following : " The views of Loos were substantiated by Schaudinn, after a careful reex- amination of a large number of Leichenstern's sections, when the intestinal contents of the ankylostoma were microscopically examined. Among 300 worms selected at random, he found 196 whose intestines contained cell fragments ether than blood cells. In the remainder he found either nothing or else blood cells to a greater or lesser amount. Repeatedly long strips of Intestinal mem- brane were traced, completely extending from the mouth through the alimentary canal into the intestine of the worm." This is Important Information when we remember that Leichtenstern was the observer of all observers who was most identified with the teaching that anky- lostoma duodenale was not only a bloodsucker, but was so prodigal of his food that he consumed blood entire to appropriate only the serum, evacuating blood cells practically unchanged. For this the noted authority dubbed the worm " the luxurious parasite." The urine in uncinariasis before and after treatment. — In the first report of the Porto Rico Anemia Commission it is stated that albumin is rarely found, although note Is made that the kidneys may be very pale and slightly fatty, sometimes being the seat of parenchymatous or interstitial inflammation, some- times of amyloid degeneration, but, generally speaking, without marked involve- ment of these organs. We would like to considerably modify our former opinion. It was based on the examination of a series of cases, but was not made, as was the blood a matter of special study. Inasmuch as Heller's nitric acid test and the absence of chnical evidence gave us no clue to the real condition. It is significant that writers on uncinariasis make practically the same statement. As a matter of fact the condition of the kidney in a well-marked case of uncinariasis is of the greatest importance, as will be shown. We noted the irritant effect of the anthelmintic drugs employed upon the digestive tract and found albuminuria after their administration, in accord with the experience of Lobker and Bruns, Calmette, Siccardi, and others with thymol and male fern Our plan for 1905, among other things, was to make a careful study of the therapy of uncinariasis and to that end a series of cases was studied in which the uncinarise expelled were counted after each anthelmintic dose. This, together with manifold other duties, consumed about all the time available from the actual administration of so large a work as the treatment of some 25,000 pGrsous. From the first, however, our attention was attracted by one case to the im- mediate and imperative duty of more carefully investigating the urine This was one m which nephritis occurred during treatment. Naturally, the first thought was Has the new anthelmintic, beta-naphthol, said to be at times a renal irritant, anything to do with this condition?" The second "Is there a latent renal lesion present in the disease?" To determine these facts an addi- tional series of cases were taken and our results follow with conclusions; but before considering these tables a few explanatory remarks should be made : It was manifestly out of the question, for lack of time, to make complete quantitative urinalyses as we desired. The day was so split up by other work Ill < O (- 2 O • TJNCINAE.IASIS IN POBTO RICO. 185 and other investigation that it was decided to elicit certain facts only, and these with great care, so that a definite conclusion could be reached. It was evident that an examination of the urinary sediment, as well as a determination of the presence or absence of albumin, should be made. In order to offer a series of cases carried far enough to furnish evidence that would be satisfactory, the continued presence of the patients in hospital was necessary, and this was precisely the most difficult part of the problem, as when they felt better they clamored to go back to work and stood not on the order of their going, but frequently went, spoiling for us many hours of toil. The original number of such cases is, therefore, reduced to 24. The practical impossibility of obtaining the 24 hours' urine and the numerous time consuming details to which we were obliged to attend personally, prevented us from mak- ing urea estimations. One of the occasions at which the urinary examination was needed was that at which purges had to be administered, and with the small force at our disposal collection of all the urine was impracticable. The invariable custom was to examine the urine on the day before and the morning of the day of treatment, before the anthelmintic was given ; then the afternoon urine on the day of the specific drug and the morning after. Thus there were two examinations before and two after each administration of the anthelmintic and the samples were faithfully taken at the same time by our trustworthy nurses in the field hospital. Albumin. — Three tests were always used at each analysis: (1) The boiling of urine with a drop or two of acetic acid to six parts urine and one part saturated salt solution, the test tube nearly full and the upper half boiled to compare with the unboiled lower half in a good light -against a dark background. We were aware that a very faint clouding could be thus obtained In many normal urines. (2) The ferrocyanide of potash test. (3) Seller's nitric acid test. When the first was faintly positive and the last negative, a slight trace was noted ; when the latter was positive in a faint but cha-racterlstie ring, not disappearing on heating, a trace was noted. Only a very few times was albumin found in considerable amount. Ordinarily the amount was so small that its percentage could not have been determined by the Bsbach albuminometer. The sediment was collected after standing some hours in conical test glasses and the urine was not centrlfugalized. The casts were generally of the smaller varieties, hyaline and finely granular forms predomi- nating Blood casts were not seen in this series and epithelial casts were un- common. Fatty casts were quite often noted. The presence of polymorphonu- clear leucocytes was at times discovered before the administration of tlie anthelmintic, and there was a tendency for them to appear, sometimes m fair numbers, afterwards. Eenal cells were not a very marked feature and were almost always scarce. ^ ^^ ■ ^ i„„i^„ to=f Urobilin was almost always present, fiuorescence by the zinc-chlonde test being elicited, but it was often remarkably slight Peptones in traces were found to be inconstant, but often demonstrable. Indlcan in abundance, as Siccardl recently states, was a very constant and persistent phenomenon. Bile Digment was relatively rarely found. „ , ,. 4.. „„„„ rmost^mterestlng fact was the invariable absence of the f^f -reaction save immediatelv after the administration of beta-naphthol, m 1 or 2 gram aoses, ™ it never failed Its presence was demonstrable three to fo™ . ^ours Tfter the dose and its effect lasted five or six hours. The next day it was afwavs absent When it was present it was beautifully pronounced and was an SLg evidence of whither or not the drug had been taken. The color of medication. Sugar was not - m O o 2 UJ ViirCINAfi,IASlS IN I>OftTO &ICO. igij brfnA^nL°'?™r"^K^/^® ^i""^' "''^^^ ^^ increase in albuminuria and often svmntnmf • L'^'"'''^.*'^*'"'^ '^ ^^'^ ^'^'^^'^t, their effect is temporary, causes no ^S^^^'l™^ '"? *^e ^*>«t majority of cases, and is rarely of importance oK„ ■^'^*^''s IS almost always an absence of inflammatory elements after tho above-mentioned increase in albumin. ^ elements after the 11' Zt^^ rarely they may set up a severe nephritis. +^7^ '^'^?^^ herein cited show that both drugs seem to have an equal nower nuXr'^nf " albuminuria with tube casts, but our experience o'^er a TaTge hafa ve?v 3h f «°^f strates to us that, all things considered, beta-naphtho! as thvZf Z V-^^^ favorable action on the kidney, and that it is not as safe ThJmn?^hi }^'^ '■^''^°''' although Its depressant effect is not so marked. 10 ' ™ '^^^ experience, caused fatal collapse. 12. Albuminuria does not always seem to depend upon the grade of anemia Id. AlDuminuna and the changes found in the kidney after death may be aue to a specific toxin elaborated by uncinariEe, but where severe anemia exists such an explanation for the condition is hardly needed. 14._ Uremia in Porto Kico is not uncommon, but is rarely seen by a physician and xs confused by the jibaros with " nervous attacks " of all kinds particu- larly with the very common hysteria major. Epilepsy is not uncommon, and we are persuaded! that sometimes this diagnosis would suffer a change on examination of the urine. We know of several instances where there was good ground for believing that the attacks were uremic in character. 15. Emphasis must be laid on the fact that the albuminuria of uncinariasis is extremely Irregular, coming and going without the slightest apparent reason. 16. Renal accidents from the use of the anthelmintics under consideration are not generally serious and are still more rarely fatal. The great severity of the present epidemic and the high mortality should make us disregard the remote danger to the patient from the use of thymol. 17. The use of beta-naphthol should be restricted to very few doses, and its administration should be limited to patients in extreme grades of the disease, on account of its less depressing effect on the vital centers — until enough uncinarise are expelled to create a favorable teaction and enable us to use thymol. How- ever employed, a dose of 2 grams should not be exceeded and no more than three successive doses given — one each week. In another article, entitled " Uncinariasis : Its development, course and treatment," by Drs. Ashford and King, read in the section on practice of medicine of the American Medical Association at the fifty-eighth annual session, held at Atlantic City, June, 1907, and published in the Journal of the American Medical Association August 10, 1907, Volume XLIX, pages 471^76, we deal with the gross morbid anatomy and microscopic changes revealed in the tis- sues of persons dying of uncinariasis in the stations of the commis- sion in the fiscal year 1905-6. These studies were pursued in Wash- ington during the work of the commission of 1906-7 in Porto Rico, but pertain to the work of the year 1905-6. We quote from that article as follows: MOBBID ANATOMY. Despite the great amount of literature on uncinariasis in recent years, no sublect is so barren of data as its pathologic anatomy, and yet this is decidedly one of its most interesting and instructive features. Not only are uncompli- cated cases, suitable for the drawing of conclusions, difficult to acquire but the consent of the relatives to autopsies is by no means easy to secure. Above all deaths occur far out in the country, and usually before an autopsy can be performed post-mortem changes are well advanced. The latter obstacle was OUT most troublesome one, as the death rate in our field hospital was very small • indeed, it was but one-third of 1 per cent for the entire number of 18,865 treated between May and December, 1905, at all stations combined. In spite of these difficulties 11 out of 12 autopsies were made m such manner as to furnish accurate information, in so far as the gross anatomy is concerned; TsuDPlled us with tissue In a very good state of preservation for microscopic study The minute anatomy of the other 2 is not included on account of the length of time after death at which the autopsy was made. Of the 9 specified 188 UNCINARIASIS IN PORTO RIOO. above, 1 subject was 5 years of age and had never received any anthelmintics, 1 was 14, and the remainder between 25 and 50. Six showed extreme anemia, 1 other was an intense case, and 2 more were moderately severe. Only 2 were complicated by other conditions ; in 1 a healed lesion of pulmonary tuberculosis was found; the other presented the Intestinal lesions of amebic dysentery. Nothing was shown in the latter to invalidate our conclusions. GENEEAL OBSERVATIONS. As a rule, the body shows no emaciation, and the amount of adipose tissue is apparently normal. There Is not only much edema, but all soft parts, including skin, muscle, and internal organs, have suffered great change in color, due to the nitense anemia. The skin and subcutaneous tissue are very pale and sodden with fluid. The muscles are brownish gray, friable, and often atrophied. On microscopic section the individual mus<^ cells are frequently separated, and the protoplasm seemingly starved and reduced in amount, an observation which, indeed, applies to nearly all organs. On opening the abdomen, an excess of pale yellow or straw colored peritoneal fluid is observed, the amount reaching enormous quantities in certain cases where ascites is a prominent feature. In one of our cases this serum was reddish yellow, but no adhesions or other signs of inflammation were found. Serous efCusion is also generally demonstrable in the pleurae, pericardium, and sometimes in the cerebral ventricles. THE HEART AND LUNGS. There was often hypertrophy, although not rarely a heart of normal size was encountered. It was not unusual to see an excess of pericardial fat. Not uncommonly, however, dilatation had occurred, and the organ was remarkably flabby and easily torn. Microscopically in two of three autopsies brown atrophy was well marked, and a slight degree of myocarditis was discovered. Fatty degeneration of the muscle fiber was clearly seen in two cases after fixation of the tissue by Fleming's solution. . The separation of individual cells was particularly noticeable and this was irrespective of the fixing reagent employed. The lungs were frequently the seat of oedema and passive congestion. THE LIVEB. This organ was practically never normal. Great increase in size was only once discovered, although never was there diminution. Its most frequent color was a light brownish yellow. In some cases it was very light yellow, soft and greasy to the touch and extremely friable. Microscopic sections dem- onstrated that it was often extensively 'affected in uncinariasis. Extreme fatty degeneration was the prominent feature of four cases, and in two scarcely a normal liver cell could be found, the condition of the liver here simulating marked types of fatty changes in other diseases characterized by such changes. In none of our autopsies was fatty degeneration absent. In its least exag- gerated form it chiefly affected the outer third of the lobule. In three cases there was increase of connective tissue in the portal space^ but in two of them the change was only slight, and in at least one, where there was great increase, the condition was probably due to chronic alcoholism. Connective tissue increase is evidently not a feature of uncinariasis. Daniel's observation that the liver contains considerable yellow pigment could not be confirmed save in one case, although small amounts were found in others. The pigment was not stainable by potassium ferrocyanid. Extreme dilatation of capillaries was found in two cases. THE KIDNEYS. These organs were also profoundly involved. They were very pale arid were apt to be slightly enlarged. As a rule, the capsule stripped easily. Microscopic sections showed us a practically constant picture of chronic parenchymatous, or chronic diffuse nonindurative nephritis. In persons of middle age who had suffered for some years from uncinariasis, there was increase in connective tissues, but this was marked in only one case. Usually there was little or no connective tissue increase and polymorphonuclear leucocytes were conspicuous by their absence. SAME SPECIMEN HIGHLY MAGNIFIED, SHOWING HYALINE DEGENERATION OF THE COATS OF THE CENTRAL ARTERY AND REDUCTION IN LYMPHOID ELEMENTS. I I- z UJ o a UJ II. I a < lu O z" z u- - O O o < I D. UNCINARIASIS IN POETO KICO. 189 Changes were always found In tubules and glomeruli, but the convoluted tubules sufCered most severely, and fatty degeneration and desquamation In them was marked. The collecting tubules were much less affected. There was extensive exudation into Bowman's capsule, with desquamation of its endo- thelial lining and much dilatation of the intracapsular space. Hemorrhages into Bowman's capsule, intertubular hemorrhagic areas, and blood and epithe- lial casts, were found in four of the nine bodies sectioned, and the picture was that of an acute condition superimposed on the usual chronic one described. AH four of these had received betanaphthol. In one case, yellow pigment was found, but only in small quantity. In two instances embolic abscesses existed. STOMACH. It was not usual to encounter uncinarise in the stomach, although 83 were found in its lumen in an autopsy previously reported by us.* We discovered several adherent to the wall of this organ in this year's series. A gastric catarrh was common and marked dilatation was noted in two subjects. INTESTINE. The jejunum contained most of the uneinarife found at autopsy. Some were unattached, others were adherent to the mucous membrane. In the first part of the duodenum were to be found most of the rest, a few being discovered in the ileum. None were encountered in the colon. In more than one instance the parasites were alive 12 to 15 hours after the death of the patient, whether attached or free. They were rarely red, generally white or grayish. On one occasion they were removed with some little force by fine forceps and placed in physiologic salt solution, where they lived and remained active for about 60 hours longer and then were killed for experi- mental purposes. The lesion of the intestine is confined, as far as we know, to the mucosa. It was found to be a tiny superficial erosion, not a deep ulcer, as many suppose, about 0.5 mm. (1-50 inch) in diameter and not usually characterized by any redness, save at one autopsy (1905). These erosions were very diflicult to find without a hand lens, unless a parasite had just been removed from its feeding ground, and the locality marked. The duodenum, and especially the jejunum, are the seats of a chronic intestinal catarrh, and many times after we supposed that all parasites had been removed in the course of the examination of the intestine at autopsy many more were found buried in the thick mucus which more or less completely covered them. The rest of the intestine, and even the colon, is apt to share in less degree in the general chronic inflammation. Degeneration and atrophy of the mucosa of the intestine, as well as of the stomach, were commonly observed. We have purposely left to the last a consideration of the really striking changes in the spleen, hemolymph glands and bone marrow, as these are marked and, until now, neglected in all treatises which we have read on uncinariasis. The greatest number of uncinarioe are to be found in the upper and middle thirds of the jejunum. We have found them also in the duodenum and jejunum. We have not observed many worms to be attached at the time of autopsy. At our autopsy cited in American Medicine, September 12, 1,487 uncinaria> were found — 83 m the stomach (possibly dislodged in the manipulation), 169 in the duodenum, and the rest in the jejunum. Perhaps this discrepancy may be explained by the fact that the hooks of the old-world species are the cause of their adherence to the intestinal wall. We have not seen fatal cases with few parasites unless death was due to com- plications. We have not observed that the lesions described by Roth and others are so prominent in infection by Necator amerioanus. Roth describes them as ashen-gray nodules, 0.8 mm. in diameter, with a red center 0.3 mm. m diameter and surrounded by an indurated area. In our autopsies the feeding ground of Necator americanus can easily be passed over without being noted. As to blood in the intestines, we have never found it. Not even have we found blood- stained mucus. That it occurs is seen from the numerous reports of others. (The next year blood-stained mucus and tiny red points were found at one autopsy. ) ^__ ^ Amer. Med., Sept. 5 and 12, 190.3. 190 UNCINAKIASIS IN POBTO BICO. THE SPLEEN. Most authors state that the spleen is not enlarged, but lead us to believe that it is normal. As a matter of fact, the spleen frequently Is reduced In size, soft, ^nd possesses a wrinkled capsule. Dr. Rafael Oesteros, of Guayama, Porto Eico, the director of the commission's substation in that city, reporting on one autopsy, writes of this organ as follows : " The atrophy of the spleen attracted my attention. It was as small a spleen as I have ever seen in my professional career, and at no autopsy, whether made for scientific or for medico-legal purposes, have I encountered this organ of such reduced dimensions. Its color was that of wine lees and its size was not greater than that of the kidney." Microscopic sections revealed in every one of the eight autopsies in which a portion of the spleen was preserved, a great paucity of lymphoid elements, even decided decrease in the protoplasm* of the cells. The Malpighian corpuscles were greatly reduced in size, the cells were scanty and widely separated, and the central artery presented, almost uniformly, considerable hyaline degenera- tion. Not only were the tufts smaller than normal, but they seemed fewer in number. The apparent increase in connective tissue we explain by the decided reduc- tion in lymphoid elements and blood, and it seemed relative rather than abso- lute, although in some instances thickening of the capsule was observed. Pigmentation was only once very prominent, and the pigment was of the same character as that seen in the liver. There was unusually little blood in the organ. HBMOLYMPH GLANDS. The following notes were made by us at one of our autopsies : " Great abundance of glands in the region of the abdominal aorta was noted, especially at its bifurcation. They were enlarged, and of a dull reddish hue, like pale muscle tissue. Some of these glands were as large as hazel nuts, yet there was not a trace of inflammation in the surrounding parts, and the peritoneum over them was normal and glistening." They were only sought for in one other autopsy, and then were found with the same characteristics, but in smaller number. Microscopic section showed that they were hemolymph glands, usually of the type described as splenolymph glands. Mitoses and phagocytoses of red cells were noted. BONE MAEEOW. The marrow of the midpoint of the shaft of the femur was examined In two autopsies. It was grayish red and very soft. Microscopic section disclosed. In addition to the changes described in the marrow of subjects dying of pernicious anemia, groups of eosinophilous cells, generally myelocytic. These cells were abundant, as were myeloplaxes. No attempt has been made to describe in detaU the changes to be found in the organs referred to in this brief summary. < CO _i I CL ° t _1 z O 111 > o a HI z 0- o i> 5 D UJ QJ U UJ ■ I- c/) u. < ; < O : I a H — (/) 5< UJ o z z o < THE THIRD REPORT OF THE PORTO RICO ANEMIA COMMISSION. COMMENT UPON THE REPORT OE THE COMMISSION FOR 19 06-7. The authorized edition of this work was the Spanish edition. The chairman of the commission intrusted the labor of translating it to persons whose knowledge of the English language was limited and the result is that we have to request all who have read the English edition to discard it and accept the one which herein follows, as many incorrect ideas of the campaign during this year might be formed from the poor translation to which it was unavoidably sub- jected. Even as it is here, it is far from satisfactory, but at this late date it is impossible to make any radical changes in this large work, which has already consumed over six months in preparation. The chapter entitled " Notes contributing to the study of uncinari- asis " has been greatly reduced by omitting material contained in two articles written by Drs. Ashford and King, entitled " Un- cinariasis, its development, ccfurse, and treatment " and " Observa- tions on the campaign against uncinariasis in Porto Rico." These articles were cited separately, as they were published first in the medical journals. The report has been also further reduced by the omission of the large amount of statistical data, which is elsewhere summarized, and by the reproduction of only about one-tenth of the substance of the reports of the various directors of anemia stations. LETTER OF TRANSMITTAL. San Juan, P. R., September 30, 1907. Sir : We have the honor to transmit herewith a report of the work performed by the Porto Rico Anemia Commission during the fiscal year 1906-7. , ^ , , In this report we set forth the plans adopted by the commission to check the advance of uncinariasis in Porto Rico, the statistics con- cerning the cases under treatment at the several stations in the island, the scientific and more important data acquired by the study and treatment of the disease, an itemized statement ot the expenses of the commission up to June 30, 1907, and suggestions for educa- tional and sanitary measures that should be taken to extirpate ttiis ^ T^e^'work of the commission and that of the stations has continued uninteiTuptedly during the preparation of this report^ and the cam- 192 UNCINARIASIS IN PORTO RICO. paign against the disease we are trying to check is also going on without intermission during the current fiscal year. Very respectfully, P. Gutierrez Igaeavidez, M. D. I. Gonzalez Martinez, M. D. Francisco Sein Sein, M. D. Hon. Eegis H. Post, Governor of Porto Rico. AN ACT TO CREATE A PERMANENT COMMISSION FOR THE SUPPRES- SION OF uncinariasis in PORTO RICO. Be it enacted hy-the Legislative Assembly of Porto Rico: Section 1. For the suppression of the disease known as tropical anemia or uncinariasis in Porto Rico, there is hereby created a com- mission which shall be known as " The Porto Rico Anemia Commis- sion." Said commission shall be composed of a director and two assistant directors, who shall be qualified physicians, and shall be appointed by the governor, with the approval of the executive council, for a term of four years, and until otherwise provided by law, shall receive, the chairman two thousand five hundred dollars per annum and the associates two thousand dollars each per annum. Sec. 2. It shall be the duty of the said commission to use all means in its power to prevent, combat, and suppress the disease known as tropical anemia or uncinariasis in Porto Rico, and for this purpose it is directed and authorized to establish and maintain a central station and such substations and dispensaries as, in its opinion, are necessary and are within the resources at the disposal of the com- mission for the treatment of persons suffering from uncinariasis, and to take such other action as, in its opinion, will contribute to the suppression of this disease. Sec. 3. The work of said commission shall be under the direct supervision of the governor, whose approval of all regulations of the commission, of the appointment of all physicians, employees, and other assistants, and of the expenditure of all moneys placed at the disposition of the commission, shall be required. No money shall be expended for the construction, repair, or rent of buildings to be occu- pied as stations, substations, or dispensaries, but it shall be the duty of the commission to seek the cooperation of the municipalities in its work and to secure from them the quarters needed by it, and such other assistance as the municipalities are willing and able to give; the commission may seek, in order to carry out its work, the coopera- tion and assistance of the oflEicials of the bureau of health of the insular government. Sec. 4. All property that has been acquired heretofore by the commission working for the suppression of uncinariasis in Porto Rico and belonging to the people of Porto Rico, and all records of said commission shall be turned over to the commission created by this act. Sec. 5. To carry out the purposes of this act there is hereby appro ^riated, out of any money in the treasury not otherwise appropriated, for the balance of the fiscal year ending June thirtieth, nineteen hun- dred and six, and for the fiscal year ending June thirtieth, nineteen Jmudred aiicj ggyen, the sum of fifty thousand dollars. trNCINAMASIS IN PORTO RICO. 193 Sec. 6. This act shall take effect from and after its approval. Approved, March 8, 1906. POETO KICO ANEMIA COMMISSION. Honorarv mem&ers.— Dr. B. K. Ashford, captain, assistant surgeon United Mates Army ; Dr. W. W. King, passed assistant surgeon, United States Public Health and Marine-Hospital Service. Chairman.— Dt. P. Gutierrez Igaravidez. Associated members. — Dr. I. Gonzalez Martinez, Dr. F. Sein y Sein. Assistant physicians. — Central station, Rio Piedras, Dr. J. Marcano; dis- trict station at Mayagiiez, Dr. M. Dueuo; district station at Lares, Dr. J. Benet Valdes. Directors.— Station at Bayamon, Dr. A. Stahl ; station at Vega Baja, Dr. J. H. Amadeo; station at Guayama, Dr. E. Cesteros; station at San Ger- man, Dr. P. Malaret; station at Utuado, Dr. M. Roses; station at Ponce, Dr. A. Ferran; station at Coamo, Dr. L. Igaravidez; station at Comerio, Dr. M. De La Rosa ; station at Manati, Dr. F. B. Oordero ; station at Aibonito, Dr. E. Oanino ; station at Morovis, Dr. P. Rivera ; station at San Sebastian, Dr. J. A. Franco ; station at Juncos, Dr. P. Palou ; station at Oorozal, Dr. A. Bou De La Torre; station at Yauco, Dr. R. Gatell; station at Barros, Dr. G. Santo Domingo; station at Barranquitas, Dr. F. Vizcarrondo; station at Isabela, Dr. L. Gronzalez Garmendia ; station at Quebradillas, Dr. V. Roure ; station at La,s Marias, Dr. A. Oms ; station at Humacao, Dr. I. Vidal ; station at Caguas, Dr. V. Gutierrez Ortiz ; station at Anasco, Dr. E. Casaldue ; station at Arecibo, Dr. F. Susoni ; station at Arroyo, Dr. E. Garcia Lascot ; station at Vieques, Dr. G. Carrera ; station at Cabo Rojo, Dr. A. Gaztambide ; station at Cayey, Dr. F. Izquierdo ; station at Aguada, Dr. J. Garriga ; station at Aguadilla, Dr. B. Jimenez Serra ; station at Adjuntas, Dr. C. Caballero ; station at Fajardo, Dr. J. A. Diaz. PLAN ADOPTED BY THE PERMANENT COMMISSION FOR THE EXTERMINA- TION OF UNCINARIASIS IN PORTO RICO. The commission which had been engaged in the study of anemia in Porto Rico in 1904 and which had continued its labors throughout the following year was dissolved March 30, 1906, upon the return to their respective services of two of its members — Dr. B. K. Ashford, of the Army, and Dr. W. W. King, of the Public Health and Marine- Hospital Service. The results of the investigations of this com- mission are to be found in its reports for 1904 and 1905. .The importance of these studies, the clear demonstration that the great number of those suffering from uncinariasis in the island constituted a serious menace to the social and economic future of this country, was taken into account by our legislature, which passed a law creating a permanent commission to carry its work still further and into fields impossible heretofore to cover. This law was ap- proved March 8, 1906, by the governor, Hon. Beekman Winthrop, but, although it was so framed as to permit the work to be taken up immediately upon its approval, it was deemed prudent to delay the operations of the new commission until the beginning ot the fascal year, on the 1st of July. It was, therefore, not until June 25, 1906, that the governor desig- nated the new commissioners and submitted their names to the executive council for approval. These nominations were: President of the commission. Dr. P. Gutierrez Ygaravidez, for- merly a member of the commission of 1904 and 1905. Members Dr I. Gonzalez Martinez, of Mayagiiez, and 'Dr. F. bein y bein, ot Lares, both of whom had participated in the previous work. 77759 -—S. Doc. 808, 61-3 13 194 X7NCINARIASIS IN P0E.TO EIOO. At their first meeting, in San Juan, July 2, and before proceeding to any other business, the commissioners requested of the governor the appointment of Drs. B. K. Ashford and W. W. King as honorary members of the permanent commission in recognition of their efforts in favor of the campaign which they themselves had initiated in this island and which the present organization was called upon to con- tinue. This request was grant^ by the governor, and their cre- dentials were accordingly forwarded them. The commission now proceeded to consider the mission confided them by law, the funds designated for this purpose, and the project for combatting un- cinariasis in Porto Eico set forth by the former commission in their report for 1905. It was understood that two principles were clearly defined by the last commission for the solution of the problem, and their soundness was accepted by the present one. One was the cure of the disease in stations for treatment ; the other was its prevention by the education of the patient at these stations. The necessity for applying these principles was urgent and they were known to be practical of application, as seen from the expe- rience of others besides ourselves in Europe and America who are confronting situations analogous to our own. Every other measure in form of law which might be contem- plated for the solution of the problem would have, perforce, to be tentative and at best but an aid to the two ends which this as well as the former commission desired to reach. We refer to proposi- tions to authorize a propaganda against the disease from points where no stations of the commission existed, laws which would seek to secure a proper disposition of human feces, and regulations compelling the use of shoes to prevent the cutaneous infections occur- ring among our rural population. The commission therefore decided to cure the highest number of infected possible, believing that this should be its first step in the direction of an ideal prophylaxis in a country where 90 per cent of its rural population harbored the parasite. But the project of the former commission called for a greater amount of money than that appropriated for our future work. That commission recommended that $100,000 be employed as follows : 1. For the organization of a corps of physicians which^ under a central direction, would carry on a campaign from stations, hos- pitals, and dispensaries, supplied with all of the instruments needful for clinical investigation. 2. For a salary which would be commensurate with the laborious duties which such a work would entail, at the same time relieving the physicians of all other obligations of a medical character. 3. For the creation of a corps of inspectors who would go through the country districts and encourage sick to present themselves for treatment at the same time that they would stimulate the people to observe the measures counseled for the prevention of the disease. In a word, this plan had in mind the complete extermination of the disease. But not having more than the half of that sum of money at its disposal, the commission was forced to modify the original plan, which embraced the entire island with Y great departmental stations and 30 smaHqj:- units called substations and dispensaries. The question was raised concerning the propriety of concentrat- ing the campaign in one or two districts, placing the stations in such a manner that, after a vigorous effort to cure and teach the special UNCINAE.IASIS IN PORTO EICO. 195 prevention of the disease, such a district or districts would be swept clean of their uncinariasis; but the great agricultural activity of the island did not permit us to count upon the permanent residence of its laboring population in any given district long enough for us to obtain a cure and teach even the first notions of prevention. The con- stantly increasing vibration of the country people between the coast and the highlands made such a proposition impossible. Moreover, requests for aid from towns all over the island were urgent, inasmuch as the number of sick was so enormous, and the commission icould not very well deny assistance to all municipalities wherever they might be, when it was pursuing a plan of extermination of the disease in one particular district. Here we were not dealing with an epidemic in any one district, as in Germany, Belgium, France, and Spain, where uncinariasis was limited to mines, tunnels, and brickyards ; we were face to face with a much graver problem — the total infestation of an island with an area of 3,606 square miles, with a mass of 800,000 country dwellers dissemi- nated throughout the country districts, and with a soil offering the very best conditions for the development of the larvae, prepared to infect man and produce in him the disease. In view of all these facts, the commission did not deem it prudent nor reasonable to direct its campaign toward a single district nor to limit to one region the benefits which a humane law had directed should be distributed throughout all parts of the island. We felt that the problem demanded a general crusade, and we resolved to be- gin it and carry it as far as our resources would permit us. On the principle that the greater the number of units for treatment and propaganda, the greater the ultimate success of the work, we decided to create at least the same number of stations as the former commis- sion had recommended to be established. In order to do this it was nec- essary to reduce the salary of the personnel at each station, deprive certain stations, designated by that commission, of the hospitals in- tended for them, and undertake to sustain a small number of patients at the three principal stations only for the purpose of studying the pathology and treatment of the disease. In order to carry into ettect this plan, we decided that the commission should meet at stated tunes to discuss matters of importance for its successful accomplishment, but that each commissioner should reside in his own town from which he might direct the installation and progress of the work, making the necessary inspections in all towns in a territory whose limits were to be fixed by the commission as a whole. j, • , , -^ . .t, •„i„„j Therefore, taking as a basis the number of inhabitants, the island was divided into three great zones, each one of which was placed m diarge if a commissioner. Two of the three districts were directed f?om^Lares and Mayagiiez, whose stations were kn«wn as " distn^^^ stations." The third was designated the ".^^^t'-^.^f^^J^^^^.^jf^tS in charge of the chairman of the commission ^-U of th^e distnct stations had practically the same number of stations under tneir ^uprisionrbSt all defended for statistical data general m^^^^^^^^ tion, approval of accounts, etc., upon the ^^^J^^J, ^^f /Xtion. in the for a central station near San Juan, from which all ^^tions m the island could be more easily supplied, ^^^.f^^f ^^^'ViedrT^ aSl on so large a scale, and the town council of Kio ™7^|^^^?^^; ,' miles from San Juan on the main highway to the south of the island, 196 UNCINARIASIS IN PORTO RIOO. with great generosity, placed at the disposition of the commissiora the best building in that town for the offices of the central station. The council paid for this building $600 a year, a donation to the work. This same generous attitude was taken by the municipal governments of Lares and Mayagiiez, and in both of these towns houses were provided for the installation of the district offices and reception of patients at a cost to these municipalities of $370 and $250, respectively. In all of these three stations, aside from the dispensary opened at each, a limited number of patients were hospitalized in conformity with the plan already traced. In Kio Piedras, where the lack of a hospital prevented the town council from offering a building fit for this purpose, certain rooms were prepared in the building ceded for the central office for the reception of a few urgent cases out of the vast number which de- sired and needed hospital treatment. The municipal council never- theless promised to cede part of a hospital, which at that time they were planning to build, as soon as it should be available' for occu- pancy. On the other hand, all municipalities in which stations were founded contributed to their support by fitting up and paying the rent of the house which they designated for a dispensary. As the condition of the tents and other property used for a field hospital by the former commission did not permit us to use them for the same purpose this year, it was decided to leave them in store in Aibonito, where they had been left after the last year's work. With the object of permitting other physicians working under the direction of the commission to carry on the same investigations which the commissioners were planning to make in their respective district stations, it was decided to allow sick to be treated and cared for in hospital by physicians in a limited number of stations, where the locality and number of anemics, from data furnished by the former commission, led us to believe that there were many who were seriously ill and where the towns were able to cede at least 10 beds in their municipal hospital. To such physicians a higher salary and a larger personnel were granted. In this category we placed the towns of Coamo, Guayama, Ponce, San German, Utuado, and Vega Baja. For all other municipalities, only thfe dispensary, with its out-patient work and examination of feces, was installed. It was decided, however, that the directors of all stations should devote four consecutive hours a day to the examination, inscription, and treatment of applicants at the stations, and that the microscope should be employed to assure the diagnosis of the disease in each case. As by no means every physician in charge of a station possessed a microscope and the accessories for the examination of feces, and as still fewer municipalities in which these stations were to be opened had these necessaries to furnish their physicians, it was resolved by the commission to furnish microscopes and accessories to some dispen- saries until either their directors or the municipalities should be able to provide themselves with their own. With this end in view, and realizing that every town ought to have a microscope, a necessity in these days for an adequate health service in towns, the commission invited the town councils to secure these instruments and thus cooperate with the work it was trying to do. At present the majority of towns where a station of the commission . UNCINAHIASIS IN POBTO KICO. 197 exists have laboratory equipment which is the property of the director ittlt- "' ""^ ' -f- "^^"i^^iP-lity ; some still use that furnished by the commission, awaiting their own which they have ordered In this way, therefore, we have been able to systematize in all sta- tions the microscopic examination of the feces in the case of every applicant for treatment for anemia, not only in cases where uncina- riasis was merely to be suspected but in those in which a simple glance was sufficient to fix the diagnosis. Not only this, but this examination of feces was repeated at each visit of the patient and was what served to determine the fact of "cure" when at last the blood was restored to its normal. j^^? iT^^^?*^°f °^ out-patients followed the same form as that adopted by the former commission, with slight modifications which experience had shown to be of value. A card, which we denominated a clinical card, registered briefly the history of each patient and the course and treatment of his affec- tion, specifying the result of the successive weekly microscopic exami- nations of feces, and the character and dose of the anthelmintic em- ployed. This card had a serial number and remained at the station so that at each visit of the patient it could easily serve for reference. The following is a copy of the card : (Face of card.) Porto Rico Anemia Commission. Station of CLINICAL CARD. Rural district Farm No Name Date Color Age Sex Social standing Occupation Privy Clinical form of uncinariasis . . [ Lf|ht''^''' "I Medium Mazamorra Where infected intense I Very intense Parasites, (Uncin.) (Ascar. lumb.) (Trie, dispar.) Prominent symptoms Complications and intercurrent diseases. Course and treatment (Back of the card.) Observations and intercurrent diseases Result Date. 198 TJNCINABIASIS IN POBTO RICO. . The patient was given an identification card showing the number of the clinical card and his name. This card read as follows : PoKTO Rico Anemia Commission. Station at. No. Date. Name. Residence. As the identification card was often lost, the directors of the sta- tions were advised to keep an alphabetical index of patients enrolled, showing the name and card number of each. So the work was not interrupted by such loss, nor did the patient fail to get his medicine. A new identification card was given to the patients in such cases. The daily attendance at the stations was recorded on a card show- ing the number of patients attending for the first time, those return- ing weekly for treatment, and thoge who had died or who had been cured. The first named were classified as "admitted" and those once inscribed and now returning weekly as " under treatment." As some stations had a hospital in connection with the dispensary, the card was divided into two parts, one for the dispensary and one for the hospital service of their station, with the same classification, save that the heading " discharged under treatment " was added for those who werfe discharged from the hospital but who had passed to the dispensary for further treatment. This card shows the work of each station at the end of each week and was sent by each director to the central office either on Saturday or Sunday. The data was supplied on a postal card, which also showed the balance of drugs on hand. The weekly statistical reports forwarded from all the stations were consolidated in a printed monthly bulletin issued by the central office and sent to Government officials, city councils, newspapers, and per- sons interested in this crusade. , Card kept on file at stations : Porto Rico Anemia Commission. Register of patents at ■ the station at during the week from to.. 190... -of Mon. Tues. Wed. Thurs. Fri. Sat. Sun. Total. DISPENSARY. Admitted. Under treatment Cured Died HOSPITAL. Admitted Cured Died Remarlis * M.D., Director of the Stomm. UNCINARIASIS IN PORTO RICO. Card sent to headquarters: Porto Rico Anemia, Commission. ^*"**'''* «* Report for the week from to of wo. 199 Patients. DISPENSARY. Admitted Under treatment . Cured Died HOSPITAL. Admitted Under treatment Discharged under treatment Cured Died ;::: Supplies. Thymol Befa-naphtol.. Caps. No. 0... Caps. No. 3 . . . Sulph. Soda... Balance from last week. Remarks: Received during the week. Supplies con- sumed. BElance. M. D., Director of the Station. Statement of monthly work, issued by the central office : Porto Rico Anemia Commission, Office of the Chairman, Rio Piedras, P. R Number of patients treated at the stations of the Porto Rico Anemia Commis- sion during the month of , 190__. Dispensary service. Hospital service. Stations. Admitted. Under treat- ment. Cured. Died. Admitted. Discharged, under treatment, and referred to dispensary. Cured. Died. Total Following the policy laid down by the commission, each station undertook the teaching of measures to be adopted by patients and the public for the prevention of the disease. The origin of the mal- ady was explained in a clear and simple manner, showing the worms, how they gain access to the human body, where the infection might be contracted, and giving other pertinent information. The same information was printed in a handbill, which was widely distributed throughout the rural districts. 200 UNCINARIASIS IN PORTO RIOO, The following is the form of the handbills : PoBTO Rico Anemia Commission. INSTEUCTIONS TO THE PROPRIETOES OF FARMS AND PLANTATIONS CONCERNING THE SUPPRESSION OF ANEMIA IN PORTO RICO. Anemia is the disease from which the majority of our country folks suffer. It causes more deaths in the island than all other diseases. Those peons and others whom you are sheltering and who work for you are not strong men, because they are anemic. Should they become cured they would be. better workmen. Send them to us that we may cure and teach them to prevent their disease. To prevent anemia, remember that it comes from ground itch (mazamorra) ; that ground itch is only contracted where there has been earth soiling; that to avoid ground itch it is well to use shoes. So advise your dependents and peons. But it is still more Important that each house have its privy, and that no one defecate on the surface of the ground. Compel your peons defecating while at work in the plantation to cover each stool with a little earth that may be scraped up with their knife (machete). Thus the excrement is covered and the worms killed. As soon as the patient was examined, his clinical card filled, and his identification card issued, the director of the station gave him a prescription, which was dispensed by the assistant in an adjoining room. This employee explained to him how the medicine should be taken, and in order to prevent any mistake a printed sheet contain- ing the necessary directions, clearly and concisely explained, was handed to each patient. Furthermore, the paper contained the nec- essary instructions for the prevention of the disease. The anthelmintics were administered in gelatinous capsules in two equal doses, the second dose two hours after the first. A purgative was to be taken the night before and another purgative after the second dose of the anthelmintic; The instructions referred to were printed on colored sheets that read as follows: Anemia Commission op Pobto Rico. HOW TO TAKE THE MEDICINES. Take one of the two purgatives to-night in water. Take at 6 o'clock to-morrow morning half of the capsules Take the other half at 8 o'clock the same morning Take the other purgative at 10 o'clock. Xou should neither drink wine nor any alcoholic liquor during the time vou are taking these medicines. . Come for more medicine until the physician says you are cured Have a privy in your house. Do not defecate on the surface of the ground, but in the privy. rrr^^Jt^l ^w'^ barefooted so that you may avoid contracting mazamorra in your feet. Wear shoes and you will never suffer from anemia. This commission considered, as did the former one, that the work ot inspectors visiting house after house throughout the rural dis- tricts was the best means for accomplishing prophylaxis A special card was printed, to be posted on each house visited by the inspector, so that the residents might not forget the visit An- other card was kept by the inspector as a record of that visit and'for rnimC/t°r *"™.i"? ^^ *« the central office data concerning the Sons ^ '"^ '^''*"''*' ^"^ ^^^^"^ attendance at the UNCINARIASIS IN POETO KICO. 201 These cards were printed as follows: Anemia Commission of Pobto Rico. SERVICE OP INSPECTION. Station at Rural district Serial number Date Name of the owner of the farm Residence Kind of farm Name of the owner of the house inhabitants {^-::::::::::::::::::::::::_^^-;:::::::::::::::::::::::::: Do they attend a station? If so, which? Has the house a privy? Remarks References to prove that this service has been performed- Inspector. Anemia Commission of Pobto Rico. Certificate of inspection performed by , inspector for the district of , on the of , 190—, said inspector having given to the residents the following advice : People living in this house must not defecate on the ground, but in privies. By doing so the mazamorra will not exist in the environments of the house, nor on farms, nor in roads, because mazamorra is only found in the places where people defecate. If there is no mazamorra, there will be no sufferers from anemia, because the worm producing this disease is the same mazamorra which makes its way into the intestines. Try to wear shoes and you will not get mazamorra in your feet. The importance of this inspection service was from the first realized by the commission, but it was not possible to extend it to each station, because we were not prepared to meet such a consider- • able expense. For this reason it was carried on only at the three principal stations. The work of the inspectors at Eio Piedras, Mayaguez, and L,ares induced many patients who had given up treatment to return to the stations. Many who had been undecided heretofore also came to be treated, and many privies were built in the rural districts. ■ The number of houses visited by these inspectors was 1,846 m Kio Piedras, 1,906 in Mayaguez, and 1,807 in Lares. , ^ , , , In accordance with the division that had been adopted, the com- mission gradually began to establish a larger number of stations. Work was be^n at the central station, Lares, Guayama, Coamo, San German, and Vega-Bajain July ; at Mayaguez, Aibonito, Utuado, Morovis, and San Sebastian in August; at Bayamon Corozal, Jun- coi Manati Comerio, Las Marias, and Isabela m Septeniber; at yJuco, Ponce Quebradillas, Barranquitas, and Barros m October; at Humacao in November; at ^^sco, Caguas, and Ar^^^^^ m D. cember- at Arroyo in January; at Cabo-Eojo and Cayey in J^eoru. arv at Vieques and Aguada in March; at Aguadilla in April; at ary, ai, vie4uc3 an a nvj-^^r. in oil ^^1 stations whose statistical 202 UNCINARIASIS IN PORTO BIOO. that of the third, Camuy. None of these physicians received addi- tional pay for their extra labor. The employees at each station and their salaries were as follows: Stations with hospital service {Coamo, Guayama, Ponce, San German, Utuado,. Vega-Baja). Annually. One physician, director $1, 000 One assistant 360 One nurse 120 One peon 72 Total 1,552 Stations with dispensary service only. One physician, director $720 One assistant 240 One peon 60 Total _. 1,020 Some stations began to operate without great expense shortly after the creation of the commission, because their directors rendered their services free of charge. Such was the case at Bayamon, Barran- quitas, Morovis, Isabela, Quebradillas. At the Aibonito station the Porto Rico American Tobacco Co. paid the salary of the physician on account of the great number of workingmen suffering from un- cinariasis employed on their plantations and treated in the dispen- sary at that town. The commission had only to pay the assistant and peon at these stations. During the last six months of the fiscal year the directors of those stations who for the first part of the year had done their work with- out pay received the same salary as that paid the others. The only exception made was in the case of Dr. Stahl, the venerable director of the Bayamon station, who, being already an officer of the people of Porto Rico, could not under existing laws receive additional pay. Dr. Garcia Lascot, of Arroyo, also rendered his service free of charge, due to the fact that when his station began to operate the ■ entire allotment on our budget had already been assigned to pre- existing stations, and there were no funds from which to draw to cover his salary. In the organization of the campaign against uncinariasis in Porto Rico the comniission necessarily found serious difficulties, which in the majority of cases were overcome by the good will of the munic- ipal authorities and the directors of stations. Both authorities of the towns and physicians felt themselves in duty bound to make a thorough study of the problem, and realized the great benefits to be derived from the cure of a people whose principal source of wealth IS agriculture. They were in a position to see to what extent this disease weakens the organism wastes energy, reduces the chance of success in the struggle for life, and slowly but surely leads to misery and ruin a race that should be the strong and sustaining arm of the island. RESULTS OF THE CAMPAIGN OF 1906-7 AND ITS IMPORTANCE. At the close of the fiscal year 1906-7 the 35 stations of the islajid had examined and treated 89,233 patients suffering from uncinariasis. UNCINABIASIS IN POBTO RICO. 203 . The commission deemed it wise to prepare general statistics cover- ing certain important points, such as the residence of patients, sex age, the results of treatment, etc. Therefore a circular was ad- dressed to the several offices requesting the preparation of forms showing the work done, models containing necessary explanations being sent at the same time. -^ f As the work of enrolling new patients and treating those already enrolled could not be discontinued, the preparation of these statistics considerably increased the burden of the directors of the stations who had to make great efforts to fully perform their duties. ' The forms prepared by these officials contain the following classifi- cation : Form No. i.— Number of patients enrolled at each station, and classified according to residence. Form No. g.— This sheet was prepared at the central office and is the record of the weekly visits of patients to each of the stations. Fopn No. 3. — Classification of the total number of patients ac- cording to residence, showing age and sex. Form No. 4. — Results of treatment according to the age of patients. Form No. 5. — Relation between treatment and the clinical type of the disease. The summary of Form No. 1 shows the number of patients classi- fied as to their residence, but without reference to the station where they were enrolled. Number of patients according to their place of residence. Adjuntas 2, 184 Aguada 1, 142 Aguadilla 1, 246 Aguas Buenas 89 Aibonito 2, 338 A&asco 3, 511 Arecibo 2, 555 Arroyo 291 Barceloneta 1, 531 Barranquitas 1, 129 Barros 1, 872 Bayamon 956 Cabo Rojo 2,542 Caguas 139 Camuy 2, 294 Carolina 522 Cayey 1, 669 Ciales — 1. 639 Cidra 803 Coamo 1' 326 Comerio 1> 242 Corozal 2, 364 Dorado 156 Fajardo 1^1 Guayama 1> 166 Guayanilla 408 Gurabo 253 HatiUo '^22 Humacao 2, 641 Isabela 2,218 Juana Diaz 139 Juncos 1- 5o4 Lajas 1. 637 Lares 4, 464 Las Marias -, ]o4 Loiza 21 Manatl 2,157 Maricao 79 Maunabo '. 2 Mayagiiez 3,901 Moca 2,163 Morovls 3, 325 Naguabo 49 Naranjito 517 Patillas 145 Peiluelas 9 Piedras 384 Ponce 1,454 Quebradillas 1, 223 Kincon 7 Rio Grande 14 Kio Piedras 2,310 Sabana Grande 1, 060 Salinas 21 San German 6, 103 San Juan 315 San Lorenzo 183 San Sebastian 2,331 16 458 8 320 Utuado 4, 444 498 Santa Isabel . Toa Alta Toa Baja Trujillo Alto- Vega Alta Vega Baja 2,197 Vieques- Yabucoa . Yauco 801 123 1,558 Total 89,233 204 UNCINAKIASIS IN PORTO MOO. It may be easily seen that, although there were only 35 stations operating in the island, the patients represented all the towjis in Porto Eico, a fact which shows the faith of all the people in the work and their dire necessity for cure. The commission tried to place the stations in such a manner a,B to make it possible to extend their benefit to surrounding towns, but so limited a number could not fully attend to so thickly a populated area. Nevertheless the desire to be cured is so great among the peas- ants that they come from the most distant rural districts for medi- cines. No distance is too great for them, and it is marvelous to see them tramp over villainous paths, leaving their homes at midnight in order to reach the station at sunrise. The fact that there is a much greater number of applicants than we were able to treat is ample proof that there should be at least 50 stations, so located as to cover the greatest possible area. No sooner was a station established than numbers of people has- tened to receive treatment, thereby proving the necessity for a per- manent station at that point. Whenever the attendance was small the salaries of the employees at such station were stopped ; medicines and recording cards were, however, sent gratis for use by the regular municipal physician. The attendance at each station is recorded in the following table: Total number of visits of patients to the stations. Number of weeks. Number of patients. Number of visits. 1 52 52 51 60 60 49 48 48 46 46 44 43 43 43 43 42 40 39 39 39 38 38 38 35 30 28 23 21 19 19 18 14 11 8 6 5,128 1,210 1,418 9,414 2,819 3,684 3,821 3,647 820 3,270 2,417 1,525 4,222 3,304 5,279 4,497 2,695 1,464 1,880 4,003 1,821 821 2,144 2,786 3,629 2,433 336 129 801 2,165 1,547 969 1,031 2,008 196 25,598 3 441 ■> Guayama ft 10,833 46,265 4 Ran fjprman •i 19,333 14,189 17,717 18,261 2,245 fi Rio Piedras. 7 8 Aibonito. q in Morovis. 11,924 10,731 9 215 11 1?, Comerio. . . 13 20,523 17,636 28,693 16,400 10,875 6,725 5,583 12,424 10,977 3,633 15,127 14 Corozal IS Manati, Barceloneta and Ciales 16 Utuado 17 18 Ponce 19 Yauco 20 Quebradillas and Camuy i?1 Barros M Barranquitas 9S\ Las Marias ?A Humacao 2S Anasco 20*297 26 Arecibo 12! 436 1,693 378 27 Arroyo 28 Caguas. . ., •2S> Vieques 4,010 9 097 »{) CaboRojo ;fl Cayey 7; 854 3,962 3,469 6,741 439 82 Aguada 33 Aguadilla 34 Adjuntas 35 Fajardo Total 89,233 426,131 ; • • ■ w j.y \j±±^ .fuMTiiioxo xxy jTxjitTo mco. 205 Total number of visits of p(itients to the stations — Continued. Age. Hale. Female. Total. Percentage male. Percentage female. Percentage 0189,219 patients. 572 4,406 9,952 16,127 11,622 3,746 61 401 3,534 8,605 17,288 9,926 2,938 41 973 7,940 18,567 33,415 21,548 6,684 102 58.79 65.49 63.63 48.26 53.94 5a 04 59.80 41.21 44.51 46,37 51.74 48.06 43 96 40.20 1.09 From 5 to 9 , 8 90 From. 10 to 14 20.80 From 15 to 29 37 45 From 30 to 49 24.15 Over 49 7.49 Not classified .12 Total 46,486 42,733 89,219 14 52.10 47.90 100. OO Lost cards (Anasco) 89,233 This abstract clearly shows the zeal of the directors of stations. When it is borne in mind that 89,233 patients have required 89,233 preliminary examinations, in order to accurately diagnose their dis- ease ; when it is remembered that these examinations consist of a microscopic examination of the patient's feces ; when it is considered that these examinations have been repeated weekly throughout their treatment ; that the name of each patient had to be entered on a card, as well as the history of his disease ; that the dose of medicine had to be prescribed him, his card of identification issued, and a handbill given mm explaining the cause and means of prevention of the dis- ease ; in short, when one pictures the daily throng of patients at the station, then only will the crusade of our country doctor be fully appreciated. . The total number of visits here 'recorded is 425,131, exclusive o± those made by the 22,396 cured patients at whose last visit no ova of uncinaria were found. The total number of visits to stations may be estimated at about 500,000, and this demonstrates not only the great faith of our peasants, who thus respond to the eflorts o± those who are working for the betterment of their physical and sani- tary condition, but also in still higher degree the altruism ot the physician and his assistants who have carried on this arduous labor at so insignificant a cost. After studying similar work undertaken in other countries we are in a position to assure our readers that no Tihvsician elsewhere would have treated so many patients tor so miserable a sa7ary. Calculate the fees of an expert for each visit including a Microscopic examination, and then think what the cost of half a million would amount to ! „„a ..^■ Number of patients arranged according to age and sex. ThS attract shows that 52.10 per cent of the patients were male and 47.90 per cent female. The- greater number of male patients is due to their greater exposure to infection. i k 4.„ oo However! ff we make a comparison between men from 15 to 29 years of age and women between the same age l™its, we find that the nurnbef of the latter is 17,288, or 51.74 per cent, and that of the 'T'LS'thTs txfss'o? 3^8 per cent females over the males, it To explain this exce.^ oi o.-t l number of our stations have E\'^STnrwt'o¥ttS?or,Ter. . great .nan, ^o^.. are working on coffee plantations. 206 UNCINARIASIS IN PORTO RICO. There are more patients in the age period 15 to 29 years than at any other — 33,415, or 37.45 per cent of the entire number. These figures are very disheartening, as they show that the young are most afflicted by the worm that, according to Thornhill, in re- ferring to the epidemic of ankylostomiasis in Ceylon, causes more serious ravages than cholera, not on account of the number of deaths, but on account of the vast numbers affected, the chronic nature of the disease, and the aggregate mortality — direct and specially indirect— for which it is responsible. And when in statistics that only show the results of work done in an average period of eight months, the number of patients attend- ing at the station is so great it becomes evident that the most virile part of our population is seriously threatened. Those between the ages of 30 and 49 years give a percentage of 24.15 per cent of the total number. Thus there were 54,963 patients between 15 and 49 years of age, or 61.60 per cent. The group giving the smallest con- tingent of patients is that composed of children under 5 years, those between the ages of 5 and 9, 10 and 14, and' adults of 50 years and upward. The proportion of cases occurring among children is 30.79 per cent ; that among j'^oung and middle-aged adults, 61.60 per cent ; and that among the old, 7.49 per cent. The last two tables show the result of the treatment in five classi- fications : 1. Cured. 2. Practically cured. 3. Under treatment. 4. Ceased to return. 5. Died. Results of treatment according to the age of patients. Result. in 1-1 1 1 aj s in a a -J. p. 11 10 £ .3 . 1 ■S°".nd Office of the Chairman, Hon. Ekgis H. Post. '^"^ =""""' ^^ ^•' ''"'^ ''' ^^"^• Governor of Porto Rico, San Juan, P. R. Sir: We have the honor to transmit herewith a report of the work performed by the Porto Eico Anemia Commission during the fiscal year 1907-8, and copies of the letters addressed to the commission by the city councils of the island concerning this work. Very respectfully, P. Gutierrez Igaravidez, M. D. I. Gonzalez Martinez, M. D. Francisco Sein Sein, M. D. Keport of the Permanent Commission for the Suppression of Uncinariasis in Porto Eico. The 35 stations devoted to the treatment of uncinariasis at the end of the fiscal year 1906-7 were kept open during the following year, but some of them were transferred to other towns. Those existing at Utuado, Guayama, Bayamon, Caguas, Arroyo, and Morovis were transferred to Patillas, Penuelas, Eio Grande, Ciales, Juana Diaz, and Guayanilla, and furthermore the directors of the stations at Quebradillas, Las Marias, Anasco, Manati, Agua- dilla, and Mayagiiez went periodically to Camuy, Maricao, Eincon, Barceloneta, Moca, and Hormigueros, respectively, to treat patients soliciting relief from their anemia. Consequently, we can assert that 42 towns have been helped during the past fiscal year, and the whole island has received the benefits of this work. To make the work of administration easier, the commission main- tained the plan of the division of the island into three districts, as before, but in order to secure a prompter delivery of supplies to the stations the office of the chairman, with the general supply depot, was moved from Eio Piedras to San Juan, and two subdepots wpre installed at Mayagiiez and Ponce. No essential change in the working plan was considered necessary by the commission this year. The stations have followed the same policies as those already set forth in our annual report for 1906-7, and the sick population of our rural districts has become more and more deeply interested m the prophylaxis of " anemia " as taught at our stations, and more eager to receive the specific treatment which promises so striking a curG The proof of this earnest desire for relief is found in the number of patients applying for treatment at the recently opened stations, 224 TJNCINARIASIS IN PORTO BICO. and the steady influx of new patients at points where stations have been existent for two years. Being fully aware of the difficulties to be met in the preparation of statistics, the commission tried to simplify this work by means of a printed form reading as follows: Porto Kico Anemia Commission. Station of— — — Year 1907-8. d I? Sex. Color. Age. Clinical type. Residence (Barrio). Result. Date. 1 s i 1 O 6 O i o s. CO o s o g I o i I i '■3 i i a a >> i 1 1 t5 ! ■a 1 i s p £ o •6 .2 Q Re- marks. 1 1 1 The required data were daily transferred from the clinical cards to this printed form. Each sheet had space enough for 100 cases. Con- sequently, the directors of stations were able to classify their cases, without separately examining the clinical cards, and the commission could prepare the general statistics more rapidly, taking for a basis the summaries forwarded by the stations as they appear in Table No." 2. The total number of patients treated was 81,375; 41,120 were male and 39,734 female. According to these figures, the percentage of the former was 50.53 per cent and that of the latter 48.83 per cent, 521 patients, or 0.64 per cent, remaining unclassified. The largest number of patients were males, and this is due to causes explained in our last report. The color of the patients was taken into consideration this year, and the following figures were obtained : Per«eii(t 65,455 white patients 80.42 15,399 colored patients I I_ 18,92 521 unclassified . 66 The classification as to age was somewhat modified, and the follow- ing groups were formed : Age. Patienfe. Per oent. 6,994 11.00 3b, 625 3?. 63 2t,9S8 aT.02 10,736 13.19 5,212 6.40 2,321 883 K86 1.09 £61 .&■ Under 10 years From 10 to 20 years From 21 to 30 years From 31 to 40 years From 41 to 50 years From 61 to 60 years Over 60 years UnclBssifled UNCINARIASIS IN PORTO EICO. 225 20^and?r"tn%O '^f \ tl P^*^'^*' ^>^^^ ^^'^ ^^« between 10 and b JSf iiziir ^' '''^ ''^ °"' ^"'^ "'p^'*' ^'^^^^^ *b^ g^^^t^^t ^""^- Th«is it is the laboring classes, those who must give vitality to the dftrSl^ P'"^"''^ "^ the island, who, gravely menaced by this para- sitic disease, invade our dispensaries and demand that which their experience shows them will result in the upbuilding of a failine strength and a cure for their semi-invalidism. Anyone who has had an opportunity to observe the daily labor of a station will be con- vinced ot the fact that hundreds of men desirous of strength to earn their living are thus returned to their labor, and that those men, al- toi^h in the flower of their youth, were previously unable to yield the full value of a day's work. In our last statistics the percentage of young patients was 58.25 per -cent, the difference being very little between this figure and that obtained this year. The patients under 10 years show a percentage (11 per cent) almost equal to that offered for the same class of patients in the past fiscal year (9.99 per cent). The patients whose age is between 31 to 60 and those over 60, taken as a whole, give a percentage of 31.64 per cent in 1906-7 and 23.54 per cent during 1907-8. The total number of patients treated this year, classified according to the intensity of the disease they presented, gives the following percentage for each class : Per cent. Very light 3. 71 Light 18. 39 Medium 49. 32 Intense 23. 53 Very intense 4. 26 Unclassified . 79 The relation between these percentages and the result of the treat- ment has not been estimated, but the figures are almost the same as those obtained last year. As to the results of treatment, 25,757 were entirely freed of uncina- rise and reached a normal percentage of hemoglobin; 16,192 have been considered as practically cured or freed of all evidence of dis- ease and almost entirely liberated of their uncinarife. That means 31.65 per cent for the former and 19.89 per cent for the latter, a total of 51.54 per cent cured. The number of those who abandoned treatment, after having re- ceived more than 2 doses of the anthelminitics employed, and who were therefore improved, as explained in a previous report, amounts to 12,203, or 15 per cent of the total enrollment. „ , „,. j. -, Ninety-three, or 0.12 per cent of the total number ot 81,37o, died from uncinariasis. There were no other deaths among our patients save these. . . , , . 4. Of course, the mortality that our statistics show does not represent the total mortality from uncinariasis in the entire island, because this data is only from towns where stations have been working and the number of these is but 35. Nor can this mortality be considered 77759°— S. Doc. 808, 61-3 15 226 UNCINARIASIS IN PORTO RKX). absolutely exact for the very towns where there has been a station, for some deaths occurred in patients that were not treated at the station and who were not enrolled there. But even with these exceptions the mortality from this disease has fallen considerably in the statistics furnished for the entire island. We are indebted to the honorable superintendent of health for the following table of deaths from anemia occurring in the island from 1900 to 1908, and these fi,;ures demonstrate in the clearest manner how we have succeeded in combating the mortality from this disease. Statement of deaths from anemia from 1900 to 1908. 1900-1901 11, 875 1901-2 6, 284 1902-3 6, 830 1903^ 6, 179 1904-0 4, 963 1905-6 3, 769 1906-7 1, 134 1907-8 1, 785 At the close of the fiscal year 1907-8, 26,569 patients were receiving treatment at the stations, this figure being 32.65 per cent of the total number of the patients enrolled during the whole year. Ntmiljer. Percent. Cured 25,767 16,192 12,203 26,569 93 561 51.64 Improved 15.00 32.65 Died .12 .69 81,375 100 The list of towns where the stations have been open, and the num- ber of weeks each station has been working, are registered in Table No. 1, where the records of visits made by each patient may also be found. This summary shows that the attendance has been equal to that of last year, and had we recorded the final visit made by each patient before being certified as cured, this figure would be over 500,000. In preparing these statistics we have not included the patients who Avere under treatment on June 30, 1907, and either cured or died during the following year. Table No. 3 is the record of these patients (those under treatment on June 30, 1907), the stations attended by them, and the results of treatment. As no provision was made in the budget for the fiscal year 1908-9 for the continuance of our campaign against uncinariasis in Porto Rico, the commission, with the consent of the honorable governor, ordered that all stations be closed on June 30, 1908. It was also ordered that such medicines as remained on hand in each station be delivered to the alcaldes, to be used by them for the continuance of the treatment of the poor patients of the municipalities, and that the medicines stored in San Juan, Mayagiiez, and Ponce be distributed among the municipalities for the purpose above referred to. UNCINARIASIS IN PORTO RICO. 227 It was also ordered that the laboratory supplies and other property of the insular government used in the offices of the commission be delivered to the municipal authorities, to be held by them on memo- randum receipt. The lack of appropriation to carry on the work being Imown, the coinmission considered it pertinent to ask the opinion of each munici- pality where a station had been open concerning the work performed by such station. The answers received from the municipalities are printed in the last part of this report. Only two are translated into the English language, as they are fair examples of the rest, and are as follows: EESOLUTION PASSED BY THE MUNICIPAL COUNCII, OF COAMO PETITIONINB THE LEGISLATIVE ASSEMBLY OP POKTO RICO TO CONTINUE THE WOKK OF THE POETO EICO ANEMIA COMMISSION. The mayor, D. Manuel Betances, addressed a message to this council, as follows : " It is to be regretted that the legislative assembly of Porto Rico failed to appropriate funds for the treatment of the thousands of sufferers from anemia when the efficacy of such treatment in saving human beings from certain death is a matter of common knowledge. " Of course after the stations which to-day exist have disappeared the municipalities will have greater expenses to meet, for they will be obliged to attempt as well as they are able to complete the cure of those who are now undergoing treatment and to talce up new cases which will present themselves. In my opinion, however, this will not give so favorable a result as that now being attained, for at present there is an adequate personnel and a supply of medicine ample for all, not to mention the scrupulous care with which records of cases are being Ii;ept. This could not be followed out in the future by the municipality on account of the sums which it would have to subscribe to main- tain the personnel. " This honorable council will, I have no doubt, regret, as do I, the cessation of the work of the anemia commission and its stations, and should frame a reso- lution in which the necessity for its continuance shall be made clear. This resolution should be addressed to the honorable governor, who has authority to convoke a special session of the legislative assembly, and can interest that body in appropriating an amount at least equal to that appropriated for this object for this fiscal year, 1907-1908. "A copy of this resolution should also be sent to the honorable speaker of the house of delegates, the honorable president of the executive council, and to the honorable president of the anemia commission. ' " It is unnecessary to call attention to the value to this country of the work this most worthy commission is at present doing, and would do in the future, m converting an untold number of helpless sick men into strong and active laborers, thus economizing moneys which can be applied to new necessities of therefore in view of the universally acknowledged benefits derived from the work of the'anemia commission of Porto Rico by our laboring c asses; be it ResS,veihv this councU, (1) That this council unanimously agrees to all that is recommended by the mayor, D. Manuel Betances, in the above message; f2fThatT respectfully prays the honorable governor and the Legislative ,sembT? of Porto Rico to take action upon this most important matter as Assembly _ "^st TCt%Sed"copy''ott^ls document be transmitted to the honorable governS^ the president of the house of delegates, the executive council, and the anemia commission document certifies that it is a copy of the Secretary of the Municipal Council of Goamo. A true copy : Clotilde Aponte, Acting Mayor of Coamo. 228 UNCINARIASIS IN POBTO BIOO. THE EESOLUTION ADOPTED AND APPROVED BT THE MTJNH3IPAL COUNCIL OF JUNC06 IN ITS BEOtTLAB SESSION OF THE 23d OF APEIL, 1908. A letter was read from Dr. P. Gutigrrez Igaravldez, president of fee ■anennia commission, addressed to tlie alcalde and referred by him to the comical, in which he states that no appropriation was made in the last session -of our legislature to continue the work against anemia in Porto Rico, and that on this account the commission was obliged to terminate its labors, closing the Stations on the 30th of June. He also desires to know if, apart from statistical €ata ■sent the commission, this municipality has derived any benefits in the mattesr lof public charity from the anemia station which has been working here; of. In a general way, the health of the municipality, that of its working classes, has bettered since the station was open to the public, and if, in comparison with previous years, the mortality of the adult population has diminished. The council Is surprised that the legislature has not appropriated any funds for the continuance of this work in the coming fiscal year, and believlHg the suspension of the work of these stations to be a true misfortune to oar rural population, decides, at the suggestion of the president of the council, Senor Delgado, to inform the president of the anemia commission that the work of this station has been productive of great economic benefit because, had it not existed, we would have had to considerably increase our budget for public charity in order to attend to the treatment of thousands of persons among our rural population suffering from the anemia produced by" the parasite " unci- naria," who to-day enjoy good health. For this reason the health of the munic- ipality has been decidedly improved since the opening of this station, and it would have lowered the mortality considerably among our adult population had this not been unusually Increased in the last two years. The council decides to take action In order that the service of the commission for tiie suppression of anemia In Porto Rico may not cease and adopts the following resolution : "RESOLUTION Respectfully prating the honorable Governor of Porto Rico, if he thinks it foe the general good, to convoke the Legislature in special session for the purpose of passing a law providing for the con- tinuance of the work of the Commission for the suppression of anemia IN Porto Rico by appropriating the necessary funds. "Whereas a great part of the rural population of the island suffers from anemia, a disease caused in the majority of cases by the parasite ' uncioaria ' ; "Whereas the cause of this variety of anemia has produced innumerable victims among the rural population, until in a happy hour the r«medy was -ap- plied which destroyed the disease-producing organism and converted indi- viduals who were dragging out a life of suffering and misfortune into strong and healthy men and women ; " Whereas in order to consummate this magnificent result anemia stalions were established, provided with Intelligent personnel, apparatus, and medicines; " Whereas the Legislature of Porto Rico in its last session failed to sustain these stations for the coming fiscal year, 1908-9; " Whereas these stations have saved thousands of persons from death, giving them health, and with this energy, strength, and contentment, these individuals having been previously weak and ill developed, for whom life was a burden; " Whereas there are still many thousands more in the island attacked by this cruel infirmity; "Whereas it is humane to continue the beautiful work of charity begun until this great aflllction disappears from among us, a scourge that so nitUessly invades our rural population; " Whereas the chief duty of a wise and honorable administration is to watch over the health of the people, because a sickly people lacks energy and initia- tive, and thus can be neither free nor prosperous; " Whereas the municipalities of the island are absolutely unable to meet the expenditures which this anemia occasions, because the amount devoted to pub- lic charity is too small and is intended for the treatment of other ordiuiiry Q1S6EISGS y " Whereas one of the real and positive benefits that the change of sovereignty has brought the island is the founding of the stations for the suppression of anemia in Porto Rico, and this benefit we should try to preserve forever: Therefore, be it * t- v. v^c c . UNCINARIASIS IN PORTO RICO. 229 "Resolved by the muncipal council of Juncos, (1) That this council aririrp«« to the honorable governor of Porto Rico their respectful reque^rthat he con voke the legislature in special session to pass a law providing that during the fiscal year 190^9 the commission for the suppression of anemia in Porto Rico be continued, appropriating for this end the necessary funds ■ 1. •* ^^^S^J^'i? assistance of the municipal councils throughout the island be «)llcited, that they may address similar requests to the honorable governor of Porto Kieo, founding their request upon bases similar to these herein ex- pounded ; "(3) That as soon as this resolution be approved by the honorable alcalds he- comply with- the provisions of section 1, providing the honorable governor witR certified copies of the same ; "(4) That in order to comply with the provisions of section 2 certified copies be provided the other municipal councils of the island ; "(5) That this resolution take effect from the day of its approval." Narciso Vaeona Suaeez, Secretary of the Municipal Council of the Town of Juncos. I certify that the preceding resolution was adopted by the municipal council in Its session of the 234 of April ol this month, and approved by the alcalde the 25th of the same month.. And in order to comply with its provisions, I make the aforesaid copy for Dr. P. Gutierrez Igaravidez, president of the anemia com- mission, this 27th day of April, 1908. Naboiso Vabona, Secretary. A. true copy. Babbebas. Of the $60,000 appropriated for the work of the commission in this year's work, $56,950.57 has been expended : Personnel $43, 666. 81 Medicines. 8, 391. 95 Miscellaneous expenses 1, 225. 72 Transporta,tioh 480.68 Laboratory and its equipment 831. 73 Printing 1, 366. 36 Mail and telegraph 407. 07 Elspen'Ses incident to inspection in towns and other official trips 5S0. 25 56, 950. 57 A^propriartSbB 60, 000. 00 Balance on hand tn treasury of Island 3,049.43 THE FIFTH REPORT; RENDERED BY THE DIRECTOR OF THE "ANEMIA DISPENSARY SERVICE," SUCCESSOR OF THE PORTO RICO ANEMIA COMMISSION. COMMENTS UPON THE WORK OF 1908-9. In this year the commission was disbanded, and an anemia dispen- sary service took its place. Its report is short and is reproduced in full. . A separate report was not made, as the service was made one o± the subbureaus of the bureau of health, in the department of health, charities, and corrections. Its director was Dr. Pedro Gutierrez Igaravidez. Kepoet or THE Director or the Anemia Dispensary Service of Porto Eico, 1909. AN ACT To provide for the continuation of the work of the suppression of tropical anemia, or uncinariasis, in Porto liico. Be it enacted l)y the Legislative Assembly of Porto Rico: Section 1. For continuing tlie work of suppressing the disease known aa tropical anemia, or uncinariasis, there is hereby created a special medical or- ganization to be designated as the anemia dispensary service, which shall be composed of a director, who shall be a qualified physician, and such number of physicians, residents of the several municipalities wherever possible, as will be necessary to provide the necessary medical personnel for dispensaries for the prevention and treatment of uncinariasis. The director shall be ap- pointed by the director of health, charities, and corrections for a term of two years, and until otherwise provided by law shall receive a salary of two thou- sand and five hundred dollars per annum. The physicians shall be selected by the director of the anemia service and shall receive an annual salary not exceeding four hundred and eighty dollars each. The municipalities may also appoint one assistant for the physician, at such salary as may be fixed by the respective municipal councils. Sec. 2. It shall be the duty of the director to use all means in his power to prevent, combat, and exterminate the disease known as uncinariasis in Porto Kico, and for the purpose he is directed and authorized to establish and main- tain a central office for the administration of the work, with the following assistants : One chief clerk, at nine hundred dollars per annum ; one shipping clerk, at seven hundred and twenty dollars per annum ; one typewriter, at three hundred and sixty dollars per annum ; and one messenger, at two hundred and forty dollars per annum, all to be appointed by him according to the civil- service laws and regulations of Porto Kico. It shall be the duty of the director to establish a station for the carrying on of the work in all municipalities de- siring to take advantage of the provisions of this act, said stations to be in charge of the physician appointed, in accordance with this act, with supplies and medicines provided by the insular government. Any of the municipalities of Porto Rico as are willing to cooperate in the work according to the provisions of this act, by furnishing a suitable building, shall be accorded a dispensary and the services of a physician. 230 UNCnSTABIASIS IN PORTO KICO. 231 Sec. 3. It shall be the duty of the physician designated for a town wherein a dispensary may be established under the provisions of this act to personally superintend the treatment of all cases presenting themselves, and he shall be responsible to the director for the care of the sick thereat and for the efficient administration of the dispensary. The assistant who, as far as possible, shall be a practicante, shall render all such services as may be required of him by the physician in charge of the dispensary, in accordance with such regulations as may be issued by the director for the rendition thereof. Sec. 4. It is hereby expressly provided that the provisions of section 177 of the political code are hereby suspended in so far as to permit " medicos titu- lares " already paid by the towns to receive a further compensation from the insular government for the work above stated. Sec. 5. In each municipality wherein a dispensary may be established there shall be created an advisory board, composed of the alcalde, the health officer, or a pharmacist, and president of the school board of such municipality, whose duty it shall be to inspect and report to the director upon the work of the dis- pensary at least once each month, with recomihendatlons which in their opin- ion could be adopted for the more perfect working of the said dispensary. Sec. 6. The work of the organization herein created shall be under the direct supervision of the director of health, charities, and corrections, whose approval of all regulations of the service, of appointments of physicians in charge of dispensaries, and the expenditure of money placed under the direction of the director of the anemia service shall be required. No money shall be expended for the construction, rent, or repair of buildings to be occupied as dispensaries, but in case of necessity the director of the anemia service may select and lease such quarters for the central office as may be deemed necessary. . Sec. 7. The director of the anemia service, in order to carry out his work, shall receive the cooperation and assistance of the officers of the bureau of health of the insular government. , ^, t. ^ r.- Sec 8 All property that has been acquired heretofore by the Porto Jiico anemia commission and belonging to the people of Porto Rico, mcludmg the records of said commission, shall be turned over to the director of the organiza- tion hereby created and shall by him be utilized where it may best serve the interests of the service for the diagnosis and treatment of patients or tor the investigation of problems of scientific importance so as to acquire a better "^S^c'TToc^roTtle purposes of this act there is hereby appropriated out of the moneyl in the treasury not otherwise heretofore appropriated, for t^l r^mVinrter of the fiscal year ending June thirtieth, nineteen hundred and S^e ir sum o? thfrty sevVthousand Ive hundred dollars, or so much thereof l"^XaTISam^n^^^r|£^^ hundred and seven, and all other laws or pans 'tErirThltThTict- Shall take effect from and after the first day of Octo- '^ VpreTsSmber^^ighteln^, nineteen hundred and eight. San Jtjan, P. E., June 30, 1909. S.h: I have the honor to submit herewith the annual report of the anemia dispensary service for the Ascal year -LJu». o^i^g for the continuation In accordance with the P^^^^^ff^f"* ^anemia In Porto Rico," the director of the work of the suppression of tropical anemia ^ ^.^^^^^^ of the anemia dispensary ser^if,,^f/^f f^X of the islknd informing them of to the alcaldes of the several cities and towns w: ^^^^^ ^^ started at once, the new organization of the bureau and tna^ ^^ ^^^ ^^^ ^^^^ ^^^^ according to the provisions of such act. xne b ^ reference%o the municipalities were copied ^^ thej^^^^^f ^ .Nation during the All the cities and towns having enjoyed me u ^^^ remaining towns past fiscal year asked for the granting of a d^spens y,^ ^^^^ ^^ ^^^^^^ ^^^^.^^^^ sent also their petitions, every municipality i" for the dispensaries. 232 riTCINARlASIS IN POBTO RICO, Therefore the 35 stations closed on Jme 3D, 1908, when the permanent com- mission for the suppression of anemia was discontinued, were reopened on ■November 1, 1908, and the number was gradually increased to 59,. located, in the following towns : ..... -r, Adjuntas Aguadilla, Aguas Buenas, Aibonito, Anasco, Arecibo, Arroyo,. Ear- ranauitas, Barros, Bayamon, Cabo Bojo, Oaguas, Oarouy y QuebradiliaSv e*ro- lina Cayey, Ciales, Cidra, Coamo, Comerio, Corozal, Fajardo, Guayama, ©urabo, Hatillo, Humacao, Isabela, Juana Diaz, Jayuga, Juncos, Lajas, _ Lares, Las Marias Loiza, Manati, Maricao, Maunabo, Mayaguez, Moca,. Morovis, Nagaabo, Patillas Peiiuelas Ponce, Kincon, Rio Grande, Rio Piedras, Sabaaa SEaade, Salinas,' San German, San Juan, San Lorenzo, San Sebastian, Toa Baja, Trujiilo Alto, Vega Baja, Yabucoa, Yauco, Vieques, and Vega Alta. The inscription and treatment of patients in the several dispensaries was the same as that adopted by the anemia commission in their dispensaries, with, the difiference that the forms were supplied with colored cards for patients coming for the first time to the dispensaries, the white cards being reserved for those who were previously registered, and after being examined by the physician, had received medicines. The inscription of old patients as new ones was ttos prevented. . „ -^ ^ ^ The total number of patients of the first class, viz, those coming for the first time to the dispensaries during this fiscal year, was 54,725, and of those who applied for treatment in past years and came to continue same were 9,159, making a total of 63^84 persons attended in the 59 dispensaries of the service. The model of statistics adopted in the dispensaries was the same as that used by the anemia commission in the preparation of its last report, and the classification of cases has been made easier. The patients treated during past years and classified in the last report of the anemia commission have now been classified in regard to their cure, as shown in the appended exhibit. The total number of patients was 54,725, of whom 27,026 were male and 27.699 female. According to these figures the percentage of the former was 49^39 per cent and of the latter 50.61 per cent. This is the first time that a difference in favor of females is shown in the statistics of this work. In the classification of patients as to color, the following figures w«re obtained : White patients.. Colored patients. The classification of the 54,725 patients as to age gives the following figures : Number. Fercent. Under 10 years From 10 to 20 years. From 21 to 30 years From 31 to 40 years From 41 to 50 years From 51 to 60 years Over 60 years e,66S 20,299- 14,606 7,518 3,584 1,520 530 12.19 37.09 26.69 13.74 6.S5 2.77 .97 The groups formed by the patients whose ages are between 10 and 20 and between 21 and 30 give a total number of 34,905, or 63.78 per cent, of the whole number treated. In the last statistical report the percentage of this group was 64.65 per cent, or 0.87 per cent only, over that obtained for this year. ThiS' high percentage gives always about the same figures, because men and women whose age is between 10 and 30 are those more in contact with the sources of infection. By a comparison of the percentage given by patients under 10: years, 31 to 40, 41 to 50, 51 to 60, and over 60, with that of same groups in the last statistics, we can observe what very little difference there is betweea the. coirrespendiiQg figures. rNCINARIASIS IN PORTO RICO. 233 As to the clinical form or intensity of the disease, the patients are grouped in the following manner: Patients. Per cent. Light Medium Intensfl Very intense Unclassified- 10,720 24,248 16,409 3,344 4 19. 589 44.310 29.983 6.111 .007 As to the results of treatment, 15,972 were cured and 6,734 practically cured. That means 29.19 per cent for the former and 12.30 per cent for the latter, a total of 22,706, or 41,498 per cent of the total enrollment. The classification of the 54,725 cases, according to the results of treatment, are: Pet cant. Cured and practically cured Improved Under treatment Died Unclassified The appended exhibit shows that of the 9,159 patients receiving treatment or who were attended at the dispensaries during the past year, 2,577 were cured, 1.353 were practically cured, 1,039 improved, 4,182 remained under treatment, '^^The expenses of the service consisted in the payment of salaries, the purchase of medicines and microscopes for towns that had none, the total being $32,360.91. The per capita expense shows an average of 51 cents. P. GUTIEREEZ IgAKAVIDEZ, Director Anemia Dispensary Servioe^ The DiKECTOB OF Health, Chaeities, and Cokeections. 234 UNCINAHIASIS IN POETO RICX). Numier of patients who were under treatment at the close of the last fiscal year and since cured, practically cured, under treatment, ceased to return, and died during this year. Dispensaries. Cured. Practi- cally cured. Under treat- ment. Ceased to return. Died. 97 28 279 39 6 42 22 375 30 29 10 10 232 251 9 33 21 101 76 388 191 436 12 25 40 73 S Aibonito 2 Barranquitas 32 6 61 2 750 44 14 33 95 12 38 44 47 5 25 3 13 97 155 21 38 5 33 122 10 70 6 13 185 42 1 44 Camuy y Quebradillas . - 1 Cidra Corozal Fajardo--. . '. . 9 2 1 Gurabo. . HatUlo .• 4 2 28 155 153 44 1 Isabela ii 63 117 22 24 77 75 9 16 7 30 1,271 53 19 24 13 9 12 Las Marias . . Manati 2i2 26 32 2 32 5 59 26 47 101 15 1 19 18 42 I Maunabo . . Patillas 49 35 27 13 20 14 48 137 17 Rincon 5 65 33 33 38 158 1 2 66 18 2 85 San German 107 81 44 39 68 49 66 11 San Sebastian 1 Yabucoa Yauco 7 Total 2,577 1,353 4,182 1,039 8 SUMMARY OF FOETHCOMING REPORT FOR 1909-10. (Dr. Pedro Gutierrez Igaravidez, director of the service ) AN ACT TO -S*^- » -^P-™t^^^tj^.e.,^^.™s^^^ a.ea.e. Be it enacted by the Legislative Assembly of Porto Rioo prfvZX^rXra.^d"=:^^i^^^^^^^^ -ding to corrections, a special medfcal S'rvfce to 1!f ',*"'''°* °* ^f "^' hilarities, and misslble diseases servicT consis«nrof 'a dfrecfTwho sbThe ^''\''^'^% ?o/fht^'/"''-f T"^ '^r'' ^^^ Clerical fofceas^n'.ay be co^'n de'r'ed'nece™ necessary. '''''*'*''' °' ^''^ '''^'''' ^""^ °^ ^« "^"^"^ pbysicfans as may be ^.ff^-'J; \^^?. •lirector of said service sliall be appointed by the director of nfnrn'.^if/'^'^'Vv.'^'''^- <:?"ections, and shall hold office during good behavior as provided by the eivil-service act, and, until otherwise providid by law he shall receive a salary of three thousand dollars per annum. The dli-ect^r of the service shall appoint, by competitive examination and in accordance with the eivil-seryice act, a pathological physician for each one of the seven districts I ^^^ii'°^ ,*i^® ^^'''"? '^ divided, with an annual salary of one thousand five flundred dollars, and as many physicians as may be necessai-v to install and direct the dispensaries in those towns where they are most needed in the opinion of the director. The salary of these physicians shall be determined by the director according to the work assigned to each physician. Said patho- logical physician shall have all the powers and perform all the duties provided for by section 5 of the act entitled "An act to authorize the director of health, charities, and corrections to contract for the care of tuberculosis patients in the hospitals and sanatoriums of the antituberculosis league, and for other pur- poses," approved March eleventh, nineteen hundred and nine. The director of the service shall also appoint, under the civil-service acts and regulations, an assistant to each district commissioner, with a salary of three hundred dollars per annum. Sec. 3, It shall be the duty of the director of the tropical and transmissible diseases service to use every means at his command to prevent, fight, and stamp out the disease known as uncinariasis, and to direct his own endeavors and those of the commissioner and other physicians of the service toward the advancement of the study and investigation of tropical and transmissible dis- eases, examining and collecting specimens, preparing statistics of diseases and deaths, and giving out such information as will offer the means to know and avoid said diseases, for which purpose he is charged with the creation and maintenance of a central office for the administration of the work, with the following as his assistants : A bacteriologic physician, who is to be an assistant to the director, with a salary of two thousand dollars per annum ; a chief clerk at one thousand dollars per annum ; a clerk with a salary of nine hundred dol- lars per annum ; a physician, assistant director, at one thousand two hundred dollars per annum ; a clerk with seven hundred and twenty dollars per annum ; a typewriter with six hundred dollars per annum ; a messenger and laboratory servant with three hundred and sixty dollars per annum ; all of whom shaU be appointed by the director of the service, under the provisions of the civil-service act and regulations of Porto Kico. . Sec 4 It shall be the duty of the director to open four dispensaries at the capltol in towns of each district, whose municipality shall furnish suitable quar- ters for the Installation of an office and as many other dispensaries as may be required to meet the needs of the service in different towns of the island. 236 tTNCINAEIASIS IK PORTO EICO. Sec. 5 The district physicians and the other physicians attached to this service shall carry out all the instructions originating from the director of the service and shall be responsible to the director for the medicines and sBther supplies intrusted to them. Sec, 6. It is hereby expressly provided that the provisions of section one hundred and seventy-seven of the political code are hereby suspended in so Bar as to permit " medicos titulares " already paid by the towns to receive a further compensation from the insular government for the work above stated. Sec. 7. In each municipality wherein a dispensary may be established there shall be created an advisory board composed of the alcalde^^ the health officer, or a pharmacist, and the president of the school board of such municipality, whose duty it shall be to inspect and report to the director upon the work of the dispensary at least once each month, with recommendations which, in their opinion, could be adopted for the more perfect working of the said dispen- sary: Provided, That at the end of the fiscal year the consulting board shall send to the director of the tropical and transmissible diseases service a report of the work done by the local dispensary stamping' out uncinariasis, including a project for the construction in the fields of Porto Rico of rustic cesspools, which economically but effectively shall prevent the spreading' out of materials serving as vehicles of contagion. Sec. 8. The work of the organization herein created shall be under the dSreet supervision of the director of health, charities, and correct-ions, whose ap- proval of all regulations of the service, of appointments of physicians and assistants, and of the expenditure of money placed under the direetionr ot the director of the tropical and transmissible diseases service shall be required. Sec. 9. All the property and files acquired by the director of the anemia service, under the provisions of the " act to provide for the continuation of the work of the suppression of the tropical anemia or uncinariasis in Porto Rico," approved September eighteenth, nineteen hundred and eight, and those acquired under this act for the same service shall be turned over to tbg director of the tropical and transmissible diseases service, and shall by 'Mm be utilized where it may serve the interest of the service and in complliinfie with 'the provisions of this act : Provided, That for the purpose of compltetimg, the clinic laboratory to be used in this service the director thereof i& hereby authorized, on the approval of the director of health, charities, and corrections, to obtain from the Insular chemical laboratory such apparatus and utensHs as may not be necessary for the investigations of the said laboratoiy. Sec. 10. No money shall be expended for the construction^ rent, or repair ot buUdings to be occupied as dispensaries ; but the director of th& service' may incur such expenses as may be found necessary for the establishment ef thelt office and laboratory. Sec. 11. To carry out the purposes of this act there is hereby apprepr^Ected out of any money in the Treasury not otherwise heretofore appropriated, for the fiscal year ending June thirtieth, nineteen hundted and ten, the- ama et thirty-six thousand dollars, or so much thereof as shall be necessary. Sec. 12. That an " act to provide for the continuation of the- 'work of the suppression of tropical anemia or uncinariasis in Porto Rieo,"- approved Ssp> tember eighteenth, nineteen hundred and eight, and all othep laws- &t pswfe thereof in conflict with this act are hereby repealed:. Sec. 13. This act shall take effect after the first day of Jaly; nineteen Sun* dred and nine. Approved, March 16, 1909.. The legislature of 1909 modified the I'a-w by whi'ch the amaniat dis- pensaries were governed and, with the object of exten-diug- th& in- vestigations so far made into, a broader fi,eld of action, passed a. W "to promote the study and prevention of tropical and feeajisKiissaje diseases and to continue the -work for th© suppresaioa oi imeiimriasts." This law had two objects : 1. The organization of sanitary distiiicts for the investigation, and prevention of those diseases,, pladin# a physieiaiu m ehaa?g.©tQ-f each, who should be specially fitted for laboratory work and to: Anifectt ishe various municipal physicians might apply for a microscopi'e e&srah- oration of their diagnoses. UNOINARIASIS IN POETO EICO. 237 2. The establishment of central or departmental stations for the direction of the uncinariasis work, which was being carried on in the dispensaries of the subsidiary towns, and the supply of such dispen- saries with medicine and other necessary articles. To direct this work, a central office was established in San Juan, with its bacteriological laboratory, where investigations could be made which required a special technique and special apparatus not iife*current use in a clinical laboratory. In accordance with this law, and after competitive examination, seven physicians were appointed for the seven districts of the island and one bacteriologist for the central office. Under the seven dis- trict chiefs were 55 anemia dispensaries, which treated, in all, 37,880 persons, in addition to 9,862 remaining for treatment from last year. The district chiefs were required to open their offices in the district capitals, San Juan, Ponce, Mayagiiez, Arecibo, Aguadilla, Humacao, and Guayama. These offices were dispensaries for out-patients suf- fering from uncinariasis and from tuberculosis and were, in addition, laboratories for such other investigations as might be required of them by municipal physicians. Here bacteriologic examinations of sputum were made for cases of suspected tuberculosis, with a physical examination of the patient, his inscription on a clinical card separate from that used for other diseases, and in case of a positive finding, his treatment and neces- saries for the avoidance of contagion, such as pocket spit cups, anti- septics for the clothing, and personal utensils, etc. Each dispensary had a visiting nurse for tuberculosis cases, who went from house to house where patients under the care of the dis- pensary physician reside, taking care to see that remedies applied and personal hygiene prescribed are properly applied and superintending the execution of measures counseled for the prevention of the disease. This nurse carried her record of daily work to the district physician. The service had also under its care the matter of admission to and discharge from the sanatorium of the Antituberculosis League of Porto Rico. ^. . , . . ■ 1 ^ At the end of the fiscal year the district chiefs were required to make a visit of inspection to each one of the towns in their jurisdic- tion and the service thus knows fairly well the conditions under which this new sanitary movement is developing and how the first steps are being taken in the struggle against anemia and tuberculosis. The service finds that it has about systematized microscopic examina- tions, serum reactions, and other duties of a clinical laboratory re- quested of the district and central laboratories by the physicians of the island and feels that it has responded with efficiency and prompt- ness to the demands made upon it. The medical officers of this serv- fce have thus aided the bureau of health of he island without mter- fering with its jurisdiction, and yet have mvestigated a 1 diseases wh ch have from time to time appeared or which have heretofore Ssted on a large scale to constitute a menace to the public health, recommendfng the preventive measures to be taken m each case. . In bS thf service of tropical and transmissible diseases came into *^!lTTo'i5pfy^thfb?reaVof health with .a corps of physicians especially trf^ed in the pathology of tropical and transmissible diseases. 238 UNCINARIASIS IN POBTO RICO. (2) To facilitate to the medical men of the island, especially to those practicing in the little towns and the country, a means for microscopic corroboration of their diagnoses. (3) To establish dispensaries for the treatment of tubercular out- patients, and thus give primary instruction in prophylaxis, with a visiting nurse to act as a special police for antituberculosis work. (4) To continue the work- of the extermination of anemia in nearly all of the towns of the island by means of the dispensaries. (5) To lay the foundations for a campaign for the prevention of transmissible diseases, which should be the object of every modern sanitary organization. The summary of the cases treated in this year's work appears in another part of this work. The following is a list of the dispensaries : stations for the treatment of anemia in operation during the fiscal year 1909-10. 1. Estaci6n de Adjuntas. 29. Estacion de Juncos. 2. EstaciCn de Aguada. 30. EstaciSn de Lares. 3. Estaci6n de Aguadilla. 31. EstaciCn de Lajas. 4. Bstaci6ii de Aguas Buenas. 32. EstacI6n de Manatf. 5. Estacl6n de Aibonito. 33. Estacion de Maricao. 6. EstaciSn de Anasco. 34. Estacion de Maunabo. 7. Bstaclon de Arecibo. 35. Estaci6n de Mayaguez. 8. Estacion de Arroyo. 36. EstaciSn de Moca. 9. Estacidn de Barranquitas. 37. EstaciOn de Morovis. 10. Estacion de Barros. 38. EstaciSn de Naguabo. 11. Estacion de Bayam6n. 39. Estaci6n de Patillas. 12. Estaci6n de Cabo Eojo. 40. Estaci6n de Penuelas. 13. Estaci6n de Caguas. 41. Estacion de Ponce. 14. Estacion de Camny. 42. Estaci6n de Quebradillas. 15. Estacion de Carolina. 43. Estacion de EIo Grande. 16. EstaciOn de Cayey. 44. EstaciSn de Rio Piedras. 17. Estaci6n de Ciales. 45. BstaciSn de Sabana Grande 18. Estaci6n de Cidra. 46. Estaci6n de San Juan. 19. EstaciSn de Comerlo. 47. Bstaci5n de San German. 20. EstaciSn de Corozal. 48. Bstaci6n de San Sebastian. 21. Estaci6n de Pajardo. 49. Estacion de Salinas. 22. Estacion de Guayama. 50. Estacion de Trujillo Alto. 23. Estacion de GuSnica. 51. Estacion de Vega Alta. 24. Estacion de Gurabo. 52. Estacion de Vega Baja. 25. Estaci6n de Humacao. 53. Estacion de Tabucoa. 26. Estacion de Isabela. 54. EstaciOn de Yauco. 27. Estacion de Jayuya. 55. EstaciSn de Lolza. 28. Estaci5n de Juana-Dir.z. A PLAN POR COMBATING TINCINARIASIS IN PORTO RICO. afKfet* wl-\'^r'^^'^^y ^^% "^'"^ important chapter in this work one for t??'rPnn^' ^T.^^"'*^' '^''' '' "° ^^^^ to make it a C ^Tl *»^„*he reports of the commission have clearly defined the reasons for recommendations under this heading lint'.'n.fn?.?'''^' ^^%^^1^%^- ^"^ «^^y *^« feasible means of control- nng uncmanasis in Porto Rico: 1. By treating the infected. 2. By educating the people to avoid infection. . -tor now SIX years the Porto Eican people have sustained a special medical service for the purpose of combating " anemia." The result has been seen. But special medical services are expensive, and the creation ot one medical service here and another there is a waste of good energy, an unnecessary expenditure of money, and source of friction leading to confusion of authority and loss of momentum. From the very first the men who composed the commission were of the opinion that this work should be undertaken by the insular health service, but the lack of authority over local health conditions, the lack of funds with which to work, and very many other important considerations compelled us to advise a separate service. We now renew our recommendation that the work against uncinariasis be con- tinued in the future under a centralized organization, a department of public health. Under anything less than a centralized health serv- ice, whose officers are health officers of the various municipalities, paid by insular funds, and directed by a medical chief, the campaign against uncinariasis would be more costly and not as efficient. The unit best adapted for a successful attack upon the disease has been the " anemia dispensary," and every town on the island has had one. From it has proceeded treatment of sick and propaganda by placards, pamphlets, and direct personal counsel to those who sought their health at the station. Now, however, we feel that the scope of this work must be broadened. If we compare the activity of a station to-day with what it used to be in 1906-7 we will find a falling off in the attendance. This is not due to lack of interest,- but to the fact that the dispensaries are beginning to exhaust the numbers of infected in the regions they serve — regions whose radius is usually about 3 miles, although sick are still attracted from much greater distances in individual instances at all stations. Thus the town and its near-by barrios are freeing themselves rapidly of "anemia," thanks to those dispensaries. The great mass of anemics is now in the hills, where only a tithe of the population have received treatment for uncinari- asis on account of the distance to be covered to reach the station. We are face to face with the absolute necessity for advancing if we ever expect to contribute in the labor of building up the agricultural interests of the island, apart from the saving of life and the restora- 239 240 UNCINARIASIS IN PORTO RICO. tion to health of the most helpless portion of the population of the island, which latter desideratum is alone enough to commend -us to put forth still greater effort. We inust go up into the hills by means of an ambulant service and treat with these people in their respective barrios. As the work of the dispensaries should always remain the unit upon which all local work will depend, these must be sustained, but in order to avoid raising their cost beyond a figure which would not justify their continuance for uncinariasis alone, the control over all transmissible diseases of the municipality should be assigned them. This is actually being carried out by Dr. Giuti«iTeiz, who, as chief of the tropical and transmissible diseases service, is extending the sphere of action of each of his dispensaries along these lines, with one dis- trict chief to each of the seven districts in the island to su5>ervise the work. These dispensaries are to-day, and should be in the future, true mission stations for hygienic reform. The commission has literally revolutionized the System v>f medical aid to the poor. Heretofore the medical officer of the town was sought at all hours and in all places for a prescription. Thereafter the poor procured the medicine as best they could. It was the " pre- scription," however, that was prized. With the dispensary of iiie commission came regular hours for consultation, surety of receiving the medicine prescribed, and personal contact of the medical oBker with a group of people eager to learn how to avoid preventable dis- ease. All of this really lightened the work of the doctor amd assured the patient of a place where he might conclude promptly with the business that brought him to town. Now, precisely the most important part of work tending toward the prevention of communicable disease is the educational feature and such work must be personal, direct. To succeed one iwast make the dispensary attractive, one must listen attentively t© each appli- cant, that future confidence in the doctor be established. This mission station for sanitary reform should be maxle the objective of every man, woman, and child in the municipality when they want Miedioal advice. If the case is such as to fall outside of those diseases which are classed as transmissible they could easily be referred t@ the municipal physician and the municipality could care for its case. At this dispensary all deaths should be registered and thus more accurate statistics would be obtained, as such registration couid be made at the fixed hours the physician in charge would be in attendance. The dispensary should be open at all tim'^ and two " pTacticantes " (a title conferred whose value approximates that of a sergeant of the Hospital Corps in our Army) should be connected with it, one of whom should always be in attendance during the day. The health officer of the municipality should spend at least two hours of each day save one, in the dispensary and those hours should be fixed. On the excepted day this officer, accompanied by a practi- cante and taking a portable microscope, thymol or beta-naphthol in capsules, sodium sulphate ready for dispensing in packages, amd the record cards necessary, should visit the barrios. It would Ire per- fectly feasible for him to make out an itinerary covering all the barrios in his jurisdiction, notifying the barrio aloa^lde (barrio chief) of the day and hour of his visit, and requesting that person to advise all sick to present themselves at some specified place for treatm^ut. T7NCINABIASIS IN POKTO EICO. 241 Having held his little clinic, given a short talk on some branch of preventive medicine, and notifying those present of his intention to return, etc., he should devote the rest of the day in thoroughlv informing himself of the health conditions of the barrios he vfsits hearing complaints, visiting points of special sanitary interest, etc. ' ihus attending to the needs of one barrio or even two one week another or others the next, he would, in two or three months, com- plete his rounds. Of course there are municipalities which have more than 12 barrios, and to such an assistant health officer should be assigned. After the first visit of the doctor, who should in person make the diagnosis and prescribe the treatment, the practicante should return every 10 days to renew the medicine prescribed until five doses of the anthelmintic have been administered, when the patient should be either advised to await the return of the health officer or, in view of much improved health, be urged to visit the dispensary in the town to verify his cure by a microscopic examina- tion of the feces. In this manner an ambulant service could be sup- plied at a minimum expense, the health officer would be brought into intimate contact with the people over which he is supposed to-day to exercise sanitary cJontrol, and the people themselves would be instructed in the prevention not only of uncinariasis but of all pre- ventable diseases which threaten them, besides acquiring the habit of looking to the health officer as the true guardian of their physical well-being. To make this hard service more palatable and to provide for nec- essary expense of transportation, the health officer should either re- ceive for these trips a per diem allowance for expenses or his trans- portation. The part of the planter in this work is a very important one. Head as he is of a community of working people, his advice, nay, his orders, would be far more readily obeyed than statutes of law. When the health officer effectually carries out his mission it will not be long before we may see a little extra pay added to the wage on condition that shoes are used. Indeed shoes might easily be kept for sale at cost price in the plantation stores of some large estates. Earth pollution will be restricted,- inspection of huts will be made, and a lively interest in the physical condition of laborers will be the fruit of the labors of the municipal health officer, provided that he will throw into it his personality and the cooperation of the landowner be generously given him in his work. We are thoroughly opposed to legislation which would attempt to compel the use of shoes, and we are still in much doubt as to the form a law should take prohibiting earth soiling. Our campaigns have always been made with the good will of the Porto Rican people to help us. The time is not yet ripe for punitive measures, and we would regret seeing a law enacted that would have to remain unenforced upon the statute books. - , .• j: To repeat all other measures counseled for the prevention o± un- cinariasis in the reports of the commission would be to uselessly consume time and space. If we have been able to make clear our viewpoint, that it is preferable to induce people to do for themselves what laws alone can not compel them to do, we shall leel that this chapter has not been written in vain. 77759 °_S. Doc. 808, 61-3 16 APPENDIX. 243 APPENDIX. The appendix contains the case histories of the patients who were made the subject of special study in the first three years of the cam- paign against uncinariasis, besides those of 1899 and 1902, which formed the basis for that campaign. Those of 1899, 1902, and 1904 have aheady been pubhshed, but it is necessary for us to reproduce them here, as they are not only out of print, but, as far as the most important series are concerned, were given exceedingly Hmited circu- lation. The series for Aibonito and for Rio Piedras have never been pubhshed and are really the most instructive, as they furnish data of great value for any work which contemplates the treatment of large numbers of sick as a means of eradicating the disease in its endemic form. There are over 30,000 clinical cards of our patients for 1905 and 1906, which are incomplete as to their detailed histories, but which contain valuable etiologic data and which describe the system or systems most affected by the disease, together with aU unusual symp- toms and a very fuU account of the treatment and the reSult obtained. The compilation of tliis data is, however, a work of a long time, and in the midst of a struggle to gain the mastery over an endemic that still enslaves 300,000 people it is manifestly impossible to reflect very- long on what has been done in the past. The records are being kept, however, and may some day be of mterest. For the present needs of this hurried compilation of our five official reports the following case histories will be sufficient to very faithfully reflect the types of uncinariasis which one may chance to see. 244 THE PONCE SERIES OF 1899. Upon the study of these cases the anemia of Porto Rico was found to be uncmanasis Many of the details of the case histories are omitted lor the sake of brevity, but enough are retained to elucidate each case. When the first blood records, etc., were made, the cause ot the disease was entirely unknown, and until the latter part of November cardiac stimulants and iron and arsenic were the chief drugs used. In a few recounts an instructive lesson is given of the futility of mere "tonics" in uncinariasis. Later thymol began to be employed by Dr. Ashford, but as he left the island in December the succeeding history of these unfortunates is not known. All of the cases were studied in November of 1899. PblychromatophiUa, poikilocytosis, and abundance of macrocytes and microcytes were found in nearly all; in fact, the only one in. which these were not present was case 16. The type is seen to oe severe. ii a 1 -a 'Sbg i 1 >^ 3 a, 1-1 k 4 13 Ph k 1 II Ph 1 o 2; ft E&umfi of history. 1 2 3 4 5 1,530,116 697,776 1,533,112 1,200,000 1,484,440 20 20 22 16 ID 6,800 7,960 2,000 4,200 6,000 65 59 64 64 64 21 17 22 23 24 9 15 8 6 8 6 9 6 7 4 26 144 8 109 12 13 46 8 White, male, age 14; extreme pallor; edema general; great dilatation heart; edema lungs; liver much enlarged; constipation; tempera- ture 101.6. Recount of blood 19 days later: Hemoglobin, 16 percent reds, 1,880,000. White, male, age 42; ill three years; extreme pallor; great emaciation; ulcers leg and corneal ulcers both eyes. Temperature normal to sub- normal. Recount of blood 20 days later: Hemoglobin, 23.5 per cent; reds 2 664 440. White', male, age 25; very pale; ema- ciated; ulcer leg; heart dilated; lungs edematous; spleen greatly enlarged; constipated; temperature irregularly between 98 and 99; joint pains. Recount ot blood 19 days later: Hemoglobin, 23 per cent; reds, 1,973,328. White, male, age 49; pasty yellow color; emaciated; marked edema legs; heart dilated; veins swollen and little knots over valves in brachials; pulse 64, weak, intermits every 5 beats; edema lungs; tem- perature between 98 and 100. Re- count of blood 18 days later: Hemo- globin, 17.5 per cent; reds, 801,104. White,male,age25; does not remem- ber the time when he was well; gravish yellow pallor; can hardly understand the simplest questions; insomnia; craving to fill stomach; alternates between diarrhea and constipation. Recount of blood 17 days later: Hemoglobin, 14 per cent; reds, 687,776. 245 246 UNCINABIASIS IN POKTO BICO. i" 1 >> i r =1 !t 8,800 65 26 5,600 60 23 4,800 74 17 7,800 60 17 1,500 72 20 4,600 69 22 7,680 52 26 6,800 63 17 11,000 50 10 12,700 73 17 p. Efisumfi of history. 2,193,328 1,633,328 23 123 35 23 1,271,104 1,600,000 1,800,000 2,266,656 1,268,888 2,440,000 2,353,328 17 31 White, male, age 25; has had anemia 19 years; lemon-yellow color; in- somnia; edema both legs; so weak that he has to be carried to place of examination; dyspnoea so severe as to prohibit the shghtest movement; dilated heart; temperature 100.2; nausea, vomiting, and constipation. . White, male, age 33; always anemic; marked pallor; emaciation; pot- belly marked; sUght edema legs, perns and scrotum, left foot, and wrist; pulsation brachial veins; liver dullness increased; heart dilated. White, male, age 55; marked pallor; immature cataract both eyes; "pul- sation brachial veins; heart dilated; pulse weak and intermits every fifth and seventh beat; Uver dull- ness to 3 inches below ribs; tem- perature 99.6. Recount of blood, 15 days later: Hemoglobin, 31 per cent; reds, 3,084,440. WMte, male, age 32; 2 years sick; pasty yellow pallor; edema of right arm, forearm and hand and of both feet and legs; ulcers both legs; gen- eral pulsation veins; heart dilated; temperature 99.1; constipation. Ke- countof blood, 16days later: Hemo- globin, 24 per cent; reds, 2,500,000. Mulatto, male, age 25; 2 years sick; yellow, pasty pallor marked; insomnia: pulsation veins; heart area enlarged; temperature irregu- larly between 97 and 99; nausea, vomiting; inordinate craving for food; constipation. Recount of blood, 17 days later: Hemoglobin, 13 per cent; reds, 668,880. Negro, male, age 54; 19 years sick; all circulatory symptoms with badly involved heart; nausea, vomiting, constipation; intense yellow pallor; edema lower ex- tremities. Negro, male, age 16; sick 6 years; moderate grade of symptoms, all systems; hver and spleen enlarged. White, male, age 47; 9 months sick; decided pasty pallor; pot-belly; no edema; heart dilated with enlarged liver; temperature 99.8; otherwise usual symptoms. White, male, age 22; disease began 1 month ago; dizziness, headache, tinnitus aurium; insomnia; high degree emaciation; great pallor skin and mucous membranes; pul- sation veins; heart much enlarged; cardiac dilatation; loud murmurs all over heart; pulse 84, weak, com- pressible; temperature 100.4; nau- sea, pain in abdomen, constipa- tion; dullness over entire right lung with small moist raies on this side, and increased resonance and bronchial breathing. Liver great- ly enlarged and tender; history, amebic dysentery. Diagnosed ab- scess liver but not proven, owing to patient'sretusal operation andleav- mg camp. Tliis diagnosis doubtful now in view of history. A case of true acute uncinariasis. Negro, male, age 18; 2 years sick; usual involvement of all systems. THE PONCE SERIES OF 1899. 247 S3 o 2,934,444 2,140,000 19 a bo a m 23 5,200 18,000 9 20 1,560,000 30 as 60 2,400 3S a-3 8^ 12 10 ■!2 J sa sa p. §a sa 10 36 125 R6sum6 of history. White, male, age 41; IJ years sick; no edema; hypertrophy heart; usual symptoms save lungs where consolidation was noted over entire right side, probably tubercular. Has abundant tertian malarial par- asites in blood. Negro, male, age 18; marked ascites; heart normal; pallor marked; pulse ■weak and intermittent. Lungs: Dullness right apex and both bases diffuse moist r&fes, large and small, heard all over chest; fine crepitant rftles right upper lobe; breathing rapid and thoracic. Temperature 101.4 Lobular pneumonia. White, female, age 40; had no pro- nounced symptoms until about 6 months ago. but has been anemic 10 years. Well developed; muscular tissues soft and doughy; complex- ion sallow; appearance bright; headache; no gastric affection; al- ways tired on slightest exertion; sleep irregular; menstruation al- ways regular, but very watery; pain in left arm and leg; no mur- murs in heart; pulse weak and thready; liver much enlarged, also spleen. No symptoms from de- gestive system save constipation. Mulatto, male, age 22; always in good health until about 1 year ago; IS like a waxen image; liver and spleen enlarged and tender. Rest of picture that of severe case. 1 Unknown. THE POITCE SERIES OF 1902. These cases were studied by Ashford and King and published in "American Medicine" (Sept. 5 and 12, 1903, Vol. VI, Nos. 10 and 11, pp. 391-396 and 431-438). Nineteen of them were very complete in symptomatology and are used in this work to assist in forming a basis for a summary of the clinical features of the disease. Such cases are Nos. 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 17, 23, 26, 51, 52. The entire series of 100 cases are divided into two groups: First group. — These are cases in which the blood records are com- plete for red and white cell counts, hemoglobin percentages and dif- ferential counts of leucocytes. In addition, the case histories are much more detailed. Second group. — Cases in which only a brief summary of the type of case is given and the hemoglobin and differential counts. The first group comprises the graver cases. 248 THE PONCE SEBIES OF 1902. 249 I 1^3 S O Jj+J © 0-a ■sa o i mM'Jlt (D op o a=) gg-^i a t3 -= !*-§ f. I s i +3 (fl ad bo^'i Bd «_ m o d~ d+j '^■St3 R rt « d 03 Cj ^ 3 b S-S fe MO O S^ ►4 .-bog p ^ a w S '3 ;r a £ s i- a cj<:2 m o a £ gv, OS p ? 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N I""* ^1 +J ft ■ - u 0) V . rt 2 o §9° ° " d Jll a i JS ti 03X3 'O to II Up, " S P O CO CO "2 S.2 ■S ^ S g~ « 03 a 0) 3 Is 5S >-.a.° ^a'-i .2 ® ft cd CO O CO OJjj ffl S gj 8oo 3 o-*5 ■^■^ 9 3 2® ^5 ■a Sg-a 32-g rap© 2h co,0 -> >, Tt< . J^ c« rt--s a r^ ?l^l '^3 .3 «a "If i^'l J^ P OH - d - ^a §a rag oE: •Ofl a . to i2 a; o) — [» S»!" M o o ■asBo JO 'ON 256 UNCINAEIASIS IN PORTO RICO. i a "S Pi ? a> ct P.P|H 1 3 ^"-1" .Q g^e f?? t^g^ 11 ^-|g ^y, e a o 5 S CO 5 ^ oj ""IP 2 fl C3 d-P CD 0_n rj^ a g-tio-g W ^ (=1 "^ m .2+^.y > .. S © ® +3 fe ca fl oj a a Ph"^ ".M cs p 83 J .-S-S 2 '^waag.29p«| O tS 03 +J 3f? en •-23 •a? a « o o "■i CI m p .P is 3 So. 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Doc. 808, 61-3 17 258 UNCINAKIASIS IN POETO RICO. a p. a S3 a r It .g .1 £>P| sla- O V ^ l2 s '2 >> "S d M S u a> u !=J > P O va°aa cd o3 oj .. o3 d 'd w m f*^ m « P. a a ; 01 0) £ .ags •~a2 <3> a a g l» Pi o a n > p ■saiiqdomsoa P S 1 CQ lO a> (N (D O lO ■* •sa:^looqduiXi aSj^q -^ CO CO so t* o t^ OlOO M TttO ■sa^ooiiduLil II'BTItg oca OCOCOCO CO CO CO 3] Oi-rti OtOii-i -nnoqdioiujiio j; J8d 'aiqoiSorueH 5 lO miocoT ■ja^eianiitn: oiqno J9d sjiso pajj ■ oo ■ oo •snoBea -pjrexa podiq jo 9}Ba fl'Slg'gJg-gg-gg'g'SSs-gS g-g d-g^.2afl gS •§ ga a§ •C a 3a|a§as0 | «a> ma ■a '2 i| l§ il la s^^a j, J, t< .o' 1^ 1^ -So ia| oo ^ 5 O 5 ■esBojo -0^ « ^ U3 (O 00 00 00 00 s a THE PONCE SEBIES OP 1902, 259 9^ fell ai|§| t,"^ ca S D o o 2 ^5 I- §.S3 fc, -13 -" r: g'S^ ! "•pa -3 1 OJa JS— a Co "S ai Mg ■"its as ■Sa-s sgasl ■g^a*! i-Sg* &5-9p,B aga^" p &SSS oo "3 4J ra d (3*^„^ Tj OJ M H ^ Q^ S ft bosad "^ ^'^'^^ ^a§d gaaas2a'&a!§ 3 a THE UTUADO SERIES OF 1904. These case histories were pubhshed ia the report of the Porto Kico Anemia Commission of 1904, and as they are very complete and well portray the clinical picture of two, at least, of the three types, the moderate and the marked, they are included herein. All of these patients were kept in the field hospital, within a few steps of the dispensary, and we were in constant contact with them: Age: • Below 10 yeara of age o Between 10 and 14, inclusive 18 Between 15 and 19, inclusive 9 Between 20 and 29, inclusive -^ 13 Between 30 and 39, inclusive 13 Between 40 and 60, inclusive 3 61 Sex: = Males 44 Females 17 61 Color: = White 46 Mulatto 15 Negro 61 The chief value of the blood records is that they are taken at regu- lar intervals of a week, at the same time of day and at a time before the administration of the specific drug which prevented the influence of the same upon the blood. The abbreviation "Hb." signifies hemoglobin; "E," eosinophiles; II P," polymorphonuclear neutrophiles; "S. L.," small lymphocytes; "L. L.," large lymphocytes; "B," basophiles; "S. C," ttirck's stim- ulation cells; "My," myelocytes. Although not expressed in all cases, Charcot-Leyden crystals were never absent from the feces. The coagulation of the blood was almost always very slow, and the num- ber of degenerated leucocytes was great in practically every case; especially was this true of eosinophiles. The number of leucocytes counted for the differentials was usually 250, but at times reached 500. These histories had to be condensed into the smallest possible space. For this reason and in order to have a connected account, no separation of objective and subjective signs has been attempted. Hemic murmurs refer to the heart. Although anatomically the abdomen embraces the epigastrium, we have used the former to refer to the lower abdomen and mention the two separately from the great difference in their clinical significance in this disease. Such abbreviations as, "2-15," "4-40," etc., signify 2 or 4 grams of thymol and 15 or 40 grams of sodium sulphate before and after taking thymol. In other words, the number preceding the hyphen is the dose of thymol, the number following it the dose of sodium sulphate, Case l.—J. S., town of Utuado. Admitted, May 8, 1904. Age, 23; male; white; niarried. Laborer on coffee estates. States that he has no work on account of illness. Sister died of anemia. Eats usual food of country people. Has severe mazamorra every year at time of rains. Has had much iron and quinine. Well marked pallor; bps very cyanotic; ia well developed and well nourished. No edema; pruritus of 260 THE XJTTJADO SERIES OP 1904. 261 feet; no atrophy of skin but same is dry and liarsh; does not perspire Little aDDetitP- ga^tralgia; nausea; no vomiting; flatufence; decided tendernSsTdomen and^S' ^TtLTt^T'' ^^Z^T"^^}' enteralgia; feces, normal color Ld consistence, but f^h^ul %lT. ^^"^ ^^°°,'^ ^ ^'' ^^°°^V "^^^y ^Sgs of uncinaria, ascaris, and tricho- cephalus. Spleen normal; liypr extends to 1 inch below ribs. Suffers U-eatlv from dyspnea, palpitations, and pam in region of heart. Pulse 110, strong andfull He^ not enlaxged; slight hemic murmur best heard at third left iAtercostaTspace S Ch minTclr^M'^i*^^?^*^?^ °* ^'"*r ?« i? ^^^1^ ^^'^ supraclavicular regions SX.i,'f/¥'*- ^''''} dizziness and tinnitus aurium. Constant frontal and cerebellar headache, Sleepless and cast down. Suffers from fainting spells. Patellar reflex diminished Intelligence excellent. Complete impotence for from 15 to 20 months. Susceptible to cold. Paresthesia lower limbs decided. Urine sp gr 1 017; reaction, acid; color.amber; nothing abnormal. Tendency to dilatation of pupil J blurred vision Muscles flabby, sore, and pamful. Decided general weaLess! Often has slight fever. Course 0/ case.— Uneventful, save that in early part of July he was taken with severe pam in abdomen, which precipitated an attack of hysteria mayor with all the signs of sudden and severe congestion of the brain . He lay in a trance-like condition for about three hours, but recovered completely. For a similar case see case 30. No albumen found m unne. Diagnosis. — Chronic uncinariasis; intense. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L.L. B. S. C. My. May 8 33 36 38 36 50 56 62 67 66 76 83 83 82 75 101 2,968,000 2,991,040 3,960,000 4,384,000 4,000,000 4,541,600 4,360,000 5,261,600 4,152,800 6,866,400 7,635,200 7,035,200 5,176,000 5,924,000 5,164,000 13, 200 5,000 5,200 3,200 9,200 5,200 9,800 7,200 8,800 6,400 6,200 7,400 4,000 5,000 7,800 16.8 22.4 16.4 17.6 8.6 14.8 10.8 8.8 9.0 6.0 44.8 46.4 58.3 37.0 55.0 47.6 64.4 58.4 42.7 35.6 29.6 14.8 9.0 14.0 15.6 22.4 14.4 22.4 36.0 29.2 8.4 15.2 16.3 16.0 6.8 12.0 10.0 10.4 11.4 27.2 0.4 1.2 16 23 30 .8 .4 .8 .4 14.0 13.6 1.6 June 6 13 .. 8 20 27 July 4 .3 1.2 .6 .8 11 18 25 4.8 6.6 8.4 8.8 68.8 62.0 44.0 41.2 17.2 24.8 31.2 37.6 17.6 17.2 15.2 12.0 1.2 .4 .8 .4 .4 AUB. 1 Aug. 1. .......... ............ .4 15 Remarks. — ^May 8, blood very fluid; coagulation much delayed. Slight poikilocy- tosis. June 27, many bacilli in blood. Reds seemingly normal. August 1, reds normal; some bacilli. Treatment.— Ma,Y 9, 4-40; 16th, ova uncin.; 17th, 4-40; 24th, ova uncin.; 25th, 4-30; June 2, no ova uncin. ; 19th, ova uncin. ; 20th, 4-30; 29th, a few ova uncin., some ova tricocephalus and many Charcot-Leyden crystals. One tyroglyphus longior; July 1, 4-20, preceded by0.03 podophyllin; August 8, no ova uncin.; 15th, no ova uncin. ; 22d, no ova uncin; 25th, ova uncin.; 26th, vomits sod. sulphate so was given effervescent citrate of magnesia before and after thymol 6; August 1, no ova uncin.; 8th, no ova uncin. but many ova of schistosoma mansonii; 15th, no ova uncin. iJesM^i.— Cured August 15. Is now a powerful ruddy man without a trace of his former disease. A little mucus in stools which are loaded with schistosoma eggs. Shortly after this entered the insular police force. Case Z.—i. R., barrio Salto Abajo. Admitted as outpatient. May 9. Age, 24,- male; white; single; laborer in garden and on coffee estates; weight, 135. Seven of his family are suftermg from anemia; father died of it. Has been ill 12 years Food mainly vegetable; rarely eats meat. Has had much mazamorra. Lately has consumed l quarts of an iron tonic, and many patent iron pills. He is very pale but still has a little color left in the conjunctivae. Not emaciated and general development is excellent. A little edema of face and extremities. Ulcer of right leg. Slight atrophy of skin, which is very dry. Rarely perspires. Appetite good; no gastralgia nausea or vomiting. Tongue looks as if a pen had been wiped onit; i e., two purplish ines on dorsum Flatulence; no tenderness abdomen or epigastrium; bowels regular, feces chocolate color, formed, no blood or mucus, many ova of uncmana and ascaris and meat fibers. Spleen and liver normal. No dyspnea; palpitations; no pain over heart-pulse 80, dicrotic and compressible. Heart not en arged. Soft blowing nSuf best heaxd at third left intercostal space. No pulsation veins. Dizziness, toSt^'aurium; frontal and temporal headac£e. No sleeplessness; decidedlj. hypo- chondriacal No fainting fits. Patellar reflex almost abolished . Intelligence good. No impotence. No susceptibility to cold. Very typical facies. Has paresthesias feet. 262 UNCINARIASIS IN PORTO RICO. Urine normal, sp " ■ iful. gr. 1.012. Pupils tend to dilate. Blurred vision. Muscles soft. Much weakness and breathlessness on exertion. Subject to slight sore, and painfi fever. Course of case. — Rapid improvement in all symptoms. Never had any food from hospital and, at every visit to clinic, complained of poor food at home. Diagnosis. — Chronic uncinariasis; intense. Date. Hb. Eed cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. May 9 . 38 38 37 50 59 66 90 100 113 3,968,800 4,093,280 5,400,000 5,217,600 6,000,000 6,632,000 6,301,600 6,484,400 6,000 10,200 3,600 18,400 13.6 18.8 18.0 ?.3.5 62.0 63.2 66.0 60.0 64.0 65.6 72.0 75.6 18.0 13.6 9.6 9.5 8.4 12.4 10.0 9.6 4.8 3.2 3.6 4.0 6.0 7.2 5.6 6.8 1.6 1.2 2.0 1.0 .8 1.2 1.6 1.2 16 23 0.8 1.5 8.4 2.4 ■ i 30 0.5 June 6 10,800 12.4 9,400 ; 11.2 9,200 1 10.4 22,600 6.8 13 20 27 Aug 5 Remarks. — ^May 9, blood very fluid and coagulates slowly. Poikilocjrtosis and poly- chromatophilia marked. Many microcytes; a few macrocytes. May 23, reds more normal; 48 normoblasts per cmm. June 6, 43.2 megaloblasts per cmm. June 20, reds normal. Treatment.— BlaMd'a pills used in intervals between days thymol administered. May 9, 4-30; 16th, very few ova uncin., no ova ascaris, 4-40; 23d, still a few o.va uncin., much better, 4-30; 30th, still ova uncin., 4-30; a most remarkable improvement in this case; June 6, many more ova uncin., 4-30; is taking on flesh and feels well; 13th, 4-30, still a few ova uncin.; 20th, no ova uncin.; 29th, no ova uncin. Result. — Cured, June 27. All signs of disease have disappeared and the man is fat, ruddy, and working. Case S. — ^M. G., barrio Rio Abajo. Admitted May 9. i^e, 16; male; mulatto; single; has no occupation because of his illness; usually works on coffee estates; weight, 95 pounds. Five in family suffer from anemia (we had ocular proof of this as his improvement brought the whole family down as patients); three of family died of anemia. Food, mainly vegetable, with codfish, beans, and rice at times. Has suffered much from mazamorra. Has taken much iron. Marked pallor of m. m. and cyanosis of lips. Color of skin gray. Decided emaciation. Is poorly developed. Has had general edema but does not present it now. Has had ulcers m legs. Slight atrophy of skin which is very dry and harsh. Does not perspire. Has large appetite out "vomits air"he eats. Much gastralgia and nausea; flatulence; tenderness, epigas- trium and abdomen; meteorism; constipated; enteralgia; feces, dark yellowish brown, much undigested food, meat and vegetable fibers, many Charcot-Leyden crystals, a great many ova of uncinaria, a few of ascaris and tricocephalus. Spleen and liver normal. Dyspnea; palpitation and pain over heart; pulse 80, very weak and com- pressible. Badly formed chest. No heart murmur. Much pain in chest. Dizzi- ness; roaring in ears keeps him awake at night; frontal and temporal headache; neu- ralgic pain in head; sleepless. Is very miserable and cast down. Intelligence veiy limited. Says he is always "frozen" from cold. Paresthesia, legs and feet. Pupifs tend to dilate; vision blurred. Muscles flabby, painful, and sore. He is exceedingly weak. Has had fever. ' Course. — A very marked case of dilated stomach; a ravenous appetite but persistent vomiting. Boy continued, in spite of this, to improve daily. Is an earth eater. Diagnosis. — Chronic uncinariasis; intense. Complication. — Dilatation of stomach. Date. Hb. Eed cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. May 9 25 29 31 35 41 46 59 59 84 100 103 2,640,000 2,560,000 3,040,000 3,208,000 3,844,000 4,074,400 3,666,400 4,292,800 4,110,400 4,582,400 6,048,800 7,400 7,000 7,200 6,400 6,200 6,600 6,000 3,600 8,200 6,000 6,800 9.8 8.0 10.4 18.8 23.2 15.6 9.2 16.0 16.0 17.2 13.2 70.7 71.2 64.0 64.8 56.4 63.2 66.8 56. 4 57.6 66.0 51.6 11.5 15.6 7.5 4.4 0.5 .8 "i.'e" .8 "■2.0' .8 .8 ■'i.'e' 16 23 4.4 3.2 2.8 .8 .8 2.0 .8 .4 30 June 7 7.2 16.4 11.2 21.2 16.8 18.4 20.8 9.2 4.0 10.0 3.6 8.0 7.6 11.6 0.4 13 20 27 July 4. 11 .4 1.2 18 THE trTtJADO SERIES OP 1904. 263 Rermrh.~M.a,y 9, blood very fluid aad coagulates slowly. Slight polychromato- pmua and poikilocytosis, many microcytes. June 27, macrocytosis prevails Many degenerated leucocytes. Neutrophilic granules stain poorly in many cells Little poiJsilocytosis or polychromatophilia. July 4, reds apparently normal. 18th, reds normal. One eosinophilic myelocyte. 2Vea«nwn«.— May 9, 4-45; 16th, ova uncin.; 17th, 4-40; 23d, 4-30; 30th, ova uncin.; 31st, 4r-25; June 9, ova uncm.; 10th, 4-20; 20th, ova uncin.; 2l8t, 4-20; 27th, no ova uncm; July 2, mtro-muriatic acid, gtt V. t. i. d. for dyspepsia; 6th, few ova uncin.; 7th, 4-20; 12th, no ova uncin.; 23d, discharged. Result.— Cured, July 18. All signs of uncinariasis disappeared. Still suffering from dilatation of stomach but not to any great extent. Color good and is strong and active. Case 4. — G. V., barrio Caguana. Admitted, May 10; age, 35; male; white; single; laborer on coffee estates. Food: Rice, beans, codfiBh, and vegetables. Gives clear history of mazamorra preceding anemia, and he, himself, connects the two. Has had a great variety of iron tonics. Moderate pallor; no emaciation. No edema; general pruritus; atrophy of skin marked; ever since disease began has failed to perspire. Good appetite; no gastralgia; has nausea and vomiting; flatulence; no tenderness of epigastrium or abdomen; no meteorism; constipated; no enteralgia; feces black, streaked with yellow, meat and vegetable fibers, no blood or mucus, few ova uncinaria and many Charcot-Leyden crystals. Spleen and liver, normal. Dyspnea; palpita- tion; no jain in precordium; pulse, 72, strong and full; no heart murmur; no pain in chest. Dizziness; tinnitus aurium; little headache; sleepless; hypochrondriacal; has fainting spells; intelligence, good; impotence (a prominent symptom); reflexes nor- mal; susceptible to cold; paresthesias of legs and feet. Urine normal, sp. gr. 1.008. No tendency to dilatation of the pupil but blurred vision. Muscles flabby, but no soreness nor pain. Decided weakness. Course. — An uneventful course but a very obstinate case as will be seen from the blood chart. Diagnosis. — ^Chronic uncinariasis; intense. Date. Hb. Red cells. Leuco- cytes. S. L. L.L. B. 3. C. My. May 10. 17. 24. 30. June 7. 14. 21. 28. 5. 12. 19. 26. 2. 9. 14. July Aug. 28 39 40 44 41 44 54 73 57 57 82 84 90 86 lOO 2,656,000 3,604,400 4,040,000 4, 475, 520 5, 066, 400 4,776,000 4,555,200 4,808,800 4,888,000 8,532,800 6, 720, 000 6,035,200 5,400,000 5,715,200 0,435,200 9,000 7,600 8,400 0,200 7,200 8,400 9,200 4,400 7,800 7,000 8,200 7,600 5,800 4,200 10,200 19.6 16.8 18.0 25.6 7.2 15.6 19.6 13.2 14.4 15.2 8.8 16.8 20.0 16.0 24.8 51.2 62.4 60.4 54.8 60.8 50.0 52.8 58.4 48.4 56.0 68.4 61.2 53.6 59.2 54.4 21.6 11.2 12.0 9.6 10.8 26.8 20.8 22.0 28.4 14.4 10.4 11.2 18.0 17.6 14.0 6.8 8.8 4.8 7.2 6.0 7.6 6.0 5.2 8.4 14.4 11.6 9.2 7.6 6.8 6.8 4.0 2.4 14.2 1.6 .8 .4 Remarks —May 10, blood very fluid, a tendency which it sustained almost to the last, with slow coagulation; poikilocytosis; polychromatophilia; many macrocytes and microcvtes July 19, reds still tend toward macrocytosis but to a less degree. Treatment —May 11, 4-30; 17th, no ova uncin.; 18th, no ova uncm., two specimens examfnSoth no ovk uncin. ; 26th, one ovum uncin. ; 27th, 4-30; June 2, ova uncm. ; Id^^-tlrilth, no ova uncin. 15th, 3-25; 21st, no ova uncm.; 28th, no ova uncin^; July 5, no ova uncin.; 12th, no ova uncin.; 26th, one ovum uncm.; 27th, 4-15, pre- ceded bv 03 podophyllin; August 3, no ova uncm. K«V-Cured?iugust 3. Rosy color. Every sign of disease has disappeared. Case 5 -M M , barrio Salto Arriba. Admitted, June 24; age 14; female; muMto; sincle- country girl; aids ^ coffee picking. Anemia is the one disease of her family Pofd maMv vieetable Has had mazamorra. Moderate pasty pallor. Is fat and S'deTeSpV sShat she has not yet menstruated. Edema of face trunk and lower extremities; general pruritus; no atrophy of skm butj^^t ^^^^X.' S^ SDires Good appetite; gastralgia; nausea; no vomiting; tongue dark color flatulence tenderness epigLtrium' Ld abdomen; meteorism; ascites; bowels ^^o^fl; e^t^ralgia, feces norinalslve for lajge number of ova of uncinaria. Spleen and liver enlarged Dyspnea^alpitation, "pain in heart;" pulse, 72, weak ^^^d 'compressible, heart hemic murmur. Pain in chest. Dizziness; tinnitus aurium; headache, frontel and tempo^ sleep normal; mental condition, very peculiar; a curious half melancholic, 264 UNCINARIASIS IN PORTO RICO. half sullen expression of face; intelligence, poor; no fainting spells; patellar reflex diminished. Muscles flabby and painful. Debility. Temperature, 37.1. Course. — A very rapid improvement noted, above all in her mental condition. She completely changed her character, becoming pleasant and interested in her but- roundings. -Acute uncinariasis, moderate, rapidly becoming severe. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L.L. B. B.C. My. 45 47 65 70 90 106 4,432,000 4,381,600 4,901,600 5,506,400 5,835,200 4,999,600 7,600 11,000 10,000 6,200 9,400 9,200 9.6 13.2 13.6 12.8 20.0 18.0 53.2 60.8 51.6 46.8 40.8 58.4 28.0 19.6 25.2 27.2 33.2 13.2 8.0 6.0 9.6 12.4 48 10.0 1.2 .4 July 3 10 17 .8 .8 .4 24 0.4 31 Remarks. — June 26, blood fluid and coagulability diminished. Poikilocytosis and slight polychromatophilia. Microcytes predominate over macrocytes. Many bacilli. July 3, few bacilli. July 10, more bacilli than ever. 17th, no bacilli, reds normal. Treatment. — Blaud's pills used in the intervals. June 27, 3-20, preceded by 0.03 of podophyllin; July 5, one ovum uncin.; 6th, 3-15, preceded by 0.03 podophyllin; 10th, few ova uncin. and many Charcot-Leyden crystals; 11th, same as on 6tii; 17th, no ova uncin. but some larvae of strongyloides intestinalis; 28th, ova tmcin.; 29tii, 4-10, preceded by 0.03 podophyllin; 31st, no ova uncin.; August 2, no ova uncin. Discharged. Result. — A wonderfully rapid cure. Has gained much in weight and has a fine color. Case 6. — R. G., barrio Caniaco. Admitted, May 11. Age, 22; white; single; laborer in coffee plantations and banana patches. Says he has never lost weight but rather has gained. Brother of case 3. Has been sick for years. Cuetomary country food, but now codfish is hard to get as whole family are too sick to work. Says that every time he had three or four cents he purchased "iron powders. " Is very pallid with only a little color left in lips and gums. Not emaciated. Has had very marked edema of legs; much mazamorra; general pruritus; has had ulcer of left leg; skin dry and harsh; never perspires; no atrophy of skin. Appetite good; much gastralgia, nausea, and vomiting ; flatulence ; tenderness of abdomen and especially of epigastrium; meteorism; slight ascites; bowels, regular; enteralgia; feces, dark but normal save for eggs of uncinaria and ascaris. Spleen and liver normal. Breathlessness on walking; marked palpitation of heart with pain in precordium; pulse, 85, weak and compress- ible; heart apparently normal. Marked supraclavicular pulsation. Pain in chest. Dizziness; tinnitus annum; sleeps "continually." Has fainting spells. Is melan- choly and dispirited, with a hopeless, staring expression. Low order of intelligence. Patellar reflexes extinguished. Completely impotent; susceptible to cold, and has paresthesias of legs. Pupils tend to dilate; has obscured vision and night blindness. Muscles flabby, sore, and painful. Very pronounced weakness. Course. — This was as stubborn a case as we have had. His resistance to the toxin seemed fair, for he became active, and said he felt well, but our belief is that he still has a good number of uncin., perhaps not expelled on account of protection afiorded by folds of the m. m. and mucus. He expelled, all together, a tremendous number of parasites. Diagnosis. — Chronic uncinariasis; intense. Complication. — Tertian intermittent malarial fever. Date. May 11. 18. 25. June 1 9 16, 23, 30, July 7. 14. 21. 28. Aug. 4 11, 19, Hb. Red cells. 288,000 160,000 096,000 768,000 181,600 337,600 880,000 928,000 964,000 864,000 840,000 020, 100 804,000 475,200 728,800 Leuco- cytes. 9,000 7,800 3,800 6,200 8,400 8,600 7,000 7,600 6,800 5,000 7,400 9,600 9,400 7,600 8,600 E. 20.4 12.8 18.8 12.8 14.0 18.0 11.3 20.7 17.2 13.6 13.1 16.0 18.6 21.2 16.0 P. 61.2 62.0 62.0 60.4 65.2 54.0 65.4 63.0 56.0 46.6 60.8 70.0 56.7' 68.8 52.0 S. L. 14.0 17.6 9.2 8.8 6.0 18.8 15.6 10.6 16.6 26.4 16.1 10.8 16.6 12.0 22.4 L.L, 4.0 7.2 ao 11.2 10.0 8.0 7.0 5.4 10.8 13.2 8.4 2.8 8.5 8.0 9.2 B. 0.4 .4 .8 .8 .4 .3 .4 1.2 .8 .4 .8 S. C. 1.2 4.4 3.6 .4 .8 My. 1.6 1.2 .8 .3 THJ5 TJTUADO SERIES OF 1904. 265 ^t,f„^r**--¥ay 1.1>. tlood very fluid, coagulates slowly. High grade of polv- i 24^2 t^^nf hW '^*°'^' "^"""T- ^4°^^^^^ veryLmerL.%ewer m^crl difference of wTni"^*^ P^'h-i"'"';^ ^ '®?^'^ differential count wa^ made, and a mpnf wpl ;„v ^ eosmophile and one polymorphonuclear was noted. These speci- SvXrvtp t^^,«^„«^P^'^^tely; ^l^^. 1. 20.8 megaloblasts per cmm.; one eosinophilic SSa^ o'.i^ ^' °''^. eosinophilic myelocyte; 14th, poikilocytosis, polychroma- Sne'arly no?Sal°'^ ''' "^*''^- °^' eo^i'iopWlic Welocy^te; j'ul^ 2^8, blood f«™'^r/-~^^V?' ^"^°xi ^^*^' '*yi e^o^ous number of ova of uncinaria, and a few ova of tncocephalus. Huge number of Charcot-Leyden crystals; 19th 4-30- 26th HrivTh ™^'''-= ^-^^^'itf,?' h^M'I^^^ °^'' ^^i'^-; 3°* strongyloides and compressible."^ Heart sli7htirenlatXnfdilffPH° '''t''^'^' ^^}^%' 120; weak displaced downward and outward Ki?L m«r^^^^^ Apex wavy, mdefinite, and and harsh. Pronounced pulsatior, nf ^foTii ■ , " ^emic murmur very loud Dizziness; tinnituHSum; Se°al LXhl '""^W^- ^.^SY^^' ^""^ ^^^ ^'^^^'■ £2eTan1t^p^Lofe£ii^£ sever:^7eiy'lZtT'^M^^'tZlZ'*^f'^^ *"PP'"^ of abdomen. Accompanied by and strPiV i'-^u, j-uuii, ^wa uiii,iii., ±j.i,u, 2-20; 21st, manv ova uncin.- 22d, 3-20; 28th, ova uncm.; 29th, 3-20; July5th, ova uncin.; 11th ova uncin , many Oharcot-Leyden crystals; 13th, 3-10, with0.02podophyllin; 19th, no ova uncin ' 26th few ova uncin.; 27th, 3-10, with 0.03 podophyllm; August 2, no ova uncin Discharged. Result.— Cuied, August 2. This boy is so completely changed as hardly to be recog- nizable by his friends. He is perfectly well, ruddy, and full of mischief. Case n.—?. G., Utuado. Admitted, May 18. Age, 9; female; white; works in a banana patch; has been ill one year; usual food of the country; she says that she was well until she contracted mazamorra; has taken "iron powders." Decided pallor, of pasty, dirty, yellow color; not emaciated. Edema of face and lower extremities; eyelids very puffy. Has had ulcers on her feet; no atrophy of skin; does not perspire. Good appetite; gastralgia; nausea; no vomiting; flatulence; meteorism; constipated; enteralgia; feces soft, dark, and contain many ova of uncinaria, some of ascaris, Charcot-Leyden crystals, and meatflbers. Spleenand livernormal. A little dyspnea; palpitation; pain in precordium; pulse 120, fairly strong and full. Heart hypertro- phied; marked hemic murmur. Markedpulsation veins of neck. No cough. Much dizziness; tinnitus aurium; frontal headache. Sleepswell. Patellar reflex abolished. Has a despondent air. Intelligence good. Susceptible to cold. Urine; sp. gr. 1,014, normal. Blurred vision. Muscles flabby and painful. Temperature 37.8°- CouTse. — Uneventful convalescence . Diagnosis. — Chronic uncinariasis, very intense. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L.L. B. S. C. My. May 18 12 17 35 62 72 76 71 75 85 91 104 984,000 1,304,000 2,264,000 4,101,600 4,636,000 6,064,000 6,624,000 6,600,000 5,432,000 4,712,000 4,840,000 5,200 7,800 6,200 7,200 6,200 7,400 7,800 7,600 5,200 7,400 4,200 8.0 12.8 10.0 16.0 8.8 14.0 9.6 12.0 12.4 6.0 7.2 73.6 70.0 60.0 56.6 44.0 56.6 62.0 58.0 58.8 62.4 61.6 16.4 11.2 17.6 14.0 26.8 25.8 14.8 22.0 16.0 32.0 26.4 1.6 6.2 2.8 6.0 8.4 .8 7.2 2.0 8.4 6.6 3.2 0.4 .8 2.0 2.0 .8 1.2 1.2 1.2 1.6 1.2 1.2 7.6 6.4 7.6 1.6 6.2 4.8 "i'.s .4 8 15 ,3.6 22 29 July 6 13 .8 20 . 27 Remarks. — Blood changes typical. IVeatment.— Blaud's pills used in the intervals. May 19, 2-20; 25th, ova uncin.; 26th, 2-15: June 3, no ova uncin.; 9th, a few ova uncin.; 10th, 2-15; 17th, attack of subacute enteritis. Given calomel 0.130 followed by tanigeno 0.324 t. i. d.; 20th,. ova uncin.; 22d, 2-15; 30th, no ova uncin.; July 7, to 28, and August 6, no uncin. Result— Cured, July 27. A hearty, ruddy girl. This child has gained wonderfully in weight. Case^S.—M. E., barrio, Sabana Grande. Admitted, May 18. Age, 30; female; white; married; works in flelds as well as in house. Mother and several brothers and sisters anemic. Says she has been pale for a long tune and very sick for five months Vegetable food Cannot remember if she had mazamorra. Extreme pallor; edema of fad, trunk, and extremities; skin atrophied and dry ; appetite, poor; gastralgia; nausea; vomiting; tongue slightly coated; flatulence; pain m epigastrium andTabdomen; ascites ITiiZ?^' ^"wol= ^nr,fit/na,ted. Feces coutaiu great many ova of uncmaria. Dysp- marked. ' Bowels constipated. Feces contain i nea; palpitation; pain i/heart. Pulse 115, weak dicrotic ana compressioie. __gear. ■ ' ' '- 3inic murmur marked; strong pulsations of vessels m neck. Heart pam in chest; dizziness;.tinnltusaun1im; headache; le^P f air ; mentaUon- cough;' ditlon'ia1)ad very despondent; intelligence poor; expression very sad; syncope fre- Quent- susceptSv toheatanci cold increased. Paresthesias very marked. Blurred SlSSr system flabby, painful, sore, and very weak, can scarcely walk. Amenorrhea. Temperature slightly elevated at night. Course. — Uneventful and rapid improvement. Diagnosis. — Chronic uncinariasis, very intense. 278 USrCINAEIASIS IN POETO EIOO, Date. Hb Bed cells. Leuco- cytes. E. P. S.L. L.L. B. S.C My. Mavis 14 18 20 44 61 60 65 80 2,372,800 2,024,000 2,696,800 4,520,000 4,832,000 6,244,000 6,417,600 6,467,200 9,000 4,200 4,800 21,000 5,400 4,200 7,800 7,000 0.4 4.4 6.0 3.2 4.8 4.4 6.6 2.4 83.0 76.6 65.6 81.6 76.2 66.6 73.6 82.8 7.8 10.4 12.8 4.0 10.0 16.2 14.8 10.8 8.0 7.6 12.8 7.6 8.0 12.0 6,0 3.6 0.8 1.6 .8 .4 26 2.0 1.6 1.6 1.2 2.4 June 1 8 0.4 16 22 .. 29 July 6 .4 Remarks. — May 18, great poikilocytosis and polychromatophilia. Many macrocytea, microcytes, and oval forms; June 8, 57.6 normoblasts per cu. mm. One basophilic lymphocyte. Polymorphonuclear leucocytosis causing relatively low peicents^es' of other classes. 29th, some poikilocytosis and polychromatophilia. Few macrocytes and microcytes. July 6, no polychromatophilia nor poikilocytosis. Very few maero- cytes and microcytes. Treatment. — Blaud's pills used in intervals. May 18, tr. digitalis and tr. nux vomica; 20th, 4-30; 26th, few ova uncin.; June 8, ova uncin.; 4-25. Became out- patient; 15th, no ova uncin.; 22d, no ova uncin.; July 6, walked in from couetry without more than ordinary fatigue. Result. — Practically cured. Has rosy color. Ceased to retiam. ''. — V. R., barrio Tetuan. Admitted, May 18. Age. 22; male; White; single; laborer on coffee plantations . Father died of ' 'a pain, ' ' mother of anemia ; eight months ago he had a good healthy color ; good food before illness, now poor because of illness and inability to work. Has been ill since last coffee season, when he had severeattack of mazamorra. Has taken iron constantly since illness began, but to no effect. Very extreme pallor. Is well noimshed. Has had edema of face, legs, and trunk. Ulcer on leg. No atrophy of skin, but does not perspire. Good appetite; gastralgia; nausea; and vomiting; flatulence; no tenderness abdomen; constipated; no enteralgia; feces normal but for many ova of uncinaria. Spleen and liver normal. Suffers much frpm dyspnea; palpitation; rarely has precordial pain. Pulse 150, weak and compressible. Heart enlarged, dilated; murmur seems organic in character. Pulsation of vessels of neck. Little cough; no pain in chest. A great deal of dizziness; tinnitus aurium; sometimes frontal and temporal headache; sleeps well; is downcast and apathetic; frequent syncope; patellar reflex abolished; very susceptible to cold. Has paresthe- sias of legs. Pupil tends to dilate; has blurred vision. Muscles flabby, sore, and painful. Great weakness. Temperature, 38°. Says he does not expect to get well. Course. — A very slow convalescence. From 5th of June to 13th of July no ova of uncinaria. July 13, ova found, thymol given and Hb. rose. Diagnosis. — Chronic uncinariasis, intense. Date. Hb. Bed cells. Leuco- cytes. E. P. S.L. L.L. B. 's.c. My. May 18 20 21 20 22 22 32 32 34 32 46 60 75 70 76 90 2,195,200 2,144,000 1,672,000 1,955,200 2,332,800 2,760,000 2,384,000 2,435,200 3,137,600 4,244,000 4,496,000 4,417,600 4,636,200 5,088,000 6,440,000 9,800 7,400 7,400 7,400 6,200 6,400 5,600 8,000 8,000 8,000 8,800 9,400 10,000 7,600 7,000 4.4 8.0 8.0 5.7 6.2 1.6 9.6 10.4 6.4 8.4 13.2 16.0 12.8 9.2 10.4 74.4 58.1 53.2 54.1 51.6 61.2 30.8 65.6 64.4 66.0 49.2 52.4 49.2 46.4 51.6 14.0 19.5 12.0 21.4 30.0 26.0 32.8 20.8 16.8 22.8 21.2 17.6 22.8 27.2 24.0 4.8 9.0 14.0 12.4 12.0 19.6 22.4 12.4 20. n.6 16.4 12.8 14.0 16.4 12.4 2.4 1.5 .8 L4 .4 1.6 2.8 .8 .8 .4 25 3.9 10.4 6.0 .8 June 1 1.6 8 16 22 29 1.6 July 6 13 1.6 .8 20 27 Aug. 3 L2 1.2 .4 1.2 10 16 .4 .4 19 iJemarts.— May 18, blood like beef washings. OoagulateB slowly. Very mairked poikilocytosis; slight polychromatophilia. 89.2 normoblasts per cmSl. June 15, 74.4 normoblaste per cmm. 29th, great poikilocytosis, polychromatophilia. Microcytes very abundant and exceed macrocytes. July 6, reds same, 16 normoblasts per cmm. August 16, reds normal. ■ THE UTUADO SERIES OF 1904. 279 'ith^f^^'^^CT^^^ ^^' ^^^' 26th, many ova uncin.; 27tli, 4-25; June 4, ova uncin • 4^k^^^' ^i'^J^*^' 22d, 29th, July 6, no ova uncin.; 13th, few ova uncin.ri4rh' ^a u^nf '^n-^l 0.03 podophyllin; 20th, 28th, August 2d, 9th, 15th, and 18th;no ova uncin. Discharged from hospital. ' MesuU.—Cmed, August 18. Is perfectly well, strong, fat, and ruddy. Case SS—n.G barrio Paso Palmas. Admitted, May 19. Age, 19; female; white; single, cotteepicker. Father and one brother died of anemia. Her first symptoms were great weariness and her body "went to sleep." Usual food of country. Has maza- morra every coffee season. Has taken much iron. Extreme pallor of a dirty waxy ^ ^: /S emaciated. Edema of face and lower extremities. General pruritus Has liad ulcers on legs. Decidedatrophy of skin. Does not perspire. Goodappetite- gastralgia; no nausea or vomiting; no flatulence; tenderness of abdomen; meteorism' feces normal save for abundance of ova of uncinaria. Spleen and liver normal Dysp- nea; palpitation; precordial pain; pulse, 103, weak and compressible. Very pro- nounced hemic murmur. Marked pulsation in vessels of neck. Dizziness; tinnitus aurium; frontal and temporal headache; sleepless; has fainting spells. Patellar reflex abolished. Tactile sense normal. Is very much depressed. Has not menstruated for two or three years. Susceptible to cold. Paresthesias of feet. Blured vision. Muscles flabby, sore, and painful. Great debility. Temperature, 37.5°. This woman was brought in a hammock. From her waist down she was apparently paralyzed. Course. — In one week she was walking; from this time on, her recovery was unevent- ful. Has pulmonary tuberculosis. A casual observer might have diagnosed this case "beriberi." Diagnosis. — Chronic uncinariasis, intense. Complication. — Pulmonary tuberculosis. Date. Hb. Bed cells. Leuco- cytes. E. P. S. L. L.L. B. S.C. My. May 19 22 27 32 54 51 76 100 1,946,640 2,452,800 3,320,000 4,226,400 5,017,600 4,591,040 5,184,000 3,200 6,000 7,200 16,400 10,400 9,400 6,800 6.8 2.8 4.4 3.2 1.2 2.4 1.6 67.2 68.8 66.8 80.0 80.8 75.6 86.0 14.0 18.0 12.8 6.4 11.2 11.6 7.6 10.8 6.0 11.6 5.6 2.8 9.2 4.4 1.2 .4 .4 .8 1.6 .4 .4 26 3.6 4.0 4.0 2.4 .8 0.4 9 . 16 23 30 Remarks. — May 19. Blood very thin and coagulates slowly. Extreme poikilocytosis and polychromatophilia; 25. G megaloblasts and 12.8 normoblasts per ciiam. Many m.acrocytes and microcytes; May 26th, still great poikilocytosis; 24 megaloblasts per cu.mm. Manymacrocytes. June2,appearanceofbloodimproving; 28.8 megaloblasts per cu. mm. June 30, reds normal. Treatment.— Bland's pills used in the intervals. May 20, 4-40; 26th, few ova uncm. ; 27th, 4-20; June 4, ova uncin.; 5th, 4-20; 9th, no ova uncin.; 12th, ova uncin. ; 18th, 4-20; 24th, no ova uncin. ; 30th, no ova uncin. Many Charcot-Leyden crystals. July ' Result.— Cured of' uncinariasis. Tuberculosis quiescent. Is apparently well and strong iDut is still emaciated. Caseg6.—3. G. Q., barrio, Caonillas. Admitted May 19. Age 30; male; white; Bingle; laborer on coffee plantation. One year sick. Usual food of country. One month after last attack of mazamorra his anemia began. Has taken iron without bet- terment Moderate pallor. No emaciation. No edema. General pruritus. Ulcer oSkg No atrophy o^ skin. No dryness of skin. Good appetite; gastralgia at tunes; no musea nor vomiting; no tenderness of abdomen. Bowels regular. Feces contam ma^ ova uncinaria, Charcot-Leyden crystals, and ova of tncocephalus. Spleen painful. Course Diagnosis toms. Is very weak. Temperature 37.6 . —TTsnal for uncinariasis of this degree. Chronic ^cinariasis, moderate case but with profound nervous symp- 280 TTNCllTAMASlg IK POETO RICO. Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. 52 46 60 61 85 93 88 93 93 97 100 2,420,000 4,417,000 3,764,000 6,280,000 6,536,000 6,384,000 4,840,000 4,968,000 5,288,000 9,400 9,600 9,800 6,800 6,000 6,800 7,000 7,200 7,000 20.8 7.0 7.2 4.0 3.2 7.2 6.4 7.2 16.0 64.0 72.4 80.0 75.2 68.0 65.6 63.6 56.0 52.4 16.2 13.0 4.8 16.0 24.0 18.8 32.0 28.8 25.6 8.8 7.0 3.6 3.6 3.6 6.0 6.0 6.4 3.6 1.2 .3 .8 .8 .8 1.2 1.6 1.2 1.2 26 "". 0.3 3.6 .4 "".'i .4 .4 1.2 9 16 0.4 23 .8 30, July 7 14 28 t 5,392,000 6,800 10.0 62.4 24.0 3.6 JRemarhs.— Blood slightly more fluid than normal. Coagulates slowly. Slight poikilocytosis; macrocytes and microcytes. June 28, blood improved steadily to normal. Treatment. — Blaud's pills used in intervals. May 20, 4r-25; 26th, ova uncm.; 27th, 4-25; June 4, ova uncin.; 5th, 4-25; 9th, no ova uncin.; 10th, 4-25; 17th, ova uncin.; 18th, 4-25; 25th, no ova uncin.; 30th, no ova uncin.; July 14, no ova uncin.; August 6, discharged. Result. — Cured; July 28, all symptoms have disappeared. Rosy complexion. Case 21 . — ^M. T., barrio, Mameyes Arriba. Admitted May 20. Age 18; male; white; unmarried; field laborer and coffee picker. Mother and two brothers are patients of the commission. History of malaria, slight attack five years ago. Has been sick three years. Diet mainly vegetable, occasionally meat. Always had plenty to eat until became too weak to work steadily. Has taken various home remedies, and patent medicines advertised to cure "anemia," without appreciable effect. Is very pale. Sometimes has edema of face and arms. Has had mazamorra, which left ulcers on legs. Slight pruritus, skin atrophied and dry. Never perspires. Appetite good; gastralgia; nausea and vomiting at times; tongue clean; flatulence; meteorism; pam in abdomen and epigastrium; no ascites. Bowels constipated. Feces contain many ova of uncinaria. Dyspnea on exertion; palpitation and slight pain over heart. Pulse 90, fairly strong and full, but compressible. Very pronounced hemic murmur. No cough. DizzinesSj marked tinnitus aurium; severe headache. Sleeps badly. Mental condition and intelligence, good; expression despondent, Impotent. Pares- thesias. No eye symptoms. Muscles flabby, painful, sore, and weak. Tempera- ture 37.7° 0. Course. — Progressed rapidly to cure. Diagnosis. — Chronic uncinariasis, intense. Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L, S.C. My. May 20 27, June 3 10, 17, 24, July 1 8, 15 Aug. 1 24 25 44 54 62 70 96 97 100 120 1,000 1,000 1,800 !,800 1,000 1,400 1,300 i,400 1,000 3,400 8,400 6,000 6,000 6,800 4,200 6,200 7,200 9,000 17.2 12.0 20.0 13.2 11.2 14.4 12.8 7.4 65.2 45.6 64.0 67.2 63.2 64.0 62.4 67.2 72.0 10.3 21.2 13.6 6.8 12:8 8.8 12.4 11.2 11.6 14.6 8.0 10.8 9.6 9.2 12.0 8.0 7.2 7.4 1.1 1.2 1.6 1.6 .4 1.6 1.2 1.2 1.2 Not counted. 6.4 6.4 4.0 1.2 2.4 1.2 0.4 1.6 .4 .4 Remarhs.~M.a.y 20, well marked poikilocytosis and polychromatophilia. Some macrocytes; many microcytes; 40.8 normoblasts per cu. mm.; 27th, 67.2 normoblasts per cu. mm.; one had two nuclei; June 3d, blood improving; 17th, appearance of blood much improved; July 1, blood appears normal. Treatment.— B\a,uA's pills given in intervals. May 21, 4-30; 27th, few ova uncin.; 28th. 4-25: June Sd, many ova uncin. ; 4th, 4^25; 16th, no ova uncin.; 17th, very lew ova uncin.; 18th, 4-30; 24th no ova uncin.; July 1, no ova uncin.; 8th, no ova uncm.; 17th, no ova uncin. Dischaiged. Result.— Cxixedi. Murmur disappeared. Has excellent color. THE UTUADO SERIES OF 1904. 281 laborer InT^K- '• I^i^'^^'T, ^4?ii"ed, May 20. Age, 17; male; white; unmarried; VPB-Xwo w '^''? fields Family history indefinite; some anemic, some not. Diet rieaTT it,^ V ^^^^"^ ? little medicine from city dispensary. Sickness began about «tSLI 7^P marked pallor; no emaciation; general dfevelopment good. Skin tomVii^a- ?1 ^^i ''®"^^'' perspires. Good appetite; no gastralgia; no nausea; no 7^<,^l«f ^'tt ^® ''^?^^' '^° flatulence; no pain in abdomen or epigMtrium. Bowels ^o^^ tL„7 ?,'^®^*^°''4^? ^ff! "^°y °^^ 0^ uncinaria. No dyspnea; palpitation; no pam about heart. Pulse IH weak and compressible. Heart not eXged. Hemic mjmnur very pronounced. Distinct pulsation in external jugular vein. Dry cough Dizziness; tinuitus annum; headache; neuralgia at times; slleps well. Mental con- dition and intelligence good Expression better than usual with such patients. Reflexes slightly exaggerated; impotent; paresthesias. Blurred vision. Muscles weak and flabby. Temperature 36.8°. An interesting case in view of the compara- tively slight symptoms m relation to the low hemoglobin. Cowse.— Improved with remarkable rapidity at first, then very slowly. Diagnosis. — Chronic uncinariasis. Very intense. Date. Hb. Eed cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. May22 11 20 40 54 73 73 88 90 85 90 101 1,616,000 1,821,600 3,848,800 5,124,000 6,430,400 5,261,600 5,475,200 6,606,400 6,635,200 5, 426, 400 5,532,800 3,200 6,000 4,400 4,000 6,200 9,800 8,600 7,000 8,800 12,400 10,600 14.0 15.2 24.0 30.4 42.8 28.8 12.4 16.4 16.4 22.0 24.8 51J 56. 48.8 48.0 33.6 45.6 68.4 57 2 66.4 44.0 66.4 20.-0 13.2 9.2 8.8 8.0 10.4 9.6 11.2 8.8 16.4 10.0 12? 10.4 10.4 11.2 9.6 8.4 7.6 11.6 6.4 16.0 8.0 3.6 .8 .8 1.2 .8 1.6 .8 .4 2.1 3.6 .8 5.2 5.6 1.2 2.0 .8 .8 .8 29 ""o.'s .4 12 19 26 July 3 10 17.. 4 24 4 31 Remarks. — ^May 22, well marked poikilocytosis and polychromatophilia; 12.8 normo- blasts to cu. mm. Macrocytes more numerous than microcytes; 29th, 24 normoblasts to cu. mm.; July 3, reds appear practically normal. Treatment. — Blaud's pills used in intervals. May 22, tr. digitalis and tr. nux vomica; 23d, 3-20; 29th, many ova uncin.; June 1, 4-25; 9th, some ova uncin.; 10th, 4-20; 19th, ova uncin.; 20th, 4-25; 26th, no ova uncin.; July 3, no ova uncin.; 10th, no ova uncin.; 17th, no ova uncin.; 24th, no ova uncin. Result. — Cured. No heart murmur. His facial expression and color had so changed that acquaintances did not recognize him on his return home. Case 29. — J. M., barrio, Caguana. Admitted, June 8. Age 23; male; white; un- married; laborer on coffee, sugar, and tobacco plantations; mother and father died of "anemia." Had measles. Was 5 months in Arecibo City Hospital for "malarial fever " ('') Present sickness began about one year ago with weariness, indigestion, and shortness of breath. Diet usual vegetable food of country people. When finan- cially able bought various preparations of iron wines, sometimes with benefit, some- times without. Pallor is well marked; no emaciation; general development good. Feet and ankles edematous. Has had general pruritus, but little mazamorra. Scar of ulcer on left leg. Skin atrophied; dry; no perspiration. Appetite variable; gas- tralgia; nausea; vomiting; tongue slightly coated; no ascites; some pam m abdomen; flatSlence. Bowels, alternating diarrhea and constipation Feces contam slight amount of mucus and vast numbers of ova uncmaria. Slight dyspnea; palpitation; pain about heart. Pulse, 102; fairly strong; dicrotic; fauly full but compressible Heart not enlarged. Pronounced hemic murmur. Slight cough, expectoration and pain in chest. t)i?ziness; tinnitus aurium; headache at times; no neuralgia. Sleeps well- syncope; reflexes normal. Mental condition fair; usual hopeless expression, iTtelligSce fair; paresthesia. Blurred vision and night-blmdness. Muscles flabby, weak Tiainful and sore. Has pain in joints. Temperature, 37 O. Kf-^toproved steadily,^but very slowly. One of our most stubborn ca^es. Very difficult to expel all uncinarise. Dia^nosM.— Chronic uncinariasis, intense. 282 UNCINAEIASIS IN POBTO BICO. Date. Hb. Bed cells. leuco- cytes. E. P. S.L. L.L. B. S.C. My. 24 26 25 29 35 38 32 40 45 49 61 2,492,800 2,692,800 1,977,600 3,071,040 2,604,000 2,790,400 3,040,000 3,328,800 4,340,000 4,590,400 4,804,000 7,400 13,000 8,200 8,400 6,800 8,000 8,400 6,000 9,000 6,400 5,000 15.2 12.0 14.8 23.6 22.4 18,0 18.4 24.0 20.8 22.0 14.4 60.4 se.o 53.2 60.0 48.8 44 57.6 47.2 60.0 55.2 60.4 9.6 18.0 16.0 15.2 16.8 26.0 13.6 15.6 20.8 13.2 15.6 11.2 11.6 11.2 10.4 10.0 11.2 9.2 11.2 8.4 9.2 8.4 8 1.2 2.8 .4 1.6 .4 1.2 2.0 2.4 .4 0.4 17 1.2 24 .4 July 1 8 ,4 15 .4 22 29 19 .4 1.2 12 Remarks. — June 10, marked poikilocytosis and polychromatophilia. Macrocytes and microcytes, 88.8 normoblasts, and 29.6 megaloblasts per cu. mm.; 17, 52 nor- moblasts per cu. mm.; July 1, still poikilocytosis; not so mucli polychromatophiUa. Many more microcytes than macrocytes. One doubtful microblast (33.6 to cu. mm.); Sth. 27.2 normoblasts to cu. mm.; 15th, 32 normoblasts to cu. mm. August 5, slight poikilocytosis and polychromatophiUa, some macrocytes, more microcytes; 12th, very sli^t poikilocytosis. Few macrocytes. Many microcytes. Treatment. — Pills of Vallet'a mass given in intervals. June 10, 4-25; 17th, many ova uncin.; 18th, 4-30; 24th, ova uncin.; 25th, 4-30; July 1, ova uncin.; 2a, 4-15, preceded by 0.03 podophyllin; Sth, ova uncin. and embryos of strong intest.; 9th, 4-15, preceded by 0.03 podophyllin; 16th, ova uncin.; 17th, 4-15, preceded by 0.03 podophyllin; 22d, no ova uncin.; many embryos of strong, intest.; 23d, 4-15, preceded by 0.03 podophyllin; 29th, few ova uncin. ; 30th, 4-15 preceded by 0.03 podophyllin; August 4, Blaud's pills substituted for Vallet's pills; 5th, ova uncin. Pod. 0.02, calomel 0.26, sod. sulph. 10.; 6th, ext. male fern 8., sod. sulph. 10.; 12th, very few ova uncin. ; 13th, 4-15, preceded by 0.03 podophyllin; 19th, no ova uncin. Result. — Improved. Still has slight hemic murmur. Slight weariness and weak- ness. '.— J.M.,Jayuya. Admitted, March 29. Age, 30; male; white; single; works on coffee estates; family disease is anemia; mother and two sisters died of it. Has been sick since 12 years of age. Usual country food. Has had much mazamorra. Says he has taken medicine for his anemia ever since he was taken sick but to no purpose. Marked pallor; is fat; at times has general edema; atrophy of skin; "never can perspire." Appetite good; gastralgia; nausea; vomiting; tongue has a few pig- mented spots; flatulence; tenderness epigastrium and abdomen; pronounced meteor- ism; bowels regular; enteralgia at times; feces normal except for many ova of uneinaria. Spleen and liver normal. At times dyspnea; palpitation; very severe precordial pain. Pulse, 97, weak, compressible; decidedliemic murmur. There issuch a violentsupra- clavieular pulsation as to make one suppose, at first sight, that he has aneurffim. Severe pain in chest. Marked dizziness. ("Ave Maria! A terrible racket in my ears.") Frontal headache; neuralgia. Insomnia at times. Depressed and hysterical. Has fainting spells. Patellar reflex absent. Complete impotence. Suffers much from cold. Decided paresthesias. Blurred vision. Muscles very flabby, sore, and painful. ' ' _ Course.— A surprisingly rapid betterment; On 26th of June taken with convul- sions which lasted all day. On close questioning and observation we found that he was suffering with hystero-epilepsy. In two or three days was perfectly well. Diagnosis. — Chronic uncinariasis, intense. Date. Hb. Bed cells. Leuco- cytes. E. P. S.L. L.i.. B. S.G. My. May 29 24' 32 38 55 75 103 2,681,600 2,052,800 3,088,800 4,661,600 4,457,600 6,106,600 7,800 6,000 5,400 6,200 7,000 8,000 10.4 7.2 3.6 10.8 1.2 4.8 70.2 62.0 76.4 64.4 77.6 72.8 5.2 17.6 4.4 16.4 10.4 11.2 8.0 6.0 11.6 6.0 10.4 6.8 2.2 .4 .8 1.6 "i."2' 4.0 6.0 2.4 .8 .4 2.8 June 7 ""o.'s .8 12 19 26 July 3 ...... THE UTTJADO SERIES OE 1904. 283 -Remarks.— May 29, blood very fluid. Coagulates slowly. Decided poikilocytosis out not so extreme as usual. Macrocytes and: microcytes, latter predominatinK- 24 2 nomioblasts per cmm. July 3, reds normal. Blood has rapidly improved lYeatment --Bla.ud'B pills used in intervals. May 31, 4-30; June 8, ova uncin.; 9tn,,4-30; 12th, ovauncm.; 16th, 4-30; 19th, ova uncin.; 20th, 4-30; 26th, bromide soda tor hysterical attackO.BSOevery 2hoursfor 2days; 28th, noova uncin., butmany (.^harcot-Leyden crystals; July 3, no ova uncin. Discharged from hospital. i{emZ«.—Cured. July 3. A powerful ruddy man. Only symptom left is some supraclavicularpulsation. Case SI.— "E. M., barrio, Don Alonso. Admitted, May 28. Age 30; male- white- laborer on coffee plantations and banana patches. Three years ill. Usual food of the country. Has mazamorra every year at time of coffee crop. Has taken many iron tomes. Marked pallor; no emaciation; edema of feet and legs; general pruritus; does not perspire; no atrophy of skin but it is dry and harsh. Good appetite; gastralgia; nausea every now and then; tongue normal; flatulence; meteorism; no ascites; con- stipated; sometimes enteralgia; feces show meat fibers, many ova of uncinaria, Charcot^Leyden crystals. Spleen and liver normal. Dyspnea; palpitation; pain in precordium; pulse, 78, weak and compressible; slight hemic murmur; marked pul- sation of vessels of neck. A little cough; much pain in chest. Dizziness; tinnitus aurium; frontal headache; much insomnia; syncope at times; patellar reflex absent; is melancholy and lifeless; impotent; susceptible to cold. Urine: Specific gravity, 1,014, normal. Blurred vision. Muscles flabby and painful. Is very weak. Tem- perature37.6°. Course. — A furfuraceoua eruption on extensor surface of forearm, dorsa of hands and face developed while in hospital. Became less marked with time. Otherwise an uneventful, slow recovery. Diagnosis. — Chronic uncinariasis, intense. Date. Hb. Eed cells. Leuco- cytes. P. 3.L. L.L. S.C. My. May 30, June 7, 13 20 27 July 4 11 18 26 Aug. 2 9 16 2,216,000 1,984,000 2,768,000 3,168,000 3,224,000 3,755,200 4,480,000 3,408,000 4,256,000 4,064,000 4,488,000 5,024,000 7,800 7,200 8,400 7,400 7,400 12,600 9,600 10,400 7,600 8,800 7,400 8,000 R.4 60.0 6.0 71.2 ,5.6 73.6 4.4 78.0 4.0 68.4 S.O 63.6 7.2 69.2 ,5.2 71.2 9.4 64.6 11.2 65.2 1.5.2 62.8 28.0 68.0 19.6 19.2 16.6 17.2 26.4 26.0 20.8 19.6 22.0 21.6 17.6 10.8 5.6 2.4 4.4 .4 1.2 2.0 2.0 3.6 4.0 2.0 4.0 3.2 6.4 1.2 0.4 0.4 JRemarhs.—UBual blood changes. June 20, 29.6 normoblasts per cmm.; July 11, 38.4 normoblasts per cmm. Appearance has gradually improved until it is now about ^ Treatment.— Ysdlet'B pills used in the intervals. May 31, 4-25; June 8, ova uncin. ; 9th., 4-20; 17th, ova uncin.; 18th, 4-20; 27th, few ova uncm.; 28th, 4-20; Juy 5, no ova uncin.; 11th, ova uncin.; 12th, 4-20; 18th, no ova uncin.; _19th Vallet s pills changed to Blaud's pills; 26th, no uncin.; August 2, no ova uncm.; August 8, noova uncin.; 16th, 4-25. , , . . ,. i?emZ«.— Practically cured, August 16. Is strong and has no signs of disease save eruption noted. Good color. Case S^.-B. M., barrio, Guaonico. Admitted, May 31. Age, 25; male; mulatto; sinele laborer in country, peon on coffee estates and roads; anemia only disease m hStAiily; fXr and t^^Lothers died of it, and --°'^^l^''^^°^Xt^7odlT same disease. Patient has been ill one and a half years. Food Rice beans codfish and at times, fresh meat. Ate well while m good health, but lately illness nas pre vented hSi from earning his bread. Much mazamorra while pickmg coffee. Has taken muTh iron. Pallor marked; has a dirty yellow color Not emaciated and devetoSt good. Edema marked in le|?s and feet, and slight m face. Has general nruHtus Slight atrophy of skin, which is dry and harsh. "I used to perspire when well but since I becLie ill have ceased to do so." Appetite good; gastralgia; no Sea or vomiting; flatulence and tenderness of abdomen- meteorism; Wis nomal- somltimes lAteralgia; feces, chocolate colored, no blood nor mucus; many ov™f uncSajia and ascarfs; Charcot-Leyden crystals and meat fibers. Spleen and 284 UNCINARIASIS IN POETO EICO. liver normal. Dyspnea; palpitation; precordial pain; pulse, 88, strong and full; heart slightly enlarged, with systolic murmur. Bruit-de-diable in jugulars, with violent pulsation. No pain in chest. A little cough. Great dizziness; constant buzzing in ears, and temporal headache. Sleep normal. Is downcast and hypo- chondriacal, with a bewildered air. Has fainting spells. Patellar reflex abolished. Complete impotence for one year. Suffers from cold. Urine, sp. gr. 1,011, normal; Blurred vision. Muscles flabby and painful. Temperature, 38°_. Course. — Ate prodigious quantities of food and suffered from indigestion consider- ably. Slow case. Diagnosis. — Chronic uncinariasis, very intense. Date. Hb. Eed cells. Leuco- cytes. B., P. S. L. L.L. B S. C. My. June 1 19 30 31 32 28 28 28 47 52 63 67 86 1,897,600 2,008,000 2,136,000 2,736,000 3,155,200 3,048,000 3,176,000 3,360,000 4,392,000 4,296,000 4,730,000 5,184,000 6,400 7,600 6,400 6,800 10,000 6,800 7,600 9,800 10,200 8,800 9,200 7.400 16.4 21.2 46.4 46.8 38.8 23.4 13.6 18.8 19.6 34.4 36.4 26.8 66.0 63.2 40.0 35.2 36.2 55.2 62.0 62.8 58.0 47.2 44.0 59.2 6.8 2.4 10.0 16.4 16.4 20.0 15.6 16.0 18.0 10.4 15.6 10.8 2.8 1 2.8 2.0 .8 4.2 .8 6.0 1 2.0 3.6 6.4 2.8 2.8 6 4 8 4 2 2 2 4 8 8 8 4 6.4 10.0 .8 "4.'2" .4 1.6 8 15 ... 22 0.4 29 July 6 13 20.. .. 27 Aug, 3 .8 .4 10 17 Remarks. -^June 1, blood very fluid; coagulates slowly. Poikilocytosis and poly- chromatophilia. Macrocytes and microcytes. August 10, 36.8 normoblasts per cmm. August 17, 29.6 normoblasts per cmm. Treatment. — Vallet's pills used in the intervals. June 2j 4-30; 8th, ova uncin.;' 9th, 4-30; 16th, no ova uncin.; 17th, 4-30; 22d, no ovauncm.; 28th, no ova uncin.; July 6, few ova uncin. and tricocephalus; 7th, 4-30; 13th, ova uncin.; 14th, 4-30; 20th, ova uncin.; 21st, 4-30; 27th, no ova uncin.; Augusts, few ova uncin.; 4th, 4-15, with 0.03 podophyllin; 10th, 4-10, with 0.03 podophyllin; 17th, no ova uncin.; discharged hospital. Result. — Cured, August 17. Case S3.—L. R., Jayuya. Admitted, May 31. Age, 12; female; white. Usual food of countrj^. Has been sick eight years. Has mazamorra every year at coffee picking, at which she usually works. Extreme pallor. Not emaciated. Anasarca of extreme grade; even the scalp was edematous. General pruritus; never perspires. Anorexia; gastralgia; nausea; sometimes vomiting; bluish streaks on each side of tongue; flatulence; marked tenderness of epigastrium and abdomen; meteorism; ascites; distension of superficial veins of abdomen; feces, dark yellow color, liquid consistence, no blood nor mucus, many ova of uncinaria and ascaris, and Charcot- Leyden crystals. Spleen and liver much enlarged. Dyspnea; great palpitation; parn in precordium; pulse, 115, weak and dicrotic. Great dilatation of lieart, with marked murmurs. No cough; pain in chest. Much dizziness; constant tinnitus auriu™; temporo-frontal headache; insomnia; syncope frequent; patellar reflex abolished; tactile sense blunted; great mental depression, seems stupefied; no delir- ium; susceptible to cold. Urine, sp. gr. 1,012, normal. Blurred vision. Muscles flabby and painful. Great weakness, can not stand. Temperature, 38°. CoMree. —This patient was brought to the camp in a hammock, completely pros- trated and almost moribund. Never reacted to stimulation and slowly sank, dying in comatose state as from ventricular compression. Diagnosis. — Chronic uncinariasis; very intense. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L.L. B. S.C. My. June 1 9 15 754,400 1,232,000 14,600 11,600 6.8 20.8 54.8 69.6 29.6 2.8 4.0 2.4 0.8 .8 4.0 3.6 8 Remarks. —Blood shows usual changes very marked in character. At both exam- inations the bacillus was found. THE UTUADO SERIES OP 1904. 285 4fh ^^J^--~^T^ ^ '■'"^- ^' st^ulation by digitalia and nux vomica; 3d, 2-15: 11th S ^""^ ''''^ ^"""'S' ^^^^' •'^^<''^? <^^^"^e^ set in, and received tennii acid lltti, many ova uncm.; no thymol given this time. Died that night jtiesult. —Died June 11. *' Case 34.~'T. G. barrio Sabana Grande. Admitted Jime 5. Age, probably 10- rt^.^fT/l*°= ^°'^'- ^^"""^ ^h ^°"^^- M°t^«^ died of anemia, lives m?h uncle a S^tl^-ffl u commission. About two months ago was struck across knees; walks with difficulty on account of pain m knees. Anemia began some months ago with weakness, pains m chest and muscles, and indigestion . Usual food of country? poor in quahty. Has never been treated. Pallor marked; no emaciation; under-developed- edeiM, of legs. Has had mazamorra. Scar from ulceration on right leg Skin atro- phied and dry Appetite good; gastralgia; nausea; vomiting; tongue coated; slight flatulence; slight pam m abdomen and epigastrium. Bowels regular. Feces contain many ova of uncmaria. Slight dyspnea; palpitation; pain about heart. Pulse 90 wea,k and compressible. Soft hemic murmur. No cough. Dizziness; tinnitus aunum; herfdache; sleeps well; mental condition and intelligence surprisingly good Expression weazened. Reflexes normal; syncope. Paresthesias. No eye symptoms' Muscles painful, sore, flabby, and weak. Temperature normal. Course.— Improved slowly and steadily. Pains in knees have improved, but still walks with some difficulty. Diagnosis. — Chronic uncinariasis; intense. Date. Hb. Eed cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. June 5 24 24 31 34 32 44 46 54 55 58 60 62 3,137,600 3,720,000 3,737,600 3,590,400 3,848,800 4,960,000 5,075,200 4,284,000 4,910,400 5,222,400 5,760,000 5,672,800 20.4 29.2 31.6 18.8 24.0 21.6 14.4 22.0 20.0 14.8 10.4 18.4 62.4 38.4 44.0 61.2 56.2 60.4 62.8 63.2 52.4 69.2 60.8 57.6 4.8 14.0 6.8 8.4 10.8 16.4 9.2 14.0 13.2 15.2 14.8 17.6 6.4 10.8 8.0 10.8 7.6 11.2 12.8 10.0 13.6 10.0 12.4 6.0 1.2 .8 1.6 .4 2.4 .4 .4 .8 .8 .8 1.2 .4 3.6 6.0 6.8 1 2 12 8,600 7,600 7,000 8,000 9,200 7,600 10,400 5,200 9,000 8,800 10,000 .8 1 2 4 19 26 July 3 •'lO 17 4 24 31 Aug. 7 14 .4 19 Remarhs. — June 5, moderate poikilocytosis and polychromatophilia. Many macro- cytes, less microcytes; July 17, slight poikilocytosis and polychromatophilia. Micro- cytes now more abundant than macrocytes; August 19, blood appears normal except for numerous microcytes. Treatment. — Vallet's pills, given in intervals. June 5, 2-15; 12th, ova uncin.; 13th, 2-15; 19th, no ova uncin.; 26th, no ova uncin.; July 3, no ova uncin.; 10th, no ova uncin.; 17th, no ova uncin.; 25th, few ova uncin.; 26th, 2-15; 31st, few ova uncin.; August 1, 3-20, preceded by 0.02 podophyllin; 7th, few ova uncm.; 8th, 3-20, preceded by 0.02 podophyllin; 14th, no ova uncin. Result. — Greatly improved. Pains in knees improved, but still walks with some difficulty. Case55.— M. A., ban-ioCaguana. Admitted June 7. Age, 35; male; white; unmar- ried- laborer on coffee and sugar plantations, and on the roads. Some members of family anemic others not. Has had smallpox. Has been anemic many years, but not severely until last year's coffee picking, when he suffered greatly with mazamorra. States that he had plenty to eat until he became too sick to work Has taken iron with temporary benefit. Pallor well marked, but not extreme. Under-developed, but no emaciation. Legs slightly edematous. General pruritus; scars on legs from mazamorra ulcers. Marked skin atrophy; dry; no perspnation. Appetite good; gastralgia at times; sometimes nausea and vomiting; tongue clean; no tenderness in abdomin, but some over stomach. Bowels constipated. Feces contain many ova of uncinaria. Dyspnea on exertion; palpitation; sharp pam at times oyer heart Pulse 78 weak and compressible. Hemic murmur No cough. Dizziness; tmnitus auriumfheadache; sleeps well; syncope. Mental condition and intelligence good. Expression weazened and woeful. Impotent 5 years Reflexes good Paresthesias. Increased susceptibility to cold. Blurred vision. Muscles weak, flabby, sore, painful Temperature normal. Cowrse.— Steady, though not rapid, improvement. -Chronic uncinariasis; intense. and 286 UNCINARIASIS IN POETO KICO. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L.L. B. S. C. My. 23 27 29 30 40 42 46 60 64 73 77 2,672,800 2,297,600 2,484,600 2,164,000 3,201,600 3,656,000 3,772,800 3,448,000 4,532,800 4,524,000 4,960,000 6,000 4,400 8,800 6,400 9,400 8,800 9,000 11,600 7,200 5,000 4,000 6 4 2 4 6.0 32 4.0 4 4 2 4 2 2.8 2.4 52 63.6 79 2 77,6 79.2 83.2 84.4 77.6 79.6 74.8 70.4 61.2 12.4 8.8 8.0 8.4 8.0 8.0 9.2 9.2 12.4 12.8 24.4 12.8 5.6 6.8 8.0 4.4 2,0 8.8 8.0 8.4 12.4 8.0 1.6 1.6 .8 1.2 .4 1.2 2.0 .8 1.2 1 2 1.2 3.2 2.0 .8 16 0.4 23 30 July 7 16 21 29 ■■'.T ,4 AuE. 4 .4 ^ n 18 , Remarks. — June 9, slight poikilocytosis and polychromatopMlia. Some naaerocytes and microcytes; 16th, microcytes more than macrocytes; 17.6 normoblasts per cu. mm.; 23d, lymphocyte with basophilic granules; 18th, appearance of blood haa improved steadily until it now looks normal except for microcytes. Treatment. — Vallet'a pills during intervals. June 10, 4-25; 23d, many ova uncin.; 24th, 4-25; July 2d, many ova uncin.; 4-25; 7th, ova uncin.; 8th, 4-25, preceded by 0.03 podophyllin. Left hospital; 15th, Blaud's pills substituted for Vallet's pills. Ova uncin.; 16th, 4-15, preceded by 0.03 podophyllin; 22d, ova uncin.; 23d, 4-15, preceded by 0.03 podophyllin; 29th, ova uncin.; 30th, 4-15, preceded by 0.03 podo- phyllin; August 4, no ova uncin.; 11th, no ova uncin.; 19th, 4-25. Result. — Feels perfectly well. Practically cured except for slight hemic murmur; Case 36. — P. C. S., barrio Angeles. Admitted, June ID. Age 16; male; white; laborer on coffee estates. Disease of family is anemia. Two brothers died of it. Has been four years sick. Usual food of country. Has had much mazamorra. Has taken much iron but in spite of this gets worse every day. Very pale. Not ema- ciated but underdeveloped. Edema of face and lower extremities. General pruri- tus; skin always dry; never perspires. No appetite; gastralgia; sometimes nausea and vomiting; flatulence; tenderness of abdomen; meteorism; constipation alternates with diarrhea; sometimes enteralgia. Feces normal save for many ova of uncinaria, Charcot-Leyden crystals, and meat fibers. Spleen and liver normal. Dyspnea; palpitation; precordial pain; pulse, 120, weak. Heart enlarged, blowing systolie murmur. Apex beat low and very marked. Marked pulsation in jugulars. Nocougk; a little pain in chest. Much dizziness; constant roaring in ears; frontal headache; sleeps well; patellar reflex absent. Tactile sense poor. Is very melanchoMc. Suf- fers from cold. Urine, sp. gr. 1,011, normal. Blurred vision. Muscles flabby, painful, and weak. Temperature, 39°. Course. — Irregular improvement, sometimes slow, at others rapid. "' '"" -Chronic uncinariasis; very intense. Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. .Tnnp in 12 12 20 30 30 30 35 66 69 86 101 1,160,000 1,248,000 1,636,000 1,904,000 2,920,000 2,960,000 3,160,000 4,304,000 4,472,000 6,096,000 5,136,000 4,600 4,600 7,000 4,400 7,400 7,200 7,600 6,200 7,000 7,000 7,400 5.2 9.0 12.0 14.0 10.0 8.4 13.2 20.8 11.2 7.6 8.6 67.6 70.0 60.0 66.0 65.6 60.0 56.2 49.6 62.0 72.0 72.0 11.6 20.0 24.0 12.0 19.2 26.0 24.8 25.2 31.2 13.2 14.2 4.4 1.0 2.4 4.0 4.0 2.8 5.6 2.8 2.4 6.0 5.0 2.8 8.4 17 24 1.2 ""i.2' 2.0 1.2 1.6 2.4 1.2 .2 .4 4.0 July 1 ^ 8 :;:;:::::::;;:;::: 15 .4 0.4 22 29 Aug. 5 '"".S 12 18 Remarks. — Usual changes found in severe uncinariasis. rreotemi!.— Vallet's pills used in intervals. June 11, 3-20; 17th, many ova uncin.; 18th, 3-20; 25th, ova uncin.; 26th, 3-20; July 1, ova uncin.; 2d, 3-15, with 0.03 podo- phyllin; 8th, has had diarrhea a week; 9th, no ova uncin.; 10th, 3-15, with 0.03 podo- phyllin; 15th, no ova uncin.; 16th, changed from Vallet's pills to Blaud's; 22d, no ova uncm., but many Charcot-Leyden crystals; 23d, 3-15, with 0.03 podophyllin; 29th, no ova uncm.; August 5, no ova uncin.; 6th, 3-15, with 0.03 podophyllin; 12th, found ova uncin.; 13th, 4-15, with 0.03 podophyllin; 14th, discharged. Result.— Cxiredi, August 14. A remarkable change in this boy's appearance and disposition. Color good. Is agile and strong. THE TJTUADO SERIES OF 1904. 287 fii^-k^nJJLZ^- Jii ^^^° ^Tf'^i ^ea^"°V^J'''f."' ^" ■, ^ J^ d^omatophTlIZ Vny macrocytes and microcytes. Cells still chlorotic and some 292 UNCINARIASIS IN PORTO BICO. are "stippled." Many degenerate leucocytes. July 17, reds well formed but micro- cytes still numerous; a great number of blood plates; 31st, same. Treatment. — Blaud's pills used in intervals. June 23, 4-20, with 0.02 podophyllin; 27th, many ova uncin.; 28th, same as 23d; July 3, many ova uncia.; 4th, same as June 23; 10th, ova uncin. and a few Charcot-Leyden crystals; 11th, same as June 23; 17th, no ova uncin.; 25th, ova uncin,; 26th, same as June 23; 27th, discharged from hospital; August 4, no ova uncin. Result. — Cured, August 4. Is a remarkably healthy, ruddy man. Case 45. — G. C. O., barrio Santa Rosa. Admitted, June 20. Age, 8; male; mulatto. Has been sick two years. Usual food of the country. Haa had mazamorra. Has taken much iron. Very pale; no emaciation; well developed; edema of feet and legs; general pruritus. Has ceased to perspire since he has been ill. Good appetite; gas- tralgia; nausea; acknowledged that he ate earth; flatulence; no tenderness abdomen or epigastrium; meteorism; no ascites; bowels constipated; sometimes entera^;ia; feces, normal but for many ova of uncinaria and some of ascaris. Spleen and liver normal. Dyspnea; palpitation; precordial pain; pulse, 80, weak and compressible. Slight hypertrophy of heart, and soft blowing systolic murmur. Marked pulsation in vessels of neck. No cough nor pain in chest. Dizziuess; constant tinnitus aurium; frontal headache; sleep normal; is stupefied, dazed; patellar reflex abolished. Sus- ceptible to cold. Urine, speciflc gravity 1,012, normal. Blurred vision. Muscles flabby and painful. Is very weak. Temperature 37.8° Course. — Slow but certain convalescence. Diagnosis. — Chronic uncinariasis; very intense. Date. Hb. Bed cells. Leuco- cytes. E. P. S.L. L.L. B. S. C. My. 16 18 17J 23i 24 20 31 42 62 1,776,000 1,768,000 1,746,400 2,120,000 2,240,000 2,256,000 2,448,000 3,592,000 3,976,000 7,400 6,200 5,400 4,200 5,400 5,200 5,200 7,400 7,600 4.8 9.6 17.6 12.4 12.0 18.0 14.0 11.6 19.2 62.8 60.8 48.8 44.8 52.8 42.4 55.2 55.2 51.6 22.8 25.6 23.6 34.4 28.0 30.0 24.4 30.0 22.4 5.2 2.0 7.6 8.0 4.4 6.8 2.0 1.2 4.4 1.2 1.6 .8 "i'o' 1.2 1.2 1.6 3.2 .4 1.2 .4 2.8 .8 2.4 .4 .8 27 July 4 0.4 ^ 11 18 25 Aug. 1 8 4 15 Remarks. — ^Usual blood changes. June 27, 49.6 normoblasts per cmm. ; July 11, 16.8 normoblasts per cmm. IVeotoeni.— (Blaud's pills used in intervals.) June22,2-15; 27th, ova imcin.; 28th, 2-15; July 4, ova uncin.; 5th, 2-15; 11th, ova uncin.; 12th, 2-15; 18th, ova uncin.; 19th, 2-15; 25th, ova imcin.; 26th, 2-15; August 1, ova uncin.; 2d, 2-15; 11th, no ova uncin.; 17th, no ova uncin.; 19th, no ova uncin. Left in charge of Dr. Vizcarrondo, of Utuado, who reports that he became ruddy, strong, and well a month thereafter. Result. — Cured, September. Hemoglobin percentage not taken. Case 46.— J. D., barrio Santa Rosa. Admitted, June 21. Age, 19; male; mulatto; single; laborer on coffee estates; someof his family anemic; mother, two brothers, and two uncles died of anemia. Has been sick two years. Usual country food. Has mazamorra at every coffee crop. Has taken much iron to no purpose. Moderate pallor. Skin dark gray. Is well nourished. Slight edema of feet. General pruritus. Has had ulcers from mazamorra on feet. No atrophy of skin, but it is dry and harsh. Good appetite; gaatralgia; nausea and vomiting; flatulence; tenderness abdomen and epigastrium; meteorism. Bowels regular; enteralgia. Feces normal save for great quantity of ova of uncinaria. Spleen and liver normal. Dyspnea; palpitation; pain in precordium. Pulse, 100, strong and full. Harsh cardiac murmur best heard at apex. Pulsation at root of neck not noticeable. Cough and pain in chest. Dizziness; tinnitus aurium. Temporal and cerebellar headache; sleeps well. Is very depressed and nervous. Seems afraid he is going to be harmed in hospital, but his anxiety to receive treatment is very apparent. Complete impotence. Very susceptible to cold. Decided paresthesias in legs. Blurred vision. Muscles flabby, sore, and painful. Marked weakness. _ Course. — Rapid and uneventful convalescence. His expression changed from one in the depths of woe to that of a sky-larking, happy-go-lucky darky. Diagnosis.— Chronic uncinariasis of medium severity. THE UTUADO SERIES OF 1904. 293 Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L.L. B. S. C. My. Tune 21 35 50 54 70 85 104 2,732,800 4,008,800 4,030,400 4,857,600 6,856,000 6,310,400 8,200 10,400 6,400 9,200 4,000 5,800 4.0 4.8 2.8 6.0 6.0 4.8 64.0 70.8 72.8 56.0 54.0 68.0 25.6 16.4 13.2 19.6 22.8 22.8 6.2 6.2 10.4 15.6 15.6 13.2 1 2 1.2 .4 2.8 1.2 1.2 28 July 5 1.6 12 19 26 .4 nucrocytes predominating although macroc^es plentiful P^le Srs l^s^Zni aSTorrr'- ^--°^----"-dpo?rlydeveloped.'riT5,rbouram:! Treaiment.-^Bimd'B pills used in intervals.) June 22, 4-20, with 02 Dodonhvllii. • ^th ova uncm.; 29th, 4-15, with 0.02 podophyUin; July 4,' 0^™™ 5Z 4 15' rnr-%Lisroinfoii°tir'^^^'^-'- "^^'^^-^ Result.— Cmed, July 26. In perfect health, spirits, and color. Case 47.— S M. B., barrio Tetuan. Admitted, June 21. Age 30- male- whi'tP- mamed, with five chUdren; laborer on coffee estates; wife and some of Ws chUdren have anemia; some have not. He was perfectly well until last coffee crop. Food usual of country, but now poor. Previously he had enough to eat because he had a garden, but is now too sick to work it. His last attack of mazamorra, he says, was temble. Very marked pallor. Has a dirty, pasty yellow color. Has edema of feet ajid ulcers from mazamorra. Does not perspire. Has little appetite; gastralgia; nau- sea and vomitmg; flatulence; great tenderness of abdomen and epigastrium; con- stipated; at times enteralgia; feces contain many ova of uncinaria. Spleen and liver normal. Much dyspnea; palpitation; precordial pain; pulse, 115, weak, dicrotic and compressible. No heart murmurs. Veins of arm stand out, pulsate, and each valve 13 a little elevation. Great pulsation of vessels at root of neck. Cough; no pain in chest. Dizziness; tinnitus aurium; little headache. Is profoundly convinced he is sick, but deeply suspicious of the doctor and prepared for the worst. Subject to famting spells. Patellar reflex abolished. His expression is most hopeless. Intelli- gence good; is an astute, hard-headed jibaro. Complete impotence. Susceptible to cold. "Hands feel asleep and tingle." Blurred vision. Muscles flabby, sore, and painful. Marked weakness. Course. — Recovery rapid. Thia man, without any organic lesion of heart nor albu- min in urine, had a severe edema of both feet, with fever, July 3, which lasted 10 days. He was sent home with 70 per cent Hb., on July 15. On the 27th, he returned with 102 per cent Hb. and bitterly complaining of poor vegetable food. Diagnosis. — ^Chronic uncinariasis; intense. Date. Hb. Bed cells. Leuco- cytes. E. r. S. L. L.L. B. S. C. My. 32 62 60 70 93 102 2,195,200 2,768,800 3,360,000 4,061,600 6,000,000 6,261,600 5,000 7,000 7,000 4,000 7,000 7,800 10.8 4.4 7.2 9.2 5.2 4.8 66.0 76.0 65.2 67.2 65.2 67.6 9.6 6.4 20.8 9.6 14.8 17.2 12.8 10.4 5.6 11.6 12.4 7.2 0.8 1.2 .8 1.6 1.2 1.6 29 .. 1.2 .4 .8 .8 1.2 0.4 July 6 13 20 .4 27 .4 Remarks.— June 22, blood very fluid and coagulates slowly. Polychromatophilia absent. Moderate poikilocytosis; 29th, many macrocytes, fewer microcytes, now de- cided polychromatophilia. July 6, marked polychromatophilia, but poikilocytosis hardly perceptible. Few macrocytes and microcytes; 13th, several "stippled" reds; many degenerated leucocytes; 20th, many degenerated leucocytes, reds nearly nor- mal; 27th, reds normal. .,„„„, , , „. IVeatoeni.— (Blaud'spillsusedinintervals.) June23, 4-15, with 0.03 of podophyUin; 29th, few ova uncin., and many Charcot-Leyden crystals; 30th, same as 23d. For three days had paregoric for diarrhea. July 6 and 13, no ova uncin. Discharged hospital. Result.— Gvaed July 27. Is perfectly well and has good color. 294 UNCINAEIASIS IN POETO EICO. C(Me4S.—R. G., barrio Rio Abajo. Admitted June 20. A^e, 28; male; white; mar- ried ; laborer on coffee and banana plantations. Brother anemic, mother in Mr health. Father and three brothers and sisters died of anemia. Has been anemic for some years, gradually getting worse. Had mazamorra each year during cofiee picking. Usual food, says that he does not eat as much as he has to eat because it gives him indigestion. Took some "iron powders," but quit as they did him no good. Pallor very marked; slightly emaciated (probably due to indigestion). Development good. Says he has had edema of face, trunk, and extremities; none at present. General pruritis; no ulceration; skin atrophied and dry. Appetite fair; gastralgia; constant nausea; vomiting, almost every day; tongue clean; flatulence; meteorism; pain and tenderness marked over stomach and abdomen. Bowels constipated; feces contain a meat abundance of ova of uncinaria. Dyspnea; marked palpitation; precordial pain. Pulse 90, fairly strong. Soft hemic murmur at base and apex. Heart Bymptoms more pronounced than in some other cases with greater anemia. Dizziness; tinnitus aurium; headache and sometimes neuralgia; sleeps poorly; fainting spells; reflexes slightly exaggerated. Mental condition and intelligence good; expression fair; impo- tence; increased susceptibility to cold. Paresthesias. Blurred vision. Muscles painful, flabby, and weak. Temperature normal. Course. — As a general rule improved rapidly, although blood record twice shows fall in hemoglobin, followed by rapid rise. Diagnosis. — Chronic uncinariasis; intense. Date. Hb. Eed cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. June 21 26 35 45 40 67 80 88 80 102 2,517,600 3,261,600 5,492,800 4,777,600 6,252,800 6,266,400 6,786,400 6,655,200 7,008,800 4,800 6,200 5,600 7,000 10,200 9,000 6,000 7,600 7,200 26.0 12.8 19.6 19.6 25.2 33.6 20.8 26.4 29.2 42.4 70.4 50.0 62. S 44.8 35.2 65.6 50.4 46.8 12.S 16.0 11.6 14.8 19.6 12.4 13.6 15.2 15.2 10.4 13.2 5.6 11.6 10.0 10.4 9.2 7.6 0.4 .4 .8 .4 2.8 .4 .4 .4 1.2 3.2 28 July 5 0.4 ^12 19 .8 1.2 .4 ' 26. . Aug. 2 ^ 10 17 Remarks.— Jxme 21, macroscopic appearance of blood fair. Moderate poikilocytosis and polychromatophilia. Some macrocytes and microcytes, about equal in number; 19.2 normoblasts to cu. mm.; 28th, 49.6 normoblasts to cu. mm. July 5, less poikilo- cytosis and polychromatophilia. Microcytes more numerous than macrocytes; 67.2 normoblasts to cu. mm.; 12th, 28 normoblasts; 26th, blood appears much improved. Microcytes still numerous. August 10, blood appears normal except for some micro- cytes. Treatment. — Blaud's pills given during intervals. June 22, 4^15,. preceded by 0.03 podophyllin; 28th, many ova imcin.; 29th, 4-20, preceded by0.02 podophyllin; July 6, ova uncin.; 7th, thymol as previously; 9th, Dover's powder for diarrhea and irrita- tive cough; 12th, ova uncin. ; 13th, 4-10, preceded by 0.02 podophyllin; 19th, few ova uncin.; 20th, thymol as previously; 26th, few ova uncin.; 27th, thymol as previously; August 2, few ova uncin. ; 3d, 4-25; 10th, no ova uncin. ; 11th, 4-25; 17th, no specimen of feces. Result. — August 17, cured. Complains of slight indigestion. No heart murmur. Case 49. — A. G.. barrio Arenas. Admitted June 25. Age, 13; male; white. Sister in hospital here for same disease. Another sister and brothers very anemic. Has been sick three years. Usual food of the country. Has had much mazamorra. Has taken much iron. Extreme pallor; no emaciation. Once had general edema. Atro- phy of skin, which is dry and perspires very little. Good appetite; gastralgia; nausea and vomiting; tenderness of abdomen and epigastrium; meteorism; bowels regular; cnteralgia; feces show an enormous number of ova of uncinaria. Spleen and liver normal. No dyspnea nor precordial pain. Pulse 125, weak, and compressible. No heart murmur. _ No ma,rked pulsation of vessels of neck. No cough nor pain in chest. Dizziness; tinnitus aurium; frequent temporal headache. Sleeps well. Is depressed and lifeless. Has had fainting spell. Patellar reflex diminished. Has no pares- thesias. No disturbances of vision. Muscles flabby, sore, and painful. la very weak. Courae.--Rapid and uneventful recovery. Diagnosis. — Chronic uncinariasis; intense. THE TJTUADO SEBIES OP 1904. 295 Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. June 28 26 32 45 60 70 80 77 87 2,284,000 3,524,000 4,706,400 4,556,000 4,888,800 4,817,600 4,684,000 5,800 8,200 19,600 9,400 8,200 12,600 9,400 11.2 6.0 6.8 4.8 11 2 11.2 17.2 48.0 49.6 64.8 41.2 43.6 59.2 47.6 29.6 31.6 20.0 32.8 26.0 15.6 22.0 10.0 12.4 16.0 20.0 16.4 12. C 11.2 1.2 .4 2.0 1.2 2.8 .4 1.6 July 5 12 0.4 19 26 Aug. 2 1.6 .4 ^ 9 : 20 1 Remarks. — June 28, blood very fluid, coagulates Blowly. Great poikilocytosis and potychromatophilia. Many macrocytes and microcyteB. July 5, reds same as above; 12th, reds improving; 26th, reds nearly normal. Treatment. — Blaud's pills used in intervals. June 28, 2-10, with O.OSpodophyUin; July 5, ova uncin.; 6th, same as June 28; 12th, ova uncin.; 13th, same as June 28; 19th, few ova uncin. ; 20th, same as June 28; 26th, ova uncin. ; 27th, same as June 28; August 2, no ova uncin. Discharged from hospital with 80 per cent Hb. Results.— Cmed, August 20; a healthy, ruddy boy. Case 50.— M, H. V., barrio Vivl Arriba. Admitted, June 22. Age, 13; male; white; works on coffee plantation. Anemia is a family disease. One sister died of it. He has been sick four years. Food, poor. Has had mazamorra frequently. Has taken iron tonics, but to no pmpose. Verypale; emaciated; no edema; general pruritus at times; skin dry; slightatrophy of skin. Appetite good; gastralgia; nausea and vomit- ing at times; tenderness in epigastrium; enteralgia; bowels regular; feces, light green- ish gray undigested food, mucus, many ova of uncinaria and ascaris. Spleen and livfer enlarged. Dyspnea; palpitation; pulse, 128, strong and full. Pulsation marked in jugulars and artenes of neck. Hemic murmur; no cough; pam m chest, piz^i- nesB- tinnitus aurium; frontal headache; insomnia; is very depressed and lifeless. Patellar reflex diminished. Suffers from cold. Paresthesias of feet. Blurred vision. Muscles flabby. Great weakness. Temperature 39.2°. Course. — Uneventful and rapid recovery. Diagnosis. — Chronic uncinariasis; intense. Date. June 22. 29. July 6. 13. 20. 27. Hb. 27 43 75 GO 91 102 Red cells. 2, 080, 000 2,200,000 4,741,600 3, 406, 400 4, 692, 800 5,832,800 Leuco- cytes. 16,200 11,600 12,000 7,000 6.400 7,600 E. 2.4 15.2 16.0 16.4 24.8 18.8 79.2 63.6 53.2 55.2 44.0 58.8 S.L. 14.0 10.8 20.8 16.8 14.8 12.0 L.L. 3.6 8.8 8.0 14.8 6.8 B. 0.8 1.2 1.2 2.0 1.6 3.2 S. C. 0.4 My. reds nearly normal. ,-„+o,„c,i» Tunp 23 thvmol 2, podophyllin 0.02; Treatwmt.-Bh.nd's V^^^^^^Z J^^^'^J^^^ei rf Charcot?Leyaen crystals; 29th, many ova uncin. and ascans, a°alth; father and anothe^ brother who have no anSml h«« t^vJ .Food is the same as mother and branes marked; oHace &T Go^d se^p™^ ^^^1 '^"''"'l^- ^''^^°' °* '^''^°^ "^em- Has had mazamorra General «nifftn«V^'^4°PT''^= no emaciation; no edema, ga^tralgia; nausea; vomiW tK h^toTO^^^^^^ ^°°^ ^PP«*"« = no pain or tenderness of ablompn Rr>S ^ h~ ^° ^atulence; no meteorism; ber of ova of undnaria andXiv Crrcot t'I'^p. Feces contain a moderate num^ cordial pain, but some pafpitatTn^ Puke 102lfirwf *^^'k ?° dyspnea nor pre- d^eyZ-r^^"'^ improvement. Became active, more in^tellig^nrand very mis- Diagnosis.— Acute uncinariasis; intense. Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. June 23 25 29 55 85 81 70 95 109 4,128,000 3,772,800 4,737,600 6,337,600 5,346,400 4, 372, 800 5,694,400 6,097,600 6,200 11,800 11,800 11,200 4,600 6,000 4,400 8,000 7.6 8.0 8.8 9.6 6.0 8.0 7.6 8.0 65.2 68.8 66.0 69.2 63.2 54.0 66.4 64.0 15.2 10.4 10.8 13.2 14.4 23.6 17.6 20.0 10.8 12,0 8.0 8.0 15.2 14.0 8.0 7.6 8.0 0.4 30 July 7 6.8 14 ;.:::;: .4 21 28 .8 .4 .4 .4 Aug. 4 11 Remarks —June 23 blood drop slightly paler than normal. Marked poikilocytosis and polychromatophiha. More microcytes than macrocytes. August 4, reds appear normal. Has improved steadily. Microcytosis was always prominent. Treatm£nt.—Bla,ud'B pills used during intervals. June 28, 3-15, preceded by 03 podophyllin; 30th, ova uncin. (second day after thymol); July 1, thymol as previ- ously; 7th, no ova uncin.; 8th, no ova uncin.; 14th, few ova uncin.; 15th, thymol as previously; 20th, no ova uncin.; 27th, no ova uncin.; 29th, thymol as previously August 4, few ova uncin.; 5th, calomel 0.13, podophyllin 0.02, Mix mas 8., sod. sulph. 10.; 11th, no ova uncin. Result. — Cured. No heart murmur nor other symptoms. Has fine color. Case S4.—T>. G., barrio Caguana. Admitted, June 22. Age, 16; male; mulatto; laborer on coffee plantations. Anemia is a family disease. Sick one year. Usual food of country. Has had mazamorra. Has taken iron tonics. Pronounced pallor with a puffy look in face. Skin gray, not emaciated; no edema save of face. General pruritus; dry skin. Appetite good; gastralgia; nausea; no vomiting; tenderness of abdomen and epigastrium; meteorism. Bowels regular; no enteralgia. Feces contain many ova of uncinaria and tricocephalus. Spleen and liver enlarged. Dyspnea; palpitation; precordial pain; pulse, 96, weak and compressible. Hemic murmur. Dizziness; tinnitus aurium; headache; insomnia; syncope; reflexes normal; expression is lifeless. Muscles flabby, sore, and painful. Is weak. Temp. 37.5°. Course. — Rapid and uneventful recovery. Diagnosis. — Chronic uncinariasis. Moderate severity. Date. Hb. Bed cells. Leuco- cytes. E. P. S.L. L.L. 40 4,336,000 4,200 17.0 19.5 35.0 28.5 34 3,528,000 5,000 24.4 40.4 22.8 12.0 .5,5 4,080,000 6,800 26.8 44.0 16.8 12.4 71 4,261,600 6,400 22.8 41.2 19.6 16.4 78 4,240,000 5,400 22.4 42.4 21.6 13.6 104 6,506,000 5,800 35.2 34.0 16.0 14.8 B. 3. C. My. Jane 24. July 1, 8. 15. 22. 298 XJNOINAEIASIS IN POETO EICO. Remarhs. — ^June 24, blood very fluid and slow to coagulate. Great poikilocytosis and polychromatophilia; enormous macrocytes; 16.8 normoblasts per cmm. July 1, Btill great macrocytosis; 15th, polycbromatophllia and poikilocytosis still very marked but macrocytosis aljating; 22d, wonderful improvement in reds; 29th, reds practically normal. iji.ii.-t_ Treatment.— B\3.u6.'s pills used in the intervals. June 26, 0.03 of podopnyllin, with 15 sod. sulphate; no uncin. expelled; 27th, many ova of uncin.; 28th, 2-10, -with 0.03 podophyllin; July 1, many ova uncin. ; 2d, same as June 28; 8th, many ova uncin. ; 9th, same as Jime 28; 15th, ova uncin.; 16th, same as June 28; 22d, few ova uncin.; 23d, same as June 28; 29th, ova uncin.; 30th, same as June 28; August 11, no ova uncin. Discharged from hospital. Result.— CmeA, August 11. Boy is healthy and strong. Case 55.— E. C, barrio Sabana Grande. Admitted, June 23. Age, 12; male; white; two years sick; usual food of countrjj; mazamorra; has taken much iron; pallor marked; no edema; dry skin. Good appetite; no gastralgia; no nausea or vomiting; tenderness in epigastrium; meteorism; bowels regular; feces, only abnormality is large quantity of ova of uncinaria. Spleen and liver enlarged. No dyspnea; no palpitation; no precordial pain. Pulse 76, weak and wiry. Intense hemic murmur; no cough nor pain in chest. Dizziness; tinnitus aurium; headache; sleep normal; patellar reflex dimin- ished. Expression indifferent and lifeless. Muscles flabby and painful. Great weakness. Temperature 37.6°. Course. — Uneventful rapid convalescence. Diagnosis. — Chronic uncinariasis in which an acute attack is just about develop- ing; moderate grade. Date. Hb. Eed cells. Leuco- cytes. E. P. S. L. L.L. B. S. C. My. June 24 . ... 39 34 43 60 63 73 100 2,560,000 3,296,000 3,106,400 4,164,000 5,248,000 4,772,800 5,368,800 5,400 12,400 11,800 10,000 11,200 11,000 15,600 26.4 22.8 28.8 19.2 13.3 14.8 11.6 30.8 49.4 47.6 41.6 35.7 45.6 66.0 28.0 19.2 15.2 23.2 22.6 23.2 10.0 12.8 7.0 7.2 11.6 26.0 12.0 n.6 1.6 1.2 .8 1.2 1.0 2.4 .8 oU ■"3.'2' 1.4 2.0 July 1 0.4 ^8 .4 15 22 29 Aug. 5 Remarks. — June 24, blood very fluid and coagulates slowly. Corpuscles fairly well formed. Leucocytes degenerated and eosinophiles large; 43.2 normoblasts per cmm. Decided macrocytosis; polychromatophilia. July 1, great polychromatophilia and macrocytosis. Some macrocytes are enormous; poikilocytosis; 74.4 megaloblasts and 173.6 normoblasts per cmm. Two normoblasts in process of mitosis. EosindphUes large and leucocytes degenerated. Some polymorphonuclears lack granules, others have large granules, and these cells are of all sizes. July 8, reds better formed but many macrocytes and microcytes; little poikilocytosis and much polychromatophilia; 15th, reds well formed but still macrocytes, microcytes, polychromatophilia and a little poikilocytosis. August 5, blood normal. Treatment. — Blaud's pills used in intervals. June 26, 0.02 podophyllin and 15. sod. sulphat. no worms expelled; June 28, 2-10, and 0.02 podophyllin; many uncinarise expelled; July 1, ova uncin. ; July 2, same as June 28 ; 8th, ova uncin. and a few Charcot- , Leyden crystals; 9th, same as June 28; 15th, ova uncin.; 16th, same as June 28; 22d, no ova uncin.; 30th, no ova uncin.; 31st, same as June 28; August 5th, no ova uncin. Discharged. Result. — Cured, August 5. Fat, well, and rosy. Case 56. — ^J. G., barrio Caniaco. Admitted, June 25. Age, 23; male; white; unmarried; laborer on coffee plantations. Nearly all of family have anemia; some have died of it. He has been sick several years. Has taken "iron powders" without benefit. Pallor well marked; not emaciated; general development good. Has suffered much with mazamorra. No edema; slight pruritus; skm atrophied, very dry, and harsh. Says he never sweats "a single drop." Good appetite; no gastralgia; no nausea; no vomiting; tongue clean; slight tenderness over stomach and abdomen; no flatulence, meteorism, or ascites. Bowels regular; no enteralgia; feces contain ^eat many ova of uncinaria. Liver and spleen normal. Slight dyspnea; palpita- tion; sometimes precordial pain. Pulse, 78, full and fairly strong. No hemic mur- mur. Slight cough, no pain in chest. Dizziness; tinnitus aurium; slight headache; THE TJTUADO SBKIES OF 1904. 299 sleep good; subject to syncope; reflexes abolished; intelligence good; mental condition dull; expression, morose and apathetic. Impotent, susceptible to cold; paresthesias. No eye symptoms. _ Muscles weak and painful; joint pains. Temperature normal. Course. — Steady improvement. This man assisted the camp scavenger, and soon informed us that he was better, calling attention to his profuse sweating while at work, as an evidence of that fact. Diagnosis. — Chronic uncinariasis; intense case. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L.L. B. S. C. My. 33 39 59 64 72 77 97 94 103 3,221,600 3,128,000 3,395,200 4,664,000 4,195,200 4,301,600 6,061,600 5,686,400 5,484,000 6,000 7,200 8,200 4,800 7,000 8,800 11,000 10,200 9,400 13.6 8.8 16.4 28.0 16.4 19.2 20.4 17.6 13.6 63.2 72.4 62.0 54.0 66.8 63.6 60.4 65.2 66.0 6.0 10.8 13.2 12.4 6.8 11.6 10.8 11.2 16.0 13.6 7.6 8.0 4.0 9.6 4.8 8.4 6.0 4.4 0.8 .4 .4 1.6 .4 .8 2.0 0.8 July 2 . . 16 23 30 13 jRemaj-ifcs.— June 25, macroscopic appearance of blood is fair. Microscopically shows poikilocytosis and marked polychromatophilia. Macrocytes are extremely large, about equal in number to microcytes. July 9, appearance of blood much better than last week. August 6, reds are practically normal. , ■, , „ „o IVeaimcni.— Blaud^s pills used in intervals. June 27, 4-20, preceded by 0.03 podophyllin; July 3, many ova uncin.; 4th, thymol as previously; 9th, many ova uncin ; 10th, thymol aa previously; 17th, ova uncin.; 18th, thymol as previously; 23d ova uncin.; 24th, thymol as previously; 30th, ova uncm.; 31at, ext. filix mas 8., preceded by 0.26 calomel and 0.02 podophyllin. Passed many uncmana. August 6 ova uncin ; 7th, filix mas repeated in same manner; 13th, ova uncm.; hlix maa "epeated- 19th, very few ova uncin. Left camp without taking anthelmintic. liesuU —Cured in regard to his anemia but still retains a few uncinarwe. Ca«e 57.— U.M.,Utuado. Admitted, June 27. Outpatient. Age, 12; female; white; schoolgirl Family (3 in number) all have anemia. She has always been pale and Sy^Previous Lease, measles. Food good now fomierly poor Has taten pur- gatives. Slightpallor;noemaciation; well developed. H^s had slight edema of ankles Had mazamorra and resulting small ulcer on leg. General pruritus; skm not atrophied nor d^vS appetite; galtralgia: nausea; vomiting; flatulence; meteonsm; tender- nSso7erstomaVa?idabdSmen.>lightdiarrhea,fecesconta^^^^^^^ ■BvHTmea on exertion; palpitation; pain m precordium; pulse, 99, lull ana srrong, dilXt hemirmiSmur No cough; slight pafn in chest. t)izziness; tinnitus aunum; headache XpsTeU Mentaf condition, very ;good; intelligence very bright expression, pleSan^; reflexes abolished; paresthesias. No eye symptoms. Muscles '"^'^cZi-^X irptveSfx^cl^t for riack of malarial fever which caused a slight set-back. . . . t,, , j.„ „„„„ • JD^onom.-Chronic uncinariasis. Moderate case CompZicaiwn.-Tertian intermittent malarial fever. Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. S. C. My. 56 62 68 61 61 67 75 80 83 5,025,600 4,332,800 4,484,000 5, 657, 600 4,737,600 5,364,000 5,910,400 6,168,800 6,200,000 12,600 12,400 10,200 12,400 10,200 11,600 9,400 6,800 12,200 14.4 17.2 22.0 13.2 26.8 18.0 18.4 14.0 31.6 59.6 52.8 56.4 63.2 46.0 58.0 47.6 58.0 46.8 16.0 17.2 12.4 16.0 18.4 16.8 22.0 18.0 13.2 8.0 11.6 8.4 7.2 7.6 5.6 10.4 10.0 6.4 1.6 "".8 .4 .4 1.2 1.6 0.4 1.2 July 4 11 .4 0.4 25 Aug. 1 8 15 19 2.0 300 UNCINABIASIS IN POETO RICO. Remarks.— J\me 27, blood drop appears normal. Moderate poikilocytosis and Eolychromatophilia. Some macrocytes; many microcytes. August 19, 50.6 normo- lasts to cu. mm. July 4, 49.6 normoblasts to cu. mm. August 19, blood has steadily improved until it is now practically normal. Treatment.— ^0 iron waa given until July 20. June 28, 2-15; July 11, many ova uncin.; 12, 2-10, preceded by 0.02 podophyllin; 14, chill, fever, etc., diagnosed malaria, and quinine given; 15, no chill, less fever; 16, no fever; 18, ova uncin.; 19, 3-10, preceded by 0.02 podophyllin; 20, began taking Blaud's pills; August 1, few ova uncin.; 2, 3-10, preceded by 0.03 podophyllin; 8, no ova uncin.; 16, 2 ova uncin., 3-10, preceded by 0.02 podophyllin. Result.— FracticaWy cured. Color good, and feels perfectly well. Case 58.— K. A. S. C. Utuado. Admitted June 27. Age, 6; male; white; from one of the beat known families in Utuado. Sick one month. Previous treatment: He was No.' 559 of general series; admitted May 29; very few ova uncin. found; given 1-10; June 6, no uncin.; June 7, 1-15; June 12, no uncin. Returned the 27th of June with heavy infection. Food of best kind. No clear history of mazamorra but had a suspicious eruption between toes. Moderate pallor of mucous membranes but little of general integument. No edema; dry ekm. No appetite; gastralgia; nausea; vomitmg; tongue white coated; no tenderness of abdomen or epigastrium; constipation; no enteralgia. Feces, dark and semi-liquid, enormous number of ova of uncmaria, some of ascaris and tricocephalus (the largest number of ova we have seen). Spleen and liver normal. Breathless on slightest exertion. Palpitation; no pre- cordial pain. Pulse, 96, a little weak and compressible. Short dry cough; no pain in chest. Dizziness; tinnitus aurium; no headache; sleeps well but uneasily; is very nervous and cries on being approached with lancet for puncturing ear, a rare cir- cumstance as we have found among these children. Reflexes normal. Temperature, 36.9°. Course. — This remarkable case was very carefully studied. The only possible skin infection must have occurred a couple of months before his first coming to clinic (May 29). The extraordinary blood record was repeated to insure its correctness. Diagnosis. — Acute uncinariasis; light case. Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. s. c. My. June 27 65 107 4,352,000 5,346,400 7,200 9,000 9.5 7.2 57.5 65.2 27.5 22.4 2.0 14.4 0.5 .4 3.0 .4 July4... Remarks: — June 27, blood fluid and coagulates slowly. No poikilocytosis nor polychromatophilia . treatment. — No iron used. June 28, 2-15, preceded by 0.01 of podophyllin. July 4, no ova uncin. Result. —Cured, July 4. It is remarkable that his symptoms should disappear in so short a time, but he is perfectly well now. Case 59. — S. O. Barrio Salto Arriba. Admitted June 28. Age, 35; femalp; mulatto, widow; housework and coffee picking. One brother died of anemia. She has been sick for several years, very.ill for one year. Does not remember title beginning. Vegetable food, poor quality. Has taken "reconstituent pills," which did not recon- stitute. Pallor very marked; no emaciation; development good. Has had puffiness of face; has now slight edema of trunk and legs. Had mazamorra; no pruritus; skin very dry and atrophied. Good appetite; gastralgia; little nausea and vomiting; flatulence; meteorism; ascites; tenderness over epigastrium and abdomen. Bowels irregular, alternating diarrhea and constipation; no enteralgia. Feces contain many ova of uncinaria. Dyspnea; much palpitation; pain over heart. Pulse, 126, very weak. Very pronounced hemic murmur, and scarcely detectable dilatation of heart. Pulsation in external jugulars. No cough. Great dizziness; tinnitus aurium; headache; no neuralgia; sleeps poorly; subject to syncope; reflexes good; mental condition, very bad; intelligence, scarcely any; expression, picture of misery. Paresthesias. Amenorrhea for 9 months; aborted about one year ago. Blurred vision. Muscles, very flabby, sore, and painful. Is too weak to walk without assistance. Temperature normal. Course. — Made no progress tor three weeks, then improved rapidly. Towards end was cook's helper. Diagnosis. — Chronic uncinariasis; intense. THE UTTJADO SEEIES OF 1904. 301 Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. S. C. My. June 28 18 22 16 20 30 60 67 74 76 1,212.800 1,332,800 964,000 1,070,400 2,408,800 2,924,000 4,332,800 4,630,400 4,842,800 11,200 10,600 5,600 6,000 2,200 7,400 5,600 4,600 7,400 4.8 2.4 8.4 6.0 2.0 2.8 4.0 7.6 4.4 72.8 70.8 79.2 74 70.8 81.2 74.4 75.2 68.0 6.4 9.2 6.4 7.2 9.2 8. 8.4 8.8 14.4 16.0 17.2 6.0 10.8 15.2 6.8 12.0 8.4 12.4 12... 0.4 19 26 ;;■". .8 .4 0.4 2.4 .4 .8 1.6 Aug. 2 9 16 .8 Remarks. —June 28, blood pale, watery, and coagulates slowly. Extreme poikilo- cytosis and polychromatophiha, macrocytosis prevails. July 5, 42.4 normoblasta to cu. mm. 12th, reds are greatly deformed. Macrocytes are most numerous and of great Bize, many larger than leucocytes. 67.2 megaloblasts and 44.8 normoblasts to cu mm. 26th, reds improved. Still macrocytosis but cells appear less "washed out;" 8.8 megaloblasts and 8.8 normoblasts to cu. mm. August 2d, appearance of blood much better. 19th, blood appears almost normal. Treatment. — Blaud's pills used in intervals. June 30, 4-15, preceded by 0.03 podophyllin; July 4, tr. digitalis and tr. nux vomica; 6th, ova uncin. ; 7lh, thymol repeated; 13th, many ova uncin.; 14th, thymol repeated; 19th, few ova uncin.; 20th, thymol repeated; 26th, few ova uncin.; 27th, thymol repeated; August 2d, no ova uncin.; 8th, no ova uncin.; 13th, stopped digitalis and nux vomica; 19th, no ova uncin. Result. — The improvement in this patient is remarkable. Has good color, no edema, slight murmur. Peels well except for some weakness. Case 60. — M. G., barrio Mameyes. Admitted, July 4. Age, 13; male; white; works sometimes on coffee plantations. Three brothers died of anemia. He has been ill six years. Has usual food of country. Has had much mazamorra. Has taken much iron. Marked pallor. Not emaciated. Edema of legs. General pruritus. Good appetite; sometimes gastralgia; nausea; no vomiting; flatulence; no tenderness of abdomen; somemeteorism; constipated; sometimes enteralgia; feces, many ova of unci- naria, Charcot-Leyden crystals, and some ova of ascaris. Normal spleen and liver. Slight dyspnea; palpitation; precordial pain. Pulse, 90, strong and full. Heart en- larged, with systolic hemic murmur. Pulsation of vessels of neck pronounced. No cough, but pain in chest. Much dizziness and tinnitus aurium; temporal headache. Sleep normal; reflexes normal. Expression sad and lifeless. Susceptible to cold. Urine; 1,014, normal. Blurred vision. Muscles flabby, painful, and weak. Tem- perature, 38°. Course. — Rapid convalescence. Diagnosis. — Chronic uncinariasis, intense. July 7.. 14. 21. 28. Aug. 3.. 10. Hb. Eed cells. 2,360,000 2,504.000 3,800.000 4,064,000 4,808,000 4,824,000 Leuco- cytes. 10,800 7,200 6,600 7,200 8,200 8,600 E. 6.8 12.0 11.2 24.8 18.8 16.0 P. 50.8 53.6 57.2 44.4 40.4 42.4 S.L. 36.0 23.2 29.2 20.4 32.8 29.2 L.L. 5.6 5.6 .8 3.2 3.6 4.0 0.8 1.2 3.6 .8 3.6 S. C. 3.6 3.6 2.8 My. 2.0 iJeTMriiis.— Usual blood changes for this type. .,,„„„ , i, ,,• Treatment— Blsiud'a pills used in intervals. Ju y 8, 3-10, with 0.02 podophyllm, 14th, many ova uncin.; 15th, 3-10, with 0.02 podophyllm; 21st,. many ova uncm; 9M q in with 02 DodoDhvllin; 28th, ova of uncm. and ascaris 29th, 3-10, with 02 p^opSlin; AuPt t ova uncin.'; 4th, 3-10, with 0.02 podophyllin; 11th, no °^^emZt^Cured, August 11th, perfectly healthy and of good color. 302 UNCINABIASIS IN POETO BIOO. 61— Z. J. I., barrio Roncador. Admitted, July 17. Age, 11; male; white; coffee picker; his mother died of anemia; he has been sick one year; usual food of country; mazamorra often; has taken much iron. Marked pallor; not emaciated; edema face and legs; no atrophy of skin. Good appetite; gastralgia; no nausea or vomiting; flatulence; tender abdomen; meteorism; bowels constipated; sometimes enteralgia; feces contain many ova of uncinaria, Charcot-Leyden crystals, and meat' fibers. Spleen and liver normal. Dyspnea; palpitation; precordial pain; pulse, 112 and weak. Slight hemic murmur and pulsation in vessels of neck noticeable. No cough nor pain in chest. Dizziness; much tinnitus aurium; frontal head- ache; sleep normal; patellar reflex absent. Is very dispirited. Susceptible to cold. Urine; S. G. 1,010, normal. Blurred vision. Muscles, flabby and painful. Is very weak. Temperature 38°. Course. — Very rapid convalescence. Diagnosis. — Chronic uncinariasis, intense. Date. Hb. Red cells. Leuco- cytes. E. P. S.L. L.L. B. S.C. My. July 17 22 42 64 71 87 1,676,000 2,960,000 3,366,000 3,656,000 4,744,000 8,200 10,400 6,800 5,400 11,200 2.0 22.0 16.0 24.4 26.8 78.8 61.6 48.8 48.4 62.8 18.4 14.4 26.0 17.6 IS.O 0.8 .4 6.8 6.8 2.4 24 1.2 1.2 2.4 Q.4 .4 .4 31 .-. 0.8 Aug. 7. . 14 Remarks. — Usual blood changes of severe grade of uncinariasis. Treatment. r-BUud'B pills used in the intervals. July 18, 2-10, with 0.02 podo- phyllin; 24th, ova uncm.; 25th, 2-20, with 0.02 podophyllin; 31st, no ova uncin.; August 2, 2-30, with 0.02 podophyllin; 7th, no ova uncin.; but many Charcot-Leyden crystals; 17th, no ova uncin. Discharged from hospital. Result. — Cured, August 17. Perfectly well. Good color. THE AIBONITO SERIES OF 1905. BETANAPHTHOL GKOUP THYMOL GROUP. These two groups are formed of cases continuously under observa- tion in hospital in whom all worms expelled as a result of the specific drugs were counted. Our technique was as follows : All feces for 24 hours after the administration of the first dose of the drug were saved. This was strained into a bucket througla several thicknesses of gauze and the filtrate well and repeatedly washed. This latter was then washed out into porcelain dishes, in which there had been placed a 4 per cent solution of formaldehyde. The dishes were then carried into a separate room, where a gutter painted a jet black had been mounted so as to run into another bucket through a very gentle incline. Starting at the upper end of this gutter a very few drops of the filtrate were allowed to fall into the gutter and this material was thus dispersed in a thin layer over the surface, so as to expose all solid elements. Then with a fine stream of water from a wash bottle and a pair of thumb forceps the worms were recovered. A full count generally required from one to two hours, and of all that we have had to do in investigating this disease we can not conceive of a more tiresome, disgusting, and unhealthful labor. While there are but 70 cases here, as a matter of fact fully 70 more were begun and had to be abandoned when patients, feeling well, insisted on leav- ing camp for their homes, thus spoiling the records and ruining the case for scientific ends. ' The clinical histories are exceedingly brief, and only such points in the course of the cases are noted as seem to lend especial interest. A few cases were at first treated with male fern, but when the futility of that drug was demonstrated the regular medication was apphed. The blood record is incomplete. It was physically impossible for us to make a complete record and, in view of the previous year's study, unnecessary. So merely the hemoglobin is noted from time These records have never been heretofore published, although they are the most valuable of our series. ,i. i , Attention is invited to the large number of cases m whom the later doses of the anthelmintic were those which brought away the largest worms This is contrary to early observations on uncinariasis but there is no doubt in our minds that it is the small-sized and not the large-sized uncinari^ which are first expelled In this connection it will be noted that sometimes 18 and more hours passed after the administration of the anthelmintic before r^^^^^f ^^/P^n^ the Fever, diarrhea, and albuminuria were frequently ^fen during tJie course of treatmeAt. The first was generally dispelled after the first dose of the anthelmintic; the second was more frequently occasioned bv thvmol, and the third symptom by betanaphtfiol. ... ^TheTemarkable lack of iffect of iron in the anemia of uncinariasis may be seen by comparing the rise of lib. m those who did and those who did not receive that drug. ^^ 304 ■UNCINARIASIS IN POETO EICO. Series of 30 cases of uncinariasis treated by hetanaphthol. Case, 5802; age, 18; sex, male; grade, intense; no iron used in this case; antlielmintio; betanaphthol; total days, 42; total rise Hb., 27 per cent; total uncinarise expelled, 1,316. Date. Ova uncin- arise. Dose in grams. Uncin- arise expelled after anthel- mintic. Hemo- globin. Remarks. Oct 30 Moderate 2.0 2.0 2.0 2.0 2.0 2.0 432 495 233 76 70 10 Per cent. 18 17 25 31 28 45 Nov. 13 Moderate ..do 19 27 Deo. 4 7 do Headache. 10 Much albumin and casts. Case, 6655; age, 35; sex, male; grade, intense; Blaud's piUs used; anthelmintic, betanaphthol; total days, 44; total rise Hb., 43 per cent; total uncinarise expelled, 1,122. Oct. 24. . ... Many • 2.0 507 161 273 21 No albumin in urine. 26 Worms passed result ol yesterday's Nov. 1 2.0 26 dose. 6 . . Chill and fever. 7 Moderate 2.0 29 8 67 29 80 5 Result of yesterday's dose. 15 Moderate do 2.0 2.0 2.0 29 39 49 64 22 29 Dec. 6 Case, 6089; age, 50; sex, female; grade, medium; tincture chloride iron used; anthelmintic; betanaphthol; total days, 30; total rise Hb., 47 per cent; total uncinariffi expelled, 333. Nov. 24 Many 1.0 1.0 1.0 1.0 312 9 12 36 Dec. 2 Few y Moderate 46 19 23 82 Case, 5434; age, 12; sex, female; grade, intense; Blaud's pills used; anthebnintio; betanaphthol; total days, 38; total rise Hb., 52 percent; total uncinarise expelled, 864. Oct. 14 Moderate 2.0 2.0 306 414 34 40 Three small ascarides expelled. One pair uncinarise in copulation. Also expelled one ascaris. Vomited; severe headache; slight diarrhea. Urine shows slight trace of albumin; lew^yaline and granular casts only. 23 29 Nov. 4 Many 2.0 130 Oct. 10 69 68 86 Nov. 11 None 2.0 2.0 15 of hyaline casts; very few granular oasts. 20 do Case, 5676; age, 10; sex, female; grade, medium; Blaud's pills used; anthelmintic; betanaphthol; total days, 33; total rise Hb., 36 per cent; total uncinarise expelled, 406. Oct. 24... Moderate Few 2.0 2.0 2.0 2.0 387 19 53 65 64 73 79 89 No albumin in urine. Faint trace of albumin; 31 Nov. 6 None 10 do 21 29 305 THE AIBONITO SEMES OP 1905. Series of SO cases of uncinariasis treated by betanapthol—Continued. "■ '"''■■ ^"A^^^?i?S^1i:^^I^S*^^.^^.?SFS^^^^^^^ -1 unci. Date. Ova uncin- ariae. Dose in grams. Uncin- ariae expelled alter antliel- TTiiTitie. Hemo- globin. Remarks. Sept. 22 Per cent. Fever averages 102 to 105; no parasites m blood; delirium. Chill followed by fever. 105. Temperature 98.4. No parasites in blood. Temperature normal. Temperature 103 at 12 noon. Temperature: a. m., 101; 12 m., 104; 6 p. m., 102. Temperature: a. m., 100; 12 m., 100; 6 p. m., 100. Quinine given. Temperature normal for three days. 23 24 1 25 26 27 29 Oct. 8 10 Moderate .do 2.6 2,0 2.0 469 32 18 20 79 29 Few Nov. 6 95 88 100 Vomiting. Trace Oi" albmnin in urine. 13 2.0 2.0 2.0 2.0 H 20 Moderate 27 12 Deo. 5 do Case, 6807; age, 28; sex, female; grade, medium; no iron used in this case; anthelmintic; betanaphthol; com- plication, chronic otitis media; total days, 15; total rise Hb., Gl per cent; total uncinarise expelled, 497. Oct. 30.. Moderate do 2.0 2.0 325 128 35 Nov. 7 10 81 96 14... Moderate do 2.0 2.0 1 14 21 25 Joint pains, severe. 29 Moderate do .... 2.0 2.0 2.0 17 12 Deo. 6 16 None Thymol used this time. Case, 4243; age, 9; sex, male; grade, medium; Blaud's pills used; anthelmintic; betanaphthol; total days, 26; total rise Hb., 23 per cent; total uncinariie expelled, 247. Sept. 12 20 Few 1.0 1.0 1.0 242 3 1 C5 Trace of albumin, before treatment do began. None Oct 1 88 5 1.0 1 Case, 5944; age, 10; sex, male; grade, medium; Blaud's pills used; anthelmintic; betanaphthol; total days, 24; total rise Hb., 58 per cent; total uncinaris expelled, 654. 1.0 1.0 1.0 1.0 026 9 19 35 49 79 93 13 Moderate None 21 29 do Case, 4241; age, 11; sex, male; grade, benign; Blaud's pills used; anthelmintic; betanaphthol; total c total rise Hb., 13 per cent; total uncmariae expelled, 680. Sept. 12. 20. Oct. 28. 1. 5. Moderate. None ..-.do None., 2.0 2.0 2.0 2.0 675 5 Diarrhea. Diarrhea had ceased. 77759°— S. Doc. 808, 61-3- -20 306 UNCINARIASIS IN PORTO RICO. Series of SO cases of uncinariasis treated by betanapthol — Continued. Case, 3204; age, 13; sex, male; grade, intense; Blaud's pills used; anthelmintic; betanaphthol; total days, 67; total rise Hb., 70 per cent; total uncinarise expelled, 1,727. Date. Ova uncin- ariae. Dose in grams. Uncin- arise expelled after anthel- mintic. Hemo- globin. Eenmrks. Aug. 17 Moderate 2.0 2.0 1,569 106 Per cent. 29 No albumin. Pieces of betanaphthol, forming cast of capsule, passed en- tire. Uremic convulsions; promptly re- lieved by treatment. Diarrhea. 9 76 2.0 36 14 Convulsions ending in stupor, relieved 19 8 8 99 96 by pilocarpine. 25 Few 2.0 28 Albumin in urine; no casts. Oct. 1 99 3 None 2.0 Case, 4197; age, 7; sex, male; grade, very intense; Blaud's pills used; anthelmintic, betanaphthol; total days, 39; total rise Hb., 78 per cent; total uncinariae expelled, 1,778. Sept 10 Many 1.0 1,587 20 U 22 Few 1.0 1.0 1.0 2.0 141 22 18 10 Diarrhea has ceased. 29 Moderate do 58 14 18 98 Case, 3476; age, 10; sex, female; grade, intense; Blaud's pills used; anthelmintic, betanaphthol; total days, 35; total rise Hb., 70 per cent; total uncinariae expelled, 650. Aug. 23.. Sept. 1.. 8. 13., 20.. 27.. Moderate. . ....do None ....do ....do do 2.0 2.0 2.0 2,0 2.0 2.0 591 7 3 49 18 98 Diarrhea. Diarrliea had ceased. Thymol used this time. Traces of alburjin in urine; no casts. Case, 5237; age, 12; sex, male; grade, intense; reduced iron used; anthelmintic, betanaphthol; total days, total rise Hb., 40 per cent; total uncinarise expelled, 1,108. Oct. 9 Moderate do 2.0 2.0 2.0 725 166 76 18 16 23 do 19 37 29 30 Moderate 2.0 12 Nov. 6 34 6 Moderate 2.0 12 47 16 Moderate do 2.0 2.0 117 12 23 58 Case, 6848; age, 24; sex, male; grade, very intense; no iron used; anthelmintic, betanaphthol; total days, 18; total rise Hb., 11 per cent; total uncinariae expelled, 235. Nov. 1. 10. 18. Many Moderate. . None 2.0 115 33 2.0 103 44 2.0 17 THE AIBONITO SERIES OP 1905. 397 Senes of SO cases of uncinariasis treated by ietanapftoZ-Continued. cases we have ever seen, and almost ''^irafiaXin^o^n?' sT^^^^^^ largement; fever; presence of afin/^iiil,. ^ anemia; hypostatic conKest from blood; generS severe an^^^ and dp^fh^K *° J;^^ bacillus coll total days, eo; total rise Hb ,Tper SLt Jo?;' ^^Sn ^' Claud's pills use, , II iiKi ceni, lotal unemanse expelled, 2,234. '■', betanaphtho Date. Aug. Aug. 19-Sept. 2. Sept. Ova uncin- ariaa. Dose in grams Moderate.. Few., Oct. 17.. 24., 30., 12.. None... ....do., ....do.. ....do.. TJncin- ariffl expelled after anthel- mintic. Hemo- globin. Per cent. 2.0 2.0 2.0 2.0 2.0 1.0 2,007 201 Remarks. Temperature 38J° C; a trace of albu- min; granular and hyaline casts temperature, ranges from normal or ™oT5??'r.™ ."^^ morning to from ill to 38 C. at night. Sputum con- tarns no tubercle bacilli on repeated exammations. Not at all emaci- ated. On September 2 fever disap- peared, and as man was nearly dead from anemia, betanaphthol was ad- mimstered. Slight trace of albumin in urine, not discernible by Heller's test. No casts, but few polymorphonuclear leucocytes. All worms expelled are very large. This man became an employee of the pharmacist of Aibonito. His hemo- globin rose to 105 per cent eventu- ally, and he was known as "el Colo- rado," the red-faced man. On ad- mission he was apparently so stupid as not to understand the simplest things said to him. He developed into an unusually bright messenger. Case, 3475; age, 45; sex, female; grade, intense; lactate of iron used; anthehmntic, betanaphthol; total davs 21; total rise Hb., 47 per cent; total uncinarise expelled, 1,566. ( + ?) Aug. 24.. 31.. Sept. 12. . 19.. 26.. Oct. 3.. Moderate. do Few ....do ....do None -...do 2.0 2.0 2.0 2.0 2.0 2.0 2.0 804 (?) 379 279 66 38 68 105 Stool lost. Diarrhea. Case, 3783; age, 6; sex, female; grade, medium; Blaud's pills used; anthelmintic, betanaphthol; total days, 28; total rise Hb., 62 per cent; total imcinariae expelled, 73. Sept. 4 Moderate 2.0 63 25 10 12 Few 2.0 1.0 10 I have carefully investigated to see if 19 Oct. 1 87 this child were not saved and there is no doubt that none were lost, nor any part of her excrement for 12 hours after each dose of the anthel- mintic. (Note by Dr. Ashford, whose case this was.) 308 UNCINARIASIS IN PORTO RICO. Series of 30 cases of uncinariasis treated by betanapthol — Continued. Case, 4647; age, 60; sex, female; grade, intense; Blaud's pills used; anthelmintic, betanapMhol; total unclna- rise expelled, 642. Date. Ova uncin- arise. Dose in grams. Uncia- ariae expelled after anthel- mintic. Hemo- globin. Remarks. Sept 21 Many 2.0 2.0 386 54 Per cent. 27 Moderate 30 65 Oct. 3 Few 2.0 2.0 2 89 11 2 All uncinarise large; also expelled 34 H Moderate None tricocephali. 20 60 Case, 3605; age, 22; sex, female; grade, intense; Blaud's pills used; anthelmintic, betanaplitiiol; total days, 47; total rise Hb., 34 per cent; total uncinariee expelled, 1,387. Aug. 28 Moderate 2.0 978 57 Sept. 2 inent. Diarrhea ceased. 8 Bew 2.0 2.0 2.0 2.0 2 258 26 56 65 4 16 Moderate do 50 21 Oct. 1 13 do 9i All very large uncinarise. No albumin, all large uncinarise. 20 94 Case, 3356; age, 12; sex, male; grade, intense; saccharated oxide of iron given; anthelmintic, hetanaphthol; total days, 36; total rise Hb., 75 per cent; total uncinariae expelled 2,724. Aug. 18 21 2.0 2 2,372 307 24 casts. Very small stool almost entirely com- posed of worms. 29 do Sept. 1 47 2,6 28 8 99 14 2.0 2 17 All uncinarise expelled were large. 22 do 90 Case, 3190; age, 60; sex, male; grade, intense; iron, quinine, and strychnine used; anthelmintic, hetanaph- thol; total days, 49; total rise Hb., 75 per cent; total uncinarise expelled, 995. Aug. 16 17 Few 2 603 Slight trace of albumin in urine. 19 21 23 23 Few 2.0 2.0 2.0 235 92 113 30 do 35 59 Slight trace of albumin in urine. In very small stool worms all large. No albumin in urine, much mucin, and one hyaline cast. Small stool, all large worms. Sept. 6 10 do 13 Moderate None... 2.0 2 2 43 5 4 20 27 do 30 98 Oct. 3 2.0 Case, 4934; age, 7; sex, male; grade, intense; Blaud's pills used; anthelmintic, hetanaphthol; total days, 37; total rise Hb., 68 per cent; total uncinaris expelled, 352. Sept. 24 2.0 2.0 2.0 339 2 8 37 Oct. 1 Moderate None U 19 20 86 23 Few.... 2.0 2 Diarrhea had ceased. 29 95 3D None 2.0 1 THE AIBONITO SERIES OF 1905. Series of SO cases of uncinariasis treated by betanapthol—Continned. 309 e, 5808; age, 26; sex, female; grade, benign; no iron used; anthelmintic, betanaphthol; total uncmarl» expelled, 118. Date. Ova uncin- ariae. Dose in grams. Uncin- ari» expelled alter anthel- mintic. Hemo- globin. Remarks. Oct. 31 Moderate 2.0 84 12 9 7 3 Per cent. 118 Nov. 1 Twelve worms expelled 18 hours after last dose. 8 Few 2.0 2.0 2.0 2.0 15 Moderate 22 120 29 do Case, 5533; age, 35; sex, male; grade, intense; lactate of iron used; anthelmintic, betanaphthol; total days, 6G; total rise Hb., 63 per cent; total uncinari^ expelled, 946. Oct. 18 Some 2.0 708 20 . .. . 22 24 Moderate 2.0 233 29 39 35 45 85 Severe diarrhea. Nov. 12 20 Diarrhea ceased. 16 None 2.0 5 Case 5826- age, 11; sex, male; grade, intense; no iron used; anthelmintic, hetanaphthol; total days, 23; total rise Hb., 34 per cent; total uncinariae expelled, 152. Nov. 1 2 10 12 17 23 Many. Many. Many. 2.0 'i'.O "2."6' Twenty hours after last dose. Case, 5537; age, 16; sex, male; grade, medium; reduced iron used; anthelmintic betanaphthol; total days, 56; ' 6> • total rise Hb., 61 per cent; total uncmanaj expelled, 1,195. Oct. 18.. 24.. 31. Nov. 7. 12. 14. 22. Deo. Many Moderate. do.... do..... Moderate. do do..... do Few 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 693 108 182 37 105 case. 5609; age, ^,- ma^^-^vJ^^^; l?-^^;^t:r^^^ "^^""""'^ Oct. 18. 25. 29. Nov. 1. 5. 8. 12. 16. 21. 24. Many Moderate. . Moderate.. Moderate.. Moderate., do 2.0 2.0 2.0 2.0 278 372 100 35 310 TJNCINABIASIS IN PORTO BICO. Series of SO cases of uncinariasis treated by betanaphtol — Continued. Ca^e, 5626; age, 15; sex, female; grade, intense; no iron used; anthelmintic, betanaphthol; total days, 31; total rise Hb., 29 per cent; total imcinarige expelled, 725. Date. Ova uncin- arise. Dose in grams. Uncin- arise expelled after anthel- mintic. Hemo- globin. Remarks. Oct 23 Moderate 2.0 661 Per cent. 27 Last dose of betanaphthol at 7 a. m. 25 Large movement at 8.30 a. m.; no worms expelled, but at 10 a. m. in a small movement she expelled 400. At 12 noon expelled 261. Expelled 1 male unctnaria in stage 29 Moderate 2.0 62 36 of fatty degeneration. 31 Diarrhea. Nov 5 55 2.0 2 Diarrhea has ceased. 12 56 Case, 5809; age, 8; sex, male; grade, benign; no iron used; anthelmintic, betanaphthol; total uncinariae expelled, 159. Nov. 1 Moderate .... do 1.0 1.0 97 9 97 8 12 85 16 Moderate do 1.0 1.0 1.0 1.0 1.0 2 18 4 15 14 22 113 29 do Dec 6 do 13 Pew Series of 40 cases of uncinariasis treated by thymol. Case, 6077; sex, male; age, 18; grade, intense; thymol anthelmintic; Blaud's pills used; complication, tertian benign malaria; total number days, 54; total rise Hb., 54 per cent; total number uncinariae expelled, 776. Nov. 23 1.0 114 40 42 • 29 30 Manv 1.0 245 Dec. 6 64 7 1.0 166 13 70 14 Moderate Few 1.0 1.0 29 189 20 23 80 85 94 27 Few 1.0 1.0 43 Jan. 15 Moderate Case, 4287; sex, male; age, — ; grade, very Intense; male fern and thymol anthelmintics; Blaud's pills used; complication, none; prominent symptoms, intense pallor, general anasarca, great prostration; all usual symptoms marked; total number days, 47; total rise Hb. , 67; total number uncinarise expelled 1,122. Sept. 23 29 Many Moderate 6.0 6.0 8.0 4 12 Male fern used this time. Do. Oct. 2 2 19 4 Joint pains severe. Edema of face disappeared; thymol used this time; 8 trichocephall also expelled. Thymol used. Thymol used; also expelled 4 triotio- cephali. Thymol used. Thymol used; also expelled 1 trioho- cephalus. 9 4.0 4.0 4.0 4.0 4.0 919 185 15 3 16 . Moderate None 41 49 68 72 79 22 28 do Nov. 4 do .... 8 THE AIBONITO SERIES OP 1905. Series of 40 cases of uncinariasis treated by Ihymol-Continu^d. 311 Ca3e,529X; se., ,e.a,e. '^^^^'^l^S^^^^^.^^^^ims usea; toUMa.. 3. Date. Oct. 9. 16. 24. 31. Nov. S. 14. 16. 21.. Ova uncin- arise. Many . . Few... ....do. None . . None. Dosein grains. 3.0 3.0 3.0 3.0 2.0 Uncin- ariEe expelled after anthel- mintic. 287 30 Hemo- globin. Per cent. 22 40 46 72 Remarks.' Also expelled 1 ascaris. Severe diarrhea with fever. Diarrhea ceased; temperature normal. Case, 5287; sex, male; age f^ g-de, intense; anthelmintic, thymol; Blaud's pills used; total days loxai rise lib., 51 per cent; total uncmariae expelled, 1,979. ' ' Oct. 10. 17. 24. Nov. 1., 7.. 14., 21.. 27.. Many Moderate. Few. .do. Moderate.. None -...do.... 4.0 4.0 4.0 4.0 4.0 4.0 4.0 1,223 492 230 11 20 Case, 3722; sex, male; age 22; grade, medium; thymol anthelmintic, Blaud's pills used- total davs 27- total rise Hb., 36 per cent; total uncinariae expelled, 1,367. ^ ' ' Aug. 9. 17. 20. 23. 27. Moderate., None . . -...do. None.. 4.0 4.0 4.0 Much albumin and many casts in urine before treatment began. Fever and dysentery with blood and mucus. Case, 4290; sex, male; age, 40; grade, intense; thymol anthelmintic; Blaud's pills used- total days'61- total rise Hb., 79 per cent; total uncinariae expelled, 1,361. ' ' Sept. 13 Moderate do 4.0 4.0 4,0 1,237 77 20 10 UncinariiB were expelled the 15th, 24 hours after; also 4 ascarides. 20 27 28 38 Oct. 1 4 None 4.6 4.0 4.0 4.0 '4.0 13 3 4 1 11 do 18 do 25 - . do 64 95 Nov. 2 do Case, 6991; sex, male; age, 25; grade, very intense; anthelmintics, male fern and thymol; iron, arsenic, and stryohjiine used; total days, 30; total rise Hb, 19 per cent; total number uncinarias expelled, 4,395. Nov. 22 Many 2.5 25 Trace albumin and casts in urine be- 23 fore treatment; male fern used this time. EyeUds puffy. 29 Moderate do 4.0 3.0 3.0 3.0 2 3,080 480 218 23 22 33 Male fern used this time. Dec. 6 Thymol used this time. do Anasarca face; thymol used this time. 20 Few 40 44 27 None . . 3.0 312 UNCINARIASIS IN PORTO RICO. Series of 40 cases ofuneinariaw treated by thymol — Continued. Case, 5158; sex, male; age, 17; grade, benign; anthelmintic, thymol; Blaud's pills used; complication, hystero-epilepsy; total uncinarise expelled, 1,007. Date. Ova uncin- arise. Dose in grams. Uncin- arise expelled after anthel- mintic. Hemo- globin. Remarks. Oct. 4 Many 3.0 3.0 3.0 3.0 49 775 119 93 6 13 2 17 3 Per cent. Hystero-epilepsy. 11 Moderate do 18 Expelled 1 tricooephalus. 25 26 — \ Nov. 1 Few None 3.0 3.0 3.0 3.0 3.0 Expelled 4 tricocephali. 8 15 Moderate None . 22 29 do Case, 5188; age, 32; sex, male; grade, very intense; anthelmintic, thymol; Blaud's pills used; complication, can not coimt lingers at distance of 18 inches; total days, 50; total rise Hb, 49 per cent; total uncinarise expelled, 3,493. Oct. 8 . Many 4.0 4.0 4.0 4.0 4.0 3,101 203 183 6 32 3D Can not count fingers at distance of 18 to 20 inches. No cataract. 15 ... Moderate do 22 29 Few 35 40 63 81 Nov. 5 12 .. .do 26 Eyesight unimproved. Case, 4605; sex, female; age, 40; grade, very intense; anthelmintic, thymol; Blaud's pills used; Nov. 18 to 24, had a cataleptic attack, preceded by "epilepsy;" hysteria major frequently; total days, 56; total rise Hb, 51 per cent; total uncinariae expelled, 1,167. Sept. 20 Many 3.0 719 18 ^ 27 :.... Oct. 4 Moderate 3.0 83 50 Diarrhea stopped. Severe diarrhea and prostration. 7 Nov. 8 3.0 346 12 69 15 3.0 19 Nov. 18, had an attack, apparently epi- leptic, foaming and bleeding at mouth, biting tongue, pupils dilated, unconscious; history of previous at- tacks, scars on tongue; by night lapsed into semiconscious, hysteric state. Nov. 19, lies semiconscious, moves and sometimes talks inco- herently; becomes worse on being noticed; screams at night. Nov. 20, same; will not swallow; slight cata- lepsy, which can be overcome by gentle, steady force; eyes staring, but covertly notices what goes on; con- tinnal slight grinding of teeth. Nov. 22, talks rationally; is cured. Case, 6058; age, 16; sex, male; grade, very benign; anthehnintic, thymol; no non given- prominent svmn- toms are wearmess and pains in chest and legs; total uuclnariEe expelled, 574. Nov. 23. 30. Deo. 8. Moderate. , None ....do.... 4.0 4.0 4.0 120 THE AIBONITO SERIES OF 1905. Series of 40 cases of undnariasis treated by %moZ— Continued. 313 Case, 3985; age, 52; sex, male; grade, intense; anthelmintic, thymol; Blaud's pills used; total unoinarlEe Date. Ova uncin- arise. Dose in grams. XTnciu- ariffi expelled after anthel- mintic. Hemo- globin. Eemarks. Sept. 7 Moderate do 4.0 4.0 4.0 215 212 62 Per cent. 18 No albumin in urine. 14 21 Few 24 Facial neuralgia. 28 Moderate 4.0 4.0- 4.0 41 21 Oct. 16 31 do Case, 3921; age, 28; sex, male; grade, intense; anthelmintic, thymol; Blaud's pills used; total days, 76; total rise Hb, 100 per cent; total uncuiariae expelled, 2,073. Sept. 6 13 Moderate Few 3.0 3.0 3.0 3.0 3.0 3.0 3.0 1,404 517 96 36 18 2 20 No albumin in urme. 20 . .do 27 do i20' Oct. 5 None 12 ... ... -do . 20 do Case, 5333; age, 45; sex, male; grade, m.ediura.; antlielm.intic, tliym.ol; Blaud's pills; total days, 21; total rise Hb, 45 per cent; total uncinariae expelled, 959. Oct. 10 Moderate 3.0 884 35 No albumin in ru-me. 13 Severe diarrhea. 18 Moderate 4.0 68 65 Diarrhea has ceased. 21 Albumin in urine, no casts. Moderate 4.0 17 29 68 80 30 None . - . 4.0 Case 5363- age 12- sex, male; grade, verv intense; anthelmintic, thymol; Blaud's pills; total days, 36; total ' ' rise Hb, 105 percent; total uncinariae expelled, 1,021. Oct 13 Many 2.0 2.0 489 111 16 31 No albumin in urine. 19 Moderate 26 - Moderate do 2.0 2.0 2.0 2.0 287 14 18 45 60 90 120 Diarrhea ceased. Nov 2 10 do case, 6608; age, 18; -, n^?i f^; ^^^ ^Jl'S^iSSilS^^r '^"--^ Oct. 16- 23. 29. Nov. 4. 12. 16. 17. Moderate - do.... do.... None do.... None.. 3.0 704 36 3.0 288 60 3.0 8 62 3.0 7 70 3.0 100 3. .. Expelled 2 tricocephali. , ■ t „. „„+v,oiTninti>- thvmol; Blaud's piUs used; total days, 31; case, 6509; age, 18; ^ex, malej^grade, ^^te^^g^fSuncinlgexpeUed, 2.of6. Oct. 15. 22. Nov. 3. 8- 15. Moderate. do.... do.... Few None do.... 2.0 2 2.0 2.0 2.0 2.0 1,0 28 37 70 90 95 120 One tricocephalus. No albumin in urine. One tricocephalus. 314 UNCINARIASIS IN PORTO RlCO. Series of 40 cases of uncinariasis treated by thymol — Continued. Case, 5545; age, 30; sex, male; grade, very intense; anthelmintic; thymol;' Blaud's pills used; total days, 31; total rise Hb., 47 per cent; total unoinarise expelled, 1,871. Date. Ova uncin- arise. Dose in grams. Uncin- ansd expelled after anthel- mintic. Hemo- globin. Bemarks. Oct. 17 Many 4.0 1,610 Per eent. 35 Albumin in urine before treatment. 21 Diarrhea. 28 Moderate Few 4.0 3.0 3.0 3.0 252 8 1 40 63 64 82 Diarrhea has ceased. Nov. 6 11 .do 17 Case, 5550; age, 8; sex, male; grade, intense; anthelmintic, thymol; Blaud's pills used; total days, 30; total rise Hb., 90 per cent; total uncinaria3 expelled, 465. Oct. 17. 24. 29. Nov. 5. 11. 16. Many Moderate.. Few Moderate., Few do.... 1.0 281 20 1.0 142 52 1.0 25 80 1.0 7 92 1.0 5 100 1.0 5 110 Albumin in urine before treatment. Case, 5642; age, 20; sex, male; grade, intense; anthelmintic, thymol; Blaud's pills used; total days, 43; total rise Hb., 110 per cent; total uncinarise expelled, 544. Oct. 22. 28. Nov. 3. 9. 15. 21. 27. Dec. 3. Moderate., do.... do.... Few do.... do.... do.... None 3.0 236 • 10 3.0 107 18 3.0 105 32 3.0 72 54 3.0 22 74 3.0 2 92 3.0 3.0 110 120 Albumin in urine before treatment. Case, 3203; age, 29; sex, male; grade, intense; anthelmintic, thymol; Blaud's piUs used; total days, 60; total rise Hb., 72 per cent; total uncinariee expelled, 490. Aug. 17 Moderate 4.0 358 27 25 27 Diarrhea stopped. 28 Moderate None 4.0 4.0 90 41 Sept. 5 9 Temperature, 40.5. Diarrhea; temperature normal. 11 16 4.0 20 70 92 24 26 4.0 1 Albumin and uric add. Oct. 1 99 3 None 4.0 Albumin trace; no casts. Case, 5737; age, 58; sex, male; grade, medium; anthelmintic, thymol; total days, 22; total rise Hb., 31 per cent; total uncinariae expelled, 908. Oct. 27 Moderate None... 3.0 3.0 40 3.0 887 21 59 45 68 93 Nov. 3 11 Few. . . . 17 ■X-tim AiBO]MlTO SERIES OF 1905. Series of 40 cases of uncinariasis treated by t%moi— Continued. female; grade, intense; anthelmintic, thymol; Blaud's pi total rise Hb., 60 per cent; total unoinanaa expeUed, 881. 315 Case, 3784; age, 25; sex, female; grade, intense; anthelmintic thymol; Blaud's pills used; total days 28; Date. Ova uncin- ariae. Dose in grams. Uncin- ariaB expelled after anthel- mintic. Hemo- globin. Remarks. Sept. 4 Many 3.0 4.0 4.0 4.0 4.0 660 169 47 5 Per cent. 40 Neuralgia. Diarrhea for 3 days. Worms very large as compared with first expelled. ^ 15.::::::::::: Moderate Few 21 27 do Oct. 1 100 Case, 3622; age, 15; sex.female; grade, very intense; anthelmintic, thymol; Blaud's pills used; total days, 33; total rise Hb., 56 per cent; total uncinariffi expelled, 1,362. Aug. 28. Sept. 5. 9. 13. 20. Many. None.. None... ao. 4.0 4.0 4.0 40 1,307 19 Many small. All very large. Diarrhea; trace albumin. Diarrhea has ceased. Case, 4766; age, 30; sex, female; grade, intense; anthelmintics male fern and thymol; Blaud's pills used; total days, 56; total rise Hb., 45 per cent; total uncinarlse expelled, 1,446. Sept. 22 28 Moderate 6.0 6.0 4 25 Male fern used. Do. Oct. 1 21 8 4.0 4.0 4.0 4.0 4.0 3.0 1,321 108 17 Thymol used. 14 Moderate Few Do. 21 43 70 70 Do. 29 Do. Nov 9 .do Do. .do Do. Case 3526- age 25- sex, female; grade, intense; anthelmintic, thymol; Blaud's pills used; total days, i ' ' s' ' ' total rise Hb., 57 per cent; total uncinariaj expelled, 424. Aug. 25.. Sept. 1-. 8.. 15., 20.. 22. Oct. 28. 1. Moderate.. do.... Few Moderate.. Few. None. 4.0 4.0 4.0 4.0 93 205 85 31 37 All worms very large. Diarrhea. Diarrhea ceased; only one ovum found in specimen. oc o^ f„,„=ip- OT-adp medium- anthehnintic, thymol; Blaud's pills used; total days, 34; Case, 5022; age, 25; sex, f«J^^|l^%g^J^^'J^%'™entTtotal micinarii expelled, 847. Oct. 1- 9. 14. 16. 20. 26. 29 Nov. 3:: Moderate.. Few None. None. 4.0 4.0 4.0 "i.O 818 17 64 38 Diarrhea. Diarrhea ceased. 316 UNCINARIASIS IN POBTO RICO. Series of 40 cases of uncinariasis treated by thymol — Continued. Case, 6087; age, 40; sex, female; grade, intense; anthelmintic, thymol; no iron used; total days, 28; total rise Hb., 28 per cent; total uncinariee expelled, 1,148. Date. Ova uncin- arise. Dose in grams. Uncin- arise expelled after anthel- mintic. Hemo- globin. Remarks. Nov. 19 Moderate .do 4.0 4.0 918 174 Per cent. 39 25 29 Diarrhea. Few 4.0 4.0 4.0 44 12 68 Diarrhea has ceased. 11 .do 17 None Case, 6049; age, 22; sex, male; grade, medium; anthehnintie, thymol; no iron used; total days, 14; total rise Hb., 20 per cent; total uncinariae expelled, 236. Nov. 22 Moderate .do 4.0 4.0 182 61 89 Some fever, disappearing in two days. 28 Dec. 3 109 5 4.0 4.0 3 12 do Case, 6032; age, 25; sex, male; CTade, benign; anthelmintic, thymol; no iron used; total days, 15; total rise Hb., 32 per cent; total uncinarise expelled, 336. Nov. 19 Moderate None 4.0 4.0 4.0 309 25 2 88 26 ■. Dec. 3 do 120 Case, 3291; age, 40; sex, male; grade, medium; anthelmintic, thymol; Blaud's pills used; complication, estivo-autumnal malarial fever; quinine administered; total days, 24; total rise Hb., 39 per cent; total uncinari£e expelled, 326. Aug. 14 Few 4.0 285 73 After thymol urine full of hyaline, granular and epithelial casts. Much albumin and abundant urates and oxalate calcium crystals. Chill and fever. Blood showed many crescents estivo-autumnal fever. 17 23 Few 4.0 4.0 36 1 98 31 One expelled was male. Very severe diarrhea. Sept. 1 4 6 None ...... . 2.0 4 112 Betanaphthol used. AH four expelled were males. Case, S990; age, 54; sex, male; grade, intense; anthelmintic, thymol; no iron used; total uncinariee ex- pelled, 716. Nov. 17 Moderate do Few.. . . 2.0 2.0 2.0 2.0 2.0 481 216 12 7 40 25 Dec. 3 50 10 None 17 do Case, 4674; age, 30; sex, male; grade, very intense; anthelmintic, thymol; Blaud's piUs used; total days, 30; total rise Hb., 6 per cent; total unoinarlae expelled, 1,136. Sept. 21 Few 4.0 4.0 4.0 4.0 4.0 1,070 61 This case had only a few ova of unci- naria in the stools. 27 Oct. 4 do 29 12 do 2 3 Also one tricocephalus. 17 do 20 35 THE AIBONITO SERIES OF 1905. Series of 40 cases of uncinariasis treated by thymol— Continued. 317 Case, 5124; age, 25; sex, lemale; grade, very intense; anthelmintic, thymol; arsenic *„ grain used- t^tn.! days, 34; total rise Hb., 38 per cent; total uncinarii expelled, 623.'*' ^ ' Date. Ova unoin- ari£e. Dose in grams. Uncin- ariae expelled after anthel- mintic. Hemo- globin- Remarks. Oct. 4 Many.. 4.0 4.0 4.0 641 57 23 Per cent. 19 11 18 Few 37 21 Arsenic raised to ^„ grain. 26 4.0 4.0 2 39 Not. 2 do 6 47 Case, 4626; age, 18; sex, male; grade, medium; anthelmintic, thymol; Blaud's pills and quinine used; total days, 10; total rise Hb., 8 per cent; total uneinariae expelled, 249. Sept. 23. Oct. 2. Moderate.. None 4.0 4.0 234 15 Crescents in blood. Chill and fever. All uncinarise very large. Case, 4286; age, 22; sex, male; grade, intense; anthelmintic, thymol; complication, tertian benign malarial tever; Blaud's pills and quinine used; total days, 22; total rise Hb., 42 per cent; total uncinarite expelled, 1,160. Sept. 9 4.0 4.0 4.0 4.0 1,149 10 60 16 Few ingly small. Tertian benign mala^ rial parasites found in blood. Chill and fever. Malaria controlled. 23 do do 30 1 92 Case, 3934; age, 25; sex, male; grade, medium; anthelmintic, thymol; Blaud's pills used; total days, 63; total rise Hb., 47 per cent; total uncinariio expelled, 1,110. Sept. 5. 13. 20. 27. Oct. 4. 11. 27. Moderate., .do..-. None-. do. do. do. 4.0 4.0 4.0 4.0 4.0 4.0 670 372 46 15 7 82 Neuralgia. Case 6067- age, 38; sex, male; grade, intense; anthelmintic, thymol; Blaud's pUls used; total days, 22; total y^inia, uuu< , age, uo, , ,^n^^ ^^^ ^ ^^^ ^^^^. ^^^^j uncmariffi expelled, 96. Oct. 24. Dec. 1. 16. Moderate. Few None do...- 2.0 2.0 2.0 2.0 Diarrhea. Do. rase 6257- age 18- sex, male; grade, intense; anthelmintic, thymol; Blaud.s pills used; total days, 24; total Case, 5^5/, age, i», i>aj^, "'"g^'^b., 32 per cent; total uncmanas expelled, 2,316. Many Moderate.. Few 4.0 3.0 3.0 2,264 39 13 76 Diarrhea. Oct. 8 15 ■ 22 29 31 __ --^^^;^^^ used; total days, 19; Oct. 6. . 16.- 20.. 23.. Many Moderate.. 4.0 4.0 1,215 150 318 UliTCINABIASIS IN POE.TO RICO. UEINE GROXJP. These 24 cases were studied solely for the purpose of determining the effect of the drug upon the urine. In the course of this investi- gation it cropped out that albumin and casts were frequent in per- sons infected who had not only not had the specific drugs, which we believe an inspection of these histories wUl demonstrate are at least renal irritants, but in persons whose anemia was not marked. The points investigated were: (1) Albumin. (2) Balsamic resins. (3) Diazo-reaction. (4) Peptones. (5) Urobilin. (6) The sediment, by sedimentation of several hours in test glass. (7) The specific gravity, reaction, and color. (8) Irregularly, indican. Our method was unvarying for each case; the urine was examined completely, as per above, the night before and the morning of the administration of the anthelmintic, i. e., twice before the dose; and the afternoon of the day in which the drug was given and the next morning, i. e., twice after the anthelmintic. In the tabled cases to follow, it will be noticed that no note is made of the balsamic resins, the diazo-reaction, the peptones, urobiliii, iadican, or reaction or color. Balsamic resins, were not found; the diazo-reaction was never found before either drug and never after thymol, hut it was invary- ingly found after betaThaphthol, always the afternoon of the day the drug was given and rarely the next morning. In other words, the presence of the diazo-reaction of betanaphthol was fleeting. The reaction was intense and was never doubtful. Peptones were demonstrated very frequently, but their presence was so exceedingly irregular that no good purpose would be sub- served in tabling our results; the same may be said of urobilin, which at times was very prominent. It is regrettable that indican was not systematically sought, but was always found when the test was applied. The reaction was practically always decidedly acid. The color after thymol, at times (and far less frequently than we expected), became an olive green on standing. There wasno change in color after the administration of betanaphthol. Before the ad- ministration of either drug the color was found. to be light, rather than dark, and polyuria was a marked feature. There were three tests for albumin applied: 1. Boilmg with the addition of a couple of drops of acetic acid thereafter. This was the test that brought out the faint trace of albumin not found many times by the other tests. 2. The potassium ferro-cyanide test. 3. The c. p. nitric acid ring test. This test was often confused by the large amount of urates found after the administration of the anthelmintics. The cases referred under the hemoglobin readmgs are: 5087, 5810, 5804, 5827, 5803, 5852, 5785, 6076, and 5934. Cases 5802, 5809, 5808, 5826, 5991, 5172, 6067, 6087, 5990, 6032, 6049, 6058, 6077 are the same cases as those found with the same number under the headings "thymol" and "betanaphthol" groups. The abbreviations used are: "SI. tr." and "Tr." for slight trace and trace; "F." for few, "Mod." for moderate, "M." for much or many, "P." for present. THE AIBONITO SERIES OP 1905. 319 Summary. Case 5087. Grade, moderate; age, 28; sex, female; betanaphthol given; no iron used; gastric symptoms Erominentj al- umin appeared under treat- ment; total worms ekpelled, 497. Case 5802. Grade, intense; age, 18; sex, male; betar naplitliol given; no iron used; albumin present and increased in amount: total worms expelled, 1,315. Case 5810. Grade, very benign; age, 5; sex, fe- male; betanaph- thol; albumin appeared under treatment; total worms expelled, 10 (Y). Case 5804. Grade, intense; age, 17; sex, male; beta- naphtbol; no iron given; albu- min present but did not increase in amount; the prominent symptoms were those of the cir- c u 1 a t o r y and nervous systems total worms ex- pelled, 908. Case 5827. Grade, intense; age, 9; sex, male; beta- naphthol; no iron given; albu- min present and increased under treatment but subsided rapid- ly; prominent symptoms those of circulatory system; total worms expelled, 268. Case 5826. Grade, intense; age, H: sex, male; bota- naphthol; no iron given; albu- min present and increased a good deal under treat- ment; total worms expellea, 94. 35 110 112 i26' 27 "24' "si' Casts. Crystals. ° a Before 1st After 1st. Before 2d. After 2d Before 3d . . . After 3d Before 4th... After 4th.... Before 5th... After 6th...- Before 6th... After 0th.... Before 7th. . . After 7th.... "42' 2 "2 87 2 Before 1st.. After 1st... Before 2d... After 2d.... Before 3d.. After 3d.... Before 4th.. After 4th... 325 128 1.032 1.027 Before 1st . . Afterlst... Before 2d . . After 2d.... Before 3d.. After 3d.... Before 4th.. After 4th. . . Before 5tli. . After 5th... Before 6th.. After 6th... 5 days later. Before 1st.. After 1st . . . Before 2d... After 2d.... Before 3d .. After 3d.... Before 4th. . After 4th... Before 1st.. After 1st . . . Before 2d. . . After 2d.... Before 3d.. After 3d.... Before 4th. After 4th... Before 5th. After 5th.. Before 6th... After 6th.. Before 7th. After 7th. . Before 8th. After 8th.. 1.015 1.019 1.017 1.028 1.011 1.017 1.007 1.014 1.018 1.021 1.006 1.018 1.008 1.010 1.007 1.010 1.008 1.004 1.008 1.017 1.009 1.016 118 42 Before 1st.. Afterlst... Before 2d... After 2d.... Before 3d... After 3d.... Before 4th.. After 4th. . . 177 192 (?) 1.015 1.030 1.014 1.013 1.006 1.010 1.006 1.005 1.013 1.018 1.011 1.012 1.013 1.015 1.010 1. 015 1.008 1.025 1.015 1.020 1.010 1.019 1.013 1.025 1.018 1. 030 1.020 1.037 1.037 1.035 1.007 1.039 1.014 1.007 1.015 1.009 1. 026 1.Q.17 1.029 None. None. SI. tr. SI. tr. SI. tr. SI. tr. 81. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. Si. tr. None, Si. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. Si. tr. SI. tr. Mod. M. M. None. None. None. None. None. SI. tr. SI. tr. Si. tr. F. SI. tr. Si. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. SI. tr. Tr. Mod. Mod. M. SI. tr. Mod. F. F. F. F. F. F. M. P. M. F. F. M. M. F. F. SI. tr. SI. tr. Sl.tr. SI. tr. Tr. Tr. M. M. M. P. Mod. Few. Few. Few. Few. Mod. Mod. Mod. Mod. M. M. M. M. M. P. P. P. P. P. P. P. F. 320 UNCINABIASIS IN POETO BICO. 4 it i ■2 = 1=3 ^ ex, i Casts. Crystals 4 Summary. 1 1 ■p. i 3 1 1 i Case 6803. Grade, moderate; age, 45; sex, female; 66 2 ■Rpforp l. WHOM UKIKK BATA WAS OBTAINKB BHT NOT COMPLETED.' and epithelial casts. Many ova uncin. After urinalysis, t20BNJiiTv6 nrinT^ albumen, few hyaline casts, no blood July 8 10 and 1 1 uriTi^T,'^ M^J^-' ™t V 16 17, and 18, unne— no albumin. July 20, 2-20 B N ■ some uncin ova TiiW 99 urme-slighttmce albumin July 26, 2-^20 B. N.; some uncS ova JiSy 28 ^In^ slight trace albumin. Discharged from hospital ^uch improved. Augurt 3 uZt^ Hn R m''"?^ ■ ^^V^^ ^^^A ^^" ^^^^ for cramps in legs at times, fo uncin^ ot^ n .»,'/^ urinalysis. August 12, no uncin. ova, 2-20 B. N. Cured base ia^O.—J^rancisca Kivera, aged 16, female; great many ova uncin.; very intense case; meat pallor, debility, and practically all of the nervous, circulatory, and diges- o'^K ^^^^?^^^? of severe case of uncinariasis . Admitted to hospital June 24 Given T 1 ?■ J '^^^^"^ ^ P"ls used m intervals. June 29, many ova uncin., 2-20 B N July 2 and 6, no albumin. July 6, after urinalysis, 2-20 B. N., many uncin. ova. July 8, 10, 11, and 12, no albumin. July 13, some uncin. ova, 2-20 B. N. and two hoursafterlastdose, urine— noalbumin. July 15, 16, 17, 18, urine— no albumin. July 19, some uncin. ova. Has severe headache and fever due to acute coryza. No para- sites of malaria. July 20, urine— no albumin. Given 0.30 quinine sulphate every three hours to-day. July 21, has suddenly become blind with signs of congestion of the brain. Temperature 100. Stopped quinine and gave 0.32 calomel. Milk diet. July 22, urine — albumin. July 24, most of her sight has returned. Much better. No fever. July 27, ujine— no albumin. After urinalysis given 2-20 B. N., had few ova uncin. July 28, urine — no albumin. July 31, urine — albumin, no casts but many erythrocytes, leucocytes and cellular elements attendant upon admixture of menstrual fluid with urine. August 1, has a very heavy "cold." Urine — albumin. Menstruation ceased. August 2, few uncin. ova, 2-20 B. N. August 3, urine — albu- min, very few hyaline and granular casts. August 4, menstruation has returned but is scanty, Another sudden attack of blindness similar to the first. August 6, blind- ness has about disappeared. Urine — albumin. August 7 and 8, urine — albumin. August 9, urine — ^no albumin. No uncin. ova, 2-20 B. N. August 13, no uncin. ova. Discharged the hospital in excellent color and without symptoms of disease. Says she still suffers sliditly from obscure vision. Cured of uncinariasis. Case 1790. — Antonio Davila, aged 25, male; great many ova uncin.; very intense case; all symptoms of intense case uncinariasis save edema. Also malaria. July 5, examination blood revealed large number Plasmodia. Hb. 43 per cent. Given 0.20 calomel and in two hours began quinine sulphate, 0.32, every three hours, which was continued for three days. No further symptoms of malaria manifested themselves thereafter. July 5, 6, 7, and 8, urine — ^no albumin. July 9, 2-10 B. N. Blaud's pills used in intervals. Urine — ^two hours after first dose of B. N., albumin and hya- line and granular casts. July 10, 11, 12, 14, 15, and 16, urine — ^no albumin. July 17, many ova uncin., 2-20 B. N. Urine — ^no albumin after this dose. July 18, urine — no albumin. July 20 and 22, urine — albumin. July 24, some ora uncin., 2-20 B. N. Urine — after his dose slight trace albumin. July 26, discharged hospital greatly im- proved. August 1, urine — ^before dose, very slight trace albumin. Very few uncin. ova, 2-20 B.N. August 8, urine — before dose, no albumin . No uncin. ova, 2-20 B.N. August 15, few uncin, ova, 4-20 thymol. August 22, few uncin. ova, 4-20 thymol. August 29, urine— no albumin. No uncin. ova, 4-20 thymol. September 7, few uncin ova, 4-20 thymol. •' September 14, urine— no albumin. No uncin. ova, 4-20 thymol. September 22, no uncin. ova, 2-20 B. N. November 25, urme— not a trace of albumin by any test. Man cured completely and has excellent color. Case 13 —Cruz Ortiz, aged 25, male; few uncinaria (one ovum to every 4 or 5 micro- scopic fields); medium case; prominent symptoms are: Marked paresthesia of feet and legs and cramps in legs, debility, dizzmess and pain m region of liver and in pit of stomach Admitted to dispensary June 2 and given 3-30 B.N. Hb . , 58 per cent. June 9, very few uncin. ova, 3-25 B . N . Hb . , 62 per cent. June 16, very few uncm. 1 Abbreviations as per report of 1904, Appendix. 324 TJNCINABIASIS IN POETO KICO. ova, 3-25 B. N. Hb., 61 per cent. June 23, 3-25 B. N., very few uncin. ova. Bb., 75 per cent. June 29, last night suddenly taken with severe vomiting and purging wim cramps in the legs and suppression of urine. He has had these attacks before; the first was in January. He was given calomel 0.065 every hour for four doses and brandy hypodermicaUy every two hours. To-day admitted to hospital. Has vomited every thmg he took all day and is in a state of collapse. June 30, condition the same. Vomited every thing he took all day. Passed a small quantity of smoky urine for first time in 48 hours. Urine — smoky and scanty, loaded with albumin and hyaline, granular, amyloid and epithelial casts, no blood, some renal cells and much bile pig- ment. Flaxseed meal poultices applied to the kidneys and at night leaves of digi- talis added to same; also given 0.032 calomel every hour to eight doses. The hypo- dermic administration of brandy was continued. Pulse slow (50 to 60 to the minute) and weak. Is profoundly depressed. Gravely ill. July 1, is urinating more freely and urine is less smoky. There is little sediment. Urine — albumin; hyaline, gran- ular and fatty casts. Continued to poultice all day with digitalis leaves until 4.30 p. m. Effect on pulse excellent, which is slow and full. Gave one-fiftieth grain of triaitrin every three hours to four doses, then prescribed spirits of nitrous ether 20 drops, and solution of acetate of ammonia, 40 drops, every tJiree hours. Given TtiilTr diet. Man is better. July 2, given only the sweet spirits of nitre aiid acetate of potash as per above. Abundant and clear urine. July 3, urine — has passed 2,000 c. c. urine in last 24 hours. Some albumin. Feels well and hungry but retained on milk diet and given nitre and acetate of potash as per above every four hours. July 4, has been placed on general diet as he is remarkably improved. Urine — absolutely no albumin. July 5, urine — no albumin whatsoever but a few hyaline and granular casts. States that he is subject to these attacks with suppression of urine, vomiting, pain in stomach, fever, headache and cramps in legs. Had an attack of this nature in January last from which he nearly died. That was his first attack but he has had one more previous to this one. Examination of feces this date revealed many ova of uncin. July 6, Blaud's pills were begun to day and continued in the intervals between specific medication. Urine — no albumin. July 7, Hb. 77 per cent. July 8, 10, 11, and 12, lu-ine — no albumin. July 13, many ova uncinaria, 1-20 tiiymol. Urine — after dose, no albumin. July 14, 15, 16, 17, and 18, urine — ^no albumin. July 20, some uncin. ova, 1-20 thymol. Urine — after dose, no albumin. July 22, urine — no albumin July 23, pain in back over site of kidneys and fever. July 25, same; urine— no albumin. July 26, urine— no albumin. Hb., 98 per cent. Man very much improved. Seems well. July 27, some imcin. ova, 4-20 thymol. Bloody stool after taking the thymol. Urine — absolutely no albumin but a heavy precipi- tate of salmon color, containing great abundance of uric acid crystals and many hya- line and granular casts. Given nitre and acetate of potash as before every three hours. July 28, urine— completely clear and without sediment; no albumin. Feels perfectly well and was discharged from hospital. Given the following to take for two weeks: Boric acid, 0.130; potas. bicarb 0.130; extract, buchu, 0.065; extract, triticum rip. 0.065; extract corn silk, 0.032; extract hydrangea, 0.032; atropine sul- phate, 0.00013. One tablet three times a day. August 9, urme — ^no albumin. Man is much better but still complains of pains and cramps in legs. August 17, urine — no albumin. Same remark as above. , Case 1758. — Canuto Rivera, aged 48, male; many ova of uncin.; intense case; prin- cipal symptoms pain in pit of stomach, dizziness and debility; very pale. Admitted to hospital. Urine— no albumin. July 4, 2-25 B. N. Blaud's pUls used in the mtervals. July 6, urine— slight trace of albumin, no casts. This test was made by Heller's inethod and was probably uric acid, as I failed to confirm it on boiling. July 7, complains of pain in urination and says he has often passed small stones. Urine — albumm, no casts but much bladder epithelium and some blood. July 8, purulent discharge from the penis, but says it comes from a boil (?). Urine— many pus cells and calcium oxalate crystals; albumin. July 10, high fever and diarrhea. Urine — slight trace of albumin. July 11, urme— slight trace albumin. Furious diarrhea Given calomel 0.013 every half hour for five doses, followed by tr. opium, three min- ims; tr. rhubarb, 5 minims; tr. capsicum, 5 minims; spt. peppermint, 5 minims; spt camphor, 5 minims; administered in tablet form every three hours. July 12 has much fever. His diarrhea seems to have been due to stufling himself with food "^/^T '""^' ^ *®^ ^y^'"'® ^'^'^ Sranular casts. July 13, much fever Added to E, above noted bismuth-beta-naphtholate 3 grains; guaicol one-fourth grain- thy- mol one-eighth gram; eucalyptol one-fourth grain; one tablet every three houra Urme— albumm. July 15, the diarrhea is as severe as ever and to limit bacterial activity he was given a solution of 1 to 1,000 aqueous solution of acetozone to drink ad libitum in addition to other medication. Urme— heavy ring by Heller's test most of which is due to urates; albumin. July 16, urine— slight ring by Heller's test butalbumm demonstrable on boiling test. July 17, bismuth-beta-naphtholate stopped SUMMARY OF CASES IN HOSPITAL. 325 haTan ar^^'f \t^£ ^lY'' '^,!:'^5~'^'^'',^ ''■^<=«- Abundance of urates. July 18, chloride so^^,Hn°- ^^°^°5'-^°«i8, small tampon soaked in 1 to a 1,000 adrenaW temDer!t^,rl qr • Urme-shght trace of albumin and a few hyaline c^sts. July 20, temperature 96. Diarrhea much less. Urme— albumin. July 21 all medioation stopped. .Diarrhea has ceased. July 22, urine-slight tracf alburn^ JuZ 23 some uncm. pva, 3-20 thymol Blaud's pills used from time forth in the inte^vab July 24, urme— albumm. Normal temperature; no diarrhea. July 27, urine— albumm; much uric acid; many bladder cells and a very few hyaline casts July 28 urme— slight trace of albumm and a few hyaline casts. July 30, some uncm ova 3-20 thymol. Has rather severe acute conjunctivitis. July 31, urine- slight trace of albumm. August 1, urme— slight trace of albumin. Has general edema to an alarm- iBg degree. Given powdered digitalis leaves, 1 grain; strychnine sulphate, one- Bixtieih gram; caffeine one-half grain; extract cactus grandiflora one-half grain; one tablet every three hours. August 6, 3-20 thymol. Urine— after dose, no albumin. August 7, 8, and 9, albumin in urine. August 13, much less edema; only seen now in feet. Some uncin. ova, 4-20 thymol. August 15, all edema has disappeared. Stopped heart stimulant. August 15, 16, and 17, urine — albumin. August 20, few uncin. ova, 4-20 thymol. August 27, some uncin. ova, 4-20 thymol. August 28, urine— trace albu- min. Septernber 2, some uncin. ova, 4-20 thymol. September 10, few uncin. ova, 4-20 thymol. Urine — before dose, albumin; many mucus threads, calcium oxalate crys- tals, few kidney cells, and a very few hyaline and granular casts. September 17, few uncin. ova, 4-20 thymol. September 24, no uncin. ova. September 26, no uncin. ova, 4-20 thymol. October21, no uncin. ova. Discharged cured. Is the picture of health and cured of all save "la pereza" (laziness). Known as "El sargento de los vagos" ("The sergeant of the tramps".) Case 54. — Zacarfas Col6n, aged 35, male; some uncin. ova; intense case with usual symptoms, plus intense jaundice. Admitted to clinic in dispensary. June 5, 3-30 B. N. June 11, still many uncin. ova, 3-25 B. N. June 18, still uncin. ova, 3-25 B.N. June 25, 3-25 B.N. July 1, few uncin. ova, 3-25 B.N. Blaud's pills begun. July 8, many uncin. ova, 2-15 B.N. Urine — slight trace albumin and tremendous quantity of bile pigment; hyaline casts. Is profoundly jaundiced. July 15, few uncin. ova, still very much jaundiced; given one-half grain podophyllin and 2 grains calomel. July 22, some uncin. ova, 2-15 B.N. July 29, few uncin. ova; the man is really quite sick and was admitted to hospital. He has a most intense golden yellow jaundice. Was placed on nitro-muriatic acid, 5 drops t. i. d., and sodium phosphate 15 grains, a. m. and p.m. Urine — much bile pigment; granular and hyaline casts and albumin; no tu:obilin. July 31, urine — albumin but not so much bile pigment. August 1 and 6, uiine — albumin and bile pigment in excess. August 7, urme — albumin and excess of bile pigment. August 8, man much improved. Urine — still albumin but a great reduction in bile pigment. August 9, urine— albumin. August 16, urine— slight trace of albumin. August 17, urine— trace albumin. Thymol 4-20. August 19, urine— no albumin. August 20, jaundice has nearly disappeared. August 23, severe diarrhea ; tannic acid . 25 every three hours . August 27 , diarrhea checked ; stopped tan- nicacid. August28, urine— very slight trace albumin; no excess bile pigment Very few uncin ova 4-20 thymol. September 9, discharged from hospital apparently well. September 11, few uncm. ova, 4-20 thymol. Urine— before drug, very slight trace of albumin, so slight as to raise question; no excess bile pigment; no casts. September 18, no uAcin. ova, 2-20 B. N. September 25, 2-20 B. N. October 2, no uncm. ova. CasffTO^-^omas Sierra, male; many uncin. ova; very intense case. This was one of the worst ca^es we had, with all the symptoms of a very intense case edema of leel and high degree of ascites; has severe pam m lumbar region and complete pros- trftion July 4 urine-much albumin and great number of hyaline; granular and fX casts urin; very pale straw color. July 5, as man was apparently about to die mtiy casra, urmtJ ve > jj t It: r m Blaud's pills given m the mtervals. July 7, from uncinariasis given 1-15 B. g^ ^^^^^^^ P „f tf^^^^e of digitalis every three unne-no albumm (!)_July 8, g^J^^^^ ^P^ ^^ urine-no albumin (!). July 12, S one blood cast. July 28,.urin^da^ gree- » ^^^^^^^ ^g^tTaTl fece^T2^4\^ou™^a%-^f nT^^^^^^^ after careful search. Haa 326 UNCINARIASIS IN POBTO RICO. severe dyspepsia. Given soda mint tablets. August 6, 7, and 8, urine-;-much albumin. August 8, given 20 drops of sweet spirits of niter and 40 drops of spirits of Mindererus three times a day. August 12, 2-15 thymol; no ova uncin. _ August 16 and 17, urine — much albumin. August 18, no ova tmcin. ; discharged hospital, apparently well but still suffering from the chronic nephritis he had at entrance. Has slight edema of legs. Case 1774.— Zosi Cristino Figueroa, aged 25, male; many ova uncin.; medium case. His chief symptoms are the usual ones pertaining to the stomach and circulatory systems of a medium case of uncinariasis, complicated by those of a chronic dysentery which he has had some years. Admitted to hospital. July 4, urine — no albumin. July 6, urine— before drug, no albumin. Given 2-20 B. N. Blaud's pills used in the intervals. July 7, 8, and 11, urine— no albumin. July 12, lu-ine— no albumin. July 13, some uncin. ova, 2-20 B.N. Urine— after drug, no albumin. July 14, 15, and 16, urine— no albumin. July 20, few ova uncin., 2-25 B.N. Urine— after drug, no albumin; abundance of urates. July 22 and 24, urine— no albumin. July 27, some uncin. ova, 2-20 B.N. Urine — before drug, no albumin. July 28, 31, urine — ^no albumin. August 1, some uncin. ova, 2-20 B. N. Urine — after drug, no albumin. August 7, urine — no albumin. August 8, some uncin. ova, 2-20 B.N. Urine — after drug, albumin. August 9, as result of B. N. the feces of the last 24 hours contained 15 uncinaria, one pair in act of copulation. Urine — no albumin. August 14, soine uncin. ova, 4-20 thymol. Augustl6, urine — trace albumin. August 21, few uncinaria ova, 4-20. Has severe neuralgia and pronoimced dyspepsia. August 26, few ova uncin., thymol 4-20. Discharged hospital, apparently well save a chronic nervous dyspepsia. August 28, urine — no albumin. December 16, absolutely no albumin; Hb., 110 per cent. Suffers very little now from stomach due to taking pepsin comp. Has headache, dizziness, and roaring in ears. Case 1890. — Leonarda Marrero, female; great many uncin. ova, very intense case. Aged 50. June 29, 2-15 B.N. Blaud's pills used in the intervals. July 2, urine — ^no albumin. July 4, urine — no albumin. Many uncin. ova., 2-20 B.N. July 6, urine — albumin; no casts on careful examination but many epithelial cells, free erythrocytes and vaginal epithelium; cells from the pelvis of the kidney, in sheets like oyster shells. July 7, 8, 10, and 11, urine — albumin. July 12, 14, and 15, urine — ^much albumin and diarrhea. July 16, thymol, 3-20. Urine — albumin. July 17, 18, 20, and 22, urine — albumin. July 23, few uncin. ova, 4-20 thymol. July 24, urine — albumin. July 27, urine — slight trace albumin. July 30, 3-20 thymol, no uncin. ova. July 31, urine — slight trace albumin; great abundance of blood, pus, fibrin, and imbricated masses of cells from the pelvis of the kidney; no casts. August 1 and 3, urine — ^no albumin. August 5, no imcin. ova. August 6, 7, 8, urine — albumin. Discharged hospital, cured. Case 2069. — Julio Santiago, aged 23, male; very intense case, with edema; many ova of uncin. July 12, urine — slight trace of aibumin on boiling but none by nitric acid. Hb., 50 per cent. July 13, 2-20 B. N. Urine— after B. N., no albumin. Blaud's pills used. July 14, urine — slight trace of albumin. July 15, diarrhea. Treated by calomel first and then paregoric. Urine — no albumin. July 16, urine — trace albumin. July 17 and 18, urine — no albumin. July 19, diarrhea stopped. July 20, urine — no albumin. July 21, 3-20 thymol. July 22, urine — no albumin after thymol. Thymol 3-20. July 23, diarrhea. July 24, urine — no albumin; much urates. July 25, urine — albumin, very few casts and much mucin. July 28, urine — much albumin. July 31, urine — much mucin and many calcium oxalate crystals; no casts; some renal cells; very slight trace of albumin. August 1, urine — albumin. August 3, all diarrhea stopped after treating continually with opium, bismuth, and, finally, silver nitrate pills. August 6, urine— no albumin. August 7, urine — very faint trace of albumin. August 8, some ova uncin . , 4-20 thymol. Urine — no albumin. August 9, after careful search of the stools of the 24 hours following the thymol found 15 uncin. August 13, urine— no albumin. No uncin. ova, 2-20 B. N. Hb., 58 per cent. Discharged hospital. THE EIO PIEDRAS SERIES OF 1906. mS c*oSplJte'^^'''^°"^ ^^' ^"^ advantage over the second in that the histories are Second group. Nearly all of these cases had eucalyptol, which accounts for their short stay m hospital. -^r , u* uucix FIRST GROUP. Case 1.—3. S., Yabucoa. Admitted November 12, 1906: age, 14; male; white- laborer. At age of 10 had malaria. Four or five months ago his present illness began! Poor food. Mazamorra contracted in a banana plantation. Mucous membranes pal- lid. Skin dry and harsh. Is well nourished and well developed. Appetite good. Gastralgia at times before meals. Sometimes vomits; tongue somewhat coated; epi- gastric and general abdominal tenderness; constipation; feces normal, save for mucus and inany ova of uncinarise and trichocephalus. A little dyspnea; palpitation and pain in heart, latter especially in the morning. Pulse regular, weak, and compres- sible. Heart hypertrophied and dilated; hemic murmurs. Pain in chest. Is always dizzy. Tinnitus aurium. Temporo-frontal headache. Somnolent. Reflexes good. Intelligence fair. Blurred vision in right eye. Muscles weak and flabby. Tem- perature normal. Edema of lower extremities. Blood. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L. L. B. Nov. 12 44 51 S, 084,000 6,266,400 7,800 8,000 10.8 31.2 68.0 45.2 18.4 14.8 2.4 8.0 0.4 Dec. 4... .8 Diagnosis. — Acute uncinariasis. Treatment. — November 13, 3-25 thymol; November 20, same; November 27, same; December 3, same; December 4, same. Result. — Cured. Case 2.— P. G., Rio Piedras, barrio Mameyes. Admitted November 14, 1906; age 42; male; mulatto; single; laborer in coffee and banana plantations. Father died of anemia. Patient has been sick four years; food poor; had mazamorra for the last time a year ago. Marked pallor. Development good; no emaciation. Slight edema (rf face and considerable of lower extremities; suffers from pruritus. Skin dry and harsh. Good appetite; no gastralgia; has nausea; vomits, especially at mght; tongue pale and coated; stomach and abdomen are tender; constipation and enteralgia; yel- low feces with a little mucus; many ova of uncinaria and a few of trichocephalus. Suffers from dyspnea and palpitations, but no pain in heart. Pulse weak and com- pressible. Pain in chest; frequent dizziness; tinnitus annum; sleeps anywhere he sits down ; mentality slow. Reflexes and tactile sense good . No impotence. Blurred vision. Muscles flabby, weak, sore, and painful. Blood. Date. Hb. Bed cells. Leuco- cytes. E. P. S. L. L. L. B. 19 29 2,671,040 3,191,040 4,800 6,400 7.6 14.0 72.0 62.0 17.2 21.2 2.4 2.8 0.8 Dec. 29 Trenfment —November 14, thymol 4-25; December 1, thymol 3-25. ^"inproved. Would not consent to stay in hospital longer. 327 328 UNCINARIASIS IN POBTO EICO. Case 3.— a. M., Rio Piedras, barrio Frailes. Admitted December 29, 1906; age, 20; male; white; single; laborer in country; has been sick two years; has had maza- morra Extreme pallor of conjunctivse; some emaciation; poor general development, had such edema of face at times as not to be able to open his eyes; edema ot legs; pruritus; skin dry and harsh. No appetite; severe gastralgia; no nausea or vomiting, but does suffer from meteorism; much diarrhea; many ova of uncinanee.trreat dysp- nea; palpitations and pain in heart marked. Pulse weakand compressible. Hyper- trophy of heart; bruit-de-diable; pain in chest. Much dizziness and tinmtus aunum. Temporal headache; insomnia; mental condition poor. Frequent syncope. Is intel- ligent. Weakness. Muscles flabby and painful. Blood. Date. Hb. Bed cells. Leuco- cytes. E. P. S.L. L.L. B. Dec 29 18 2,502.160 8,200 6.8 78.8 11.6 2.4 0.4 Diagnosis. — Chronic uncinariasis. Treatment. — December 29, sod. sulphat., 35 grams. December 30, beginning in the morning, he took the following formula, divided into three doses, one dose every 15 minutes: Eucalyptol, 2; chloroform, 3; castor oil, 40. After this dose 410 uncinariee were expelled, all alive. The drug caused such severe collapse that hypodermics of strychnine had to be administered. January 3, 1907, same formula, but divided into two doses. Expelled 32 uncinarise. Same severe reaction. January 24, same formula, but divided into three doses. Expelled 2 uncinariae. Same reaction. February 3, same formula; same reaction, and expelled 3 uncinarise. February 12, same dose; expelled no uncinariae. After a month's rest from this severe treatment, he was allowed to recuperate and was then given 4 grams of thymol, as he had many ova of uncinarise in his stools. His stool was lost and so, unfortunately, nothing was known of the number expelled. Result. — This man is entirely cured, is strong, of good color, and is now working as messenger in the office of the director of the transmissible diseases service. Case 4- — A. C, Rio Piedras, barrio Caimitas. Admitted November 2, 1906; age, 70; male; white; single; laborer; mother died of uncinariasis; patient has had dysentery, asthma, spasms, and varicella. Two years ago suffered a severe infection from mazamorra. Is very pale and a little emaciated. Fair development. Edema of lower extremities; atrophy of the skin; skin dry and harsh. Not much appetite; gastralgia; nausea; tongue pallid, deeply seamed and dotted with black spots; flatu- lence; tenderness of abdomen; meteonsm; constipation; feces normal, save for a little mucus; many ova of uncinarise. Dyspnea, palpitations, and pain in heart. Pulse weak and compressible. Pain in chest; dizziness; tinnitus auiium; headache. At times syncope. Reflexes are normal. Blurred vision. Muscles flabby, paiiiiul, sore, and weak. Blood. Date. Hb. Bed cells. Leuco- cytes. E. P. S.L. L.L. B. Nov. 2 8 9 16 16 50 1,542,160 1,768,800 2,673,200 2,017,600 3,600 4,000 3,200 4,000 39.6 24 8 6.4 3.2 43.2 44.4 56.0 69.6 11.2 16.4 30.4 17.2 S.6 13.6 6.8 9.2 0.4 .8 .4 .8 11 Deo. 10 29. . . Peb. 5 Diagnosis. — Chronic uncinariasis. Treatment. — November 2, thymol 3-20; expelled 150 uncinariae and 1 tiicho- cephalus. November 12, thymol 4-25; expelled 433 uncinariae. November 29 thymol 4-35; expelled 247 imcinariae. December 10, thymol 4-25- expelled 82 uncinariae. December 20, thymol 4-25; expelled 2 uncinariae ' Jamiarv qq thymol 4-35; expelled 35 uncinariae. ' •'*"'^*'T ^'>> THE RIO PIEDRAS SERIES OP 1906. 329 diii';7£.>^"ln°^ ^^^ ^^1%,^^ ^?®°lia, which is rapidly disappearing. He was alliSive ^^' ' ^ ^' ^""^ °^'^^"' examinations of feces, which wire ^^^"^-^ Si^^i\' ^^° Piedras barrio Cupey. Admitted October 26, 1906; age 30- male; white; laborer: mother died of uncinariasis; measles at 12 years of age- infec- tion 4 years ago; food poor, chiefly vegetable; mazamorra frequent in coffee panta- tion and swamps. Skm dry and harsh. Appetite good; gastralgia so severe as to make himcoldall over; nausea; vomits at times after meals; tonguecoated; abdominal tenderness; much diarrhea; enteralgia; feces normal, save for a little mucus- many ova of uncinanae, few of trichocephalus. Little dyspnea; pain in heart and palpi- tation. Pulse weak and compressible. Pain in chest; extreme dizziness- frontal and temporal headache; pain in his joints; insonlnia; reflexes normal. Extremities and face edematous. Blood. Date. Hb. Red cells. Leuco- cyte.s. E. P. S. L. L. L. B. Oct. 26 21 29 26 2,461,600 2,720,000 3,090,200 6,600 7,000 6,800 20.0 17.2 8.4 47.6 66.4 65.6 20.0 17.2 31.6 10.8 6.4 3.6 1.6 2.8 Nov. 2 16 Diagnosis. — Chronic uncinariasis. Treatment. — October 26, thymol 4-25; expelled 792 uncinariae. November 7, thymol 4-25; expelled 50 uncinariae. November 17, thymol 4-25; expelled 6 uncinariae. November 28, thymol 4-25; expelled 26 uncinariae. Result. — Cured, 85 per cent Hb. Case 6. — C. F., Carolina, barrio Piedras Blancas. Admitted December 15; age 29; male; white; laborer. Mazamorra from working in trenches. Extreme pallor; edema of face very severe; both extremities same; skin dry and harsh. No appetite; severe gastralgia; flatulence; diarrhea; enteralgia; feces normal, save for many ova of uncinariae and few of trichocephalus. Intense dyspnea; marked palpita- tion and pain in heart. Pulse weak and compressible. Heart hypertrophied and dilated. Bruit-de-diable. Much dizziness; parietal headache; tinnitus aurium. Blood. Date. Hb. Red cells. Leuco- cytes- E. P. S. L. L. L. B. 19 2,915,200 8,000 10.4 70.0 15.6 2.8 1.2 li/manus-is. — Chronic uncinariasis. . , ^ T^ i, la i • Treatment.— Decemhei 15, 35 grams sod. sulphat. at night December 16,eariym the morning given: Eucalyptol, 2; chloroform, 3; castor oil, 40;taken in three doses 15 Snutes apLt^ Vomited one dose; had vertigo and had to be aroused from collapse bvhvpodermic stimulation. Expelled 91 uncinanae. December 21 sod. sulphat 40 NexfW took eucalyptol in same combination, but of the three doses into which thif was dSd he only had two. Expelled 110 uncmanae. December 29, sod B^Xr 45 Next day took eucalyptol as per above in three doses Expelled 42 unSnariae Januarre, sod. sulphL*; 45. Next day took eucalyptol as per above, but in two doses. Expelled 35 uncinanae. Result. — Cured. n -y J r town of Caauas Admitted November 20, 1906; age 8; female; Case?.— J. tr., to^'i.°'^f';:^?fV^!,-„„„„rT)v field- skin dry and harsh ; eats uncooked white; haa mazamorra; ^f.^^ted ma near-by field ^^n^r/ ^^^^^ ^j^^^ber of ova of e^Uy ana has frontal headache. Edema of lower extremities. 330 UNCINARIASIS IN POKTO BICO. Blood. Date. Hb. Red cells. Leuco- cytes. E. P. S. L. L. L. B. Nov.20 30 3,275,200 6,000 4.4 67.2 31.6 6.0 0.8 Diagnosis. — Acute uncinariasis. Treatment. — November 20, 12 grams sod. sulphat. November 21, eucalyptol, 1; chloroform, 1.5; castor oil, 25. Every 20 minutes she had one of the three portions into which this dose was divided. At 11.45 a. m., or 3 hours after this dose of euca- lyptol, she was given 0.5 of eucalyptol, 1 gram chloroform and 10 of castor oil. After these doses she expelled 11 uncinariae. i3ecember 6, sod. sulphat., 12. Next day she took eucalyptol, 2; chloroform, 3; castor oil, 40. This was prepared to take in three doses, but she only took two. Expelled 260 uncinariae. Result. — This child left the hospital simply because of the terrible effect of the drug. Case 8. — P. L., Rio Piedras, barrio Monacillo. Admitted November 19, 1906; age, 54; male; mulatto; laborer in country; mazamorra in the last coffee harvest; has been sick 14 years. Very pale; edema of scrotum and lower extremities. Skin dry- and harsh. Gastralgia; sometimes nausea and vomiting; tongue coated; appetite poor; feces normal save for many ova of uncinariae and a few of trichocephalus. Has dyspnea, palpitations, and pain in heart. Pulse weak and compressible. Much dizziness and constant tinnitus aurium. Temporo-occipital headache. Reflexes normal. Blood. Date. Hb Red cells. Leuco- cytes. E. P. S.L. L.L. B. Nov.19 20 28 3,613,280 3,728,880 6,200 6,600 8.4 9.2 64.0 64.0 20.0 18.8 7.6 7.2 Dec. 4 0.8 Diagnosis. — Chronic uncinariasis. Treatment.— Tea